Transplanting kidneys from donation after cardiac death donors with acute kidney injury

Abstract

Donation after cardiac death (DCD) and acute kidney injury (AKI) donors have historically been considered independent risk factors for delayed graft function (DGF), allograft failure, and inferior outcomes. With growing experience, updated analyses have shown good outcomes. There continues to be limited data, however, on outcomes specific to DCD donors who have AKI. Primary outcomes for this study were post–kidney transplant patient and allograft survival comparing two donor groups: DCD AKIN stage 2‐3 and DBD AKIN stage 2‐3. In comparing these groups, there were no short‐ or long‐term differences in patient (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.54‐1.93, P = .83) or allograft survival (HR 1.47, 95% CI 0.64‐2.97, P = .32). In multivariate models, the DCD/DBD status had no significant impact on the estimated GFR (eGFR) at 1 (P = .38), 2 (P = .60), and 3 years (P = .52). DGF (57.9% vs 67.9%, P = .09), rejection (12.1% vs 13.9%, P = .12), and progression of interstitial fibrosis/tubular atrophy (IFTA) on protocol biopsy (P = .16) were similar between the two groups. With careful selection, good outcomes can be achieved utilizing severe AKI DCD kidneys. Historic concerns regarding primary nonfunction, DGF resulting in interstitial fibrosis and rejection, and inferior outcomes were not observed. Given the ongoing organ shortage, increased effort should be undertaken to further utilize these donors.

Simultaneous liver–kidney transplantation from donation after cardiac death donors: an updated perspective

“…These findings are consistent with our experience using solitary DCD kidney allografts. 11,13 Based on these data and our clinical experience, we believe that DGF is actually an expected normal event posttransplant and should be treated as such. It is by far more common in DCD donors but does not impact long-term outcomes.…”

“…These outcomes are consistent with our centers' experience with solitary DCD liver and kidney allografts as well as with the most recent national UNOS data. 11,14 In this updated series on DCD SLK, we found the incidence of ischemic cholangiopathy to be low at 10.0% and no DCD liver allografts were lost to ischemic cholangiopathy within the first year (Tables 4 and 5 11,19,20 In this series, the observed DGF rates were higher in the DCD cohort (40.0% vs 23.7%) although this did not reach statistical significance ( Table 2). The length of DGF was also found to be longer in the DCD SLK cohort (median 20 vs 4 days).…”

“…21 More recently, we have looked at the impact of DGF in the setting of severe acute kidney injury donors, DCD donors, and extended-criterion donors (kidney donor profile index [KDPI] ≥ 85%). 11,19,20 For these donors, the observed duration of DGF is also longer (median 10 days versus 8 days) but does not impact long-term renal function recovery. 19,20 TA B L E 3 SLK biopsy results In addition, despite longer periods of DGF, we have not observed any differences on protocol biopsy specific to IFTA or fibrosis progression.…”

“…Reported outcomes for solitary DCD kidney and liver allografts have demonstrated continuing improvement, however, data specific to DCD SLK transplants remains limited. 11,12,14,[16][17][18] To date, there have only been 2 single-center reports and 2 UNOS data analyses published on outcomes specific to DCD SLK (Table 5). 14,[16][17][18] LaMattina et al reported excellent outcomes (100% 1-year patient and graft survival) with DCD SLK in a small group of 5 patients.…”

“…With growing experience, more recent studies have, however, consistently shown improving outcomes and increased organ utilization for both solitary DCD kidney and liver transplants. [9][10][11][12][13][14][15] The observed increase of nationally performed DCD SLK transplants have also been suggestive of improved outcomes, but, to date, there continues to be limited granular data on outcomes specific to this group. 14,16 As such, the aims of this study were to compare (1) patient and allograft survival rates,…”