Outcomes of kidney transplantation (KT) after controlled circulatory death (cDCD) with highly expanded criteria donors (ECD) and recipients have not been thoroughly evaluated. We analyzed in a multicenter cohort of 1161 consecutive KT, granular baseline donor and recipient factors predicting transplant outcomes, selected by bootstrapping and Cox proportional hazards, and were validated in a contemporaneous European KT cohort (n = 1585). 74.3% were DBD and 25.7% cDCD-KT. ECD-KT showed the poorest graft survival rates, irrespective of cDCD or DBD (log-rank < 0.001). Besides standard ECD classification, dialysis vintage, older age, and previous cardiovascular recipient events together with low class-II-HLA match, long cold ischemia time and combining a diabetic donor with a cDCD predicted graft loss (C-Index 0.715, 95% CI 0.675-0.755). External validation showed good prediction accuracy (C-Index 0.697, 95%CI 0.643-0.741). Recipient older age, male gender, dialysis vintage, previous cardiovascular events, and receiving a cDCD independently predicted patient death. Benefit/risk assessment of undergoing KT was compared with concurrent waitlisted candidates, and despite the fact that undergoing KT outperformed remaining waitlisted, remarkably high mortality rates were predicted if KT was undertaken under the worst risk-prediction model. Strategies to increase the donor pool, including cDCD transplants with highly expanded donor and recipient candidates, should be performed with caution.

Background The use of kidneys from elderly controlled donation after circulatory death (cDCD) donors has increased significantly in recent years. Concerns about outcomes achieved with these elderly cDCD kidneys have arisen. We aimed to compare outcomes from elderly cDCD kidney transplant recipients (KTrs) and elderly donation after brain death donors (DBDs) in KTrs. Methods We conducted a single-centre retrospective study including 87 cDCD-KTrs (46 from donors ≥65 years of age and 41 from &lt;65 years) and 126 DBD-KTrs from donors ≥65 years of age from 2013 through 2017). Young cDCD-KTrs were used as controls. The median follow-up was 27.1 months for all cDCD-KTrs and 29.7 months for DBD-KTrs ≥65 years of age. Results Donors &gt;65 years of age represented more than half of our global cDCD cohort (52.9%). KTs from elderly cDCDs had similar rates of delayed graft function, primary non-function and vascular complications compared with young cDCD-KTrs and elderly DBD-KTrs. Short and medium-term graft survival from elderly cDCD kidneys are excellent and are comparable to those from young cDCD and elderly DBD kidneys (90% young cDCD versus 88% elderly cDCD versus 80% elderly DBD at 36 months, P = 0.962 and 0.180, respectively). Although recipients from cDCDs ≥65 years of age showed lower 3-year patient survival (78% versus 87% in elderly DBD-KTrs; P = 0.01), recipient age was the only determinant of patient survival [hazard ratio 1.10 (95% confidence interval 1.02–1.17); P &lt; 0.01], without any influence of donor characteristics. Conclusions The use of kidneys from elderly cDCDs is increasing in Spain. Short- and medium-term graft outcomes are similar when comparing kidneys from elderly cDCDs and DBDs. Recipient age is the only determinant of patient survival. Additional studies are needed to assess long-term outcomes.

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