Deceased-donor acute kidney injury is not associated with kidney allograft failure

Abstract

Deceased-donor acute kidney injury (AKI) is associated with organ discard and delayed graft function, but data on longer-term allograft survival are limited. We performed a multicenter study to determine associations between donor AKI (from none to severe based on AKI Network stages) and all-cause graft failure, adjusting for donor, transplant, and recipient factors. We examined whether any of the following factors modified the relationship between donor AKI and graft survival: kidney donor profile index, cold ischemia time, donation after cardiac death, expanded-criteria donation, kidney machine perfusion, donor-recipient gender combinations, or delayed graft function. We also evaluated the association between donor AKI and a 3-year composite outcome of all-cause graft failure or estimated glomerular filtration rate ≤ 20 mL/min/1.73m2 in a subcohort of 30% of recipients. Among 2,430 kidneys transplanted from 1,298 deceased donors, 585 (24%) were from donors with AKI. Over a median follow-up of 3.7 years, there were no significant differences in graft survival by donor AKI stage. We found no evidence that pre-specified variables modified the effect of donor AKI on graft survival. In the subcohort, donor AKI was not associated with the 3-year composite outcome. Donor AKI was not associated with graft failure in this well-phenotyped cohort. Given the organ shortage, the transplant community should consider measures to increase utilization of kidneys from deceased donors with AKI.

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

“…Historically, donation after cardiac death (DCD) donors and kidneys from donors with acute kidney injury (AKI) were considered independent risk factors for DGF, allograft failure, and inferior outcomes . With increasing experience, however, updated studies have shown good independent outcomes for both DCD and AKI donor kidneys, including those with severe AKI (AKIN stage 2‐3) . Despite this progress, limited data exist on outcomes specific to AKI DCD donor kidneys.…”

“…With growing DCD experience, updated data have shown comparable outcomes between donation after brain death (DBD) and DCD kidneys, including good long‐term graft survival in DCD kidney transplant recipients . Similarly, excellent results, equivalent to those of non‐AKI donors, have been observed in kidney transplants using AKI donors . To date, however, there continues to be limited data on outcomes specific to DCD AKI donors .…”

“…7-9 Similarly, excellent results, equivalent to those of non-AKI donors, have been observed in kidney transplants using AKI donors. 10,11 To date, however, there continues to be limited data on outcomes specific to DCD AKI donors. 12 As such, the goals of this study were: (a) to compare patient and kidney allograft survival rates for DBD and DCD AKI donors, and (b) assess 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.…”

Outcomes of kidney transplant from deceased donors with acute kidney injury and prolonged cold ischemia time - a retrospective cohort study

“…Multiple single‐center studies have demonstrated that kidneys transplanted from donors with AKI, typically defined as a terminal creatinine ≥2.0 mg/dl, have an increased risk of delayed graft function (DGF), with greater risk of DGF seen with more severe AKI . Despite the increased risk of early complications, these kidneys are associated with excellent allograft survival and allograft function in the short term, even with increasing severity of AKI in the donor [.] However, the majority of kidney transplants included in these studies had cold ischemia time (CIT) <24 h.…”

Frequency and outcomes of kidney donation from intensive care patients with acute renal failure requiring renal replacement therapy

“…This is possibly due to selection bias as only the ‘best’ donor kidneys with very severe AKI were utilized. A more recent publication by Hall provided 3 years recipient outcome data from a large cohort of AKI donors and found no difference in graft survival according to AKI stage, although no donors received RRT . Excellent short‐term graft outcomes were reported in a single centre study which included donors with severe AKI requiring RRT …”