Equivalent Long-term Transplantation Outcomes for Kidneys Donated After Brain Death and Cardiac Death: Conclusions From a Nationwide Evaluation

Abstract

Background Despite growing waiting lists for renal transplants, hesitations persist with regard to the use of deceased after cardiac death (DCD) renal grafts. We evaluated the outcomes of DCD donations in The Netherlands, the country with the highest proportion of DCD procedures (42.9%) to test whether these hesitations are justified. Methods This study included all procedures with grafts donated after brain death (DBD) (n = 3611) and cardiac death (n = 2711) performed between 2000 and 2017. Transplant outcomes were compared by Kaplan Meier and Cox regression analysis, and factors associated with short (within 90 days of transplantation) and long-term graft loss evaluated in multi-variable analyses. Findings Despite higher incidences of early graft loss (+ 50%) and delayed graft function (+ 250%) in DCD grafts, 10-year graft and recipient survival were similar for the two graft types (Combined 10-year graft survival: 73.9% (95% CI: 72.5–75.2), combined recipient survival: 64.5% (95 CI: 63.0–66.0%)). Long-term outcome equivalence was explained by a reduced impact of delayed graft function on DCD graft survival (RR: 0.69 (95% CI: 0.55–0.87), p < 0.001). Mid and long-term graft function (eGFR), and the impact of incident delayed graft function on eGFR were similar for DBD and DCD grafts. Interpretation Mid and long term outcomes for DCD grafts are equivalent to DBD kidneys. Poorer short term outcomes are offset by a lesser impact of delayed graft function on DCD graft survival. This nation-wide evaluation does not justify the reluctance to use of DCD renal grafts. A strong focus on short-term outcome neglects the superior recovery potential of DCD grafts.

Results of an explorative clinical evaluation suggest immediate and persistent post-reperfusion metabolic paralysis drives kidney ischemia reperfusion injury

“…Importantly, 10-year transplantation outcomes for the Netherlands are at least equal to countries with younger donors, such as the United States. 37 As expected the majority of þDGF cases were DCD grafts. We noticed similar metabolic profiles for DBD and DCD grafts; however, the power of this explorative study is obviously too low to detect subtle differences between these 2 donor types.…”

Improved National Results With Simultaneous Liver‐Kidney Transplantation Using Donation After Circulatory Death Donors

“…In addition, no difference in median recipient creatinine at last follow‐up (1.2 mg/dL) was seen between the 2 groups. Previous studies have shown similar longterm outcomes between kidney transplantation alone from DCD and DBD donors . Despite similar longterm outcomes, a higher rate of delayed graft function (DGF) has been well documented when kidney grafts from DCD donors are used compared with those from DBD donors.…”

“…Previous studies have shown similar longterm outcomes between kidney transplantation alone from DCD and DBD donors. (16,17) Despite similar longterm outcomes, a higher rate of delayed graft function (DGF) has been well documented when kidney grafts from DCD donors are used compared with those from DBD donors. The 2 single-center studies investigating DCD-SLKT contained data on post-SLKT DGF.…”

Delayed Graft Function and Acute Rejection in Kidney Transplant Patients with Positive Panel-Reactive Antibody and Negative Donor-Specific Antibodies

“…Optimal induction interventions should be able to repair renal structural damage while inhibiting the immune response (7)(8)(9)(10)(11). There are some studies about DGF, acute rejection, and graft loss in donation after cardiac death and brain death; however, studies on living donation are limited (12)(13)(14). In this study, we focused on the association between DGF and acute rejection in patients who received kidneys from living donors with positive PRA and negative DSA.…”