Impact of acute kidney injury in elderly versus young deceased donors on post-transplant outcomes: A multicenter cohort study

Abstract

We investigated the impact of acute kidney injury (AKi) in elderly deceased-donors (DDs) vs. AKi in young DDs on post-transplant clinical outcomes. A total of 709 kidney transplant recipients (KTRs) from 602 DDs at four transplant centers were enrolled. KTRs were divided into young-DDKT and elderly-DDKT groups according to the age of DD of 60 years. Both groups were subdivided into non-AKI-KT and AKI-KT subgroups according to AKI in DDs. We investigated short-term and long-term clinical outcomes of non-AKI-DDKT and AKI-DDKT subgroups within young-DDKT and elderly-DDKT groups. The incidence of DGF in the AKI-DDKT subgroup was higher and the allograft function within 12 months after KT in the AKI-DDKT subgroup was lower than those in the non-AKI-DDKT subgroup in both young-DDKT and elderly-DDKT groups. Death-censored allograft survival rate was significantly lower in the AKI-elderly-DDKT subgroup than that in the non-AKI-elderly-DDKT subgroup, but it did not differ between AKI-young-DDKT and non-AKI-young-DDKT subgroup. In multivariable analysis, AKI-elderly-DDKT was an independent risk factor for allograft failure (hazard ratio: 2.648, 95% CI: 1.170-5.994, p = 0.019) and a significant interaction between AKI and old age in DDs on allograft failure was observed (p = 0.001). AKI in elderly DDs, but not in young DDs, can significantly affect long-term allograft outcomes of KtRs. With a tremendous increase in the number of patients with end-stage renal disease, donor shortage in kidney transplantation (KT) has become a worldwide crucial issue to solve 1-3. In this regard, the use of kidneys from elderly deceased donors (DDs) has been proposed as an important strategy for solving this donor shortage 4-7. It has been reported that the proportion of elderly brain death patients was higher than that of younger brain death patients and that KT from elderly DDs could give survival benefit in comparison with those remaining on dialysis 8. In addition, in contrast to living donor KT, kidney donation from elderly DD is fully free from donor safety issue. These reasons justify the use of kidney from elderly DDs.

Impact of acute kidney injury in deceased donors with high Kidney Donor Profile Index on posttransplant clinical outcomes: a multicenter cohort study

“…Our previous study reported that the allograft outcome was poor when ECD was accompanied by AKI [18]. Our other study also reported that the elderly donor had a poor allograft outcome when accompanied by AKI [28]. In other words, the poor kidney state of the DDs prior to KT can have a synergistic effect when this situation is accompanied by AKI.…”

“…On the contrary, another research reported that the poor kidney state of the DDs prior to KT can cause persistent low graft function after KT [ 38 ]. In our previous study, there was no difference in the allograft function among KTs from DDs with a stable kidney state, but KT from DDs with a poor kidney state such as elderly DDs or high KDPI DDs showed persistent low allograft function after KT [ 19 , 28 ]. In our study, the high KDPI-KTR group showed significantly lower allograft function compared with the low KDPI-KTR group.…”

“…We demonstrated that the presence of AKI in ECDs significantly impacted the long-term allograft outcomes of KTRs [ 18 ]. Furthermore, we also demonstrated that AKI in elderly DDs can significantly affect long-term allograft outcomes of KTRs [ 28 ]. In other words, when the underlying kidney status of the donor was bad, the prognosis was poor when AKI occurred.…”

Outcome of kidney transplantations from ≥65‐year‐old deceased donors with acute kidney injury

“…They mostly also indicated a higher incidence of DGF but no negative effect on long-term graft function and survival when kidneys from ECDs with AKI were compared to no-AKI ECD kidneys. 19,21,25,[27][28][29][30] However, the term ECD was introduced as early considered to be even more high-risk than "traditional" ECDs, for example, donors that are ≥65-yearsold and/or have a variety of cardiovascular comorbidities such as diabetes or arterial hypertension.…”

“…Less studies have been performed on the impact of AKI in expanded criteria donors (ECDs). They mostly also indicated a higher incidence of DGF but no negative effect on long‐term graft function and survival when kidneys from ECDs with AKI were compared to no‐AKI ECD kidneys 19,21,25,27–30 . However, the term ECD was introduced as early as 2003 comprising donors that are either aged 60 years or older at time of death or aged 50–59 years with two of the following three criteria (a) history of hypertension; (b) serum creatinine >1.5 mg/dl; or (c) death by cardiovascular accident.…”