Impact of Donor Age on Clinical Outcomes of Primary Single Kidney Transplantation From Maastricht Category-III Donors After Circulatory Death

Abstract

BackgroundStandard-criteria donation after circulatory death (DCD) kidney transplants (KTx) have higher primary nonfunction, delayed graft function (DGF), and rejection rates than age-matched donation after brain death (DBD) but similar graft survival. Data on expanded-criteria DCD are conflicting and many centers remain concerned regarding their use.MethodsIn this single-center observational study with 5-year follow-up, we analyzed data from 112 primary DCD Maastricht category-III single KTx receiving similar organ preservation and maintenance immunosuppression. Patients were sorted as young DCD (donor <60 years, 72 recipients) or old DCD (donor ≥60 years, 40 recipients). Old DCD outcomes were compared with young DCD and to a DBD control group (old DBD, donor ≥60 years, 40 recipients).ResultsAfter 5 years, old DCD showed lower patient survival (66% vs 85%; P = 0.014), death-censored graft survival (63% vs 83%; P = 0.001), and Modification of Diet in Renal Disease estimated glomerular filtration rate (34, 27.0-42.0 mL/min per 1.73 m2 vs 45.0, 33.0-58.0 mL/min per 1.73 m2; P = 0.021) than young DCD with higher DGF (70% vs 47.2%; P = 0.029) and graft thrombosis (12.5% vs 1.4%; P = 0.021). Comparison between old DCD and old DBD showed similar 5-year patient survival (66% vs 67%; P = 0.394) and death-censored graft survival (63% vs 69%; P = 0.518) but higher DGF (70% vs 37.5%; P = 0.007) and lower estimated glomerular filtration rate (34, 27.0-42.0 mL/min per 1.73 m2 vs 41, 40.0-42.0 mL/min per 1.73 m2; P = 0.029). Multivariate Cox regression analysis showed that donor 60 years or older (hazard ratio, 3.135; 95% confidence interval, 1.716-5.729; P < 0.001) and induction with anti–IL2-receptor-α monoclonal antibody (hazard ratio, 0.503; 95% confidence interval, 0.269-0.940, P = 0.031 in favor of induction with rabbit antithymocyte globulin) are independent predictors of transplant loss.ConclusionsOverall, single KTx from DCD Maastricht category-III donors 60 years or older have inferior outcomes than KTx from donors younger than 60 years. Comparison with age-matched DBD showed similar patient and graft survivals. However, the discrepancy in graft function between DCD and DBD deserves further investigation.

Kidney transplantation outcomes from elderly donors after circulatory death: a comparison with elderly brain-dead donors

“…Overall, ECD–DCDs have shown poorer patient and graft outcomes compared with SCD–DCDs, but not inferior to ECD–DBDs [ 6 , 17 , 29–31 , 34 ]. The 3-year death-censored graft survival for ECD–DCD kidneys is 70–90% [ 6 , 30 , 31 , 35 ]. In our study, elderly cDCD kidneys showed good medium-term graft survival (88%), comparable to that from young cDCD and elderly DBD kidneys (90 and 80%, respectively).…”

Survival benefit of accepting kidneys from older donation after cardiac death donors

“…Recent studies have shown that recipients of older DCD kidneys had inferior outcomes compared to those of young DCD or older donation after brain death (DBD) kidneys. DCD donor kidneys from older donors were more likely to have delayed graft function and lower estimated GFR (eGFRs) at 1‐year posttransplant compared to recipients of young DCD 9‐11 and older DBD kidneys 6,10‐13 . Recipients of older DCD kidneys had worse graft and patient survival 5‐years posttransplant compared to those of young DCD kidneys 11,14 .…”

“…However, many of these studies were single‐center or national registry studies from other countries, which may have limited generalizability to US populations. Furthermore, patients evaluating an older DCD kidney offer are not choosing between an older DCD kidney and a healthier kidney; instead, they are choosing between accepting the current offer or waiting for a better offer that may never come 6,9‐13 . Studies on extended criteria deceased donor transplants have also identified recipient characteristics such as age, race, and time on dialysis as independent risk factors for inferior graft survival 15 and delayed graft function 16 .…”

Adipose-Derived Stem/Stromal Cells in Kidney Transplantation: Status Quo and Future Perspectives

“…As such, an increasing number of so-called marginal kidneys are now being transplanted into high-risk recipients. The main consequence of this aggressive policy is a striking rise in the incidence of delayed graft function (DGF) [ 1 , 2 , 3 ]. Clinically defined as the need for dialysis during the first post-transplant week, DGF is a complex entity that can negatively affect both patient and allograft survival [ 4 ].…”

“…Lymphodepleting agents such as polyclonal rabbit anti-thymocyte globulin (rATG) or alemtuzumab (a monoclonal antibody targeting CD52) have been increasingly used in ECD and DCD KT to reduce the risk of rejection associated with IRI and minimize calcineurin inhibitor (CNI) exposure. Current data demonstrate excellent results in term of early acute rejection rates and successful CNI sparing, but the overall impact on DGF and long-term transplant survival remain marginal [ 2 , 3 , 28 , 29 ]. Peri-operative administration of complement inhibitors represent another feasible option as the complement system plays a key role in IRI, antigen presentation, and allograft rejection [ 6 ].…”