Kidney nonprocurement in deceased donors with acute kidney injury

Abstract

Background: Acute kidney injury (AKI) is common in deceased organ donors and is associated with high rates of kidney discard by transplant centers. High discard rates may consequently drive nonprocurement of these kidneys by organ procurement organizations. We aimed to study the relationship between donor AKI and kidney nonprocurement.Methods: Using U.S. registry data, we identified donors with at least one organ recovered from 2008 to 2018. We compared characteristics of donors with no kidneys procured across AKI stages, and used multivariable logistic regression to evaluate the relationship between AKI severity and kidney nonprocurement.Results: Overall 14 543 kidneys from 7620 donors were not procured, among which 93% were from donors with AKI. For 6945 donors with no kidneys procured but an extrarenal organ recovered, most had stage 3 (51%), followed by stage 1 (27%) and stage 2 AKI (15%). Nonprocured stage 3 donors were the youngest and had the lowest Kidney Donor Risk Index of all nonprocured donors. Adjusted odds of kidney nonprocurement were 1.14 (95%CI 1.02-1.27) for stage 1, 1.25 (95%CI 1.12-1.41) for stage 2, and 10.37 (95%CI 9.30-11.56) for stage 3 donors, compared to non-AKI donors.Among donors with minimum creatinine <1.5 mg/dl, stage 2 and 3 AKI were still associated with significantly higher odds of nonprocurement.Conclusions: AKI severity is a strong risk factor for kidney nonprocurement. Efforts to address the organ shortage should focus on encouraging procurement and utilization of kidneys from deceased donors with severe AKI, given the large and rising prevalence of donor AKI and excellent transplant outcomes with these kidneys.

Kidney Transplant Outcomes From Deceased Donors Who Received Dialysis

“…However, recent evidence suggests that transplanting kidneys from certain deceased donors with AKI (determined either by sensitive markers of tubular injury or by clinical AKI) is associated with similar risk of graft failure compared with transplanting kidneys from deceased donors without AKI . Therefore, careful selection of kidneys from deceased donors with AKI may improve the number of available kidneys and access to kidney transplant …”

“…[4][5][6] Therefore, careful selection of kidneys from deceased donors with AKI may improve the number of available kidneys and access to kidney transplant. [6][7][8] The procurement of kidneys from deceased donors with stage 3 AKI doubled over the past 10 years. 9 However, up to 44% of these kidneys are not transplanted due to concerns that kidneys from these donors may lead to more intense acute tubular injury that is less likely to recover and more likely have inferior longer-term graft outcomes.…”

Age modulates protein-outcome associations in deceased donor kidneys

“…It is likely that molecular analyses could offer a clearer, higher resolution assessment of organ state; but this requires deeper understanding of molecular phenotypes specifically associated with poor outcomes rather than the immediate but potentially recoverable acute injury sustained during the donor management process and organ retrieval. For example, deceased donors are often assessed as having AKI based on serum creatinine levels 14 , which implies an inflammatory response, however AKI does not itself associate with longer term poor outcomes [13][14][15][16] , so we should not expect all inflammatory associated molecular signatures to be outcomeassociated. A broad picture analysis at relevant molecular phenotype levels is necessary; an obvious first candidate is the proteome as this represents the end-state response associated with both changes in expression and post-translational regulation.…”

“…Deceased donors are frequently assessed as having sustained damage (i.e. AKI) based on serum creatinine levels 11 , however this metric poorly associates with longer term outcomes [11][12][13][14] .…”