Kidney transplantation after rescue allocation—meticulous selection yields the chance for excellent outcome

Abstract

Background The small number of organ donors forces transplant centres to consider potentially suboptimal kidneys for transplantation. Eurotransplant established an algorithm for rescue allocation (RA) of kidneys repeatedly declined or not allocated within 5 h after procurement. Data on the outcomes and benefits of RA are scarce to date. Methods We conducted a retrospective 8-year analysis of transplant outcomes of RA offers based on our in-house criteria catalogue for acceptance and decline of organs and potential recipients. Results RA donors and recipients were both older compared with standard allocation (SA). RA donors more frequently had a history of hypertension, diabetes or fulfilled expanded criteria donor key parameters. RA recipients had poorer human leucocyte antigen (HLA) matches and longer cold ischaemia times (CITs). However, waiting time was shorter and delayed graft function, primary non-function and biopsy-proven rejections were comparable to SA. Five-year graft and patient survival after RA were similar to SA. In multivariate models accounting for confounding factors, graft survival and mortality after RA and SA were comparable as well. Conclusions Facing relevant comorbidities and rapid deterioration with the risk of being removed from the waiting list, kidney transplantation after RA was identified to allow for earlier transplantation with excellent outcome. Data from this survey propose not to reject categorically organs from multimorbid donors with older age and a history of hypertension or diabetes to aim for the best possible HLA matching and to carefully calculate overall expected CIT.

Kidney Transplantation After Rescue Allocation—the Eurotransplant Experience: A Retrospective Multicenter Outcome Analysis

“…Considering this, transplant physicians obviously tended toward accepting RA offers, condoning increased donor age, prolonged CITs, and unfavorable HLA matching, just to escape this dilemma and shorten waiting time (Table 1). Despite the evidentially negative, though reasonable, compromises, PNF turned out to be comparable between RA and SA as previously reported, 8 which additionally encourages acceptance of RA offers. The question is whether a recommendation should be made for RA kidneys to be considered for more candidates apart from older patients and those with comorbidities, frailty, and an increased risk of delisting or higher risk of mortality after transplant.…”

“…Although both ETKAS- and ESP-listed recipients profited from DDRT of RA grafts, we recommend to adhere to certain basic donor- and transplant-specific parameters such as careful consideration of proteinuria, hypertension, and diabetes of the donor and a limited donor–recipient age difference like previously recommended. 8 In CCOs for younger recipients, a patient with a favorable HLA match should be preferred over a candidate with an unfavorable match and even despite a potentially prolonged CIT in case of a young donor to further increase the outcome according to our data.…”

“…2 This survey confirmed worse HLA matches and inferior HLA favorability of RA DDRTs of recipients listed within the ETKAS program (Table 2). 8,30 Furthermore, less advantageous CMV-constellations were just recently identified in a single-center study. 8 Taking this into account, preferring a recipient with a more favorable match in CCOs in future and assumingly better HLA matches in REAL versus CCO might even have an additional positive impact on outcome (Table 4B).…”

“…Kidneys transplanted after rescue allocation have been reported to originate from older donors with a higher rate of diabetes, hypertension, fulfilled ECD criteria, 6,8 and both increased acute and chronic histopathological changes were observed in zero-time biopsies from RA kidneys. 8 DDRTs after RA were characterized by a prolonged CIT, worse HLA matching, and increased cytomegalovirus (CMV) transmission risk, but a reduced waiting time, 8 which was validated by this study.…”

“…We therefore performed this comprehensive long-term ET multicenter study to resolve the question of RA DDRT outcome, thus far only addressed in single-center reports. 8,30,31…”