Shipping living donor kidneys and transplant recipient outcomes

Abstract

Kidney paired donation (KPD) is an important tool to facilitate living donor kidney transplantation (LDKT). Concerns remain over prolonged cold ischemia times (CIT) associated with shipping kidneys long distances through KPD. We examined the association between CIT and delayed graft function (DGF), allograft survival, and patient survival for 1267 shipped and 205 nonshipped/internal KPD LDKTs facilitated by the National Kidney Registry in the United States from 2008 to 2015, compared to 4800 unrelated, nonshipped, non-KPD LDKTs. Shipped KPD recipients had a median CIT of 9.3 hours (range = 0.25-23.9 hours), compared to 1.0 hour for internal KPD transplants and 0.93 hours for non-KPD LDKTs. Each hour of CIT was associated with a 5% increased odds of DGF (adjusted odds ratio: 1.05, 95% confidence interval [CI], 1.02-1.09, P < .01). However, there was not a significant association between CIT and all-cause graft failure (adjusted hazard ratio [aHR]: 1.01, 95% CI: 0.98-1.04, P = .4), death-censored graft failure ( [aHR]: 1.02, 95% CI, 0.98-1.06, P = .4), or mortality (aHR 1.00, 95% CI, 0.96-1.04, P > .9). This study of KPD-facilitated LDKTs found no evidence that long CIT is a concern for reduced graft or patient survival. Studies with longer follow-up are needed to refine our understanding of the safety of shipping donor kidneys through KPD.

The first 9 years of kidney paired donation through the National Kidney Registry: Characteristics of donors and recipients compared with National Live Donor Transplant Registries

“…When KPD exchanges produce compatible transplants, excellent results have been reported in both the US and other parts of the world [7, 20–23]. In addition, as recently reported in depth, the shipping of kidneys during paired exchange has not been associated with inferior transplant outcomes [24]. Although the number with primary non-function, 0.34% was low, the numbers with first week dialysis 4.9% is higher than in-center exchanges.…”

“…7,[21][22][23][24] In addition, as recently reported in depth, the shipping of kidneys during paired exchange has not been associated with inferior transplant outcomes. 25 Although the number with primary nonfunction (0.34%) was low, the number with first week dialysis (4.9%) is higher than in-center exchanges.…”

Early graft losses in paired kidney exchange: Experience from 10 years of the National Kidney Registry

“…Participation in national exchange programs challenges this preference. Medium‐ and long‐term graft survival for these transplants are high, which is expected of living donor kidney transplantation (LDKT) even in the context of longer KPD cold ischemic times . However, scarce data exist on primary nonfunction (PNF, or loss within 30 days of transplant), other early graft failures, and surgical complications that may continue to cause a reluctance by many transplant centers to enter larger multicenter, diverse geographical KPD systems.…”

“…In the beginning, there was great trepidation about the negative impact of longer cold ischemic times imposed by shipping, especially for highly sensitized and retransplanted patients . However, reports that demonstrated a slight increase in delayed graft function (DGF) but no impact on graft or patient survival encouraged wider sharing and allowed for cold ischemia times that exceed 20 hours . These reports focus on long‐term outcomes, but little has been reported on the occurrences of graft failures within days or months of transplantation.…”

The risk of graft loss 5 years after kidney transplantation is increased if cold ischemia time exceeds 14 hours

“…Prolonged CIT increases the risk of delayed graft function (DGF) or primary nonfunction (PNF) of the transplant, mainly due to ischemic acute tubular necrosis . This correlation between the duration of cold ischemia and the incidence of DGF is the main reason why this condition is rare after renal transplantation using living donors (LDs), in which the time between recovery of the organ and reperfusion is kept to a minimum …”