Survival Benefit in Older Patients Associated With Earlier Transplant With High KDPI Kidneys

Abstract

Background Given high dialysis mortality rates for patients >60 years old, accepting a kidney with a high kidney donor profile index (KDPI) score could enable earlier and potentially preemptive transplantation (preKT). However, evidence regarding the risks of high KDPI allografts in older patients is limited. Our objective was to determine the relative benefit for older patients of KDPI>85% transplant either preemptively or not compared with remaining on the waitlist. Methods UNOS data from 2003–2012 for adult deceased donor kidney transplant candidates was analyzed to evaluate patient survival in patients >60 years old for preKT and non-preKT KDPI>85% transplants compared to candidates remaining on the waitlist including patients who received KDPI 0–85% transplants according to multivariate Cox regression models. Results In the first year posttransplant for KDPI>85% recipients >60 years old, preKT had a reduced mortality hazard (HR=0.61, 95%CI=0.41–0.90) and non-preKT an increased mortality hazard (HR= 1.15, 95%CI=1.03–1.27) compared with the waitlist including KDPI 0–85% transplant recipients. At 1–2 years and after 2 years, both KDPI >85% groups had significant reductions in mortality (1–2 yrs: preKT HR= 0.38, 95%CI=0.23–0.60 and non-preKT HR= 0.52, 95%CI=0.45–0.61; and 2+ yrs: preKT HR= 0.50, 95%CI=0.38–0.66 and non-preKT HR= 0.64, 95%CI=0.58–0.70, respectively). Conclusions PreKT and non-preKT KDPI>85% transplant was associated with lower mortality hazard after the first year compared with the waitlist including KDPI 0–85% transplants in patients >60 years old. Further consideration should be given to increased utilization of high KDPI grafts in older patients with the goal of avoiding or limiting time on dialysis.

Warm ischemic time as a critical risk factor of graft failure from donors after cardiac death: A single‐center experience over three decades in the Kidney Donor Profile Index/Kidney Donor Risk Index era in Japan

“…Currently, >60% of such grafts with a high KDPI (>85%) are discarded, representing approximately 3000 kidneys annually in the USA . Transplantation of grafts with a KDPI >85% was reported to be an acceptable option for older patients compared with remaining on the waiting list . In Japan, the number of deceased‐donor renal transplantations is extremely small .…”

“…24 Transplantation of grafts with a KDPI >85% was reported to be an acceptable option for older patients compared with remaining on the waiting list. 25 In Japan, the number of deceased-donor renal transplantations is extremely small. 26 Determining the best way to increase the number of deceased-donor renal allografts and maintaining the vitality of renal allografts recovered from DCD donors thus remains an important issue for renal transplant surgeons in Japan.…”

Measuring Transplant Center Performance: the Goals Are Not Controversial but the Methods and Consequences Can Be

“…[23] Furthermore, multiple studies have documented the survival benefit associated with high KDPI transplant compared with waitlist mortality including those who go on to undergo low KDPI transplant. [24, 25] Interestingly, donor acceptance patterns are also undoubtedly highly influenced by fiscal realities. Schold et al demonstrated even greater reductions in living donor kidney transplants (LDKT) compared with ECD transplants in centers with LP evaluations as highlighted in Figure 2.…”

Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk?

“…Additionally, two recent observational studies have shown that utilization of kidneys with a high Kidney Donor Profile Index (>85%) or deceased diabetic donor kidneys also provides a higher survival in older recipients compared with waitlisted patients [64, 65]. However, an elegant Dutch observational study performed in elderly KT patients receiving deceased-donor grafts from elderly donors (≥65 years) demonstrated an increased mortality risk compared with waitlisted elderly patients remaining on dialysis [66].…”