Retrospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Aug 9, 2018; 8(4): 102-109
Published online Aug 9, 2018. doi: 10.5500/wjt.v8.i4.102
Kidney transplantation in older recipients: Preemptive high KDPI kidney vs lower KDPI kidney after varying dialysis vintage
Bhavna Chopra, Kalathil K Sureshkumar
Bhavna Chopra, Kalathil K Sureshkumar, Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
Author contributions: Chopra B participated in literature search, data analysis and manuscript writing; Sureshkumar KK participated in literature search, data analysis and manuscript writing.
Institutional review board statement: The IRB has received this information and finds it qualifies for exempt status according to the following category in the code of regulations: 45 CFR 46.101 (b) Category (4) and with a “Waiver of HIPAA Authorization”.
Informed consent statement: Since the data set is de-identified, IRB exempted the study from requiring informed consent.
Conflict-of-interest statement: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Kalathil K Sureshkumar, MD, Associate Professor, Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA 15212, United States. kalathil.sureshkumar@ahn.org
Telephone: +1-412-3593319 Fax: +1-412-3594136
Received: April 10, 2018
Peer-review started: April 11, 2018
First decision: May 3, 2018
Revised: May 21, 2018
Accepted: May 30, 2018
Article in press: May 31, 2018
Published online: August 9, 2018
Processing time: 120 Days and 13.4 Hours
Abstract
AIM

To evaluate the outcomes of transplanting marginal kidneys preemptively compared to better-quality kidneys after varying dialysis vintage in older recipients.

METHODS

Using OPTN/United Network for Organ Sharing database from 2001-2015, we identified deceased donor kidney (DDK) transplant recipients > 60 years of age who either underwent preemptive transplantation of kidneys with kidney donor profile index (KDPI) ≥ 85% (marginal kidneys) or received kidneys with KDPI of 35%-84% (better quality kidneys that older wait-listed patients would likely receive if waited longer) after being on dialysis for either 1-4 or 4-8 years. Using a multivariate Cox model adjusting for donor, recipient and transplant related factors- overall and death-censored graft failure risks along with patient death risk of preemptive transplant recipients were compared to transplant recipients in the 1-4 and 4-8 year dialysis vintage groups.

RESUTLS

The median follow up for the whole group was 37 mo (interquartile range of 57 mo). A total of 6110 DDK transplant recipients above the age of 60 years identified during the study period were found to be eligible to be included in the analysis. Among these patients 350 received preemptive transplantation of kidneys with KDPI ≥ 85. The remaining patients underwent transplantation of better quality kidneys with KDPI 35-84% after being on maintenance dialysis for either 1-4 years (n = 3300) or 4-8 years (n = 2460). Adjusted overall graft failure risk and death-censored graft failure risk in preemptive high KDPI kidney recipients were similar when compared to group that received lower KDPI kidney after being on maintenance dialysis for either 1-4 years (HR 1.01, 95%CI: 0.90-1.14, P = 0.84 and HR 0.96, 95%CI: 0.79-1.16, P = 0.66 respectively) or 4-8 years (HR 0.82, 95%CI: 0.63-1.07, P = 0.15 and HR 0.81, 95%CI: 0.52-1.25, P = 0.33 respectively). Adjusted patient death risk in preemptive high KDPI kidney recipients were similar when compared to groups that received lower KDPI kidney after being on maintenance dialysis for 1-4 years (HR 0.99, 95%CI: 0.87-1.12, P = 0.89) but lower compared to patients who were on dialysis for 4-8 years (HR 0.74, 95%CI: 0.56-0.98, P = 0.037).

CONCLUSION

In summary, our study supports accepting a “marginal” quality high KDPI kidney preemptively in older wait-listed patients thus avoiding dialysis exposure.

Keywords: Preemptive kidney transplantation; Kidney donor profile index; Dialysis vintage; Kidney transplant outcomes; Older recipients; Waiting list

Core tip: Increasing waiting-time for deceased donor kidney (DDK) transplantation adversely impacts older patients disproportionately. Dialysis vintage and transplantation of “marginal kidneys” are associated with inferior post-transplant outcomes. Using OPTN/United Network for Organ Sharing database from 2001-2015, we compared the outcomes of preemptive transplantation of marginal [kidney donor profile index (KDPI) ≥ 85%] DDKs compared to transplanting better quality DDKs (KDPI 35%-84%) after being on dialysis for 1-4 and 4-8 years in patient > 60 years old. Preemptive transplantation of marginal kidneys provided non-inferior graft and patient outcomes compared to transplanting better quality kidneys in older patients on maintenance dialysis. Early transplantation could also provide quality of life and cost benefits.