Single-center experience with acute kidney injury deceased donor kidneys from marginal donors
Alejandra Mena-Gutierrez2, Berjesh Sharda1, Matthew Garner1, Alan Farney1, Giuseppe Orlando1, Colleen Jay1, Amber Reeves-Daniel2, Natalia Sakhovskaya2, Robert Stratta1.
1Department of Surgey, Section of Transplantation, Atrium Health Wake Forest Baptist, Winston Salem, NC, United States; 2Department on Internal Medicine, Section of Nephrology, Atrium Health Wake Forest Baptist, Winston Salem, NC, United States
Introduction: Many centers will selectively transplant kidneys from standard criteria donors (SCD) with terminal acute kidney injury (AKI). However, there is limited experience with transplanting kidneys either from expanded criteria donors (ECD) or donation after cardiac death (DCD) deceased donors (DD) with terminal AKI and many of these organs may be discarded. The study purpose was to review retrospectively our experience with transplanting kidneys from “marginal” AKI DDs (MDDs).
Methods: AKI kidneys were defined by a doubling of the DD's admission serum creatinine (SCr) level and a terminal SCr level >2.0 mg/dl whereas MDD kidneys were defined as DCD or ECDs using UNOS definitions. Dual kidney and multi-organ transplant recipients were excluded. All patients received depleting antibody induction and triple maintenance therapy (FK, MPA, steroids).
Results: From 1/07 to 11/21, we transplanted 236 single AKI DD kidneys including 29 from ECDs/16 DCDs (n=45 MDDs) and 191 from SCDs. When comparing the 2 groups, mean donor age (47 MDD vs 33 years SCD), KDPI (72% MDD vs 45% SCD), and recipient age (59 MDD vs 50 years SCD) were lower in the SCD group. Mean terminal SCr level (2.8 MDD vs 3.2 mg/dl SCD) was higher in the SCD group but cold ischemic times (mean 24.4 hours) were comparable even though 58% of AKI MDD kidneys were imported from other donor service areas. 60% of patients had at least 5 years follow-up in both groups. The incidence of delayed graft function (DGF, dialysis in the first week) was 38% MDD vs 59% SCD (p=0.012) whereas the incidence of primary nonfunction (PNF) was 0 MDD vs 2.1% SCD (p=NS). One-year patient and kidney graft survival rates (GSR) were 98% vs 97% and 93% vs 93% (p=NS) in the MDD vs SCD groups, respectively. Mean 1-year SCr (1.7 MDD vs 1.5 mg/dl SCD) and GFR (43 MDD vs 56 ml/min/1.73 m2 SCD) levels suggested improved renal function with SCD kidneys. With a mean follow-up of 65 months in the MDD group, overall patient and kidney GSRs were 78% vs 75% (p=NS) and 73% vs 59% (p=0.088) in the MDD vs SCD groups, respectively. However, actual 5-year kidney GSRs were 68% MDD vs 75% SCD (p=NS).
Conclusion: In spite of diminished 1-year renal function, the use of kidneys from AKI DDs can be safely liberalized to include selected ECD and DCD donors without incurring a higher risk of DGF, PNF, or intermediate-term graft loss.
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