Use and Outcomes of Kidneys from Donation after Circulatory Death Donors in the United States

Abstract

Donation after circulatory death (DCD) donors are an important source of kidneys for transplantation, but DCD donor transplantation is less common in the United States than in other countries. In this study of national data obtained between 2008 and 2015, recovery of DCD kidneys varied substantially among the country's 58 donor service areas, and 25% of DCD kidneys were recovered in only four donor service areas. Overall, 20% of recovered DCD kidneys were discarded, varying from 3% to 33% among donor service areas. Compared with kidneys from neurologically brain dead (NBD) donors, DCD kidneys had a higher adjusted odds ratio of discard that varied from 1.25 (95% confidence interval [95% CI], 1.16 to 1.34) in kidneys with total donor warm ischemic time (WIT) of 10-26 minutes to 2.67 (95% CI, 2.34 to 3.04) in kidneys with total donor WIT >48 minutes. Among the 12,831 DCD kidneys transplanted, kidneys with WIT≤48 minutes had survival similar to that of NBD kidneys. DCD kidneys with WIT>48 minutes had a higher risk of allograft failure (hazard ratio, 1.23; 95% CI, 1.07 to 1.41), but this risk was limited to kidneys with cold ischemia time (CIT) >12 hours. We conclude that donor service area-level variation in the recovery and discard of DCD kidneys is large. Additional national data collection is needed to understand the potential to increase DCD donor transplantation in the United States. Strategies to minimize cold ischemic injury may safely allow increased use of DCD kidneys with WIT>48 minutes.

Keywords: Epidemiology and outcomes; cadaver organ transplantation; transplant outcomes.

Graphical abstract

Figure 1.

The controlled DCD procedure showing metrics of ischemic injury, including (1) total donor WIT calculated from the time of WLST to the initiation of cold perfusion, (2) functional WIT defined from onset of sustained hypotension and hypoxia to initiation of perfusion, (3) time to death defined from WLST to declaration of death, and (4) agonal phase defined from onset of sustained hypotension and hypoxia to cessation of circulation. The no touch period is typically of 5 minutes in duration.

Figure 2.

Variation in the proportion of DCD kidneys. The proportion of kidneys recovered from DCD donors varied from 1% to 32% (median =13%; quartile 1, quartile 3 =8, 19) between the 57 DSAs that recovered at least one DCD kidney during the study period.

Figure 3.

The proportion of DCD donor kidneys discarded was correlated with the proportion of NBD donor kidneys discarded within DSAs (Pearson correlation coefficient =0.66; P=0.001). DSAs in which the proportion of DCD kidneys discarded was greater than the proportion of NBD kidneys discarded are denoted by black circles.

Figure 4.

DCD kidneys with total donor WIT >27 minutes had a higher adjusted odds of discard compared with NBD donor kidneys when the Kidney Donor Profile Index (KDPI) ≥ 26%.

Figure 5.

The incidence of all cause graft failure, and death with a functioning graft was higher in patients who received a DCD donor transplant with total donor warm ischemic time of 34–48 and > 48 minutes. Cumulative incidence curves including 76,826 NBD kidney transplant recipients. The numbers of DCD recipients in subgroups with total WIT 10–26, 27–34, 34–48, and >48 minutes were 6555, 3160, 1680, and 1044, respectively.