Equivalent Long-term Transplantation Outcomes for Kidneys Donated After Brain Death and Cardiac Death: Conclusions From a Nationwide Evaluation

Abstract

Background: Despite growing waiting lists for renal transplants, hesitations persist with regard to the use of deceased after cardiac death (DCD) renal grafts. We evaluated the outcomes of DCD donations in The Netherlands, the country with the highest proportion of DCD procedures (42.9%) to test whether these hesitations are justified.

Methods: This study included all procedures with grafts donated after brain death (DBD) (n = 3611) and cardiac death (n = 2711) performed between 2000 and 2017. Transplant outcomes were compared by Kaplan Meier and Cox regression analysis, and factors associated with short (within 90 days of transplantation) and long-term graft loss evaluated in multi-variable analyses.

Findings: Despite higher incidences of early graft loss (+ 50%) and delayed graft function (+ 250%) in DCD grafts, 10-year graft and recipient survival were similar for the two graft types (Combined 10-year graft survival: 73.9% (95% CI: 72.5-75.2), combined recipient survival: 64.5% (95 CI: 63.0-66.0%)). Long-term outcome equivalence was explained by a reduced impact of delayed graft function on DCD graft survival (RR: 0.69 (95% CI: 0.55-0.87), p < 0.001). Mid and long-term graft function (eGFR), and the impact of incident delayed graft function on eGFR were similar for DBD and DCD grafts.

Interpretation: Mid and long term outcomes for DCD grafts are equivalent to DBD kidneys. Poorer short term outcomes are offset by a lesser impact of delayed graft function on DCD graft survival. This nation-wide evaluation does not justify the reluctance to use of DCD renal grafts. A strong focus on short-term outcome neglects the superior recovery potential of DCD grafts.

Keywords: Delayed graft function; Donation after brain death; Donation after cardiac death; Graft survival; Kidney transplantation; Outcome.

Fig. 1

A. Recipient death censored 10-year graft survival of DBD (blue) and DCD (red) grafts transplanted in the Netherlands; HR (DBD reference): 1.07 (95% CI: 0.96–1.20); p = 0.22. Schoenfeld residuals the proportional hazard assumption after fitting the model: p: 0.88. B. 10-year recipient survival for recipients of a DBD (blue) or DCD (red) graft; HR (DBD reference): 1.03 (0.93–1.14); p = 0.56.

Fig. 2

Differential impacts of delayed graft function on recipient death censored graft survival of DBD and DCD grafts (grafts with primary non function are excluded). HR for graft loss after delayed graft function in DCD grafts (DBD reference): 0.69 (95% CI: 0.55–0.87); P = 0.001.