The Benefits of Preemptive Transplantation Using High-Kidney Donor Profile Index Kidneys

Abstract

Background: The Kidney Donor Profile Index (KDPI) is a percentile score summarizing the likelihood of allograft failure: A KDPI ≥85% is associated with shorter allograft survival, and 50% of these donated kidneys are not currently used for transplantation. Preemptive transplantation (transplantation without prior maintenance dialysis) is associated with longer allograft survival than transplantation after dialysis; however, it is unknown whether this benefit extends to high-KDPI transplants. The objective of this analysis was to determine whether the benefit of preemptive transplantation extends to recipients of transplants with a KDPI ≥85%.

Methods: This retrospective cohort study compared the post-transplant outcomes of preemptive and nonpreemptive deceased donor kidney transplants using data from the Scientific Registry of Transplant Recipients. 120,091 patients who received their first, kidney-only transplant between January 1, 2005, and December 31, 2017, were studied, including 23,211 with KDPI ≥85%. Of this cohort, 12,331 patients received a transplant preemptively. Time-to-event models for the outcomes of allograft loss from any cause, death-censored graft loss, and death with a functioning transplant were performed.

Results: Compared with recipients of nonpreemptive transplants with a KDPI of 0%-20% as the reference group, the risk of allograft loss from any cause in recipients of a preemptive transplant with KDPI ≥85% (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.39 to 1.64) was lower than that in recipients of nonpreemptive transplant with a KDPI ≥85% (HR, 2.39; 95% CI, 2.21 to 2.58) and similar to that of recipients of a nonpreemptive transplant with a KDPI of 51%-84% (HR, 1.61; 95% CI, 1.52 to 1.70).

Conclusions: Preemptive transplantation is associated with a lower risk of allograft failure, irrespective of KDPI, and preemptive transplants with KDPI ≥85% have comparable outcomes with nonpreemptive transplants with KDPI 51%-84%.

Graphical abstract

Figure 1

Study cohort. KDPI, Kidney Donor Profile Index; SRTR, Scientific Registry of Transplant Recipients.

Figure 2

Impact of preemptive transplantation on graft loss from all causes, including death, stratified by donor KDPI. Kaplan–Meier curves of graft loss from all causes, including death, in recipients receiving kidneys with KDPI 0%–20% (A), KDPI 21%–50% (B), KDPI 51%–84% (C), and KDPI ≥85% (D) after deceased donor transplantation, stratified by preemptive transplantation (solid line) and nonpreemptive transplantation (dashed line). The P values represent the statistical significance of the log-rank test for each analysis.

Figure 3

Impact of preemptive transplantation in mate kidney cohort on graft loss from all causes, stratified by KDPI. Kaplan–Meier curves of graft loss from all causes, including death, by KDPI group: KDPI 0%–20% (A), KDPI 21%–50% (B), KDPI 51%–84% (C), and KDPI ≥85% (D) among mate kidney transplants in which one kidney was transplanted preemptively (solid line) and another kidney transplanted after treatment with maintenance dialysis (dashed line). The P values represent the statistical significance of the log-rank test (A–D) for each analysis.

Figure 4

Unadjusted incidence rate of preemptive transplantation between 2005 and 2017, overall and stratified by donor KDPI (0–84%, ≥85%). The vertical dashed line represents the implementation of the new kidney allocation system in 2014.

Figure 5

Association of delayed graft function (DGF) on post-transplant outcomes in recipients transplanted preemptively and nonpreemptively. Kaplan–Meier curves of graft loss from all causes, including death (A), and death-censored graft loss (B) in recipients receiving transplants preemptively and nonpreemptively, stratified by the occurrence of postoperative DGF. The P values represent the statistical significance of the log-rank test for each analysis.