Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients

Jane J Long¹, Jennifer D Motter², Kyle R Jackson³, Jennifer Chen⁴, Babak J Orandi⁵, Robert A Montgomery², Mark D Stegall¹, Stanley C Jordan⁶, Enrico Benedetti⁷, Ty B Dunn⁸, Lloyd E Ratner⁹, Sandip Kapur¹⁰, Ronald P Pelletier¹¹, John P Roberts¹², Marc L Melcher¹³, Pooja Singh¹⁴, Debra L Sudan¹⁵, Marc P Posner¹⁶, Jose M El-Amm¹⁷, Ron Shapiro¹⁸, Matthew Cooper¹⁹, Jennifer E Verbesey¹⁹, George S Lipkowitz²⁰, Michael A Rees²¹, Christopher L Marsh²², Bashir R Sankari²³, David A Gerber²⁴, Jason R Wellen²⁵, Adel Bozorgzadeh²⁶, A Osama Gaber²⁷, Eliot C Heher²⁸, Francis L Weng²⁹, Arjang Djamali³⁰, J Harold Helderman³¹, Beatrice P Concepcion³¹, Kenneth L Brayman³², Jose Oberholzer³², Tomasz Kozlowski³³, Karina Covarrubias³⁴, Allan B Massie³⁵, Mara A McAdams-DeMarco³⁵, Dorry L Segev³⁶, Jacqueline M Garonzik-Wang³⁷

Affiliations

¹ Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.
² Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA.
³ Department of Surgery, Emory University, Atlanta, Georgia, USA.
⁴ Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
⁵ Department of Surgery, University of Alabama, Birmingham, Alabama, USA.
⁶ Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, California, USA.
⁷ Department of Surgery, University of Illinois-Chicago, Chicago, Illinois, USA.
⁸ Department of Surgery, University of Pennsylvania, Philadelphia, Philadelphia, USA.
⁹ Department of Surgery, Columbia University Medical Center, New York, New York, USA.
¹⁰ Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, New York, USA.
¹¹ Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA.
¹² Department of Surgery, University of California-San Francisco, San Francisco, California, USA.
¹³ Department of Surgery, Stanford University, Palo Alto, California, USA.
¹⁴ Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Philadelphia, USA.
¹⁵ Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
¹⁶ Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA.
¹⁷ Integris Baptist Medical Center, Transplant Division, Oklahoma City, Oklahoma, USA.
¹⁸ Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA.
¹⁹ Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.
²⁰ Department of Surgery, Baystate Medical Center Springfield, Massachusetts, Massachusetts, USA.
²¹ Department of Urology, University of Toledo Medical Center, Toledo, Ohio, USA.
²² Department of Surgery, Scripps Clinic and Green Hospital, La Jolla, California, USA.
²³ Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA.
²⁴ Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
²⁵ Department of Surgery, Barnes-Jewish Hospital, St. Louis, Missouri, USA.
²⁶ Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA.
²⁷ Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA.
²⁸ Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
²⁹ Renal and Pancreas Transplant Division, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA.
³⁰ Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA.
³¹ Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
³² Department of Surgery, University of Virginia, Charlottesville, Virginia, USA.
³³ Department of Surgery, University of Florida, Gainesville, Florida, USA.
³⁴ Department of Surgery, University of California San Diego, San Diego, California, USA.
³⁵ Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.
³⁶ Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA.
³⁷ Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, USA. Electronic address: garonzikwang@wisc.edu.

PMID: 37748554
PMCID: PMC10767749
DOI: 10.1016/j.ajt.2023.09.010

Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients

Jane J Long et al. Am J Transplant. 2023 Dec.

. 2023 Dec;23(12):1980-1989.

doi: 10.1016/j.ajt.2023.09.010. Epub 2023 Sep 23.

Authors

Affiliations

¹ Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.
² Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA.
³ Department of Surgery, Emory University, Atlanta, Georgia, USA.
⁴ Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
⁵ Department of Surgery, University of Alabama, Birmingham, Alabama, USA.
⁶ Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, California, USA.
⁷ Department of Surgery, University of Illinois-Chicago, Chicago, Illinois, USA.
⁸ Department of Surgery, University of Pennsylvania, Philadelphia, Philadelphia, USA.
⁹ Department of Surgery, Columbia University Medical Center, New York, New York, USA.
¹⁰ Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, New York, USA.
¹¹ Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA.
¹² Department of Surgery, University of California-San Francisco, San Francisco, California, USA.
¹³ Department of Surgery, Stanford University, Palo Alto, California, USA.
¹⁴ Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Philadelphia, USA.
¹⁵ Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
¹⁶ Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA.
¹⁷ Integris Baptist Medical Center, Transplant Division, Oklahoma City, Oklahoma, USA.
¹⁸ Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA.
¹⁹ Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.
²⁰ Department of Surgery, Baystate Medical Center Springfield, Massachusetts, Massachusetts, USA.
²¹ Department of Urology, University of Toledo Medical Center, Toledo, Ohio, USA.
²² Department of Surgery, Scripps Clinic and Green Hospital, La Jolla, California, USA.
²³ Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA.
²⁴ Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
²⁵ Department of Surgery, Barnes-Jewish Hospital, St. Louis, Missouri, USA.
²⁶ Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA.
²⁷ Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA.
²⁸ Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
²⁹ Renal and Pancreas Transplant Division, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA.
³⁰ Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA.
³¹ Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
³² Department of Surgery, University of Virginia, Charlottesville, Virginia, USA.
³³ Department of Surgery, University of Florida, Gainesville, Florida, USA.
³⁴ Department of Surgery, University of California San Diego, San Diego, California, USA.
³⁵ Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.
³⁶ Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA.
³⁷ Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, USA. Electronic address: garonzikwang@wisc.edu.

PMID: 37748554
PMCID: PMC10767749
DOI: 10.1016/j.ajt.2023.09.010

Abstract

Older compatible living donor kidney transplant (CLDKT) recipients have higher mortality and death-censored graft failure (DCGF) compared to younger recipients. These risks may be amplified in older incompatible living donor kidney transplant (ILDKT) recipients who undergo desensitization and intense immunosuppression. In a 25-center cohort of ILDKT recipients transplanted between September 24, 1997, and December 15, 2016, we compared mortality, DCGF, delayed graft function (DGF), acute rejection (AR), and length of stay (LOS) between 234 older (age ≥60 years) and 1172 younger (age 18-59 years) recipients. To investigate whether the impact of age was different for ILDKT recipients compared to 17 542 CLDKT recipients, we used an interaction term to determine whether the relationship between posttransplant outcomes and transplant type (ILDKT vs CLDKT) was modified by age. Overall, older recipients had higher mortality (hazard ratio: _1.632.07_2.65, P < .001), lower DCGF (hazard ratio: _0.360.53_0.77, P = .001), and AR (odds ratio: _0.390.54_0.74, P < .001), and similar DGF (odds ratio: _0.461.03_2.33, P = .9) and LOS (incidence rate ratio: _0.880.98_1.10, P = 0.8) compared to younger recipients. The impact of age on mortality (interaction P = .052), DCGF (interaction P = .7), AR interaction P = .2), DGF (interaction P = .9), and LOS (interaction P = .5) were similar in ILDKT and CLDKT recipients. Age alone should not preclude eligibility for ILDKT.

Keywords: HLA-incompatible; clinical research/practice; kidney transplantation; living donor; older; outcomes.

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Figures

**Figure 1.**
Mortality (A) and death-censored graft failure (B) among older and younger ILDKT recipients. Older ILDKT recipients have higher mortality (A), but lower death-censored graft failure (B) compared to their younger counterparts (p for all <0.001).

**Figure 2.**
Mortality (A) and death-censored graft failure (B) among older ILDKT recipients. Older ILDKT recipients have similar overall patient survival (p=0.4), but higher death-censored graft failure compared to older CLDKT recipients (p<0.001).

See this image and copyright information in PMC

References

1. OPTN. Transplants in the U.S. by Recipient Age. National Data.
1. Montgomery R, Lonze B. Desensitization in HLA-incompatible kidney recipients and survival. … England Journal of …. Published online 2011. - PubMed
1. Pham TA, Lee JI, Melcher ML. Kidney paired exchange and desensitization: Strategies to transplant the difficult to match kidney patients with living donors. Transplantation Reviews. 2017;31(1):29–34. doi:10.1016/j.trre.2017.01.003 - DOI - PubMed
1. Malvezzi P, Jouve T, Noble J, Rostaing L. Desensitization in the Setting of HLA-Incompatible Kidney Transplant. Experimental and Clinical Transplantation. 2018;4:367–375. doi:10.6002/ect.2017.0355 - DOI - PubMed
1. Haririan A, Nogueira J, Kukuruga D, et al. Positive Cross-Match Living Donor Kidney Transplantation: Longer-Term Outcomes. American Journal of Transplantation. 2009;9(3):536–542. doi:10.1111/j.1600-6143.2008.02524.x - DOI - PubMed

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Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients

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Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients

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