Kidney Transplant Outcomes From Deceased Donors Who Received Dialysis

Abstract

Importance: Recipient outcomes after kidney transplant from deceased donors who received dialysis prior to kidney donation are not well described.

Objective: To compare outcomes of transplant recipients who received kidneys from deceased donors who underwent dialysis prior to kidney donation vs recipients of kidneys from deceased donors who did not undergo dialysis.

Design, setting, and participants: A retrospective cohort study was conducted including data from 58 US organ procurement organizations on deceased kidney donors and kidney transplant recipients. From 2010 to 2018, 805 donors who underwent dialysis prior to kidney donation were identified. The donors who underwent dialysis prior to kidney donation were matched 1:1 with donors who did not undergo dialysis using a rank-based distance matrix algorithm; 1944 kidney transplant recipients were evaluated.

Exposure: Kidney transplants from deceased donors who underwent dialysis prior to kidney donation compared with kidney transplants from deceased donors who did not undergo dialysis.

Main outcomes and measures: The 4 study outcomes were delayed graft function (defined as receipt of dialysis by the kidney recipient ≤1 week after transplant), all-cause graft failure, death-censored graft failure, and death.

Results: From 2010 to 2018, 1.4% of deceased kidney donors (805 of 58 155) underwent dialysis prior to kidney donation. Of these 805 individuals, 523 (65%) donated at least 1 kidney. A total of 969 kidneys (60%) were transplanted and 641 kidneys (40%) were discarded. Among the donors with kidneys transplanted, 514 (mean age, 33 years [SD, 10.8 years]; 98 had hypertension [19.1%] and 36 had diabetes [7%]) underwent dialysis prior to donation and were matched with 514 (mean age, 33 years [SD, 10.9 years]; 98 had hypertension [19.1%] and 36 had diabetes [7%]) who did not undergo dialysis. Kidney transplants from donors who received dialysis prior to donation (n = 954 kidney recipients) were associated with a higher risk of delayed graft function compared with kidney transplants from donors who did not receive dialysis (n = 990 kidney recipients) (59.2% vs 24.6%, respectively; adjusted odds ratio, 4.17 [95% CI, 3.28-5.29]). The incidence rates did not significantly differ at a median follow-up of 34.1 months for all-cause graft failure (43.1 kidney transplants per 1000 person-years from donors who received dialysis prior to donation vs 46.9 kidney transplants per 1000 person-years from donors who did not receive dialysis; adjusted hazard ratio [HR], 0.90 [95% CI, 0.70-1.15]), for death-censored graft failure (22.5 vs 20.6 per 1000 person-years, respectively; adjusted HR, 1.18 [95% CI, 0.83-1.69]), or for death (24.6 vs 30.8 per 1000 person-years; adjusted HR, 0.76 [95% CI, 0.55-1.04]).

Conclusions and relevance: Compared with receiving a kidney from a deceased donor who did not undergo dialysis, receiving a kidney from a deceased donor who underwent dialysis prior to kidney donation was associated with a significantly higher incidence of delayed graft function, but no significant difference in graft failure or death at follow-up.

Figure 1.. Identification and Adjudication Process for Deceased Donors by Dialysis Status, Matching, and Linkage to Kidney Transplant Recipients

^aIntoxication with methanol, ethylene glycol, lithium, or other substances or medications. ^bIncludes dialysis for severe hyperkalemia, acidosis, hypervolemia, hyperammonemia, and other electrolyte abnormalities without laboratory evidence of stage 2 to 3 acute kidney injury.

Figure 2.. Geographic Variation in Kidney Transplants From Deceased Donors Who Underwent Dialysis Across 58 Donation Service Areas in the US From 2010 to 2018

Geographical heat map depicting rates and locations of kidneys transplanted from deceased donors who underwent dialysis during their final hospitalization.

Figure 3.. Recipient Short- and Longer-Term Outcomes After Kidney Transplant From Matched Deceased Donors

HR indicates hazard ratio; OR, odds ratio. ^aThe data in column 4 are adjusted ORs (95% CIs). Short-term is defined as within 7 days after kidney transplant. ^bFor the kidney recipient comparisons by matched donor dialysis status (underwent dialysis vs did not undergo dialysis), logistic and Cox proportional hazard regression models were used and adjusted for the following covariates: cold ischemic time, recipient age, body mass index, diabetes as the cause of recipient end-stage kidney disease, preemptive transplant status, previous kidney transplant, level of human leukocyte antigen mismatch, panel reactive antibody category (0%, 1%-20%, 21%-80%, and >80%), and donor estimated glomerular filtration rate at hospital admission. Sandwich estimators were used to account for outcome dependency when both donor kidneys were explanted. ^cIncludes dialysis for severe hyperkalemia, acidosis, hypervolemia, hyperammonemia, and other electrolyte abnormalities without laboratory evidence of stage 2 or 3 acute kidney injury. ^dThe data in column 4 are adjusted HRs (95% CIs).

Figure 4.. Kaplan-Meier Survival Curves of Longer-Term Outcomes for Recipients After Kidney Transplant From Matched Donors by Dialysis Status