Impact of suboptimal donor to suboptimal recipient kidney transplant on delayed graft function and outcome

Abstract

Introduction: The demographics of donor and recipient candidates for kidney transplantation (KT) have substantially changed. Recipients tend to be older and polymorbid and KT to suboptimal recipients is associated with delayed graft function (DGF), prolonged hospitalization, inferior long-term allograft function, and poorer patient survival. In parallel, donors are also older, suffer from several comorbidities, and donations coming from circulatory death (DCD) predominate, which in turn leads to early and late complications. However, it is unclear how donor and recipient risk factors interact.

Methods: In this retrospective cohort study, we assess the impact of a KT from suboptimal donors to suboptimal recipients. We focused on: 1) DGF; 2) hospital stay and number of dialysis days after KT and 3) allograft function at 12 months.

Results and discussion: Among the 369 KT included, the overall DGF rate was 25% (n = 92) and median time from reperfusion to DGF resolution was 7.8 days (IQR: 3.0-13.8 days). Overall, patients received four dialysis sessions (IQR: 2-8). The combination of pre-KT anuria (<200 ml/24 h, 32%) and DCD procurement (14%) was significantly associated with DGF, length of hospital stay, and severe perioperative complications, predominantly in recipients 50 years and older.

Keywords: delayed graft function; donor after circulatory death; hospital stay duration; kidney transplant; recipient anuria.

Figure 1

(A,B) Absolute and relative frequency of KT with and without DGF during the study period. (C) Time on dialysis after reperfusion for 92 patients with DGF. Median time from reperfusion to end of last dialysis was 7.8 days. DGF, Delayed Graft Function; KT, Kidney Transplantation.

Figure 2

Prediction models for DGF in the Bernese cohort. (A–C) Prediction model for DGF with organ procurement (DBD versus DCD), residual urine volume (≥200 ml/24 h vs. <200 ml/24 h), donor and recipient age as exploratory parameters. (D–F) Prediction model for DGF with first warm ischemia time (per 15 min), residual urine volume (per 100 ml), donor and recipient age as quantitative exploratory variables. (B,E) ROC analysis and calculated AUC for the respective models. (C,F) Calibration analysis of empirical, estimated probabilities and Brier scores from the reduced models applied to the entire cohort. (D) Estimated risk for DGF based on the reduced model. DGF, Delayed Graft Function; DCD, Donation after Circulatory Death; DBD, Donation after Brain Death.

Figure 3

Perioperative complications, hospital stay duration and eGFR at 12 months after KT. (A) Absolute and relative frequencies of Clavien-Dindo complications ≥ IIIb (interventions under complete anaesthesia, intensive care unit treatment, death) in the various groups. (B) Absolute and relative rate of Clavien-Dindo grade ≥ IIIb complications stratified for recipients younger and older than 50 year at time of KT. (C) Duration until first hospital discharge after KT for the various groups, (D,E) Kidney function outcome. KT, Kidney Transplantation; eGFR, estimated Glomerular Filtration Rate; DCD, Donation after Circulatory Death.

Figure 4

Perioperative interventions and DGF risk. Logistic regression model predicting DGF events from exploratory given variables and log-transformed cold ischemia time and residual urine volume as co-founding parameters. DGF, Delayed Graft Function; KT, Kidney Transplantation; ATG, Antithymocyte Globulin.