Kidney transplants for dialysis have better results

A retrospective cohort study found that patients receiving kidneys from donors on dialysis were at significantly higher risk of delayed graft function (DGF) but had no long-term differences in graft failure, renal function, or death.

Chirag Parikh, MD, PhD, of Johns Hopkins University in Baltimore, and his colleagues found that among 954 transplant patients, DGF was significantly more prevalent in patients who received kidneys not undergoing dialysis compared with those who received kidneys not undergoing dialysis (59.2% vs. 24.6%; adjusted OR, 4.17, 95% CI, 3.28-5.29).

However, with a median follow-up of 34 months, there was no significant difference in the risk of graft failure (HR 0.90, 95% CI 0.70-1.15) or death (HR 0.76, 95% CI 0.55-1.04). Renal function at 12 months was also not different between the two groups, with similar estimated glomerular filtration rates (eGFR; 64.7 vs. 65.1 mL/min/1.73 m).²between-group difference 0.51, 95% CI -3.26 to 4.42), Parikh and co-authors JAMA.

“Given the severe organ shortage and increasing rates of discarded kidneys from potential donors, there is growing interest in using kidneys from less-than-ideal donors, such as kidneys from deceased donors with AKI. [acute kidney injury]),” the researchers wrote.

“Given the high incidence of DGF after kidney transplants from donors who had undergone dialysis, recipients who may be healthy enough to tolerate repeated hemodialysis sessions after transplantation if DGF occurs should be considered for transplantation of kidneys from these donors,” the researchers added.

Parikh and his colleagues analyzed data from the United States Organ Procurement and Transplantation Network from 2010 to 2018. During that time, 1.4% of deceased donors underwent dialysis before organ donation (805 of more than 58,000 donors). The most common reason was acute kidney injury (AKI) (76%). An additional 14% were on dialysis for alcoholism, and 10% were on dialysis for other reasons, such as severe hyperkalemia, acidosis, hypervolemia, or hyperammonemia.

The study involved 514 donors who received dialysis and 954 recipients who received one of their kidneys. The researchers compared the outcomes of this group with a matched group of 514 donors who did not receive dialysis and 990 recipients who received one of their kidneys. Primary outcomes included delayed graft function (defined as the recipient receiving dialysis within one week of transplant), all-cause graft failure, and death.

in editorial Despite this demonstration of feasibility, Xingxing Cheng, M.D., Ph.D., and Colin Lenihan, M.D., Ph.D., of the Stanford University School of Medicine in California, who accompanied the study, urged careful selection of donors.

“At first glance, it seems counterintuitive to use kidneys from donors who underwent dialysis before death,” the researchers wrote, “yet kidneys have a remarkable potential to regenerate and recover even after severe damage.”

For transplants from these donors to be successful, the researchers said, it is necessary to reliably identify kidneys that are likely to recover after transplantation. “In this study, the donors were young, had good renal function, and had mostly been on short dialysis periods, so they belonged to the category of patients with good prospects for kidney recovery,” they noted.

Still, the total number of kidneys available from these donors will likely be small compared to the overwhelming demand, Chen and Lenihan added. “Furthermore, the current transplant regulatory and reimbursement environment will likely discourage such expansion for many programs,” they said.

Parikh and his colleagues noted that kidneys from young, healthy donors were more likely to be selected for transplantation, making the study susceptible to confounding factors and selection bias. In addition, the study lacked information on patient characteristics, such as race, comorbidities, and changes in immunosuppression over time, they said.

The researchers note that there were large regional variations in the procurement and acceptance of kidneys from donors on dialysis, “which suggests that more kidneys may become available if organ procurement organizations and transplant centers were to carefully expand the criteria for dialysis donation to stabilize donors with severe AKI and to extend kidney procurement and acceptance criteria to donors on dialysis who are currently not considered eligible because of severe AKI,” they suggest.