Should we use kidneys from donors with acute kidney injury for renal transplantation?

Short-Term, Mid-Term, and Long-Term Outcomes after Deceased Donor Kidney Transplantation in Patients with AKI: A Systematic Review and Meta-Analysis

Key Points

Background

AKI is a common complication in hospitalized patients and may occur in potential kidney donors. Observational studies have suggested that kidney transplantation in patients with AKI is feasible and safe, but no systematic evaluation has been performed.

Methods

We performed a systematic review and meta-analysis to evaluate the outcomes of kidney transplantation in patients with AKI. We searched MEDLINE, Embase, Cochrane, Google Scholar, and other databases for studies reporting outcomes of donor kidneys with AKI. We included single-center, multicenter, and registry-based studies and analyzed them according to the definition and severity of AKI. End points were primary and delayed graft function (DGF), primary nonfunction (PNF), length of hospital stay, rejection, graft function, and patient and graft survival at 1, 3, 5, and 8–10 years after transplantation. This study was registered in PROSPERO, number CRD42021260088.

Results

We identified 33 single-center, four multicenter, and seven registry studies with more than 100,000 patients published between 2005 and 2022. Recipients from donors with AKI had a higher risk of DGF (relative risk, 1.51; 95% confidence interval [CI], 1.35 to 1.68). Graft function at discharge was worse in the AKI group (MDCrea [95% CI]: 0.96 mg/dl [0.36 to 1.56, I2=96%], MDGFR [95% CI]: −8.88 ml/min per 1.73 m2 [−15.32 to −2.44, I2=93%]), but improved thereafter and was similar in both groups at 3 months after transplantation (MDCrea [95% CI]: −0.05 mg/dl [−0.18 to 0.07, I2=0%], MDGFR [95% CI]: −1.83 ml/min per 1.73 m2 [−5.29 to 1.63, I2=91%]). Primary nonfunction and patient and graft survival were similar at 1, 3, 5, and 8–10 years after transplantation. There were no differences in rejections regardless of AKI definition and severity.

Conclusions

Transplantation of kidneys with AKI is associated with satisfactory short-term and long-term outcomes and should be pursued to increase the donor pool.

Impact of acute kidney injury and renal recovery status in deceased donor to kidney transplant outcome: results from the Thai national transplant registry

The influence of acute kidney injury (AKI) and renal recovery in deceased donor (DD) on long-term kidney transplant (KT) outcome has not previously been elucidated in large registry study. Our retrospective cohort study included all DDKT performed in Thailand between 2001 and 2018. Donor data was reviewed case by case. AKI was diagnosed according to the KDIGO criteria. Renal recovery was defined if DD had an improvement in AKI to the normal or lower stage. All outcomes were determined until the end of 2020. This study enrolled 4234 KT recipients from 2198 DD. The KDIGO staging of AKI was as follows: stage 1 for 710 donors (32.3%), stage 2 for 490 donors (22.3%) and stage 3 for 342 donors (15.6%). AKI was partial and complete recovery in 265 (17.2%) and 287 (18.6%) before procurement, respectively. Persistent AKI was revealed in 1906 KT of 990 (45%) DD. The ongoing AKI in DD significantly increases the risk of DGF development in the adjusted model (HR 1.69; 95% CI 1.44-1.99; p < 0.001). KT from DD with AKI and partial/complete recovery was associated with a lower risk of transplant loss (log-rank P = 0.04) and recipient mortality (log-rank P = 0.042) than ongoing AKI. KT from a donor with ongoing stage 3 AKI was associated with a higher risk of all-cause graft loss (HR 1.8; 95% CI 1.12-2.88; p = 0.02) and mortality (HR 2.19; 95% CI 1.09-4.41; p = 0.03) than stage 3 AKI with renal recovery. Persistent AKI, but not recovered AKI, significantly increases the risk of DGF. Utilizing kidneys from donors with improving AKI is generally safe. KT from donors with persistent AKI stage 3 results in a higher risk of transplant failure and recipient mortality. Therefore, meticulous pretransplant evaluation of such kidneys and intensive surveillance after KT is recommended.

Short-term outcomes after transplantation of deceased donor kidneys with acute kidney injury: a retrospective analysis of a multicenter cohort of marginal donor kidneys with post-explantation biopsies

BACKGROUND

Deceased donor kidneys with acute kidney injury (AKI) are often discarded because of concerns about inferior transplant outcomes. A means of grading the quality of such kidneys is the performance of procurement biopsies.

METHODS

This is a retrospective study of 221 brain death donors with marginal kidneys transplanted in 223 recipients in Germany. Marginal kidneys were defined as kidneys with procurement biopsies done exceptionally to assess suitability for transplantation in otherwise potentially discarded organs. The impact of deceased donor AKI on patient survival and death-censored graft survival at 1, 3 and 5 years and graft function at 1 and 3 years after transplantation was investigated.

RESULTS

Recipients of kidneys with stage 3 AKI had a greater incidence of delayed graft function [DGF; OR_{Stage 1}: 1.435 (95% CI 0.438-0.702), OR_{Stage 2}: 2.463 (95% CI 0.656-9.245), OR_{Stage 3}: 4.784 (95% CI 1.421-16.101)] but a similar graft and patient survival compared to recipients of donors without AKI and with AKI stage 1 and 2 as well. The coexistence of recipient DGF and donor AKI was associated with the lowest graft survival and function rates.

CONCLUSION

The transplantation of deceased donor marginal kidneys with AKI confers a higher risk for DGF but is associated with acceptable graft and patient outcomes, which do not differ in comparison with marginal donor kidneys without AKI. Graft prognosis is especially poor if donor AKI and recipient DGF concur. Donor AKI was a risk factor independent of the histological lesions of procurement biopsies.

Delayed Graft Function in Kidney Transplant: Risk Factors, Consequences and Prevention Strategies

Background. Delayed graft function is a frequent complication of kidney transplantation that requires dialysis in the first week posttransplant. Materials and Methods. We searched for the most relevant articles in the National Institutes of Health library of medicine, as well as in transplantation, pharmacologic, and nephrological journals. Results. The main factors that may influence the development of delayed graft function (DGF) are ischemia–reperfusion injury, the source and the quality of the donated kidney, and the clinical management of the recipient. The pathophysiology of ischemia–reperfusion injury is complex and involves kidney hypoxia related to the duration of warm and cold ischemia, as well as the harmful effects of blood reperfusion on tubular epithelial cells and endothelial cells. Ischemia–reperfusion injury is more frequent and severe in kidneys from deceased donors than in those from living donors. Of great importance is the quality and function of the donated kidney. Kidneys from living donors and those with normal function can provide better results. In the peri-operative management of the recipient, great attention should be paid to hemodynamic stability and blood pressure; nephrotoxic medicaments should be avoided. Over time, patients with DGF may present lower graft function and survival compared to transplant recipients without DGF. Maladaptation repair, mitochondrial dysfunction, and acute rejection may explain the worse long-term outcome in patients with DGF. Many different strategies meant to prevent DGF have been evaluated, but only prolonged perfusion of dopamine and hypothermic machine perfusion have proven to be of some benefit. Whenever possible, a preemptive transplant from living donor should be preferred.

The benefits of initiating continuous renal replacement therapy after brain death in organ donors with oligoanuric acute kidney injury

Acute kidney injury (AKI) in deceased organ donors is increasing due to the escalation in anoxic brain-deaths. The management of an organ donor with oligoanuric AKI is frequently curtailed due to hemodynamic and electrolyte instability. Although continuous renal replacement therapy (CRRT) corrects the effects of AKI, it is rarely started after the diagnosis of brain-death (BD). Since 2017, we have initiated CRRT in organ donors with oligoanuric AKI to allow more time to stabilize the donor and improve the function of the thoracic organs. We now report our experience with the first 27 donors with oligoanuric AKI that received CRRT after the diagnosis of BD, with organs transplanted as the primary outcome. The average duration of CRRT was 30.1±14.4 hours and the mean ultrafiltration volume was 5,141±4,272 milliliters. The time from BD declaration to cross clamp was significantly longer in the CRRT group versus a historical cohort with oligoanuric AKI that was not dialyzed (62.8±18.3 vs 37.1±14.9 hours; p<0.01) The mean number of total organs transplanted per donor in the CRRT group was greater than the historical cohort, 2.9±1.7 vs 1.4±0.6 (p = 0.<01), respectively. The mean number of thoracic organs transplanted per donor also increased between the two groups, 1.4±1.2 vs 0.6±0.9 (p = 0.02). Thirty-seven percent of the kidneys were successfully transplanted with a mean serum creatinine of 1.4 mg/dL at six months. We suggest that OPOs consider starting CRRT in organ donors with oligoanuric AKI to possibly increase the number of organs transplanted. This article is protected by copyright. All rights reserved.

Impact of acute kidney injury on graft outcomes of deceased donor kidney transplantation: A nationwide registry-based matched cohort study in Korea

BACKGROUND

Favorable long-term and short-term graft survival and patient survival after kidney transplantation (KT) from deceased donors with acute kidney injury (AKI) have been reported. However, few studies have evaluated effects of donor AKI status on graft outcomes after KT in Asian population. Thus, the purpose of this study was to evaluate graft function after KTs from donors with AKI compared to matched KTs from donors without AKI using a multicenter cohort in Korea.

METHODS

We analyzed a total of 1,466 KTs collected in Korean Organ Transplant Registry between April 2014 and December 2017. KTs from AKI donors (defined as donors with serum creatinine level ≥ 2 mg/dL) and non-AKI donors (275 cases for each group) were enrolled using a 1:1 propensity score matching. Graft outcomes including graft and patient survival, delayed graft function (DGF), rejection rate, and serially measured estimated glomerular filtration rate (eGFR) were evaluated.

RESULTS

After propensity matching, KTs from AKI donors showed higher rate of DGF (44.7% vs. 24.0%, p < 0.001). However, the rejection rate was not significantly different between the two groups (KTs from AKI donors vs. KTs from non-AKI donors). eGFRs measured after 6 months, 1 year, 2 years and 3 years were not significantly different by donor AKI status. With median follow-up duration of 3.52 years, cox proportional hazards models revealed hazard ratio of 0.973 (95% confidence interval [CI], 0.584 to 1.621), 1.004 (95% CI, 0.491 to 2.054) and 0.808 (95% confidence interval [CI], 0.426 to 1.532) for overall graft failure, death-censored graft failure and patient mortality, respectively, in KTs from AKI donors compared to KTs from non-AKI donors as a reference.

CONCLUSIONS

KTs from AKI donors showed comparable outcomes to KTs from non-AKI donors, despite a higher incidence of DGF. Results of this study supports the validity of using kidneys from deceased AKI donors in Asian population.

We listed patients and we should transplant them

Twenty percent of kidneys recovered for transplantation are discarded. The most common reason for not transplanting these kidneys is to organ quality and biopsy findings. Yet, organ quality measures are not associated with discard rates and kidneys with poorer quality measures lead to greater life span for the recipient compared to staying on dialysis. Biopsy findings are not correlated with graft survival in most cases. The risk aversion of transplant centers from using "high-risk" kidneys can be, in part at least, attributed to negative consequences of poor graft survival with possible program sanctions or possible loss of insurance contracts. CMS has taken a first step by eliminating short-term graft survival as a performance measure for transplant centers. Many of the discarded kidneys will provide good results if transplanted and would recognize that patients value getting a transplant above graft survival.