Published online Aug 9, 2018. doi: 10.5500/wjt.v8.i4.102
Peer-review started: April 11, 2018
First decision: May 3, 2018
Revised: May 21, 2018
Accepted: May 30, 2018
Article in press: May 31, 2018
Published online: August 9, 2018
It is unclear whether preemptive transplantation of high kidney donor profile index (KDPI) (marginal quality) kidneys and thus avoiding maintenance dialysis in older recipients would be beneficial compared to waiting for and transplanting lower KDPI (better quality donor organ) kidneys after being on dialysis for varying lengths of time. We sought to answer this by utilizing the national transplant database.
The aim of this study was to evaluate the outcomes of transplanting marginal kidneys preemptively compared to better-quality kidneys after varying dialysis vintage in older recipients.
The objective of our study was to explore the benefits of transplanting marginal quality kidney preemptively compared to waiting for better quality kidney transplantation after exposure to varying times on dialysis.
Using United Network for Organ Sharing database, we identified patients > 60 years who underwent first time deceased donor kidney (DDK) transplantation between January 2001 and December 2015, after receiving induction and discharged on calcineurine inhibitor/Mycophenolate Mofetil immunosuppression. We further identified patients who underwent preemptive DDK with KDPI ≥ 85% and those who underwent DDK with KDPI of 35%-84% after being on maintenance dialysis for either 1-4 years or 4-8 years. Cox model was used to compare adjusted graft and patient outcomes between the groups. HR with 95%CI was calculated. A P value of < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS software version 18.
Adjusted overall graft failure risk and death-censored graft failure risk in preemptive high KDPI kidney recipients were similar when compared to group that received lower KDPI kidney after being on maintenance dialysis for either 1-4 years or 4-8 years. Adjusted patient death risk in preemptive high KDPI kidney recipients were similar when compared to groups that received lower KDPI kidney after being on maintenance dialysis for 1-4 years but lower compared to patients who were on dialysis for 4-8 years.
Our study supports accepting a “marginal” quality high KDPI kidney preemptively in older wait-listed patients thus avoiding dialysis exposure. In order to best serve older patients on the waiting list, clinicians should be open to offers of high KDPI kidneys and get the patients involved in this important and very personal decision making process. A pre-emptive kidney transplant- even if it is a marginal organ, could come with an added quality of life benefit associated with earlier transplantation and possibly cost benefit. It is acceptable to use marginal quality kidneys in older transplant recipients, rather than having them wait on dialysis for better quality kidney. It has been widely accepted that marginal quality organs are acceptable for use in older transplant recipients. But there has been hesitance in accepting these kidneys for recipients who are not on dialysis yet. The purpose of this study was to evaluate the impact of avoiding dialysis vintage by preemptive transplantation of marginal kidneys in older recipients when compared to receiving better quality organ while remaining on dialysis. Avoiding dialysis with early transplantation should be favorably considered even with marginal quality kidneys. It will be logistically hard to design a prospective study trying to answer the same question; but that would be ideal. Future study should identify older patients who declined preemptive offer of marginal kidneys and went on to get better quality kidneys at a later point after being on dialysis. Control group should be older patients who accepted those marginal kidneys preemptively. Post-transplant outcomes between the 2 groups should be compared. It is acceptable to use a marginal quality kidney in an older recipient, thereby avoiding dialysis exposure. The current study supports the hypothesis of transplanting marginal quality kidney preemptively in older patients. The findings of this study enable transplant professionals to make a more informed choice when faced with the option of getting a marginal kidney offer for their older wait listed patients with chronic kidney disease who are not on dialysis yet.
Avoiding dialysis exposure with early transplant even with a marginal kidney is potentially beneficial. Future studies should look at the outcomes of older patients who turned down a marginal kidney for preemptive transplantation and received better quality kidney after exposure to variable dialysis time compared to older patients who accepted the declined marginal kidneys preemptively and thus avoided dialysis exposure. Future study should identify older patients who declined preemptive offer of marginal kidneys and went on to get better quality kidneys at a later point after being on dialysis. Control group should be older patients who accepted those marginal kidneys preemptively. Post-transplant outcomes between the 2 groups should be compared.