Investigators Suggest Expanding Donor Pool with Discarded Kidneys

January 13, 2020
kidney transplantWith an emphasis of expanding the donor pool, investigators are looking at discarded kidneys to increase the amount of donor kidneys available.

New data suggests the transplant community should expand their use of deceased donor acute kidney injury (AKI) kidneys and investigator whether currently discarded AKI kidneys can be effectively used.

A team led by Caroline Liu, MHS, Division of Nephrology, Department of Medicine, The Johns Hopkins University School of Medicine, examined whether deceased donor AKI associated with recipient graft survival after matching on deceased donor acute kidney injuries propensity.

“Deceased donor AKI kidneys transplanted in the study period had recipient graft survival comparable to that of non-AKI kidneys,” investigators wrote. “This study’s findings suggest that the transplant community should evaluate whether currently discarded AKI kidneys from donors without substantial comorbidities can be used more effectively.”

The investigators examined a total of 6832 deceased donors with AKI and 15,310 deceased donors without AKI who had at least 1 kidney transplanted in the US, from 2010-2013.

The investigators used a 1:1, propensity score-matched analysis to match deceased donors with AKI to deceased donors without AKI. They then investigated outcomes in their corresponding kidney recipients. Recipients were also assessed for the time to death-censored graft failure and the following secondary outcomes—delayed graft function, primary nonfunction, and the time to all-cause graft failure.

The registry-based cohort study of deceased donors with and without acute kidney injuries who had no independent association with both short and long-term recipient graft survival.

The investigators found the recovery and transplantation of AKI kidneys varied by organ procurement organization, with 39 of 58 organizations reporting high recovery and high discard rates of AKI kidneys. Approximately 98% of the donors with AKI were matched to deceased donors without AKI.

Deceased donor AKI status had no association with death-censored graft failure (HR, 1.01; 95% CI, .95-1.08) or all-cause graft failure (HR, .97; 95% CI, .93-1.02) and the results were consistent after examining by AKI stage and adjusting for recipient and transplant characteristics. 

The investigators also found that more recipients of AKI kidneys developed delayed graft function (29% vs 22%, P < .001), while few recipients (120 of 25,323 [0.5%]) developed primary nonfunction regardless of deceased donor AKI status.

There is currently a shortage of available donor kidneys in the US, leading to an expansion of acceptable donors to include kidneys from older donors or donors with HIV or hepatitis C.

As of October 2019, approximately 95,000 patients with end-stage renal disease who cleared medical evaluations remained on the waiting list, with approximately 9000 patients are removed from the waiting list every year because of death or deteriorating health, indicating that the organ shortage is far from resolved despite increased use of kidneys from higher-risk deceased donors.

Last year, an international taskforce updated 2008 guidelines for the prevention, diagnosis, treatment, and management of hepatitis C virus (HCV) infections in adult chronic kidney disease (CKD) populations.

The team, led by Michel Jaboul, MD, of Université Catholique de Louvain and Paul Martin, MD of the University of Miami, recently published "The Kidney Disease: Improving Global Outcomes (KDIGO)" 2018 clinical practice guideline with 66 new recommendations that include more widespread use of direct-acting antivirals (DAAs) instead of interferon drugs to treat infections for this population.

The recommendations include screening all CKD patients for HCV infection at the time of their initial evaluation and using an immunoassay followed by nucleic acid testing if the immunoassay is positive. They also recommend screening all patients for infection upon initiation of hemodialysis and at the time of evaluation for kidney transplantation.

Patients are recommended to be evaluated for antiviral therapy, an interferon-free regimen, and a choice of specific regimen based on the HCV genotype, viral load, prior treatment history, drug-drug interactions, glomerular filtration rate, stage of hepatic fibrosis, kidney and liver transplant candidacy, and comorbidities.

Liu and colleagues concluded in their analysis that transplant organizations and care providers should evaluate whether they can more effectiely use currently-discarded AKI kidneys from donors without substantial comorbidities.

The study, “Association of Deceased Donor Acute Kidney Injury With Recipient Graft Survival,” was published online in JAMA Network Open.
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