Kidney Transplant Outcomes Associated With the Use of Increased Risk Donors in Children

Sarah J. Kizilbash; Michelle N. Rheault; Qi Wang; David M. Vock; Srinath Chinnakotla; Tim Pruett; Blanche M. Chavers

Disclosures

American Journal of Transplantation. 2019;19(6):1684-1692. 

In This Article

Results

Six percent of pediatric deceased donor recipients received a kidney from an IRD donor between January 1, 2005 and December 31, 2015. Figure 1 shows the trends in IRD kidney transplant over the study period. The rates of IRD transplant increased to nearly 13% after the implementation of the new CDC criteria for IRDs in 2014.

Figure 1.

Trends in pediatric IRD kidney transplant. IRD, increased risk donor

Donor Characteristics

The demographic and clinical characteristics of IRDs and non-IRDs are presented in Table 2. The IRDs were more likely to be male (P = .04) and black (P < .001). There were no differences between body mass index (BMI) and KDPI scores between IRDs and non-IRDs. IRDs were less likely to have stroke and more likely to have head trauma as their cause of death. None of the IRD and one non-IRD fulfilled the specifications for an expanded criteria donor. Four percent (13) of IRDs and 4.3% (209) of non-IRD organs were donations after cardiac death (P = .76).

Infection profile. None of the IRDs tested positive for HIV or hepatitis C, however, 2 (0.66%) tested positive for hepatitis B core antibody. Among non-IRDs, all tested negative for HIV and hepatitis C but 18 (0.42%) tested were positive for hepatitis B core antibody, and 4 (0.08%) tested positive for hepatitis B surface antigen.

Recipient Characteristics

Table 2 presents the demographic and clinical characteristics of kidney transplant recipients. There was no difference in the mean age at transplant, gender, or race between IRD and non-IRD recipients. The causes of ESRD were also similar between the two groups (P = .58). Common causes of ESRD included congenital anomalies of the kidney and urinary tract (IRD vs. non-IRD: 30.6% vs. 31.1%), glomerulonephritis (IRD vs non-IRD: 17.4% vs. 16.1%), focal segmental glomerulosclerosis (IRD vs. non-IRD: 17.7% vs. 14.4%), and cystic kidney diseases (IRD vs. non-IRD: 3.7% vs. 3.9%).

IRD recipients were more likely to have blood group O compared with non-IRD recipients (62.5% vs. 52.3%, P < .001). IRD recipients also had higher mean cPRA compared with non-IRD recipients (0.085 vs. 0.065, P = .015). The prevalence of pretransplant dialysis (P = .81) and mean pretransplant dialysis duration (P = .52) were similar between IRD and non-IRD recipients.

None of the IRD recipients but 15 (0.31%) non-IRD received treatment for hepatitis B (lamivudine) posttransplant.

Transplant Outcomes

Delayed graft function and acute rejection. The rates of delayed graft function were similar between IRD and non-IRD recipients (11.0% vs. 8.7%, P = .17). There was also no difference in the 1-year acute rejection free survival between IRD and non-IRD recipients (65.1% vs. 64.4%, P = .91). The difference between acute rejection remained insignificant after adjusting for covariates (aHR: 0.98, 95% CI: 0.81-1.19, P = .82).

Graft survival: As shown in Figure 2, we found no difference in the overall and death-censored graft survival between IRD and non-IRD recipients (P = .40 and .55, respectively). Table 3 compares the 1-, 3- and 5-year overall and death-censored graft survival between recipients with IRD and non-IRD transplants.

Figure 2.

IRD versus non-IRD patient and graft survival. IRD, increased risk donor

There was no difference in the risk of graft loss between IRD and non-IRD recipients after adjusting for covariates (aHR: 0.89, 95% CI: 0.70-1.13, P = .32). Likewise, death-censored graft survival was similar between the groups after multivariate adjustment (aHR: 0.91, 95% CI: 0.71-1.17, P = .46).

Among patients who suffered graft loss, the causes of loss were similar between IRD and non-IRD recipients. Only 2 (3.0%) of IRD recipients and 34 (2.9%) of non-IRD recipients lost their graft due to an infection. Chronic allograft nephropathy was the most common cause of graft loss in both groups (28.8 vs. 35.1%, P = .94).

Patient survival: We did not find any difference in patient survival between IRD and non-IRD recipients (P = .87) (Table 3 and Figure 2). There was also no difference in the risk of death between IRD and non-IRD recipients on multivariate analysis (aHR: 0.93, 95% CI: 0.54-1.59, P = .79). However, patient survival was significantly higher after IRD transplants compared with remaining on the waitlist and declining subsequent IRD kidneys but possibly accepting a non-IRD deceased donor kidney (aHR: 0.48, 95% CI: 0.26-0.88, P = .018). The causes of death were similar between IRD and non-IRD recipients (P = .94). Only 1 IRD recipient (25%) and 25 (24.5%) non-IRD died due to an infection.

There was no dissimilarity in the incidence of posttransplant malignancy in IRD versus non-IRD recipients (2.2% vs. 2.3%, P = .96). Similarly, the recurrence of primary disease was similar between IRD and non-IRD recipients (4.9% vs. 3.3%, P = .13).

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