Impact of Warm Ischemia Time on Donation After Circulatory Death Kidney Transplant Outcomes.

BACKGROUND: Efforts to address the shortage of donor organs include increasing the use of renal allografts from donors after circulatory death (DCD). While warm ischemia time (WIT) is thought to be an important factor in DCD kidney evaluation, few studies have compared the relationship between WIT and DCD kidney outcomes, and WIT acceptance practices remain variable. METHODS: We conducted a single-center retrospective review of all adult patients who underwent deceased donor kidney transplantation from 2000 to 2021. We evaluated the impact of varied functional warm ischemia time (fWIT) in controlled DCD donors by comparing donor and recipient characteristics and posttransplant outcomes between high fWIT (>60 min), low fWIT (≤60 min), and kidneys transplanted from donors after brain death (DBD). RESULTS: Two thousand eight hundred eleven patients were identified, 638 received low fWIT DCD, 93 received high fWIT DCD, and 2080 received DBD kidneys. There was no significant difference in 5-year graft survival between the DCD low fWIT, high fWIT, and DBD groups, with 84%, 83%, and 83% of grafts functioning, respectively. Five-year patient survival was 91% in the low fWIT group, 92% in the high fWIT group, and 90% in the DBD group. An increase in kidney donor risk index (KDRI) (HR 3.37, 95% CI = 2.1-5.7) and high CIT compared to low CIT (HR 2.12, 95% CI = 1.4-3.1) have higher hazard ratios for 1-year graft failure. CONCLUSIONS: Increased acceptance of kidneys from selected DCD donors with prolonged fWIT may present an opportunity to increase kidney utilization while preserving outcomes. Our group specifically prioritizes the use of kidneys from younger donors, with lower KDPI, and without acute kidney injury, or risk factors for underlying chronic kidney disease.

A Survey of United States Transplant Center Donation After Circulatory Death Kidney Transplant Practices in the Modern Era.

BACKGROUND: The mismatch between the number of patients awaiting kidney transplantation and the supply of donor organs has contributed to the increase in kidney transplantation from donors after circulatory death (DCD). Persistently long waiting times have led the transplant community to continue to explore the use of expanded- criteria DCD kidneys. In parallel, advances in organ preservation strategies have contributed to an overall increase in DCD organ transplantation and are altering the transplant landscape. Some of these techniques may improve kidney allograft outcomes and affect how DCD kidneys are used. We aimed to better understand practices in accepting DCD kidney offers in the modern era. METHODS: Directors of 196 US kidney transplant centers were emailed a link to an online survey over a 5-week period. RESULTS: Forty-eight out of the 364 directors (13%) responded, with all United Network for Organ Sharing regions represented. Definitions of warm ischemia time (WIT) used in DCD kidney evaluation varied widely among the respondents. The maximum total WIT limit varied, with 19 (39.6%) <60-minute responses, followed by 16 (33%) <90-minute responses, and 10 (20.8%) <120-minute responses. CONCLUSIONS: Despite increasing DCD kidney transplantation volumes in the United States, there are no standardized procurement biopsy practices, organ procurement organization preoperative protocols, or consensus definition or limits of WIT. Agreement on terminology may facilitate rapid clinical communication, efficiency of organ allocation and utilization, recording of data, research, and improvements in policy.

Long-term Survival of Grafts From Small and Very Small Pediatric Donors in Women vs Men With End-stage Kidney Disease.

This cohort study compares graft survival of kidneys from small and very small pediatric donors in women vs men with end-stage kidney disease.