Early Graft Loss after Deceased-Donor Kidney Transplantation: What are the Consequences?

Abstract Background Decreasing kidney discards continues to be of paramount importance for improving organ transplant access, but transplantation of non-ideal deceased donor kidneys may have higher inherent risks of early graft loss (EGL). Patients with EGL (defined as graft failure within 90 days following transplant) are allowed reinstatement of waiting time according to UNOS policy. The purpose of this study was to examine outcomes for patients experiencing EGL. Study Design We performed a single center retrospective review of adult deceased donor kidney transplant (DDKT) alone recipients from 2001-2018 comparing those with EGL (including primary non-function [PNF]) to those without. Results EGL occurred in 103 (5.5%) of 1,868 patients including 57 (55%) PNF, 25 (24%) deaths, 16 (16%) thrombosis, 3 (3%) rejection, and 2 (2%) disease recurrence. Kidney Donor Profile Index (KDPI) >85% and donation after circulatory death (DCD) DDKTs did not increase risk of either EGL or PNF unless combined with prolonged cold ischemic time (CIT). For KDPI >85% with CIT >24 hours, the risk of EGL or PNF was tripled (EGL OR=2.9, 95% CI=1.6-5.2; PNF OR=3.6, 95% CI=1.7-7.7). For DCD with CIT >24 hours, increased risks were likewise seen for EGL (OR=2.4, 95% CI=1.3-4.3) and PNF (OR=3.2, 95% CI=1.5-7). One-year and 5-year patient survival rates were 60% and 50% after EGL, 80% and 73% after PNF, and 99% and 87% for controls. Only 24% of either EGL or PNF patients were re-transplanted. Conclusions EGL and PNF were associated with low re-transplant rates and inferior patient survival. Prolonged CIT compounds risks associated with KDPI >85% and DCD donor kidneys. Thus, policies promoting rapid allocation and increased local use of these kidneys should be considered.