Chopra Bhavna, Sureshkumar Kalathil K
Division of Nephrology and Hypertension, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States.
World J Transplant. 2018 Aug 9;8(4):102-109. doi: 10.5500/wjt.v8.i4.102.
To evaluate the outcomes of transplanting marginal kidneys preemptively compared to better-quality kidneys after varying dialysis vintage in older recipients.
Using OPTN/United Network for Organ Sharing database from 2001-2015, we identified deceased donor kidney (DDK) transplant recipients > 60 years of age who either underwent preemptive transplantation of kidneys with kidney donor profile index (KDPI) ≥ 85% (marginal kidneys) or received kidneys with KDPI of 35%-84% (better quality kidneys that older wait-listed patients would likely receive if waited longer) after being on dialysis for either 1-4 or 4-8 years. Using a multivariate Cox model adjusting for donor, recipient and transplant related factors- overall and death-censored graft failure risks along with patient death risk of preemptive transplant recipients were compared to transplant recipients in the 1-4 and 4-8 year dialysis vintage groups.RESUTLSThe median follow up for the whole group was 37 mo (interquartile range of 57 mo). A total of 6110 DDK transplant recipients above the age of 60 years identified during the study period were found to be eligible to be included in the analysis. Among these patients 350 received preemptive transplantation of kidneys with KDPI ≥ 85. The remaining patients underwent transplantation of better quality kidneys with KDPI 35-84% after being on maintenance dialysis for either 1-4 years ( = 3300) or 4-8 years ( = 2460). 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 (HR 1.01, 95%CI: 0.90-1.14, = 0.84 and HR 0.96, 95%CI: 0.79-1.16, = 0.66 respectively) or 4-8 years (HR 0.82, 95%CI: 0.63-1.07, = 0.15 and HR 0.81, 95%CI: 0.52-1.25, = 0.33 respectively). 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 (HR 0.99, 95%CI: 0.87-1.12, = 0.89) but lower compared to patients who were on dialysis for 4-8 years (HR 0.74, 95%CI: 0.56-0.98, = 0.037).
In summary, our study supports accepting a "marginal" quality high KDPI kidney preemptively in older wait-listed patients thus avoiding dialysis exposure.
评估在老年受者中，与在不同透析龄后移植质量更好的肾脏相比，抢先移植边缘肾脏的效果。
利用2001年至2015年的器官共享联合网络（OPTN/United Network for Organ Sharing）数据库，我们确定了年龄大于60岁的已故供体肾脏（DDK）移植受者，这些受者要么接受了肾脏捐赠者特征指数（KDPI）≥85%的肾脏抢先移植（边缘肾脏），要么在透析1 - 4年或4 - 8年后接受了KDPI为35% - 84%的肾脏移植（如果等待更长时间，老年等待名单上的患者可能会接受的质量更好的肾脏）。使用多变量Cox模型，对供体、受者和移植相关因素进行调整，比较抢先移植受者与透析龄为1 - 4年和4 - 8年组的移植受者的总体和死亡截尾的移植物失败风险以及患者死亡风险。
全组的中位随访时间为37个月（四分位间距为57个月）。在研究期间确定的6110名年龄大于60岁的DDK移植受者中，发现有资格纳入分析。在这些患者中，350例接受了KDPI≥85的肾脏抢先移植。其余患者在维持透析1 - 4年（n = 3300）或4 - 8年（n = 2460）后接受了KDPI为35% - 84%的质量更好的肾脏移植。与在维持透析1 - 4年（HR 1.01，95%CI：0.90 - 1.14，P = 0.84和HR 0.96，95%CI：0.79 - 1.16，P = 0.66）或4 - 8年（HR 0.82，95%CI：0.63 - 1.07，P = 0.15和HR 0.81，95%CI：0.52 - 1.25，P = 0.33）后接受较低KDPI肾脏的组相比，抢先移植高KDPI肾脏受者的调整后总体移植物失败风险和死亡截尾移植物失败风险相似。与在维持透析1 - 4年后接受较低KDPI肾脏的组相比，抢先移植高KDPI肾脏受者的调整后患者死亡风险相似（HR 0.99，95%CI：0.87 - 1.12，P = 0.89），但与透析4 - 8年的患者相比更低（HR 0.74，95%CI：0.56 - 0.98，P = 0.037）。
总之，我们的研究支持在老年等待名单上的患者中抢先接受“边缘”质量的高KDPI肾脏，从而避免透析暴露。
