Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland.
JAMA Surg. 2020 Mar 1;155(3):e195472. doi: 10.1001/jamasurg.2019.5472. Epub 2020 Mar 18.
Living kidney donation is associated with increased long-term risk of end-stage renal disease (ESRD). An early postdonation marker of ESRD risk could improve postdonation risk assessment and counseling for kidney donors and allow early intervention for donors at increased risk.
To determine the association between renal function in the first 6 months postdonation and subsequent risk of ESRD in kidney donors.
DESIGN, SETTING, AND PARTICIPANTS: This secondary analysis of a prospective national cohort uses a population-based registry of all living kidney donors in the United States between October 26, 1999, and January 1, 2018, with follow-up through December 31, 2018. All kidney donors who had donated in the date range and had serum creatinine measured at 6 months (±3 months) postdonation were included.
Renal function as measured by estimated glomerular filtration rate 6 months after donation (eGFR6).
End-stage renal disease, ascertained via linkage to Centers for Medicare & Medicaid Services data.
A total of 71 468 living kidney donors were included (of 109 065 total donors over this period). Their median (interquartile range) eGFR6 was 63 (54-74) mL/min/1.73 m2. Cumulative incidence of ESRD at 15 years postdonation ranged from 11.7 donors per 10 000 donors with eGFR6 values greater than 70 mL/min/1.73 m2 to 33.1 donors per 10 000 donors with eGFR6 values of 50 mL/min/1.73 m2 or less. Adjusting for age, race, sex, body mass index, and biological relationship, every 10 mL/min/1.73 m2 reduction in eGFR6 was associated with a 28% increased risk of ESRD (adjusted hazard ratio, 1.28 [95% CI, 1.06-1.54]; P = .009). The association between predonation eGFR and ESRD was not significant and was fully mediated by eGFR6 (adjusted hazard ratio, 1.00 [95% CI, 0.86-1.17]; P = .97). The postdonation eGFR value was a better marker of ESRD than eGFR decline after donation or the ratio of eGFR6 to predonation eGFR, as determined by the Akaike information criterion (in which a lower value indicates a better model fit; eGFR6, 1495.61; predonation eGFR - eGFR6, 1503.58; eGFR6 / predonation eGFR, 1502.30).
In this study, there was an independent association of eGFR6 with subsequent ESRD risk in living kidney donors, even after adjusting for predonation characteristics. The findings support measurement of early postdonation serum creatinine monitoring in living kidney donors, and the use of these data to help identify donors who might need more careful surveillance and early intervention.
活体肾脏捐献与长期终末期肾病（ESRD）风险增加有关。ESRD 风险的早期捐献后标志物可以改善捐献者的捐献后风险评估和咨询，并允许对风险增加的捐献者进行早期干预。
确定捐献后 6 个月内肾功能与肾脏捐献者随后发生 ESRD 的风险之间的关系。
设计、地点和参与者：这是一项对美国全国队列的前瞻性队列进行的二次分析，该队列使用了 1999 年 10 月 26 日至 2018 年 1 月 1 日期间所有活体肾脏捐献者的基于人群的登记处，随访至 2018 年 12 月 31 日。所有在该日期范围内捐献且在捐献后 6 个月（±3 个月）时测量血清肌酐的肾脏捐献者均被纳入。
捐献后 6 个月时估计肾小球滤过率（eGFR6）衡量的肾功能。
通过与医疗保险和医疗补助服务数据的链接确定终末期肾病。
共纳入 71468 名活体肾脏捐献者（在此期间共纳入 109065 名捐献者）。他们的中位（四分位间距）eGFR6 为 63（54-74）mL/min/1.73 m2。在 15 年的随访中，eGFR6 值大于 70 mL/min/1.73 m2的捐献者中，每 10000 名捐献者中有 11.7 名发生 ESRD，而 eGFR6 值为 50 mL/min/1.73 m2或更低的捐献者中，每 10000 名捐献者中有 33.1 名发生 ESRD。在调整年龄、种族、性别、体重指数和生物学关系后，eGFR6 每降低 10 mL/min/1.73 m2，ESRD 的风险增加 28%（调整后的危险比，1.28 [95%CI，1.06-1.54]；P=0.009）。与 ESRD 相关的预测 eGFR 无显著相关性，并且完全由 eGFR6 介导（调整后的危险比，1.00 [95%CI，0.86-1.17]；P=0.97）。根据赤池信息量准则（其中较低的值表示更好的模型拟合；eGFR6，1495.61；eGFR6 减去捐献后的 eGFR，1503.58；eGFR6 除以捐献前的 eGFR，1502.30），与捐献后 eGFR 下降或 eGFR6 与捐献前 eGFR 的比值相比，eGFR6 是 ESRD 的更好标志物。
在这项研究中，即使在调整了预测特征后，eGFR6 与活体肾脏捐献者随后发生 ESRD 的风险之间仍存在独立关联。这些发现支持对活体肾脏捐献者进行早期捐献后血清肌酐监测，并利用这些数据来帮助确定可能需要更仔细监测和早期干预的捐献者。
