Diabetic donor kidneys provide survival advantage in high-risk waitlisted patients
At centres with long wait times, kidney transplant-waitlisted patients at high risk of mortality may benefit most from transplantation with diabetic donor kidneys, which, while associated with higher mortality compared with nondiabetic donor kidneys, afford greater survival benefit compared with remaining on the waitlist, according to an observational study from the United States.
In a cohort of 437,619 adult kidney transplant candidates from the Organ Procurement and Transplantation Network database, including 8,101 recipients of diabetic donor kidneys and 126,560 recipients of nondiabetic donor kidneys, mortality rate was 35 deaths per 1,000 person-years among transplant recipients. The median follow-up was 8.9 years. [Clin J Am Soc Nephrol 2017;12:974-982]
Compared with remaining on the waitlist or transplantation with a nondiabetic donor kidney, receipt of diabetic donor kidney was associated with a 9-percent lower mortality (adjusted hazard ratio [HR], 0.91; 95 percent CI, 0.84 to 0.98).
Of note was that mortality risk did not significantly differ between recipients of nondiabetic donor kidneys with a Kidney Donor Profile Index (KDPI) score >85 percent and recipients of diabetic donor kidneys with a KDPI score >85 percent (adjusted HR, 0.86 vs 1.09, respectively).
Survival benefit with diabetic donor kidney transplantation was greatest among diabetic patients at centres with long waitlist times but was not observed among patients aged <40 years.
“Although diabetic donor kidneys contribute additional mortality risk compared with nondiabetic deceased donor kidneys, this study highlights the importance of continuing to use marginal donor kidneys in appropriate circumstances,” said lead author Dr Jordana Cohen from the Hospital of the University of Pennsylvania in Philadelphia.
Cohen highlighted the evident reservations to use diabetic kidneys to date, given the substantial percentage of transplant centres that still do not transplant diabetic donor kidneys into potential candidates.
While the use of marginal donor kidneys has been a necessary response to the donor organ shortage, “diabetic donor kidneys have the potential to shorten waitlist times and ideally reduce the risk of death on the waitlist [when accepted by appropriate candidates],” Cohen said.
Thus, diabetic donor kidneys offer the greatest potential benefit to patients in areas with the longest waitlist times and with the highest risk of dying on the waitlist, she added.
In an editorial, Dr Richard Formica Jr from the Yale University School of Medicine in New Haven, Connecticut, calls the work of Cohen et al. an important study providing data to support the use of deceased donor kidneys that are likely to be discarded. [Clin J Am Soc Nephrol 2017;12:871-873]
“[The study] adds to the many laudable efforts to both increase the number and improve utilization of deceased donor kidneys,” Formica wrote.
However, he also stressed that the finding of diabetic donor kidneys providing potential survival benefit must be viewed in the context of the larger problem facing the nephrology community as it struggles to care for patients with end-stage renal disease: lack of access to kidney transplantation.
Although the lack of access should be addressed on many fronts—including improved population health, earlier identification of precritical disease, advancement in pharmacologic therapy, and novel biomedical and technological approaches—Formica pointed out that outcomes of such strategies remain in the future, while the need is immediate.
“Presumed consent [for organ donation] may not be a viable option in the United States; however, the current conversation about how to solve the crisis of too many people in need of a kidney and not enough available organs must expand beyond the comfortable topics of reducing organ discards and increasing living kidney donation,” he said.