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Deceased-Donor Characteristics and the Survival Benefit of Kidney Transplantation
Robert M. Merion, MD;
Valarie B. Ashby, MA;
Robert A. Wolfe, PhD;
Dale A. Distant, MD;
Tempie E. Hulbert-Shearon, MS;
Robert A. Metzger, MD;
Akinlolu O. Ojo, MD, PhD;
Friedrich K. Port, MD, MS
JAMA. 2005;294:2726-2733.
Context Transplantation using kidneys from deceased donors who meet the expanded criteria donor (ECD) definition (age  60 years or 50 to 59 years with at least 2 of the following: history of hypertension, serum creatinine level >1.5 mg/dL [132.6 µmol/L], and cerebrovascular cause of death) is associated with 70% higher risk of graft failure compared with non-ECD transplants. However, if ECD transplants offer improved overall patient survival, inferior graft outcome may represent an acceptable trade-off.
Objective To compare mortality after ECD kidney transplantation vs that in a combined standard-therapy group of non-ECD recipients and those still receiving dialysis.
Design, Setting, and Patients Retrospective cohort study using data from a US national registry of mortality and graft outcomes among kidney transplant candidates and recipients. The cohort included 109 127 patients receiving dialysis and added to the kidney waiting list between January 1, 1995, and December 31, 2002, and followed up through July 31, 2004.
Main Outcome Measure Long-term (3-year) relative risk of mortality for ECD kidney recipients vs those receiving standard therapy, estimated using time-dependent Cox regression models.
Results By end of follow-up, 7790 ECD kidney transplants were performed. Because of excess ECD recipient mortality in the perioperative period, cumulative survival did not equal that of standard-therapy patients until 3.5 years posttransplantation. Long-term relative mortality risk was 17% lower for ECD recipients (relative risk, 0.83; 95% confidence interval, 0.77-0.90; P<.001). Subgroups with significant ECD survival benefit included patients older than 40 years, both sexes, non-Hispanics, all races, unsensitized patients, and those with diabetes or hypertension. In organ procurement organizations (OPOs) with long median waiting times (>1350 days), ECD recipients had a 27% lower risk of death (relative risk, 0.73; 95% confidence interval, 0.64-0.83; P<.001). In areas with shorter waiting times, only recipients with diabetes demonstrated an ECD survival benefit.
Conclusions ECD kidney transplants should be offered principally to candidates older than 40 years in OPOs with long waiting times. In OPOs with shorter waiting times, in which non-ECD kidney transplant availability is higher, candidates should be counseled that ECD survival benefit is observed only for patients with diabetes.
Author Affiliations: Departments of Surgery (Dr Merion) and Internal Medicine (Dr Ojo), University of Michigan Health System, Ann Arbor; Scientific Registry of Transplant Recipients, Ann Arbor (Drs Merion, Wolfe, Ojo, and Port and Mss Ashby and Hulbert-Shearon); Department of Biostatistics, University of Michigan, Ann Arbor (Dr Wolfe and Mss Ashby and Hulbert-Shearon); Department of Surgery, State University of New York Health Science Center at Brooklyn (Dr Distant); TransLife-Florida Hospital Medical Center, Orlando (Dr Metzger); and University Renal Research and Education Association, Ann Arbor (Dr Port).
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