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Transplant recipients with kidneys from donors who underwent dialysis had significantly higher risk for delayed graft function (DGF) but no long-term differences in graft failure, kidney function, or death, according to a retrospective cohort study.

Among 954 such transplant recipients, DGF was substantially more common (59.2% vs 24.6%; adjusted OR 4.17, 95% CI 3.28-5.29) compared with matched patients who received kidneys that had not undergone dialysis, found Chirag Parikh, MD, of Johns Hopkins University in Baltimore, and colleagues.

However, at a median follow-up of 34 months, there were no significant differences in risk for graft failure (HR 0.90, 95% CI 0.70-1.15) or death (HR 0.76, 95% CI 0.55-1.04). Kidney function at 12 months was also not different between the two groups, with similar estimated glomerular filtration rate (eGFR; 64.7 vs 65.1 mL/min/1.73 m², between-group difference 0.51, 95% CI -3.26 to 4.42), Parikh and co-authors reported in .

"Given the severe shortages of organs and the increases in the rates of discarded kidneys from potential donors, there is growing interest in using less-than-ideal donor kidneys (such as kidneys from deceased donors with AKI [acute kidney injury])," the researchers wrote.

"Considering the high incidence of DGF after receiving kidneys from donors who underwent dialysis, kidneys from these donors should be considered for recipients who may be sufficiently healthy to tolerate repeated hemodialysis sessions after the transplant if DGF occurs," they added.

Parikh and colleagues analyzed data from the U.S. Organ Procurement and Transplant Network from 2010 to 2018. During that time, 1.4% of deceased donors underwent dialysis prior to donation (805 of more than 58,000 donors.) The most common reason was AKI (76%). An additional 14% underwent dialysis for alcohol poisoning and 10% for other reasons like severe hyperkalemia, acidosis, hypervolemia, and hyperammonemia.

The study included 514 donors who underwent dialysis and 954 recipients who received one of their kidneys. The researchers compared outcomes in this group with a matched group of 514 donors who had not undergone dialysis and 990 recipients who received one of their kidneys. The main outcomes included delayed graft function (defined as receipt of dialysis by the recipient 1 week or sooner after transplant), all-cause graft failure, and death.

In an accompanying the study, Xingxing Cheng, MD, and Colin Lenihan, MBBCh, PhD, both of the Stanford University School of Medicine in California, urged careful donor selection despite this demonstration of feasibility.

"On its face, using kidneys from donors who received dialysis prior to dying seems counterintuitive," they wrote. "However, kidneys have a remarkable potential for regeneration and recovery even after severe insults."

For transplants from these donors to be viable, kidneys with a high likelihood of recovering after transplant must be reliably identified, they said. "In this study, the donors belong to the category of patients in whom kidney recovery would be expected because they were young with good baseline kidney function and the duration of their dialysis was mostly short," they noted.

Even so, the overall number of kidneys obtained from these donors is likely to be small compared with the overwhelming demand, Cheng and Lenihan added. "In addition, the current transplant regulatory and reimbursement environment will tend to deter such expansion for many programs," they said.

Parikh and colleagues pointed out that the study was subject to confounding and selection bias, as kidneys from younger and healthier donors were more likely to be selected for transplant. In addition, the study lacked information on patient characteristics including race, comorbidities, and changes in immunosuppression over time, they said.

There was large geographic variation in the practice of procuring and accepting kidneys from donors who had received dialysis, the researchers said. "This suggests that more kidneys might become available if organ procurement organizations and transplant centers carefully expand their threshold of offering dialysis to stabilize donors with severe AKI, as well as expand their kidney procurement and acceptance criteria to donors receiving dialysis but not currently considered eligible because of severe AKI," the group suggested.

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