OBJECTIVES - To assess the long term outcomes of transplantation using expanded criteria donors (ECD; donors aged ≥60 years or aged 50-59 years with vascular comorbidities) and assess the main determinants of its prognosis.
DESIGN - Prospective, population based cohort study.
SETTING - Four French referral centres.
PARTICIPANTS - Consecutive patients who underwent kidney transplantation between January 2004 and January 2011, and were followed up to May 2014. A validation cohort included patients from another four referral centres in France who underwent kidney transplantation between January 2002 and December 2011.
MAIN OUTCOME MEASURES - Long term kidney allograft survival, based on systematic assessment of donor, recipient, and transplant clinical characteristics; preimplantation biopsy; and circulating levels of donor specific anti-HLA (human leucocyte antigen) antibody (DSA) at baseline.
RESULTS - The study included 6891 patients (2763 in the principal cohort, 4128 in the validation cohort). Of 2763 transplantations performed, 916 (33.2%) used ECD kidneys. Overall, patients receiving ECD transplants had lower allograft survival after seven years than patients receiving transplants from standard criteria donors (SCD; 80% v 88%, P<0.001). Patients receiving ECD transplants who presented with circulating DSA at the time of transplantation had worse allograft survival after seven years than patients receiving ECD kidneys without circulating DSA at transplantation (44% v 85%, P<0.001). After adjusting for donor, recipient, and transplant characteristics, as well as preimplantation biopsy findings and baseline immunological parameters, the main independent determinants of long term allograft loss were identified as allocation of ECDs (hazard ratio 1.84 (95% confidence interval 1.5 to 2.3); P<0.001), presence of circulating DSA on the day of transplantation (3.00 (2.3 to 3.9); P<0.001), and longer cold ischaemia time (>12 h; 1.53 (1.1 to 2.1); P=0.011). Recipients of ECD kidneys with circulating DSA showed a 5.6-fold increased risk of graft loss compared with all other transplant therapies (P<0.001). ECD allograft survival at seven years significantly improved with screening and transplantation in the absence of circulating DSA (P<0.001) and with shorter (
CONCLUSIONS - Circulating DSA and cold ischaemia time are the main independent determinants of outcome from ECD transplantation. Allocation policies to avoid DSA and reduction of cold ischaemia time to increase efficacy could promote wider implement of ECD transplantation in the context of organ shortage and improve its prognosis.
BMJ. 2015 Jul 31;351:h3557. doi: 10.1136/bmj.h3557.
Aubert O1, Kamar N2, Vernerey D1, Viglietti D3, Martinez F4, Duong-Van-Huyen JP5, Eladari D6, Empana JP1, Rabant M7, Verine J8, Rostaing L2, Congy N9, Guilbeau-Frugier C10, Mourad G11, Garrigue V11, Morelon E12, Giral M13, Kessler M14, Ladrière M14, Delahousse M15, Glotz D16, Legendre C17, Jouven X18, Lefaucheur C16, Loupy A19.
1 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France.
2 Department of Nephrology and Organ Transplantation, Rangueil, Toulouse, France INSERM U1043, Purpan, Toulouse Paul Sabatier University, Toulouse DIVAT (Données Informatiques VAlidées en Transplantation Network), France.
3 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris.
4 Department of Kidney Transplantation, Necker Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne Paris.
5 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France Department of Pathology, Necker Hospital, Paris.
6 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France Department of Renal Physiology, Georges Pompidou European Hospital, Paris.
7 Department of Pathology, Necker Hospital, Paris.
8 Department of Pathology, Saint-Louis Hospital, Paris.
9 Paul Sabatier University, Toulouse Molecular Immunogenetics Laboratory, EA 3034, Faculty of Medicine Purpan, IFR150 (INSERM), Toulouse, France Department of Immunology, Rangueil Hospital, Toulouse.
10 Paul Sabatier University, Toulouse Department of Pathology, Rangueil, Toulouse.
11 DIVAT (Données Informatiques VAlidées en Transplantation Network), France Department of Nephrology and Kidney Transplantation, Montpellier, France.
12 DIVAT (Données Informatiques VAlidées en Transplantation Network), France Department of Nephrology and Kidney Transplantation, Groupement Hospitalier, Hôpital Edouard Herriot, Lyon, France Centaure Network, France.
13 DIVAT (Données Informatiques VAlidées en Transplantation Network), France Centaure Network, France Department of Nephrology and Kidney Transplantation, Nantes, France.
14 DIVAT (Données Informatiques VAlidées en Transplantation Network), France Centaure Network, France Department of Nephrology and Kidney Transplantation, Nancy, France.
15 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France Department of Nephrology and Kidney Transplantation, Foch Hospital, Suresnes, Paris.
16 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France DIVAT (Données Informatiques VAlidées en Transplantation Network), France Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris.
17 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France DIVAT (Données Informatiques VAlidées en Transplantation Network), France Department of Kidney Transplantation, Necker Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne Paris Centaure Network, France.
18 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France Department of Cardiology, Georges Pompidou European Hospital, Paris.
19 Paris Translational Research Centre for Organ Transplantation, INSERM, UMR-S970, Paris Descartes University, 75015 Paris, France DIVAT (Données Informatiques VAlidées en Transplantation Network), France Department of Kidney Transplantation, Necker Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne Paris