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Risk factors for delayed graft function and their impact on graft outcomes in live donor kidney transplantation

International Urology and Nephrology volume 53, pages 439–446 (2021)Cite this article

Abstract

Background

Delayed graft function (DGF) is a manifestation of acute kidney injury uniquely framed within the transplant process and a predictor of poor long-term graft function1. It is less common in the setting of living donor (LD) kidney transplantation. However, the detrimental impact of DGF on graft survival is more pronounced in LD2.

Purpose

To study the effects of DGF in the setting of LD kidney transplantation.

Methods

We performed a retrospective analysis of LD kidney transplantations performed between 2010 and 2018 in the UNOS/OPTN database for DGF and its effect on graft survival.

Results

A total of 42,736 LD recipients were identified, of whom 1115 (2.6%) developed DGF. Recipient dialysis status, male gender, diabetes, end-stage renal disease, donor age, right donor nephrectomy, panel reactive antibodies, HLA mismatch, and cold ischemia time were independent predictors of DGF. Three-year graft survival in patients with and without DGF was 89% and 95%, respectively. DGF was the greatest predictor of graft failure at three years (hazard ratio = 1.766, 95% CI: 1.514–2.059, P = 0.001) and was associated with higher rates of rejection (9% vs. 6.28%, P = 0.0003). Among patients with DGF, the graft survival rates with and without rejection were not different.

Conclusion

DGF is a major determinant of poor graft functional outcomes, independent of rejection.

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Fig. 1

Availability of data and material

Available in UNOS/OPTN registry.

References

  1. Wolfe RA et al (1999) Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 341(23):1725–1730

    CAS  PubMed  Google Scholar 

  2. Nemati E et al (2014) Does kidney transplantation with deceased or living donor affect graft survival? Nephrourol Mon 6(4):e12182

    PubMed  PubMed Central  Google Scholar 

  3. Redfield RR et al (2016) Predictors and outcomes of delayed graft function after living-donor kidney transplantation. Transpl Int 29(1):81–87

    CAS  PubMed  Google Scholar 

  4. Orandi BJ et al (2015) Center-level variation in the development of delayed graft function after deceased donor kidney transplantation. Transplantation 99(5):997–1002

    CAS  PubMed  PubMed Central  Google Scholar 

  5. Butala NM et al (2013) Is delayed graft function causally associated with long-term outcomes after kidney transplantation? Instrumental variable analysis. Transplantation 95(8):1008–1014

    CAS  PubMed  PubMed Central  Google Scholar 

  6. Aceto P et al (2019) Perioperative-, recipient-, and donor-related factors affecting delayed graft function in kidney transplantation. Exp Clin Transplant 17(5):575–579

    PubMed  Google Scholar 

  7. Park HS et al (2012) Delayed graft function in living-donor renal transplantation: 10-year experience. Transplant Proc 44(1):43–46

    CAS  PubMed  Google Scholar 

  8. Yarlagadda SG et al (2008) Marked variation in the definition and diagnosis of delayed graft function: a systematic review. Nephrol Dial Transplant 23(9):2995–3003

    PubMed  PubMed Central  Google Scholar 

  9. Mallon DH et al (2013) Defining delayed graft function after renal transplantation: simplest is best. Transplantation 96(10):885–889

    CAS  PubMed  Google Scholar 

  10. Mustian MN et al (2018) Landscape of ABO-incompatible live donor kidney transplantation in the US. J Am Coll Surg 226(4):615–621

    PubMed  PubMed Central  Google Scholar 

  11. Krishnan AR et al (2016) Prolonged ischemic time, delayed graft function, and graft and patient outcomes in live donor kidney transplant recipients. Am J Transplant 16(9):2714–2723

    CAS  PubMed  Google Scholar 

  12. Ojo AO et al (1997) Delayed graft function: risk factors and implications for renal allograft survival. Transplantation 63(7):968–974

    CAS  PubMed  Google Scholar 

  13. Weber S et al (2018) Delayed graft function is associated with an increased rate of renal allograft rejection: a retrospective single center analysis. PLoS ONE 13(6):e0199445

    PubMed  PubMed Central  Google Scholar 

  14. Siedlecki A, Irish W, Brennan DC (2011) Delayed graft function in the kidney transplant. Am J Transplant 11(11):2279–2296

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Brennan DC et al (2006) Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med 355(19):1967–1977

    CAS  PubMed  Google Scholar 

  16. Hanaway MJ et al (2011) Alemtuzumab induction in renal transplantation. N Engl J Med 364(20):1909–1919

    CAS  PubMed  Google Scholar 

  17. Kasiske BL et al (2002) Preemptive kidney transplantation: the advantage and the advantaged. J Am Soc Nephrol 13(5):1358–1364

    PubMed  Google Scholar 

  18. Doshi MD et al (2011) Recipient risk factors associated with delayed graft function: a paired kidney analysis. Transplantation 91(6):666–671

    PubMed  Google Scholar 

  19. Mogulla MR, Bhattacharjya S, Clayton PA (2019) Risk factors for and outcomes of delayed graft function in live donor kidney transplantation - a retrospective study. Transpl Int 32(11):1151–1160

    PubMed  Google Scholar 

  20. Cobo G, Lindholm B, Stenvinkel P (2018) Chronic inflammation in end-stage renal disease and dialysis. Nephrol Dial Transplant 33(suppl_3):ii35-iii40

    Google Scholar 

  21. Asderakis A et al (1998) Pre-emptive kidney transplantation: the attractive alternative. Nephrol Dial Transplant 13(7):1799–1803

    CAS  PubMed  Google Scholar 

  22. Bertoni E, Salvadori M (2009) Preemptive living donor kidney transplant. G Ital Nefrol 26(4):478–487

    PubMed  Google Scholar 

  23. Parekh J, Bostrom A, Feng S (2010) Diabetes mellitus: a risk factor for delayed graft function after deceased donor kidney transplantation. Am J Transplant 10(2):298–303

    CAS  PubMed  Google Scholar 

  24. Cosio FG et al (2008) Patient survival and cardiovascular risk after kidney transplantation: the challenge of diabetes. Am J Transplant 8(3):593–599

    CAS  PubMed  Google Scholar 

  25. Schachtner T, Stein M, Reinke P (2017) Increased alloreactivity and adverse outcomes in obese kidney transplant recipients are limited to those with diabetes mellitus. Transpl Immunol 40:8–16

    CAS  PubMed  Google Scholar 

  26. Hekmat R, Eshraghi H (2010) Correlation of pretransplant hyperglycemia and delayed graft function in kidney transplantation. Iran J Kidney Dis 4(2):147–152

    PubMed  Google Scholar 

  27. Molnar MZ et al (2011) Higher recipient body mass index is associated with post-transplant delayed kidney graft function. Kidney Int 80(2):218–224

    PubMed  PubMed Central  Google Scholar 

  28. Lynch RJ et al (2009) Obesity, surgical site infection, and outcome following renal transplantation. Ann Surg 250(6):1014–1020

    PubMed  Google Scholar 

  29. Navaneethan SD et al (2009) Weight loss interventions in chronic kidney disease: a systematic review and meta-analysis. Clin J Am Soc Nephrol 4(10):1565–1574

    PubMed  PubMed Central  Google Scholar 

  30. Park KM et al (2004) Testosterone is responsible for enhanced susceptibility of males to ischemic renal injury. J Biol Chem 279(50):52282–52292

    CAS  PubMed  Google Scholar 

  31. Aufhauser DD Jr et al (2016) Improved renal ischemia tolerance in females influences kidney transplantation outcomes. J Clin Invest 126(5):1968–1977

    PubMed  PubMed Central  Google Scholar 

  32. McGee J et al (2010) Donor-recipient gender and size mismatch affects graft success after kidney transplantation. J Am Coll Surg 210(5):718-725e1 ((725-6))

    PubMed  PubMed Central  Google Scholar 

  33. Oh CK et al (2006) Gender-related differences of renal mass supply and metabolic demand after living donor kidney transplantation. Clin Transplant 20(2):163–170

    PubMed  Google Scholar 

  34. Ozdemir-van Brunschot DM et al (2016) Is the reluctance for the implantation of right donor kidneys justified? World J Surg 40(2):471–478

    PubMed  Google Scholar 

  35. Amezquita Y et al (2008) Risk factors for early renal graft thrombosis: a case-controlled study in grafts from the same donor. Transplant Proc 40(9):2891–2893

    CAS  PubMed  Google Scholar 

  36. Simpkins CE et al (2007) Cold ischemia time and allograft outcomes in live donor renal transplantation: is live donor organ transport feasible? Am J Transplant 7(1):99–107

    CAS  PubMed  Google Scholar 

  37. Treat EG et al (2014) Outcomes of shipped live donor kidney transplants compared with traditional living donor kidney transplants. Transpl Int 27(11):1175–1182

    PubMed  Google Scholar 

  38. Gill J et al (2017) Cold ischemia time up to 16 hours has little impact on living donor kidney transplant outcomes in the era of kidney paired donation. Kidney Int 92(2):490–496

    PubMed  Google Scholar 

  39. Nassiri N et al (2020) The “oldest and coldest” shipped living donor kidneys transplanted through kidney paired donation. Am J Transplant 20(1):137–144

    PubMed  Google Scholar 

  40. Foster MC et al (2013) APOL1 variants associate with increased risk of CKD among African Americans. J Am Soc Nephrol 24(9):1484–1491

    CAS  PubMed  PubMed Central  Google Scholar 

  41. Woodle ES et al (2005) Multivariate analysis of risk factors for acute rejection in early corticosteroid cessation regimens under modern immunosuppression. Am J Transplant 5(11):2740–2744

    PubMed  Google Scholar 

  42. Kasiske BL et al (1991) The effect of race on access and outcome in transplantation. N Engl J Med 324(5):302–307

    CAS  PubMed  Google Scholar 

  43. Humar A et al (2002) Risk factors for slow graft function after kidney transplants: a multivariate analysis. Clin Transplant 16(6):425–429

    CAS  PubMed  Google Scholar 

  44. Troppmann C et al (1995) Delayed graft function, acute rejection, and outcome after cadaver renal transplantation. The multivariate analysis. Transplantation 59(7):962–968

    CAS  PubMed  Google Scholar 

  45. Halloran PF, Melk A, Barth C (1999) Rethinking chronic allograft nephropathy: the concept of accelerated senescence. J Am Soc Nephrol 10(1):167–181

    CAS  PubMed  Google Scholar 

  46. Martinez-Mier G et al (2013) Rejection is a strong graft survival predictor in live donor pediatric renal transplantation using cyclosporine, mycophenolate mofetil, and steroids: 5-year outcomes in a single Mexican center. Transplant Proc 45(4):1442–1444

    CAS  PubMed  Google Scholar 

  47. Chen GD et al (2013) Donor factors predictive for poor outcomes of living donor kidney transplantation. Transplant Proc 45(4):1445–1448

    CAS  PubMed  Google Scholar 

  48. Pourfakhr P et al (2020) Half saline-bicarbonate solution as intraoperative fluid replacement therapy leads to less acidosis and better early renal function during deceased-donor transplant. Exp Clin Transpl 18(1):34–38

    Google Scholar 

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Affiliations

  1. Department of Urology and Renal Transplant, University of Toledo, 3000, Arlington Ave, MS1091, Toledo, OH, 43614, USA

    Shivashankar Damodaran, Obi Ekwenna, Puneet Sindhwani & Jorge Ortiz

  2. College of Medicine and Life Sciences, University of Toledo, 3000, Arlington Ave, Toledo, OH, 43614, USA

    Brenna Bullock

  3. Schar School of Policy and Government, George Mason University, Arlington Campus, Van Metre Hall 520, 3351 N. Fairfax Dr. MS#3B1, Arlington, VA, 22201, USA

    Mehdi Nayebpour & Naoru Koizumi

  4. Department of Surgery and Kidney Transplant, University of Toledo, 3000, Arlington Ave, MS1095, Toledo, OH, 43614, USA

    Shivashankar Damodaran, Brenna Bullock, Obi Ekwenna, Mehdi Nayebpour, Naoru Koizumi, Puneet Sindhwani & Jorge Ortiz

Authors
  1. Shivashankar Damodaran
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  2. Brenna Bullock
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  3. Obi Ekwenna
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  4. Mehdi Nayebpour
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  5. Naoru Koizumi
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  6. Puneet Sindhwani
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  7. Jorge Ortiz
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Contributions

SD: concept/design, Data analysis/interpretation, Drafting article, Critical revision of article. BB: drafting article, critical revision of article. MN: data analysis/interpretation, Statistics, Data collection. NK: data analysis/interpretation, Statistics, Data collection. OE—Critical revision of article, Approval of article. PS: critical revision of article, Approval of article. JO: concept/design, Data analysis/interpretation, Critical revision of article, Approval of article.

Corresponding author

Correspondence to Shivashankar Damodaran.

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Deidentified data from UNOS/OPTN registry, not applicable.

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Deidentified data from UNOS/OPTN registry, not applicable.

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Damodaran, S., Bullock, B., Ekwenna, O. et al. Risk factors for delayed graft function and their impact on graft outcomes in live donor kidney transplantation. Int Urol Nephrol 53, 439–446 (2021). https://doi.org/10.1007/s11255-020-02687-5

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  • DOI: https://doi.org/10.1007/s11255-020-02687-5

Keywords

  • Kidney transplantation
  • Living donors
  • Delayed graft function
  • Graft survival
  • Graft rejection