Contributed by Ty Dunn, MD, MS
Transplant provides the best outcomes and quality of life for patients with end-stage renal disease. The waiting list for donor kidneys, however, has grown dramatically, nearly doubling since 2004,1 and far out-distances available organs. Recent research efforts have turned to re-evaluating donor organ criteria and transplant performance measures in hopes of expanding the pool of available donor organs. In this patient case, a donor organ identified as having an increased risk of graft failure provides a successful transplant outcome for a patient with significant comorbidities.
A 74-year-old female patient with end-stage renal disease was referred to the University of Minnesota Health Transplant Care Clinic for a kidney transplant evaluation. She had a host of coexisting health conditions, including nonrheumatic aortic valve stenosis, coronary artery disease, type 2 diabetes, anemia of chronic kidney disease, and hypertension. The patient was receiving at-home peritoneal dialysis for kidney failure. She had not located a living donor.
The patient was placed on the United Network of Organ Sharing transplant waiting list for a donor kidney. Owing to the patient’s age and comorbidities, however, she was at an increased risk of being removed from the list before receiving a kidney, since the average wait time for her blood type is 5 years. In 2016, after the patient’s initial presentation in clinic, the University of Minnesota Transplant Program joined the first cohort in the Collaborative Innovation and Improvement Network (COIIN) for organ transplant, a study that assesses the use of expanded donor criteria and works to refine existing methods for matching available deceased-donor kidneys with appropriate recipients. The Transplant Program’s extensive experience in complex and high-risk transplant procedures identified them for participation in the study.2
While participating within the COIIN study, University of Minnesota Health transplant surgeons received notice of an available matching kidney from a 63-year-old deceased donor. The donor had been a smoker with a 10-year history of diabetes. Kidney biopsy showed 22% glomerular scarring. The kidney donor profile index score (KDPI) was 87%, indicating an increased risk of early graft failure3 and an average organ longevity of approximately 5.6 years.4 Kidney function, however, was good, with the donor’s serum creatinine level measured at below 1.0 mg/dL.
The patient agreed to undergo transplant, and surgeons performed a successful kidney transplant on the patient, then aged 77. A year later, at age 78, the patient’s serum creatinine level was 0.84 mg/dL, and she is home enjoying life with her husband.
Kidneys from living donors are associated with the best outcomes; however, deceased-donor kidneys can provide patients with good kidney function and extended life expectancy. In this patient’s case, a deceased-donor kidney with normal function but a lower-longevity/ higher-risk KDPI score enabled a successful outcome and improved quality of life, allowing the patient to avoid the risk of morbidity and mortality associated with continued dialysis.
The number of patients awaiting transplant continues to far exceed available donor organs. In hopes of expanding access, a new initiative re-evaluates the use of a subset of deceased-donor kidneys.Continue reading