*Purpose: Primary nonfunction (PNF) defined as dialysis dependent for 3 months post-transplant, is a rare but catastrophic outcome for recipients. PNF also negatively impacts transplant center performance measures and subsequent kidney offer acceptance at that center. Accurate risk stratification of kidneys is essential to reducing the current high kidney discard rate in the United States. In this study, we evaluated the potential role of novel biomarkers in the risk stratification of deceased-donor kidneys for the development of PNF post transplantation, to allow for more appropriate allocation decisions.

*Methods: The Deceased Donor Study (DDS) includes 1137 recipients (862 donors) that were prospectively enrolled across 5 OPOs and transplanted in 13 centers from 2010 through 2013. NGAL, KIM1, IL-18, LFAPB and YKL-40 were measured in donor urine obtained at the time of donor nephrectomy. We obtained outcomes information through a detailed chart review at the participating centers.

*Results: Among the 1137 transplant recipients, 18 (1.5%) patients experienced PNF. These kidneys were obtained from donors that were older (51 vs 41 yrs, p=0.01) with higher KDRI (1.59 vs 1.31, p<0.01) and more likely to be DCD (39% vs 19%, p<0.01). No differences were noted in the cause of death, comorbidities (DM, HTN, HCV), use of hypothermic perfusion, acute kidney injury or terminal creatinine (1.34 vs 1.21 mg/dL, p=0.51). Recipients of kidneys that developed PNF were also older (62 vs 54 yrs, p=0.01). Median urinary LFAPB was over 2.5 fold higher for kidneys that experienced PNF (39 [17 - 114] vs 14 [4 - 60] ng/mL). No differences were noted in KIM1, IL-18, NGAL and YKL-40 levels.

*Conclusions: Clinical phenotyping of donors does not identify donor kidneys that result in PNF. The use of the donor urinary biomarker LFABP, obtained from the donor prior to procurement may help in risk stratification by identifying very donor kidneys that are at a high risk of PNF.

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