Current kidney allocation in the US includes national sharing of ECD kidneys in cases of 0 HLA- A- B DR mismatches. Concerns regarding prolonged CIT associated with national sharing of ECD kidneys have limited their utilization and have, in part, resulted in proposals to abandon national sharing of ECD kidneys.

We sought to examine the relative impact of CIT and HLA matching on long-term graft outcomes of ECD transplants in the current era.

Methods: All (n=22,041) adult transplant candidates in the US who received an ECD kidney between 2000-10 were identified using the SRTR database. Transplants were then grouped based on their CIT and HLA- A B DR match (0-6). The relative hazard for all cause graft loss was then compared between these groups using a multivariable Cox proportional hazards model, adjusting for the following covariates: recipient age, sex, race, ESRD cause, dialysis duration, and peak PRA; donor age, sex, race, cause of death; and warm ischemic time, use of pulsatile perfusion, transplant center, year of transplant.

Results: The median CIT among the n=5,723(26%) ECD transplants with shared kidneys was 25 hours (20,32) compared to 17 hrs(12,22) in the n=16,318 (74%) ECD recipients with local donor organs. The figure outlines the hazard for all cause graft loss with increasing degrees of CIT and greater HLA mismatches. The impact of CIT on graft loss is minimal in 0HLA mismatch transplants, with a similar hazard for graft loss seen in 0 HLA mismatch transplants with a CIT>24 hours and transplants with any level of HLA mismatch with CIT<12 hours. When the analysis was restricted to cases where pulsatile perfusion was NOT used, similar results were seen.

Conclusion: The long term benefits of 0HLA mismatch kidneys appear to outweight the impact of prolonged CIT in ECD transplants. These data support the sharing of ECD kidneys for 0HLA mismatch transplants.

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