*Purpose: Expanded-criteria donor (ECD) kidney transplants are at higher risk of kidney injury. Biomarkers that better predict short and long-term outcomes in ECD kidney transplant recipients are needed.

*Methods: In this prospective study, we evaluated the prognostic value of seven biomarkers of kidney injury (KIM-1, SuPAR), repair (MCP-1, YKL-40) and inflammation (MCP-1, TNFR1, TNFR2 and CXCL9) in 50 ECD kidney transplant recipients at a single center. Blood samples were collected on days 0, 7, 30, 90, 180 and 360 after transplantation (Fig. 1A). Plasma biomarker levels were measured using a Meso Scale Discovery platform. Biomarker tertiles and mean estimated glomerular filtration rate (eGFR) of different groups were compared using one-way analysis of variance (ANOVA). Linear and logistic regression analyses of biomarkers were performed to assess their predictivity of allograft outcomes.

*Results: The median age of recipients was 51 years, 74% were male, and the most common etiology of end-stage kidney disease was diabetic nephropathy. One-year patient and allograft survival were both 100%. Five patients developed biopsy-proven acute rejection. Higher day 7 tertiles of KIM-1, SuPAR, TNFR1 and TNFR2 were associated with lower eGFR at days 7 and 30 but not at day 360 (Fig. 1B). Combining day 30 eGFR and change in biomarker levels from day 7-30, we developed a multivariate logistic regression model that was able to predict stability vs. decline in eGFR from day 30-360 with an area under the receiver operating characteristic (ROC) curve of 0.85 (Fig. 1C).

*Conclusions: Single biomarker values provide a cross-sectional view of allograft status but have limited predictive value for allograft outcomes. Changes in biomarker levels over time can give a more dynamic picture of allograft status and better predict one-year outcomes.

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