Background: Increasing numbers of Donation after Circulatory Death (DCD) kidneys are retrieved from Expanded Criteria (EC) donors, but uncertainties persist regarding how best to assess suitability for transplantation. This study examines the value of time zero biopsy analysis of pre-existing donor kidney disease in predicting outcomes following DCD and Donation after Brain Death (DBD) kidney transplantation.

Methods: All consecutive, deceased donor, single kidney transplants performed in our centre between 06/2006 and 08/2010 (n=313) were studied. Implantation biopsies were scored for glomerular, tubular, parenchymal and vascular disease (global histology score; 0-12 as per Remuzzi et al; NEJM 2006). Kaplan-Meir estimates were used to assess patient and graft survival [mean (SD) follow up: 3.5 (1.2) years] and multivariate analyses were employed to identify factors associated with graft survival and renal function (estimated Glomerular Filtration Rate, eGFR).

Results: There was no difference in graft survival and 1-year eGFR between DCD [n=213, median (range) donor age: 54 (14-78)] and DBD [n=100, median (range) donor age: 50 (5-82)] kidneys, although the incidence of delayed graft function was higher in the former (61% vs 44% respectively, p=0.04). Although procurement from EC donors (n=111) had no impact on outcomes, survival of kidneys with global histology scores of ≥5 was significantly poorer than those that scored less (HR: 3.8. CI: 1.1-13.3, p=0.0009), with multivariate analysis confirming only cold ischaemic time over 12 hours and global histology score as independent predictors of graft survival. Notably, high histology scores conferred the same survival disadvantage for DCD and DBD kidneys, suggesting that DCD kidneys, even those procured from EC donors, are not inherently poorer than DBD kidneys. Recipient age over 65 years was the sole factor associated with patient survival (HR: 4.5, CI: 1.4-17.1, p=0.0001) and multivariate analysis revealed donor age as the only predictor of eGFR at 1 year (-0.27ml/min/1.73 m2 per year age increase, p=0.015).

Conclusion: Donor baseline kidney disease and donor age influence outcomes following deceased donor kidney transplantation but their effect is not greater for DCD kidneys. Pre-implantation biopsy analysis may aid evaluation and use of DCD and DBD kidneys from EC donors.

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