Background: In 2002, UNOS proposed the use of Expanded Criteria Donors (ECD=brain dead donor > 60 years, or 50-59 years with two criteria: CVA as cause of death, history of hypertension, creatinin level >1.5mg/dL. Regarding the high number of studies related the association ECD/SCD and survival outcomes, we performed a meta-analysis to validate the ECD as an indicator of marginal donor.

Methods: Studies related to the comparison of long-term outcomes between ECD and SCD kidney recipients using multivariable analyses, or reporting survival curves for ECD recipients were included. Only studies with adequate methodology (inclusion criteria listed, endpoint definitions, respect of the ECD rule, appropriate statistical analyses, etc) were retained.

Results: Among 2336 publications identified, only 32 were finally included after inclusion criteria verification. 5 studies reported appropriately HR, all concluded to poorer outcomes in ECD. 29 studies reported survival curves. At 5 year post-transplantation, the pooled patient survival probabilities were respectively 78.4% and 86.4% among ECD and SCD recipients, the pooled graft survival probabilities were 75.5% and 84.6% and the pooled graft-patient survival were 61.3% and 75.0%. Differences in survival outcomes between ECD and SCD recipient may be lower in Europe than in North America (by comparing death survival probability, European pooled HR=1.32 vs. North American pooled HR=1.73).

Conclusion: Non-adjusted pooled survival curves demonstrated that ECD kidneys have lower worse prognosis than SCD kidneys, but differences are less marked in Europe than in USA. Moreover, all the study with adequate methodology and provided adjusted HR were from USA. Therefore, except in USA, the use of the ECD as an indicator of marginal donor should be use with caution until publication of other worldwide studies with appropriate methodology.≥≥≥≥≥

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