Impact of Recipient and Donor Non-immunological factors on the Outcome of Expanded Criteria Deceased Donors Kidney Transplantation Dr Hajar Al Hayyan

Background Extended criteria donors (ECD) kidneys are defined as those with relative risk of graft loss > 1.7 over standard kidney and include : : Kidneys from donors aged >60 years, When the donor death is due to cerebrovascular cause In the presence of donor hypertension.

With the shortage of kidneys, ECD are being increasing used. Overall, ECD Accounted for 14.8% of transplanted kidneys in 2001 (in USA) 40% were discarded compared to 8% of the standard kidneys. The high discard rate is attributed to poor organ function /quality

Background Adjusted graft survival in ECD kidneys has been reported to be 8% lower at 1 year and 15–20% lower at 3–5 years ECD kidneys render a survival benefit but should be given principally to patients over the age of 40 years and when the waiting list is long Other factors that impair graft survival include cold ischemic time (CIT), delayed graft function (DGF), terminal donor renal function.

Objective To study the graft and patient survival and graft function in Extended Criteria deceased donor kidney transplants To study the influence of recipient and donor non- immunological factors on the outcome of Extended Criteria deceased donor kidney transplants

Methods This is a retrospective study of all DD transplants that took place in the Kingdom of Saudi Arabia between from 1 / 1/2003 to 31/12/2007. The donors’ demographic data as well as SCr at kidney retrieval were obtained. CrCl was calculated using Cockcroft- Gault (CG) formula. Data collected on acute rejection, delayed graft function (DGF), cold ischemic time (CIT), graft loss, mortality, hospitalization period, SCr & calculated CrCl (CG) at last follow up,.

Methods: We studied the effects on graft survival and function of CIT, DGF, donor renal function at the time of kidney retrieval, age of the donor and recipient and transplant centers’ output volume Kaplan-Meier Method was used to calculate graft and patient survival, Chi square to compare percentages and proportions, two-tailed independent t test to compare continuous data. Multivariate analysis was performed to determine factors that may have influenced the graft outcome

Results At retrieval the frequency of donors with CrCl (CG) 40 years were 31.7% and 32% respectively. CIT > 24 hours, DGF and acute rejection (AR) occurred in 27.1 %, 33.4% and 16.5% of cases respectively. The overall 1- and 5-year graft and patient survival rates were 88% &79.8% and 96.6 % and 92.3% respectively

The graft renal function was inferior when AR occurred ( p=0.0001), with DGF (p=0.0001), with CIT > 20 hrs (p=0.005), in older recipients (p=0.002), when the donor death was non-traumatic (p=0.022), with older donors (p=0.0001) and when donor ICUs had a bed capacity of > 20 (0.03) However, the graft renal function was not influenced by the donor renal functions at retrieval donor weight or donor- recipient gender pairings

Males87.50% Mean weight (kg)65.7 (12.4) Duration in ICU (days)7.4 (6) SCr at retrieval (umol/l)153.2 (164) Serum creatinine > 150 umol/l24.7% CrCl retrieval <60 mls/min31.7% CIT > 24 hours27.1% Age > 40 years32.0% Weight > 70 Kgs27.5% Mean CIT (hours)20.2 (7.3) Donor Details ( ) (n= 273)

Male56.50% Rate of DGF33.40% Rate of rejection16.20% Graft loss by end of follow up14.50% Mean age (yrs)33.9 (14.9) Mean duration of follow up (days)626.7 (505) Mean SCr at last follow up (umol/l)127.6 (75) CrCl (CG) at last FU (mls/min)56.4 (27) Recipient Details ( ) (n= 524)

SCr umol/l) (std)PCrCl (mls/min)P With DGF (n=145)223.7 (198.5) (27) Without DGF (n=145)139.4 (139.4)61.8 (29) With acute rejection (n=74) (2606) (28) Without rejection (n=395) 149.3(120.0) 59.0 (26) CIT<20hours (n=205) (166) (26) 0.11 CIT >20 hours (n=206)159.1 (141)54.3 (28) Right (n=221) 188 (180) Left (n=247) 155 (145)58.3 Effect of Certain factors on graft function at last F/U

Factorn 1-year graft survival3-year graft survival p Cause of death traumatic Non-Traumatic Cold ischemic time hours > 20 hours Rejection yes No retrieval umole/ > 150 umole/L Number of ICU beds < 20 ICU > 20 ICU beds

SCr at retrieval <150 umol/l SCr at retrieval >150 umol/l p Frequency of acute rejection episodes15.2%20.8%0.092 Frequency of DGF29.7%45.%0.001 SCr at the end of observation period160.7 (171)143.7 (132)0.32 Two-year graft survival83.6%84.6%0.93 Two-year patient survival96.1%95.4%0.22 Effect of donor SCr at organ retrieval on acute rejection episodes, DGF & final graft SCr,

Fig 4

Conclusions The one-and 5-year graft survival rates were excellent (88 % & 79.8%). The graft function was excellent ( SCr was 127 (+/-75) umol/l & CrCl was 56.4 (27) mls/min.) Graft survival was not negatively affected by: Acute terminal rise the donor SCr. Donor age of > 50 years.

Conclusions Graft survival was negatively affected by: CIT > 20 hours. Donor ICU of < 20 beds capacity. Inferior graft function was observed when: AR occurred CIT is > 20 hours. The right donor kidney was use Donor age > 50 years