December 05, 2019
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Tool predicts risk of graft loss in children undergoing living donor kidney transplantation

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A donor risk index designed specifically for pediatric transplant candidates was effective in assessing risk of graft loss in living donor kidney transplantation.

“The Kidney Donor Risk Index (KDRI) and related Kidney Donor Profile Index (KDPI) were created to quantify the risk of graft loss due to donor factors in adult [deceased donor kidney transplantation] DDKT,” Heather L. Wasik, MD, of the department of pediatric nephrology at Johns Hopkins University School of Medicine, and colleagues wrote. “Recently, a living donor KDPI (LKDPI) was created to quantify the risk of graft loss due to donor factors in adults undergoing [living donor kidney transplantation] LDKT, on the same scale as the DD KDPI. Thus, the LKDPI aids in organ selection by allowing for comparison of living donor (LD) kidneys to each other and to deceased donor (DD) kidneys.”

According to the researchers, although pediatric kidney transplant candidates have multiple potential living donors, there is no evidence-based tool to compare potential living donors nor to assesses the impact of choosing transplantation with either a marginal living donor or deceased donor kidney. With this in mind, they conducted a retrospective cohort study of 7,155 pediatric patients who underwent kidney transplantation for the first time between January 2005 and December 2015 (37% living donor vs. 63% deceased).

First determining the living donor characteristics associated with graft loss (including, HLA-B mismatch, HLA-DR mismatch, donor systolic blood pressure and donor estimated GFR), they then created a pediatric-specific living donor KDPI.

Researchers found the median living donor KDPI was -25 (interquartile range: -56 to 12) with 68% of donors having less risk than any deceased donor kidney vs. 25% with more risk than the median deceased donor kidney. At 10 years, recipients of kidneys with higher living donor KDPI had a higher cumulative incidence of graft loss (39% experienced graft loss for KDPI 20 vs. 19% for KDPI < -60).

They suggested these findings “challenge the common belief that a living donor is always superior to a deceased donor kidney,” because more than 10% of living donors had a KDPI above the median score for deceased donors.

“Although the implications of rejecting a LD kidney for a DD kidney with a lower KDPI must be considered given the scarcity of DD kidneys, many pediatric patients will require repeated KT and thus it is important to optimize graft survival in this population,” they wrote.

“[T]he [pediatric] P-LKDPI may help in the selection of a LD when multiple LDs are available, may help to choose a DD kidney when a potential LD exists, and may help to evaluate offers through KPD.” – by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.