Merion RM et al. (2005) Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 294: 2726–2733

Nearly 42% of all patients on the US renal transplant waiting list, including 31% of all candidates younger than 40 years, have chosen to accept kidneys from EXPANDED CRITERIA DONORS (ECDS). A retrospective analysis of data from the US Scientific Registry of Transplant Recipients has revealed, however, that many of these self-selected patients would derive no survival advantage from earlier ECD transplantation compared with waiting for a non-ECD kidney.

The analysis included recipients of kidneys from deceased ECDs (n = 7,790), and from living or deceased non-ECDs (n = 56,255), as well as wait-listed patients who did not undergo renal transplantation (n = 45,082). A greater percentage of patients in the ECD group died during the first two post-transplant weeks than in the other groups. Despite this, after 3.5 years, the cumulative survival rate of recipients of kidneys from ECDs slightly exceeded that of patients who received non-ECD grafts plus those who remained on dialysis (76% vs 75%, respectively, at 5 years). ECD transplant recipients had a lower adjusted risk of death beyond 33 weeks post-transplantation.

Subgroup analyses showed that receipt of ECD-derived kidneys conferred a significant survival benefit upon specific patient cohorts (those older than 39 years, those with diabetes and those who had been wait-listed for >1,350 days; P<0.001 for all) but others (those younger than 40 years and those who had been wait-listed for 1,350 days) did not derive any significant survival benefit.

These results might spur decision makers to develop an allocation policy for ECD kidneys based on age, presence of diabetes and waiting time. Patients should at least be advised of their own likely individual survival benefit when deciding whether to accept an ECD kidney.