Assessing Kidney Transplantation Using ECMO-Supported Donors Within a KDPI-Based Allocation System

Peter J Altshuler; Devon J Pace; William A Preston; Sage A Vincent; Ashesh P Shah; Jaime M Glorioso; Warren R Maley; Adam M Frank; Carlo B Ramirez; Sharon West; Richard Hasz Jr; Adam S Bodzin

doi:10.1097/TXD.0000000000001521

Assessing Kidney Transplantation Using ECMO-Supported Donors Within a KDPI-Based Allocation System

Transplant Direct. 2023 Oct 10;9(11):e1521. doi: 10.1097/TXD.0000000000001521. eCollection 2023 Nov.

Affiliations

¹ Department of Surgery, Thomas Jefferson University, Philadelphia, PA.
² Gift of Life Donor Program, Philadelphia, PA.

Abstract

Background: Organ donors supported by extracorporeal membrane oxygenation (ECMO) have historically been considered high-risk and are judiciously utilized. This study examines transplant outcomes using renal allografts from donors supported on ECMO for nondonation purposes.

Methods: Retrospective review of the Gift of Life (Pennsylvania, New Jersey, Delaware) organ procurement organization database, cross-referenced to the Organ Procurement and Transplantation Network database, assessed kidney transplants using donors supported on venoarterial (VA) and venovenous (VV) ECMO for nondonation purposes. Transplants using VA- and VV-ECMO donors were compared with Kidney Donor Profile Index (KDPI)-stratified non-ECMO donors. Regression modeling of the entire ECMO and non-ECMO populations assessed ECMO as predictive of graft survival. Additional regression of the ECMO population alone assessed for donor features associated with graft survival.

Results: Seventy-eight ECMO donors yielded 128 kidney transplants (VA: 80, VV: 48). Comparing outcomes using these donors to kidney transplants using organs from KDPI-stratified non-ECMO donors, VA- and VV-ECMO donor grafts conferred similar rates of delayed graft function and posttransplant renal function to KDPI-matched non-ECMO counterparts. VA-ECMO kidneys demonstrated superior graft survival compared with the lowest-quality (KDPI 86%-100%) non-ECMO kidneys and similar graft survival to KDPI <85% non-ECMO kidneys. VV-ECMO showed inferior graft survival to all but the lowest-quality (KDPI 86%-100%) non-ECMO kidneys. VV-ECMO, but not VA-ECMO, was associated with increased risk of graft loss on multivariable regression (hazard ratios-VA: 1.02, VV: 2.18). Higher KDPI, advanced age, increased body mass index, hypertension, and diabetes were identified as high-risk features of ECMO donors.

Conclusions: Kidney transplantation using appropriately selected ECMO donors can safely expand the donor pool. Ongoing studies are necessary to determine best practice patterns using kidneys from these donors.