Live Donors for First Kidney Transplant Improve Kids' Life-Years

When facing the likelihood of requiring at least two kidney transplants in their lives, pediatric patients with kidney failure who receive their first transplant from live kidney donor have more favorable outcomes vs those who receive organs from deceased donors, new research shows.

"Opting for a live donor kidney first provides more net life-years under most scenarios; opting for a deceased donor kidney first and delaying the live donor to be a backup in a pediatric recipient is preferred only under a few narrow conditions," write the authors in research published this week in JAMA Network Open.

Organ allocation protocols often prioritize pediatric patients to receive the highest quality deceased donor kidneys. When patients also have the option of receiving a kidney from a live donor, such as a family member, some may choose to save that option for later use and take advantage of the available deceased donor organ first, while running the risk of possibly losing the opportunity for the live donor organ later in life.

Access to multiple deceased donor transplants did not compensate for missing the live donor transplant opportunity, the authors found.

"This study found that a pediatric cohort with access to multiple deceased donor kidneys would not, on average, outperform a cohort that also has access to live donor kidneys," the authors note.

However, data are lacking on the key question of whether the sequence of receiving a live vs a deceased donor kidney transplant has any effect on long-term patient survival.

Live vs Deceased Donor Kidney Transplant in Pediatric Patients

To investigate the issue, first author Bryce A. Kiberd, MD, of Dalhousie University, in Halifax, Nova Scotia, and colleagues evaluated data from the US Renal Data System 2019 Report on pediatric patients who were either awaiting a transplant, had received a transplant, or had experienced graft failure. Survival data on adult patients from the report were also analyzed.

Two scenarios were considered, using a decision analytic Markov model. In the first, patients received a live donor-kidney transplant without waiting, and if this failed, they had the opportunity to return to the waiting list and obtain a deceased donor transplant.

Under the second scenario, patients initially on the waiting list received a deceased donor transplant, and if that failed, they received a subsequent live donor transplant. The scenario also considered the possibility of a live donor not being available later, in which case the patient would need to wait for a second deceased donor transplant.

The life-year estimates with the models were assessed for recipients at ages 3, 5, 10, 15, 20, and 25 years.

Receipt of Live Donor Kidney Increases Net Life-Years

The results showed that receipt of a live donor kidney first followed by a deceased donor kidney was associated with significant increases in net life-years over the course of a lifetime, compared with the reverse sequence, among those aged 5 (1.82 [95% CI, 0.87 – 2.77] additional life-years) and aged 20 (2.23 [95% CI, 1.31 – 3.15] additional life-years).

There were meanwhile no significant benefits overall in net life-years based on sequence of live vs deceased donor kidneys among patients aged 10 (0.36 [95% CI, -0.51 to 1.23] additional life-years) and 15 (0.64 [95% CI, -0.15 to 1.39] additional life-years).

A key reason for the lack of benefit with initial live donor kidney transplant among those 10 to 14 is likely that the age group has the lowest waiting-list mortality, the authors speculate.

"Because of the relatively high waiting-list mortality of patients younger than 10 years, they are better served with a live donor-first sequence," they explain.

Some exceptions were observed in prediction models when considering various caveats.

For instance, for those aged 10 years, a live donor-deceased donor sequence was more beneficial under the condition that eligibility for a second transplant was low (2.09 [95% CI, 1.20 – 2.98] additional life-years) or if the live donor was no longer available (2.32 [95% CI, 1.52 – 3.12] additional life-years).

And for those aged 15 years, the live donor-deceased donor sequence was favorable if the eligibility for a second transplant was low (1.84 [95% CI, 0.96 – 2.72] additional life-years) or if the live donor was no longer available (2.49 [95% CI, 1.77 – 3.27] additional life-years).

While the data did not allow for analysis of trends in sequential preferences, senior author Karthik K. Tennankore, MD, a nephrologist and associate professor of medicine at Dalhousie University's Department of Medicine, told Medscape Medical News that "we speculate that many end up using sequential deceased donor organs."

The factors underpinning those decisions may include perceptions that "it is convenient to get a high-quality deceased donor organ quickly for pediatric recipients."

In addition, there may be the belief that "it's a much longer wait and the quality of [a deceased donor] organ will be lower for an adult recipient."

Declines in Live Donor Kidney Transplantation Are Highest Among Pediatric Patients

Live donor kidney transplant rates have decreased in the US in the past 2 decades, particularly among pediatric patients, with data showing that, compared with rates from 2001–2005, there were 41% fewer live donor kidney recipients among pediatric patients in 2015–2019, the authors note.

In comparison, live donor kidney transplants decreased by 27% in those aged 18 to 34 and increased by 21% in recipients older than 50 in the same periods.

Factors in general could include stricter eligibility criteria for live donors, while the decline among pediatric patients is partly the result of efforts to prioritize those recipients for the higher quality deceased donor kidneys, the authors speculate.

However, the current findings suggest those measures could have unintended negative implications of reducing potential benefits from live donor organs.

"Prioritization of deceased donor kidney transplant for pediatric recipients has greatly improved patient survival but may have inadvertently reduced live donor rates and remaining life-years," the authors note.

"The reduction in live donors in this population during the last 20 years has and will have a significant negative effect on patient outcomes," they add. "Preemptive live donor transplant should be vigorously pursued for all age groups."

The authors have disclosed no relevant financial relationships.

JAMA Netw Open. Published January 6, 2022. Full text

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