Study: Deceased-donor kidney transplants do not benefit all patients equally

A major international study, being presented today at the 62nd ERA Congress, reveals that the long-accepted survival advantage of deceased-donor kidney transplantation does not extend equally to every patient and every donor organ.

A large-scale analysis, drawing on data from the European Renal Association (ERA) Registry, examined five-year survival outcomes in 64,013 wait-listed adults across Catalonia, Denmark, France, Norway, and the UK who began dialysis between 2000 and 2019. Using a robust target trial emulation (TTE) framework designed to mirror the structure of a randomised clinical trial, the researchers compared long-term survival between those who received kidney transplants and those who remained on dialysis.

TTE allowed us to eliminate many of the biases that have clouded older registry studies and get as close as ethically possible to a randomised clinical trial. We found that transplantation with standard-criteria kidneys still offers a clear survival benefit at virtually every age, but in the oldest, most comorbid recipients receiving lower-quality organs, that edge can all but disappear."

Dr. Rachel Hellemans, lead author

The data showed a consistent survival advantage with standard-criteria donor kidneys – those from donors under 60 without significant risk factors for poor kidney function – regardless of recipient age or underlying health conditions.

However, the picture is less clear with expanded-criteria donor (ECD) kidneys, including organs from older donors or those with risk factors that may affect kidney quality. Among patients aged 75 and older, five-year survival rates were around 57–58%, only slightly higher than the 54% seen in patients who remained on dialysis. This was particularly the case for those with cardiovascular disease or those receiving kidneys from donors after circulatory death.

A key factor behind these findings is the higher early post-transplant mortality observed in high-risk patients. "The first few months after surgery are the most unpredictable window," noted Dr Hellemans, "when frailty, surgical risk, and intensified immunosuppression can override the long-term gains seen in lower-risk groups."

The director of the ERA Registry, Dr. Vianda Stel added, "The breadth of data we could access via the ERA Registry showed that the survival advantage of a transplant plateaus for the very oldest or highest-risk patients who are likely to receive an expanded-criteria or circulatory-death donor kidney. This arms clinicians with guidance to have informed discussions with their patients. The message isn't 'don't transplant older people.' It's 'be open about uncertainty when the numbers say benefit may be marginal.'"