Korean J Transplant.  2021 Sep;35(3):149-160. 10.4285/kjt.21.0014.

Impact of delayed graft function on clinical outcomes in highly sensitized patients after deceased-donor kidney transplantation

• Kim SG
• Hong S
• Lee H
• Eum SH
• Kim YS
• Jin K
• Han S
• Yang CW
• Park WY
• Chung BH

• KMID: 2520676
• DOI: http://doi.org/10.4285/kjt.21.0014

Abstract

Background
We investigated whether the development of delayed graft function (DGF) in pre-sensitized patients affects the clinical outcomes after deceased-donor kidney transplantation (DDKT).
Methods
The study included 709 kidney transplant recipients (KTRs) from three transplant centers. We divided KTRs into four subgroups (highly sensitized DGF, highly sensitized non-DGF, low-sensitized DGF, and low-sensitized non-DGF) according to panel reactive antibody level of 50%, or DGF development. We compared post-transplant clinical outcomes among the four subgroups.
Results
Incidence of biopsy-proven acute rejection (BPAR) was higher in two highly sensitized subgroups than in low-sensitized subgroups. It tended to be higher in highly sensitized DGF subgroups than in the highly sensitized non-DGF subgroups. In addition, the highly sensitized DGF subgroup showed the highest risk for BPAR (hazard ratio, 3.051;P=0.005) and independently predicted BPAR. Allograft function was lower in the two DGF subgroups than in the non-DGF subgroup until one month after transplantation, but thereafter it was similar. Death-censored graft loss rates and patient mortality tended to be low when DGF developed, but it did not reach statistical significance.
Conclusions
DGF development in highly sensitized patients increases the risk for BPAR in DDKT compared with patients without DGF, suggesting the need for strict monitoring and management of such cases.

Keyword

Kidney transplantation; Delayed graft function; Sensitization; Graft loss; Acute rejection

Figure

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  Fig. 1 Patient distribution. Of the 709 deceased donor kidney transplantation (KT) recipients included in this study, 579 had panel-reactive antibody (PRA) less than 50%, and 130 had PRA 50% or more. Of the deceased-donor kidney transplantation (DDKT) recipients with a PRA of less than 50%, 470 did not develop delayed graft function (DGF), and 109 developed DGF. Among DDKT recipients with a PRA of 50% or more, 103 did not develop DGF and 27 developed DGF.

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  Fig. 2 Comparison of biopsy-proven acute rejection (BPAR) incidence in the four subgroups by Kaplan-Meier analysis. DGF, delayed graft function.

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  Fig. 3 Comparison of changes in allograft function after kidney transplantation among patients in the four subgroups classified according to human leukocyte antigen pre-sensitization and delayed graft function (DGF) development. eGFR, estimated glomerular filtration rate; CKD, chronic kidney disease; EPI, epidemiology collaboration. a)P<0.05 vs. low-sensitized non-DGF; b)P<0.05 vs. low-sensitized DGF; c)P<0.05 vs. highly sensitized-non-DGF; d)P<0.05 vs. highly sensitized DGF.

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  Fig. 4 Comparison of death-censored allograft survival in the four subgroups. Compared with low-sensitized non-delayed graft function (non-DGF) subgroup, death-censored allograft survival was decreased in low-sensitized DGF subgroup (P=0.006). a)P<0.05 vs. low-sensitized non-DGF.

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  Fig. 5 Comparison of patient mortality in the four subgroups. Compared with low-sensitized non-delayed graft function (non-DGF) subgroup, patient mortality tended to be higher in the two DGF subgroups, but was not statistically significant (P=0.058 vs. low-sensitized DGF, P=0.080 vs. highly sensitized DGF). P>0.05 for each comparison.

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