Tailoring Kidney Transplant Strategies: Unraveling the Impact of Acute Kidney Injury and Preservation Methods Across Different Strata of Kidney Risk.

Background: The use of donor kidneys with acute kidney injury (AKI) aims to expand the organ pool, but uncertainty remains regarding their outcomes across different Kidney Donor Profile Index (KDPI) groups and preservation methods.

Methods: We retrospectively analyzed 108 160 deceased donor kidney transplants from the OPTN database, focusing on adult recipients of kidneys from donors with or without AKI between December 2014 and December 2022. Propensity matching was used for each KDPI group (1-20, 21-59, 60-84, and 85-100), comparing donors with AKIN stages 0-1 to AKIN stages 2-3. Cox proportional hazards analysis assessed graft survival by AKIN stages and preservation type.

Results: The use of AKIN stage 2-3 kidneys significantly increased over the study period. AKIN does not negatively impact graft survival in the KDPI 1-20 group and is linked to improved survival in KDPI 21-59 and 60-84. In the KDPI 85-100 group, AKIN stage 2-3 shows a trend toward increased graft failure. Pump preservation reduces delayed graft function (DGF) across most KDPI groups but does not consistently improve long-term survival, except in KDPI 85-100.

Conclusion: Transplantation with AKIN stage 2-3 kidneys is viable, but outcomes vary by KDPI group. Tailored guidelines should consider transplant center capabilities.