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Strategies for an Expanded Use of Kidneys From Elderly Donors

Pérez-Sáez, María José MD, PhD; Montero, Núria MD; Redondo-Pachón, Dolores MD; Crespo, Marta MD, PhD; Pascual, Julio MD, PhD

doi: 10.1097/TP.0000000000001635

The old-for-old allocation policy used for kidney transplantation (KT) has confirmed the survival benefit compared to remaining listed on dialysis. Shortage of standard donors has stimulated the development of strategies aimed to expand acceptance criteria, particularly of kidneys from elderly donors. We have systematically reviewed the literature on those different strategies. In addition to the review of outcomes of expanded criteria donor or advanced age kidneys, we assessed the value of the Kidney Donor Profile Index policy, preimplantation biopsy, dual KT, machine perfusion and special immunosuppressive protocols. Survival and functional outcomes achieved with expanded criteria donor, high Kidney Donor Profile Index or advanced age kidneys are poorer than those with standard ones. Outcomes using advanced age brain-dead or cardiac-dead donor kidneys are similar. Preimplantation biopsies and related scores have been useful to predict function, but their applicability to transplant or refuse a kidney graft has probably been overestimated. Machine perfusion techniques have decreased delayed graft function and could improve graft survival. Investing 2 kidneys in 1 recipient does not make sense when a single KT would be enough, particularly in elderly recipients. Tailored immunosuppression when transplanting an old kidney may be useful, but no formal trials are available.

Old donors constitute an enormous source of useful kidneys, but their retrieval in many countries is infrequent. The assumption of limited but precious functional expectancy for an old kidney and substantial reduction of discard rates should be generalized to mitigate these limitations.

The authors review strategies for organ utilization, including expanded criteria donors, advanced age kidneys, Kidney Donor Profile Index policy, preimplantation biopsy, dual kidney transplant, machine perfusion, and special immunosuppressive protocols. Many opportunities for increased utilization are identified. Supplemental digital content is available in the text.

1 Department of Nephrology, Hospital del Mar, Barcelona, Spain.

2 Department of Nephrology, Hospital Universitari de Bellvitge, L’Hospitalet del Llobregat, Barcelona, Spain.

Received 25 May 2016. Revision received 8 December 2016.

Accepted 9 December 2016.

M.J.P.S. and N.M. contributed equally.

MJPS has support from a Rio Hortega contract, ISCIII. MC and JP are supported by grants FIS ISCIII-FEDER PI13/0598, Programa de Intensificación ISCIII 2015 and RedinRen RD12/0021/0024. NM did this work as part of her doctoral thesis at the Universitat Autònoma Barcelona.

The authors declare no conflicts of interest.

M.J.P.S. did data extraction and drafted the article. N.M. run the literature search, did data extraction, carried out analyses and drafted the article. D.R.-P. did data extraction and drafted the article. M.C. did data extraction and drafted the article. J.P. designed the review, did data extraction, and drafted the article.

All authors approved the final version.

The protocol of this systematic review is published in PROSPERO register (CR D42016036861).

Correspondence: Julio Pascual, Department of Nephrology, Hospital del Mar, Barcelona, Spain. (

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

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