Does the Kidney Donor Profile Index (KDPI) predict graft and patient survival in a Spanish population?
Abstract
Background and objective: The Kidney Donor Profile Index (KDPI), together with other donor and recipient variables, can optimise the organ allocation process. This study aims to check the feasibility of the KDPI for a Spanish population and its predictive ability of graft and patient survival. Materials and methods: Data from 2734 kidney transplants carried out in Andalusia between January 2006 and December 2015 were studied. Cases were grouped by recipient age, categorised by KDPI quartile and both graft and patient survival were compared among groups. Results: The KDPI accurately discriminated optimal organs from suboptimal or marginal ones. For adult recipients (aged: 18–59 years) it presents a hazard ratio of 1.013 (P < 0.001) for death-censored graft survival and of 1.013 (P = 0.007) for patient survival. For elderly recipients (aged: 60+ years), KDPI presented a hazard ratio of 1.016 (P = 0.001) for death-censored graft survival and of 1.011 (P = 0.0007) for patient survival. A multivariate analysis identified the KDPI, donor age, donation after circulatory death, recipient age and gender as predictive factors of graft survival. Conclusions: The results obtained show that the KDPI makes it possible to relate the donor’s characteristics with the greater or lesser survival of the graft and the patient in the Spanish population. However, due to certain limitations, a new index for Spain based on Spanish or European data should be created. In this study, some predictive factors of graft survival are identified that may serve as a first step in this path.
Full text
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
Re is a
de
la
Sociedad
Española
de
Ne ología
w
w
w. e is ane ologia.com
O iginal
a icle
Does
he
Kidney
Dono
P ofile
Index
(KDPI)
p edic
g a
and
pa ien
su i al
in
a
Spanish
popula ion?夽
Jo ge
Cal illo-A bizua,b,∗,
Miguel
A.
Pé ez-Valdi iac,
Miguel
A.
Gen il-Go an esc,
Pablo
Cas o-de-la-Nuezd,
Auxiliado a
Mazuecos-Blancae,
Albe o
Rod íguez-Beno ,
Ma ía
C.
G acia-Guindog,
F ancisco
Bo ego-U ielh,
Me cedes
Cabello-Díazi,
Ra ael
Bedoya-Pé ezj,
Manuel
Alonso-Gild,
Me cedes
Salguei a-Lazoa,b,k,
Lau a
M.
Roa-Rome oa,b
aG upo
de
Ingenie ía
Biomédica,
Uni e sidad
de
Se illa,
Se illa,
Spain
bCen o
de
In es igación
Biomédica
en
Red
en
Bioingenie ía,
Bioma e iales
y
Nanomedicina
(CIBER-BBN),
Spain
cHospi al
Uni e si a io
Vi gen
del
Rocío,
Se illa,
Spain
dCoo dinación
Au onómica
de
T asplan e
de
Andalucía,
Se illa,
Spain
eHospi al
Pue a
del
Ma ,
Cádiz,
Spain
Hospi al
Reina
So ía,
Có doba,
Spain
gHospi al
Vi gen
de
las
Nie es,
G anada,
Spain
hHospi al
de
Jaén,
Jaén,
Spain
iHospi al
Regional
de
Málaga,
Málaga,
Spain
jHospi al
In an il
Vi gen
del
Rocío,
Se illa,
Spain
kHospi al
Uni e si a io
Vi gen
Maca ena,
Se illa,
Spain
a
i
c
l
e
i
n
o
A icle
his o y:
Recei ed
7
No embe
2017
Accep ed
16
June
2018
A ailable
online
27
No embe
2018
Keywo ds:
Kidney
ansplan a ion
G a
su i al
Su i al
analysis
KDPI
a
b
s
a
c
Backg ound
and
objec i e:
The
Kidney
Dono
P ofile
Index
(KDPI),
oge he
wi h
o he
dono
and
ecipien
a iables,
can
op imise
he
o gan
alloca ion
p ocess.
This
s udy
aims
o
check
he
easibili y
o
he
KDPI
o
a
Spanish
popula ion
and
i s
p edic i e
abili y
o
g a
and
pa ien
su i al.
Ma e ials
and
me hods:
Da a
om
2734
kidney
ansplan s
ca ied
ou
in
Andalusia
be ween
Janua y
2006
and
Decembe
2015
we e
s udied.
Cases
we e
g ouped
by
ecipien
age,
ca e-
go ised
by
KDPI
qua ile
and
bo h
g a
and
pa ien
su i al
we e
compa ed
among
g oups.
Resul s:
The
KDPI
accu a ely
disc imina ed
op imal
o gans
om
subop imal
o
ma ginal
ones.
Fo
adul
ecipien s
(aged:
18–59
yea s)
i
p esen s
a
haza d
a io
o
1.013
(P
<
0.001)
o
dea h-censo ed
g a
su i al
and
o
1.013
(P
=
0.007)
o
pa ien
su i al.
Fo
elde ly
ecipien s
(aged:
60+
yea s),
KDPI
p esen ed
a
haza d
a io
o
1.016
(P
=
0.001)
o
dea h-
censo ed
g a
su i al
and
o
1.011
(P
=
0.0007)
o
pa ien
su i al.
A
mul i a ia e
analysis
iden ified
he
KDPI,
dono
age,
dona ion
a e
ci cula o y
dea h,
ecipien
age
and
gende
as
p edic i e
ac o s
o
g a
su i al.
DOI
o
o iginal
a icle:
h ps://doi.o g/10.1016/j.ne o.2018.06.009.
夽Please
ci e
his
a icle
as:
Cal illo-A bizu
J,
Pé ez-Valdi ia
MA,
Gen il-Go an es
MA,
Cas o-de-la-Nuez
P,
Mazuecos-Blanca
A,
Rod íguez-Beno
A,
e
al.
¿P edice
el
Kidney
Dono
P ofile
Index
(KDPI)
la
supe i encia
del
inje o
y
del
pacien e
en
una
población
espa ˜
nola?.
Ne ologia.
2018;38:587–595.
∗Co esponding
au ho .
E-mail
add ess:
jo [email p o ec ed]
(J.
Cal illo-A bizu).
2013-2514/©
2018
Sociedad
Espa ˜
nola
de
Ne olog´
ıa.
Published
by
Else ie
Espa ˜
na,
S.L.U.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
588
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
Conclusions:
The
esul s
ob ained
show
ha
he
KDPI
makes
i
possible
o
ela e
he
dono ’s
cha ac e is ics
wi h
he
g ea e
o
lesse
su i al
o
he
g a
and
he
pa ien
in
he
Spanish
popula ion.
Howe e ,
due
o
ce ain
limi a ions,
a
new
index
o
Spain
based
on
Spanish
o
Eu opean
da a
should
be
c ea ed.
In
his
s udy,
some
p edic i e
ac o s
o
g a
su i al
a e
iden ified
ha
may
se e
as
a
fi s
s ep
in
his
pa h.
©
2018
Sociedad
Espa ˜
nola
de
Ne olog´
ıa.
Published
by
Else ie
Espa ˜
na,
S.L.U.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://c ea i ecommons.o g/licenses/
by-nc-nd/4.0/).
¿P edice
el
Kidney
Dono
P ofile
Index
(KDPI)
la
supe i encia
del
inje o
y
del
pacien e
en
una
población
espa ˜
nola?
Palab as
cla e:
T asplan e
enal
Supe i encia
del
inje o
Análisis
de
supe i encia
KDPI
e
s
u
m
e
n
An eceden es
y
obje i o:
El
Kidney
Dono
P ofile
Index
(KDPI),
jun o
a
o as
a iables
del
donan e
y
ecep o ,
puede
op imiza
el
p oceso
de
asignación
de
ó ganos.
Es e
es udio
iene
como
obje-
i o
comp oba
la
aplicabilidad
del
KDPI
en
una
población
espa ˜
nola,
así
como
su
capacidad
de
p edicción
de
la
supe i encia
del
inje o
y
del
pacien e.
Ma e iales
y
mé odos:
Se
es udia on
2.734
asplan es
enales
lle ados
a
cabo
en
Andalucía
en e
ene o
de
2006
y
diciemb e
de
2015.
Los
casos
se
ag upa on
po
edad
del
ecep o
y
cua il
del
KDPI
y
se
compa a on
en e
g upos
an o
la
supe i encia
del
inje o
como
la
del
pacien e.
Resul ados:
El
KDPI
disc imina
con
p ecisión
los
ó ganos
óp imos
de
los
subóp imos
o
ma ginales.
Pa a
ecep o es
en e
18
y
59
a˜
nos
p esen a
un
haza d
a io
de
1,013
(p
<
0,001)
pa a
supe i encia
de
inje o
censu ada
pa a
mue e
y
de
1,013
(p
=
0,007)
pa a
supe i en-
cia
del
pacien e.
Pa a
ecep o es
mayo es
de
60
a˜
nos
el
haza d
a io
es
de
1,016
(p
=
0,001)
pa a
supe i encia
del
inje o
censu ada
pa a
mue e
y
de
1,011
(p
=
0,007)
pa a
supe i encia
del
pacien e.
Un
análisis
mul i a ian e
iden ificó
como
ac o es
p edic i os
de
la
supe i encia
del
inje o
el
KDPI,
la
edad
del
donan e,
la
donación
as
mue e
ci cula o ia,
la
edad
y
el
sexo
del
ecep o .
Conclusiones:
El
KDPI
pe mi e
elaciona ,
a
g andes
asgos,
las
ca ac e ís icas
del
donan e
con
la
mayo
o
meno
supe i encia
del
inje o
y
del
pacien e
en
la
población
espa ˜
nola.
No
obs an e,
debido
a
cie as
limi aciones,
con end ía
elabo a
un
índice
p opio
a
pa i
de
los
da os
espa ˜
noles
o
eu opeos.
En
es e
abajo
se
iden ifican
algunos
ac o es
p edic i os
de
la
supe i encia
del
inje o
que
pueden
se i
como
p ime
paso
en
esa
línea.
©
2018
Sociedad
Espa ˜
nola
de
Ne olog´
ıa.
Publicado
po
Else ie
Espa ˜
na,
S.L.U.
Es e
es
un
a ´
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(h p://c ea i ecommons.o g/licenses/
by-nc-nd/4.0/).
In oduc ion
End-s age
enal
disease
(ESRD)
is
an
inc easing
wo ldwide
heal h
conce n,
and
kidney
ansplan a ion
is
he
bes
ea -
men
o
su i al
and
quali y
o
li e
o
people
wi h
ESRD.1,2
The
ageing
o
dono s
(cu en ly
achie ing
a
mean
o
59.2
yea s
in
Spain3)
and
he
high
disca ding
a e
o
o gans
by
biopsy4
a e
among
he
main
obs acles
o
ansplan a ion.
Pe o ming
a
igh
assessmen
o
kidney
quali y
and
easibili y
is
a
cu -
en
challenge
o
educe
disca ding
a e
o
o gans
po en ially
alid.
The e
a e
se e al
me hods
o
assess
he
quali y
o
kidneys5
and,
o
o gan
alloca ion,
he
Kidney
Dono
Risk
Index
(KDRI)
has
acqui ed
special
ele ance.
The
KDRI
combines
14
dono
and
ansplan
ac o s
and
p o ides
an
es ima ion
o
he
ela-
i e
isk
o
g a
ailu e
a e
kidney
ansplan
om
a
deceased
dono
compa ed
o
he
e e ence
dono .6Al hough
i s
disc imina o y
powe
is
mode a e,
he
KDRI
ep esen s
a
s ep
o wa d
in
p e ansplan a ion
kidney
assessmen
and
allo-
g a
p edic ion.
A
new
alloca ion
policy
based
on
he
KDRI
was
imple-
men ed
by
he
end
o
2014
in
he
Uni ed
S a es.
Since
some
ansplan
ac o s
a e
gene ally
unknown
a
he
ime
o e
is
made,
his
policy
uses
a
new
index,
he
Kidney
Dono
P ofile
Index
(KDPI)7based
on
he
dono -only
KDRI
e sion
includ-
ing
10
dono
ac o s.
The
KDPI
is
he
nume ical
anking
o
he
o gan
o
be
e alua ed
compa ed
o
all
kidneys
eco e ed
he
p e ious
yea .
Du ing
he
alloca ion
p ocess,
he
KDPI
is
an
aid
ool
o
decide
whe he
o
accep
an
o e
o
a
deceased
dono
kidney,
o en
disca ding
o gans
wi h
KDPI
>
85%
(conside ed
high
isk
dono s).
Las
10
yea s
in
Spain,
and
conc e ely
in
Andalucía,
he
accep ance
o
a
kidney
om
an
expanded
c i e ia
dono
(ECD)8
has
p ima y
based
on
he
esul
o
p eimplan a ion
biopsy.9
Bu
biopsy
con inues
ha ing
a
con o e sial
ole
on
he
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
589
assessmen
o
enal
g a
easibili y.
Meanwhile
some
s udies
jus i y
i s
use
specially
o
double
ansplan ,10 o he s
doub
abou
i s
p edic ion
capaci y
o
enal
unc ioning.11–13
Using
a
isk
index
(such
as
he
KDPI)
could
help
he
decision-making
in
Spain
o
ECD
cases
when
decision
depends
on
he
esul s
o
he
biopsy.
Se e al
s udies
suppo
his
hypo hesis.
Que a d
e
al.8showed
ha
he
ela-
i e
di e ences
be ween
ECD
and
s anda d
c i e ia
dono s
(SCD)
we e
lowe
in
Eu ope
han
in
No h
Ame ica,
pa -
icula ly
o
dea h-censo ed
g a
ailu e.
Ano he
s udy
concluded
ha
high-KDPI
ansplan a ion
o e s
a
be e
su i al
e sus
emaining
on
he
wai lis
o
ecipien s
olde
han
50
yea s
when
wai
ime
is
highe
han
33
mon hs.14
This
s udy
aims:
(1)
o
check
he
adequacy
o
he
KDPI
o
disc imina e
di e ences
on
g a
and
pa ien
su i al
o
Spain
ecipien s,
and
(2)
o
iden i y
p edic o
ac o s
o
g a
su i al
ha
could
con ibu e
o
c ea e
a
Spanish
o
Eu opean
index.
Ma e ials
and
me hods
A
e ospec i e
analysis
was
pe o med
on
da a
om
a
da abase
held
by
he
Regional
T ansplan
Coo dina ion
o
Andalusia
(SICATA).
Da a
we e
e ie ed
o
single
kidney
ansplan s
pe o med
be ween
Janua y
2006
and
Decembe
2015.
G a
ailu e
was
defined
by
e u n
o
ch onic
main e-
nance
dialysis.
The
final
ollow-up
da e
was
31
Decembe
2015.
S a is ical
analyses
we e
pe o med
using
SPSS
24.0
(IBM
SPSS
S a is ics
o
Windows,
Ve sion
24.0.
IBM
Co p.,
A monk,
NY,
USA).
Since
in
Spain
i
is
no
possible
o
calcula e
KDPI
as
in
US,
ou
app oach
is
o
use
he
s udy
popula ion
i sel
o
map
KDPI
om
dono
ac o s
(see
Sec ion
Discussion
o
a
com-
men
abou
his
limi a ion).
Cases
we e
anked,
ca ego ised
in
qua ile,
and
compa ed
o
g a
su i al
(dea h-censo ed
and
uncenso ed)
and
pa ien
su i al
using
Kaplan–Meie
log-
ank
su i al
analysis.
The
associa ions
be ween
he
KDPI
as
a
con inuous
a iable
and
su i al
o
g a
and
pa ien
we e
de e mined
using
Cox
Reg ession
uni a ia e
analysis.
Cases
esul ing
on
pa ien ’s
dea h
wi h
unc ioning
g a
we e
excluded
since
his
is
a
compe i i e
e en
o
g a
ailu e
and
i
may
al e
he
esul s.
Fu he mo e,
he
disc imina i e
abili y
o
he
KDPI
was
es ed
wi h
Ha ell’s
C
s a
o
Cox
models.
Cox
mul i a ia e
eg ession
was
used
o
iden i ying
p edic o
ac o s
o
g a
su i al.
Recipien
isk
ac o s
significan ly
associa ed
wi h
g a
ailu e
using
uni a iable
sc eening
a
he
le el
o
P
<
0.05
we e
included
in
he
final
mul i a iable
model.
These
we e
age,
gende ,
heigh ,
diabe es
as
p ima y
enal
disease,
ime
on
enal
eplacemen
he -
apy
(RRT),
HIV
and
HCV
s a us.
Dono
a iables
included
HLA
misma ch
and
elemen s
con o ming
KDPI.
Since
e hnici y
o
Spain
popula ion
is
highly
uni o m,
dono
and
ecipien
ace
we e
no
included.
Resul s
Demog aphics
Da a
o
3406
kidney
ansplan s
we e
e ie ed.
A
o al
o
672
cases
we e
excluded
due
o
missing
da a,
and
2734
kidney
ansplan s
we e
included
in
he
analysis.
The
demog aphics
o
he
ecipien
and
dono
coho
a e
displayed
in
Table
1.
As
he
SICATA
does
no
eco d
e hnici y,
we
classified
all
ecipi-
en s
in
ou
popula ion
as
Caucasian.
KDPI
and
g a
su i al
As
men ioned,
KDPI
was
calcula ed
by
using
he
own
s udy
popula ion,
and
cases
we e
g ouped
by
qua iles.
Fig.
1
shows
he
e olu ion
o
he
numbe
o
o gans
in
each
qua ile
o
his
popula ion
du ing
he
inclusion
pe iod.
The
numbe
o
o gans
om
he
fi s
qua ile
(i.e.,
hose
wi h
he
bes
cha ac e is-
ics)
dec eases,
meanwhile
he
numbe
o
o gans
in
he
ou h
qua ile
( he
one
wi h
he
wo s
p ognosis)
inc eases.
This
is
a
consequence
o
he
g ea e
use
and
accep ance
o
o gans
wi h,
a
p io i,
wo se
cha ac e is ics
( o
example,
om
old
dono s).
Table
2
shows
he
ecipien s
classified
acco ding
o
KDPI
qua ile
o
he
ecei ed
o gan.
In
he
compa ison
o
cha ac-
e is ics
be ween
subpopula ions
by
applying
S uden ’s
T
and
Mann–Whi ney
U
es s,
esul s
show
ha
ecipien ’s
age
is
a
cha ac e is ic
ha
influences
he
qua ile
o
he
ecei ed
g a .
Recipien s
mos
likely
o
ecei e
an
o gan
om
he
qua ile
wi h
he
wo s
p ognosis
(i.e.,
he
ou h)
a e
hose
o
mo e
ad anced
age.
On
he
o he
hand,
days
on
enal
eplacemen
he apy
influences
o
ecei e
an
o gan
om
he
hi d
o
he
ou h
qua ile.
Finally,
nei he
he
sex
no
he
BMI
o
he
ecipien
influence
he
qua ile
o
which
he
assigned
o gan
belongs.
By
analysing
kidney
g a
su i al
by
KDPI
qua ile
o
ecipien s
o
18–59
yea s,
i
is
obse ed
ha
he
KDPI
accu-
a ely
disc imina e
g a
su i al
o
dono s
wi h
he
lowes
o
highes
isk
qua iles
achie ing
di e en
le els
o
su -
i al
a
3
yea s
(93.4%,
91.4%,
87.2%,
and
85.9%)
and
5
yea s
(91.4%,
88.1%,
85.8%
and
85.9%)
(Fig.
2a).
Fig.
2
compa es
dea h-
censo ed
and
uncenso ed
g a
su i al
esul ing
in
a
sligh ly
lowe
su i al
in
he
uncenso ed
case
ac oss
qua iles,
wha
is
cohe en
wi h
he
age
ange
o
his
coho .
G a
su i al
is
ound
significan
di e en
be ween
he
fi s
qua ile
(op imal
dono s)
and
he
hi d
and
ou h
qua -
iles
(ma ginal
dono s),
bu
he e
is
no
di e ence
be ween
qua iles
o
medium
and
low
quali y
(Table
3).
Then,
i
can
be
s a ed
ha
he
KDPI,
om
a
pa icula
dono
quali y
le el,
s ops
being
use ul
o
disc imina e
g a
su i als.
Fo
his
ecipien
g oup,
a
uni a ia e
Cox
eg ession
analysis
showed
ha
KDPI,
when
analysed
as
a
con inuous
a i-
able,
was
associa ed
wi h
dea h-censo ed
g a
su i al
in
his
g oup
wi h
a
haza d
a io
o
1.013
(P
<
0.001;
95%
CI:
1.006–1.019).
590
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
Table
1
–
Recipien
and
dono
cha ac e is ics.
Coho
cha ac e is ics
All
cases
(N
=
2734)
Age
18–59
yea s
(N
=
1821)
Age
60+
yea s
(N
=
913)
Recipien
Age
(yea s)
52.08
(12.99)
45.00
(9.70)
66.19
(4.35)
Gende
(%
male)
1725
(63.09%)
1172
(64.32%)
553
(60.57%)
BMI
(kg/m2)
27.79
(11.66)
26.51
(10.04)
30.51
(14.11)
Time
on
RRT
(days)
1535.9
(2670.1)
1664.60
(2956.38)
1279.31
(1954.10)
Dono
Age
(yea s)
51.48
(16.0)
43.11
(12.85)
67.79
(5.50)
Gende
(%male)
1671
(61.1%)
1191
(65.91%)
480
(51.78%)
BMI
(kg/m2)
27.18
(4.40)
26.77
(4.39)
27.98
(4.31)
Cause
o
dea h:
ce eb o ascula
acciden
1742
(63.72%)
1014
(56.12%)
728
(78.53%)
DCD
149
(5.45%) 111
(6.14%) 38
(4.10%)
C ea inine
le el
(mg/dL)
0.87
(0.41)
0.91
(0.45)
0.79
(0.29)
Medical
his o y
Hype ension
905
(33.1%)
420
(23.24%)
485
(52.32%)
Diabe es
298
(10.9%)
122
(6.75%)
176
(18.99%)
Hepa i is
C
17
(0.62%%)
10
(0.55%)
7
(0.76%)
T ansplan
No
1
2552
(93.34%)
1674
(91.92%)
878
(96.17%)
2
166
(6.07%)
132
(7.25%)
34
(3.72%)
3
16
(0.59%)
15
(0.82%)
1
(0.11%)
HLA
DR
misma ch
0
1415
(51.76%)
928
(50.96%)
487
(53.34%)
1
1009
(36.91%) 690
(37.89%) 319
(34.94%)
2
310
(11.34%) 203
(11.15%)
107
(11.72%)
Da a
a e
p esen ed
as
mean
(SD)
o
n
(%).
BMI,
body
mass
index;
DCD,
dono
a e
ci cula o y
dea h
(all
ca ego ies
included);
HLA,
human
leucocy e
an igen;
RRT,
enal
eplacemen
he apy.
On
he
senio
popula ion
(60+
yea s),
kidney
g a
achie es
3-yea
su i al
o
97.3%,
93.6%,
89.6%,
and
84.5%;
and
5-
yea
su i al
o
95.1%,
89.4%,
86.6%,
and
79.6%,
espec i ely
(Fig.
3a).
These
su i al
le els
a e
simila
(o
e en
highe )
o
hose
epo ed
abo e
o
he
coho
o
18–59
yea s
since
hey
e e
o
dea h-censo ed
g a
su i al.
The
uncenso ed
g a
su i al
analysis
(Fig.
3b)
shows
how
he
ecipien ’s
age
leads
o
a
significan
educ ion
o
su i al
o
all
he
qua iles.
The
KDPI
does
no
disc imina e
be ween
consecu i e
qua -
iles
in
he
g oup
o
ecipien s
olde
han
60
yea s
(Table
4).
As
occu ed
on
he
adul
popula ion,
he
highe
he
KDPI,
he
wo se
g a
su i al.
Mo eo e ,
he
KDPI
disc imina es
among
op imal
and
ma ginal
quali y
dono s
bu
no
among
medium
and
low-quali y
dono s.
Finally,
he
uni a ia e
Cox
eg ession
analysis
showed
ha
he
KDPI
was
significan ly
associa ed
wi h
dea h-censo ed
g a
ou come
wi h
a
haza d
a io
o
1.016
(P
=
0.001;
95%
CI:
1.006–1.025).
Finally,
we
analysed
he
disc imina o y
abili y
o
he
KDPI
in
Spain
by
means
o
Ha ell’s
C.
Fo
a
bina y
ou come
(g a
su i al
s.
dea h-censo ed
g a
loss),
a
C
index
o
0.5
ep esen s
a
p edic ion
no
mo e
accu a e
han
chance.
Ac oss
all
qua iles
and
o
he
whole
popula ion
(age:
18+
yea s),
he
Ha ell’s
C
o
he
KDPI
o
g a
and
pa ien
su i al
was
0.56
and
0.63,
espec i ely.
This
is
a
p edic-
i e
powe
limi ed
and
equi alen
o
he
esul s
in
he
USA
(i.e.,
C-s a is ic
=
0.62).2
350
300
250
200
150
100
50
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Año
Núme o de donan es
Q1
Q2
Q3
Q4
To al
Fig.
1
–
E olu ion
o
o al
numbe
o
kidneys
and
pe
qua ile
du ing
he
inclusion
pe iod
o
he
s udied
coho .
KDPI
and
pa ien
su i al
Fig.
4
shows
pa ien
su i al
o
ecipien s
o
18–59
yea s
(a)
and
60+
yea s
(b).
Fo
he
fi s
subpopula ion,
KDPI
shows
mino
disc imina ion
among
qua iles,
al hough
he
haza d
a io
o
pa ien
su i al
associa ed
o
KDPI
o
his
g oup
is
1.013
(P
=
0.007;
95%
CI:
1.004–1.023).
Fo
ecipien s
olde
han
60
yea s,
KDPI
shows
majo
di e ences
among
qua -
iles
(Fig.
4b),
and
he
haza d
a io
o
pa ien
su i al
is
1.011
(P
=
0.007;
95%
CI:
1.003–1.018).
The e o e,
KDPI
is
a
po en ial
indica o
o
pa ien
su i al
al hough
wi h
a
lowe
disc imi-
na ion
be ween
qua iles.
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
591
Table
2
–
Recipien
cha ac e is ics
classified
by
KDPI
qua iles
o
ecei ed
o gans.
Q1
Q2
Q3
Q4
Age
(yea s)
40.48
(11.16)
43.94
(10.95)
50.64
(11.24)
60.79
(9.02)
Gende
(%
male) 228
(62.98%) 350
(64.46%)
451
(62.55%)
696
(62.82%)
BMI
(kg/m2) 24.71
(4.65) 26.03
(8.73) 26.97
(9.78)
30.38
(14.81)
Time
on
RRT
(days)
1593
(2954)
1434
(1877)
1866
(3722)
1351
(1971)
Da a
a e
p esen ed
as
mean
(SD)
o
n
(%).
BMI,
body
mass
index;
RRT,
enal
eplacemen
he apy.
Censu ada pa a mue e
Tiempo pos - ansplan e (años)
1e
cua il
1e
cua il
2º cua il
2º cua il
4º cua il
4º cua il
3e cua il
3e cua il
Tiempo pos - ansplan e (años)
Supe i encia de inje o (%)
Supe i encia de inje o (%)
No censu ada
100
90
80
70
60
50
100
90
80
70
60
50
0
2
4
6
8 10
0
2
4
6
8 10
Indi iduos en iesgo
Cua il 1
Cua il 2
Cua il 3
Cua il 4
885
Inicio
Año 2
Año 4
Año 6
Año 8
Año 10
639
258
39
674
457
172
22
543
315
104
11
377
202
64
9
189
90
28
5
0
2
5
14
ab
Fig.
2
–
Kaplan–Meie
g a
su i al
acco ding
o
KDPI
qua ile
o
ecipien s’
age
18–59
yea s:
(a)
dea h-censo ed,
(b)
uncenso ed.
Mul i a ia e
analysis
A
se
o
candida e
p edic o s
(i.e.,
a
p io i
p edic
g a
su i al)
we e
selec ed
based
on
he
li e a u e.15–17 A
uni a ia e
Cox
eg ession
analysis
was
pe o med
o
each
p edic o
o
assess
i s
ele ance
on
g a
su i al.
The
ollowing
p edic o s
ela ed
o
ecipien
and
ansplan
ac o s
we e
significan :
age,
gen-
de ,
heigh ,
HIV
s a us,
HCV
s a us,
p ima y
enal
disease,
HLA
misma ch,
and
ime
on
enal
eplacemen
he apy.
Dono
ac-
o s
we e
included
in
wo
sepa a e
ways:
as
pa
o
he
KDPI
and
as
indi idual
ac o s.
Two
Cox
p opo ional
haza ds
g a
su i al
analysis
we e
pe o med
(Table
5).
In
he
fi s
analysis
(i.e.,
dono
ac o s
included
as
KDPI,
Table
5a),
he
KDPI
was
he
mos
significan
ac o
p edic ing
g a
su i al.
Recipien
age
and
gende
a e
also
signifi-
can ly
ela ed
o
he
ansplan
ou come.
The
haza d
a io
o
ecipien
age
is
lowe
han
1
(0.983)
wha
is
cohe en
wi h
he
ype
o
analysis
pe o med,
dea h-censo ed.
Censo ing
dea hs
con e s
ecipien
age
in
a
p o ec ing
ac o
o
g a
loss,
ha
is
consis en
wi h
se e al
s udies.18
When
KDPI
dono
ac o s
a e
analysed
sepa a ely
(Table
5b),
dono
age
and
dona ion
a e
ci cula o y
dea h
s a us
a e
he
p edic ing
ac o s
o
g a
su i al
(in
addi ion
o
ecipien
age
and
gende ).
The e
was
no
e idence
o
p edic ion
by
he
o he
ac o s
wi h
he
s udy
coho .
Discussion
The
KDPI
may
mean
a
significan
imp o emen
o
decision-
making,
bu
i s
disc imina o y
powe
on
g a
su i al
is
limi ed
(Ha ell’s
C,
0.56)
and
he
easibili y
o
high-KDPI
g a s
(some imes
disca ded)
on
ecipien s
olde
han
60
yea s
is
unce ain.
Resul s
ob ained
a e
in
acco dance
wi h
hose
o
a
ecen
s udy
alida ing
dono -only
KDRI
(i.e.,
KDPI)
on
a
Du ch
popula ion
and
ob aining
a
disc imina o y
abili y
(Ha ell’s
C)
o
0.62.19
Ou
wo k
s a es
ha
KDPI
disc imina es
g a
and
pa ien
su i al
o
ecipien s
o
18–59
yea s,
wi h
di e ences
be ween
ecipien s
o
op imal
dono s
(KDPI
<
25%)
and
he
es .
Fo
ecipien s
olde
han
60
yea s,
he
KDPI
p edic ion
powe
is
equally
limi ed,
bu
e en
hen,
i
igh ly
disc imina es
be ween
he
fi s ,
he
hi d
and
he
ou h
qua iles
(i.e.,
be ween
op imal
and
ma ginal
dono s).
The
KDPI
is
also
use ul
592
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
Table
3
–
Compa isons
o
g a
su i al
o
qua ile
pai s.
Recipien
coho :
18–59
yea s.
Qua ile
Q2
Q3
Q4
Chi-squa e
P
Chi-squa e
P
Chi-squa e
P
Q1
3.004
0.083
8.296
0.004
5.559
0.018
Q2
–
–
2.235
0.135
2.773
0.096
Q3
–
–
–
–
0.604
0.437
S a is ically
significan
P- alues
a e
shown
in
bold.
Censu ada pa a mue e
Tiempo pos - ansplan e (años) Tiempo pos - ansplan e (a
ños)
Supe i encia de inje o (%)
Supe i encia de inje o (%)
No censu ada
100
90
80
70
60
50
100
90
80
70
60
50
0
2
4
6
810
0
2
4
6
810
Indi iduos en iesgo
Inicio
Año 2
Año 4
Año 6
Año 8
Año 10
Cua il 1 76
225
364
248
143
230
168
57 41
115
149
70
27
70
82
26 7
29
31
16 0
1
5
0
Cua il 2
Cua il 3
Cua il 4
ab
Fig.
3
–
Kaplan–Meie
g a
su i al
acco ding
o
KDPI
qua ile
o
ecipien s’
age
60+
yea s:
(a)
dea h-censo ed,
(b)
uncenso ed.
o
disc imina ing
pa ien
su i al
among
qua iles.
I
is
no e-
wo hy
in
bo h
subpopula ions
he
poo
disc imina ion
abo e
he
median
( hi d
and
ou h
qua iles);
his
migh
sugges
a
lack
o
accu acy
o
he
index
om
a
ce ain
le el
o
quali y,
o
ha
o he s
cha ac e is ics
no
collec ed
by
he
index
(e.g.,
biopsy)
a e
in ol ed.
Rega ding
ecipien s
olde
han
60
yea s,
he e
is
an
asso-
cia ion
be ween
g a
su i al
and
KDPI.
Se e al
s udies
ha e
analysed
di e en
e ec s
caused
by
expanded
o
high-KDPI
dono s
acco ding
he
ecipien ’s
age,
s a ing
ha
he
influence
on
su i al
is
lowe
in
olde
ecipien s.
Ma
e
al.
s udied
i
he
use
o
SCD
o
ECD
kidneys
influences
di e en ly
on
pa ien
su i al
i
he
ecipien ’s
age
is
highe
o
lowe
han
60
yea s.20
They
analysed
3822
cases
be ween
1997
and
2009
s a ing
ha
in
younge
ecipien s
he e
was
an
excess
isk
o
all-cause
mo ali y
(adjus ed
HR
=
1.55;
95%
CI:
1.23–1.97)
and
dea h
wi h
unc ioning
g a
(adjus ed
HR
=
1.72;
95%
CI:
1.28–2.29)
a e
ansplan a ion
wi h
ECD
kidneys
compa ed
wi h
SCD
kid-
neys.
This
conclusion
could
no
be
applied
o
olde
ecipien s
(adjus ed
HR
=
1.11;
95%
CI:
0.80–1.54,
and
adjus ed
HR
=
1.30;
95%
CI:
0.89–1.89,
espec i ely).
The
au ho s
se
ha
an
excess
isk
o
all-cause
mo ali y
on
younge
ecipien s
o
an
ECD
kidney
is
caused
by
he
inc ease
o
ca dio ascula
mo ali y
associa ed
o
wo se
enal
unc ion
o
he
g a
(and
educed
GFR)
ob ained
wi h
his
kind
o
dono .
Ch onic
inflamma-
ion
and
he
s a e
o
immunosupp ession
associa ed
wi h
u aemia
lead
o
accele a ed
a he oscle osis
ha
would
jus-
i y
hese
poo
esul s.21 Ou
wo k
ag ees
since
he
su i al
o
younge
ecipien s
is
clea ly
a ec ed
by
he
KDPI
(Fig.
4a).
I
also
s eng hs
he
impo ance
o
main aining
he
p inciple
o
alloca ion
‘old
o
old’.
He nandez
e
al.
s udied
he
odds
o
dea h
and
g a
loss
ega ding
o gan
quali y
measu ed
by
KDPI,
di ided
in
fi e
ca ego ies,
among
coho s
o
ecipien s
wi h
di e en
age
anges.22 The
su i al
o
ecipien s
om
50
o
69
yea s
ecei ing
a
low-quali y
g a
is
significan ly
educed.
Howe e ,
ecipien s
om
70
o
79
yea s
ecei ing
a
e y
low-quali y
g a
had
a
lowe
dea h
isk
han
ecipien s
om
50
o
69
yea s.
Recipien s
olde
han
79
yea s
had
he
lowes
isk.
These
esul s
a e
consis en
wi h
ou
s udy
since
he
KDPI
haza d
a io
o
pa ien
su i al
is
lowe
in
he
popula ion
o e
60
yea s
(HR
=
1.011)
han
among
hose
aged
18–59
yea s
(HR
=
1.013).
A
majo
objec i e
o
he
US
alloca ion
sys em
is
o
alloca e
low-KDPI
g a s
(be e
quali y)
o
pa ien s
wi h
high
es ima ed
su i al
(based
on
he
Es ima ed
Pos
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
593
Table
4
–
Compa isons
o
g a
su i al
o
qua ile
pai s.
Recipien
coho :
60+
yea s.
Qua ile
Q2
Q3
Q4
Chi-squa e
P
Chi-squa e
P
Chi-squa e
P
Q1
2.057
0.151
4.319
0.038
8.081
0.004
Q2
–
–
1.731
0.188
5.674
0.017
Q3
–
–
–
–
1.570
0.210
S a is ically
significan
P- alues
a e
shown
in
bold.
Table
5
–
Significan
ac o s
in
a
isk-adjus ed
Cox
p opo ional
haza ds
g a
su i al
analysis.
Adul
deceased
dono
and
adul
ecipien
pe o med
in
Spain,
Janua y
1,
2006,
o
Decembe
31,
2015.
Va iable
Ca ego y
Wi h
KDPI
(a)
Wi h
dono
cha ac e is ics
(b)
HR
(95%
CI)
P
HR
(95%
CI)
P
KDPI
Con inuous
2.217
(1.699–2.892)
<0.001
–
–
Recipien
age
(yea )
Con inuous
0.983
(0.971–0.994)
0.003
0.982
(0.970–0.994)
0.003
Recipien
gende
Female
1.00
–
1.00
–
Male
1.277
(0.976–1.669)
0.075
1.339
(1.062–1.689)
0.013
Dono
age
(yea )
Con inuous
–
–
1.025
(1.013–1.037)
<0.001
Dona ion
a e
ci cula o y
dea h
s a us
Yes
–
–
1.776
(1.03–3.062)
0.039
No
–
–
1.00
–
(a)
Haza d
a ios
a e
adjus ed
o
ac o s
in
he
able,
and
ecipien
heigh ,
HIV
and
HCV
s a us,
p ima y
enal
disease,
HLA
misma ch,
ime
on
RRT.
(b)
Haza d
a ios
a e
adjus ed
o
ac o s
e e ed
in
(a)
and
dono
ac o s:
gende ,
hype ension,
c ea inine
le el,
heigh ,
weigh ,
his o y
o
diabe es
and
hepa i is,
and
cause
o
dea h.
HR,
haza d
a io;
CI,
confidence
in e al;
HLA,
human
leucocy e
an igen.
Supe i encia de pacien e (%)
100
90
80
70
60
02468 10 024
6
810
Supe i encia de pacien e (%)
100
90
80
70
60
Tiempo pos - ansplan e (años) Tiempo pos - ansplan e (años)
Recep o es: 18-59 años
Recep o es: 60+ a
ños
Inicio
Inicio
Año Año
Año Año Año Año Año Año Año Año
2424
6810 6810
1
1
5
29
31
1627
71
82150
116
41
168
230364
248
143 70 26
7
0
225
7614
5
2
05
28
90
191377
202
65
911
104
319
545675
458
172
2239
258
639
885Cua il 1
Cua il 2
Cua il 3
Cua il 4
57
ab
Fig.
4
–
Kaplan–Meie
pa ien
su i al
acco ding
o
KDPI
qua ile:
(a)
ecipien s’
age:
18–59
yea s,
(b)
ecipien s’
age:
60+
yea s.
T ansplan
Su i al,
EPTS7).
Thus,
young
ecipien s
bene-
fi
om
he
bes -quali y
dono s.
When
a
high-KDPI
g a
is
alloca ed
o
a
senio
ecipien ,
he
dele e ious
e ec
on
pa ien
su i al
is
mani es .
Howe e ,
ou
esul s
s a e
ha
ecipien s
olde
han
60
yea s
can
also
benefi
o
ex ended
su i al
(as
Fig.
4b
shows).
Al hough
alloca ion
sys ems
in
Spain
and
US
a e
di e en ,
mo i a ion
is
alike.
The
aim
is
o
ob ain
a
longe i y
ma ching,
so
cases
o
alloca ion
o
op imal
dono s
o
olde
ecipien s
a e
uncom-
mon.
594
n
e
o
l
o
g
i
a.
2
0
1
8;3
8(6):587–595
Finally,
he e
is
a
couple
o
po en ial
limi a ions
o
his
wo k.
Fi s ly,
KDPI
is
calcula ed
by
using
he
s udy
popula-
ion
i sel .
I
would
be
mo e
app op ia e
o
use
a
e e ence
Eu opean
dono
popula ion
(as
i
is
done
in
US)
bu
he e
is
no
such
egis y
a ailable.
The
au ho s
hink
ha
i
is
be e
o
use
he
s udy
coho
i sel
o
calcula e
he
KDPI
han
using
he
comple ely
di e en
popula ion
published
by
he
US
O gan
P ocu emen
and
T ansplan a ion
Ne wo k.23
Secondly,
o
he
e ospec i e
egis y
analysis
pe o med,
some
cases
had
o
be
excluded
due
o
missing
da a.
Miss-
ing
da a
is
due
o
andom
ailu e
in
manual
egis y
on
da a
in oduc ion,
so
he e
is
no
e idence
o
sugges
his
has
a
nega i e
e ec
on
in e p e a ion.
The e o e,
he
anal-
ysis
pe o med
a e
so-called
comple e-case
analysis,
and
no
da a
impu a ion
echnique
has
been
used
o
eplace
missing
da a.
In
summa y,
his
is
one
o
he
fi s
s udies
o
alida e
he
use
o
KDPI
in
a
Spanish
coho .
Howe e ,
due
o
ce ain
limi-
a ions
on
he
KDPI
ansla ion
o
Spain,
c ea ing
a
new
index
om
Spanish
o
Eu opean
da a
would
be
ad isable.24 In
his
wo k,
some
p edic i e
ac o s
o
g a
su i al
a e
iden ified
ha
can
se e
as
a
fi s
s ep
in
his
pa h.
Al hough
i
is
co ela ed
significan y
wi h
he
g a
and
pa ien s’
su i al,
mo e
s udies
should
be
pe o med
aim-
ing
o
inc ease
he
p edic i e
powe
o
kidney
dono
sco es
o
complemen
hem
wi h
o he
da a
sou ces
ha
mean
a
eal
clinical
aid
o
p o essionals
in
p e ansplan a ion.
Inc easingly,
ecipien s
demand
wide
in o ma ion
abou
he
g a
quali y
o
ecei e,
and
he
KDPI
is
a
igh
s ep
in
ha
di ec ion.
Howe e ,
new
echnology
ends
may
b ing
ools
ha
in eg a e
in o ma ion
om
di e en
da a
sou ces
(clinical,
biological,
his ological,
.
.
.)
abou
dono s
and
ecip-
ien s
o
pe o m
su i al
es ima ions
wi h
highe
p edic i e
powe .
Conflic s
o
in e es
The
au ho s
ha e
no
conflic s
o
in e es
o
decla e.
Acknowledgemen s
This
wo k
has
been
pa ially
suppo ed
by
he
Biomedical
Enginee ing
G oup
a
Uni e si y
o
Se illa,
and
a
g an
om
he
Fondo
de
In es igación
Sani a ia
inside
p ojec
PI15/00306.
e
e
e
n
c
e
s
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Wol e
RA,
Ashby
VB,
Mil o d
EL,
Ojo
AO,
E enge
RE,
Agodoa
LY,
e
al.
Compa ison
o
mo ali y
in
all
pa ien s
on
dialysis,
pa ien s
on
dialysis
awai ing
ansplan a ion,
and
ecipien s
o
a
fi s
cada e ic
ansplan .
N
Engl
J
Med.
1999;341:
1725–30.
2.
Rao
PS,
Me ion
RM,
Ashby
VB,
Po
FK,
Wol e
RA,
Kayle
LK.
Renal
ansplan a ion
in
elde ly
pa ien s
olde
han
70
yea s
o
age:
esul s
om
he
Scien ific
Regis y
o
T ansplan
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T ansplan a ion.
2007;83:1069–74.
3.
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Sis ema
de
In o mación
de
la
Coo dinación
Au onómica
de
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Andalucía.
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Insuficiencia
Renal
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In o me
2015.
2016.
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Wang
CJ,
We mo e
JB,
C a y
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C i e ia
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Kidney
Dono
P ofile
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o
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dono s
alloca ed
by
s anda dized
p e ansplan
dono
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dis ibu ion
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A,
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Ha hay
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T ansplan a ion
Ne wo k
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Hamidi
O,
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M,
Tapak
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isk
ac o s
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su i al
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pa ien s
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andom
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MZ,
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DV,
Chen
Y,
Ra el
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Alex
A,
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L,
Alexande
M,
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J,
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Mucsi
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e
al.,
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o
and
app op ia eness
o
enal
ansplan a ion
in
elde ly
pa ien s
wi h
end-s age
enal
disease:
a
li e a u e
e iew
and
posi ion
s a emen
on
behal
o
he
Eu opean
Renal
Associa ion-Eu opean
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e
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Valida ion
o
he
p ognos ic
Kidney
Dono
Risk
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o
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GR,
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among
younge
and
olde
ecipien s
o
kidney
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om
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e
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g
i
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21.
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Immune
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RA,
Malek
SK,
Mil o d
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Finlayson
SR,
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o
dono
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T ansplan a ion.
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23.
O gan
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T ansplan a ion
Ne wo k
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