Outcomes of Kidney Transplants From Standard Criteria Donors With Diabetes: A Propensity Score-Matched Study

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Rationale & Objective Few studies have evaluated the impact of using donors with diabetes, which often leads to higher rates of organ refusal by transplant centers, based on the concern that the disease may negatively impact graft quality and the recipient outcomes. Therefore, this study aimed to evaluate 5-year outcomes of kidney transplant recipients (KTRs) who received kidneys from donors with diabetes but who met the standard United Network for Organ Sharing (UNOS) criteria. Study Design Observational and longitudinal cohort study. Setting & Participants KTRs who received kidneys from deceased donors meeting standard UNOS criteria between 2013 and 2017 at a large-scale Brazilian center of transplantation. Exposure Presence of diabetes in the donor. Outcomes Five-year estimated glomerular filtration rate (eGFR, mL/min/1.73 m 2 ) and graft survival. Analytical Approach Comparison of KTRs from donors with (DM+) and without (DM−) diabetes, involving the entire cohort and after a 1:2 propensity score-matched analysis. eGFR was compared using generalized estimated equation and graft survival by Fine and Gray subdistribution hazards models. Results Of 3,059 KTRs, 1,931 (63.1%) met the standard UNOS criteria, 73 being DM+ (3.8%). Before matching, the 1- and 5-year eGFRs were 42.5 and 34.6 among DM+, whereas they were 50.8 and 44.8 among DM−, respectively, with a significant mean difference in all eGFR measures (−9.07; P = 0.001), but with no interaction between presence of diabetes and time ( P = 0.54). All demographic disparities between groups were controlled by propensity score. After matching, the 1- and 5-year eGFRs were 42.5 and 34.6 among DM+, whereas they were 46.1 and 38.8 among DM−, respectively, with no mean difference in all eGFR measures (−3.65; P = 0.26) and also with no interaction between presence of diabetes and time ( P = 0.91). The 5-year graft survival was 84.6% for KTRs of DM+ vs. 88.1% (subdistribution HR=1.40; P=0.25) before and 84.3% (subdistribution HR=1.02; P = 0.96) after propensity score matching. Limitations Retrospective and single-center study. Conclusions Five-year eGFR and graft survival were inferior among KTRs of donors with diabetes; however, when the key demographic disparities were controlled using propensity score matching, no impact was observed in long-term outcomes when donors with diabetes are used. Plain-language Summary Many kidney transplants are declined when the donor has diabetes, because teams worry these kidneys will not last as long. We studied adults who received kidneys from donors with and without diabetes in a large Brazilian center and followed them for years after surgery. At first glance, kidneys from donors with diabetes seemed to have worse function and survival. However, after carefully adjusting for key differences between donors and recipients in each group, the long-term outcomes were in fact very similar. Our findings suggest that diabetes alone should not automatically exclude a kidney from being used for transplantation. This would help to expand the donor pool and reduce waiting time for people needing a transplant.