Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression?

Table 1 Expanded criteria donor kidney transplantation: Epidemiological data

Pro	Contra
Annual mortality rate in dialysis patients exceeds 20%[2]	70% increased risk for graft failure vs SCD kidneys[12]
Rapidly growing transplant waiting lists and, subsequently, increasingly longer waiting times[1-3]	17% primary graft non-function vs SCD kidneys[12]
Survival advantage of ECD kidney transplant recipients over dialysis patients remaining on transplant waiting list[2,4,6,15]	38% of ECD kidneys were discarded vs 9% for all other kidneys[12]
	Increased treatment cost and resource use[3,4]
	Mortality in perioperative period greater in ECD kidney recipients[4,13]
	Higher DGF rates, more acute rejection episodes and decreased long-term graft function in ECD vs SCD kidneys[12-14]

ECD: Expanded criteria donor; SCD: Standard criteria donor; DGF: Delayed graft function.

Table 2 Subgroups with significant survival benefit after expanded criteria donor kidney transplantation according to epidemiological data[4,6,7,16]

Patients older than 40 yr

Long median waiting time (> 4 yr)

Patients with diabetes or hypertension

Patients of low immunological risk

Dialysis patients with vascular access problems

Dialysis patients whose life expectancy in dialysis is lower than the estimated waiting time for kidney transplantation

Table 3 Expanded criteria donor kidney transplantation: Maximizing benefit

Modifying allocation rules for ECD kidneys in an effort to match the appropriate kidney to the appropriate recipient

Minimizing risk factors for DGF: Lowering CIT, pulsatile perfusion preservation

Preimplantation renal biopsy for ECD kidney recipients

Simultaneous dual ECD kidney transplantation

Restricting the use of ECD kidneys to patients of low immunological risk

Applying individualized immunosuppressive regimens

ECD: Expanded criteria donor; DGF: Delayed graft function; CIT: Cold ischemia time.

Table 4 Modifying and individualizing the immunosuppressive regimen in expanded criteria donor kidney transplantation: Main strategies

Induction with ATG

Reduce overall immunosuppression burden, especially in elderly recipients of ECD kidney transplants

Reduced CNI exposure regimens (target CNI blood levels 25%-50% lower)

Delayed CNI introduction regimens

CNI-free regimens based on MMF and steroids with ATG induction

CNI-free Belatacept-based regimens

Reduced CNI exposure and CNI-free mTOR-inhibitors-based regimens

ATG: Antithymocyte globulin; ECD: Expanded criteria donor; CNI: Calcineurin inhibitor; mTOR: Mammalian target of rapamycin; MMF: Mycophenolate mofetil.