Impact of Donation After Circulatory Death on Outcomes of Expanded Criteria Donor Kidney Transplants

•A significant proportion of kidneys from DCD/ECD donors had higher 1-year & 3-year cumulative total graft loss and death censored graft loss than otherwise similar NDD/ECD outcomes. The KDPI scores did not differ between groups, so did not adequately reflect the quality of these organs.•DCD/ECD had inferior graft function, both in terms of estimates of glomerular filtration rate, as well as requirements for erythropoiesis stimulating agents and phosphate binders, outcomes we considered indicative of higher burden of chronic kidney disease.•Accepting or discarding ECD/DCD offer should be made on a case-by-case basis taking in to account multiple variables including time on dialysis, time on waitlist and panel reactive antibody.•KDPI may not adequately capture the risk of poor outcomes in this subset of organs. Expanded criteria donor (ECD) kidneys experience suboptimal outcomes compared with standard criteria donor kidneys. To examine the additional impact of deceased organ category, donation after circulatory death (DCD), and neurologic determination of death (NDD) on ECD outcomes, we examined 1- and 3-year patient and graft survival in all ECD kidney recipients in our institution between January 2008 and December 2017. Of 166 ECD recipients, 49 (29.5%) were DCD and 117 (70.5%) were NDD. Delayed graft function was higher in the DCD/ECD group 61.2 % vs 32.0 % among NDD/ECD recipients. Graft loss was significantly increased among DCD/ECD (hazard ratio for graft loss 4.81 [95% CI1.78-13.01], P = .002 at 1 year and 2.03 [95% CI 1.03-4.0], P = .042 at 3 years). Death-censored graft loss was higher among DCD/ECD (hazard ratio was 10.12 [95% CI, 2.14, 47.92], P = .004 at 1 year and 2.83 [95% CI, 1.24, 6.46], P = .014 at 3 years). There was no statistically significant difference in all-cause mortality. Our study demonstrated that DCD/ECD kidneys have lower graft survival compared with NDD/ECD kidneys. Time on dialysis, waiting time, and panel reactive antibody should be taken into account when offering these organs to patients.