Expanded Kidney Donors: Survival Rates
Donor Criteria Affect Kidney Transplant Survival Rates
Updated June 08, 2025
For older and high-risk patients needing a kidney transplant, using expanded-criteria donors might not provide the same survival advantage as using standard donors. This is according to an analysis of over 64,000 individuals in the european Renal Association (ERA) registry.
Dr. Rachel Hellemans,a nephrologist at Antwerp university Hospital,Belgium,presented the findings at the 62nd ERA Congress 2025. She emphasized that assessing transplant suitability should consider donor quality, not just the patient’s condition. The research highlights the importance of donor selection in kidney transplantation and its impact on patient outcomes.
Hellemans acknowledged the organ shortage, noting that older patients’ access to standard-criteria donor kidneys depends on local allocation systems and waiting times.Extended waiting periods can worsen a patient’s condition, potentially leading them to accept an expanded-criteria donor kidney, which generally performs less effectively. The study underscores the complexities of kidney allocation and the trade-offs patients face.
while acknowledging that some patients might value transplantation with expanded criteria kidneys to improve their quality of life, Hellemans urged clinicians to carefully interpret and communicate the study’s results. Despite thorough pre-transplant evaluations, unpredictability and risks remain, especially early after the transplant. the research emphasizes the need for informed patient discussions about the potential benefits and risks of different donor options in kidney transplantation.
“When determining who is a suitable transplant candidate, we shouldn’t only focus on the patient alone, as the outcomes will also depend on donor quality,” said Hellemans.
The study, analyzing data from the ERA Registry, examined adults in France, Catalonia (Spain), Denmark, Norway, and the United Kingdom who were on dialysis and wait-listed for a first deceased donor kidney transplant between 2000 and 2019. Researchers compared 5-year survival rates for those receiving standard-criteria donor kidneys (from donors under 60 without significant risk factors) versus expanded-criteria donor kidneys (from donors 60 or older,or those 50-59 with specific risk factors like hypertension or cerebrovascular accident).
The researchers used a target trial emulation method to minimize biases common in registry-based studies. This approach treated the observational data as if it came from a randomized controlled trial, comparing outcomes for transplant recipients with those remaining on dialysis. The study design aimed to provide more reliable evidence regarding the impact of donor criteria on kidney transplant outcomes.
Results indicated that standard-criteria donors led to substantially better 5-year adjusted survival rates compared to remaining on dialysis,regardless of the recipient’s age. Though, the survival benefit from expanded-criteria donors decreased with increasing recipient age, nearly disappearing for those receiving organs after circulatory death.the findings suggest that the benefits of kidney transplantation using expanded criteria donors may be limited for older recipients.
Patients aged 75 and older receiving kidneys from expanded criteria donors had estimated 5-year survival rates of 57%-58%, only slightly higher than the 54% for those on dialysis. Similar trends were observed in recipients with diabetes or cardiovascular disease.The study highlights the diminishing returns of expanded criteria kidney transplantation in specific patient populations.
Hellemans noted that increased early post-transplant mortality in older patients receiving expanded criteria kidney donations was a key factor. Mortality risk sharply increased in the first 10 months post-transplant, then decreased, with the hazard ratio for death at 5 years being 1.01 (95% CI, 0.74-1.36) for both approaches.The research points to the increased risks associated with expanded criteria kidney transplantation, particularly in the immediate post-operative period.
What’s next
Future research should focus on refining donor selection criteria and developing strategies to mitigate the increased early post-transplant mortality observed in older recipients of expanded-criteria donor kidneys. Further analysis of U.S.data is also needed to confirm thes findings.