Organ Donation After Euthanasia Can Safely Expand Kidney Donor Pool, Study Finds

Robert Minnee, MD, PhD

Credit: Erasmus MC

New research is calling attention to the potential value of organ donation after euthanasia (donation after circulatory death type V [DCD-V]) kidney grafts for expanding the donor kidney pool.¹

The retrospective cohort study was conducted in the Netherlands, one of 5 countries in the world where DCD-V is performed, and leveraged deceased donor kidney transplantation data from the start of a national organ donation euthanasia program in 2012 through 2023. Results showed DCD-V kidney transplantation yielded similar short- and long-term outcomes compared with donation after circulatory death after withdrawal of life-sustaining therapies (DCD-III) and donation after brain death (DBD) kidney transplantation.¹

“DCD-V has tremendous potential to increase the number of transplantable organs. This is important given the persistent shortage of eligible donor organs,” Robert Minnee, MD, PhD, a transplant surgeon at Erasmus Medical Center in the Netherlands, and colleagues wrote.¹ “To determine if DCD-V is a safe way to increase the donor pool, it is critical to investigate the outcomes of these organs.”

Euthanasia and medical assistance in dying (MAiD) have been legalized in the Netherlands since 2002, and in 2012, a DCD-V program was initiated that increased the utilization of euthanasia. Since then, organ donation after euthanasia has become a topic of interest with the intent of expanding the kidney donor pool, but to date, little is known about the short- and long-term outcomes of transplants with these organs.^1,2

To compare DCD-V kidney graft outcomes with DCD-III and DBD kidney graft outcomes to determine whether DCD-V grafts provide acceptable results, investigators conducted a retrospective cohort study in the Erasmus Medical Center using data acquired from the Dutch Transplant Foundation database for all deceased-donor kidney transplantations in the Netherlands from January 2012 until July 2023. Investigators included DCD-III, DBD, and DCD-V transplants but excluded kidney transplants from DCD-I (dead on arrival at hospital) and DCD-II (unsuccessful resuscitation), as these donation procedures are no longer performed in the Netherlands.¹

The primary outcome was death-censored graft survival, defined as the period between transplantation and the moment of irreversible graft loss signified by the return to dialysis or retransplantation or the date of the last follow-up if the graft was still functioning. Secondary outcomes included the incidence of delayed graft function (DGF), permanent nonfunction (PNF), serum creatinine concentration, and patient survival until 5 years after kidney transplantation.¹

During the study period, 158 DCD-V kidneys were transplanted from 92 DCD-V donors, 145 of which were included in the present analysis, compared with 1936 DCD-III kidneys and 1255 DBD kidneys. Of the 92 DCD-V donors, 47 (51%) had neurodegenerative diseases and 23 (25%) had an indication for euthanasia because of psychiatric disorders. The median recipient age was 59 (Interquartile range [IQR], 46-66) years in the DCD-V cohort, compared with 61 (IQR, 50-68) years in the DCD-III cohort (P = .08) and 61 (IQR, 50-68) years in the DBD cohort (P = .03).¹

Investigators noted DGF occurrence in DCD-V kidneys (26%) was significantly lower than in DCD-III kidneys (49%; P <.001) and similar to DGF occurrence in DBD kidneys (22%; P = .46). Additionally, although there was no difference in the occurrence of PNF between DCD-V and DCD-III kidneys (6% vs 6%; P = .79), they noted PNF occurred more frequently in DCD-V kidneys compared with DBD kidneys (4%; P <.001).¹

Further analysis revealed there was no difference in 5-year death-censored graft survival between DCD-V grafts (82%) and DCD-III (86%; P = .99) or DBD (84%; P = .99) grafts. There was also no difference in 5-year patient survival between DCD-V kidney transplants (69%) and DCD-III (76%; P = .45) or DBD (73%; P = .74) kidney transplants.¹

To correct for confounders, propensity score matching (PSM) and subsequent analysis were performed between the DCD-III and DCD-V groups, with matching based on confounders for DGF. The “nearest” method was used to match cases in a 1:1 ratio with a caliper of 0.1.¹

In total, 116 DCD-V transplants were matched to 116 DCD-III transplants. Investigators noted there were no differences in donor or recipient characteristics between groups and pointed out the difference in DGF remained statistically significant after PSM (23% in the DCD-V group vs 51% in the DCD-III group; P <.001). Additionally, PNF occurrence was similar in both groups (5% vs 6%; P = .78) and there was no difference in death-censored graft survival or patient survival. Although serum creatinine concentration was lower at 3 months, 1 year, and 3 years after transplantation in the DCD-V group, this did not reach statistical significance.¹

Investigators acknowledged multiple limitations to these findings, including the use of the agonal phase rather than actual donor warm ischemic time (dWIT) and missing values from the database due to the retrospective nature of the study.¹

“This study’s results show that DCD-V kidney grafts yielded similar outcomes until 5 years after transplantation as DCD-III and DBD grafts. This suggests that DCD-V is a safe and valuable way to increase the kidney donor pool,” investigators concluded.¹

References

1. ^{Slagter JS, Kimenai HJAN, van de Wetering J, et al. Kidney Transplant Outcome Following Donation After Euthanasia. JAMA Surgery. doi:10.1001/jamasurg.2024.3913}
2. ^{Bollen J, de Jongh W, Hagenaars J, et al. Organ Donation After Euthanasia: A Dutch Practical Manual. American Journal of Transplantation. 10.1111/ajt.13746}