Functional status-based risk-benefit analyses of high-KDPI kidney transplant versus dialysis

Yearly, over half of deceased-donor kidneys with kidney donor profile index (KDPI) > 85 were discarded, yet they could improve survival outcomes for dialysis patients. The potential risk of high-KDPI kidney transplant (KT) depends on the patient's overall health summarized by functional status, which should be examined. The analyzed cohort consisted of adult deceased-donor KT candidates on dialysis listed in 2005-2014. A multivariate Cox proportional hazards model was fitted with functional status, measured using Karnofsky Performance Score (KPS), and transplant status as time-varying covariates. Derived from the Cox model, survival curves were analyzed to compare the survival outcomes between dialysis and transplant with different kidney qualities across three different KPS strata: 10-40, 50-70, and 80-100. With KDPI 0-99 KT, KPS 10-40 patients will survive ≥4.38 years median compared with 3.21 years median if they remained on dialysis. For KPS 50+ patients, the median survival years increase from 5.82 to 6.60 years on dialysis to ≥7.83 years after KDPI < 100 KT. The risk-adjusted analyses suggested that patients are expected to benefit more from KDPI 81-99 KT than from remaining on dialysis.