Understanding the Relationship Between Severe Donor Diabetes Insipidus, Kidney Donor Profile Index, and Recipient...

Severe diabetes insipidus (DI) causes dynamic changes in creatinine before organ donation. It is unknown whether terminal or peak creatinine is the optimal measure of graft quality among donors with severe DI.

Adult donors after brain death were identified from the United Network for Organ Sharing database, years 2015-2022. Kidney Donor Profile Index (KDPI) was computed using both terminal creatinine (KDPI-Terminal) and peak creatinine (KDPI-Peak). Model fit for the prediction of graft failure and reduced glomerular filtration rate (GFR) was compared. Logistic regression was used to determine the association between KDPI group reclassification and graft function.

Of 28 718 kidney transplants, 29% of donors met criteria for severe DI. No differences in estimated GFR (eGFR) or all-cause graft failure were observed on the basis of the presence of DI. Among donors with severe DI, KDPI-Peak improved prediction of reduced eGFR at 1 y (eGFR <60 mL/min/1.73 m², eGFR <30 mL/min/1.73 m²). Additionally, patients who received organs from donors with severe DI whose KDPI group would be reclassified on the basis of the use of peak rather than terminal creatinine had 2-fold increased odds of reduced eGFR at 1 y (eGFR <30 mL/min/1.73 m²; odds ratio, 1.92; 95% confidence interval, 1.37-2.69).

This national analysis confirms that while the presence of severe DI alone is not associated with graft outcomes, the use of peak creatinine significantly improves risk stratification of donor graft quality. Precise risk stratification is critical for efforts to improve appropriate kidney allocation and increase confidence in organ function after transplant.