The Impact of Donor and Recipient Diabetes on Patient and Graft Survival in Kidney Transplant Recipients

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Introduction With the growing demand for kidney transplants, kidneys from donors with diabetes are used more frequently. This raises the concerning possibility that a kidney with early-stage diabetic nephropathy may be transplanted into a recipient who subsequently develops post-transplant dysglycemia; however, it is unclear what impact this will have on graft function and survival. This study investigated graft and patient survival when the donor, recipient, or both have diabetes. Methods Data from the Australia and New Zealand Dialysis and Transplant Registry were used to analyse first-time adult recipients of deceased-donor kidneys between 2003-2022. Cox proportional hazards models were used to compare primary outcomes of death-censored graft survival and patient survival across combinations of donor and recipient diabetic status. Secondary outcomes of rejection and eGFR over time were analysed with logistic regression and linear mixed models, respectively. Results The 11,343 recipients included 7377 donor/recipient nondiabetic pairs (D-/R-); 3253 diabetic recipients/nondiabetic donors (D-/R+); 524 nondiabetic recipients/diabetic donors (D+/R-) and 189 both diabetic (D+/R+). Death-censored graft survival was reduced only in the D+/R+ group (adjusted hazard ratio [aHR] 1.70, 95% CI 1.15- 2.51, P= 0.008). Diabetic recipients had the poorest survival, particularly in the D+/R+ group (aHR 1.77, 95% CI 1.33- 2.37, P <0.001). There was no difference in rejection and only a minor reduction in eGFR for recipients of diabetic donor kidneys. Conclusion The D+/R+ combination is associated with inferior graft and patient survival and should be considered cautiously. This study supports continued utilisation of diabetic donors with no impact on graft or patient survival in nondiabetic recipients.

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