Survival benefit of deceased donor kidney transplantation versus continued dialysis: international target trial emulation.

Rachel Hellemans, Nicholas C Chesnaye, Anneke Kramer, Edouard L Fu, Miha Arnol, Anders Åsberg, Claus Bistrup, Pietro Manuel Ferraro, Kristian Heldal, Jaakko Helve, Camille Legeai, James Medcalf, Dorothea Nitsch, Laia Oliveras, María José Pérez-Sáez, Belén Ponte, Emilie Savoye, Mårten Segelmark, Shaminie Shanmugaranjan, Søren S Sørensen, Roser Torra, Alberto Ortiz, Kitty J Jager, Vianda S Stel

Journal: BMJ (Clinical research ed.) 2026;394():e100624

PMID: 42759976

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Abstract

OBJECTIVE

To quantify the survival benefit of deceased donor kidney transplantation versus continued dialysis according to patients' characteristics (age, diabetes, cardiovascular disease), donor quality (standard criteria donor or expanded criteria donor) and donor retrieval type (donation after brain death or donation after circulatory death).

DESIGN

Target trial emulation.

SETTING

European Renal Association Registry data from five countries or regions: Catalonia (Spain), Denmark, France, Norway, and the UK.

PARTICIPANTS

Patients aged ≥20 years receiving dialysis and waitlisted for a first deceased donor kidney-only transplant between 2000 and 2019.

MAIN OUTCOME MEASURES

Five year patient survival following deceased donor kidney transplantation versus continued dialysis within monthly sequential trials. Flexible parametric spline models estimated adjusted five year patient survival across recipient age.

RESULTS

Of 64 036 waitlisted patients receiving dialysis, 39 244 received a deceased donor kidney transplant: 16 897 (43.1%) from a standard criteria donor/donation after brain death donor, 4324 (11.0%) from a standard criteria donor/donation after circulatory death donor, 14 799 (37.7%) from an expanded criteria donor/donation after brain death donor, and 3224 (8.2%) from an expanded criteria donor/donation after circulatory death donor. Standard criteria donor/donation after brain death and standard criteria donor/donation after circulatory death transplantation showed higher estimated five year survival compared with continued dialysis regardless of recipient age. However, the survival benefit associated with expanded criteria donor/donation after brain death transplantation and, particularly, expanded criteria donor/donation after circulatory death transplantation decreased with increasing recipient age, albeit with greater statistical uncertainty among older patients. For example, among 75 year olds, estimated five year survival following expanded criteria donor/donation after circulatory death transplantation did not differ significantly from that with continued dialysis (59% (95% confidence interval 51% to 66%) versus 55% (54% to 55%); hazard ratio 0.97, 95% confidence interval 0.70 to 1.33), irrespective of diabetes or cardiovascular disease status. This group had a threefold higher early post-transplant mortality than those continuing dialysis.

CONCLUSIONS

Standard criteria donor kidney transplantation was consistently associated with a survival benefit compared with continued dialysis. By contrast, the survival benefit associated with expanded criteria donor transplantation declined with increasing recipient age, particularly for expanded criteria donor/donation after circulatory death transplantation, such that the oldest recipients had a smaller and more statistically uncertain estimated survival advantage over continued dialysis.

Address: Department of Nephrology, Antwerp University Hospital, Edegem, Belgium.; Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.; ERA Registry, Department of Medical Informatics, Amsterdam UMC, Amsterdam, Netherlands.; Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, Netherlands.; Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, Netherlands.; Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.; Department of Pharmacy, University of Oslo, Oslo, Norway.; Department of Nephrology, Odense University Hospital, Odense, Denmark.; Department of Clinical Research, University of Southern Denmark, Odense, Denmark.; Section of Nephrology, Department of Medicine, Università degli Studi di Verona, Verona, Italy.; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.; Finnish Registry for Kidney Diseases, Finnish Institute for Health and Welfare, Helsinki, Finland.; Organ and Tissue Procurement and Transplantation Department, Agence de la biomédecine, Saint Denis La Plaine, France.; UK Renal Registry, UK Kidney Association, Bristol, UK.; University of Leicester, John Walls Renal Unit, Leicester, UK.; UK Renal Registry, UK Kidney Association, Bristol, UK.; Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.; Renal Department, Royal Free London NHS Foundation Trust, London, UK.; Department of Nephrology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.; Nephrology Department, Hospital del Mar, Barcelona, Spain.; Hospital del Mar Research Institute, Barcelona, Spain.; Faculty of Medicine, Nephrology and Hypertension Division, University Hospitals of Geneva, Geneva, Switzerland.; Department of Clinical Sciences, Lund University, Lund, Sweden.; Department of Endocrinology, Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden.; Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK.; Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.; Department of Nephrology, Universitat Autònoma de Barcelona, Barcelona, Spain.; ISCIII RICORS2040, Barcelona, Spain.; Department of Nephrology and Hypertension, IIS-Fundación Jiménez Diaz-UAM, Madrid, Spain.; ISCIII RICORS2040, Madrid, Spain.; ERA Registry, Department of Medical Informatics, Amsterdam UMC, Amsterdam, Netherlands [email protected].; Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, Netherlands.

DOI: 10.1136/bmj-2026-100624

MeSH Terms: Humans, Kidney Transplantation, Renal Dialysis, Middle Aged, Female, Kidney Failure, Chronic, Registries, Male, Adult, Tissue Donors, Waiting Lists, Europe, Aged, Brain Death