Donor Acute Kidney Injury and Outcomes After Deceased Donor Kidney Transplantation: A 50-Case Single-Center Study From Japan.

INTRODUCTION: Elevated terminal donor creatinine often leads to kidney discard, although donor acute kidney injury (AKI) may represent reversible tubular injury. We evaluated the impact of donor AKI stage on delayed graft function (DGF), early graft recovery, and long-term graft survival in a Japanese deceased-donor kidney transplantation cohort.

METHODS: We retrospectively analyzed 50 consecutive deceased-donor kidney transplants performed between 2010 and 2025. Donor AKI was classified according to the Kidney Disease: Improving Global Outcomes creatinine criteria. KDPI was calculated using the OPTN refit KDRI model (October 2024 implementation). DGF was defined as dialysis requirement within 7 days after transplantation. Death-censored graft survival was analyzed using the Kaplan-Meier method, and Cox proportional hazards modeling was performed as a univariate analysis due to the limited number of events.

RESULTS: DGF occurred in 38 patients (76%). Higher donor AKI stage correlated significantly with DGF occurrence (ρ  =  0.372, p  =  0.009), dialysis session count (ρ  =  0.316, p  =  0.027), and lower eGFR at 3 months (ρ  =- 0.472, p  <  0.001) and 6 months (ρ  = - 0.408, p  =  0.004). During a median follow-up of 75 months, four graft losses occurred. Death-censored graft survival did not differ between AKI stage 0 and stages 1-3 (log-rank p  =  0.90). Five- and 10-year survival rates were 95.8% and 91.2%, respectively.

CONCLUSIONS: Donor AKI was associated with increased early graft morbidity but not with inferior long-term graft survival. Elevated terminal creatinine alone should not automatically preclude kidney utilization, particularly when reversible tubular injury is suspected.