ABSTRACT Introduction The UK public's willingness to donate, knowledge of, and concerns about different organ donation scenarios are not known. Methods A validated questionnaire was developed based on a literature review of the ethical issues associated with uncontrolled Donation after Circulatory Death (uDCD). Participants read three scenarios (Donation after Brain Death [DBD], controlled, and uncontrolled Donation after Circulatory Death [cDCD and uDCD]) relating to being asked about organ donation (with clear explanations of what was involved) in a randomised order. Each vignette was followed by Likert and open‐ended questions. Quantitative and thematic analyses were undertaken. Results Five hundred and five UK participants, representative of ethnicity, gender, and age (range 18–79) were recruited via Prolific and completed the survey. Participants were likely/willing to donate in 366/504 (73%) for DBD; 336/505 (67%) for cDCD; and 368/503 (73%) for uDCD. Ninety‐six per cent believed uDCD is already part of donation practice. Qualitative analysis revealed altruism as the most dominant theme. Participants did not want organs wasted, wanted to respect loved ones' wishes, and thought organ donation would provide comfort for the bereaved. For uDCD 71% agreed/strongly agreed that prioritising the chance to donate, including invasive techniques, was most important, noting the value of time for discussion; 93% thought they would need less than 4 h to decide. A small proportion of people did not support organ donation in any situation, largely for bodily integrity and religious reasons. Conclusions In this questionnaire survey, the UK public broadly supported donation in different circumstances, including uDCD, which the majority think already happens. Patient or Public Contribution A Patient and Public Involvement (PPI) group of more than 30 people have been involved in a larger research project on uDCD. Two of these, both bereaved relatives of potential donors, were consulted about the design and content of the questionnaire, and provided written and oral feedback, leading to changes in wording and style; the overall research proposal, nature of questions and recruitment was supported. One of these, JC, became a core part of the research team, attending meetings with other team members and contributing to the critical analysis and write up of the research; in particular she independently read the entire dataset searching for contradictory or outlying examples and agreed that the themes reported were representative, was involved in the final drafting of the manuscript, and is a co‐author.

Abstract Background Kidney transplantation (KT) is increasingly offered to older, comorbid patients, deemed ‘high-risk recipients’ (HRR). We aimed to quantify outcomes and predictors of mortality in HRRs in a contemporary cohort. Methods We analysed 1125 consecutive adult KT recipients (2014–2023), including 161 (14.3%) designated HRR by multidisciplinary team (MDT). Baseline donor and recipient characteristics, perioperative outcomes, and 5-year survival were compared. Predictors of mortality were assessed using multivariable Cox regression, and HRR designation was predicted via logistic regression. Red cell distribution width (RDW), a validated frailty marker, was explored as a predictor of survival. Results HRRs were older (64 versus 53 years), more frequently diabetic, and had higher rates of ischaemic heart disease (IHD). Clavien–Dindo Complications Grade ≥III occurred more frequently in HRRs (24.2% versus 16.1%, P = 0.018). Patient 5-year survival was 85.7% for standard-risk versus 67.9% for HRRs (log-rank P < 0.0001). In adjusted multivariable Cox regression, age (HR 1.86 per decade, 95%c.i. 1.52–2.28), IHD (HR 2.53, 95%c.i. 1.47–4.33), retransplantation (HR 2.10, 95%c.i. 1.17–3.77), and RDW (HR 1.23 per 1% increase, 95%c.i. 1.09–1.39) independently predicted mortality (P < 0.001). Logistic regression indicated that age, diabetes, IHD, and prolonged waiting list duration predicted MDT high-risk designation (AUC 0.83). When HRR status alone was used in the model, it predicted worse 5-year survival (HR 1.86, 95%c.i. 1.16–2.96, P = 0.01). Conclusions HRRs experience lower 5-year survival. Recipient age and elevated RDW are dominant predictors of mortality, supporting integration of objective metrics with the already robust MDT assessment to improve prognostication and patient counselling.

Background:Pre-implantation biopsy may help select kidneys retrieved from elderly deceased donors for transplantation, but concerns persist that it may cause unnecessary discard of kidneys that would have provided acceptable transplant function. The PITHIA trial tested the hypothesis that introduction of a National Digital Pathology Service (NDPS) would increase the proportion of kidneys transplanted from elderly donors and/or improve their function. Methods:A stepped-wedge cluster randomised controlled registry trial delivered the NDPS to 22 UK kidney transplant centres (clusters) in 5 sequences at four-monthly intervals, using a restricted randomisation technique to ensure similar cluster sizes in the intervention and control status. Upon access to the intervention, centres could request urgent pre-implantation biopsy on kidneys from deceased donors aged 60 years or older. Co-primary outcome measures were the proportion of kidneys transplanted upon first offer according to whether the centre had access or not to the biopsy service, and the 1-year eGFR of the kidneys that were transplanted. Analysis adjusts for clustering and underlying secular trends, with 97.5% Confidence Intervals (CI) reported to reflect the two co-primary outcomes. The trial is complete (Trial Registration Number: ISRCTN 11708741). Findings:The trial commenced on 1st October 2018 and ended on 31st January 2022. Of the 2502 eligible kidneys offered, 1355 single and 67 dual transplants were performed. Regarding the first primary endpoint, a non-significantly lower proportion of those kidneys first offered to centres with access to the biopsy service were transplanted compared with those offered to centres without access (295 of 1241 (23.8%) vs. 377 of 1261 (29.9%): adjusted Odds Ratio (97.5% CI) 0.91 (0.60-1.39); p = 0.6083). For the second primary endpoint, the adjusted mean (SE) 1-year eGFR of the transplant kidneys was similar, irrespective of whether the implanting centre had access to the biopsy service or not (43.7 (1.3) ml/min/1.73 m2 vs. 42.2 (1.3) ml/min/1.73 m2; adjusted mean difference (97.5% CI) 1.53 (-2.33 to 5.40); p = 0.37). Secondary outcome analysis of how the biopsy service was adopted revealed that biopsies were performed on 287 of the 1493 (19.2%) kidneys offered to at least one centre with access to the biopsy service, with marked variation between transplant centres in requests for biopsy, and in implantation rates of biopsied kidneys. Nevertheless, 191 (66.6%) of biopsied kidneys were transplanted, compared with 643 of the 1009 (63.7%) kidneys only ever offered to centres without biopsy access, and 588 of the 1206 (48.8%) kidneys that were not biopsied, despite being offered to at least one centre with biopsy access. Interpretation:Implementation of the NDPS did not significantly increase transplantation rates of elderly deceased donor kidneys upon first offer, nor improve 1-year eGFR of the transplanted kidneys. This may reflect inter-centre variation in adoption and application of the biopsy service; such variations would need to be considered when designing future studies of pre-implantation biopsy analysis. Funding:NIHR Research for Patient Benefit programme (RfPB PB-PG-1215-20033).

Wound infections are a common complication following kidney transplantation, affecting around 30% of obese recipients. Prophylactic subcutaneous drains are effective at reducing wound infection rates in some surgical procedures but are untested in transplantation. We present the findings of patient experience questionnaire as part of The Trial of Wound drain In Surgical site infection in kidney (TWIST), a trainee-led UK multi-centre randomised controlled trial. Participants with a BMI of >30 were recruited between April 2019 and April 2024, and were randomised to subcutaneous drain or no subcutaneous drain and stratified by BMI (30-34.9, 35-35.9, 40+) and diabetes. The use of a simultaneous deep drain was at the surgeon's discretion. Participants completed a patient-reported outcome measures (PROM) questionnaire at discharge. 330 patients were recruited from nine UK transplant centres. No significant differences were identified in patient-reported outcomes for pain, mobility, or sleep quality among groups receiving no drains, a superficial drain, a deep drain, or both. Similarly, no significant differences were found in wound or drain site leakage however, a notable 18.9% of patients indicated they would refuse a drain in future. One centre did not use deep drains in any patients, while two centres used them in 100% of patients. In the remaining six centres, deep drain usage ranged from 27% to 93%. Drains were well tolerated by the majority of kidney transplant recipients although an unexpected number would refuse future drain use and there was wide variation in drain use between UK transplant centres.

The quality assurance provided by preimplantation biopsy quantification of chronic damage may allow greater use of kidneys from expanded criteria donors, and thereby expand the deceased donor pool. Preimplantation biopsy may, however, identify additional acute or chronic pathologies not considered in the scoring of chronic damage, and these may influence the decision to implant or discard the kidney. This single-centre retrospective cohort study of a contemporary UK donor population systematically characterised the nature of additional findings in 1,046 preimplantation and implantation biopsies over an eight-year period. A diverse range of findings were identified in 111/1,046 (11%) organs; most frequently diabetic glomerulopathy, focal segmental glomerulosclerosis, (micro)thrombi, neutrophil casts, and immunoglobulin/complement staining. Seventy (63%) of these were transplanted, with subsequent biopsy in 41 (58%) cases confirming that 80% of the initial acute changes had spontaneously resolved, while there was no progression of diabetic glomerulopathy, and the lesions of focal segmental glomerulosclerosis were not identified. Over 75% of assessable grafts with additional histological findings at the time of transplant showed adequate function at one-year following transplant. In conclusion, most histological abnormalities that may be identified in addition to chronic scarring in preimplantation kidney biopsies would not preclude transplantation nor predict poor graft function.

Background Arteriovenous fistulas are considered the best option for haemodialysis provision, but as many as 30% fail to mature or suffer early failure. Objective To assess the feasibility of performing a randomised controlled trial that examines whether, by informing early and effective salvage intervention of fistulas that would otherwise fail, Doppler ultrasound surveillance of developing arteriovenous fistulas improves longer-term arteriovenous fistula patency. Design A prospective multicentre observational cohort study (the ‘SONAR’ study). Setting Seventeen haemodialysis centres in the UK. Participants Consenting adults with end-stage renal disease who were scheduled to have an arteriovenous fistula created. Intervention Participants underwent Doppler ultrasound surveillance of their arteriovenous fistulas at 2, 4, 6 and 10 weeks after creation, with clinical teams blinded to the ultrasound surveillance findings. Main outcome measures Fistula maturation at week 10 defined according to ultrasound surveillance parameters of representative venous diameter and blood flow (wrist arteriovenous fistulas: ≥ 4 mm and > 400 ml/minute; elbow arteriovenous fistulas: ≥ 5 mm and > 500 ml/minute). Mixed multivariable logistic regression modelling of the early ultrasound scan data was used to predict arteriovenous fistula non-maturation by 10 weeks and fistula failure at 6 months. Results A total of 333 arteriovenous fistulas were created during the study window (47.7% wrist, 52.3% elbow). By 2 weeks, 37 (11.1%) arteriovenous fistulas had failed (thrombosed), but by 10 weeks, 219 of 333 (65.8%) of created arteriovenous fistulas had reached maturity (60.4% wrist, 67.2% elbow). Persistently lower flow rates and venous diameters were observed in those fistulas that did not mature. Models for arteriovenous fistulas’ non-maturation could be optimally constructed using the week 4 scan data, with fistula venous diameter and flow rate the most significant variables in explaining wrist fistula maturity failure (positive predictive value 60.6%, 95% confidence interval 43.9% to 77.3%), whereas resistance index and flow rate were most significant for elbow arteriovenous fistulas (positive predictive value 66.7%, 95% confidence interval 48.9% to 84.4%). In contrast to non-maturation, both models predicted fistula maturation much more reliably [negative predictive values of 95.4% (95% confidence interval 91.0% to 99.8%) and 95.6% (95% confidence interval 91.8% to 99.4%) for wrist and elbow, respectively]. Additional follow-up and modelling on a subset ( n = 192) of the original SONAR cohort (the SONAR-12M study) revealed the rates of primary, assisted primary and secondary patency arteriovenous fistulas at 6 months were 76.5, 80.7 and 83.3, respectively. Fistula vein size, flow rate and resistance index could identify primary patency failure at 6 months, with similar predictive power as for 10-week arteriovenous fistula maturity failure, but with wide confidence intervals for wrist (positive predictive value 72.7%, 95% confidence interval 46.4% to 99.0%) and elbow (positive predictive value 57.1%, 95% confidence interval 20.5% to 93.8%). These models, moreover, performed poorly at identifying assisted primary and secondary patency failure, likely because a subset of those arteriovenous fistulas identified on ultrasound surveillance as at risk underwent subsequent successful salvage intervention without recourse to early ultrasound data. Conclusions Although early ultrasound can predict fistula maturation and longer-term patency very effectively, it was only moderately good at identifying those fistulas likely to remain immature or to fail within 6 months. Allied to the better- than-expected fistula patency rates achieved (that are further improved by successful salvage), we estimate that a randomised controlled trial comparing early ultrasound-guided intervention against standard care would require at least 1300 fistulas and would achieve only minimal patient benefit. Trial Registration This trial is registered as ISRCTN36033877 and ISRCTN17399438. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR135572) and is published in full in Health Technology Assessment ; Vol. 28, No. 24. See the NIHR Funding and Awards website for further award information.

Introduction:We assess if ultrasound surveillance of newly-created arteriovenous fistulas (AVFs) can predict nonmaturation sufficiently reliably to justify randomized controlled trial (RCT) evaluation of ultrasound-directed salvage intervention.Methods:Consenting adults underwent blinded fortnightly ultrasound scanning of their AVF after creation, with scan characteristics that predicted AVF nonmaturation identified by logistic regression modeling.Results:Of 333 AVFs created, 65.8% matured by 10 weeks. Serial scanning revealed that maturation occurred rapidly, whereas consistently lower fistula flow rates and venous diameters were observed in those that did not mature. Wrist and elbow AVF nonmaturation could be optimally modeled from week 4 ultrasound parameters alone, but with only moderate positive predictive values (PPVs) (wrist, 60.6% [95% confidence interval, CI: 43.9-77.3]; elbow, 66.7% [48.9-84.4]). Moreover, 40 (70.2%) of the 57 AVFs that thrombosed by week 10 had already failed by the week 4 scan, thus limiting the potential of salvage procedures initiated by that scan's findings to alter overall maturation rates. Modeling of the early ultrasound characteristics could also predict primary patency failure at 6 months; however, that model performed poorly at predicting assisted primary failure (those AVFs that failed despite a salvage attempt), partly because patency of at-risk AVFs was maintained by successful salvage performed without recourse to the early scan data.Conclusion:Early ultrasound surveillance may predict fistula maturation, but is likely, at best, to result in only very modest improvements in fistula patency. Power calculations suggest that an impractically large number of participants (>1700) would be required for formal RCT evaluation.

Introduction Cardiovascular events are a major cause of mortality following successful kidney transplantation. Arteriovenous fistulas (AVFs) are considered the best option for haemodialysis, but may contribute to this excess mortality because they promote adverse cardiac remodelling and ventricular hypertrophy. This raises the question whether recipients with a well-functioning kidney transplant should undergo elective AVF ligation. Methods and analysis The COBALT feasibility study is a multicentre interventional randomised controlled trial (RCT) that will randomise renal transplant patients with stable graft function and a working AVF on a 1:1 basis to standard care (continued conservative management) or to AVF ligation. All patients will perform cardiopulmonary exercise testing (CPET) on recruitment and 6 months later. Daily functioning and quality of life will be additionally assessed by questionnaire completion and objective measure of physical activity. The primary outcome—the proportion of approached patients who complete the study (incorporating rates of consent, receipt of allocated intervention and completion of both CPETs without withdrawal)—will determine progression to a full-scale RCT. Design of the proposed RCT will be informed by an embedded qualitative assessment of participant and healthcare professional involvement. Ethics and dissemination This study has been approved by the East Midlands—Derby Research Ethics Committee (22/EM/0002) and the Health Research Authority. The results of this work will be disseminated academically through presentation at national and international renal meetings and via open access, peer-reviewed outputs. Existing networks of renal patient groups will also be used to disseminate the study findings to other key stakeholders. Trial registration number ISRCTN49033491.

Abstract Background Superficial surgical site infection is a common morbidity following bowel resection surgery involving stoma formation with clinical and financial implications. The aim of the study was to evaluate the role of topical skin adhesive, 2-octylcyanoacrylate (2-OCA) in reducing wound infections following colorectal stoma surgery. Methods We performed a retrospective, single centre, cohort study using clinical notes. Patients over the age of 18, undergoing bowel resection (elective or emergency) with stoma formation over a period 5 years from January 2015 to December 2019 were included. The primary endpoint was surgical site infection. Patients either received wound dressing with 2- OCA or standard wound dressing. Results 604 patients were included. Median age was 69 (Range 18- 97). 187 (31%) patients received 2-OCA (group 1) and 417 (69%) received standard care (Group 2). 288 (47%) patients were female, 134 (22%) had body mass index > 30, 87 (14%) were diabetic and 90 (15%) were smokers. 279 (46%) patients had ASA score of 3 and 4 (37% vs 50% p=0.0006). 282 (47%) patients went through emergency surgery (34% vs 53% p<0.0001). 279 (64%) patients underwent dirty surgery (17% vs 32% p<0.0001). 220 (35%) patients developed SSI (28% vs 40% p<0.0015). BMI greater than 30 (OR 2.32, p<0.0001), Diabetes (OR 0.54 p<0.0241), dirty surgery (OR 0.43p<0.0001), standard care, no 2-OCA use (OR 1.52 p=0.0343) were associated with SSI. Conclusion Our study demonstrates that there is association between 2-OCA use and reduced SSI in colorectal surgery involving stoma formation when compared to standard methods of wound dressing. Further randomised clinical trial is recommended to demonstrate causation.

Background: Superficial surgical site infection (SSI) is a common morbidity following bowel resection surgery involving stoma formation with clinical and financial implications. The study aimed to evaluate the role of topical skin adhesive, 2-octylcyanoacrylate (Dermabond®) (2-OCA) in reducing wound infections following colorectal stoma surgery. Methods: We performed a retrospective, single-centre, cohort study using clinical notes. All patients, over the age of 18, undergoing bowel resection either elective or emergency, with stoma formation over five years from January 2015 to December 2019 were included. The primary endpoint was SSI, defined by the clinical manifestation of inflammation including pain, erythema, and discharge, regardless of the microbiological culture results. Patients received either 2-OCA glue as wound dressing or standard firm adhesive wound dressing e.g. Opsite. Results: Overall, 604 patients were included in the study. The median age was 67; 187 (31%) patients received Dermabond (Group 1) and 417 (69%) received standard care (Group 2). A total of 288 (47%) patients were female, 134 (22%) had body mass index (BMI) greater than 30, 87 (14%) were diabetic, and 90 (15%) were smokers. A total of 279 (46%) patients had an American Society of Anesthesiologists (ASA) score of 3 and 4; 282 (47%) patients went through emergency surgery, 279 (64%) patients underwent dirty surgery, and 220 (35%) patients developed SSI. BMI greater than 30 compared to < 30 (OR: 2.32, 95% CI: 1.54-3.49, p<0.0001), diabetes compared to no diabetes (OR: 0.54, 95% CI: 0.32-0.92, p<0.0241), dirty surgery compared to clean surgery (OR: 2.26, 95% CI: 1.51-3.37, p<0.0001) and standard care, no 2-OCA glue use compared to the use of 2-OCA glue (OR: 1.52, 95% CI: 1.03-2.24, p=0.0343) were associated with SSIs. Conclusion: Our study demonstrates that there is an association between 2-OCA and reduced SSIs in bowel resection surgery involving stoma formation when compared to standard methods of wound dressing. Further randomised clinical trials are recommended to strengthen this evidence and demonstrate causation.

Introduction: Patients with renal disease prioritise symptoms and functionality over the biochemistry and clinical guidelines, which clinicians traditionally rely on. Whilst kidney transplantation is expected to offer better survival and quality of life than dialysis, many recipients suffer limitations in their daily lives, due to factors associated with transplantation, such as immunosuppression side effects and infection. This study aimed to assess patient reported outcomes after kidney transplantation, to improve understanding and facilitate enhanced holistic post-transplant care. Methods: A retrospective analysis of a prospectively maintained database of patients completing PHQ-9 and GAD-7 questionnaires, each consecutive year following renal transplantation, was conducted between 2013 and 2020 at a single institution. Results: 698 patients returned PHQ-9 and GAD-7 questionnaires during the time period. After excluding incomplete records, 599 patients were included in the final analysis. There was a male preponderance (81.0%), and median age of 54 (range 19-84). The median number of consecutive completed annual questionnaires per patient was 3 (range 1-8). The majority of patients (70.1%) scored no depression on PHQ-9, followed by 18.5% reporting mild depression, with 11.3% falling into moderate to severe categories. Mean score at last assessment was worse than at first assessment (4.0 vs 2.6, p<0.001), but remained within the ‘no depression’ category. With GAD-7, 83.1% of patients scored minimal anxiety, followed by 9.6% reporting mild anxiety, with the remaining 7.1% scoring moderate or severe anxiety. Mean score at last assessment was worse than at first assessment (2.9 vs 1.9, p<0.001), but remained within the ‘minimal anxiety’ range. Discussion: Most patients undergoing renal transplantation do not suffer from depression or anxiety post-operatively, however, a significant proportion experience moderate to severe depression and anxiety. Prospective studies understanding the causes, and links with routinely collected biochemical data, will enable clinicians to identify and support at risk patients, delivering holistic evidenced based care.

Enhanced recovery after surgery (ERAS) reduces complications and shortens hospital stay without increasing readmission or mortality. However, its role in living donor nephrectomy (LDN) has not yet been defined. Medline, Embase, CINAHL, PsycINFO, and Cochrane Central were searched prior to 08/01/21 for all randomized controlled and cohort studies comparing ERAS to standard of care in LDN. The study was registered on PROSPERO (CRD: CRD42019141706). One thousand, three hundred seventy‐seven patients were identified from 14 studies (698 patients with ERAS and 679 patients without). There were considerable differences in the protocols used, and compliance with general ERAS recommendations was poor. Meta‐analysis of laparoscopic procedures (including hand‐ and robot‐assisted) revealed that duration of stay was significantly reduced by 0.98 days with ERAS (95% CI = 0.36–1.60, P = .002) and opiate requirement by 32.4 mg (95% CI = 1.1–63.7, P = .04). There was no significant difference n readmission rates or complications. Quality of evidence was low to moderate assessed using the GRADE tool. This review suggests there is a positive benefit of ERAS in laparoscopic LDN. However, there was considerable variation in ERAS protocols used, and the quality of evidence was low; as such, a guideline for ERAS in LDN should be developed and validated.

There is uncertainty about the safety of kidney transplantation during the SARS‐CoV‐2 pandemic due to the risk of donor transmission, nosocomial infection and immunosuppression use. We describe organ donation and transplant practice in the UK and assess whether kidney transplantation conferred a substantial risk of harm. Data from the UK transplant registry were used to describe kidney donation and transplant activity in the UK, and a detailed analysis of short‐term, single‐center, patient results in two periods: during the pre‐pandemic era from 30th December 2019 to 8th March 2020 (“Pre‐COVID era”) and the 9th March 2020 to 19th May 2020 (“COVID era”). Donor and recipient numbers fell by more than half in the COVID compared to the pre‐COVID era in the UK, but there were more kidney transplants performed in our center (42 vs. 29 COVID vs. pre‐COVID respectively). Overall outcomes, including re‐operation, delayed graft function, primary non‐function, acute rejection, length of stay and graft survival were similar between COVID and pre‐COVID era. 6/71 patients became infected with SARS‐CoV‐2 but all were discharged without critical care requirement. Transplant outcomes have remained similar within the COVID period and no serious sequelae of SARS‐CoV‐2 infection were observed in the peri‐transplant period.

PURPOSE OF REVIEW:The identification and utilization of kidneys from uncontrolled donation after circulatory death (uDCD) donors for transplantation may increase transplantation rates markedly. This article summarizes the latest international results from successful uDCD kidney transplant programmes and considers how such programmes may impact on the transplant waiting list. RECENT FINDINGS:The results of more than 1000 uDCD donor kidney transplants have been reported since 2007 from France and Spain. Estimates from France, Spain and Sweden suggest that effective utilization of the potential uDCD donor pool might increase donation rates by 25%. The main concern relating to uDCD kidney transplantation is the high incidence of primary nonfunction with the incidence of primary nonfunction reported as 7-8% even with careful donor selection and the use of normothermic regional perfusion at the time of organ recovery. Notwithstanding, reported 1- year graft survival figures are equivalent to those from expanded criteria donors (ECD) and 10-year graft survival of between 72 and 82% was reported in the two single-centre series with longest reported follow-up period. SUMMARY:Uncontrolled DCD kidney transplantation has been successfully implemented in several regions in France and Spain. Wider implementation of uDCD programmes would increase substantially the number of kidneys for transplantation, while maintaining acceptable transplant outcomes.

Quality assessment in kidney transplantation involves inspection to identify negative markers of organ quality. However, there is a paucity of evidence guiding surgical appraisal, and currently there is no evidence to differentiate important features from those that can be safely ignored. We propose a method to standardize surgical assessment and derived a simple rule to rapidly identify kidneys suitable for transplantation. Donor and recipient data were recorded alongside clinical outcomes in a prospectively maintained database. We developed a proforma (Cambridge Kidney Assessment Tool, CKAT) and used it to assess deceased donor kidney transplants. Factors predictive of utilization were identified by multivariate and univariate logistic regression analysis of CKAT-assessment scores, and test performance was evaluated using standard 2 x 2 contingency tables. Ninety-seven kidneys were included at a single center (2013-2014), and 184 CKAT assessments were performed. A CKAT threshold of "Carrell + Perfusion >3" was highly specific (99%) and performed favorably to consultant opinion (specificity 95%). 96% of the kidneys implanted in accordance with the rule survived to 1 year (mean eGFR 45.3 mL/min/1.73 m(2)). To our knowledge, this is the first attempt to objectively define macroscopic features that are relevant to kidney utilization. Common language could support training in organ assessment and ultimately help address unnecessary discard of donor kidneys.

BACKGROUND AND OBJECTIVES:Kidneys from elderly deceased donors are often discarded after procurement if the expected outcomes from single kidney transplantation are considered unacceptable. An alternative is to consider them for dual kidney transplantation. We aimed to examine the utilization of kidneys from donors aged ≥60 years in the United Kingdom and compare clinical outcomes of dual versus single kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:Data from the United Kingdom Transplant Registry from 2005 to 2017 were analyzed. We examined utilization rates of kidneys retrieved from deceased donors aged ≥60 years, and 5-year patient and death-censored graft survival of recipients of dual and single kidney transplants. Secondary outcomes included eGFR. Multivariable analyses and propensity score analysis were used to correct for differences between the groups. RESULTS:During the study period, 7841 kidneys were procured from deceased donors aged ≥60 years, of which 1338 (17%) were discarded; 356 dual and 5032 single kidneys were transplanted. Donors of dual transplants were older (median, 73 versus 66 years; P<0.001) and had higher United States Kidney Donor Risk Indices (2.48 versus 1.98; P<0.001). Recipients of dual transplants were also older (64 versus 61 years; P<0.001) and had less favorable human leukocyte antigen matching (P<0.001). After adjusting for confounders, dual and single transplants had similar 5-year graft survival (hazard ratio, 0.81; 95% CI, 0.59 to 1.12). No difference in patient survival was demonstrated. Similar findings were observed in a matched cohort with a propensity score analysis method. Median 12-month eGFR was significantly higher in the dual kidney transplant group (40 versus 36 ml/min per 1.73 m2; P<0.001). CONCLUSIONS:Recipients of kidneys from donors aged ≥60 years have similar 5-year graft survival and better graft function at 12 months with dual compared with single deceased donor kidney transplants.