Introduction
In the USA, patients with diabetes and end-stage renal disease are less likely to undergo deceased donor kidney transplantation (DDKT) or living donor kidney transplantation (LDKT). We explored the survival benefit of DDKT and LDKT among patients with diabetes.
Research design and methods
We used the United Network for Organ Sharing Standard Transplant Analysis and Research file to identify adults placed on the kidney waiting list between January 2014 and January 2024. Waitlist failure was evaluated with Fine and Gray analysis; life-years from transplant, equal survival (ES), and equal risk (ER) were extrapolated using lognormal survival regression; and life-years gained was quantified via restricted mean survival over 10 years.
Results
Patients with diabetes were more likely to experience 10-year waitlist failure (subdistribution HR 2.27, 95% CI 2.23 to 2.32) and receive inferior DDKT grafts (Kidney Donor Profile Index 49% vs 35%, p<0.001) compared with patients without diabetes. For patients with diabetes, LDKT, compared with DDKT, offered more life-years from transplant (18.2 years vs 14.1 years), resulted in more life-years gained (29% vs 24% relative increase over 10 years, p<0.001) and decreased ES by 19 months and ER by 30 months.
Conclusions
Proceeding to transplantation offers significant survival benefit for end-stage renal disease patients with diabetes, with LDKT offering superior survival compared with DDKT. By reducing time on the waiting list and providing superior grafts, the benefit of LDKT is particularly enhanced among patients with diabetes, and targeted efforts should be made to expand living donor access for this population.
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