Which renal transplant candidates should accept marginal kidneys in exchange for a shorter waiting time on dialysis?

Renal transplantation has been established as a life-saving procedure for patients with ESRD. Deceased donor kidneys convey variable life expectancies for recipients. However, limited information is available to guide patients and patient advocates concerning the appropriateness to list for expanded criteria donations (ECD). Half-lives for wait-listed transplant candidates were estimated from the time of ESRD onset on the basis of recipient age, primary diagnosis, and organ quality using survival models. In addition, we evaluated the likelihood of candidates' receiving a transplant on the basis of age and other characteristics by duration of waiting time. Older patients (65+) had longer life expectancy when they accepted an ECD within 2 yr of ESRD onset (5.6 yr) compared with waiting for a standard kidney (5.3 yr) or a living donation (5.5 yr) after 4 yr of dialysis. Conversely, younger recipients (18 to 39 yr) had longer life expectancy with a living donation (27.6 yr) or standard kidney (26.4 yr) after 4 yr on dialysis compared with an ECD after 2 yr of dialysis (17.6 yr). Increased candidate age was associated with the likelihood of not receiving a transplant during the period on the waiting list as a result of mortality and separately related to morbidity and delisting. Older and frailer transplant candidates benefit from accepting lower quality organs early after ESRD, whereas younger and healthier patients benefit from receiving higher quality organs even with longer dialysis exposure. These findings are important for transplant candidates and advocates decision-making and for potential further implementation in allocation policy.