Emerging Perspectives in TransplantationIschemia reperfusion injuryEarly Sirolimus Conversion as Rescue Therapy in Kidneys With Prolonged Delayed Graft Function in Deceased Donor Renal Transplant

•Increasing rate of delayed graft function (DGF) is seen with the use of Donation after Circulatory Death (DCD) and Extended Criteria Donor (ECD) kidneys.•Use of calcineurin inhibitors (CNIs) may add to insult by causing acute and chronic nephrotoxicity ultimately leading to Primary Non-Function (PNF).•Early conversion to sirolimus (SRL) in patients with prolonged DGF helps salvage renal graft function and achieve long-term graft survival in some cases where conventional treatment has failed.

BackgroundIncreasing rate of delayed graft function (DGF) is seen with the use of Donation after circulatory death (DCD) and extended criteria donor (ECD) kidneys. Use of calcineurin inhibitors (CNIs) may add to insult by causing acute and chronic nephrotoxicity ultimately leading to primary non-function (PNF). We report our experience of early sirolimus (SRL) conversion in such cases in an attempt to salvage graft function.MethodsRetrospective study to analyze the impact of early conversion of SRL in patients with prolonged DGF. Two groups were identified: a study (SRL) group with 14 patients and a historic control (CNI) group with 28 patients case-matched based on donor and recipient characteristics.ResultsSRL group included 8 ECD donors with mean DGF duration of 42.3 ± 38.3 days and were converted to SRL 46.6 ± 20.6 days post-transplantation. CNI group had DGF duration of 26.5 ± 9.9 days (P = .03).Mean recipient eGFR (mL/min per 1.73 m2) was 12.2 ± 4.3 pre-SRL and 26.0 ± 11.5, 34.1 ± 17.3 and 28.6 ± 14.3 at 3, 12 and 24 months post-SRL conversion respectively. Seven patients achieved sustained good graft function (mean Cr at 1 year of 140 μmol/L). The mean eGFR of the case-matched control group was 31.7 ± 11.7, 36.3 ± 14.1, and 34.9 ± 13.9 over the same time period (P = .104, .540, and .217).ConclusionConversion to SRL in patients with prolonged DGF may help salvage renal graft function and achieve long-term graft survival in some cases where conventional treatment has failed. We suggest a prospective study of this targeted group to validate such benefit.