A new risk-balanced donor–recipient matching model incorporating individual characteristics in kidney transplantation

Objective: to improve kidney transplant (KT) outcomes by developing a risk-balance donor–recipient matching algorithm, with individualized immunosuppressive therapy, and to evaluate its efficacy and safety compared with the standard approach. Materials and methods. The study included 712 KT recipients. Group I (n = 472) comprised patients who underwent transplantation between 2018 and 2023 using the standard donor allocation and immunosuppression approach. Group II (n = 240) included recipients transplanted between 2024 and 2025 following the implementation of the new matching model. The proposed model stratifies recipients by immunological risk and aligns them with appropriate donor types, avoiding combinations of marginal donor organs with high-risk recipients. Based on risk stratification, modified induction immunosuppressive regimens and administration of calcineurin inhibitors were applied. The primary endpoint was the incidence of delayed graft function. Secondary outcomes included rates of infectious complications, acute rejection, length of hospital stay, and length of stay in the intensive care unit. Results. The incidence of delayed graft function was significantly lower in Group II compared with Group I (17.5% vs 37.1%, p < 0.001). Infectious complications were also reduced (6.3% vs 13.1%, p = 0.007). The median length of hospital stay decreased from 19 to 15 days (p < 0.001). No statistically significant differences were observed between the groups in terms of acute rejection rates or length of stay in the intensive care unit. Conclusion. The implementation of a risk-balanced donor–recipient matching algorithm, combined with personalized immunosuppressive therapy, substantially reduced the incidence of delayed graft function without increasing the risk of acute rejection.

1. GBD 2023 Kidney Failure with Replacement Therapy Collaborators. Global, regional, and national prevalence of kidney failure with replacement therapy and associated aetiologies, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet Glob Health. 2025 Aug; 13 (8): e1378–e1395. doi: 10.1016/S2214-109X(25)00198-6. PMID: 40712611.

2. Lentine KL, Smith JM, Lyden GR, Miller JM, Dolan TG, Bradbrook K et al. OPTN/SRTR 2022 Annual Data Report: Kidney. Am J Transplant. 2024 Feb; 24 (2S1): S19– S118. doi: 10.1016/j.ajt.2024.01.012. PMID: 38431360.

3. Boerstra BA, Boenink R, Astley ME, Bonthuis M, Abd ElHafeez S, Arribas Monzón F et al. The ERA Registry Annual Report 2021: a summary. Clin Kidney J. 2023 Nov 15; 17 (2): sfad281. doi: 10.1093/ckj/sfad281. Erratum in: Clin Kidney J. 2024 Oct 21; 17 (10): sfae311. doi: 10.1093/ckj/sfae311. PMID: 38638342; PMCID: PMC11024806.

4. Minkovich M, Gupta N, Liu M, Famure O, Li Y, Selzner M et al. Impact of early surgical complications on kidney transplant outcomes. BMC Surg. 2024 May 27; 24 (1): 165. doi: 10.1186/s12893-024-02463-7. PMID: 38802757; PMCID: PMC11129490.

5. Khubutia MSh, Dmitriev IV, Balkarov AG, Anisimov YuA, Shmarina NV, Zagorodnikova NV et al. Single-center experience in kidney transplantation: outcomes, conclusions, and perspectives. Russian Journal of Transplantology and Artificial Organs. 2024; 26 (4): 90–99. [In Russ, English abstract]. doi: 10.15825/1995-1191-2024-4-90-99.

6. Negret MA, Rodriguez MP, Díaz‑Brochero C, Abril S, Grillo S, Garcia‑Padilla P. Impact of delayed graft function on overall and graft survival in recipients of deceased donor kidney transplants. BMC Nephrol. 2025 Nov 12; 26 (1): 633. doi: 10.1186/s12882-025-04540-2. PMID: 41225375; PMCID: PMC12613648.

7. Yao Z, Kuang M, Li Z. Risk factors for delayed graft function in patients with kidney transplantation: a systematic review and meta-analysis. BMJ Open. 2025 Mar 22; 15 (3): e087128. doi: 10.1136/bmjopen-2024-087128. PMID: 40122561; PMCID: PMC11934381.

8. Shabunin AV, Drozdov PA, Nesterenko IV, Makeev DA, Zhuravel OS, Astapovich SA. Risk factors for delayed kidney graft function from a deseased donor. Transplantologiya. The Russian Journal of Transplantation. 2022; 14 (3): 265–277. [In Russ, English abstract]. doi: 10.23873/2074-0506-2022-14-3-265-277.

9. Steenvoorden TS, Evers L, Vogt L, Rood JAJ, Kers J, Baas MC et al. The differential impact of early graft dysfunction in kidney donation after brain death and after circulatory death: Insights from the Dutch National Transplant Registry. Am J Transplant. 2025 Mar; 25 (3): 556–566. doi: 10.1016/j.ajt.2024.09.030. PMID: 39343037.

10. Cooper M, Wiseman AC, Doshi MD, Hall IE, Parsons RF, Pastan S et al. Understanding Delayed Graft Function to Improve Organ Utilization and Patient Outcomes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis. 2024 Mar; 83 (3): 360–369. doi: 10.1053/j.ajkd.2023.08.018. PMID: 37844725.

11. Shmarina NV, Dmitriev IV, Khubutiya BZ, Pinchuk AV. Transplantation of expanded criteria kidney grafts to elderly recipients in the N.V. Sklifosovsky Research Institute for Emergency Medicine. Transplantologiya. The Russian Journal of Transplantation. 2018; 10 (3): 175–184. [In Russ, English abstract]. doi: 10.23873/2074-0506-2018-10-3-175-184.

12. Jallah BP, Kuypers DRJ. Impact of Immunosenescence in Older Kidney Transplant Recipients: Associated Clinical Outcomes and Possible Risk Stratification for Immunosuppression Reduction. Drugs Aging. 2024 Mar; 41 (3): 219–238. doi: 10.1007/s40266-024-01100-5. PMID: 38386164.

13. Morath C, Döhler B, Kälble F, Pego da Silva L, Echterdiek F, Schwenger V et al. Pre-transplant HLA Antibodies and Delayed Graft Function in the Current Era of Kidney Transplantation. Front Immunol. 2020 Aug 26; 11: 1886. doi: 10.3389/fimmu.2020.01886. PMID: 32983110; PMCID: PMC7489336.

14. Zecher D, Bach C, Staudner C, Böger CA, Bergler T, Banas B et al. Characteristics of donor-specific anti-HLA antibodies and outcome in renal transplant patients treated with a standardized induction regimen. Nephrol Dial Transplant. 2017 Apr 1; 32 (4): 730–737. doi: 10.1093/ndt/gfw445. PMID: 28339671.

15. Aleksandrova VO, Dmitriev IV, Borovkova NV, Balkarov AG, Mushta NA, Shmarina NV et al. Diagnostic value of anti-HLA antibody monitoring in the diagnosis of immunological complications following kidney transplantation. Russian Journal of Transplantology and Artificial Organs. 2024; 26 (3): 91–98. [In Russ, English abstract]. doi: 10.15825/1995-1191-2024-3-91-98.

16. Shabunin AV, Drozdov PA, Makeev DA, Nesterenko IV, Zhuravel OS, Karapetyan LR et al. Personalized dosing protocol for extended-release tacrolimus in kidney transplant recipients in the early postoperative period. Russian Journal of Transplantology and Artificial Organs. 2023; 25 (1): 52–61. [In Russ, English abstract]. doi: 10.15825/1995-1191-2023-1-52-61.

17. Hariharan S, Israni AK, Danovitch G. Long-Term Survival after Kidney Transplantation. N Engl J Med. 2021 Aug 19; 385 (8): 729–743. doi: 10.1056/NEJM-ra2014530. PMID: 34407344.

18. Poggio ED, Augustine JJ, Arrigain S, Brennan DC, Schold JD. Long-term kidney transplant graft survival – Making progress when most needed. Am J Transplant. 2021 Aug; 21 (8): 2824–2832. doi: 10.1111/ajt.16463. PMID: 33346917.

19. Sethi S, Najjar R, Peng A, Mirocha J, Vo A, Bunnapradist S et al. Allocation of the Highest Quality Kidneys and Transplant Outcomes Under the New Kidney Allocation System. Am J Kidney Dis. 2019 May; 73 (5): 605–614. doi: 10.1053/j.ajkd.2018.12.036. PMID: 30929853.

20. Moein M, Golkarieh A, Vlassis I, Saidi R, Lioudis M. Comparative analysis of outcomes in high KDPI spectrum kidney transplants using unsupervised machine learning algorithm. PLoS One. 2025 Aug 26; 20 (8): e0324265. doi: 10.1371/journal.pone.0324265. PMID: 40857289; PMCID: PMC12380269.

21. Schaapherder A, Wijermars LGM, de Vries DK, de Vries APJ, Bemelman FJ, van de Wetering J et al. Equivalent Long-term Transplantation Outcomes for Kidneys Donated After Brain Death and Cardiac Death: Conclusions From a Nationwide Evaluation. EClinicalMedicine. 2018 Oct 9; 4–5: 25–31. doi: 10.1016/j.eclinm.2018.09.007. PMID: 31193600; PMCID: PMC6537547.

22. Van Heurn LW, Talbot D, Nicholson ML, Akhtar MZ, Sanchez‑Fructuoso AI, Weekers L et al. Recommendations for donation after circulatory death kidney transplantation in Europe. Transpl Int. 2016 Jul; 29 (7): 780–789. doi: 10.1111/tri.12682. PMID: 26340168.

23. Ghadimi M, Dashti‑Khavidaki S, Khatami MR, Mahdavi‑Mazdeh M, Gatmiri M, Minoo FS et al. Comparing the Effect of Immediate versus Delayed Initiation of Tacrolimus on Delayed Graft Function in Kidney Transplant Recipients: A Randomized Open-label Clinical Trial. J Res Pharm Pract. 2018 Apr-Jun; 7 (2): 69–76. doi: 10.4103/jrpp.JRPP_17_90. PMID: 30050959; PMCID: PMC6036871.

24. Sawinski D, Trofe‑Clark J, Leas B, Uhl S, Tuteja S, Kaczmarek JL et al. Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis. Am J Transplant. 2016 Jul; 16 (7): 2117–2138. doi: 10.1111/ajt.13710. PMID: 26990455.

25. Liu Y, Liu H, Shen Y, Chen Y, Cheng Y. Delayed Initiation of Tacrolimus Is Safe and Effective in Renal Transplant Recipients With Delayed and Slow Graft Function. Transplant Proc. 2018 Oct; 50 (8): 2368–2370. doi: 10.1016/j.transproceed.2018.03.101. PMID: 30316359.

26. Stumpf J, Budde K, Witzke O, Sommerer C, Vogel T, Schenker P et al. Fixed low dose versus concentration-controlled initial tacrolimus dosing with reduced target levels in the course after kidney transplantation: results from a prospective randomized controlled non-inferiority trial (Slow & Low study). EClinicalMedicine. 2023 Dec 22; 67: 102381. doi: 10.1016/j.eclinm.2023.102381. PMID: 38152417; PMCID: PMC10751828.