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Peer-reviewedCC BY 4.0Kidney International Reports

Donor-Recipient Size Mismatch is a Critical Determinant of Kidney Transplant Outcome

  • Dharesh Raj Amarnath1,2,3
  • Georgios Kourounis2,3,4
  • Emily K. Glover2,3,4,5
  • Mohammed Zeeshan Akhtar6
  • Neil S. Sheerin2,3,4,5
  • Colin H. Wilson2,3,4
  • Samuel J. Tingle2,3,4
6 affiliations
  1. 1Newcastle University School of Medicine, Newcastle upon Tyne, UK
  2. 2National Institute of Health and Care Research Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
  3. 3Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
  4. 4Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
  5. 5Renal Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  6. 6Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, USA
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Abstract

Introduction: In kidney transplantation, the donor kidney should provide sufficient nephron mass to meet recipient demands. Although nephron mass cannot be easily measured, size-mismatch metrics could be useful surrogates for nephron supply and requirement. However, the impact of donor-recipient size-mismatch on post-transplant-kidney outcome remains uncertain.

Methods: Population cohort study using United Network for Organ Sharing data (2010–2024) including adult kidney-only transplants. Multivariable nonlinear (restricted cubic spline) regression models with interaction terms were used to analyze associations. Primary size-mismatch metric was donor-recipient body-surface-area (BSA) ratio, because BSA is a well-established surrogate for nephron number and requirement.

Results: In 155,438 single-kidney transplants, donor-recipient BSA-ratio was associated with 1-year estimated glomerular filtration rate (eGFR), 1- and 5-year graft survival (all P < 0.001), with small donor kidneys in larger recipients having consistently inferior outcome. Keeping other factors constant, BSA-ratio in the 5th percentile versus 95th percentile (0.76 vs. 1.37) was associated with a 1-year eGFR of 50.7 versus 71.2 ml/min per 1.73 m2 (difference = 20.5, 95% confidence interval [CI] = 19.9–21.1) and the hazard of 5-year graft loss was almost doubled (adjusted hazard ratio [aHR] = 1.93, 95% CI = 1.75–2.13). After donor age, donor-recipient BSA-ratio was most strongly associated with 1-year eGFR, with a stronger association than the other 34 examined factors. Nonlinear interaction analyses revealed the association between BSA-ratio and outcome remained consistent regardless of donor age or donor-recipient sex-mismatch.

Conclusion: Donor-recipient size-mismatch, measured by BSA-ratio, is strongly associated with post-transplant outcome. It is more strongly associated with outcome than most other factors used in current offering schemes and risk indices. Therefore, size-mismatch should be considered in kidney offering schemes and adjusted for as a critical potential covariate and/or confounder in observational studies and prospective trials.

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Cite

BibTeXRIS
BibTeX
@article{amarnath2026donorrecipient,
  title = {{Donor-Recipient Size Mismatch is a Critical Determinant of Kidney Transplant Outcome}},
  author = {Dharesh Raj Amarnath and Georgios Kourounis and Emily K. Glover and Mohammed Zeeshan Akhtar and Neil S. Sheerin and Colin H. Wilson and Samuel J. Tingle},
  journal = {Kidney International Reports},
  year = {2026},
  month = sep,
  doi = {10.1016/j.ekir.2026.107100},
  url = {https://doi.org/10.1016/j.ekir.2026.107100},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Donor-Recipient Size Mismatch is a Critical Determinant of Kidney Transplant Outcome
AU  - Dharesh Raj Amarnath
AU  - Georgios Kourounis
AU  - Emily K. Glover
AU  - Mohammed Zeeshan Akhtar
AU  - Neil S. Sheerin
AU  - Colin H. Wilson
AU  - Samuel J. Tingle
PY  - 2026
DA  - 2026/09/23
JO  - Kidney International Reports
DO  - 10.1016/j.ekir.2026.107100
UR  - https://doi.org/10.1016/j.ekir.2026.107100
AB  - Introduction: In kidney transplantation, the donor kidney should provide sufficient nephron mass to meet recipient demands. Although nephron mass cannot be easily measured, size-mismatch metrics could be useful surrogates for nephron supply and requirement. However, the impact of donor-recipient size-mismatch on post-transplant-kidney outcome remains uncertain.  Methods: Population cohort study using United Network for Organ Sharing data (2010–2024) including adult kidney-only transplants. Multivariable nonlinear (restricted cubic spline) regression models with interaction terms were used to analyze associations. Primary size-mismatch metric was donor-recipient body-surface-area (BSA) ratio, because BSA is a well-established surrogate for nephron number and requirement.  Results: In 155,438 single-kidney transplants, donor-recipient BSA-ratio was associated with 1-year estimated glomerular filtration rate (eGFR), 1- and 5-year graft survival (all P < 0.001), with small donor kidneys in larger recipients having consistently inferior outcome. Keeping other factors constant, BSA-ratio in the 5th percentile versus 95th percentile (0.76 vs. 1.37) was associated with a 1-year eGFR of 50.7 versus 71.2 ml/min per 1.73 m2 (difference = 20.5, 95% confidence interval [CI] = 19.9–21.1) and the hazard of 5-year graft loss was almost doubled (adjusted hazard ratio [aHR] = 1.93, 95% CI = 1.75–2.13). After donor age, donor-recipient BSA-ratio was most strongly associated with 1-year eGFR, with a stronger association than the other 34 examined factors. Nonlinear interaction analyses revealed the association between BSA-ratio and outcome remained consistent regardless of donor age or donor-recipient sex-mismatch.  Conclusion: Donor-recipient size-mismatch, measured by BSA-ratio, is strongly associated with post-transplant outcome. It is more strongly associated with outcome than most other factors used in current offering schemes and risk indices. Therefore, size-mismatch should be considered in kidney offering schemes and adjusted for as a critical potential covariate and/or confounder in observational studies and prospective trials.
SN  - 2468-0249
ER  -