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Rampersad C, Bau J, Orchanian-Cheff A, Kim SJ. Impact of donor smoking history on kidney transplant recipient outcomes: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100854. [PMID: 38608414 DOI: 10.1016/j.trre.2024.100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/01/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Impact of donor smoking history on kidney transplant recipient outcomes is undefined. METHODS We systematically searched, critically appraised, and summarized associations between donor smoking and primary outcomes of death-censored and all-cause graft failure (DCGF, ACGF), and secondary outcomes of allograft histology, delayed graft function, serum creatinine, estimated glomerular filtration rate, and mortality. We searched MEDLINE, Embase, and Cochrane Databases from 2000 to 2023. Risk of bias was assessed using Risk of Bias in Non-randomized Studies - of Exposure tool. Quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation Working Group recommendations. We pooled results using inverse variance, random-effects model and reported hazard ratios for time-to-event outcomes or binomial proportions. Statistical heterogeneity was assessed with I2 statistic. RESULTS From 1785 citations, we included 17 studies. Donor smoking was associated with modestly increased DCGF (HR 1.05 (95% CI: 1.01, 1.09); I2 = 0%; low quality of evidence), predominantly in deceased donors, and ACGF in adjusted analyses (HR 1.12 (95% CI: 1.06, 1.19); I2 = 20%; very low quality of evidence). Other outcomes could not be pooled meaningfully. CONCLUSIONS Kidney donor smoking history was associated with modestly increased risk of death-censored graft failure and all-cause graft failure. This review emphasizes the need for further research, standardized reporting, and thoughtful consideration of donor factors like smoking in clinical decision-making on kidney utilization and allocation.
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Affiliation(s)
- Christie Rampersad
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Jason Bau
- Department of Medicine, Division of Transplant Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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2
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Cruz Mususú W, García-Lopez A, Lozano-Suarez N, Gómez-Montero A, Orellano-Salas M, Vargas-Pérez L, Escobar-Chaves X, Girón-Luque F. Understanding the dynamics of deceased organ donation and utilization in Colombia. Rev Panam Salud Publica 2024; 48:e24. [PMID: 38464873 PMCID: PMC10921909 DOI: 10.26633/rpsp.2024.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/19/2023] [Indexed: 03/12/2024] Open
Abstract
Objective To obtain a comprehensive overview of organ donation, organ utilization, and discard in the entire donation process in Colombia. Methods A retrospective study of 1 451 possible donors, distributed in three regions of Colombia, evaluated in 2022. The general characteristics, diagnosis, and causes of contraindication for potential donors were described. Results Among the 1 451 possible donors, 441 (30.4%) fulfilled brain death criteria, constituting the potential donor pool. Families consented to organ donation in 141 medically suitable cases, while 60 instances utilized legal presumption, leading to 201 eligible donors (13.9%). Of those, 160 (11.0%) were actual donors (in whom operative incision was made with the intent of organ recovery or who had at least one organ recovered). Finally, we identified 147 utilized donors (10.1%) (from whom at least one organ was transplanted). Statistically significant differences were found between age, sex, diagnosis of brain death, and donor critical pathway between regions. A total of 411 organs were transplanted from 147 utilized donors, with kidneys being the most frequently procured and transplanted organs, accounting for 280 (68.1%) of the total. This was followed by 85 livers (20.7%), 31 hearts (7.5%), 14 lungs (3.4%), and 1 pancreas (0.2%). The discard rate of procured deceased donors was 8.1%. Conclusions About one-tenth of donors are effectively used for transplantation purposes. Our findings highlight areas of success and challenges, providing a basis for future improvements in Colombia.
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Affiliation(s)
| | - Andrea García-Lopez
- Colombiana de TrasplantesBogotáColombiaColombiana de Trasplantes, Bogotá, Colombia
| | | | - Andrea Gómez-Montero
- Colombiana de TrasplantesBogotáColombiaColombiana de Trasplantes, Bogotá, Colombia
| | | | | | | | - Fernando Girón-Luque
- Colombiana de TrasplantesBogotáColombiaColombiana de Trasplantes, Bogotá, Colombia
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3
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Lim WH, Au E, Teixeira-Pinto A, Ooi E, Opdam H, Chapman J, Johnson DW, Kanellis J, Davies CE, Wong G. Donors With a Prior History of Cancer: Factors of Non-Utilization of Kidneys for Transplantation. Transpl Int 2023; 36:11883. [PMID: 38020745 PMCID: PMC10643206 DOI: 10.3389/ti.2023.11883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Cancer transmission from deceased donors is an exceedingly rare but potentially fatal complication in transplant recipients. We aimed to quantify the likelihood of non-utilization of kidneys for transplantation from donors with a prior cancer history. We included all intended and actual deceased donors in Australia and New Zealand between 1989 and 2017. Association between prior cancer history and non-utilization of donor kidneys was examined using adjusted logistic regression. Of 9,485 deceased donors, 345 (4%) had a prior cancer history. Of 345 donors with a prior cancer history, 197 (57%) were utilized for transplantation. Donor characteristics of age, sex and comorbidities were similar between utilized and non-utilized donors with prior cancer. The time from cancer to organ donation was similar between utilized and non-utilized donors, irrespective of cancer subtypes. Donors with a prior cancer history were less likely to be utilized [adjusted OR (95% CI) 2.29 (1.68-3.13)] than donors without prior cancer. Of all actual donors, the adjusted OR for non-utilization among those with prior cancer was 2.36 (1.58-3.53). Non-melanoma skin cancer was the most frequent prior cancer type for utilized and non-utilized potential donors. Donors with prior cancers were less likely to be utilized for transplantation, with no discernible differences in cancer characteristics between utilized and non-utilized donors.
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Affiliation(s)
- Wai H. Lim
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Eric Au
- Department of Renal Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Kids Research Institute, The Children’s Hospital at Westmead, Sydney, NSW, Australia
| | - Esther Ooi
- Medical School, University of Western Australia, Perth, WA, Australia
- School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Helen Opdam
- DonateLife, Organ and Tissue Authority, Canberra, NSW, Australia
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Jeremy Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - David W. Johnson
- Princess Alexandra Hospital, Metro South Integrated Nephrology and Transplant Services, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health, Melbourne, VIC, Australia
- Centre for Inflammatory Disease, Monash University, Melbourne, VIC, Australia
| | - Christopher E. Davies
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Germaine Wong
- Department of Renal Medicine, Westmead Hospital, Sydney, NSW, Australia
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Kids Research Institute, The Children’s Hospital at Westmead, Sydney, NSW, Australia
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Webb CJ, McCracken E, Jay CL, Sharda B, Garner M, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Single center experience and literature review of kidney transplantation from non-ideal donors with acute kidney injury: Risk and reward. Clin Transplant 2023; 37:e15115. [PMID: 37646473 DOI: 10.1111/ctr.15115] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION There is limited experience transplanting kidneys from either expanded criteria donors (ECD) or donation after circulatory death (DCD) deceased donors with terminal acute kidney injury (AKI). METHODS AKI kidneys were defined by a donor terminal serum creatinine level >2.0 mg/dL whereas non-ideal deceased donor (NIDD) kidneys were defined as AKI/DCD or AKI/ECDs. RESULTS From February 2007 to March 2023, we transplanted 266 single AKI donor kidneys including 29 from ECDs, 29 from DCDs (n = 58 NIDDs), and 208 from brain-dead standard criteria donors (SCDs). Mean donor age (43.7 NIDD vs. 33.5 years SCD), KDPI (66% NIDD vs. 45% SCD), and recipient age (57 NIDD vs. 51 years SCD) were higher in the NIDD group (all p < .01). Mean waiting times (17.8 NIDD vs. 24.2 months SCD) and dialysis duration (34 NIDD vs. 47 months SCD) were shorter in the NIDD group (p < .05). Delayed graft function (DGF, 48%) and 1-year graft survival (92.7% NIDD vs. 95.9% SCD) was similar in both groups. Five-year patient and kidney graft survival rates were 82.1% versus 89.9% and 82.1% versus 75.2% (both p = NS) in the NIDD versus SCD groups, respectively. CONCLUSIONS The use of kidneys from AKI donors can be safely liberalized to include selected ECD and DCD donors.
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Affiliation(s)
- Christopher J Webb
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Emily McCracken
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
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Lin Y, Teixeira-Pinto A, Craig JC, Opdam H, Chapman JC, Pleass H, Carter A, Rogers NM, Davies CE, McDonald S, Yang J, Lim WH, Wong G. Trajectories of systolic blood pressure decline in kidney transplant donors prior to circulatory death and delayed graft function. Clin Kidney J 2023; 16:1170-1179. [PMID: 37398694 PMCID: PMC10310517 DOI: 10.1093/ckj/sfad047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Kidneys donated after circulatory death suffer a period of functional warm ischaemia before death, which may lead to early ischaemic injury. Effects of haemodynamic trajectories during the agonal phase on delayed graft function (DGF) is unknown. We aimed to predict the risk of DGF using patterns of trajectories of systolic blood pressure (SBP) declines in Maastricht category 3 kidney donors. METHODS We conducted a cohort study of all kidney transplant recipients in Australia who received kidneys from donation after circulatory death donors, divided into a derivation cohort (transplants between 9 April 2014 and 2 January 2018 [462 donors]) and a validation cohort (transplants between 6 January 2018 and 24 December 2019 [324 donors]). Patterns of SBP decline using latent class models were evaluated against the odds of DGF using a two-stage linear mixed effects model. RESULTS In the derivation cohort, 462 donors were included in the latent class analyses and 379 donors in the mixed effects model. Of the 696 eligible transplant recipients, 380 (54.6%) experienced DGF. Ten different trajectories, with distinct patterns of SBP decline were identified. Compared with recipients from donors with the slowest decline in SBP after withdrawal of cardiorespiratory support, the adjusted odds ratio (aOR) for DGF was 5.5 [95% confidence interval (CI) 1.38-28.0] for recipients from donors with a steeper decline and lowest SBP [mean 49.5 mmHg (standard deviation 12.5)] at the time of withdrawal. For every 1 mmHg/min reduction in the rate of decline of SBP, the respective aORs for DGF were 0.95 (95% CI 0.91-0.99) and 0.98 (95% CI 0.93-1.0) in the random forest and least absolute shrinkage and selection operator models. In the validation cohort, the respective aORs were 0.95 (95% CI 0.91-1.0) and 0.99 (95% CI 0.94-1.0). CONCLUSION Trajectories of SBP decline and their determinants are predictive of DGF. These results support a trajectory-based assessment of haemodynamic changes in donors after circulatory death during the agonal phase for donor suitability and post-transplant outcomes.
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Affiliation(s)
- Yingxin Lin
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Faculty of Science, School of Mathematics and Science, University of Sydney, Sydney, NSW, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Kids Research Institute, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Helen Opdam
- Department of Surgery, DonateLife, Organ and Tissue Authority, Canberra, ACT, Australia
| | - Jeremy C Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Henry Pleass
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
- Specialty of Surgery, University of Sydney, Sydney, NSW, Australia
| | - Angus Carter
- Intensive Care Unit, Cairns Hospital, Cairns, QLD, Australia
| | - Natasha M Rogers
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Christopher E Davies
- Department of Renal Medicine, Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Stephen McDonald
- Department of Renal Medicine, Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Jean Yang
- Faculty of Science, School of Mathematics and Science, University of Sydney, Sydney, NSW, Australia
| | - Wai H Lim
- Faculty of Health and Medical Science, University of Western Australia, Perth, WA, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Kids Research Institute, Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
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Ibrahim M, Callaghan CJ. Beyond donation to organ utilization in the UK. Curr Opin Organ Transplant 2023; 28:212-221. [PMID: 37040628 DOI: 10.1097/mot.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
PURPOSE OF REVIEW Optimizing deceased donor organ utilization is gaining recognition as a topical and important issue, both in the United Kingdom (UK) and globally. This review discusses pertinent issues in the field of organ utilization, with specific reference to UK data and recent developments within the UK. RECENT FINDINGS A multifaceted approach is likely required in order to improve organ utilization. Having a solid evidence-base upon which transplant clinicians and patients on national waiting lists can base decisions regarding organ utilization is imperative in order to bridge gaps in knowledge regarding the optimal use of each donated organ. A better understanding of the risks and benefits of the uses of higher risk organs, along with innovations such as novel machine perfusion technologies, can help clinician decision-making and may ultimately reduce the unnecessary discard of precious deceased donor organs. SUMMARY The issues facing the UK with regards to organ utilization are likely to be similar to those in many other developed countries. Discussions around these issues within organ donation and transplantation communities may help facilitate shared learning, lead to improvements in the usage of scarce deceased donor organs, and enable better outcomes for patients waiting for transplants.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London
- NHS Blood and Transplant, Bristol, UK
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Ibrahim M, Mehew J, Martin K, Forsythe J, Johnson RJ, Callaghan C. Outcomes of Declined Deceased Donor Kidney Offers That Are Subsequently Implanted: A UK Registry Study. Transplantation 2023; 107:1348-1358. [PMID: 36706063 DOI: 10.1097/tp.0000000000004467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Deceased donor kidneys are often declined for ≥1 patients but then implanted into another. Studies are needed to guide transplant clinicians and patients, especially given the increasing age and comorbidity of donors. This study compares outcomes of recipients of transplanted kidneys that were initially declined with outcomes of patients who remained on the waiting list. METHODS This UK Transplant Registry study examined named-patient, adult donation after brain death donor single kidney-only offers that were declined for donor- or organ-related reasons (DORRs), in which the kidney was subsequently transplanted from January 1, 2010, to December 31, 2018. Outcomes included graft function and survival of kidneys transplanted following DORR decline, survival and transplant status of patients who had a kidney declined, and intercenter decline rates. RESULTS A total of 4722 kidneys declined for DORRs, which eventually resulted in single kidney-only transplants, were examined. One year after the offer decline, 35% of patients for whom the organ was declined remained on the list, 55% received a deceased donor transplant at a median of 174 d after the initial offer decline, and 4% had been removed or died. For patients transplanted following offer decline, there was no significant difference in 5-y graft survival when comparing the outcomes to those recipients who received the declined kidney. There was significant variation in DORR decline rates between UK transplant units (17%-54%). CONCLUSIONS This study shows reasonable outcomes of kidneys previously declined for DORRs and supports the utilization of those considered to be of higher risk for carefully selected recipients.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Jennifer Mehew
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Kate Martin
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - John Forsythe
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Rachel J Johnson
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Kidney Donation after circulatory death: The Veneto Region experience in Italy. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2023.100129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
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Garner M, Jay CL, Sharda B, Webb C, Farney AC, Orlando G, Rogers J, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Long-term outcomes of kidney transplantation from deceased donors with terminal acute kidney injury: Single center experience and literature review. Clin Transplant 2023; 37:e14886. [PMID: 36524320 DOI: 10.1111/ctr.14886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/05/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Long-term outcomes of kidney transplantation from deceased donors (DDKTs) with terminal acute kidney injury (AKI) are not well defined. METHODS Single center retrospective review of DDKTs from 1/31/07-12/31/19. AKI kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level AND a terminal SCr ≥2.0 mg/dl. RESULTS A total of 188 AKI DDKTs were performed, including 154 from brain-dead standard criteria donors (SCD). Mean donor age was 36 years and mean Kidney Donor Profile Index was 50%; mean admission and terminal SCr levels were 1.3 and 3.1 mg/dl, respectively. With a mean follow-up of 94 months (median 89 months), overall patient (both 71.3%) and graft survival (54% AKI vs. 57% non-AKI) rates were comparable to concurrent DDKTs from brain-dead non-AKI SCDs (n = 769). Delayed graft function (DGF) was higher in AKI kidney recipients (47% vs. 20% non-AKI DDKTs, p < .0001). DGF was associated with lower graft survival in recipients of both AKI and non-AKI SCD kidneys but the impact was earlier and more pronounced in non-AKI recipients. CONCLUSIONS Despite having more than twice the incidence of DGF, kidneys from deceased donors with terminal AKI have long-term outcomes comparable to non-AKI SCD kidneys and represent a safe and effective method to expand the donor pool.
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Affiliation(s)
- Matthew Garner
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher Webb
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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10
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Akalay S, Hosgood SA. How to Best Protect Kidneys for Transplantation-Mechanistic Target. J Clin Med 2023; 12:jcm12051787. [PMID: 36902572 PMCID: PMC10003664 DOI: 10.3390/jcm12051787] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
The increasing number of patients on the kidney transplant waiting list underlines the need to expand the donor pool and improve kidney graft utilization. By protecting kidney grafts adequately from the initial ischemic and subsequent reperfusion injury occurring during transplantation, both the number and quality of kidney grafts could be improved. The last few years have seen the emergence of many new technologies to abrogate ischemia-reperfusion (I/R) injury, including dynamic organ preservation through machine perfusion and organ reconditioning therapies. Although machine perfusion is gradually making the transition to clinical practice, reconditioning therapies have not yet progressed from the experimental setting, pointing towards a translational gap. In this review, we discuss the current knowledge on the biological processes implicated in I/R injury and explore the strategies and interventions that are being proposed to either prevent I/R injury, treat its deleterious consequences, or support the reparative response of the kidney. Prospects to improve the clinical translation of these therapies are discussed with a particular focus on the need to address multiple aspects of I/R injury to achieve robust and long-lasting protective effects on the kidney graft.
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Affiliation(s)
- Sara Akalay
- Department of Development and Regeneration, Laboratory of Pediatric Nephrology, KU Leuven, 3000 Leuven, Belgium
| | - Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence:
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11
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Gonzalez JM, Villarreal C, Fasci A, Rocco DD, Salazar S, Khalil A, Wearden B, Oseghale J, Garcia M, Portillo DJ, Hood RL. Evaluating the Performance of a Nonelectronic, Versatile Oxygenating Perfusion System across Viscosities Representative of Clinical Perfusion Solutions Used for Organ Preservation. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 10:bioengineering10010002. [PMID: 36671574 PMCID: PMC9854583 DOI: 10.3390/bioengineering10010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
Introduction: On the United States' Organ Transplantation Waitlist, approximately 17 people die each day waiting for an organ. The situation continues to deteriorate as the discrepancy between harvested organs and the number of patients in need is increasing. Static cold storage is the clinical standard method for preserving a harvested organ but is associated with several drawbacks. Machine perfusion of an organ has been shown to improve preservation quality as well as preservation time over static cold storage. While there are machine perfusion devices clinically available, they are costly and limited to specific organs and preservation solutions. This study presents a versatile oxygenating perfusion system (VOPS) that supplies oxygen and pulsatile perfusion. Materials and Methods: Experiments evaluated the system's performance with a human kidney mimicking hydraulic analog using multiple compressed oxygen supply pressures and aqueous solutions with viscosities ranging from 1 to 6.5 cP, which simulated viscosities of commonly used organ preservation solutions. Results and Conclusions: The VOPS produced mean flow rates ranging from 0.6 to 28.2 mL/min and perfusion pressures from 4.8 to 96.8 mmHg, which successfully achieved the desired perfusion parameters for human kidneys. This work provides evidence that the VOPS described herein has the versatility to perfuse organs using many of the clinically available preservation solutions.
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Affiliation(s)
- Jose M. Gonzalez
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Carorina Villarreal
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Anjelyka Fasci
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - David Di Rocco
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Sophia Salazar
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Anis Khalil
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Brandt Wearden
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Jessica Oseghale
- Department of Biomedical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Mariana Garcia
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
| | - Daniel J. Portillo
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
- Correspondence: (D.J.P.); (R.L.H.)
| | - R. Lyle Hood
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
- Department of Biomedical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
- Correspondence: (D.J.P.); (R.L.H.)
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12
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Woud WW, Arykbaeva AS, Alwayn IP, Baan CC, Minnee RC, Hoogduijn MJ, Boer K. Extracellular Vesicles Released During Normothermic Machine Perfusion Are Associated With Human Donor Kidney Characteristics. Transplantation 2022; 106:2360-2369. [PMID: 35749756 PMCID: PMC9698093 DOI: 10.1097/tp.0000000000004215] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/27/2022] [Accepted: 05/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Extracellular vesicles (EVs) are tissue-specific particles released by cells containing valuable diagnostic information in the form of various biomolecules. The characterization of EVs released by kidney grafts during normothermic machine perfusion (NMP) may present a promising avenue to assess graft status before transplantation. METHODS We phenotyped and determined the concentrations of EVs in the perfusate of 8 discarded expanded-criteria donor human kidneys during 6 h of NMP. Perfusate samples were taken at 0/60/180/360 min and examined with nanoparticle tracking analysis and imaging flow cytometry (IFCM). Using IFCM, EVs were identified by their expression of common EV markers CD9, CD63, and CD81 (tetraspanins) in combination with either platelet endothelial cell adhesion molecule (CD31), pan-leukocyte protein (CD45), or carboxyfluorescein succiminidyl ester (CFSE) fluorescence. RESULTS Nanoparticle tracking analysis measurements revealed the release of nanoparticles <400 nm into the perfusate during NMP. With IFCM, tetraspanin protein signatures of the released nanoparticles were characterized, and the majority (~75%) of CFSE+ EVs were found to be CD81+, whereas ~16% were CD9+ and ~8% CD63+. Correlation analysis of concentrations of identified EV subsets with crude donor characteristics and NMP viability characteristics revealed significant correlations with cold ischemia time, donor age, and renal flow. CONCLUSIONS Our findings demonstrate that discarded expanded-criteria donor kidney grafts release distinct EV subsets during NMP. Because these subsets correlate with well-established indicators of transplant outcome, EVs might represent new potential candidates for assessment of kidney graft quality.
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Affiliation(s)
- Wouter W. Woud
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Asel S. Arykbaeva
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Ian P.J. Alwayn
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Carla C. Baan
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Robert C. Minnee
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam,The Netherlands
| | - Martin J. Hoogduijn
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Karin Boer
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
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13
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Chen S, Chang S, Wang D, Chen J, Guo H, Shi H, Jiang J, Chen ZK, Chen Z, Zhang W. Successful Unilateral Dual-Kidney Transplant of Discarded Kidneys From Two Expanded Criteria Donors. EXP CLIN TRANSPLANT 2022; 20:1035-1039. [PMID: 36524890 DOI: 10.6002/ect.2022.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In recent years, dual-kidney transplant has become an established method to overcome the inferior quality of donor organs and to allow the recovery of discarded human kidneys. However, in some cases, 1 of the 2 donor kidneys is unsuitable for transplant because of severe pathological changes, and the remaining marginal kidney is often discarded regardless of whether it meets criteria for dual-kidney transplant. Here, we report the use of marginal kidneys from 2 different donors, both of whom had missed kidney donation as a result of the serious pathological changes in their contralateral kidney. We combined the 2 donors' marginal kidneys for dual-kidney transplant, which were implanted into the right iliac fossa of the recipient after cold ischemia times of 13 hours 40 minutes and 30 hours 30 minutes, respectively. The recipient had fully recovered and showed favorable renal function without complications at discharge and at the 1.5-year follow-up. To the best of our knowledge, this is the first case report of successful unilateral dual-kidney transplant of discarded kidneys from 2 expanded criteria donors.
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Affiliation(s)
- Song Chen
- From the Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,From the Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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14
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Schutter R, Vrijlandt WAL, Weima GM, Pol RA, Sanders JSF, Crop MJ, Leuvenink HGD, Moers C. Kidney utilization in the Netherlands - do we optimally use our donor organs? Nephrol Dial Transplant 2022; 38:787-796. [PMID: 36318454 PMCID: PMC9976738 DOI: 10.1093/ndt/gfac300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND To ensure optimal utilization of deceased donor kidneys, it is important to understand the precise reasons why kidneys are discarded. In this study we aimed to obtain a comprehensive overview of kidney utilization and discard during the entire donation process in the Netherlands. METHODS In this retrospective cohort study we analysed kidney utilization of 3856 kidneys in the Netherlands between 1 January 2015 and 31 December 2020. For every kidney that was not transplanted, we determined the moment of and reason for discard through a unique case-by-case assessment. RESULTS Kidney discard according to the traditional definition (procured but not transplanted) was 7.8%. However, when kidneys that seemed medically suitable at the beginning of the donation process were also included, many more potential donor kidneys were lost and the total non-utilization was 24.4%. Subjectively presumed impaired organ quality was responsible for 34.2% of all discarded kidneys. Two-thirds of kidneys discarded due to acute kidney injury (AKI) had only AKI stage 1 or 2. CONCLUSION The classical definition of organ discard underestimates the non-utilization of deceased donor kidneys. Strategies to improve kidney utilization could be a revision of the maximum allowed agonal time in donation after circulatory death, careful consideration in reporting and accepting kidneys from donors with AKI and a prospectively filled registry of detailed organ discard reasons, including the 'silent' non-utilization before procurement.
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Affiliation(s)
| | | | | | - Robert A Pol
- Department of Surgery – Organ Donation and Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Stephan F Sanders
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meindert J Crop
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery – Organ Donation and Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery – Organ Donation and Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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15
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Gonzalez-Viedma A, Van Dyck R, De Beule J, Ghesquière B, Jochmans I. Unraveling metabolism during kidney perfusion using tracer studies, a systematic review. Artif Organs 2022; 46:2118-2134. [PMID: 35848397 DOI: 10.1111/aor.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/02/2022] [Accepted: 07/03/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Understanding kidney metabolism during perfusion is vital to further develop the technology as a preservation, viability assessment, and resuscitation platform. We reviewed the evidence on the use of labeled metabolites (tracers) to understand "on-pump" kidney behavior. METHODS PubMed, Embase, Web of Science, and Cochrane databases were systematically searched for studies evaluating metabolism of (non)radioactively labeled endogenous compounds during kidney perfusion. RESULTS Of 5899 articles, 30 were included. All were animal studies [rat (70%), dog (13%), pig (10%), rabbit (7%)] perfusing but not transplanting kidneys. Perfusion took place at hypothermic (4-12°C) (20%), normothermic (35-40°C) (77%), or undefined temperatures (3%). Hypothermic perfusion used albumin or a clinical kidney preservation solution, mostly in the presence of oxygen. Normothermic perfusion was mostly performed with oxygenated crystalloids often containing glucose and amino acids with unclear partial oxygen tensions. Active metabolism of carbohydrate, amino acid, lipids, and large molecules was shown in hypothermic and normothermic perfusion. Production of macromolecules, such as prostaglandin, thromboxane, and vitamin D, takes place during normothermic perfusion. No experiments compared differences in metabolic activity between hypothermic and normothermic perfusion. One conference abstract showed increased anaerobic metabolism in kidneys donated after circulatory death by adding labeled glucose to hypothermically perfused human kidneys. CONCLUSIONS Tracer studies during kidney perfusion contribute to unraveling kidney metabolic behavior in pre-clinical models. Whether findings are truly translational needs further investigation in large animal models of human kidneys. Furthermore, it is essential to better understand how ischemia changes this metabolic behavior.
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Affiliation(s)
- Arantxa Gonzalez-Viedma
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Robbe Van Dyck
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Julie De Beule
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Bart Ghesquière
- Metabolomics Expertise Center, Center for Cancer Biology, VIB Center for Cancer Biology, Leuven, Belgium.,Metabolomics Expertise Center, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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16
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Mudalige NL, Sun K, Plumb L, Casula A, Evans KM, Inward C, Marks SD. Increasing trends in hemodialysis and living donor kidney transplantation for children and young people in the United Kingdom. Pediatr Transplant 2022; 26:e14232. [PMID: 35075740 DOI: 10.1111/petr.14232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/17/2021] [Accepted: 12/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The UK Renal Registry is responsible for the national collection and reporting of data on all children receiving long-term kidney replacement therapy [KRT], including kidney transplantation. METHODS All 13 UK pediatric nephrology centers contributed to providing individual patient data from the pediatric population incident to and prevalent to KRT as per the date 31 December 2018. Data for children aged 16-<18 years were presented separately as some were managed under adult care settings with different methods of data collection. Demographics and biochemical data, including kidney function and prevalence of cardiovascular risk factors [hypertension, hypercholesterolemia, BMI] were reported. RESULTS Eight hundred and twenty-six children (65.4 per million age-related population [pmarp]) and 199 young people (139.4pmarp) in the United Kingdom were prevalent to KRT on 31 December 2018. Overall, the incidence of KRT during 2018 was 9.1 pmarp and 12.6 pmarp in children and young people, respectively. Congenital anomalies of the kidney and urinary tract (CAKUT) were the most prevalent primary diagnoses (52%). Living and deceased donor transplantation was the most common treatment modality (78%). Patients on dialysis had lower age standardized mean height and weight ranges recorded in comparison to transplant patients [median height z score -1.8 vs. -1.1]. 73.1% patients had one or more cardiovascular disease risk factors. CONCLUSIONS This study highlights increasing prevalence of hemodialysis and living donor transplantation as modalities for KRT. Of those incident to KRT, the highest patient survival was seen among 8-12 years and lowest <2 years. Moreover, there was a demographic shift from Caucasian toward Asian/other ethnicity and from CAKUT to other primary kidney diseases.
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Affiliation(s)
- Nadeesha Lakmal Mudalige
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Kristi Sun
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Lucy Plumb
- UK Renal Registry, Bristol, UK.,Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | | | | | - Carol Inward
- Department of Pediatric Nephrology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stephen D Marks
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK.,Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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17
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. The use of marginal kidneys in dual kidney transplantation to expand kidney graft utilization. Curr Opin Organ Transplant 2022; 27:75-85. [PMID: 34939967 DOI: 10.1097/mot.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to chronicle the history of dual kidney transplantation (DKT) and identify opportunities to improve utilization of marginal deceased donor (MDD) kidneys through DKT. RECENT FINDINGS The practice of DKT from adult MDDs dates back to the mid-1990s, at which time the primary indication was projected insufficient nephron mass from older donors. Multiple subsequent studies of short- and long-term success have been reported focusing on three major aspects: Identifying appropriate selection criteria/scoring systems based on pre- and postdonation factors; refining technical aspects; and analyzing longer-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. MDDs with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or nonrecovery. SUMMARY DKT may reduce organ discard and optimize the use of kidneys from MDDs. New and innovative technologies targeting ex vivo organ assessment, repair, and regeneration may have a major impact on the decision whether or not to use recovered kidneys for single or DKT.
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Affiliation(s)
- Robert J Stratta
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Harriman
- The Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Venkat Gurram
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Komal Gurung
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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18
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. Dual kidney transplants from adult marginal donors: Review and perspective. Clin Transplant 2021; 36:e14566. [PMID: 34936135 DOI: 10.1111/ctr.14566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/08/2021] [Accepted: 12/13/2021] [Indexed: 11/28/2022]
Abstract
The practice of dual kidney transplantation (DKT) from adult marginal deceased donors (MDDs) dates back to the mid-1990s with initial pioneering experiences reported by the Stanford and Maryland groups, at which time the primary indication was estimated insufficient nephron mass from older donors. Multiple subsequent studies of short and long-term success have been reported focusing on three major aspects of DKT: Identifying appropriate selection criteria and developing scoring systems based on pre- and post-donation factors; refining technical aspects; and analyzing mid-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. Deceased donors with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or non-recovery. However, DKT may reduce organ discard and optimize the use of kidneys from MDDs. In an attempt to promote utilization of MDD kidneys, the United Network for Organ Sharing introduced new allocation guidelines pursuant to DKT in 2019. The purpose of this review is to chronicle the history of DKT and identify opportunities to improve utilization of MDD kidneys through DKT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - David Harriman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, V5Z1M9, Canada
| | - Venkat Gurram
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Komal Gurung
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
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19
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King KL, Chaudhry SG, Ratner LE, Cohen DJ, Husain SA, Mohan S. Declined Offers for Deceased Donor Kidneys Are Not an Independent Reflection of Organ Quality. KIDNEY360 2021; 2:1807-1818. [PMID: 35372993 PMCID: PMC8785847 DOI: 10.34067/kid.0004052021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/06/2021] [Indexed: 02/04/2023]
Abstract
Background Deceased donor kidney offers are frequently declined multiple times before acceptance for transplantation, despite significant organ shortage and long waiting times. Whether the number of times a kidney has been declined, reflecting cumulative judgments of clinicians, is associated with long-term transplant outcomes remains unclear. Methods In this national, retrospective cohort study of deceased donor kidney transplants in the United States from 2008 to 2015 (n=78,940), we compared donor and recipient characteristics and short- and long-term graft and patient survival outcomes grouping by the sequence number at which the kidney was accepted for transplantation. We compared outcomes for kidneys accepted within the first seven offers in the match-run, after 8-100 offers, and for hard-to-place kidneys distinguishing those requiring >100 and >1000 offers before acceptance. Results Harder-to-place kidneys had lower donor quality and higher rates of delayed graft function (46% among kidneys requiring >1000 offers before acceptance versus 23% among kidneys with ≤7 offers). In unadjusted models, later sequence groups had higher hazard of all-cause graft failure, death-censored graft failure, and patient mortality; however, these associations were attenuated after adjusting for Kidney Donor Risk Index (KDRI). After adjusting for donor factors already taken into consideration during allocation, and recipient factors associated with long-term outcomes, graft, and patient survival outcomes were not significantly different for the hardest-to-place kidneys compared with the easiest-to-place kidneys, with the exception of death-censored graft failure (adjusted hazard ratio, 1.16, 95% CI, 1.05 to 1.28). Conclusion Late sequence offers may represent missed opportunities for earlier successful transplant for the higher-priority waitlisted candidates for whom the offers were declined.
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Affiliation(s)
- Kristen L King
- Department of Medicine, Columbia University Irving Medical Center, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Sulemon G Chaudhry
- Division of Transplant Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Lloyd E Ratner
- Division of Transplant Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - David J Cohen
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - S Ali Husain
- Department of Medicine, Columbia University Irving Medical Center, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Sumit Mohan
- Department of Medicine, Columbia University Irving Medical Center, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, New York, New York
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20
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Kayler LK, Nie J, Noyes K. Hardest-to-place kidney transplant outcomes in the United States. Am J Transplant 2021; 21:3663-3672. [PMID: 34212471 DOI: 10.1111/ajt.16739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 01/25/2023]
Abstract
The outcomes of hardest-to-place kidney transplants-accepted last in the entire match run after being refused by previous centers-are unclear, potentially translating to risk aversion and unnecessary organ discard. We aimed to determine the outcomes of hardest-to-place kidney transplants and whether the organ acceptance position on the match run sufficiently captures the risk. This is a cohort study of the United Network for Organ Sharing data of all adult kidney-only transplant recipients from deceased donors between 2007 and 2018. Multiple regression models assessed delayed graft function, graft survival, and patient survival stratified by share type: local versus shared kidney acceptance position scaled by tertile. Among 127 028 kidney transplant recipients, 92 855 received local kidneys. The remaining received shared kidneys at sequence number 1-4 (n = 12 322), 5-164 (n = 10 485) and >164 (n = 11 366). Hardest-to-place kidneys, defined as the latest acceptance group in the match-run, were associated with delayed graft function (adjusted odds ratio 1.83, 95% confidence interval [CI] 1.74-1.92) and all-cause allograft failure (adjusted hazard ratio [aHR] 1.11, 95% CI 1.04-1.17). Results of this IRB-approved study were robust to the exclusion of operational allocation bypass and mandatory shares. The hardest-to-place kidneys accepted later in the match run were associated with higher graft failure and delayed graft function.
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Affiliation(s)
- Liise K Kayler
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Jing Nie
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
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21
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Abstract
BACKGROUND Despite the kidney supply shortage, 18%-20% of deceased donor kidneys are discarded annually in the United States. In 2018, 3569 kidneys were discarded. METHODS We compared machine learning (ML) techniques to identify kidneys at risk of discard at the time of match run and after biopsy and machine perfusion results become available. The cohort consisted of adult deceased donor kidneys donated between December 4, 2014, and July 1, 2019. The studied ML models included Random Forests (RF), Adaptive Boosting (AdaBoost), Neural Networks (NNet), Support Vector Machines (SVM), and K-nearest Neighbors (KNN). In addition, a Logistic Regression (LR) model was fitted and used for comparison with the ML models' performance. RESULTS RF outperformed other ML models. Of 8036 discarded kidneys in the test dataset, LR correctly classified 3422 kidneys, whereas RF correctly classified 4762 kidneys (area under the receiver operative curve [AUC]: 0.85 versus 0.888, and balanced accuracy: 0.681 versus 0.759). For the kidneys with kidney donor profile index of >85% (6079 total), RF significantly outperformed LR in classifying discard and transplant prediction (AUC: 0.814 versus 0.717, and balanced accuracy: 0.732 versus 0.657). More than 388 kidneys were correctly classified using RF. Including biopsy and machine perfusion variables improved the performance of LR and RF (LR's AUC: 0.888 and balanced accuracy: 0.74 versus RF's AUC: 0.904 and balanced accuracy: 0.775). CONCLUSIONS Kidneys that are at risk of discard can be more accurately identified using ML techniques such as RF.
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Affiliation(s)
- Masoud Barah
- Industrial Engineering and Management Sciences, Northwestern University, Evanston, IL
| | - Sanjay Mehrotra
- Industrial Engineering and Management Sciences, Northwestern University, Evanston, IL
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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22
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Schutter R, Lantinga VA, Hamelink TL, Pool MBF, van Varsseveld OC, Potze JH, Hillebrands JL, van den Heuvel MC, Dierckx RAJO, Leuvenink HGD, Moers C, Borra RJH. Magnetic resonance imaging assessment of renal flow distribution patterns during ex vivo normothermic machine perfusion in porcine and human kidneys. Transpl Int 2021; 34:1643-1655. [PMID: 34448269 PMCID: PMC9290094 DOI: 10.1111/tri.13991] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023]
Abstract
Acceptance criteria of deceased donor organs have gradually been extended toward suboptimal quality, posing an urgent need for more objective pre‐transplant organ assessment. Ex vivo normothermic machine perfusion (NMP) combined with magnetic resonance imaging (MRI) could assist clinicians in deciding whether a donor kidney is suitable for transplantation. Aim of this study was to characterize the regional distribution of perfusate flow during NMP, to better understand how ex vivo kidney assessment protocols should eventually be designed. Nine porcine and 4 human discarded kidneys underwent 3 h of NMP in an MRI‐compatible perfusion setup. Arterial spin labeling scans were performed every 15 min, resulting in perfusion‐weighted images that visualize intrarenal flow distribution. At the start of NMP, all kidneys were mainly centrally perfused and it took time for the outer cortex to reach its physiological dominant perfusion state. Calculated corticomedullary ratios based on the perfusion maps reached a physiological range comparable to in vivo observations, but only after 1 to 2 h after the start of NMP. Before that, the functionally important renal cortex appeared severely underperfused. Our findings suggest that early functional NMP quality assessment markers may not reflect actual physiology and should therefore be interpreted with caution.
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Affiliation(s)
- Rianne Schutter
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Veerle A Lantinga
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Tim L Hamelink
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Otis C van Varsseveld
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Jan Hendrik Potze
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Jan-Luuk Hillebrands
- Department of Pathology & Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Marius C van den Heuvel
- Department of Pathology & Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Rudi A J O Dierckx
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands.,Department of Nuclear Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Ronald J H Borra
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands.,Department of Nuclear Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
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23
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Dabare D, Hodson J, Nath J, Sharif A, Kalia N, Inston N. Macroscopic assessment of the quality of cold perfusion after deceased-donor kidney procurement: A United Kingdom population-based cohort study. Clin Transplant 2021; 35:e14272. [PMID: 33638883 DOI: 10.1111/ctr.14272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 11/29/2022]
Abstract
Concern regarding the quality of cold perfusion (QOP) during macroscopic assessment of procured kidneys is a common reason for discard. In the UK, QOP is routinely graded by both retrieving and implanting teams during back-bench surgery as: 1 (good), 2 (fair), 3 (poor) or 4 (patchy). We evaluated the association of this grading with organ utilization, graft outcomes, and agreement between teams. Data on all deceased-donor kidneys procured between January 2000 and December 2016 were analyzed for discard rates, while association with graft outcomes was studied in single adult transplants. Of 31,167 kidneys procured, 90.6%, 5.7%, 1.7%, and 2.1% were assigned grades 1, 2, 3, and 4, respectively, at retrieval. QOP was an independent risk factor of discard, with the highest rates observed in grade 3 kidneys (41.8%), compared to 6.5% in grade 1 (aOR 7.67, 95% CI 5.44-10.82, p < .001). Grading at retrieval was an independent predictor of delayed graft function (p = .019) and primary non-function (p = .001), but not long-term graft survival (p = .111). Implanting grade was an independent predictor of all three outcomes (p < .001, p < .001, and p = .002, respectively). Consistency of grading between teams was poor (Kappa = 0.179). QOP influences utilization and predicts outcomes, but a standardized and validated scoring system is required.
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Affiliation(s)
- Dilan Dabare
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jay Nath
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Neena Kalia
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Nicholas Inston
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
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24
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Alechinsky L, Abdessater M, Parra J, Malaquin G, Huot O, Bastien O, Barrou B, Drouin SJ. Retrieved but not transplanted kidneys: how to limit the losses? A retrospective national study. Transpl Int 2021; 34:1845-1852. [PMID: 33570752 DOI: 10.1111/tri.13844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/18/2020] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
Despite the organ shortage, a significant number of deceased donor kidneys are retrieved but not transplanted (RNTK). This study aims to describe and analyze the main causes of potential grafts discard and to propose adequate solutions. We collected data from the Cristal database of the French Biomedicine Agency about RNTK over one year. Expert opinion was taken from urologists with extensive expertise in renal transplantation. They retrospectively analyzed each record to assess the appropriateness of each graft refusal and subsequent kidney discard. Of 252 kidneys were retrieved but not transplanted in France over one year. The main reasons for discard were vascular abnormalities in 43.7% (n = 110), suspicion of malignant tumor in 18.7% (n = 47), and severe histological lesions on preimplantation biopsy in 12.3% (n = 31). The reason for kidney refusal was undetermined in 4.8% (n = 12). Iatrogenic lesions were responsible for 26.2% (n = 66). Overall, 46.0% (n = 16) and 25.0% (n = 63) of the grafts were, respectively, properly and improperly denied, and the analysis was not possible in 29.0% (n = 73). In total, 36.9% of RNTK could have been transplanted. Reduction of iatrogenic lesions, improvement of microsurgical repair skills, and proper histological examination are necessary to reduce the number of RNTK. A prospective study applying the proposed principles is undoubtedly essential to complete this work.
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Affiliation(s)
- Louise Alechinsky
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | - Maher Abdessater
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | - Jerôme Parra
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | | | - Olivier Huot
- Agence de la Biomédecine, Saint Denis la Plaine Cedex, France
| | - Olivier Bastien
- Agence de la Biomédecine, Saint Denis la Plaine Cedex, France
| | - Benoit Barrou
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
| | - Sarah J Drouin
- Department of Urology and Renal Transplantation, APHP - Sorbonne University, Pitié Salpêtrière University Hospital, Paris, France
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25
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Li J, Rogers NM. Keeping the Kidney: Assessing Donor Organ Viability by Magnetic Resonance Imaging. Transplantation 2020; 104:1767-1768. [PMID: 32826842 DOI: 10.1097/tp.0000000000003324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jennifer Li
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia.,Westmead Clinical Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Natasha M Rogers
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, Westmead, NSW, Australia.,Westmead Clinical Medical School, University of Sydney, Camperdown, NSW, Australia.,Renal Division, Westmead Hospital, Westmead, NSW, Australia
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26
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Mehrotra S, Schantz K, Friedewald JJ, Ladner DP, Becker Y, Formica R, Barah M, Gu J, Gordon EJ. Physician and patient acceptance of policies to reduce kidney discard. Clin Transplant 2020; 34:e14054. [PMID: 32738167 PMCID: PMC7929781 DOI: 10.1111/ctr.14054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Despite the shortage of kidneys for transplantation in the United States, approximately 18%‐20% of deceased donor kidneys are discarded each year. These discarded kidneys can offer a survival benefit to suitable patients. Revisions to the current kidney allocation policy may be needed to reduce deceased donor kidney discard. We surveyed transplant physicians and patients to assess their perceived acceptability of policy proposals to reduce the discard of deceased donor kidneys. Members of professional societies (AST, ASTS) and a patient organization (AAKP) were invited to complete the survey. Responses were obtained from 97 physicians and 107 patients. The majority of physicians (73.4%) and patients (73.8%) "somewhat" or "completely" accepted a policy for fast‐tracking kidneys at risk of discard. Physicians and patients also supported returning a proportion of waiting time to patients who accept KDPI >85 kidneys and experience graft failure within the first 12 months, with 36% of physicians and 50% of patients electing to return 100% of the waiting time. The majority of physicians (75%) "somewhat or completely" accepted a policy to skip less aggressive centers for KDPI 90 + offers. Physicians and patients provided insights into factors researchers, and policymakers should consider in the design and implementation of these policies.
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Affiliation(s)
- Sanjay Mehrotra
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Karolina Schantz
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - John J Friedewald
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Daniela P Ladner
- Comprehensive Transplant Center Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Masoud Barah
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Jiayi Gu
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Elisa J Gordon
- Comprehensive Transplant Center Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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27
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Stewart ZA, Shah SA, Formica RN, Kandaswamy R, Paramesh AS, Friedman J, Squires R, Cooper M, Axelrod DA. A call to action: Feasible strategies to reduce the discard of transplantable kidneys in the United States. Clin Transplant 2020; 34:e13990. [DOI: 10.1111/ctr.13990] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Zoe A. Stewart
- Department of Surgery New York University Medical Center New York New York USA
| | - Shimul A. Shah
- Department of Surgery University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Richard N. Formica
- Department of Medicine Yale School of Medicine New Haven Connecticut USA
| | - Raja Kandaswamy
- Department of Surgery University of Minnesota Minneapolis Minnesota USA
| | - Anil S. Paramesh
- Department of Surgery Tulane University School of Medicine New Orleans Louisiana USA
| | - Jessica Friedman
- Department of Surgery Tulane University School of Medicine New Orleans Louisiana USA
| | - Ronald Squires
- Association of Organ Procurement Organizations Vienna Virginia USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute Washington District of Columbia USA
| | - David A. Axelrod
- Department of Surgery School of Medicine University of Iowa Iowa City Iowa USA
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28
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Comparative Analysis of Risk Factors in Declined Kidneys from Donation after Brain Death and Circulatory Death. ACTA ACUST UNITED AC 2020; 56:medicina56060317. [PMID: 32604873 PMCID: PMC7353903 DOI: 10.3390/medicina56060317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 01/10/2023]
Abstract
Background and objectives: Kidneys from donation after circulatory death (DCD) are more likely to be declined for transplantation compared with kidneys from donation after brain death (DBD). The aim of this study was to evaluate characteristics in the biopsies of human DCD and DBD kidneys that were declined for transplantation in order to rescue more DCD kidneys. Materials and Methods: Sixty kidney donors (DCD = 36, DBD = 24) were recruited into the study and assessed using donor demographics. Kidney biopsies taken post cold storage were also evaluated for histological damage, inflammation (myeloperoxidase, MPO), von Willebrand factor (vWF) expression, complement 4d (C4d) deposition and complement 3 (C3) activation using H&E and immunohistochemistry staining, and Western blotting. Results: More DBD donors (16/24) had a history of hypertension compared with DCDs (8/36, p = 0.001). The mean warm ischemic time in the DCD kidneys was 12.9 ± 3.9 min. The mean cold ischemic time was not significantly different between the two groups of kidney donors (DBD 33.3 ± 16.7 vs. DCD 28.6 ± 14.1 h, p > 0.05). The score of histological damage and MPO, as well as the reactivity of vWF, C4d and C3, varied between kidneys, but there was no significant difference between the two donor types (p > 0.05). However, vWF reactivity might be an early indicator for loss of tissue integrity, while C4d deposition and activated C3 might be better predictors for histological damage. Conclusions: Similar characteristics of DCD were shown in comparison with DBD kidneys. Importantly, the additional warm ischemic time in DCD appeared to have no further detectable adverse effects on tissue injury, inflammation and complement activation. vWF, C4d and C3 might be potential biomarkers facilitating the evaluation of donor kidneys.
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29
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Butler CR, Perkins JD, Johnson CK, Blosser CD, De Castro I, Leca N, Sibulesky L. Contemporary patterns in kidney graft survival from donors after circulatory death in the United States. PLoS One 2020; 15:e0233610. [PMID: 32469937 PMCID: PMC7259576 DOI: 10.1371/journal.pone.0233610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Kidney transplants from donors after circulatory death (DCD) make up an increasing proportion of all deceased donor kidney transplants in the United States (US). However, DCD grafts are considered to be of lower quality than kidneys from donors after brain death (DBD). It is unclear whether graft survival is different for these two types of donor kidneys. MATERIALS AND METHODS We conducted a retrospective cohort study of US deceased donor kidney recipients using data from the United Network of Organ Sharing from 12/4/2014 to 6/30/2018. We employed a Cox proportional hazard model with mixed effects to compare all-cause graft loss and death-censored graft loss for DCD versus DBD deceased donor kidney transplant recipients. We used transplant center as the random effects term to account for cluster-specific random effects. In the multivariable analysis, we adjusted for recipient characteristics, donor factors, and transplant logistics. RESULTS Our cohort included 27,494 DBD and 7,770 DCD graft recipients transplanted from 2014 to 2018 who were followed over a median of 1.92 years (IQR 1.08-2.83). For DCD compared with DBD recipients, we did not find a significant difference in all-cause graft loss (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.87-1.05 in univariable and HR 1.03 [95% CI 0.95-1.13] in multivariable analysis) or for death-censored graft loss (HR 0.97 (95% CI 0.91-1.06) in univariable and 1.05 (95% CI 0.99-1.11) in multivariable analysis). CONCLUSIONS For a contemporary cohort of deceased donor kidney transplant recipients, we did not find a difference in the likelihood of graft loss for DCD compared with DBD grafts. These findings signal a need for additional investigation into whether DCD status independently contributes to other important outcomes for current kidney transplant recipients and indices of graft quality.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - James D. Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America
| | - Christopher K. Johnson
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine, Peoria, IL, United States of America
| | - Christopher D. Blosser
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Iris De Castro
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, United States of America
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30
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Kidney Perfusion as an Organ Quality Assessment Tool-Are We Counting Our Chickens Before They Have Hatched? J Clin Med 2020; 9:jcm9030879. [PMID: 32210197 PMCID: PMC7141526 DOI: 10.3390/jcm9030879] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 02/07/2023] Open
Abstract
The final decision to accept an organ for transplantation remains a subjective one. With “poor organ quality” commonly cited as a major reason for kidney discard, accurate, objective, and reliable quality assessment is essential. In an era of increasingly higher-risk deceased donor kidneys, the catch is to accept those where the risk–benefit scale will tip in the right direction. Currently available assessment tools, such as risk-scores predicting outcome and zero-time biopsy, perform unsatisfactory, and assessment options during static cold storage are limited. Kidney perfusion technologies are finding their way into clinical practice, and they bring a new opportunity to assess kidney graft viability and quality, both in hypothermic and normothermic conditions. We give an overview of the current understanding of kidney viability assessment during ex situ kidney perfusion. A pragmatic framework to approach viability assessment is proposed as an interplay of three different compartments: the nephron, the vascular compartment, and the immune compartment. Although many interesting ways to assess kidney injury and function during perfusion have been proposed, none have reached the stage where they can reliably predict posttransplant outcome. Larger well-designed studies and validation cohorts are needed to provide better guidance.
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31
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Ayorinde JOO, Hamed M, Goh MA, Summers DM, Dare A, Chen Y, Saeb‐Parsy K. Development of an objective, standardized tool for surgical assessment of deceased donor kidneys: The Cambridge Kidney Assessment Tool. Clin Transplant 2020; 34:e13782. [DOI: 10.1111/ctr.13782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/05/2020] [Accepted: 01/08/2020] [Indexed: 11/26/2022]
Affiliation(s)
- John O. O. Ayorinde
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Mazin Hamed
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Mingzheng Aaron Goh
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Dominic M. Summers
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Anna Dare
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Yining Chen
- Department of Statistics London School of Economics London UK
| | - Kourosh Saeb‐Parsy
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
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32
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Examining the Increased Rates of Deceased Donor Kidney Nonutilization in Australia: What Has Changed? Transplantation 2019; 103:2582-2590. [PMID: 31764891 DOI: 10.1097/tp.0000000000002761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND From 2013, Australia has experienced a sustained increase in the proportion of deceased donor kidneys that are retrieved but not utilized for transplantation. We aimed to determine whether this could be explained by changes in donor characteristics over time. METHODS Registry data were used to examine predictors of kidney nonutilization over the period 2005-2017. Multilevel mixed effect logistic regression modeling and propensity score analysis were used to determine whether era of donation (2013-2017 versus 2005-2012) was an independent predictor of organ nonutilization after controlling for donor characteristics. RESULTS A total of 7810 kidneys were retrieved for the purpose of transplantation with 334 (4.3%) not utilized. The nonutilization rate was 5.8% in 2013-2017 compared to 2.7% in 2005-2012. Despite adjustment for donor characteristics, donation in the more recent era remained a significant predictor of kidney nonutilization (adjusted odds ratio, 1.98; 95% confidence interval, 1.54-2.54; P < 0.001). This finding was confirmed in the propensity score analysis. CONCLUSIONS Kidneys retrieved in Australia since 2013 were more likely not to be utilized for transplantation even after adjusting for changes in donor characteristics. The abrupt increase may be explained by increased clinical risk aversion, changes in unmeasured donor factors or logistical issues. Although nonutilization rates in Australia remain low by international standards, further clinical auditing of the reasons for offer decline may help to optimize resource utilization and maximize transplant opportunities.
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33
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Mori G, Cerami C, Facchini F, Fontana F, Alfano G, Giovanni R, Cappelli G. Kidney Transplantation From Circulatory Death Donors: Monocentric Experience. Transplant Proc 2019; 51:2865-2867. [DOI: 10.1016/j.transproceed.2019.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/30/2019] [Accepted: 07/09/2019] [Indexed: 12/12/2022]
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34
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Subclinical Changes in Deceased Donor Kidney Proteomes Are Associated With 12-month Allograft Function Posttransplantation-A Preliminary Study. Transplantation 2019; 103:323-328. [PMID: 30157158 PMCID: PMC6365243 DOI: 10.1097/tp.0000000000002358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Cerebral injury during donation after brain death may induce systemic damage affecting long-term kidney function posttransplantation. Conventional evaluation of donor organ quality as a triage for transplantation is of limited utility. Methods We compared donor kidneys yielding opposing extremes of the continuum of posttransplantation outcomes by several common kidney biopsy evaluation techniques, including Kidney Donor Profile Index and Remuzzi scoring, and analyzed tissue from a minimal sample cohort using label-free quantitation mass spectrometry. Further assessment of the proteomic results was performed by orthogonal quantitative comparisons of selected key proteins by immunoblotting. Results We show that common evaluation techniques of kidney biopsies were not predictive for posttransplantation outcomes. In contrast, despite the limited cohort size, the proteomic analysis was able to clearly differentiate between kidneys yielding extreme posttransplantation outcome differences. Pathway analysis of the proteomic data suggested that outcome-related variance in protein abundance associated with profibrotic, apoptosis, and antioxidant proteins. Immunoblotting confirmation further supported this observation. Conclusions We present preliminary data indicating that there is scope for existing evaluation approaches to be supplemented by the analysis of proteomic differences. Furthermore, the observed outcome-related variance in a limited cohort was supported by immunoblotting and is consistent with mechanisms previously implicated in the development of injury and cytoprotection in kidney transplantation. Proteomic analyses using mass spectrometry and immunoblot of a small cohort of kidneys from brain death donors is superior to predict graft function (estimated glomerular filtration rate at 3 and 12 months) versus clinical and histological standard classifications. Supplemental digital content is available in the text.
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35
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Chandak P, Phillips BL, Uwechue R, Thompson E, Bates L, Ibrahim I, Sewpaul A, Figueiredo R, Olsburgh J, Hosgood S, Nicholson ML, Wilson C, Callaghan CJ. Dissemination of a novel organ perfusion technique: ex vivo normothermic perfusion of deceased donor kidneys. Artif Organs 2019; 43:E308-E319. [PMID: 31087667 DOI: 10.1111/aor.13499] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 04/07/2019] [Accepted: 05/07/2019] [Indexed: 12/17/2022]
Abstract
Ex vivo normothermic perfusion (EVNP) technology is a promising means of organ preservation, assessment, and preconditioning prior to kidney transplantation, which has been pioneered by a single group. We describe the challenges of setting up clinical EVNP programs in 2 new centers, as well as early patient outcomes. Governance, training, and logistical pathways are described. In order to demonstrate safety and proficiency in this new technique, early patient outcomes are also described. Patient outcomes included the incidence of primary nonfunction, delayed graft function, graft and patient survival at 1 year. Contralateral kidneys undergoing static cold storage alone were used as a comparator group. Between March 2016 and July 2017, EVNP was performed on 14 kidneys from 12 donors (11 kidneys in center 1, 3 kidneys in center 2). Of the 14 kidneys that underwent EVNP, 12 organs were implanted into 10 recipients. Two pairs of kidneys were implanted as dual grafts and 1 kidney was implanted simultaneously with a pancreas. The remaining 7 kidneys were transplanted as single allografts. Seven pairs of kidneys were available for paired analysis comparing EVNP versus static cold storage. Graft and patient outcomes were comparable between the 2 preservation techniques. The introduction of a clinical EVNP service requires a careful multimodal approach, drawing on the expertise of specialists in transplantation, hematology, and microbiology. Both new clinical EVNP programs demonstrated proficiency and safety when a structured dissemination process was followed.
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Affiliation(s)
- Pankaj Chandak
- Department of Nephrology and Transplantation, Guy's and St Thomas' Hospitals NHS Trust and King's College London, London, United Kingdom
| | - Benedict L Phillips
- Department of Nephrology and Transplantation, Guy's and St Thomas' Hospitals NHS Trust and King's College London, London, United Kingdom
| | - Raphael Uwechue
- Department of Nephrology and Transplantation, Guy's and St Thomas' Hospitals NHS Trust and King's College London, London, United Kingdom
| | - Emily Thompson
- National Institute of Health Research Blood and Transplant Research Unit, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Lucy Bates
- National Institute of Health Research Blood and Transplant Research Unit, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Ibrahim Ibrahim
- National Institute of Health Research Blood and Transplant Research Unit, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Avinash Sewpaul
- National Institute of Health Research Blood and Transplant Research Unit, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Rodrigo Figueiredo
- National Institute of Health Research Blood and Transplant Research Unit, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Jonathon Olsburgh
- Department of Nephrology and Transplantation, Guy's and St Thomas' Hospitals NHS Trust and King's College London, London, United Kingdom
| | - Sarah Hosgood
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | | | - Colin Wilson
- National Institute of Health Research Blood and Transplant Research Unit, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' Hospitals NHS Trust and King's College London, London, United Kingdom
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36
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Zhou S, Massie AB, Holscher CM, Waldram MM, Ishaque T, Thomas AG, Segev DL. Prospective Validation of Prediction Model for Kidney Discard. Transplantation 2019; 103:764-771. [PMID: 30015701 PMCID: PMC6330256 DOI: 10.1097/tp.0000000000002362] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many kidneys are discarded every year, with 3631 kidneys discarded in 2016 alone. Identifying kidneys at high risk of discard could facilitate "rescue" allocation to centers more likely to transplant them. The Probability of Delay or Discard (PODD) model was developed to identify marginal kidneys at risk of discard or delayed allocation beyond 36 hours of cold ischemia time. However, PODD has not been prospectively validated, and patterns of discard may have changed after policy changes such as the introduction of Kidney Donor Profile Index and implementation of the Kidney Allocation System (KAS). METHODS We prospectively validated the PODD model using Scientific Registry of Transplant Recipients data in the KAS era (January 1, 2015, to March 1, 2018). C statistic was calculated to assess accuracy in predicting kidney discard. We assessed clustering in centers' utilization of kidneys with PODD >0.6 ("high-PODD") using Gini coefficients. Using match run data from January 1, 2015, to December 31, 2016, we examined distribution of these high-PODD kidneys offered to centers that never accepted a high-PODD kidney. RESULTS The PODD model predicted discard accurately under KAS (C-statistic, 0.87). Compared with utilization of low-PODD kidneys (Gini coefficient = 0.41), utilization of high-PODD kidneys was clustered more tightly among a few centers (Gini coefficient, 0.84 with >60% of centers never transplanted a high-PODD kidneys). In total, 11684 offers (35.0% of all high-PODD offers) were made to centers that never accepted a high-PODD kidney. CONCLUSIONS Prioritizing allocation of high-PODD kidneys to centers that are more likely to transplant them might help reduce kidney discard.
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Affiliation(s)
- Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madeleine M Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Scientific Registry of Transplant Recipients, Minneapolis, MN
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Bath MF, Hosgood SA, Nicholson ML. Vasoreactivity to Acetylcholine During Porcine Kidney Perfusion for the Assessment of Ischemic Injury. J Surg Res 2019; 238:96-101. [PMID: 30769250 DOI: 10.1016/j.jss.2019.01.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 12/07/2018] [Accepted: 01/08/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND The effects of renal allograft ischemic injury on vascular endothelial function have not been clearly established. The aim of this study was to examine vascular reactivity to acetylcholine (ACh) in kidneys subjected to ischemic injury and reperfusion. METHODS Porcine kidneys were exposed to different combinations of warm ischemic time (WIT) and cold ischemic time (CIT) as follows: 15 min (n = 7), 60 min (n = 6), 90 min (n = 6), or 120 min (n = 4) WIT + 2 h CIT or 15 min WIT + 16 h CIT (n = 8). Kidneys were reperfused at 38°C for 3 h. After reperfusion, ACh was infused into the circuit to assess endothelium-dependent vascular reactivity. RESULTS The dose-response relationships between renal blood flow and ACh demonstrated that ACh doses of 10-10 to 10-7 mmol/L caused vasodilatation, whereas doses in the range 10-6 to 10-4 mmol/L led to vasoconstriction. For kidneys exposed to 15-90 min WIT, there was a clear relationship between increasing ischemic injury and reduced vasodilatation to ACh. In contrast, kidneys subjected to 120 min WIT completely lost vasoreactivity. The vasodilatory response to ACh was diminished, but not lost, when CIT was increased from 2 h to 16 h. Peak renal blood flow after ACh infusion correlated with the functional parameters in kidneys with 2 h CIT (P < 0.05). CONCLUSIONS The loss of renal vascular reactivity after 120 min WIT suggests endothelial dysfunction leading to loss of nitric oxide synthesis/release. Measurement of vasoreactivity to ACh in an isolated organ perfusion system has the potential to be developed as a marker of ischemic renal injury before transplantation.
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Affiliation(s)
- Michael F Bath
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
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Phillips BL, Kassimatis T, Atalar K, Wilkinson H, Kessaris N, Simmonds N, Hilton R, Horsfield C, Callaghan CJ. Chronic histological changes in deceased donor kidneys at implantation do not predict graft survival: a single‐centre retrospective analysis. Transpl Int 2019; 32:523-534. [DOI: 10.1111/tri.13398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/13/2018] [Accepted: 01/04/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Benedict L. Phillips
- Department of Nephrology and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Theodoros Kassimatis
- Department of Nephrology and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Kerem Atalar
- Department of Nephrology and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Hannah Wilkinson
- Department of Nephrology and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Nicos Kessaris
- Department of Nephrology and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Naomi Simmonds
- Department of Histopathology Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Rachel Hilton
- Department of Nephrology and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Catherine Horsfield
- Department of Histopathology Guy's and St Thomas’ NHS Foundation Trust London UK
| | - Chris J. Callaghan
- Department of Nephrology and Transplantation Guy's and St Thomas’ NHS Foundation Trust London UK
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Ayorinde JO, Summers DM, Pankhurst L, Laing E, Deary AJ, Hemming K, Wilson EC, Bardsley V, Neil DA, Pettigrew GJ. PreImplantation Trial of Histopathology In renal Allografts (PITHIA): a stepped-wedge cluster randomised controlled trial protocol. BMJ Open 2019; 9:e026166. [PMID: 30659043 PMCID: PMC6340453 DOI: 10.1136/bmjopen-2018-026166] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Most potential kidney transplant donors in the UK are aged over 60 years, yet increasing donor age is associated with poorer graft survival and function. Urgent preimplantation kidney biopsy can identify chronic injury, and may aid selection of better 'quality' kidneys from this group. However, the impact of biopsy on transplant numbers remains unproven. The PreImplantation Trial of Histopathology In renal Allografts (PITHIA) study will assess whether the introduction of a national, 24 hours, digital histopathology service increases the number, and improves outcomes, of kidneys transplanted in the UK from older deceased donors. METHODS AND ANALYSIS PITHIA is an open, multicentre, stepped-wedge cluster randomised study, involving all UK adult kidney transplant centres. At 4-monthly intervals, a group of 4-5 randomly selected clusters (transplant centres) will be given access to remote, urgent, digital histopathology (total intervention period, 24 months). The trial has two primary end points: it is powered for an 11% increase in the proportion of primary kidney offers from deceased donors aged over 60 years that are transplanted, and a 6 mL/min increase in the estimated glomerular filtration rate of recipients at 12 months post-transplant. This would equate to an additional 120 kidney transplants performed in the UK annually. Trial outcome data will be collected centrally via the UK Transplant Registry held by NHS Blood and Transplant (NHSBT) and will be analysed using mixed effects models allowing for clustering within centres and adjusting for secular trends. An accompanying economic evaluation will estimate the cost-effectiveness of the service to the National Health Service. ETHICS AND DISSEMINATION The study has been given favourable ethical opinion by the Cambridge South Research Ethics Committee and is approved by the Health Research Authority. We will present our findings at key transplant meetings, publish results within 4 years of the trial commencing and support volunteers at renal patient groups to disseminate the trial outcome. TRIAL REGISTRATION NUMBER ISRCTN11708741; Pre-results.
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Affiliation(s)
| | - Dominic M Summers
- Department of Surgery, University of Cambridge, Cambridge, UK
- NHS Blood and Transplant, Watford, Hertfordshire, UK
| | | | - Emma Laing
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Alison J Deary
- NHS Blood and Transplant Clinical Studies Unit, Cambridge, UK
| | - Karla Hemming
- Department of Public Health, University of Birmingham, Birmingham, UK
| | - Edward Cf Wilson
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Victoria Bardsley
- Department of Histopathology, University of Cambridge, Cambridge, UK
| | - Desley A Neil
- Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Mohan S, Chiles MC, Patzer RE, Pastan SO, Husain SA, Carpenter DJ, Dube GK, Crew RJ, Ratner LE, Cohen DJ. Factors leading to the discard of deceased donor kidneys in the United States. Kidney Int 2018; 94:187-198. [PMID: 29735310 PMCID: PMC6015528 DOI: 10.1016/j.kint.2018.02.016] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 01/31/2018] [Accepted: 02/01/2018] [Indexed: 01/22/2023]
Abstract
The proportion of deceased donor kidneys procured for transplant but subsequently discarded has been growing steadily in the United States, but factors contributing to the rising discard rate remain unclear. To assess the reasons for and probability of organ discard we assembled a cohort of 212,305 deceased donor kidneys recovered for transplant from 2000-2015 in the SRTR registry that included 36,700 kidneys that were discarded. 'Biopsy Findings' (38.2%) was the most commonly reported reason for discard. The median Kidney Donor Risk Index of discarded kidneys was significantly higher than transplanted organs (1.78 vs 1.12), but a large overlap in the quality of discarded and transplanted kidneys was observed. Kidneys of donors who were older, female, Black, obese, diabetic, hypertensive or HCV-positive experienced a significantly increased odds of discard. Kidneys from donors with multiple unfavorable characteristics were more likely to be discarded, whereas unilaterally discarded kidneys had the most desirable donor characteristics and the recipients of their partner kidneys experienced a one-year death-censored graft survival rate over 90%. There was considerable geographic variation in the odds of discard across the United States, which further supports the notion that factors beyond organ quality contributed to kidney discard. Thus, while the discard of a small fraction of organs procured from donors may be inevitable, the discard of potentially transplantable kidneys needs to be avoided. This will require a better understanding of the factors contributing to organ discard in order to remove the disincentives to utilize less-than-ideal organs for transplantation.
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Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA.
| | - Mariana C Chiles
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Dustin J Carpenter
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Geoffrey K Dube
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - R John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - David J Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
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Organs and organisations: Situating ethics in organ donation after circulatory death in the UK. Soc Sci Med 2018; 209:104-110. [PMID: 29852397 DOI: 10.1016/j.socscimed.2018.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 12/29/2022]
Abstract
Controlled organ donation after circulatory death (DCD) has recently been revived in the UK, as part of attempts to increase organ donation rates. The re-introduction of DCD has subsequently become the focus of bioethical controversy, since it necessitates intervening in the care of dying patients to obtain quality donor organs. Transplant policy responses to these concerns have generated new legal and ethical guidelines to address uncertainties around DCD, producing claims that the UK has overcome' the ethical challenge of DCD. In contrast, by drawing on Lynch's call to 'respecify' ethics, this paper argues that ethics in DCD cannot be reduced to abstract directives for practice, but, instead, are composed and dealt with as an organisational problem. To do this, I utilise data from an ethnographic study examining the production of the 'minority ethnic organ donor' within UK organ donation settings; in particular, the data pertains to a case hospital which was in the process of developing a DCD programme during the period of fieldwork. Findings show that the ethics of DCD are encountered as practical sets of problems, constructed in relation to particular institutional locales. I describe how these issues are worked-around by creating conditions to make DCD organisationally possible, and through the animation of standard procedures into acceptable forms of practice. I argue that ethics in DCD go far beyond normative bioethical principles, to encompass concerns around: the reputation of hospital Trusts, public perceptions of organ donation, the welfare of potential donor families, and challenges to the work of health professionals caring for dying patients. The paper enriches understanding of ethics in science and medicine by showing how ethics are assembled and negotiated as a practical-organisational concern, and calls for further examination of how DCD gets constructed as a potential problem and is made to happen in practice.
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Orlando G, Khan MA, El-Hennawy H, Farney AC, Rogers J, Reeves-Daniel A, Gautreaux MD, Doares W, Kaczmorski S, Stratta RJ. Is prolonged cold ischemia a contraindication to using kidneys from acute kidney injury donors? Clin Transplant 2018; 32:e13185. [PMID: 29285808 DOI: 10.1111/ctr.13185] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 11/27/2022]
Abstract
To determine the impact of prolonged cold ischemia time (CIT) on the outcome of acute kidney injury (AKI) renal grafts, we therefore performed a single-center retrospective analysis in adult patients receiving kidney transplantation (KT) from AKI donors. Outcomes were stratified according to duration of CIT. A total of 118 patients receiving AKI grafts were enrolled. Based on CIT, patients were stratified as follows: (i) <20 hours, 27 patients; (ii) 20-30 hours, 52 patients; (iii) 30-40 hours, 30 patients; (iv) ≥40 hours, nine patients. The overall incidence of delayed graft function DGF was 41.5%. According to increasing CIT category, DGF rates were 30%, 42%, 40%, and 78%, respectively (P = .03). With a mean follow-up of 48 months, overall patient and graft survival rates were 91% and 81%. Death-censored graft survival (DCGS) rates were 84% and 88% for patients with and without DGF (P = NS). DCGS rates were 92% in patients with CIT <20 hours compared to 85% with CIT >20 hours (P = NS). In the nine patients with CIT >40 hours, the 4-year DCGS rate was 100%. We conclude that prolonged CIT in AKI grafts may not adversely influence outcomes and so discard of AKI kidneys because of projected long CIT is not warranted when donors are wisely triaged.
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Affiliation(s)
- Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Muhammad A Khan
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hany El-Hennawy
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael D Gautreaux
- Section of Nephrology, Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - William Doares
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Scott Kaczmorski
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Husain SA, Chiles MC, Lee S, Pastan SO, Patzer RE, Tanriover B, Ratner LE, Mohan S. Characteristics and Performance of Unilateral Kidney Transplants from Deceased Donors. Clin J Am Soc Nephrol 2018; 13:118-127. [PMID: 29217537 PMCID: PMC5753314 DOI: 10.2215/cjn.06550617] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/29/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The fraction of kidneys procured for transplant that are discarded is rising in the United States. Identifying donors from whom only one kidney was discarded allows us to control for donor traits and better assess reasons for organ discard. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study using United Network for Organ Sharing Standard Transplant Analysis and Research file data to identify deceased donors from whom two kidneys were procured and at least one was transplanted. Unilateral pairs were defined as kidney pairs from a single donor from whom one kidney was discarded ("unilateral discard") but the other was transplanted ("unilateral transplant"). Organ quality was estimated using the Kidney Donor Risk Index and Kidney Donor Profile Index (KDPI). We compared all-cause graft failure rates for unilateral transplants to those for bilateral transplant Kaplan-Meier methods, and life table methodology was used to evaluate 1-, 2-, 3-, and 5-year survival rates of transplants from bilateral and unilateral donors. RESULTS Compared with bilateral donors (i.e., both kidneys transplanted) (n=80,584), unilateral donors (i.e., only one kidney transplanted) (n=7625) had higher mean terminal creatinine (1.3±2.1 mg/dl versus 1.1±0.9 mg/dl) and KDPI (67%±25% versus 42%±27%), were older, and were more likely to have hypertension, diabetes, hepatitis C, terminal stroke, or meet Centers for Disease Control and Prevention high-risk donor criteria. Unilateral discards were primarily attributed to factors expected to be similar in both kidneys from a donor: biopsy findings (22%), no interested recipient (13%), and donor history (7%). Anatomic abnormalities (14%), organ damage (11%), and extended ischemia (6%) accounted for about 30% of discards, but were the commonest reasons among low KDPI kidneys. Among kidneys with KDPI≥60%, there was an incremental difference in allograft survival over time (for unilateral versus bilateral transplants, 1-year survival: 83% versus 87%; 3-year survival: 69% versus 73%; 5-year survival: 51% versus 58%). CONCLUSIONS A large number of discarded kidneys were procured from donors whose contralateral kidneys were transplanted with good post-transplant outcomes.
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Affiliation(s)
- Syed Ali Husain
- Division of Nephrology, Department of Medicine and
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Mariana C. Chiles
- Division of Nephrology, Department of Medicine and
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Samnang Lee
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | | | - Rachel E. Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; and
| | - Bekir Tanriover
- Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas
| | - Lloyd E. Ratner
- Division of Transplantation, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine and
- The Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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Hosgood SA, Thompson E, Moore T, Wilson CH, Nicholson ML. Normothermic machine perfusion for the assessment and transplantation of declined human kidneys from donation after circulatory death donors. Br J Surg 2017; 105:388-394. [PMID: 29210064 PMCID: PMC5887977 DOI: 10.1002/bjs.10733] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 06/16/2017] [Accepted: 09/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND A significant proportion of donation after circulatory death (DCD) kidneys are declined for transplantation because of concerns over their quality. Ex vivo normothermic machine perfusion (NMP) provides a unique opportunity to assess the quality of a kidney and determine its suitability for transplantation. METHODS In phase 1 of this study, declined human DCD kidneys underwent NMP assessment for 60 min. Kidneys were graded 1-5 using a quality assessment score (QAS) based on macroscopic perfusion, renal blood flow and urine output during NMP. In phase 2 of the study, declined DCD kidneys were assessed by NMP with an intention to transplant them. RESULTS In phase 1, 18 of 42 DCD kidneys were declined owing to poor in situ perfusion. After NMP, 28 kidneys had a QAS of 1-3, and were considered suitable for transplantation. In phase 2, ten of 55 declined DCD kidneys underwent assessment by NMP. Eight kidneys had been declined because of poor in situ flushing in the donor and five of these were transplanted successfully. Four of the five kidneys had initial graft function. CONCLUSION NMP technology can be used to increase the number of DCD kidney transplants by assessing their quality before transplantation.
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Affiliation(s)
- S A Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - E Thompson
- Freeman Hospital, Newcastle University, Newcastle upon Tyne, UK
| | - T Moore
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - C H Wilson
- Freeman Hospital, Newcastle University, Newcastle upon Tyne, UK
| | - M L Nicholson
- Department of Surgery, University of Cambridge, Cambridge, UK
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47
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Blum MF, Liu Q, Soliman B, Dreher P, Okamoto T, Poggio ED, Goldfarb DA, Baldwin WM, Quintini C. Comparison of normothermic and hypothermic perfusion in porcine kidneys donated after cardiac death. J Surg Res 2017; 216:35-45. [PMID: 28807212 DOI: 10.1016/j.jss.2017.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/18/2017] [Accepted: 04/11/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Normothermic machine perfusion (NMP) is an alternative strategy for preserving kidneys donated after cardiac death (DCD). The relative efficacy of prolonged NMP compared to hypothermic machine perfusion (HMP) in DCD kidneys with moderate ischemic injury is undetermined. This study compares NMP and HMP kidney preservation in a porcine DCD model. METHODS Ten porcine kidneys underwent NMP or HMP preservation following 45 minutes of warm ischemia and 5 hours of cold ischemia. After 8 hours of machine preservation, hemodynamic stability, renal function, perfusate biomarkers, and histologic integrity were assessed in a simulated reperfusion model. RESULTS During simulated reperfusion, no differences were observed in oxygen consumption, urine production, creatinine clearance, fractional excretion of sodium, proteinuria, and perfusate levels of lactate dehydrogenase and aspartate aminotransferase. Resistance was no different after 30 minutes of simulated reperfusion. Histologically, NMP kidneys demonstrated increased vacuolization after preservation and greater loss of tubular integrity after simulated reperfusion. Perfusate levels of alkaline phosphatase (AP) and gamma glutamyltransferase (GGT) were higher in NMP kidneys during preservation, but upon simulated reperfusion, AP and GGT levels were higher in HMP-preserved kidneys. Peak AP and GGT during simulated reperfusion of HMP kidneys were over 14 times higher than peak AP and GGT during preservation of NMP kidneys. CONCLUSIONS NMP provided comparable preservation of renal function as HMP and minimized AP and GGT release upon reperfusion.
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Affiliation(s)
- Matthew F Blum
- Transplant Center, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Qiang Liu
- Transplant Center, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Basem Soliman
- Transplant Center, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paul Dreher
- Transplant Center, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Toshihiro Okamoto
- Transplant Center, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David A Goldfarb
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - William M Baldwin
- Department of Immunology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cristiano Quintini
- Transplant Center, Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Hosgood SA, Saeb-Parsy K, Wilson C, Callaghan C, Collett D, Nicholson ML. Protocol of a randomised controlled, open-label trial of ex vivo normothermic perfusion versus static cold storage in donation after circulatory death renal transplantation. BMJ Open 2017; 7:e012237. [PMID: 28115329 PMCID: PMC5278243 DOI: 10.1136/bmjopen-2016-012237] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Ex vivo normothermic perfusion (EVNP) is a novel technique that reconditions the kidney and restores renal function prior to transplantation. Phase I data from a series of EVNP in extended criteria donor kidneys have established the safety and feasibility of the technique in clinical practice. METHODS AND ANALYSIS This is a UK-based phase II multicentre randomised controlled trial to assess the efficacy of EVNP compared with the conventional static cold storage technique in donation after circulatory death (DCD) kidney transplantation. 400 patients receiving a kidney from a DCD donor (categories III and IV, controlled) will be recruited into the study. On arrival at the transplant centre, kidneys will be randomised to receive either EVNP (n=200) or remain in static cold storage (n=200). Kidneys undergoing EVNP will be perfused with an oxygenated packed red cell solution at near body temperature for 60 min prior to transplantation. The primary outcome measure will be determined by rates of delayed graft function (DGF) defined as the need for dialysis in the first week post-transplant. Secondary outcome measures include incidences of primary non-function, the duration of DGF, functional DGF defined as <10% fall in serum creatinine for 3 consecutive days in the first week post-transplant, creatinine reduction ratio days 2 and 5, length of hospital stay, rates of biopsy-proven acute rejection, serum creatinine and estimated glomerular filtration rate at 1, 3, 6 and 12 months post-transplant and patient and allograft survival. The EVNP assessment score will be recorded and the level of fibrosis and inflammation will also be measured using tissue, blood and urine samples. Ethics and dissemination. The study has been approved by the National Health Service (NHS) Health Research Authority Research Ethics Committee. The results are expected to be published in 2020. TRIAL REGISTRATION NUMBER ISRCTN15821205; Pre-results.
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Affiliation(s)
- Sarah A Hosgood
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Kourosh Saeb-Parsy
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | | | | | | | - Michael L Nicholson
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Hosgood SA, Saeb‐Parsy K, Hamed MO, Nicholson ML. Successful Transplantation of Human Kidneys Deemed Untransplantable but Resuscitated by Ex Vivo Normothermic Machine Perfusion. Am J Transplant 2016; 16:3282-3285. [PMID: 27273794 PMCID: PMC5096065 DOI: 10.1111/ajt.13906] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 05/26/2016] [Accepted: 05/28/2016] [Indexed: 01/25/2023]
Abstract
We report the successful transplantation of a pair of human kidneys that were declined for transplantation due to inadequate in situ perfusion but subsequently transplanted after perfusion and assessment using ex vivo normothermic perfusion (EVNP). The kidneys were from a 35-year-old man, a donation after circulatory death donor. Both kidneys were declined by all UK transplant centers. On arrival, the kidneys had significant areas of incomplete clearance of blood from the microcirculation that did not clear after a further attempt to flush them. Kidneys underwent 60 min of EVNP with an oxygenated packed red blood cell-based solution warmed to 35.2°C. During EVNP, the patchy areas cleared in both kidneys. The mean renal blood flow and total urine output were 68.0 mL/min/100 g and 560 mL in the left kidney and 59.9 mL/min/100 g, 430 mL in the right, respectively. Based on the EVNP perfusion parameters, both kidneys were deemed suitable for transplantation. They were transplanted without any complications, and both recipients had initial graft function. The serum creatinine levels at 3 months were 1.2 mg/dl in the recipient of the left kidney and 1.62 mg/dl in the recipient of the right kidney. EVNP technology can be used to assess and rescue kidneys previously deemed unsuitable for transplantation.
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Affiliation(s)
- S. A. Hosgood
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK
| | - K. Saeb‐Parsy
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK
| | - M. O. Hamed
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK
| | - M. L. Nicholson
- Department of SurgeryUniversity of CambridgeAddenbrooke's HospitalCambridgeUK
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Mohan S, Foley K, Chiles MC, Dube GK, Patzer RE, Pastan SO, Crew RJ, Cohen DJ, Ratner LE. The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States. Kidney Int 2016; 90:157-63. [PMID: 27182001 DOI: 10.1016/j.kint.2016.03.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/01/2016] [Accepted: 03/17/2016] [Indexed: 10/21/2022]
Abstract
Factors contributing to the high rate of discard among deceased donor kidneys remain poorly understood and the influence of resource limitations of weekends on kidney transplantation is unknown. To quantify this we used data from the Scientific Registry of Transplant Recipients and assembled a retrospective cohort of 181,799 deceased donor kidneys recovered for transplantation from 2000-2013. We identified the impact of the day of the week on the procurement and subsequent utilization or discard of deceased donor kidneys in the United States, as well as report the geographic variation of the impact of weekends on transplantation. Compared with weekday kidneys, organs procured on weekends were significantly more likely to be discarded than transplanted (odds ratio: 1.16; 95% confidence interval: 1.13-1.19), even after adjusting for organ quality (adjusted odds ratio: 1.13; 95% confidence interval: 1.10-1.17). Weekend discards were of a significantly higher quality than weekday discards (Kidney Donor Profile Index: 76.5% vs. 77.3%). Considerable geographic variation was noted in the proportion of transplants that occurred over the weekend. Kidneys available for transplant over the weekend were significantly more likely to be used at larger transplant centers, be shared without payback, and experienced shorter cold ischemia times. Thus, factors other than kidney quality are contributing to the discard of deceased donor kidneys, particularly during weekends. Policy prescriptions, administrative or organizational solutions within transplant programs may potentially mitigate against the recent increase in kidney discards.
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Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA.
| | - Karl Foley
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Mariana C Chiles
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Geoffrey K Dube
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - R John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - David J Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
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