Machine Perfusion or Cold Storage in Deceased-Donor Kidney Transplantation

Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
New England Journal of Medicine (Impact Factor: 55.87). 02/2009; 360(1):7-19. DOI: 10.1056/NEJMoa0802289
Source: PubMed


Static cold storage is generally used to preserve kidney allografts from deceased donors. Hypothermic machine perfusion may improve outcomes after transplantation, but few sufficiently powered prospective studies have addressed this possibility.
In this international randomized, controlled trial, we randomly assigned one kidney from 336 consecutive deceased donors to machine perfusion and the other to cold storage. All 672 recipients were followed for 1 year. The primary end point was delayed graft function (requiring dialysis in the first week after transplantation). Secondary end points were the duration of delayed graft function, delayed graft function defined by the rate of the decrease in the serum creatinine level, primary nonfunction, the serum creatinine level and clearance, acute rejection, toxicity of the calcineurin inhibitor, the length of hospital stay, and allograft and patient survival.
Machine perfusion significantly reduced the risk of delayed graft function. Delayed graft function developed in 70 patients in the machine-perfusion group versus 89 in the cold-storage group (adjusted odds ratio, 0.57; P=0.01). Machine perfusion also significantly improved the rate of the decrease in the serum creatinine level and reduced the duration of delayed graft function. Machine perfusion was associated with lower serum creatinine levels during the first 2 weeks after transplantation and a reduced risk of graft failure (hazard ratio, 0.52; P=0.03). One-year allograft survival was superior in the machine-perfusion group (94% vs. 90%, P=0.04). No significant differences were observed for the other secondary end points. No serious adverse events were directly attributable to machine perfusion.
Hypothermic machine perfusion was associated with a reduced risk of delayed graft function and improved graft survival in the first year after transplantation. (Current Controlled Trials number, ISRCTN83876362.)

Download full-text


Available from: Jean-Paul Squifflet, Oct 03, 2015
1 Follower
49 Reads
  • Source
    • "The transplant community must also monitor the effects of changes in organ procurement practices, especially defining optimal identification and management of marginal donors and more investment in live donation. There should also be emphasis on measurements to improve the quality of marginal organs such as ex vivo preservation methods or extracorporeal support for donors after cardiac death to assess viability and provide resuscitation of DCD and ECD organs [28,29]. A recent randomized trial have shown that protective ventilatory strategies such as low tidal volume can double the number of patients whose lungs were used for transplantation compared to conventional ventilatory methods [30]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Organ shortage is the greatest challenge facing the field of organ transplantation today. A variety of approaches have been implemented to expand the organ donor pool including live donation, a national effort to expand deceased donor donation, split organ donation, paired donor exchange, national sharing models and greater utilization of expanded criteria donors. Increased public awareness, improved efficiency of the donation process, greater expectations for transplantation, expansion of the living donor pool and the development of standardized donor management protocols have led to unprecedented rates of organ procurement and transplantation. Although live donors and donation after brain death account for the majority of organ donors, in the recent years there has been a growing interest in donors who have severe and irreversible brain injuries but do not meet the criteria for brain death. If the physician and family agree that the patient has no chance of recovery to a meaningful life, life support can be discontinued and the patient can be allowed to progress to circulatory arrest and then still donate organs (donation after circulatory death). Increasing utilization of marginal organs has been advocated to address the organ shortage.
    International Journal of Organ Transplantation Medicine 08/2014; 5(3):87-96.
  • Source
    • "Prolonged cold static storage of organs for transplantation leads to tissue damage and dysfunction of the primary graft (Lima et al. 2006), as well as inferior survival of long-term grafts (Salahudeen 2004). A technological improvement of this technique, involving continuous perfusion of the graft with preservative solution using a perfusion pump, has been shown to improve cold-storage time and initial function of the graft after kidney transplant (Moers et al. 2009), but applications to other solid organs including ex-vivo perfusion of the lung have entered clinical practice, especially driven by the expansion of extended-criteria donors and by donation of organs after cardiac death (Roman et al. 2013). All forms of therapeutic cooling operate on the same unifying principle—hypothermia leads to a reduction in metabolic rate—a highly desirable response during periods of diminished supply. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Supply and demand relationships govern survival of animals in the wild and are also key determinants of clinical outcomes in critically ill patients. Most animals' survival strategies focus on the supply side of the equation by pursuing territory and resources, but hibernators are able to anticipate declining availability of nutrients by reducing their energetic needs through the seasonal use of torpor, a reversible state of suppressed metabolic demand and decreased body temperature. Similarly, in clinical medicine the majority of therapeutic interventions to care for critically ill or trauma patients remain focused on elevating physiologic supply above critical thresholds by increasing the main determinants of delivery of oxygen to the tissues (cardiac output, perfusion pressure, hemoglobin concentrations, and oxygen saturation), as well as increasing nutritional support, maintaining euthermia, and other general supportive measures. Techniques, such as induced hypothermia and preconditioning, aimed at diminishing a patient's physiologic requirements as a short-term strategy to match reduced supply and to stabilize their condition, are few and underutilized in clinical settings. Consequently, comparative approaches to understand the mechanistic adaptations that suppress metabolic demand and alter metabolic use of fuel as well as the application of concepts gleaned from studies of hibernation, to the care of critically ill and injured patients could create novel opportunities to improve outcomes in intensive care and perioperative medicine.
    Integrative and Comparative Biology 05/2014; 54(3). DOI:10.1093/icb/icu047 · 2.93 Impact Factor
  • Source
    • "DGF is an early indicator for organ quality and preservation. In 2009, Cyril Moers et al conducted an RCT using a paired design, in which both kidneys were from the same donor, with one kidney undergoing HMP and the other CS; they showed a significant reduction in the DGF rate of 26.5% in the HMP preservation group compared with 20.8% in CS [27]. In a retrospective single-center analysis of 141 ECD kidneys, Stratta et al reported a remarkable reduction in the rate of DGF with HMP preservation (11%) versus CS(37%)[11]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Expanded criteria donors (ECDs) are currently accepted as potential sources to increase the donor pool and to provide more chances of kidney transplantation for elderly recipients who would not survive long waiting periods. Hypothermic machine perfusion (HMP) is designed to mitigate the deleterious effects of simple cold storage (CS) on the quality of preserved organs, particularly when the donor is in a marginal status. We compared the transplant outcomes in patients receiving ECD kidneys with either HMP or CS graft preservation. Articles from the MEDLINE, EMBASE and Cochrane Library databases were searched and all studies reporting outcomes from HMP versus CS methods of kidney preservation were included in this meta-analysis. The parameters analyzed included the incidence of delayed graft function (DGF), primary non-function (PNF) and one-year graft and patient survival. A total of seven studies qualified for the review, involving 2374 and 8716 kidney grafts with HMP or CS preservation respectively, all from ECD donors. The incidence of delayed graft function (DGF) was significantly reduced with an odd ratio(OR) of 0.59 (95% CI 0.54-0.66, P<0.001) and one-year graft survival was significantly improved with an OR of 1.12 (95% CI 1.03-1.21, P = 0.005) in HMP preservation compared to CS. However, there was no difference in the incidence of PNF (OR 0.54, 95% CI 0.21-1.40, P = 0.20), and one-year patient survival (OR 0.98, 95% CI 0.94-1.02, P = 0.36) between HMP and CS preservation. HMP was associated with a reduced incidence of DGF and an with increased one-year graft survival, but it was not associated with the incidence of PNF and one-year patient survival.
    PLoS ONE 12/2013; 8(12):e81826. DOI:10.1371/journal.pone.0081826 · 3.23 Impact Factor
Show more