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.)

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    • "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]. "
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    • "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. "
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    • "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]. "
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