Case-matched comparison of long-term results of non-heart beating and heart-beating donor renal transplants
Department of Transplant Surgery, Leicester General Hospital, Leicester, UK. British Journal of Surgery
(Impact Factor: 5.54).
06/2009; 96(6):685-91. DOI: 10.1002/bjs.6607
Function and survival of non-heart-beating donor (NHBD) renal transplants have been shown to be comparable to those from heart-beating donors (HBDs) up to 10 years after transplantation. However, there are few data on outcome after 10 years, particularly from uncontrolled NHBD donors.
All NHBD renal transplants (predominantly uncontrolled) performed between April 1992 and January 2002 were retrospectively matched with HBD renal transplants performed over the same period.
Some 112 NHBD renal transplants were compared with 164 HBD renal transplants. Delayed graft function was significantly higher in the NHBD group (83.9 versus 22.0 per cent respectively; P < 0.001). Primary non-function rates were similar (5.4 versus 1.8 per cent respectively; P = 0.164). Overall serum creatinine was significantly higher in NHBDs (P < 0.001). Median graft and patient survival was 126 months for NHBD and 159 months for HBD kidneys. Death-censored graft survival at 1, 5, 10 and 15 years was respectively 91.8, 77.5, 61.0 and 44.2 per cent for NHBD, and 91.1, 86.3, 71.7 and 58.5 per cent for HBD kidneys (P = 0.108).
Despite increased delayed graft function rates and serum creatinine levels, the long-term survival of NHBD renal transplants was similar to those from HBDs. However, there was a trend to poorer function and survival from 10 years after transplant.
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Available from: Mohammed Zeeshan Akhtar
- "In situ preservation with a double balloon triple lumen catheter can be used safely to preserve kidneys in Maastricht category III donors, if direct cannulation of the aorta cannot be performed C[44,56,57]In donors with in situ preservation (ISP), intraperitoneal cooling may allow a better cooling of the organs than ISP alone D666768It is recommended to use streptokinase (1.5 MIU/L) in the initial flush out during organ procurement C[69-71 ]Preservation Hypothermic machine perfusion is feasible and safe. In DCD kidneys, HMP has not shown an effect on graft survival B[18,72737475If HMP is used to preserve DCD kidneys, it may be preferable to use it immediately after kidney explantation DDiscard of DCD kidneys on the basis of machine perfusion characteristics or machine perfusate biomarkers alone is not recommended C82838485868788Recipient selection The risk of DGF should not be considered as a criterion to discard a DCD kidney for transplantation B[10,16,39,93949596979899Children should preferably not receive a DCD kidney CDCD kidneys are not the first choice for patients with a retransplantation C[10,16,98]Recipient management DCD kidney transplantation should be avoided in patients with known cardiac failure or low blood pressure D Optimal pre-operative, operative and direct postoperative fluid management is essential to optimize graft survival of DCD kidneys C[103,105,106]In DCD kidney recipients with DGF, regular monitoring with echo Doppler, renography, or both is recommended, as well as frequent biopsies, in order to rule out acute rejection D Delayed implementation or use of lowdose CNI could help to reduce the incidence of DGF DConclusion Donation after circulatory death kidney transplantation has occurred as consequence of the need to address the organ deficit. These guidelines provide recommendations on donor selection, organ and recipient management. "
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ABSTRACT: Donation after circulatory death (DCD) donors provide an invaluable source for kidneys for transplantation. Over the last decade we have seen a substantial increase in the number of DCD kidneys, particularly within Europe. We provide an overview of risk factors associated with DCD kidney function and survival and formulate recommendations from the 6(th) international conference on organ donation in Paris, for best practice guidelines. A systematic review of the literature was performed using Ovid Medline, Embase and Cochrane databases. Topics are discussed, including donor selection, organ procurement, organ preservation, recipient selection and transplant management. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
Available from: Sebastien Giraud
- "However, organs from these donors are more prone to ischemia-reperfusion injury because DCD kidneys suffer a period of warm ischemic damage (no-flow and low-flow periods) in addition to cold ischemia during ex-vivo conservation. Consequently, the risk of primary nonfunction and delayed graft function is higher
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Extracorporeal membranous oxygenation is proposed for abdominal organ procurement from donation after circulatory determination of death (DCD). In France, the national Agency of Biomedicine supervises the procurement of kidneys from DCD, specifying the durations of tolerated warm and cold ischemia. However, no study has determined the optimal conditions of this technique. The aim of this work was to develop a preclinical model of DCD using abdominal normothermic oxygenated recirculation (ANOR). In short, our objectives are to characterize the mechanisms involved during ANOR and its impact on abdominal organs.
We used Large White pigs weighing between 45 and 55 kg. After 30 minutes of potassium-induced cardiac arrest, the descending thoracic aorta was clamped and ANOR set up between the inferior vena cava and the abdominal aorta for 4 hours. Hemodynamic, respiratory and biochemical parameters were collected. Blood gasometry and biochemistry analysis were performed during the ANOR procedure.
Six ANOR procedures were performed. The surgical procedure is described and intraoperative parameters and biological data are presented. Pump flow rates were between 2.5 and 3 l/min. Hemodynamic, respiratory, and biochemical objectives were achieved under reproducible conditions. Interestingly, animals remained hemodynamically stable following the targeted protocol. Arterial pH was controlled, and natremia and renal function remained stable 4 hours after the procedure was started. Decreased hemoglobin and serum proteins levels, concomitant with increased lactate dehydrogenase activity, were observed as a consequence of the surgery. The serum potassium level was increased, owing to the extracorporeal circulation circuit.
Our ANOR model is the closest to clinical conditions reported in the literature and will allow the study of the systemic and abdominal organ impact of this technique. The translational relevance of the pig will permit the determination of new biomarkers and protocols to improve DCD donor management.
Available from: Jonathon Olsburgh
- "Whilst long term outcomes and graft survival are similar between DBDs and DCDs, it has been well established that kidneys from DCD’s have higher rates of primary non-function (PNF) and delayed graft function (DGF) than from DBD kidneys [1-4]. These differences impact on in-hospital stay and overall costs which are consequently much higher in DCD compared to DBD transplants. "
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There is no national policy for allocation of kidneys from Donation after circulatory death (DCD) donors in the UK. Allocation is geographical and based on individual/regional centre policies. We have evaluated the short term outcomes of paired kidneys from DCD donors subject to this allocation policy.
Retrospective analysis of paired renal transplants from DCD’s from 2002 to 2010 in London. Cold ischemia time (CIT), recipient risk factors, delayed graft function (DGF), 3 and 12 month creatinine) were compared.
Complete data was available on 129 paired kidneys.115 pairs were transplanted in the same centre and 14 pairs transplanted in different centres. There was a significant increase in CIT in kidneys transplanted second when both kidneys were accepted by the same centre (15.5 ± 4.1 vs 20.5 ± 5.8 hrs p < 0.0001 and at different centres (15.8 ± 5.3 vs. 25.2 ± 5.5 hrs p = 0.0008). DGF rates were increased in the second implant following sequential transplantation (p = 0.05).
Paired study sequential transplantation of kidneys from DCD donors results in a significant increase in CIT for the second kidney, with an increased risk of DGF. Sequential transplantation from a DCD donor should be avoided either by the availability of resources to undertake simultaneous procedures or the allocation of kidneys to 2 separate centres.
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