A case-control comparison of the results of renal transplantation from heart-beating and non-heart-beating donors

Total recovery of heart grafts of non-heart-beating donors after 3 hours of hypothermic coronary oxygen persufflation preservation in an orthotopic pig transplantation model

BACKGROUND

The coronary oxygen persufflation (COP) technique has been previously shown to allow prolonged heart preservation of 14 hr with optimal recovery in a pig model of orthotopic transplantation. This technique may be applicable to hearts grafted from non-heart-beating donors (NHBD).

METHODS

Experiments were performed on pigs to test the effectiveness of oxygenated preservation, using COP for preservation of NHBD hearts. After 16 min of in situ normothermic ischemia, the hearts were flushed with histidine-tryptophan-ketoglutarate (HTK) solution or modified HTK solution (mBHTK) including 30 mmol/L 2,3-butanedione monoxime, 40 mg/L hyaluronidase,15 micromol/L adenosine, and 50 micromol/L calcium. Hearts were stored in the flush solutions for 3.3 hr or additionally persufflated with gaseous oxygen through the coronary arteries (COP) and transplanted orthotopically.

RESULTS

Simple storage in HTK did not allow recovery of these hearts, whereas mBHTK storage resulted in improved function with 1.1 L/min cardiac output. The cardiac output reached 2.8 L/min (68% of normal values) with a left ventricular developed pressure of 101 mm Hg only after mBHTK+COP. Then the hearts were able to guarantee the circulation of the recipient for the test period after weaning from the heart-lung machine.

CONCLUSIONS

Even in an NHBD with more than 15 min of in situ ischemia, the use of COP in combination with mBHTK solution for 3.3-hr storage of the heart allows excellent recovery of transplanted hearts and normal weaning from the heart-lung machine. This indicates that COP combined with mBHTK may be an optimal preservation technique for use with NHBD hearts.

Long-term renal function in kidneys from non-heart-beating donors: A single-center experience

BACKGROUND

Cadaveric kidneys from brain-stem-dead donors continue to be limited because the number of donors has reached a plateau. Wide recruitment of non-heart-beating donors (NHBD) could significantly increase the donor pool. NHBD renal transplants are underused because of the concern of poor quality graft function from such donors. In response to this perception, we reviewed 46 NHBD renal transplants performed in our center since 1998.

METHODS

All NHBD kidneys were machine-perfused using the Newcastle continuous-hypothermic pulsatile preservation system before transplantation. A control heart-beating-donor (HBD) group was taken as the next consecutive HBD renal transplant to the NHBD transplant. The outcome and quality of function of the groups of renal transplants were analyzed for short-term and long-term performance.

RESULTS

The renal transplant patients were matched for donor and recipient factors. Survival rates for allografts and patients were similar for 1 to 3 years. There was an increased incidence of delayed graft function in the NHBD renal transplants in the perioperative period. The creatinine clearance was 22.8+/-2.3 mL/minute for NHBD patients and 44.4+/-2.9 mL/minute for HBD patients at the time of discharge from hospital. This difference equalized after 3 months and the creatinine clearance for NHBD was 44.2+/-2.4 mL/minute and for HBD 49.2+/-3.4 mL/minute.

CONCLUSIONS

Our results for NHBD renal transplants confirm that such grafts suffer primary warm ischemic injury, shown by the increased incidence of acute tubular necrosis and consequent delayed graft function. This produced poor renal function at the time of hospital discharge. After 3 months, the renal function of NHBD cases improved to the level seen in HBD patients.

Kidney transplantation from donors without a heartbeat

BACKGROUND

The dramatic shortage of kidney donors has triggered interest in other sources of organs, such as donors without a heartbeat. Accumulating evidence suggests that the short-term survival of cadaveric kidneys from such donors is similar to that of cadaveric kidneys from donors with a heartbeat. However, no data from large, matched studies with long-term follow-up are available. We conducted a matched, single-center study of kidney transplants obtained from donors without a heartbeat and those from donors with a heartbeat, with a 15-year follow-up period.

METHODS

Between 1985 and 2000, 122 kidney transplantations involving donors without a heartbeat were performed at the University of Zurich, in Switzerland. Outcomes of these procedures were compared with those of 122 transplantations of kidneys from donors with a heartbeat. The recipients were matched according to age, sex, number of transplantations, and calendar period of transplantation.

RESULTS

The characteristics of the recipients did not differ significantly between the two groups. We observed a significantly higher incidence of delayed graft function among the patients who received kidneys from donors without a heartbeat (48.4 percent) than among the patients who received kidneys from donors with a heartbeat (23.8 percent) (P<0.001). However, the long-term rate of graft survival was similar in the two groups (P=0.98): at 10 years, the rate of graft survival was 78.7 percent for kidneys from donors without a heartbeat and 76.7 percent for kidneys from donors with a heartbeat.

CONCLUSIONS

Although the incidence of delayed graft function is significantly higher with kidneys from donors without a heartbeat than with kidneys from donors with a heartbeat, there is no difference in long-term outcome between the two types of graft.

Use of non-heart-beating donors in renal transplantation

The rate of renal transplantation has plateaued and is now limited by the number of donor organs available. In the past all donor kidneys came from living donors or controlled non-heart beating donors. It was not until the introduction of brainstem death criteria that cadaveric heart beating donors became the main source. Recently, there has been renewed interest in non-heart beating donors, who have already suffered cardiorespiratory arrest. Kidneys from these donors have a unique set of problems associated with increased duration of warm ischaemia. To minimise this, the kidneys are cooled in situ using an intra-aortic balloon catheter and are perfused with cold hyperosmolar citrate. Retrieval can then proceed in the normal fashion. Despite a higher level of delayed graft function, the results from non-heart beating renal transplantation are good, with long term function comparable to cadaveric organs. If used safely, they enable significant expansion of the donor pool. Techniques in the future, such as machine perfusion preservation, may further improve the results from non-heart beating programmes.