1
|
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.
Collapse
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
| |
Collapse
|
2
|
Ibrahim M, Greenhall GHB, Summers DM, Mumford L, Johnson R, Baker RJ, Forsythe J, Pettigrew GJ, Ahmad N, Callaghan CJ. Utilization and Outcomes of Single and Dual Kidney Transplants from Older Deceased Donors in the United Kingdom. Clin J Am Soc Nephrol 2020; 15:1320-1329. [PMID: 32690721 PMCID: PMC7480543 DOI: 10.2215/cjn.02060220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Kidneys from elderly deceased donors are often discarded after procurement if the expected outcomes from single kidney transplantation are considered unacceptable. An alternative is to consider them for dual kidney transplantation. We aimed to examine the utilization of kidneys from donors aged ≥60 years in the United Kingdom and compare clinical outcomes of dual versus single kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from the United Kingdom Transplant Registry from 2005 to 2017 were analyzed. We examined utilization rates of kidneys retrieved from deceased donors aged ≥60 years, and 5-year patient and death-censored graft survival of recipients of dual and single kidney transplants. Secondary outcomes included eGFR. Multivariable analyses and propensity score analysis were used to correct for differences between the groups. RESULTS During the study period, 7841 kidneys were procured from deceased donors aged ≥60 years, of which 1338 (17%) were discarded; 356 dual and 5032 single kidneys were transplanted. Donors of dual transplants were older (median, 73 versus 66 years; P<0.001) and had higher United States Kidney Donor Risk Indices (2.48 versus 1.98; P<0.001). Recipients of dual transplants were also older (64 versus 61 years; P<0.001) and had less favorable human leukocyte antigen matching (P<0.001). After adjusting for confounders, dual and single transplants had similar 5-year graft survival (hazard ratio, 0.81; 95% CI, 0.59 to 1.12). No difference in patient survival was demonstrated. Similar findings were observed in a matched cohort with a propensity score analysis method. Median 12-month eGFR was significantly higher in the dual kidney transplant group (40 versus 36 ml/min per 1.73 m2; P<0.001). CONCLUSIONS Recipients of kidneys from donors aged ≥60 years have similar 5-year graft survival and better graft function at 12 months with dual compared with single deceased donor kidney transplants.
Collapse
Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom .,National Health Service Blood and Transplant, Bristol, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - George H B Greenhall
- Department of Nephrology and Transplantation, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom.,National Health Service Blood and Transplant, Bristol, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Dominic M Summers
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Lisa Mumford
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Rachel Johnson
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Richard J Baker
- Department of Nephrology, St James's University Hospital, The Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom
| | - John Forsythe
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Gavin J Pettigrew
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Niaz Ahmad
- Department of Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom.,National Health Service Blood and Transplant, Bristol, United Kingdom
| |
Collapse
|
3
|
Lee KW, Park JB, Cha SR, Lee SH, Chung YJ, Yoo H, Kim K, Kim SJ. Dual kidney transplantation offers a safe and effective way to use kidneys from deceased donors older than 70 years. BMC Nephrol 2020; 21:3. [PMID: 31902366 PMCID: PMC6943896 DOI: 10.1186/s12882-019-1664-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 12/10/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose Dual kidney transplantation (DKT) offers a way to extend the use of kidneys from expanded criteria donors (ECDs). Here, we compared the outcomes of DKT with those of single kidney transplantation from standard criteria donors (SCDs) and ECDs. Methods In 2014, we began performing DKT using both kidneys from deceased donors greater than 70 years of age with one of two risk factors: serum creatinine (sCr) level over 3.0 mg/dl or eGFR under 30 ml/min. By 2017, we had performed 15 DKTs. We compared the outcomes of the 15 DKT recipients with those of 124 patients who received a kidney from an SCD and 80 patients who received a kidney from an ECD. Results Compared with ECDs and SCDs, DKT donors were older, had a higher diabetes burden, and a higher sCr level (p < 0.01, < 0.01, and 0.03, respectively). DKT recipients were also older and had a higher diabetes burden than recipients of kidneys from ECDs and SCDs (p < 0.01, both). DKT recipients had a lower nadir sCr and shorter duration to nadir sCr than single ECD KT recipients (p < 0.01and 0.04, respectively). Conclusions The survival rates of DKT grafts were compatible with those of single KT grafts. Therefore, DKT may be considered a suitable an option to expand the donor pool.
Collapse
Affiliation(s)
- Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - So Ra Cha
- Organ Transplantation Center, Samsung Medical Center, Seoul, South Korea
| | - Seo Hee Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Young Jae Chung
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Heejin Yoo
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, South Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| |
Collapse
|
4
|
Seth A, Sharma A, Singh S, Pandey GS, Kenwar DB. A Novel Technique of Dual Kidney Transplantation (DKT) From Adult Donors. Urology 2019; 130:201-204. [PMID: 31051165 DOI: 10.1016/j.urology.2019.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 04/12/2019] [Accepted: 04/22/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To discuss a novel technique of dual kidney transplantation that has not been described in literature. METHODS Dual Kidney Transplantation (DKT) is done for kidneys from expanded criteria donors. The 3 described techniques in literature (bilateral placement, unilateral placement with separate or patch anastomosis) have some disadvantages. This newer technique describes the use of the donor iliac artery as an interposition Y graft for joining both kidneys of the dual kidney transplant. This method can overcome some of the disadvantages associated with the previously described techniques. The ureters were implanted in urinary bladder separately in one recipient and together in another recipient. RESULTS This technique was used in 2 cases. The cold ischemia time was 275 minutes and 765 minutes, respectively while the operative time was 187 minutes and 192 minutes, respectively in the 2 patients. The first patient has creatinine of 0.83 mg/dl on last follow up at 6 months whereas the other patient has creatinine of 1.12 mg/dl at 3 months follow up. Computed tomography angiography of both the patients revealed good contrast uptake in both kidneys with no stenosis, torsion or lymphocele. CONCLUSION The newer technique avoids scarring of both iliac fossa in DKT while reducing operative time and secondary warm ischemia time by doing a single arterial anastomosis in the recipient and allows easier placement of both kidneys in the right iliac fossa.
Collapse
Affiliation(s)
- Abhinav Seth
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Sarbpreet Singh
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Gaurav Shankar Pandey
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Deepesh Benjamin Kenwar
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Research and Education, Chandigarh, India.
| |
Collapse
|
5
|
Traynor C, Saeed A, O'Ceallaigh E, Elbadri A, O'Kelly P, de Freitas DG, Dorman AM, Conlon PJ, O'Seaghdha CM. Pre-transplant histology does not improve prediction of 5-year kidney allograft outcomes above and beyond clinical parameters. Ren Fail 2018; 39:671-677. [PMID: 28832239 PMCID: PMC6446141 DOI: 10.1080/0886022x.2017.1363778] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Pre-implant kidney biopsy is used to determine suitability of marginal donor kidneys for transplantation. However, there is limited data examining the utility of pre-implant histology in predicting medium term graft outcome. This retrospective study examined kidney transplants over a 10-year period at a single center to determine if pre-implant histology can identify cases of eGFR ≤35 ml/min/1.73m2 at 5 year follow up beyond a clinical predictive logistic regression model. We also compared outcomes of dual kidney transplants with standard single kidney transplants. Of 1195 transplants, 171 received a pre-implant kidney biopsy and 15 were dual transplants. There was no significant difference in graft and patient survival rates. Median eGFR was lower in recipients of biopsied kidneys compared with standard kidney transplants (44 vs. 54 ml/min/1.73m2, p < .001). Median eGFR of dual transplant and standard kidney transplants were similar (58 vs. 54 ml/min/1.73m2, p = .64). Glomerular sclerosis (p = .05) and Karpinski Score (p = .03) were significant predictors of eGFR at 5-years in multivariate analysis but did not improve discrimination of eGFR ≤35 ml/min/1.73m2 at 5-years beyond a clinical prediction model comprising donor age, donor hypertension and terminal donor creatinine (C-statistic 0.67 vs. 0.66; p = .647). Pre-implant histology did not improve prediction of medium-term graft outcomes beyond clinical predictors alone. Allograft function of dual transplant kidneys was similar to standard transplants, suggesting that there is scope to increase utilization of kidneys considered marginal based on histology.
Collapse
Affiliation(s)
- C Traynor
- a Department of Nephrology and Transplantation , Beaumont Hospital , Dublin , Ireland
| | - A Saeed
- b Royal College of Surgeons , Dublin , Ireland
| | | | - A Elbadri
- a Department of Nephrology and Transplantation , Beaumont Hospital , Dublin , Ireland
| | - P O'Kelly
- a Department of Nephrology and Transplantation , Beaumont Hospital , Dublin , Ireland
| | - D G de Freitas
- a Department of Nephrology and Transplantation , Beaumont Hospital , Dublin , Ireland
| | - A M Dorman
- c Department of Pathology , Beaumont Hospital , Dublin , Ireland
| | - P J Conlon
- a Department of Nephrology and Transplantation , Beaumont Hospital , Dublin , Ireland
| | - C M O'Seaghdha
- a Department of Nephrology and Transplantation , Beaumont Hospital , Dublin , Ireland
| |
Collapse
|
6
|
Gaughan KP, Haroon U, Davis NF, Mohan P. Urothelial carcinoma of an allograft ureter 10 years after deceased donor kidney transplantation. BMJ Case Rep 2018; 2018:bcr-2017-223087. [PMID: 29754130 DOI: 10.1136/bcr-2017-223087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The incidence of urothelial carcinoma (UC; formerly transitional cell carcinoma) is higher among renal transplant recipients compared with the general population. Upper urinary tract UC (UUT-UC) of allograft urothelium is a rare event with approximately 40 cases reported in the literature. Herein, we describe the clinical presentation and management of UUT-UC in a transplant ureter 10 years after deceased donor kidney transplantation.
Collapse
Affiliation(s)
| | - Usman Haroon
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | - Niall F Davis
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | | |
Collapse
|
7
|
Montero N, Redondo-Pachón D, Pérez-Sáez MJ, Crespo M, Cruzado JM, Pascual J. Dual kidney transplantation as a strategy to use expanded criteria donors: a systematic review. Transpl Int 2018; 31:838-860. [DOI: 10.1111/tri.13157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/29/2018] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Nuria Montero
- Department of Nephrology; Hospital Universitari de Bellvitge; L'Hospitalet del Llobregat; Barcelona Spain
| | | | | | - Marta Crespo
- Department of Nephrology; Hospital del Mar; Barcelona Spain
| | - Josep M. Cruzado
- Department of Nephrology; Hospital Universitari de Bellvitge; L'Hospitalet del Llobregat; Barcelona Spain
| | - Julio Pascual
- Department of Nephrology; Hospital del Mar; Barcelona Spain
| |
Collapse
|
8
|
Cocco A, Shahrestani S, Cocco N, Hameed A, Yuen L, Ryan B, Hawthorne W, Lam V, Pleass H. Dual kidney transplant techniques: A systematic review. Clin Transplant 2017; 31. [PMID: 28544075 DOI: 10.1111/ctr.13016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Dual kidney transplantation (DKT) was developed to improve outcomes from transplantation of extended criteria donors (ECD). This study examined which surgical techniques have been reported for DKT and whether any technique had superior patient and graft survival. METHOD Electronic databases were searched for published studies mapping to MESH terms: "kidney or renal" AND "transplan*" AND "dual or double." Single case reports, studies of patients less than 18 years old, studies which did not describe the surgical technique, and studies that did not report patient or graft survival were excluded. RESULTS Fifteen reports of 434 DKT recipients were identified. Three techniques were described: bilateral placement; unilateral placement with separate anastomoses; and unilateral placement with patch anastomoses. Patient survival across all three techniques was over 95% at 1 year, and graft survival was also similar at over 90%. Rates of delayed graft function were between 20% and 30% across all techniques. CONCLUSION The three techniques have equivalent delayed graft function as well as patient and graft survival rates. This is an encouraging result as it means that the surgeon can choose to use the technique which is most appropriate for their own skills and for the patient.
Collapse
Affiliation(s)
| | | | - Nicholas Cocco
- Department of Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | | | | | | | | | - Henry Pleass
- Westmead Hospital, Westmead, NSW, Australia.,University of Sydney, Sydney, NSW, Australia.,Department of Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| |
Collapse
|
9
|
Abstract
The old-for-old allocation policy used for kidney transplantation (KT) has confirmed the survival benefit compared to remaining listed on dialysis. Shortage of standard donors has stimulated the development of strategies aimed to expand acceptance criteria, particularly of kidneys from elderly donors. We have systematically reviewed the literature on those different strategies. In addition to the review of outcomes of expanded criteria donor or advanced age kidneys, we assessed the value of the Kidney Donor Profile Index policy, preimplantation biopsy, dual KT, machine perfusion and special immunosuppressive protocols. Survival and functional outcomes achieved with expanded criteria donor, high Kidney Donor Profile Index or advanced age kidneys are poorer than those with standard ones. Outcomes using advanced age brain-dead or cardiac-dead donor kidneys are similar. Preimplantation biopsies and related scores have been useful to predict function, but their applicability to transplant or refuse a kidney graft has probably been overestimated. Machine perfusion techniques have decreased delayed graft function and could improve graft survival. Investing 2 kidneys in 1 recipient does not make sense when a single KT would be enough, particularly in elderly recipients. Tailored immunosuppression when transplanting an old kidney may be useful, but no formal trials are available.Old donors constitute an enormous source of useful kidneys, but their retrieval in many countries is infrequent. The assumption of limited but precious functional expectancy for an old kidney and substantial reduction of discard rates should be generalized to mitigate these limitations.
Collapse
|
10
|
. EXP CLIN TRANSPLANT 2015; 13. [DOI: 10.6002/ect.2015.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
11
|
Hanf W, Petruzzo P, Meas-Yedid V, Berthiller J, Martin X, Morelon E, Badet L, Codas R. Dual kidney transplantation from uncontrolled deceased donors after cardiac arrest: a possible option. Int J Urol 2013; 21:204-6. [PMID: 23944687 DOI: 10.1111/iju.12237] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/28/2013] [Indexed: 11/28/2022]
Abstract
Organ shortage is a major problem in organ transplantation. For this reason, transplantation teams have found it necessary to revisit their organ acceptance criteria. Uncontrolled deceased donors after cardiac arrest could increase the donor pool by 20%, but at the same time there is a greater risk of delayed graft function and primary non-function. Dual kidney transplantation is an option when single kidney transplantation cannot be carried out because of lack of organ quality. We report for the first time our four first dual kidney transplantation from uncontrolled deceased donors after cardiac arrest with a follow up longer than 1 year. We described graft outcomes until 5 years, and histology at 3 and 12 months after transplantation. All organs were machine perfused in order to assess their quality leading to a single kidney transplantation or dual kidney transplantation decision. After 1 year of follow up, all grafts were functional with a mean estimated glomerular filtration rate of 44.5 ± 3.3 mL/min/1.73 m(2), and a mean inulin clearance of 43.7 ± 13.6 mL/mn/1.73 m(2). These findings suggest that dual kidney transplantation can represent a viable option for kidneys unsuitable for single kidney transplantation without increasing the rate of surgical complications. Successful transplantation is linked to histological, biological and donor clinical criteria, as well as perfusion parameters.
Collapse
Affiliation(s)
- William Hanf
- Department of Nephrology, Transplantation and Clinical Immunology, Edouard Herriot Hospital, Lyon, France
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Friedman AL. Cautious Renal Transplantation for the Elderly Is Realistic. ACTA ACUST UNITED AC 2011; 119 Suppl 1:c14-8. [DOI: 10.1159/000328020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|