Results of Kidney Transplantation from High–Terminal Creatinine Donors and the Role of Time-Zero Biopsy

Arteriolar hyalinization at 0-hour biopsy predicts long-term graft function in deceased kidney transplantation

OBJECTIVES

Regarding the relationship between donor kidney quality and renal graft function after deceased kidney transplantation (KTx) following donation after cardiac death (DCD), the evaluation timing varies depending on the study. Evaluation of histology and changes in long-term renal graft function is limited.

METHODS

A retrospective single-center study included 71 recipients who underwent 0-hour biopsy for KTx from DCD. The recipients were divided into two groups to evaluate factors related to renal graft function (study1). The two groups were categorized as stable graft function and poor graft function with the change of estimated glomerular filtration rate (eGFR) after KTx. The recipients were then divided into four groups to assess whether the factors identified in study1 were related to the change in long-term renal graft function (study2). They were categorized as follows: Improved, Stable, Deteriorated, and Primary non-function with the change of eGFR after KTx.

RESULTS

In study1, donor age ≥ 50 years (29.5% vs. 65.2%; p = 0.09), banff arteriolar hyalinosis (ah) score (0.66 ± 0.78 vs. 1.2 ± 1.0; p = 0.018), and presence of glomerulosclerosis (43.2% vs. 76.2%; p = 0.017) were significant risk factors for poor long-term graft function. When the recipients were divided into four groups, the severity of ah correlated well with changes in long-term renal function.

CONCLUSIONS

We can predict the shift in long-term renal graft function after KTx from DCD according to the severity of ah by 0-hour biopsy.

Deceased Donor Kidney Transplantation From Donors With Acute Kidney Injury: Realities and Costs

OBJECTIVES

Transplant of kidneys from donors with acute kidney injury has shown favorable outcomes. We investigated the outcomes of kidney transplant recipients with deceased donors who developed acute kidney injury before organ procurement.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of recipients from January 2016 to December 2021 in a single center. Outcomes in recipients of kidney grafts from donors with and without acute kidney injury were compared.

RESULTS

The mean follow-up time was 40 months. Our study included 129 (34%) kidneys transplanted from donors with acute kidney injury and 251 (66%) kidneys from donors without acute kidney injury. Delayed graft function rate in recipients was 33% in the acute kidney injury group and 25.5% in the group without acute kidney injury (P = .099). Readmission rate at 30 days was significantly higher among recipients of kidneys with acute kidney injury compared with recipients of kidneys without acute kidney injury (45% vs 33.5%; P = .02). The mean overall costs of transplant in the acute kidney injury group were comparable to the group without acute kidney injury ($253 865 vs $253 611; P = .97). The acute rejection rate was comparable between the 2 groups (4% in both groups; P = .96). Delayed graft function rate was increased with increased stage of acute kidney injury (18% stage 1, 45% stage 2, 36% stage 3; P = .03). However, the overall length of hospital stay and costs were comparable among recipients of different stages of acute kidney injury.

CONCLUSIONS

Our study showed that kidney transplants from donors with acute kidney injury have early and late outcomes comparable to kidney transplants from donors without acute kidney injury. Allografts from donors with acute kidney injury can be used safely and can expand the donor pool in kidney transplant without increasing perioperative resource utilization.

Outcomes and implications of a single brain death examination policy on organ donation outcomes at a high-volume trauma center

BACKGROUND

Despite current neurological guidelines that a single brain death examination (SBDE) is sufficient to determine brain death, a vast majority of hospitals still use a two brain death examination (TBDE) policy based on historical practice. The purpose of this study was to analyze the outcomes and implications of an SBDE policy compared with a TBDE policy with respect to organ donation outcomes.

METHODS

We retrospectively reviewed all adult patients declared dead by neurological criteria between 2010 and 2018 at a high-volume trauma center. The study population was divided into SBDE and TBDE cohorts. Primary outcomes included time to organ donation, terminal donor creatinine and bilirubin, and number of procured and transplanted organs.

RESULTS

A total of 327 patients comprised the study population: 66.7% SBDE (n = 218 of 327 patients) and 33.3% TBDE (n = 109 of 327 patients). The SBDE group had a shorter median time from examination to procurement (38 vs. 44 hours, p = 0.02) as well as lower terminal donor creatinine (1.1 vs. 1.35 mg/dL, p = 0.004) and bilirubin (0.8 vs. 1.1 mg/dL, p = 0.04). Furthermore, the SBDE group had a significantly greater proportion of kidneys (90.6% vs. 81.6%, p = 0.02), lungs (11.8% vs. 4.6%, p = 0.02), and total organs (58.2% vs. 46.6%; p = 0.0001) procured with intent to transplant and a greater proportion of total organs transplanted (53.1% vs. 42.4%, p = 0.0004). Multivariable regression analysis confirmed that SBDE was independently associated with a shorter time to procurement, lower terminal creatinine, and increased number of procured organs.

CONCLUSION

These data highlight the potential benefit of an SBDE policy with regards to organ donation outcomes at a high-volume trauma center and should facilitate future randomized prospective studies to more rigorously test this hypothesis.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level IV.

Predictors of Acute Kidney Injury in Deceased Kidney Donors After Brain Death

BACKGROUND

Donors with acute kidney injury (AKI) are generally accepted as a valuable source of kidneys for transplant. The aim of this study was to assess the risk of developing AKI based on deceased kidney donor parameters.

MATERIALS AND METHODS

The data of 162 kidneys procured from deceased donors after brain death were collected. These included clinical characteristics of donors and histologic assessment in organ biopsy specimens. The donors' kidney terminal function was classified according to the Acute Kidney Injury Network criteria. All biopsies were performed with the use of a 16G automatic needle, and the 20-mm tissue specimen was available in all cases. Biopsy specimens were secured and prepared in a routine way with hematoxylin and eosin. The presence of chronic changes was analyzed according to the Banff 2009 classification by 1 experienced nephropathologist. The logistic regression model was used to assess the risk of AKI regarding donor characteristics and histologic findings.

RESULTS

There were 50 kidneys (30.9%) with AKI identified. The risk of AKI increased with donor age (P = .002; odds ratio [OR], 1.02; 95% CI, 1.01-1.03), body mass index (P = .003; OR, 1.05; 95% CI, 1.01-1.09), and male sex (P = .001; OR, 1.79; 95% CI, 1.31-2.27). Regarding the histologic findings, the interstitial fibrosis presence was a risk factor of AKI (P = .004; OR, 1.04; 95% CI, 1.01-1.06).

CONCLUSIONS

Older donor age, male sex, higher body mass index, and presence of interstitial fibrosis in kidney graft biopsy specimen are risk factors of AKI.

Donor Characteristics of Pancreas Transplantation in Australia and New Zealand: A Cohort Study 1984-2014

Background

The aim of this study was to audit the characteristics of pancreas donors over time in Australia and New Zealand. Pancreas transplantation was introduced in Australian and New Zealand in 1984.

Methods

We analyzed data from the Australia and New Zealand Islet and Pancreas Transplant Registry, 1984 to 2014. We investigated the variation of donor characteristics of sex, age, body mass index, smoking status, blood group, multiple organ donation, cytomegalovirus status, terminal creatinine, hypertension, and cause of death for pancreas transplantation over time. We used χ² test (Fisher test when necessary) or analysis of variance to test difference for categorical or continuous characteristics, respectively.

Results

There were 628 pancreas donors from 1984 to 2014. Donor body mass index (from 21.9 to 24.0, P < 0.001) and age (from 23.9 to 28.5, P = 0.02) have both increased while terminal creatinine has decreased (86.3 to 73.3, P = 0.01) from 1995 to 2014. In the meantime, the proportions of donors with hypertension (from 19% to 1%, P < 0.001) and who were smokers (from 54% to 15%, P < 0.001) have decreased. Profile of cause of donor death has also changed over time (P = 0.06) with increase in cerebral hypoxia/ischemia (from 3% to 17%) and reductions in intracranial hemorrhage (27% to 13%).

Conclusions

Many donor characteristics have changed over time. The most significant changes appear to reflect changes in the general population, rather than changes in donor selection.

Kidney transplantation, bioengineering and regeneration: an originally immunology-based discipline destined to transition towards ad hoc organ manufacturing and repair

Kidney transplantation (KT), as a modality of renal replacement therapy (RRT), has been shown to be both economically and functionally superior to dialysis for the treatment of end-stage renal disease (ESRD). Progress in KT is limited by two major barriers: a) a chronic and burgeoning shortage of transplantable organs and b) the need for chronic immunosuppression following transplantation. Although ground-breaking advances in transplant immunology have improved patient survival and graft durability, a new pathway of innovation is needed in order to overcome current obstacles. Regenerative medicine (RM) holds the potential to shift the paradigm in RRT, through organ bioengineering. Manufactured organs represent a potentially inexhaustible source of transplantable grafts that would bypass the need for immunosuppressive drugs by using autologous cells to repopulate extracellular matrix (ECM) scaffolds. This overview discusses the current status of renal transplantation while reviewing the most promising innovations in RM therapy as applied to RRT.

Expanding the pool of kidney donors: use of kidneys with acute renal dysfunction

Given the shortage of organs transplantation, some strategies have been adopted by the transplant community to increase the supply of organs. One strategy is the use of expanded criteria for donors, that is, donors aged >60 years or 50 and 59 years, and meeting two or more of the following criteria: history of hypertension, terminal serum creatinine >1.5mg/dL, and stroke as the donor´s cause of death. In this review, emphasis was placed on the use of donors with acute renal failure, a condition considered by many as a contraindication for organ acceptance and therefore one of the main causes for kidney discard. Since these are well-selected donors and with no chronic diseases, such as hypertension, renal disease, or diabetes, many studies showed that the use of donors with acute renal failure should be encouraged, because, in general, acute renal dysfunction is reversible. Although most studies demonstrated these grafts have more delayed function, the results of graft and patient survival after transplant are very similar to those with the use of standard donors. Clinical and morphological findings of donors, the use of machine perfusion, and analysis of its parameters, especially intrarenal resistance, are important tools to support decision-making when considering the supply of organs with renal dysfunction.

The Donor Kidney Biopsy and Its Implications in Predicting Graft Outcomes: A Systematic Review

Despite a growing organ shortage in the United States, many deceased donor kidneys removed for transplantation are discarded. Kidney biopsy findings often play a role in these discards, although it is not clear whether biopsies reliably inform acceptance decisions. Therefore, we carried out a systematic review of the medical literature on the utility of both procurement and implantation biopsies for predicting posttransplant outcomes. Between January 1, 1994 and July 1, 2014, 47 studies were published in the English language literature that examined the association between pretransplant donor biopsy findings from 50 or more donors (with more than half being from deceased donors) and either posttransplant graft failure, delayed graft function, or graft function. In general, study quality was poor. All were retrospective or did not indicate if they were prospective. Results were heterogeneous, with authors as often as not concluding that biopsy results did not predict posttransplant outcomes. The percent glomerular sclerosis was most often examined, and failed to predict graft failure in 7 of 14 studies. Of 15 semiquantitative scoring systems proposed, none consistently predicted posttransplant outcomes across studies. Routine use of biopsies to help determine whether or not to transplant a kidney should be reexamined.

The role of procurement biopsies in acceptance decisions for kidneys retrieved for transplant

BACKGROUND AND OBJECTIVES

There is a shortage of kidneys for transplant, and many patients on the deceased donor kidney transplant waiting list would likely benefit from kidneys that are currently being discarded. In the United States, the most common reason given for discarding kidneys retrieved for transplant is procurement biopsy results. This study aimed to compare biopsy results from discarded kidneys with discard attributed to biopsy findings, with biopsy results from comparable kidneys that were successfully transplanted.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this retrospective, observational, case-control study, biopsy reports were examined from 83 kidneys discarded in 2010 due to biopsy findings (cases), 83 contralateral transplanted kidneys from the same donor (contralateral controls), and 83 deceased donors randomly matched to cases by donor risk profile (randomly matched controls). A second procurement biopsy was obtained in 64 of 332 kidneys (19.3%).

RESULTS

The quality of biopsy reports was low, with amounts of tubular atrophy, interstitial inflammation, arteriolar hyalinosis, and acute tubular necrosis often not indicated; 69% were wedge biopsies and 94% used frozen tissue. The correlation between first and second procurement biopsies was poor; only 25% of the variability (R(2)) in glomerulosclerosis was explained by biopsies being from the same kidney. The percentages of glomerulosclerosis overlapped substantially between cases, contralateral controls, and randomly matched controls: 17.1%±15.3%, 9.0%±6.6%, and 5.0%±5.9%, respectively. Of all biopsy findings, only glomerulosclerosis>20% was independently correlated with discard (cases versus contralateral controls; odds ratio, 15.09; 95% confidence interval, 2.47 to 92.41; P=0.003), suggesting that only this biopsy result was used in acceptance decisions. One-year graft survival was 79.5% and 90.7% in contralateral and randomly matched controls, respectively, versus 91.6% among all deceased donor transplants in the Scientific Registry of Transplant Recipients.

CONCLUSIONS

Routine use of biopsies could lead to unnecessary kidney discards.

Evolving experience using kidneys from deceased donors with terminal acute kidney injury

BACKGROUND

Kidney transplantation from deceased donors with terminal acute kidney injury (AKI) is not widely accepted.

STUDY DESIGN

Acute kidney injury donor kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level and a terminal SCr level >2.0 mg/dL before organ recovery.

RESULTS

Over 5.5 years, we transplanted 84 AKI donor kidneys, including 64 kidneys from standard criteria donors (SCD), 11 from expanded criteria donors (ECD), and 9 from donation after cardiac death (DCD) donors. Mean donor age was 36 years (range 15 to 68 years); mean admission and terminal donor SCr levels were 1.25 mg/dL and 3.2 mg/dL, respectively (mean terminal estimated glomerular filtration rate 25.5 mL/minute). With a mean follow-up of 35 months (range 6 to 70 months), actual patient and graft survival rates are 98% and 89%, respectively, which are numerically, but not statistically, higher than concurrent kidney transplants from brain-dead (non-AKI) SCDs at our center. Delayed graft function (DGF) occurred in 34 patients (40%). Mean 1-, 12-, and 24-month SCr levels were 1.8, 1.6, and 1.7 mg/dL, respectively. Delayed graft function was associated with lower 3-year graft survival for non-AKI SCD transplants (68% vs 90%, with and without DGF), but there was no impact of DGF on graft survival for AKI donor kidneys (89% vs 91%).

CONCLUSIONS

Although AKI donor kidneys more commonly have DGF, the higher rate of DGF does not worsen graft outcomes. Kidneys from deceased donors with terminal AKI transplanted into appropriately selected patients have excellent medium-term outcomes and represent a method to safely expand the donor pool.

Monitoring and managing graft health in the kidney transplant recipient

Ongoing monitoring of kidney transplants is a widely accepted and practiced part of posttransplantation management. One reason to monitor is to evaluate whether the transplant is stable. The transplant community evaluates stability by checking kidney function. Despite problems with sensitivity and specificity, obtaining serial serum creatinine levels is the most common approach to assessing kidney function. Some programs supplement serial serum creatinine levels with surveillance kidney biopsies. Although not uniformly accepted as beneficial, surveillance biopsies are useful in select subsets of patients such as highly sensitized recipients. Recent biopsy studies shed light on which histopathology findings portend poor prognoses. The Long-Term Deterioration of Kidney Allograft Function Study (DeKAF) and similar studies that will prospectively evaluate therapeutic interventions should help the transplant community better define how to monitor and manage the kidney transplant optimally. In the meantime, Kidney Diseases: Improving Global Outcomes (KDIGO) provides an evidence-based approach toward monitoring and managing the kidney transplant.