Donors With Malignancies-Risk or Chance?

Non-standard criteria donors in pediatric kidney transplantation

KT remains the treatment of choice for ESRD in children. However, the demand for kidney transplants continues to outstrip supply, even in the pediatric scenario. We reviewed the applicability of nonSCDs for pediatric KT. There is a lack of studies analyzing this modality among pediatric donors and recipients, where most conclusions are based on predictions from adult data. Nevertheless, marginal donors might be a reasonable option in selected cases. For example, the use of older LDs is an acceptable option, with outcomes comparable to SCDs. Organs donated after cardiac death represent another possibility, albeit with logistic, ethical, and legal limitations in some countries. AKI donors also constitute an option in special situations, although there are no pediatric data on these transplants. Likewise, there are no data on the use of expanded criteria donors in pediatric patients, but this appears not to be a good option, considering the compromised long-term survival.

[Deceased donation in renal transplantation]

OBJECTIVES

To review epidemiologic data's and medical results of deceased donation in renal transplantation.

MATERIAL AND METHODS

Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "brain death; cardiac arrest; deceased donation; organ procurement; transplantation". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 2498 articles, 8 official reports and 17 newspaper articles were identified; after careful selection 157 publications were eligible for our review.

RESULTS

Deceased donation may involve either brain death or non-heartbeating donors (NHBD). Organ shortage led to the procurement of organs from expanded-criteria donors, with an increased age at donation and extended vascular disease, leading to inferior results after transplantation and underlining the need for careful donor management during brain death or cardiac arrest. Evolution of French legislation covering bioethics allowed procurement from Maastricht categories II and recently III non-heartbeating donors.

CONCLUSION

The increase of organ shortage emphasizes the need for a rigorous surgical technique during procurement to avoid loss of transplants. A history or current neoplasm in deceased-donors, requires attention to increase the pool of organs without putting the recipients at risk for cancer transmission. French NHBD program, especially from Maastricht category III, may stand for a potential source of valuable organs.

Identification of patients at risk for renal impairment after living donor kidney transplantation

PURPOSE

Outcome after living donor kidney transplantation is highly relevant, since recipient and donor were exposed to notable harm. Reliable identification of risk factors is necessary.

METHODS

Three hundred sixty-six living donor kidney transplants were included in this observational retrospective study. Relevant risk factors for renal impairment 1 year after transplantation and delayed graft function were identified with univariable and multivariable binary logistic regression and ordinal regression analysis.

RESULTS

Eighty-four patients (26.6 %) suffered from renal impairment KDIGO stage ≥4 1 year post-transplant; median estimated glomerular filtration rate was 35.3 ml/min. In multivariable ordinal regression, male recipient sex (p < 0.001), recipient body mass index (p = 0.006), donor age (p = 0.002) and high percentages of panel reactive antibodies (p = 0.021) were revealed as independent risk factors for higher KDIGO stages. After adjustment for post-transplant data, recipient male sex (p < 0.001), donor age (p = 0.026) and decreased early renal function at the first post-transplant outpatient visit (p < 0.001) were identified as independent risk factors. Delayed graft function was independently associated with long stay on the waiting list (p = 0.011), high donor body mass index (p = 0.043), prolonged warm ischemic time (p = 0.016) and the presence of preformed donor-specific antibodies (p = 0.043).

CONCLUSIONS

Broadening the donor pool with non-blood related donors seems to be legitimate, although with respect to careful medical selection, since donor age in combination with male recipient sex were shown to be risk factors for decreased graft function. Warm ischemic time and waiting time need to be kept as short as possible to avoid delayed graft function. Transplantation across HLA and ABO borders did not affect outcome significantly.

Transplantation of Restored Kidneys From Unrelated Donors After Resection of Renal Cell Carcinoma: Results From 10 Patients

PURPOSE

To relieve the chronic shortage of donor kidneys, we conducted a prospective kidney transplantation trial using kidneys removed from 10 unrelated patients (51 to 79 years of age) who had undergone nephrectomy for small renal cell carcinoma (1.5 to 3.9 cm) of low-to-moderate complexity based on RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior location relative to polar lines) nephrometry (objective description helpful for operative indication and planning).

METHODS

Donors were selected from among 15 patients who opted to undergo nephrectomy for small renal cell carcinoma. A total of 76 dialysis patients 34 to 85 years of age who agreed to undergo restored kidney transplantation were recruited as transplant candidates.

RESULTS

In stage 1 (5 cases), high-risk patients were selected without human leukocyte antigen testing, and accelerated acute rejection occurred in 4 of 5 recipients. This trial was subsequently extended with human leukocyte antigen testing, and an additional 5 patients were enrolled in stage 2. Eight recipients, including 4 recipients with a history of renal transplantation, experienced rejection; 1 patient resumed dialysis 35 months after transplantation. The most recent serum creatinine levels ranged from 1.10 to 3.19 mg/dL in the 9 recipients with functioning grafts and from 0.84 to 4.68 mg/dL in the 10 donors. No tumor recurrence was noted at 32 to 58 months after surgery in either the recipients or the donors.

CONCLUSIONS

Restored kidney transplantation using kidneys with a small renal tumor seems suitable for carefully selected high-risk recipients and, in particular, elderly kidneys can also function well. Avoiding cancer transmission, fair recipient selection, close follow-up, and a well-organized tracking system warrant further study.