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Sandal S, Paraskevas S, Cantarovich M, Baran D, Chaudhury P, Tchervenkov JI, Sapir-Pichhadze R. Renal resistance thresholds during hypothermic machine perfusion and transplantation outcomes - a retrospective cohort study. Transpl Int 2018; 31:658-669. [PMID: 29493843 DOI: 10.1111/tri.13146] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/06/2017] [Accepted: 02/21/2018] [Indexed: 12/31/2022]
Abstract
Renal resistance (RR), of allografts undergoing hypothermic machine perfusion (HMP), is considered a measure of organ quality. We conducted a retrospective cohort study of adult deceased donor kidney transplant (KT) recipients whose grafts underwent HMP. Our aim was to evaluate whether RR is predictive of death-censored graft failure (DCGF). Of 274 KT eligible for analysis, 59% were from expanded criteria donor. RR was modeled as a categorical variable, using a previously identified terminal threshold of 0.4, and 0.2 mmHg/ml/min (median in our cohort). Hazard ratios (HR) of DCGF were 3.23 [95% confidence interval (CI): 1.12-9.34, P = 0.03] and 2.67 [95% CI: 1.14-6.31, P = 0.02] in univariable models, and 2.67 [95% CI: 0.91-7.86, P = 0.07] and 2.42 [95% CI: 1.02-5.72, P = 0.04] in multivariable models, when RR threshold was 0.4 and 0.2, respectively. Increasing risk of DCGF was observed when RR over the course of HMP was modeled using mixed linear regression models: HR of 1.31 [95% CI: 1.07-1.59, P < 0.01] and 1.25 [95% CI: 1.00-1.55, P = 0.05], in univariable and multivariable models, respectively. This suggests that RR during HMP is a predictor of long-term KT outcomes. Prospective studies are needed to assess the survival benefit of patients receiving KT with higher RR in comparison with staying wait-listed.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Steven Paraskevas
- Division of General Surgery and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Dana Baran
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Prosanto Chaudhury
- Division of General Surgery and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Jean I Tchervenkov
- Division of General Surgery and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology and Multi-Organ Transplant Program, McGill University Health Centre, Montreal, QC, Canada.,Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), McGill University Health Centre, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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2
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van Heurn LWE, Talbot D, Nicholson ML, Akhtar MZ, Sanchez-Fructuoso AI, Weekers L, Barrou B. Recommendations for donation after circulatory death kidney transplantation in Europe. Transpl Int 2015; 29:780-9. [PMID: 26340168 DOI: 10.1111/tri.12682] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/19/2015] [Accepted: 08/26/2015] [Indexed: 12/29/2022]
Abstract
Donation after circulatory death (DCD) donors provides an invaluable source for kidneys for transplantation. Over the last decade, we have observed 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 sixth 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.
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Affiliation(s)
| | - David Talbot
- Department of Liver/Renal Transplant, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Michael L Nicholson
- Department of Surgery, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | | | - Laurent Weekers
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Benoit Barrou
- Department of Urology - Transplantation, GHzu Pitié Salpêtriere, Paris, France
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3
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Gallinat A, Moers C, Treckmann J, Smits JM, Leuvenink HGD, Lefering R, van Heurn E, Kirste GR, Squifflet JP, Rahmel A, Pirenne J, Ploeg RJ, Paul A. Machine perfusion versus cold storage for the preservation of kidneys from donors >=65 years allocated in the Eurotransplant Senior Programme. Nephrol Dial Transplant 2012; 27:4458-63. [DOI: 10.1093/ndt/gfs321] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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4
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Henry SD, Guarrera JV. Protective effects of hypothermic ex vivo perfusion on ischemia/reperfusion injury and transplant outcomes. Transplant Rev (Orlando) 2011; 26:163-75. [PMID: 22074785 DOI: 10.1016/j.trre.2011.09.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 07/08/2011] [Accepted: 09/02/2011] [Indexed: 12/14/2022]
Abstract
Hypothermic machine preservation (HMP) has been used in renal transplantation since the late 1960s with recent robust prospective, multicenter data showing lower rates of delayed graft function and improved graft survival. Although now clearly beneficial for renal transplantation, extrarenal machine perfusion has remained predominantly in preclinical investigations. Pancreatic HMP has drawn little clinical interest because HMP has been suggested to cause graft edema and congestion, which is associated with early venous thrombosis and graft failure. Early investigation showed no benefit of HMP in whole-organ pancreas transplant. One report did show that HMP increases islet cell yield after isolation. Preclinical work in liver HMP has been promising. Short- and long-term HMP has been shown to improve graft viability and reduce preservation injury, even in animal models of steatotic and donation after cardiac death. The first clinical study of liver HMP using a centrifugal dual perfusion technique showed excellent results with lower hepatocellular injury markers and no adverse perfusion-related outcomes. In addition, a dramatic attenuation of proinflammatory cytokine expression was observed. Further studies of liver HMP are planned with focus on developing a reproducible and standard protocol that will allow the widespread availability of this technology. Future research and clinical trials of novel organ preservation techniques, solutions, and interventions are likely to bring about developments that will allow further reduction of preservation-related ischemia/reperfusion injury and improved outcomes and allow safer utilization of the precious and limited resource of donor organs.
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Affiliation(s)
- Scot D Henry
- Division of Abdominal Organ Transplantation and Molecular Therapies and Organ Preservation Research Laboratory, Department of Surgery Columbia University Medical Center, New York, NY 10032-3784, USA
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5
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Treckmann J, Moers C, Smits JM, Gallinat A, Maathuis MHJ, van Kasterop-Kutz M, Jochmans I, Homan van der Heide JJ, Squifflet JP, van Heurn E, Kirste GR, Rahmel A, Leuvenink HGD, Pirenne J, Ploeg RJ, Paul A. Machine perfusion versus cold storage for preservation of kidneys from expanded criteria donors after brain death. Transpl Int 2011; 24:548-54. [PMID: 21332580 DOI: 10.1111/j.1432-2277.2011.01232.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to analyze the possible effects of machine perfusion (MP) versus cold storage (CS) on delayed graft function (DGF) and early graft survival in expanded criteria donor kidneys (ECD). As part of the previously reported international randomized controlled trial 91 consecutive heart-beating deceased ECDs--defined according to the United Network of Organ Sharing definition--were included in the study. From each donor one kidney was randomized to MP and the contralateral kidney to CS. All recipients were followed for 1 year. The primary endpoint was DGF. Secondary endpoints included primary nonfunction and graft survival. DGF occurred in 27 patients in the CS group (29.7%) and in 20 patients in the MP group (22%). Using the logistic regression model MP significantly reduced the risk of DGF compared with CS (OR 0.460, P=0.047). The incidence of nonfunction in the CS group (12%) was four times higher than in the MP group (3%) (P=0.04). One-year graft survival was significantly higher in machine perfused kidneys compared with cold stored kidneys (92.3% vs. 80.2%, P=0.02). In the present study, MP preservation clearly reduced the risk of DGF and improved 1-year graft survival and function in ECD kidneys. (Current Controlled Trials number: ISRCTN83876362).
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Affiliation(s)
- Jürgen Treckmann
- Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstrasse 55, Germany
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6
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Effect of a novel solution for organ preservation on equine large colon in an isolated pulsatile perfusion system. Equine Vet J 2010; 40:306-12. [DOI: 10.2746/042516408x295455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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7
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Hernández D, Rufino M, González-Posada JM, Estupiñán S, Pérez G, Marrero-Miranda D, Torres A, Pascual J. Prognostic indexes in kidney procurement and allocation. Transplant Rev (Orlando) 2007. [DOI: 10.1016/j.trre.2007.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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8
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Nyberg SL, Baskin-Bey ES, Kremers W, Prieto M, Henry ML, Stegall MD. Improving the prediction of donor kidney quality: deceased donor score and resistive indices. Transplantation 2006; 80:925-9. [PMID: 16249740 DOI: 10.1097/01.tp.0000173798.04043.af] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The deceased donor score (DDS), expanded criteria donor (ECD) definition, and resistive index (RI) were developed for pretransplant evaluation of donors. DDS and ECD are determined by a calculation of risk from donor variables, while RI is determined from flow characteristics of kidneys during machine preservation (MP). This study was designed to compare DDS, ECD status, and RI as predictors of outcome after deceased donor transplantation. We were also interested to see if DDS or ECD could identify kidneys most likely to benefit from MP. METHODS We retrospectively reviewed 48,952 deceased donor renal transplants reported to UNOS from 1997-2002. DDS (0-39 pts.), ECD status (+ or -), and preservation technique (MP vs. cold storage [CS]) were determined in all cases. RI during MP was studied in a single-center cohort of 425 transplants. RESULTS DDS was superior to ECD status and RI in its correlation with early and late renal function after transplantation. DDS identified a subgroup of ECD- kidneys, those with DDS > or = 20 pts, that functioned significantly below expectation and similar to ECD+ kidneys. Benefits of MP, which include improved early graft function and a trend towards longer graft survival, were greatest in the group of kidneys with DDS > or = 20 pts. CONCLUSIONS DDS was the best predictor of outcome after deceased donor renal transplantation and may be useful in identifying kidneys most likely to benefit from MP.
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Affiliation(s)
- Scott L Nyberg
- Division of Transplantation Surgery, Wilhelm Von Liebig Transplant Center, Mayo Clinic, Rochester, MN 55905, USA.
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9
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Stratta RJ, Rohr MS, Sundberg AK, Armstrong G, Hairston G, Hartmann E, Farney AC, Roskopf J, Iskandar SS, Adams PL. Increased kidney transplantation utilizing expanded criteria deceased organ donors with results comparable to standard criteria donor transplant. Ann Surg 2004; 239:688-95; discussion 695-7. [PMID: 15082973 PMCID: PMC1356277 DOI: 10.1097/01.sla.0000124296.46712.67] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare outcomes in recipients of expanded criteria donor (ECD) versus standard criteria donor (SCD) kidneys at a single center using a standardized approach with similar immunosuppression. SUMMARY BACKGROUND DATA Expanded criteria deceased organ donors (ECD) are a source of kidneys that permit more patients to benefit from transplantation. ECD is defined as all deceased donors older than 60 years and donors older than 50 years with 2 of the following: hypertension, stroke as the cause of death, or pre-retrieval serum creatinine (SCr) greater than 1.5 mg/dl. METHODS We retrospectively studied 90 recipients of adult deceased donor kidneys transplanted from October 1, 2001 to February 17, 2003, including 37 (41%) from ECDs and 53 (59%) from SCDs. ECD kidneys were used by matching estimated renal functional mass to recipient need, including the use of dual kidney transplants (n = 7). ECD kidney recipients were further selected on the basis of older age, HLA-matching, low allosensitization, and low body mass index. All patients received a similar immunosuppressive regimen. Minimum follow up was 9 months. RESULTS There were significant differences in donor and recipient characteristics between ECD and SCD transplants. Patient (99%) and kidney graft survival (88%) rates and morbidity were similar between the 2 groups, with a mean follow-up of 16 months. Initial graft function and the mean 1-week and 1-, 3-, 6-, 12-, and 18-month SCr levels were similar among groups. CONCLUSIONS The use of ECD kidneys at our center effectively doubled our transplant volume within 1 year. A systematic approach to ECD kidneys based on nephron mass matching and nephron sparing measures may provide optimal utilization with short-term outcomes and renal function comparable to SCD kidneys.
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Affiliation(s)
- Robert J Stratta
- Department of General Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Guarrera JV, Polyak M, O'Mar Arrington B, Kapur S, Stubenbord WT, Kinkhabwala M. PULSATILE MACHINE PERFUSION WITH VASOSOL SOLUTION IMPROVES EARLY GRAFT FUNCTION AFTER CADAVERIC RENAL TRANSPLANTATION. Transplantation 2004; 77:1264-8. [PMID: 15114096 DOI: 10.1097/01.tp.0000122221.28546.6d] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cold storage is the most common method of preservation in renal transplantation, but pulsatile machine perfusion (MP) is increasingly used for purposes of ex vivo assessment and resuscitation of high risk allografts. Vasosol (VSL) MP solution (MPS) (Pike Laboratories Inc, Eagle, PA) is a novel perfusate with enhanced vasodilatory and antioxidant capacity. We report our experience with VSL in machine preservation of renal allografts. METHODS Locally procured cadaver kidney pairs undergoing MP were randomized to VSL or control solution (Belzer MPS; Trans-Med, Elk River, MN). En bloc perfusion was performed according to standard MP procedures. Transplantation was performed at 1 of 12 local transplant centers. Donor and recipient data were collected prospectively. RESULTS Data from 162 transplanted kidneys were analyzed. A total of 82 renal grafts were perfused with VSL, and 80 were perfused with control solution. No organs were lost secondary to the technique of MP. There was no difference in donor or recipient age between groups. Kidneys perfused with VSL exhibited significantly higher rates of immediate function and significantly less delayed graft function (12.2% vs. 21.2%). Discharge creatinine and length of stay were also significantly improved in the VSL group. One-year graft and patient survivals were equivalent (95%) in both groups. CONCLUSIONS VSL improved early graft function and shortened the length of stay compared with Belzer MPS. Further improvement in preservation solutions in conjunction with pulsatile perfusion shows promise in improving early outcomes after renal transplantation, especially for extended criteria donor kidneys.
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Affiliation(s)
- James V Guarrera
- New York Presbyterian Hospital Organ Preservation Unit, New York, New York 10021, USA.
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11
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Sonnenday CJ, Cooper M, Kraus E, Gage F, Handley C, Montgomery RA. The hazards of basing acceptance of cadaveric renal allografts on pulsatile perfusion parameters alone. Transplantation 2003; 75:2029-33. [PMID: 12829906 DOI: 10.1097/01.tp.0000065296.35395.fd] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulsatile perfusion (PP) is used by some centers to provide information that may aid in the selection of cadaveric renal allografts for transplantation. However, basing organ acceptance on PP parameters alone may lead to the discarding of kidneys from otherwise suitable donors. In this case series, we report the reevaluation and transplantation of kidneys refused by other centers after evaluation with PP. METHODS Retrospective review of 14 cadaveric kidneys imported for repeat PP at our center after initially poor PP parameters from an outside organ procurement organization resulted in refusal by multiple centers. RESULTS Median age of donors was 46 (range 21-64), and mean terminal serum creatinine was 1.3+/-0.6 mg/dL. Despite favorable donor characteristics, each kidney was refused by an average of 9.3 centers. Poor PP parameters and concerns about donor quality were the reasons for refusal in the majority of cases. Pulsatile-perfusion parameters at the outside center were poor: mean flow of 103 mL/min/100 g and mean resistance of 0.321 mm Hg/(mL/min/100 g). Repeat PP parameters at our center after importation were markedly improved (flow=167 mL/min/100 g and resistance=0.195 mm Hg/[mL/min/100 g]). Eleven of 14 kidneys were transplanted and currently have acceptable graft function (mean serum creatinine=1.6 mg/dL at a median follow-up of 12 months). CONCLUSIONS This series describes the successful transplantation of 11 kidneys from acceptable donors that were initially discarded by multiple centers after poor PP parameters were obtained. The good allograft function in these organs emphasizes the importance of considering all donor factors when making allocation decisions.
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Affiliation(s)
- Christopher J Sonnenday
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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12
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Modlin CS, Goldfarb DA, Novick AC. The use of expanded criteria cadaver and live donor kidneys for transplantation. Urol Clin North Am 2001; 28:687-707. [PMID: 11791487 DOI: 10.1016/s0094-0143(01)80026-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The use of expanded criteria donors (non-traditional donors) can help lessen the current shortage of kidneys available for transplantation. The use of older donors has accounted for a large measure of the increase in the organ donation rate; however, the most significant factors found to impact on transplant success negatively traditionally have been shown to be extremes of donor age and last-hour urine output. Less significant variables affecting success rates are average systolic blood pressure, terminal serum creatinine, and days of hospitalization. With the appropriate selection of organs from expanded donors, acceptable outcomes can be obtained. When living donors are selected properly, kidneys with anatomic variants without pathologic significance can be used safely. Kidneys with a heightened potential for the development of progressive disease should not be transplanted. Efforts to decrease the cold ischemia time by increasing the use of kidneys from expanded criteria donors may improve the outcome of transplantation further. Advances in surgical techniques, preservation solutions, and methods for predicting eventual long-term renal function in kidneys from expanded donors will be critical in allowing precise selection criteria for kidneys for transplantation, resulting in the optimum use of a scarce and precious resource. Until options such as xenotransplantation become clinically feasible, the challenge will be to identify which donor organs previously considered suboptimal can be used safely to expand the organ donor pool.
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Affiliation(s)
- C S Modlin
- Section of Renal Transplantation, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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14
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15
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Balupuri S, Mantle D, Mohamed M, Shenton B, Gok M, Soomro N, Manas DM, Kirby J, Talbot D. Machine perfusion and viability assessment of non-heart-beating donor kidneys-a single-centre result. Transplant Proc 2001; 33:1119-20. [PMID: 11267218 DOI: 10.1016/s0041-1345(00)02455-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S Balupuri
- Liver and Renal Transplant Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne, United Kingdom.
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Herrera B, Eisenberg G, Desco MM, Holberndt O, Rábano A, Castilla M, García-Barreno P, Del Cañizo JF. Perfusate lactate dehydrogenase level and intrarenal resistance could not be adequate markers of perfusion quality during isolated kidney perfusion. Artif Organs 2000; 24:899-902. [PMID: 11119079 DOI: 10.1046/j.1525-1594.2000.06554.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The main goal of this work was to study the influence of perfusion pressure and flow waveform during kidney perfusion, and the relationship between renal vascular resistance (RVR) and lactate dehydrogenase (LDH) concentration in the perfusate. Simultaneous constant pressure kidney perfusions were performed with either pulsatile or continuous flow at either 30 or 80 mm Hg of constant perfusion pressure. Mean flow, pressure, and RVR were displayed online during perfusion. Perfusate samples for LDH, creatine phosphatase kinase (CPK), and alkaline phosphatase (AP) determinations were taken. At the end of the perfusion, 2 ml of Evans blue was injected into the circuit to obtain images of perfusate distribution, and the kidneys were weighed. Also, hematoxylin/eosine studies were performed, showing more Bowman's space and tubular dilation in kidneys perfused with high pressure. We did not find differences in RVR between kidneys perfused at 30 and 80 mm Hg; nevertheless, perfusate distribution was better in the 80 mm Hg perfusions. We did not find any correlation between enzyme release and RVR in kidneys perfused with different mean pressures. These findings suggest that vascular resistance and LDH concentration cannot be independently considered as adequate markers of perfusate distribution.
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Affiliation(s)
- B Herrera
- Unidad de Medicina y Cirugía Experimental, Hospital General Universitario Gregorio Marañón, Alcorcón, Madrid, Spain
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17
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Polyak MM, Arrington B, Gage F, Kapur S, Stubenbord WT, Kinkhabwala M. Supplemental reduced glutathione during cold ischemia does not improve early renal allograft function. Transplant Proc 2000; 32:32-4. [PMID: 10700956 DOI: 10.1016/s0041-1345(99)00864-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M M Polyak
- Organ Preservation Unit, New York Presbyterian Hospital-Cornell Campus, NY 10021, USA
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