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Ruberto F, Lai Q, Piazzolla M, Brisciani M, Pretagostini R, Garofalo M, Giovanardi F, Nudo F, Poli L, Zullino V, Santopietro P, Rossi M, Berloco PB, Pugliese F. The role of hypothermic machine perfusion in selecting renal grafts with advanced histological score. Artif Organs 2022; 46:1771-1782. [PMID: 35548925 PMCID: PMC9544822 DOI: 10.1111/aor.14308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/21/2022] [Accepted: 04/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies explored the role of Hypothermic Machine Perfusion (HMP) in the sub-group of non-standard renal grafts with a biopsy-proven advanced histological impairment. This study aimed to investigate the role of HMP in grafts with a Karpinski Score>3 in terms of the need for dialysis, creatinine reduction ratio at day-7 (CRR7), and 3-year graft survival. METHODS Twenty-three perfused grafts with Karpinski Score>3 evaluated between November 2017 and December 2018 were retrospectively analyzed and compared with a control group of 32 non-perfused grafts transplanted between January 2014 and October 2017. RESULTS After transplantation, perfused grafts had fewer cases requiring dialysis (8.7 vs. 34.4%; P=0.051), a better reduction in serum creatinine (median at 7 days: 2.2 vs. 4.3 mg/dL; P=0.045), and shorter length of hospital stay (median 11 vs. 15 days; P=0.01). Three-year death-censored graft survival was better in the perfused cases (91.3% vs. 77.0%; P=0.16). In perfused grafts, initial renal resistance (RR) had the best predictive value for renal function recovery after the first week, as defined by CRR7≤70% (AUC=0.83; P=0.02). A cut-off value of 0.5 mmHg/mL/min showed a sensitivity of 82.4%, a specificity of 83.3% and diagnostic odds ratio=23.4. After dividing the entire population into a Low-RR (n=8) and a High-RR Group (n=15), more cases with CRR7≤70% were reported in the latter group (86.7 vs. 13.3%; P=0.03). CONCLUSION HMP yielded promising results in kidneys with Karpinski Score>3. Initial RR should be of interest in selecting non-standard organs for single kidney transplantation even in impaired histology.
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Affiliation(s)
- Franco Ruberto
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Sapienza University of Rome, Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Mario Piazzolla
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Sapienza University of Rome, Rome, Italy
| | - Matteo Brisciani
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Sapienza University of Rome, Rome, Italy
| | - Renzo Pretagostini
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Manuela Garofalo
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Francesco Giovanardi
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Francesco Nudo
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Luca Poli
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Veronica Zullino
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Sapienza University of Rome, Rome, Italy
| | - Pietro Santopietro
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Pasquale B Berloco
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Francesco Pugliese
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Sapienza University of Rome, Rome, Italy
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2
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Karpinski Score under Digital Investigation: A Fully Automated Segmentation Algorithm to Identify Vascular and Stromal Injury of Donors’ Kidneys. ELECTRONICS 2020. [DOI: 10.3390/electronics9101644] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In kidney transplantations, the evaluation of the vascular structures and stromal areas is crucial for determining kidney acceptance, which is currently based on the pathologist’s visual evaluation. In this context, an accurate assessment of the vascular and stromal injury is fundamental to assessing the nephron status. In the present paper, the authors present a fully automated algorithm, called RENFAST (Rapid EvaluatioN of Fibrosis And vesselS Thickness), for the segmentation of kidney blood vessels and fibrosis in histopathological images. The proposed method employs a novel strategy based on deep learning to accurately segment blood vessels, while interstitial fibrosis is assessed using an adaptive stain separation method. The RENFAST algorithm is developed and tested on 350 periodic acid–Schiff (PAS) images for blood vessel segmentation and on 300 Massone’s trichrome (TRIC) stained images for the detection of renal fibrosis. In the TEST set, the algorithm exhibits excellent segmentation performance in both blood vessels (accuracy: 0.8936) and fibrosis (accuracy: 0.9227) and outperforms all the compared methods. To the best of our knowledge, the RENFAST algorithm is the first fully automated method capable of detecting both blood vessels and fibrosis in digital histological images. Being very fast (average computational time 2.91 s), this algorithm paves the way for automated, quantitative, and real-time kidney graft assessments.
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Montero N, Codina S, Cruzado JM. Prediction scores for risk of allograft loss in patients receiving kidney transplants: nil satis nisi optimum. Clin Kidney J 2020; 13:745-748. [PMID: 33125003 PMCID: PMC7577772 DOI: 10.1093/ckj/sfaa081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/21/2020] [Indexed: 12/16/2022] Open
Abstract
Long-term graft survival is the main concern of kidney transplantation. Some strategies have been tested to predict graft survival using estimated glomerular filtration rate or proteinuria at different time points, histologic assessment, non-invasive biomarkers or even machine-learning methods. However, the 'magical formulae' for allograft survival prediction does not exist yet.
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Affiliation(s)
- Nuria Montero
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), L’ Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
| | - Sergi Codina
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari de Bellvitge, L’ Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), L’ Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain
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4
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[Postoperative complications and long-term outcomes of transplantation with expended criteria donors transplants]. Prog Urol 2020; 30:655-662. [PMID: 32814659 DOI: 10.1016/j.purol.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/13/2020] [Accepted: 04/19/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to analyze early, late complications and outcomes following expended criteria donors (ECD) kidney transplantation compared to standard donors. MATERIALS AND METHODS We performed a retrospective study including 470 patients who received a kidney transplant between 2005 and 2016. Expended criteria donors were defined following the United Network of Organ Sharing criteria. In each group, length of stay, delayed graft function, surgical site infection, acute rejection, surgical complications by type and according to Clavien and Dindo classification were analyzed in univariate and multivariate analysis. The impact of ECD transplant on transplant and patient survival was assessed using a Cox proportional regression model. RESULTS One hundred and ninety seven (41.9%) patients received ECD kidney. The mean follow-up was 61,4 months (22.4-93.89). Patients with ECD transplant presented more delayed graft function (HR=2.1 (1.1-3.68), P=0.008) but the rate of complications including surgical complications was not different. Patients and transplant survival were decreased in ECD transplant group (P=0.005 et 0.001 respectively). In multivariate analysis ECD kidney was an independent factor only associated with decreased transplant survival (HR=1.81 (1.1-2.98), P=0.029) but not with patient survival. CONCLUSION ECD kidney transplantation was not associated with increased postoperative complications but a higher rate of delayed graft function. Nevertheless, it was associated with a decreased transplant survival. The use of pulsatile perfusion machine for explanted criteria transplant should be evaluated to improve these results.
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Stallone G, Grandaliano G. To discard or not to discard: transplantation and the art of scoring. Clin Kidney J 2019; 12:564-568. [PMID: 31411597 PMCID: PMC6671422 DOI: 10.1093/ckj/sfz032] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Indexed: 01/06/2023] Open
Abstract
The growing gap between inadequate supply and constantly high demand for kidney transplantation observed in the last two decades led to exploring the possibility of using organs from older donors with an increasing number of comorbidities. The main issue in this scenario is to identify transplantable organs and to allocate them to the most suitable recipients. A great number of clinical investigations proposed several acceptance/allocation criteria to reduce the discard rate of these kidneys and to improve their outcome, including histological features at the time of transplant. Despite the widespread use of several histological scoring systems, there is no consensus on their value in predicting allograft survival and there is established evidence that histological analysis is the most common reason to discard expanded criteria donor kidneys. To overcome this issue, a clinical scoring system, the Kidney Donor Profile Index (KDPI), was developed on the basis of easily accessible donor features. The KDPI score, adopted in the new US allocation procedure, has good reproducibility but presents several limitations, as suggested also in this issue of Clinical Kidney Journal. This observation should stimulate the search for novel scores combining clinical, histological and molecular features in an attempt to improve the decision process.
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Affiliation(s)
- Giovanni Stallone
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Giuseppe Grandaliano
- Department of Medical and Surgical Sciences, Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
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6
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Moeckli B, Sun P, Lazeyras F, Morel P, Moll S, Pascual M, Bühler LH. Evaluation of donor kidneys prior to transplantation: an update of current and emerging methods. Transpl Int 2019; 32:459-469. [PMID: 30903673 DOI: 10.1111/tri.13430] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023]
Abstract
The lack of suitable kidney donor organs has led to rising numbers of patients with end stage renal disease waiting for kidney transplantation. Despite decades of clinical experience and research, no evaluation process that can reliably predict the outcome of an organ has yet been established. This review is an overview of current methods and emerging techniques in the field of donor kidney evaluation prior to transplantation. Established techniques like histological evaluation, clinical scores, and machine perfusion systems offer relatively reliable predictions of delayed graft function but are unable to consistently predict graft survival. Emerging techniques including molecular biomarkers, new imaging technologies, and normothermic machine perfusion offer innovative approaches toward a more global evaluation of an organ with better outcome prediction and possibly even identification of targets for therapeutic interventions prior to transplantation. These techniques should be studied in randomized controlled trials to determine whether they can be safely used in routine clinical practice to ultimately reduce the discard rate and improve graft outcomes.
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Affiliation(s)
- Beat Moeckli
- Department of Surgery and Transplantation, Zurich University Hospital, Zurich, Switzerland
| | - Pamela Sun
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - François Lazeyras
- Department of Radiology and Medical Informatics, CIBM, Geneva University Hospital, Geneva, Switzerland
| | - Philippe Morel
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Solange Moll
- Department of Pathology, Geneva University Hospital, Geneva, Switzerland
| | - Manuel Pascual
- Transplantation Center Lausanne, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Léo H Bühler
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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7
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Colussi G, Casati C, Colombo VG, Camozzi MLP, Salerno FR. Renal transplants from older deceased donors: Is pre-implantation biopsy useful? A monocentric observational clinical study. World J Transplant 2018; 8:110-121. [PMID: 30148077 PMCID: PMC6107519 DOI: 10.5500/wjt.v8.i4.110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/09/2018] [Accepted: 05/13/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare survival of kidney transplants from deceased extended criteria donors (ECD) according to: (1) donor graft histological score; and (2) allocation of high score grafts either to single (SKT) or dual (DKT) transplant.
METHODS Renal biopsy was performed as part of either a newly adopted DKT protocol, or of surveillance protocol in the past. A total 185 ECD graft recipients were categorized according to pre-implantation graft biopsy into 3 groups: SKT with graft score 1 to 4 [SKT(1-4), n = 102]; SKT with donor graft score 5 to 8 [SKT(> 4), n = 30]; DKT with donor graft score 5 to 7 (DKT, n = 53). Graft and patient survival were analyzed by Kaplan-Meier curves and compared by log-rank test. Mean number of functioning graft years by transplant reference, and mean number of dialysis-free life years by donor reference in recipients were also calculated at 1, 3 and 6 years from transplantation.
RESULTS There were no statistically significant differences in graft and patient survival between SKT(1-4) and SKT(> 4), and between SKT(> 4) and DKT. Recipient renal function (plasma creatinine and creatinine clearance) at 1 years did not differ in SKT(1-4) and SKT(> 4) (plasma creatinine 1.71 ± 0.69 and 1.69 ± 0.63 mg/dL; creatinine clearance 49.6 + 18.5 and 52.6 + 18.8 mL/min, respectively); DKT showed statistically lower plasma creatinine (1.46 ± 0.57, P < 0.04) but not different creatinine clearance (55.4 + 20.4). Due to older donor age in the DKT group, comparisons were repeated in transplants from donors older than 70 years, and equal graft and patient survival in SKT and DKT were confirmed. Total mean number of functioning graft years by transplant reference at 1, 3 and 6 post-transplant years were equal between the groups, but mean number of dialysis-free life years by donor reference were significantly higher in SKT (mean difference compared to DKT at 6 years: 292 [IQR 260-318] years/100 donors in SKT(1-4) and 292.5 [(IQR 247.8-331.6) in SKT(> 4)].
CONCLUSION In transplants from clinically suitable ECD donors, graft survival was similar irrespective of pre-implantation biopsy score and of allocation to SKT or DKT. These results suggest use of caution in the use of histology as the only decision criteria for ECD organ allocation.
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Affiliation(s)
- Giacomo Colussi
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
| | - Costanza Casati
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
| | - Valeriana Giuseppina Colombo
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
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Ravaioli M, De Pace V, Comai G, Busutti M, Del Gaudio M, Amaduzzi A, Cucchetti A, Siniscalchi A, La Manna G, D'Errico AAD, Pinna AD. Successful Dual Kidney Transplantation After Hypothermic Oxygenated Perfusion of Discarded Human Kidneys. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1009-1013. [PMID: 28928357 PMCID: PMC5616148 DOI: 10.12659/ajcr.905377] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The recovery of discarded human kidneys has increased in recent years and impels to use of unconventional organ preservation strategies that improve graft function. We report the first case of human kidneys histologically discarded and transplanted after hypothermic oxygenated perfusion (HOPE). CASE REPORT Marginal kidneys from a 78-year-old woman with brain death were declined by Italian transplant centers due to biopsy score (right kidney: 6; left kidney: 7). We recovered and preserved both kidneys through HOPE and we revaluated their use for transplantation by means of perfusion parameters. The right kidney was perfused for 1 h 20 min and the left kidney for 2 h 30 min. During organ perfusion, the renal flow increased progressively. We observed an increase of 34% for the left kidney (median flow 52 ml/min) and 50% for the right kidney (median flow 24 ml/min). Both kidneys had low perfusate's lactate levels. We used perfusion parameters as important determinants of the organ discard. Based on our previous organ perfusion experience, the increase of renal flow and the low level of lactate following 1 h of HOPE lead us to declare both kidneys as appropriate for dual kidney transplantation (DKT). No complications were reported during the transplant and in the post-transplant hospital stay. The recipient had immediate graft function and serum creatinine value of 0.95 mg/dL at 3 months post-transplant. CONCLUSIONS HOPE provides added information in the organ selection process and may improve graft quality of marginal kidneys.
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Affiliation(s)
- Matteo Ravaioli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Vanessa De Pace
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Department of Experimental Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marco Busutti
- Department of Experimental Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Massimo Del Gaudio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Annalisa Amaduzzi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonietta A D D'Errico
- Department of Experimental Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonio Daniele Pinna
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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9
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Sánchez-Escuredo A, Sagasta A, Revuelta I, Rodas LM, Paredes D, Musquera M, Diekmann F, Campistol JM, Solé M, Oppenheimer F. Histopathological evaluation of pretransplant donor biopsies in expanded criteria donors with high kidney donor profile index: a retrospective observational cohort study. Transpl Int 2017; 30:975-986. [PMID: 28403541 DOI: 10.1111/tri.12966] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/24/2017] [Accepted: 03/27/2017] [Indexed: 12/16/2022]
Abstract
There is no consensus on the allocation of renal transplants from expanded criteria donors (ECD). The Kidney Donor Profile Index (KDPI) is used without the need for pretransplant donor biopsies (PTDB). We explored whether PTDB based on Remuzzi Score (RS) allows identification of those marginal kidneys in the highest calculated KDPI risk group (>91%) that appropriate for single transplantation. A retrospective study was conducted of 485 consecutive kidneys procured from a single center and transplanted if the RS was ≤4. We compared 5-year kidney and patients survival between KDPI groups and between RS <4 or =4 in the highest KDPI group. The median KDPI (interquartile range) was 71 (66-76) for KDPI <80% (n = 77), 86 (81-90) for KDPI 81-90% (n = 82), and 97 (94-100) for KDPI >91% (n = 205). Patient survival at 5 years was 85.7%, 85.3%, and 76.09% (P = 0.058) and death-censored graft survival was 84.4%, 86.5%, 73.6% (P = 0.015), respectively for each KDPI group. In >91% calculated KDPI group, there were no differences in graft survival depending on the RS (<4 vs. =4) (P = 0.714). The implementation of PTDB based on RS used for allocation of organs with the highest KDPI range could support to the acceptance of suitable organs for single transplantation with good patient and graft survival rate.
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Affiliation(s)
- Ana Sánchez-Escuredo
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Amaia Sagasta
- Pathology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Ignacio Revuelta
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Lida M Rodas
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - David Paredes
- Transplant Service Foundation, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Mireia Musquera
- Urology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Josep M Campistol
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Manel Solé
- Pathology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Federico Oppenheimer
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
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10
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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.
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11
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De Paolis P, Colonnelli R, Favarò A, Salem F, Vignally P, Carriero C, Iappelli M, Di Giulio S. Expanded Criteria Donor Kidney Transplantation: Comparative Outcome Evaluation Between Single Versus Double Kidney Transplantation at 8 Years: A Single Center Experience. Transplant Proc 2017; 48:329-32. [PMID: 27109948 DOI: 10.1016/j.transproceed.2016.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/02/2016] [Accepted: 02/02/2016] [Indexed: 01/06/2023]
Abstract
Transplantation of kidneys retrieved from expanded criteria donors is one of the options to expand the pool of available grafts, shorten the waiting time and increase the number of kidney transplant recipients. This study was a retrospective assessment of 99 patients who underwent renal transplantation during the period 2007-2015 with kidneys harvested from expanded criteria donors (ECD) as defined by the United Network for Organ Sharing (UNOS) following routine biopsy of all kidneys obtained by Karpinsky Score. They formed two groups: SKT (67 recipients that received a single kidney) and DKT (32 patients that received dual kidney transplant). An analysis of differences of two groups between graft and patient survival and graft function were performed after 8 years of observation. We observed between two groups the following statistical differences: Donor age (P < .001), basal high risk of recipients (P < .05), wait time before transplant (P < .05), recipient age (P < .001) delayed graft function (P < .005) while we observe similar values of donor renal function, outcome in graft and patient survival and graft function in recipients. The transplantation of kidneys obtained from expanded criteria donor, allows increase in the number of kidney transplants and in the respect of values of biopsy score and the donor renal function, showed in single or dual kidney transplantation with similar graft and patient survival.
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Affiliation(s)
- P De Paolis
- Department of Nephrology and Transplant Unit, A.O. S. Camillo-Forlanini, Rome, Italy.
| | - R Colonnelli
- Department of Nephrology and Transplant Unit, A.O. S. Camillo-Forlanini, Rome, Italy
| | - A Favarò
- Department of Nephrology and Transplant Unit, A.O. S. Camillo-Forlanini, Rome, Italy
| | - F Salem
- Department of Nephrology and Transplant Unit, A.O. S. Camillo-Forlanini, Rome, Italy
| | - P Vignally
- Department of Emergency, Hospital Galliena, Genova, Italy
| | - C Carriero
- Transplant Surgical Unit, A.O. S. Camillo-Forlanini, Rome, Italy
| | - M Iappelli
- Transplant Surgical Unit, A.O. S. Camillo-Forlanini, Rome, Italy
| | - S Di Giulio
- Department of Nephrology and Transplant Unit, A.O. S. Camillo-Forlanini, Rome, Italy
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12
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Jang HR, Park JH, Kwon GY, Park JB, Lee JE, Kim DJ, Kim YG, Kim SJ, Oh HY, Huh W. Aging has small effects on initial ischemic acute kidney injury development despite changing intrarenal immunologic micromilieu in mice. Am J Physiol Renal Physiol 2016; 310:F272-83. [DOI: 10.1152/ajprenal.00217.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 12/08/2015] [Indexed: 12/20/2022] Open
Abstract
Inflammatory process mediated by innate and adaptive immune systems is a major pathogenic mechanism of renal ischemia-reperfusion injury (IRI). There are concerns that organ recipients may be at increased risk of developing IRI after receiving kidneys from elder donors. To reveal the effects of aging on the development of renal IRI, we compared the immunologic micromilieu of normal and postischemic kidneys from mice of three different ages (9 wk, 6 mo, and 12 mo). There was a higher number of total T cells, especially effector memory CD4/CD8 T cells, and regulatory T cells in the normal kidneys of old mice. On day 2 after IRI, the proportion of necrotic tubules and renal functional changes were comparable between groups although old mice had a higher proportion of damaged tubule compared with young mice. More T cells, but less B cells, trafficked into the postischemic kidneys of old mice. The infiltration of NK T cells was similar across the groups. Macrophages and neutrophils were comparable between groups in both normal kidneys and postischemic kidneys. The intrarenal expressions of TNF-α and VEGF were decreased in normal and postischemic kidneys of aged mice. These mixed effects of aging on lymphocytes and cytokines/chemokines were not different between the two groups of old mice. Our study demonstrates that aging alters the intrarenal micromilieu but has small effects on the development of initial renal injury after IRI. Further study investigating aging-dependent differences in the repair process of renal IRI may be required.
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Affiliation(s)
- Hye Ryoun Jang
- Nephrology Division, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hyeon Park
- Nephrology Division, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ghee Young Kwon
- Department of Pathology, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea; and
| | - Jung Eun Lee
- Nephrology Division, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae Joong Kim
- Nephrology Division, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-Goo Kim
- Nephrology Division, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea; and
| | - Ha Young Oh
- Nephrology Division, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wooseong Huh
- Nephrology Division, Department of Medicine, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Wang CJ, Wetmore JB, Crary GS, Kasiske BL. The Donor Kidney Biopsy and Its Implications in Predicting Graft Outcomes: A Systematic Review. Am J Transplant 2015; 15:1903-14. [PMID: 25772854 DOI: 10.1111/ajt.13213] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- C J Wang
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - J B Wetmore
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - G S Crary
- Department of Pathology, Hennepin County Medical Center, Minneapolis, MN
| | - B L Kasiske
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
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14
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Gandolfini I, Buzio C, Zanelli P, Palmisano A, Cremaschi E, Vaglio A, Piotti G, Melfa L, La Manna G, Feliciangeli G, Cappuccilli M, Scolari M, Capelli I, Panicali L, Baraldi O, Stefoni S, Buscaroli A, Ridolfi L, D'Errico A, Cappelli G, Bonucchi D, Rubbiani E, Albertazzi A, Mehrotra A, Cravedi P, Maggiore U. The Kidney Donor Profile Index (KDPI) of marginal donors allocated by standardized pretransplant donor biopsy assessment: distribution and association with graft outcomes. Am J Transplant 2014; 14:2515-25. [PMID: 25155294 PMCID: PMC4400114 DOI: 10.1111/ajt.12928] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 06/11/2014] [Accepted: 06/14/2014] [Indexed: 01/25/2023]
Abstract
Pretransplant donor biopsy (PTDB)-based marginal donor allocation systems to single or dual renal transplantation could increase the use of organs with Kidney Donor Profile Index (KDPI) in the highest range (e.g. >80 or >90), whose discard rate approximates 50% in the United States. To test this hypothesis, we retrospectively calculated the KDPI and analyzed the outcomes of 442 marginal kidney transplants (340 single transplants: 278 with a PTDB Remuzzi score<4 [median KDPI: 87; interquartile range (IQR): 78-94] and 62 with a score=4 [median KDPI: 87; IQR: 76-93]; 102 dual transplants [median KDPI: 93; IQR: 86-96]) and 248 single standard transplant controls (median KDPI: 36; IQR: 18-51). PTDB-based allocation of marginal grafts led to a limited discard rate of 15% for kidneys with KDPI of 80-90 and of 37% for kidneys with a KDPI of 91-100. Although 1-year estimated GFRs were significantly lower in recipients of marginal kidneys (-9.3, -17.9 and -18.8 mL/min, for dual transplants, single kidneys with PTDB score<4 and =4, respectively; p<0.001), graft survival (median follow-up 3.3 years) was similar between marginal and standard kidney transplants (hazard ratio: 1.20 [95% confidence interval: 0.80-1.79; p=0.38]). In conclusion, PTDB-based allocation allows the safe transplantation of kidneys with KDPI in the highest range that may otherwise be discarded.
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Affiliation(s)
- I. Gandolfini
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - C. Buzio
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - P. Zanelli
- Immunogenetic Unit, Parma University Hospital Parma, Italy
| | - A. Palmisano
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - E. Cremaschi
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - A. Vaglio
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - G. Piotti
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - L. Melfa
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - G. La Manna
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - G. Feliciangeli
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - M. Cappuccilli
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - M.P. Scolari
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - I. Capelli
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - L. Panicali
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - O. Baraldi
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - S. Stefoni
- Section of Nephrology and Renal Transplant, Department of Specialistic, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - A. Buscaroli
- Nephrology and Dialysis Unit, Hospital of Ravenna, Italy
| | - L. Ridolfi
- Organ Procurement Organization CRT-Emilia Romagna, Bologna, Italy
| | - A. D'Errico
- Institute of Anatomopathology, University of Bologna, Italy
| | - G. Cappelli
- Nephrology Dialysis and Renal Transplantation Unit, University Hospital of Modena, Modena, Italy
| | - D. Bonucchi
- Nephrology Dialysis and Renal Transplantation Unit, University Hospital of Modena, Modena, Italy
| | - E. Rubbiani
- Nephrology Dialysis and Renal Transplantation Unit, University Hospital of Modena, Modena, Italy
| | - A. Albertazzi
- Nephrology Dialysis and Renal Transplantation Unit, University Hospital of Modena, Modena, Italy
| | - A. Mehrotra
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - P. Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - U. Maggiore
- Kidney and kidney-pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
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15
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Abstract
PURPOSE OF REVIEW The current era of organ shortage has necessitated a widening of criteria for donation, considering donors who would have been considered unsuitable before. This review summarizes the recent advances in strategies to maximize the use of marginal kidneys without compromising the outcomes. RECENT FINDINGS Various strategies have been studied and implemented to optimize procurement and allocation of marginal kidneys, and to preserve their function. In particular, a growing number of transplant centers are using donors after circulatory death. Whereas normothermic ex-vivo and postmortem perfusion are promising procedures to improve the outcomes of marginal grafts in the future, dual-kidney transplantation is a viable approach which is at present potentially underutilized. Despite active research on new strategies to evaluate organ quality, pretransplant biopsy assessment currently remains the most reliable method. The practice of using living donors with advanced age is supported by available evidence, whereas the use of young living donors with minor medical abnormalities needs further investigation. SUMMARY Progress has been made in the recent years, clarifying the best criteria for evaluating, recovering, and allocating marginal kidney donors. However, further research is needed, with special regards to the criteria for using marginal living-kidney donors.
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Affiliation(s)
- Umberto Maggiore
- aTrapianti Rene-Pancreas (U.O.C. Nefrologia), Azienda Ospedaliero-Universitaria di Parma, Parma, Italy bRenal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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