Influence of cadaveric organ source on delayed renal allograft function

Early and Long-Term Outcomes of Kidney Grafts Procured From Multiple-Organ Donors and Kidney-Only Donors

BACKGROUND

The deceased-donor kidney pool consists of 2 different populations: multiple-organ donors (MOD) and kidney donors alone (KDA). In MOD, more complicated procedure and lowest priority for kidney procurement may affect graft survival. On the other hand, poor donor status and higher comorbidity are more frequent in KDA transplants. The aim of this study was to provide detailed characteristics of the 2 groups of kidney donors (KDA vs MOD) in our center and to analyze the potential influence of the donor type on the early and long-term kidney graft function and recipient outcome.

METHODS

We performed a retrospective analysis of 729 first cadaveric kidney transplant recipients: 499 of them received the organ from MOD, 230 from KDA.

RESULTS

The frequency of delayed graft function (DGF) was higher in KDA than in MOD transplants (38.7 vs 25.1%; P < .001). Multivariate logistic regression analysis revealed that donor age, KDA, and early acute rejection independently increased the risk of DGF occurrence, whereas recipient age and cold ischemia time increased the risk of primary graft nonfunction. Kidney excretory function was significantly worse in KDA up to 10 years after transplantation. There were no differences in kidney graft and patient survivals, frequency of proteinuria, acute rejection, and cytomegalovirus episodes, and post-transplantation diabetes.

CONCLUSIONS

(1) The use of a kidney from KDA negatively affects early and late kidney graft function compared with MOD. (2) The long-term kidney graft and patient survivals are not affected by the type of organ procurement.

Extraction Time of Kidneys From Deceased Donors and Impact on Outcomes

Cold ischemia time (from flush to out-of-ice) and warm ischemia time (from out-of-ice to reperfusion) are known to impact delayed graft function (DGF) rates and long-term allograft survival following deceased donor kidney transplantation. We propose an additional ischemia time, extraction time, beginning with aortic cross-clamp and perfusion/cooling of the kidneys, and ending with removal of the kidneys and placement on ice on the backtable. During this time the kidneys rewarm, suffering an additional ischemic insult, which may impair transplant function. We measured extraction times of 576 kidneys recovered and transplanted locally between January 2006 and December 2008, then linked to Scientific Registry of Transplant Recipients (SRTR) data for outcomes. Extraction time ranged from 14 to 123 min, with a mean of 44.7 min. In SRTR-adjusted analyses, longer extraction time and DGF were statistically associated (odds ratio [OR] = 1.19 per 5 min beyond 60 min, 95% confidence interval [CI] 1.02-1.39, p = 0.03). Up to 60 min of extraction time, DGF incidence was 27.8%; by 120 min it doubled to nearly 60%. Although not statistically significant (OR = 1.19, 95% CI 0.96-1.49, p = 0.11), primary nonfunction rate also rose dramatically to nearly 20% by 120 min extraction time. Extraction time is a novel and important factor to consider when evaluating a deceased donor kidney offer and when strategizing personnel for kidney recovery.

Variations in initial renal transplant function by type of organ retrieval

BACKGROUND

Numerous factors have been associated with early delay in kidney function and thence the graft survival. However, few data are derived from different types of donation: single or multiorgan. Our goal was to analyze the association of type of retrieval with the early function of the renal graft.

METHODS

A retrospective analysis of transplantations performed in the Reina Sofia Hospital from January 2004 to June 2012 from local deceased donors was carried out. We performed a descriptive analysis of the variables and univariate and multivariate analyses with the use of logistic regression to determine the association of type of retrieval (kidney-only [KO], kidney-liver [KL], and multiorgan [MO]) with delayed graft function (DGF) and early graft failure (EGF).

RESULTS

We analyzed 287 kidney transplantations from 182 deceased donors, of which 25 (13.7%) were KO, 80 (43.9%) KL, and 77 (42.3%) MO. DGF was higher in MO retrievals compared with KL and KO (25.8% vs 24% vs 20.5%), though without reaching significance (P = .81). EGF at 3 months was 17.6% in KO compared with 10.5% in KL and 5.3% in MO (P = .2). Regarding DGF, in the multivariate analysis, donor age (P = .049) and donor sex (P = .029) appeared to be related to DGF. There were no differences by type of retrieval. Multivariate logistic regression analysis established a significant relationship between KO retrieval and EGF at 3 months (P = .005) compared with MO.

CONCLUSIONS

Early graft function at 3 months decreases when the allograft is from KO retrievals compared with MO, probably related to the more unfavorable characteristics of these donors and their corresponding recipients.

Does multiorgan versus kidney-only cadaveric organ procurement affect graft outcomes?

INTRODUCTION

The majority of kidney grafts in most European countries still come from deceased donors who provide other organs. We analyzed whether multiorgan procurement portends a worse functional outcome compared with kidney-only harvesting.

METHODS

We performed a retrospective analysis of 1043 consecutive brain-dead donor kidney transplantations performed at a single academic institution from September 2002 to June 2011. The graft outcomes using kidney-only donors (n = 243) were compared with multiorgan donor grafts (n = 800) analyzing donor age, gender, cause of death, duration of mechanical ventilation, renal function, and cold ischemic interval. We compared delayed graft function and serum creatinine values at 1, 3, 6, and 12 months posttransplantation as well as graft survivals. This methodology was also applied to the subset of expanded criteria donors: 179 kidney-only versus 474 multiorgan. The influence of donor variables on graft survival was also analyzed in a Cox regression model. Immunosuppressive regimens and preservation solutions were similar in both groups.

RESULTS

Kidney-only donors were older than their multiorgan counterparts (53.1 versus 44.8, P < .0005) and predominantly male (76.5% versus 62.6% male donors, P < .0005). Other donor variables were comparable. Kidney-only donor grafts showed a slightly higher incidence of delayed function (27.2 versus 21.1%, P = .049), but the mean serum creatinine values were similar at all intervals. No differences were observed in 7-year graft survival: 80.7% versus 79.9%. Expanded criteria donor grafts showed overlapping results, except for a higher rate of donor oligoanuria and a lower 1-month mean creatinine among kidney-only donors. Multivariate analysis revealed that the number of harvested organs did not influence graft survival.

DISCUSSION

Immediate and long-term outcomes of kidney grafts did not correlate with the number of organs harvested from the donor. The longer explantation time associated with multiorgan procurement did not seem to affect graft function.

Non-heart beating donor kidneys with delayed graft function have superior graft survival compared with conventional heart-beating donor kidneys that develop delayed graft function

Delayed graft function may have an association with reduced graft survival, and nonheart-beating donor (NHBD) kidneys have higher rates of delayed graft function (DGF) than heart-beating donor (HBD) kidneys. This study compared outcome of renal transplants from HBDs who developed DGF, with NHBDs who developed DGF. All recipients of HBD and NHBD kidneys who developed DGF were identified during a 10-year period. All patients with graft primary nonfunction were excluded from analysis. Four hundred and fifty-six functioning transplants were performed. Delayed graft function occurred in 69 (17%) HBD and 55 (93%) NHBD kidneys. The grafts developing DGF were well matched for donor and recipient age. The rate of acute rejection was similar; [n = 16/69 (23%) HBD vs. n = 13/55 (24%) NHBD]. Cold ischaemia was 21 h in the HBD group and 17 h in NHBD group (p > 0.05). Serum creatinine was similar for both groups at 1.3 and 6 years (p > 0.05 for all time points). Graft survival in the NHBD recipients with DGF was significantly better at 3 years (84%) compared with recipients of a HBD renal transplant that developed DGF (73%) (p < 0.05), and at 6 years (62% survival for HBDs and 84% survival for NHBDs). This study shows that graft survival was better for NHBD kidneys up to 6 years after transplantation.

Delayed graft function does not reduce the survival of renal transplant allografts

BACKGROUND

The aim of the present study was to investigate the effect of delayed graft function (DGF) in graft outcome when adjusted by the presence of acute rejection in the first month after transplantation.

METHODS

A total of 437 cadaveric renal transplant patients on cyclosporine and steroids were included in the study. Variables related to donor, recipient, and graft were prospectively collected.

RESULTS

The incidence of DGF was 44.4%. When patients dying with a functioning graft were censored, graft survival rates at 1 and 6 years were similar in patients with immediate function to those with DGF, when rejection was not present (96% and 81% vs. 95% and 83%, respectively). Rejection negatively influenced graft survival rates at 1 and 6 years, both in patients with immediate graft function (80% and 73%, P<0.05 vs. no DGF/no rejection) and more deeply in those with associated DGF (77% and 62%, P<0.001 vs. no DGF/no rejection). Rejection was more frequently diagnosed in patients with DGF than in those with immediate graft function (50% vs. 39.9%, P<0.05). Length of hospitalization was longer and the number of needle core biopsies was higher in patients with DGF or rejection. The presence of both complications had an additive effect.

CONCLUSIONS

This study showed that DGF did not adversely affect kidney graft survival in patients without rejection. However, it increased the length of hospitalization and the number of graft biopsies, thus increasing the cost of transplantation. Moreover, rejection was more frequent in patients with DGF, and it had a negative impact on graft outcome. Because the association of DGF and rejection gave the poorest outcome, an effort should be made to prevent both complications.

Risk factors for delayed graft function in cadaveric kidney transplantation: a prospective study of renal function and graft survival after preservation with University of Wisconsin solution in multi-organ donors. European Multicenter Study Group

BACKGROUND

Delayed graft function (DGF) remains an important complication in renal transplantation. In this multicenter study, we investigated the influence of donor and recipient factors on the occurrence of DGF and DGF's effect on long-term graft survival.

METHODS

A total of 547 transplanted kidney allografts, retrieved from multi-organ donors, were analyzed, and results were compared with literature on kidney-only donors.

RESULTS

Median follow-up of patients without graft failure was 3.4 years. Twenty-four percent of the recipients developed DGF. In univariate analysis, the following factors significantly increased the incidence of DGF: (a) among the donor factors, mean creatinine level >120 micromol/L and prolonged cold ischemia time (CIT); and (b) among the recipient factors, previous transplant(s), no intraoperative use of mannitol, poor quality of reperfusion, absence of intraoperative diuresis, and pretransplant anuria or oliguria. After stepwise logistic regression, donor age, CIT, recipient's number of previous transplants, and intraoperative diuresis proved to be of independent prognostic value for the occurrence of DGF. Overall graft survival was 91%, 87%, and 72% at 3 months, 1 year, and 4 years after transplantation, respectively. In case of DGF, graft survival was approximately 10% lower when compared with cases with immediate graft function (P<0.001). No difference in incidence of DGF was found between grafts of multi-organ donors and kidney-only donors.

CONCLUSIONS

DGF results in an approximately 10% higher rate of graft failure. DGF incidence can be reduced by the administration of mannitol during transplantation, which minimizes CIT and optimizes donor management. Grafts from multi-organ donors and kidney-only donors appear to be of equal quality.

Acute renal failure in renal allograft recipients and patients with native kidneys

In order to evaluate the role of underlying disease in the high mortality observed in acute renal failure (ARF) and risk factors related to the development of oliguric ARF in renal allograft recipients, two groups were selected: 34 patients with native kidneys, aged 16 and 57 years, and presenting ischemic ARF caused by cardiovascular collapse, with no signs of infection at the time of diagnosis; and 34 renal allograft recipients who developed ARF immediately after transplantation, without rejection. ARF was defined either as 30% increase of basal plasmatic creatinine in patients with native kidneys or nonnormalization of plasmatic creatinine at day 5 after transplantation in renal allograft recipients; oliguria as diuresis < or = 400 mL/24 h. There were no differences in age, male frequency, oliguria presence and duration, need for dialysis, and infection episodes for renal allograft recipients and patients with native kidneys. The development of sepsis (3% and 41%) and death rate (3% and 44%) were higher in patients with native kidneys (p < 0.01). The renal allograft recipients with both oliguric (n = 18) and nonoliguric (n = 16) ARF were evaluated and no difference was observed in the recipient's age, donor's age, cold ischemia time, time elapsed until plasmatic creatinine normalization, donor's plasmatic creatinine or urea, and mean arterial pressure. No differences were observed between the groups regarding frequency of infection episodes during ARF and frequency of death. In conclusion, renal allograft recipients presented a lower death rate and were less susceptible to sepsis. Cold ischemia time, age, and hemodynamic characteristics of the donor did not affect the development of oliguria.

The outcome of kidney grafts from multiorgan donors and kidney only donors

From 1988 to 1994, 15356 renal cadaveric transplantations have been performed within the Eurotransplant area (Austria, Belgium, Germany, Luxembourg and The Netherlands); 8746 kidneys were obtained from multiorgan donors and 6610 from kidney only donors. To evaluate the impact of the procurement policy, multiorgan donor (MOD) versus kidney only donor (KOD), on renal graft survival, an observational study has been performed. Multivariate analysis using Cox's proportional hazards model served to quantify the role of the procurement policy on renal graft survival after adjustment for other prognostic factors. The kidneys obtained from MODs had a significantly better graft survival at 1, 3, and 5 years after transplantation than the kidneys obtained from KODs (85%, 75%, and 58% versus 78%, 68%, and 46% (P=0.0001). In the Cox model, patients transplanted with a KOD kidney had a 1.28 times higher risk of losing their graft than patients transplanted with a MOD kidney. This benefit in graft survival for MOD kidneys could not be explained by the fact that the MODs were younger and male, and that UW was used as preservation solution. A plausible explanation is that MODs, on average, because of the nonrenal transplants, are better supervised. We expect that optimal donor management will contribute to a better outcome of all renal grafts.