The risks, benefits, and costs of expanding donor criteria. A collaborative prospective three-year study

Geographic disparities in access to liver transplantation

Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.

The organ procurement costs of expanding deceased donor organ acceptance criteria: Evidence from a cost function model

A potential solution to the deceased donor organ shortage is to expand donor acceptability criteria. The procurement cost implications of using nonstandard donors is unknown. Using 5 years of US organ procurement organization (OPO) data, we built a cost function model to make cost projections: the total cost was the dependent variable; production outputs, including the number of donors and organs procured, were the independent variables. In the model, procuring one kidney or procuring both kidneys from double/en bloc transplantation from a single-organ donor resulted in a marginal cost of $55 k (95% confidence interval [CI] $28 k, $99 k) per kidney, and procuring only the liver from a single-organ donor results in a marginal cost of $41 k (95% CI $12 k, $69 k) per liver. Procuring two kidneys for two candidates from a donor lowered the marginal cost to $36 k (95% CI $22 k, $66 k) per kidney, and procuring two kidneys and a liver lowers the marginal cost to $24 k (95% CI $17 k, $45 k) per organ. Economies of scale were observed, where high OPO volume was correlated with lower costs. Despite higher cost per organ than for standard donors, kidney transplantation from nonstandard donors remained cost-effective based on contemporary US data.

Effect of Long Cold Ischemia Time of Kidneys from Aged Donors on Prognosis of Kidney Transplantation

With the increasing incidence of end-stage renal disease (ESRD), patients' life span and life quality are significantly reduced. Kidney transplantation has gradually become the ideal method for treating ESRD, and the shortage of organ sources has become the main problem. In recent years, China has successfully realized the transformation of organ sources. Voluntary donation after the death of citizens has increased year by year, and the number of kidney transplantations has increased, which alleviates the organ shortage to a certain extent, but compared with the past, the increasing proportion of aged donors has also become an inevitable global problem. At the same time, due to the sudden and widespread distribution of voluntary donation, most donor kidneys have the problem of longer cold ischemic time (CIT). The probability of adverse events, such as delayed renal function recovery after transplantation, was also significantly increased. At present, there is little research on the effect of donor's aging and long CIT on the prognosis of renal transplantation. This paper reviews the literature in recent years and explore this problem from 2 aspects: the elderly donor and the long CIT.

Noneligible Donors as a Strategy to Decrease the Organ Shortage

Organ procurement organization (OPO) performance is generally evaluated by the number of organ procurement procedures divided by the number of eligible deaths (donation after brain death [DBD] donors aged <70 years), whereas the number of noneligible deaths (including donation after cardiac death donors and DBD donors aged >70 years) is not tracked. The present study aimed to investigate the variability in the proportion of noneligible liver donors by the 58 donor service areas (DSAs). Patients undergoing liver transplant (LT) between 2011 and 2015 were obtained from the United Network for Organ Sharing Standard Transplant Analysis and Research file. LTs from noneligible and eligible donors were compared. The proportion of noneligible liver donors by DSA varied significantly, ranging from 0% to 19.6% of total liver grafts used. In transplant programs, the proportion of noneligible liver donors used ranged from 0% to 35.3%. On linear regression there was no correlation between match Model for End-Stage Liver Disease score for programs in a given DSA and proportion of noneligible donors used from the corresponding DSA (p = 0.14). Noneligible donors remain an underutilized resource in many OPOs. Policy changes to begin tracking noneligible donors and learning from OPOs that have high noneligible donor usage are potential strategies to increase awareness and pursuit of these organs.

Perceptions of the Donation Process from Adult-to-Adult Living Liver Donors

Background

Donor safety and the impact on quality of life continue to concern transplant centers as living liver transplantation increases.

Methods

Living liver donors participated in a focus group to discuss their perceptions of the donation process.

Results

The decision to donate was a personal choice made before the request by the recipient or transplant service. Spouses verified their support, but indicated that they were not included in the process. No donors felt coerced. The explanation of the procedure was thorough but excessive. Hospital care was good; however, donors admitted being unprepared for the pain and side effects of pain medications. Ongoing incisional discomfort continued beyond 6 weeks and prevented donors from feeling normal. Donors felt conflicted about competing with the “true” patient for healthcare.

Conclusions

Donors were positive about the need and willingness to donate. Sensitivity to the order of the disclosure process is identified.

Survival Benefit From Kidney Transplantation Using Kidneys From Deceased Donors Aged ≥75 Years: A Time-Dependent Analysis

Patients with end-stage renal disease have longer survival after kidney transplantation than they would by remaining on dialysis; however, outcome with kidneys from donors aged ≥75 years and the survival of recipients of these organs compared with their dialysis counterparts with the same probability of obtaining an organ is unknown. In a longitudinal mortality study, 2040 patients on dialysis were placed on a waiting list, and 389 of them received a first transplant from a deceased donor aged ≥75 years. The adjusted risk of death and survival were calculated by non-proportional hazards analysis with being transplanted as a time-dependent effect. Projected years of life since placement on the waiting list was almost twofold higher for transplanted patients. Nonproportional adjusted risk of death after transplantation was 0.44 (95% confidence interval [CI] 0.61-0.32; p < 0.001) in comparison with those that remained on dialysis. Stratifying by age, adjusted hazard ratios for death were 0.17 (95% CI 0.47-0.06; p = 0.001) for those aged <65 years, 0.56 (95% CI 0.92-0.34; p = 0.022) for those aged 65-69 years and 0.82 (95% CI 1.28-0.52; p = 0.389) for those aged ≥70 years. Although kidney transplantation from elderly deceased donors is associated with reduced graft survival, transplanted patients have lower mortality than those remaining on dialysis.

Gender bias in Iranian living kidney transplantation program: a national report

INTRODUCTION

Strong challenges exist about living kidney transplantation practices worldwide. One of these concerns is based on the observation that in many places women constitute the majority of living kidney donors but the minority of recipients. We studied this issue in Iran by using national data for kidney transplantation.

METHODS

Data of the Iranian national registry for kidney transplantation which comprises data of all renal transplantations performed in the country during a 22 yr period were included in the study. Data of 16,672 living donors (living related [LR]=16%, living unrelated [LUR]=86%) were analyzed.

RESULTS

Males received 62.2% of all kidney transplants. From 16,672 living donors, 20% and 80% were women and men, respectively. Recipients were more likely to receive kidney allograft from their own gender groups (p<0.05). In living related donations, mothers, brothers and sons were significantly more often donors than their counterparts of opposite gender.

CONCLUSION

In contrast with previous reports from other countries, this study of Iranian national data revealed that in Iran, most related and unrelated living kidney donors are male and the percentage of recipients who are female exceeds the percentage of donors who are female. Considering previous reports from other countries, our findings suggest that Iran is the only country in which females are more likely to be recipients of a kidney allograft than donors. The reason for the predominance of male kidney donors in Iran is probably multifactorial and associated with economical, social and cultural issues. The financial incentives paid to living unrelated donors may be an attraction for males to donate a kidney although, even in living related donations, males constitute the majority of donors.

[Cell energetic loading in experimental renal transplant with different periods of warm ischemia]

INTRODUCTION AND GOALS

Renal procurement after a period of heart st op demands a previous knowledge of ischemia-reperfusion injuries means. To study cell injury mechanisms an experimental study has been designed in pigs, with different rangres of warm ischemia (0-30-45 and 90 min). The main goal was to research on the basis of ischemic injury.

MATERIAL AND METHODS

Biochemical parameters (creatinine, urine output), energetic loading (ATP, ADP, AMP and global energetic loading) and pathological studies as long as survival analysis by 5th day were completed.

RESULTS

Animal survival and graft viability range from 100% at 5th day in control and 30 min warm ischemia groups to 60% in 90 min warm ischemia group. Creatinine levels rises at 1st, 3rd and 5th day, especially in those non-viable organs. ATP levels decrease after warm ischemia period, increases ADP and AMP levels after reperfusion in those viable organs.

CONCLUSIONS

Prolonged periods of warm ischemia do not result necessarily in non-viable kidneys. Viable organs recover nucleotide levels early. Study of energetic cell loading levels is a good way to get on better in the knowledge of injury mechanisms after ischemia-reperfusion.

Outcome of kidney transplantation using expanded criteria donors and donation after cardiac death kidneys: realities and costs

Expanded criteria donors (ECDs) and donation after cardiac death (DCD) provide more kidneys in the donor pool. However, the financial impact and the long-term benefits of these kidneys have been questioned. From 1998 to 2005, we performed 271 deceased donor kidney transplants into adult recipients. There were 163 (60.1%) SCDs, 44 (16.2%) ECDs, 53 (19.6%) DCDs and 11 (4.1%) ECD/DCDs. The mean follow-up was 50 months. ECD and DCD kidneys had a significantly higher incidence of delayed graft function, longer time to reach serum creatinine below 3 (mg/dL), longer length of stay and more readmissions compared to SCDs. The hospital charge was also higher for ECD, ECD/DCD and DCD kidneys compared to SCDs, primarily due to the longer length of stay and increased requirement for dialysis (70,030 dollars, 72,438 dollars, 72,789 dollars and 47,462 dollars, respectively, p < 0.001). Early graft survival rates were comparable among all groups. However, after a mean follow-up of 50 months, graft survival was significantly less in the ECD group compared to other groups. Although our observations support the utilization of ECD and DCD kidneys, these transplants are associated with increased costs and resource utilization. Revised reimbursement guidelines will be required for centers that utilize these organs.

Cadaveric kidney transplantation: five years experience at a single center

BACKGROUND

In the past, the majority of renal transplantations in Iran were from living donors, but recently cadaveric donation of organs is increasing. We reviewed our experience on kidney transplantation from cadaveric donors for the past 5 years in our center.

METHODS

Between July 1998 and September 2004, 122 kidneys were removed from 61 cases of brain-dead patients and transplanted in 114 patients with end-stage renal disease in our center. Two kidneys had tumoral involvement and were discarded. Three kidneys were transplanted in other centers and three patients received en bloc kidney transplantations. In addition, we performed nine cases of heart, one case of liver, and one case of lung transplantations. All the recipients were followed for at least 1 year and posttreatment renal function and graft survival were determined.

RESULTS

All cadaveric donors were brain dead due to car (30%) and motocycle (70%) accidents, with ages ranging from 5 to 56 years (mean, 24/4 years). The mean warm and total cold ischemia times were 7 minutes and 8.1 hours, respectively. The mean distance between harvesting center and our hospital was 65 km. The 1-year graft survival was 92.3%, with mean serum creatinine of 1.76 +/- 0.79 at 1 year. Of other transplanted organs, the liver and lung recipients died 24 hours and 45 days after operation. Among heart recipients, four are still alive.

CONCLUSION

Cadaveric donors in developing countries including Iran can be excellent sources of organ donation.

Influence of Pulsatile Perfusion Preservation on Outcomes in Kidney Transplantation from Expanded Criteria Donors

BACKGROUND

Expanded criteria donors (ECDs) increase the donor organ pool, but the value of transplanting these kidneys has been questioned because of concerns about diminished survival, poorer renal function, and higher rates of delayed graft function.

STUDY DESIGN

Retrospective analysis of intermediate-term outcomes in ECD kidney transplantations according to method of preservation at a single center using a standardized approach.

RESULTS

Over a 5-year period, we performed 141 donations-after-brain-death ECD kidney transplantations into adult recipients. A total of 114 kidneys (81%) were managed with combined cold-storage and pulsatile perfusion preservation (PPP), and the remaining 27 (19%) were preserved with cold storage (CS). The PPP group had a higher proportion of kidneys preserved for longer than 30 hours (28% versus 0, p < 0.001) and a longer mean cold ischemia time (24.5 hours PPP versus 19 hours CS, p < 0.01). Other donor and recipient characteristics were similar between groups. Incidence of delayed graft function was 11% in PPP-stored kidneys versus 37% in CS kidneys (p = 0.002). With a mean followup of 27 months, patient (91% PPP versus 96% CS) and kidney graft survival (81% PPP versus 81.5% CS) rates were comparable. Mean 12-month serum creatinine (1.9 mg/dL) and calculated Modification of Diet in Renal Disease glomerular filtration rate (41 mL/min) values were similar between groups.

CONCLUSIONS

Despite longer cold ischemia times, recipients of ECD kidneys managed with PPP had similar survival and functional outcomes, but experienced a marked reduction in the rate of delayed graft function.

Intermediate-term outcomes with expanded criteria deceased donors in kidney transplantation: a spectrum or specter of quality?

OBJECTIVE

To compare intermediate-term outcomes in adult recipients of expanded criteria (ECD) versus concurrent standard criteria (SCD) deceased donor kidney transplants at a single center using a standardized approach.

SUMMARY BACKGROUND DATA

Expanded criteria donors (ECDs) are a source of kidneys that increase the donor organ pool, but the value of transplanting these kidneys has been questioned because of concerns regarding diminished survival and predicted poorer intermediate-term outcomes.

METHODS

Over a 47-month period, we performed 244 deceased donor kidney transplants into adult recipients, including 143 from SCDs and 101 from ECDs. Management algorithms were implemented to preserve nephron function, and recipient selection for an ECD kidney transplant was based on low immunologic risk. All patients received depleting antibody induction in combination with tacrolimus and mycophenolate mofetil. A total of 188 patients (77%) had at least a 1-year follow-up.

RESULTS

ECDs were older, had a higher BMI, had an increased incidence of cerebrovascular brain death and preexisting donor hypertension, and had a lower estimated creatinine clearance (CrCl, all P < 0.01) compared with SCDs. Cold ischemic times were similar between groups, but more ECD kidneys were preserved with pulsatile perfusion (P < 0.01). ECD kidney recipients were older, less sensitized, had a lower BMI, had fewer 0-antigen mismatches, and had a shorter waiting time (all P < 0.01) compared with SCD kidney recipients. Actual patient (93%) and kidney graft (83%) survival rates were similar between groups with a mean follow-up of 24 months. The rates of delayed graft function (DGF), acute rejection, readmissions, operative complications, major infections, and resource utilization were comparable between groups. Renal function followed longitudinally was consistently better in SCD patients (P < 0.05). Black recipients had higher rates of DGF, acute rejection, and graft loss (P < 0.05), but the effects were less pronounced in the ECD group.

CONCLUSIONS

By appropriate donor and recipient profiling and the use of management algorithms to project and protect renal function, excellent intermediate-term outcomes can be achieved with ECD kidney transplants that are comparable to SCD kidney transplants.

The Fate of Organs Refused Locally and Transplanted Elsewhere

The number of kidney allografts procured from deceased donors has been fairly constant in the past few years, while organs from living donors steadily increase. In our program, existing protocols refused some kidneys which were subsequently accepted and transplanted at other hospitals. Thus, a review of our criteria to accept kidneys became necessary.

METHODS

We studied the outcome of all kidneys refused by us but transplanted in other programs between 2002 and 2004. The data analyzed included ID no. donor, transplant center, procurement date, donor age, ischemic times, recipient alive or dead, creatinine level (when it was offered), initial function, hypertension, diabetes mellitus, biopsy, reason why the kidney was not accepted in our program, kidney functioning or lost, and cause of graft failure. The chi-square, Fisher, and t tests were used to analyze our data; P values of <.05 were regarded as significant.

RESULTS

Originally 137, we excluded kidneys exported due to mandatory sharing (26 of 137 = 18.97%) and multiorgan placement (10 of 137 = 7.3%). Thus, 101 kidneys were not accepted by us because they did not meet the existing criteria of our program, but were accepted elsewhere. Reasons for nonacceptance were divided into donor quality, donor social history, donor age, donor size/weight, positive serological test, as well as organ preservation time, organ anatomical damage, elevated creatinine, abnormal urinalysis, abnormal biopsy, and decreased urine output. Donor issues were 66 of 101 (65.3%) with a graft loss of 13.6%, and organ issues were 35 of 101 (34.7%) with a graft loss of 66.6%. Donor quality totaled 24 of 66 (36.4%) and donor social history totaled 20 of 66 (30.3%); these were the most common causes for kidney nonacceptance related to donor issues. Reasons related to organ quality included elevated creatinine (15 of 35 = 42.9%; graft loss, 46.6%), and abnormal biopsy (9 of 35 = 25.7%; graft loss, 11.1%) and organ anatomical damage (4 of 35 = 11.4%; graft loss, 75%) (P = .42). Graft loss was more frequent with creatinine levels above 2.4 mg/dL (P < .001, RR gf = 1.5). Long-term fate of these 101 kidneys transplanted elsewhere: 82 (81.2%) were still working while 19 (18.8%) were lost. The causes of graft loss were renal artery thrombosis (42.1%), renal venous thrombosis (26.3%), death for other reasons (15.8%), graft never worked (10.5%), and ESRD (5.7%). The results suggest that the criteria for refusal related to donor issues, including hypertension, diabetes mellitus, donor age and donor size, should be revised owing to the low percentage of graft loss. Other donor issues such as positive serological test and donor social history (drug use, alcoholism) represent a serious potential risk for the health of recipients; for this reason, considering these persons as possible donors is very difficult irrespective of the graft outcome. Kidney refusals related to organ issues (especially elevated creatinine and anatomical damage) due to the very high percentage of graft loss should be considered high risk and probably be excluded. The increase in the demand of kidneys to be transplanted is a very important reason for a continuous and systematic review of donor exclusion criteria in every transplant program. The results presented here have helped us to improve both our outcomes and utilizations based on scientific evidence.

Kidney Transplantation From Donors Aged 65 Years or More as Single or Dual Grafts

AIM

The organ shortage and aging donor population force transplant centers to accept donors previously considered unusable for kidney transplantation. We report the experience of two Italian transplant centers with single (SKTx) and dual (DKTx) kidney transplantation from donors aged 65 years or more.

METHODS

The study population comprised 75 SKTx (mean donor age 70.5 years) and 28 DKTx (mean donor age 75.0 years). Kidneys from donors with a calculated admission creatinine clearance <50 mL/min, a Karpinski's score on kidney biopsy between 5 and 7, or both were allocated to DKTx. Grafts with better function or lower biopsy scores were employed for SKTx.

RESULTS

Delayed graft function occurred in 45.3% of SKTx and in 39.3% of DKTx. After a mean follow-up period of 30.0 +/- 19.5 months, the acute rejection rate was 24.0% in SKTx and 7.1% in DKTx. Mean serum creatinine was 1.8 +/- 0.9 and 1.8 +/- 1.3 mg/dL in SKTx, and 1.8 +/- 1.6 mg/dL and 1.3 +/- 0.2 mg/dL in DKTx at 1 and 5 years, respectively. Patient survival was 93.3% and 91.2% in SKTx, and 92.9% and 92.9% in DKTx at 1 and 5 years, respectively. Graft survival was 92.0% and 88.3% in SKTx, and 89.3% and 89.3% in DKTx at the same time intervals. Keeping preservation time below 16 hours and avoiding calcineurin inhibitors were both associated with improved graft survival and function.

CONCLUSION

Careful donor selection, short preservation time, and tailored immunosuppression allow safe and efficient use of elderly donor kidneys.

Expanded-criteria donor kidneys: a single-center clinical and short-term financial analysis--cause for concern in retransplantation

BACKGROUND

Expanded-criteria donor (ECD) kidneys are associated with a higher risk of posttransplant failure, but they remain a favorable alternative to dialysis. Now that a uniform definition of "expanded criteria" exists, it is more appropriate than ever to evaluate their utility compared with that seen with non-ECD kidneys.

METHODS

The authors analyzed 202 cadaveric kidney-only recipients that underwent transplantation from January 1999 to September 2001, including 45 (22%) recipients whose donors met current ECD criteria.

RESULTS

ECD and non-ECD kidney recipients had similar pretransplant characteristics except for older age and increased duration of renal failure in the ECD group. Patient, graft, and death-censored graft survival in both groups were similar in primary recipients but significantly worse in retransplant recipients of ECD kidneys. The relative risk of death-censored graft loss was 1.58 in the ECD group (P = 0.45). Overall inpatient charges (minus organ acquisition charge) for 1 year posttransplant were 76,962 US dollars (ECD) versus 71,026 US dollars (non-ECD) (P = 0.53); the same charges in retransplant recipients were 136,596 US dollars (ECD) versus 91,296 US dollars (non-ECD) (P = 0.25). ECD recipients, especially retransplant recipients, had consistently higher creatinine concentrations, although the average current value of all functioning ECD grafts remains less than 2 mg/dL. ECD recipients had a higher incidence of ureteral stricture (4.4% vs. 0%), but this never resulted in graft loss.

CONCLUSIONS

Considering the widening disparity between renal allograft availability and need and the fact that ECD kidneys provide superior outcomes compared with dialysis, the authors' data encourage the continued use of ECD kidneys in primary recipients but justify caution in the retransplant setting.

Factors associated with (un)willingness to be an organ donor: importance of public exposure and knowledge

BACKGROUND

Transplantation is increasingly limited by the supply of donor organs. Identifying subgroups that do not support organ donation will allow targeted efforts to increase organ donation.

METHODS

A total of 185 non-acutely ill outpatients visiting a community physician's office voluntarily completed a survey designed to capture views and general knowledge/misconceptions about cadaveric organ donation/transplantation.

RESULTS

Of 185 patients, 86 were willing to donate, 42 were unwilling, and 57 were unsure. Willingness to donate was significantly associated with: having discussed the topic with family; having known a cadaveric organ donor; age 55 yr; having graduated high school; recognizing the organ shortage as the primary problem in transplantation; having received a post-high school degree; having seen public information within 30 d; and having a family member in health care (all p</=0.05). Not significant were: gender; race; religious affiliation or regular church attendance; knowing a transplant recipient or wait-listed patient; and having easy internet access. Those unwilling/unsure more often thought: organ allocation is based on race/income; organ donation is expensive for the donor family; designated donors may not receive full emergency room care; a brain-dead person can recover.

CONCLUSIONS

Intense efforts to improve public awareness and knowledge about organ donation/transplantation are necessary to maximize donation and the overall success of transplantation.

Increased kidney transplantation utilizing expanded criteria deceased organ donors with results comparable to standard criteria donor transplant

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.

Kidney transplantation from donors aged more than 65 years

BACKGROUND

There are no agreed criteria to predict the outcome of elderly donor kidneys or to decide between single (SKG) or dual (DKG) kidney graft transplantation.

METHODS

Between January 1999 and January 2003, 46 SKG and 14 DKG were performed from elderly donors (mean donor age 71.6 years; range: 66 to 87). Kidney biopsies were scored according to Karpinski. A calculated admission creatinine clearance <50 mL/min and/or a biopsy score of 5 or 6 were used to select kidneys for DKG. Grafts with better function or lower biopsy scores were employed for SKG.

RESULTS

Mean cold ischemia time (CIT) was 16.8 hours (range 8.1 to 28.6) in SKG, and 16.3 hours (range 4.6 to 24.3) for the first kidney and 17.4 hours (range 5.1 to 25.9) for the second graft in DKG. Delayed graft function (DGF) occurred in 34.1% SKG and in 28.5% DKG. Acute rejection rates were 9.1% for SKG and 0% for DKG. Three-year actuarial patient survival rates were 97.7% for SKG and 92.9% for DKG; for kidneys, 95.4% and 92.9%. One-year mean serum creatinine levels were 1.8 mg/dL (range 1.1 to 4.0) for SKG and 1.2 mg/dL (range 1.0 to 1.8) for DKG (P =.01). CIT longer than 16 hours was related to increased rates of DGF for both SKG (45.4% vs 22.7%) or DKG (42.9% vs 14.3%) and reduced 3-year graft survival rates (SKG: 90.9% vs 100%; DKG: 85.7% vs 100%).

CONCLUSIONS

With stringent selection criteria and short CIT (<16 hours), elderly donor kidneys may show good results, thus meaningfully expanding the donor pool.

Perceptions of the donation process from adult-to-adult living liver donors

BACKGROUND

Donor safety and the impact on quality of life continue to concern transplant centers as living liver transplantation increases.

METHODS

Living liver donors participated in a focus group to discuss their perceptions of the donation process.

RESULTS

The decision to donate was a personal choice made before the request by the recipient or transplant service. Spouses verified their support, but indicated that they were not included in the process. No donors felt coerced. The explanation of the procedure was thorough but excessive. Hospital care was good; however, donors admitted being unprepared for the pain and side effects of pain medications. Ongoing incisional discomfort continued beyond 6 weeks and prevented donors from feeling normal. Donors felt conflicted about competing with the "true" patient for healthcare.

CONCLUSIONS

Donors were positive about the need and willingness to donate. Sensitivity to the order of the disclosure process is identified.

Heart transplantation with donors fifty years of age and older

OBJECTIVE

Limited availability of donor organs has led to the progressive expansion of the criteria for donor selection, particularly a higher age limit of potential donors. We retrospectively reviewed the outcomes of patients who underwent heart transplantation using cardiac allografts 50 years of age and older and compared them with patients who had donor organs younger than 50 years.

METHOD

Between September 1989 and May 2000, 20 patients underwent orthotopic heart transplantation using donor hearts 50 years of age and older (range 50-56 years, mean 52.7 +/- 1.8 years) and were compared with 267 patients who received donor organs less than 50 years of age (range 9-49.9 years, mean 27.2 +/- 8.6 years). Patient and donor criteria were identical in both groups. Follow-up was 4 to 128 months with a mean of 37.4 +/- 2.8 months in the older donor group and 52.6 +/- 2.4 months in the younger donor group.

RESULTS

There were no differences between these 2 cohorts of patients regarding age, sex, cardiomyopathy, preoperative cytomegalovirus status, New York Heart Association class, and transplant status at transplantation. Donor characteristics, including sex, left ventricular ejection fraction, diabetes, cytomegalovirus status, and allograft ischemic times, were also similar in the 2 groups. Donor/recipient cytomegalovirus matching showed no differences as well. Thirty-day or to discharge operative mortality was similar in the older and younger donor groups (5% +/- 4.8% vs 3.5% +/- 1.1%; P =.84). Actuarial survival at 1 and 5 years was also similar in both groups (89.7% +/- 6.9% vs 91% +/- 1.8% and 53.1% +/- 14.7% vs 71.0% +/- 3.1%, respectively; P =.59). No patient in the older donor group required coronary artery bypass grafting or retransplantation during the follow-up period, whereas 2 patients in the younger donor group required coronary artery bypass, and 5 patients underwent retransplantation (P > or =.50). Two patients in the older donor group died of nonspecific allograft failure, whereas 3 patients in the younger donor group experienced similar posttransplant complication (P > or =.50).

CONCLUSIONS

Carefully selected donor hearts 50 years of age and older can be used for heart transplantation with long-term survival and related outcomes similar to those of younger donor organs. This use of selective cardiac allografts maximizes donor organ usage and expands the donor pool effectively without an adverse impact on long-term results.

Use of marginal organs from non-heart-beating cadaveric kidney donors

BACKGROUND

The severe shortage of cadaver donor kidneys for transplantation has prompted many centers to utilize older donor kidneys, which have been associated with lower graft survival rates. The aim of the present study was to examine the availability and feasibility of considering kidneys from donors over the age of 60.

METHOD

We studied 252 cadaveric renal transplant recipients (156 males, 96 females) who received kidneys from uncontrolled non-heart-beating donors between 1987 and 1997. We performed in situ cooling with especially designed double-balloon catheters to minimize warm ischemic kidney damage. Recipients were classified according to donor age (<age 60 and >age 60), and we examined graft survival rates. All patients were followed for a minimum of 1 year after transplantation.

RESULTS

Graft survival rates for recipients of kidneys from the older donor group at 1, 5, and 10 years after transplantation were 77%, 37%, and 30%, respectively. Corresponding values for the younger donor kidney recipients were 87%, 64%, and 47%, respectively (P=0.0011). Improved survival rates were noted when older kidneys were used for lighter weight recipients (<54 kg). No other significant factors impacted on older donor graft survival rates.

CONCLUSION

Older donor kidneys are associated with poorer graft survival rates. However, kidney transplants from older donors can be quite effective in lighter weight recipients (<54 kg).

Care of the potential pediatric organ donor

Although all of this information may create the impression that caring for a potential organ donor is an exceedingly complex task, in the authors' experience, this often is not true, and much energy can--and should--be devoted to the care of the bereaved family. Of crucial importance are the early recognition of brain death and the consequent radical switch of the treatment goal from preservation of the patient's brain and life to preservation of organs for the lives of others. Care for the donor is the natural extension of care for a critically ill or injured patient. During the foregoing discussion, the authors had to stress the absence of sound evidence on many points. Because many reports originate from transplant centers dedicated to a specific organ, gaining a comprehensive view on management options in the ICU further is hampered. Thus, this situation leaves another field in which investigations originating from pediatric intensivists could provide evidence urgently needed to make optimal choices. The next decade should see the thyroid hormone controversy solved by at least one controlled prospective study and the differential applicability of inotropic, vasoactive, or fluid-centered strategies. It seems self-evident that only graft survival and related parameters can form adequate endpoints for future studies.

Angiography of potential cardiac donors

OBJECTIVES

This retrospective review of organ donor records was designed to evaluate the practice of donor angiography in one organ procurement organization and determine the outcomes of angiography and its impact on the timing of the organ donation process.

BACKGROUND

Concerns about transmission of atherosclerosis from donor to recipient have been heightened by the increasing prevalence of older donors. Guidelines that advocate the use of angiography in specific settings have been published, but no formal large-scale review has been performed.

METHODS

For the period January 1993 through June 1997, we reviewed all New England Organ Bank records of donors between the ages of 40 and 65 including any from whom at least one solid organ was procured. Data abstracted included the presence of risk factors, timing of the evaluation process and angiographic findings.

RESULTS

Coronary angiography was performed in 119 donors aged 40 and older; 64.7% of these hearts were transplanted. Thirty-eight hearts were transplanted from donors not subjected to angiography and outcomes were poorer compared with donors who underwent angiography. Advanced donor age was the only significant predictor of coronary artery disease. The duration of the procurement process was not prolonged by the performance of angiography.

CONCLUSIONS

Donor coronary angiography does not complicate the donation process. Older donor age is the most powerful predictor of coronary artery disease and may explain prior observations of poorer outcome with older donor hearts. These factors should be considered when angiography is performed as part of the heart donor evaluation.

Economic cost of expanded criteria donors in cadaveric renal transplantation: analysis of Medicare payments

BACKGROUND

The use of expanded criteria donors (ECDs) in cadaveric renal transplantation is increasing in the US. We assess the economic impact of the use of ECDs to the Medicare end stage renal disease program.

METHODS

The United Nations for Organ Sharing renal transplant registry was merged to Medicare claims data for 42,868 cadaveric renal transplants performed between 1991-1996 using USRDS identifiers. Only recipients for whom Medicare was the primary payer were considered, leaving 34,534 transplants. An ECD was defined as (1) age < or =5 or > or =55 years, (2) nonheart-beating donors, donor history of (3) hypertension or (4) diabetes. High-risk recipients (HRR) were age >60 years, or a retransplant. Medicare payments from the pretransplant dialysis period were projected forward to provide a financial "breakeven point" with transplantation.

RESULTS

There were 25,600 non-HRR transplants, with 5,718 (22%) using ECDs, and 8,934 HRR transplants, of which 2,200 (25%) used ECDs. The 5-year present value of payments for non-ECD/non-HRR donor/recipient pairings was $121,698 vs. $143,329 for ECD/non-HRR pairings (P<0.0001) and, similarly was $134,185 for non-ECD/HRR pairings vs. $165,716 for ECD/HRR pairings (P<0.0001). The break even point with hemodialysis ranged from 4.4 years for non-ECD/ non-HRR pairings to 13 years for the ECD/HRR combinations but was sensitive to small changes in graft survival. Transplantation was always less expensive than hemodialysis in the long run.

CONCLUSIONS

The impact of ECDs on Medicare payments is most pronounced in high-risk recipients. Cadaveric renal transplantation is a cost-saving treatment strategy for the Medicare ESRD program regardless of recipient risk status or the use of ECDs.

Expanded criteria donors: attempts to increase the renal transplant donor pool

There is a growing disparity between the demand for and the supply of kidneys for transplantation. The demographics of the donor pool are also changing. The average potential cadaveric organ donor is now more likely to be older, at greater risk for co-morbid conditions such as hypertension or viral infections, and more likely to die from cerebrovascular disease. These factors have led to an expansion of the criteria that defines the suitable organ donor. Expanded criteria donors are defined as the following: (1) at the upper and lower extremes in age; (2) having a history of hypertension or diabetes; (3) hemodynamically unstable; (4) non-heartbeating (cardiopulmonary death rather than brain death); (5) seropositive for hepatitis B or C; (6) having systemic infections; (7) having displayed high-risk social behavior for HIV infection; (8) having a history of malignancy; (9) having abnormal organ function; or (10) with renal anatomic anomalies or injuries. Use of kidneys from these "expanded criteria donors" is a two-edged sword. While they provide more organs for transplantation, the risk of suboptimal recipient outcome is increased. A rational approach to the use of each of these types of kidneys and proper selection of recipients is essential to obtain acceptable results. The article reviews the factors that have contributed to the successful transplantation of kidneys procured from expanded criteria organ donors and how these organs can be allocated most efficaciously to the appropriate recipients.

[Frozen section biopsy in the assessment of organs for transplantation]

BACKGROUND

The success of transplantation and the increase in its indications has caused organ donations to be unable to meet the global demand. By broadening the donor selection criteria and accepting so-called suboptimal donors in an attempt to solve this problem, a careful individualized assessment is required of the validity of each donor. This often implies the need for a pretransplantation biopsy study.

MATERIAL AND METHODS

Evaluation of frozen-section biopsy studies in the assessment of graft and donor validness in the the transplantation program of the La Fe University Hospital (Valencia, Spain) during 1998, when a total of 301 solid organ transplantations were performed.

RESULTS

Sixty pretransplantation frozen-section biopsies were performed (29 of the liver, 21 renal, 3 lymph nodes, 3 brain, 2 prostatic, 1 myometrial and 1 pericardial). As a result of the bioptic study, 18 transplantations were invalidated (30% of all biopsies). The most frequent causes of invalidation were liver macroesteatosis (7 cases), malignancies (5 cases) and renal parenchymal lesions (5 cases). Among the tumor diagnosis there were one false-positive and one false-negative results of malignancy.

CONCLUSION

Frozen-section biopsies evaluation in suboptimal organ donors or donors suspected of suffering disease integrates morphological analysis in the transplantation team decision process, and affords a quality factor in the selection of donors.

Proportion of glomerulosclerosis in procurement wedge renal biopsy cannot alone discriminate for acceptance of marginal donors

BACKGROUND

The shortage of available kidneys for renal transplantation could be addressed, to some extent, by expanding the criteria for acceptance of marginal donors. The study of these criteria is limited by the selection of grafts actually retrieved and transplanted, therefore reduced to a study of risk factors. We have evaluated the potential of procurement renal biopies as an instrument for acceptance or refusal of donor kidneys for transplantation.

METHODS

This was a prospective study of a consecutive series of 200 donors. Biopsies were performed by wedge technique at the donor operation and were evaluated for proportion of glomerulosclerosis, vascular and tubular changes, and interstitial fibrosis. The study included 387 renal grafts with a representative biopsy, transplanted, and followed-up for survival and functional evaluation; 24 hr creatinine clearance at 1 and 3 weeks, and 3, 6, 12, 18, and 24 months.

RESULTS

Factors associated with initial graft function included cold ischemia time, number of DR mismatches, tubular changes, although donor age showed the strongest correlation with short- and long-term level of graft function. DR mismatches and retransplantation appeared to be the only significant risk factors for graft loss. The proportion of glomerulosclerosis (mean 8%, range 0-48%) correlated with graft function in the simple regression analysis. However, when age was taken into account glomerulosclerosis did not correlate significantly with graft function. Furthermore, glomerulosclerosis as high as 25% or more had an acceptable 3-year graft survival rate of 74.7%.

CONCLUSION

Procurement biopsy provides only limited information for the decision whether or not to accept a kidney donor.

Ethical analysis of organ recovery denials by medical examiners, coroners, and justices of the peace

CONTEXT

Despite its pivotal nature, until the early 1990s the role of medical examiners, coroners, and justices of the peace was largely ignored in discussions of the critical shortage of organs for transplantation in the United States. These officials have the right to determine, from a medico-legal perspective, whether a deceased person can be an organ donor. Thus, they play an important role in the donation process. Using a principles-based ethical framework, this article examines the problem of nonrecovery of life-saving organs for transplantation in the United States because a medical examiner or other official denies recovery.

OBJECTIVE

The goals of organ donation and the collection of forensic evidence are not mutually exclusive. An analysis of the ethical principles and obligations of beneficence, respect for autonomy, and justice reveals that medical examiners and other officials could probably, after appropriate review, release all cases under their jurisdiction for organ donation.

CONCLUSION

Medical examiners, coroners, and justices of the peace could assume a leadership role, working together on public policy with medical, social, and legal groups, spearheading efforts to stop the loss of organs due to official denials, up to and including state and federal regulation and legislation. Beyond their professional obligations, as agents of a social institution, medical examiners and other officials have the more general ethical responsibility of promoting the public health and welfare and of reinforcing societal consensus that transplantation is a social good which should be optimized through formal and informal activities.

Outcome of kidney transplantation from high-risk donors is determined by both structure and function

METHOD

Despite the need to expand the donor pool, it is unclear what parameters should be used. The value of donor renal pathology and calculated creatinine clearance (CrCl) in determining recipient outcome was assessed in 57 kidney transplants from 34 donors in whom pretransplant renal biopsies were performed because of age > or =60, hypertension, and/or vascular disease. We retrospectively compared clinical outcomes in these recipients and 57 control recipients selected to have the same baseline demographics but receiving transplants from low risk donors who were significantly younger (32+/-13.9 vs. 61+/-7.3 years) and lighter weight (71+/-18.1 vs. 84+/-20.2 kg) than the high-risk donors (P<.001 for both).

RESULTS

Recipients of high-risk kidneys had a higher incidence of delayed graft function, defined by a <10% fall in serum creatinine (Cr) in the first 24 hr, (56% vs. 30%, P<.01), a higher incidence of rejection (60% vs. 37%, P = .02) and a higher Cr level (197+/-64 vs. 144+/-54 micromol/L at 18 months, P<.005). Graft and patient survival were similar; 12% and 5% vs. 91% and 9% in high-risk vs. control groups, respectively (P = NS). Donor renal pathology was scored 0-3 (none to severe disease) in four areas: glomerulosclerosis, interstitial fibrosis, tubular atrophy, and vascular disease. A donor vessel score of 3/3 was associated with a 100% incidence of delayed graft function and a mean 1-year Cr level of 275+106 micromol/L (compared with 43% and 192+54 micromol/L in those with lower vessel scores, P<.05). Calculated donor CrCl <100 ml/min was associated with higher recipient Cr levels at 1 year, 240+/-95 micromol/L vs. 180+/-54 micromol/L in recipients of kidneys from donors with CrCl levels >100 ml/min (P<.05). The mean 1-year Cr level was 320+/-102 micromol/L in recipients with both a vascular score of 3/3 and a donor CrCl <100 ml/min and 184+/-63 micromol/L in those with neither factor (P = .001).

CONCLUSION

Calculated donor CrCl and donor vascular pathology predict recipient graft function and may be helpful in selecting high-risk donors for single kidney transplantation.

Researcher-driven versus policy-driven economic appraisal. The case of xenotransplantation

Worldwide ethical considerations have led to banning markets for human organs and to promoting supply of organs for transplantation strictly on a donor noncommercial basis. In most industrialized countries, including France, there is a shortage of organs available for transplantation. Following on the earlier debate between Titmuss and Arrow over banning the market for blood supply, this presentation first challenges the conventional economic view that the ban is necessarily responsible for these critical shortages. It will argue that it is the obstacles to adequate exhortation (i.e., the efforts to inform and persuade participants in the donor system who cannot be paid for what they supply) rather than the inefficiency per se of appeals to donor altruism that are the cause of a shortage. The paper will then discuss the way a market for non-human organs may be an efficient alternative to a donor system by supplying a substitute good. Data from a survey in a random sample of the French general population (> or = 18 years of age in June 1997; response rate = 62.0%; n = 1,011) show that less than half of the respondents (42.4%) agreed that xenotransplantations should be developed. Support for xenotransplantation was higher (50.6% vs. 38.2% in the rest of the sample, p < 0.001) among respondents who declare that in case of an accidental death of a family member, they would accept the use of his organs for transplantation, among those with the highest level of knowledge about transplantation (48.6% vs. 39.4%, p < 0.005), and among blood donors (45.9% vs. 38.3%, p < 0.02). Supply of non-human organs should remain under the control of the public sector in order to be consonant with current donor systems for human organs. Recommendations for adequate regulation of the R&D process of non-human alternatives for organ transplantations will be made.

Cardiac transplantation

Cardiac transplantation has proven to be an effective and life-saving option for those patients with congestive heart failure who deteriorate despite maximal medical management. The recipients have been able to return to life as productive citizens with improved quality as well as quantity of life. Advances in assist-device technology will mean that more patients will survive until donor hearts become available and ultimately may supplement the organ supply by serving as an alternative to transplant in some patients.

Management of the Organ Donor

Advances in immunosuppressive therapy have led to increased use of organ transplantation to treat end- organ failure. This has led to a consistent shortage of transplantable organs, with many patients dying while awaiting heart, liver, or lung transplantation. Traditional donor criteria are expanding and increase the pool of available donor organs. The organ procurement process often begins with the diagnosis of brain death, which must be made by clinical criteria and is usually con firmed by clinical testing. Because brain-dead patients suffer a variety of hemodynamic, cardiac, endocrine, respiratory, and hematologic abnormalities, manage ment in the intensive care unit demands meticulous attention and expertise. Living and, occasionally, non- heart-beating donors are also a source of donor organs. Management of the various types of donors in the operating room requires specific skills and knowledge. The persistent need for donor organs requires that poten tial organ donors be recognized and appropriately man aged to maximize the pool of available organs for the ever- increasing number of potential organ recipients.