Acceptable outcome after kidney transplantation using "expanded criteria donor" grafts. Transplantation. 2010;89:88-96. [PMID: 20061924 DOI: 10.1097/tp.0b013e3181c343a5]

Long and Short-Term Effects of Hypothermic Machine Perfusion vs. Cold Storage on Transplanted Kidneys from Expanded Criteria Donors-A Matched Comparison Study

Hypothermic machine perfusion (HMP) has been shown to reduce delayed graft function (DGF)-rates in kidneys from expanded criteria donors (ECD) and may increase graft survival compared with static cold storage (SCS). This single-center, retrospective observational study aimed to evaluate this effect. The primary endpoint was the DGF-rate, defined as the use of dialysis in the first postoperative week, excluding the first 24 h. The main secondary endpoint was graft survival at 5 years. Recipients of ECD-kidneys between 2013 and 2021 with ≤2 grafts were included (n = 438). The SCS-kidneys were marginal-matched by propensity score to the HMP-group for donor age, cold ischemia time, and graft number. Multivariable adjusted analysis for confounders in the unmatched cohort and caliper-based ID-matching constituted sensitivity analyses. HMP showed a trend to lower DGF-rate in the marginal-matched comparison (9.2% vs. 16.1%, p = 0.063). This was strengthened by a significant benefit observed for HMP in both the sensitivity analyses: an adjusted OR of 0.45 (95% CI: 0.24; 0.84; p = 0.012) in the multivariable analysis and DGF-rate of 8.7% vs. 17.4% (p = 0.024) after ID-matching. The 5-year graft survival rate was >90% in both groups, with no benefit using HMP (HR = 0.79; 95% CI:0.39-1.16; p = 0.52). Our results suggest that HMP may be effective in decreasing DGF-rates, however, without any significant benefit in graft survival.

Kidney Transplantation Outcome Predictions (KTOP): A Risk Prediction Tool for Kidney Transplants from Brain-dead Deceased Donors Based on a Large European Cohort

BACKGROUND

European kidney donation shortages mandate efficient organ allocation by optimizing the prediction of success for individual recipients.

OBJECTIVE

To develop the first European online risk tool for kidney transplant outcomes on the basis of recipient-only and recipient plus donor characteristics.

DESIGN, SETTING, AND PARTICIPANTS

We used individual recipient and donor risk factors and three outcomes (death, death with functioning graft [DWFG], and graft loss) for 32 958 transplants within the Eurotransplant kidney allocation system and the Eurotransplant senior program between January 2006 and May 2018 in eight European countries to develop and validate a risk tool.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cox proportional-hazards models were used to analyze the association of risk factors with overall patient mortality, and proportional subdistribution hazard regression models for their association with graft loss and DWFG. Prediction models were developed with recipient-only and recipient-donor risk factors. Sensitivity analyses based on time-specific area under the receiver operating characteristic curve (AUC) with leave-one-country-out validation were performed and calibration plots were generated.

RESULTS AND LIMITATIONS

The 10-yr cumulative incidence rate was 37% for mortality, 12% for DWFG, and 41% for graft loss. In recipient-donor models the leading risk factors for mortality were recipient diabetes (hazard ratio [HR] 10.73), retransplantation (HR 3.08 per transplant), and recipient age (HR 1.08). Effects were similar for DWFG. For graft loss, diabetes (subdistributional HR [SHR] 1.32), increased donor age (SHR 1.02), and prolonged cold ischemia time (SHR 1.02) had increased SHRs. All p values were <0.001.

CONCLUSIONS

Previously identified risk factors for outcomes following kidney transplants allow for outcome prediction with 10-yr AUC values of up to 0.81.

PATIENT SUMMARY

Using European data, we estimated individual risks to predict the success of kidney transplants and support physicians in decision-making. An online tool is now available (https://riskcalc.org/ktop/) for predicting kidney transplant outcomes both before and after a donor has been identified.

Shifting Paradigms for Suppressing Fibrosis in Kidney Transplants: Supplementing Perfusion Solutions With Anti-fibrotic Drugs

Great efforts have been made toward addressing the demand for donor kidneys. One of the most promising approaches is to use kidneys from donation after circulatory death donors. These kidneys, however, suffer from more severe ischemia and reperfusion injury than those obtained via donation after brain death and are thus more prone to develop interstitial fibrosis and tubular atrophy. Even though machine perfusion is increasingly used to reduce ischemia and reperfusion injury, there are no effective treatments available to ameliorate interstitial fibrosis and tubular atrophy, forcing patients to resume dialysis, undergo re-transplantation, or suffer from premature death. Safe and effective anti-fibrotic therapies are therefore greatly desired. We propose a new therapeutic approach in which machine perfusion solutions are supplemented with anti-fibrotic compounds. This allows the use of higher concentrations than those used in humans whilst eliminating side effects in other organs. To the authors' knowledge, no one has reviewed whether such an approach could reduce interstitial fibrosis and tubular atrophy; we therefore set out to explore its merit. In this review, we first provide background information on ischemia and reperfusion injury as well as interstitial fibrosis and tubular atrophy, after which we describe currently available approaches for preserving donor kidneys. We then present an evaluation of selected compounds. To identify promising compounds, we analyzed publications describing the effects of anti-fibrotic molecules in precision-cut kidneys slices, which are viable explants that can be cultured ex vivo for up to a few days whilst retaining functional and structural features. LY2109761, galunisertib, imatinib, nintedanib, and butaprost were shown to exert anti-fibrotic effects in slices within a relatively short timeframe (<48 h) and are therefore considered to be excellent candidates for follow-up ex vivo machine perfusion studies.

Advances in Kidney Preservation Techniques and Their Application in Clinical Practice

The use of cold preservation solutions to rapidly flush and cool the kidney followed by static cold storage in ice has been the standard kidney preservation technique for the last 50 y. Nonetheless, changing donor demographics that include organs from extended criteria donors and donation after circulatory death donors have led to the adoption of more diverse techniques of preservation. Comparison of hypothermic machine perfusion and static cold storage techniques for deceased donor kidneys has long been debated and is still contested by some. The recent modification of hypothermic machine perfusion techniques with the addition of oxygen or perfusion at subnormothermic or near-normothermic temperatures are promising strategies that are emerging in clinical practice. In addition, the use of normothermic regional perfusion to resuscitate abdominal organs of donation after circulatory death donors in situ before cold flushing is also increasingly being utilized. This review provides a synopsis of the different types of preservation techniques including their mechanistic effects and the outcome of their application in clinical practice for different types of donor kidney.

Kidney transplantation after rescue allocation-meticulous selection yields the chance for excellent outcome

BACKGROUND

The small number of organ donors forces transplant centres to consider potentially suboptimal kidneys for transplantation. Eurotransplant established an algorithm for rescue allocation (RA) of kidneys repeatedly declined or not allocated within 5 h after procurement. Data on the outcomes and benefits of RA are scarce to date.

METHODS

We conducted a retrospective 8-year analysis of transplant outcomes of RA offers based on our in-house criteria catalogue for acceptance and decline of organs and potential recipients.

RESULTS

RA donors and recipients were both older compared with standard allocation (SA). RA donors more frequently had a history of hypertension, diabetes or fulfilled expanded criteria donor key parameters. RA recipients had poorer human leucocyte antigen (HLA) matches and longer cold ischaemia times (CITs). However, waiting time was shorter and delayed graft function, primary non-function and biopsy-proven rejections were comparable to SA. Five-year graft and patient survival after RA were similar to SA. In multivariate models accounting for confounding factors, graft survival and mortality after RA and SA were comparable as well.

CONCLUSIONS

Facing relevant comorbidities and rapid deterioration with the risk of being removed from the waiting list, kidney transplantation after RA was identified to allow for earlier transplantation with excellent outcome. Data from this survey propose not to reject categorically organs from multimorbid donors with older age and a history of hypertension or diabetes to aim for the best possible HLA matching and to carefully calculate overall expected CIT.

Long-term outcome of kidney transplant by using restored kidney grafts after tumour ex vivo excision - a prospective study

The aim of this study is to report long-term outcomes of kidney transplantation by using the kidney graft after a small tumour ex vivo excision. A structured programme was established to use the restored kidney graft from urological referral after radical nephrectomy. The criteria were defined as tumour size ≤3 cm, margin clear on frozen section and recipients aged ≥60 years or those on the urgent list for transplantation as a result of imminent lack of dialysis access. The recipients were followed up regularly for surveillance of tumour recurrence. Between February 2007 and February 2018, 28 recipients had kidney transplantation by using the restored kidney grafts. The tumour size was 2.6 ± 0.7 cm. The follow-up was median 7 years without evidence of tumour recurrence. The patient and graft survival was satisfactory. Kidney transplantation by using restored kidneys after a small tumour excision is a novel source for selected recipients. The long-term patient and graft survival is satisfactory. Although there is a risk of tumour recurrence, it is rare event. Together with literature review, we would support use of kidney graft after a small tumour excision for selected recipients.

Molecular Fingerprints of Borderline Changes in Kidney Allografts Are Influenced by Donor Category

The fate of transplanted kidneys is substantially influenced by graft quality, with transplantation of kidneys from elderly and expanded criteria donors (ECDs) associated with higher occurrence of delayed graft function, rejection, and inferior long-term outcomes. However, little is known about early molecular fingerprints of these events in different donor categories. Borderline changes represent the most frequent histological finding early after kidney transplantation. Therefore, we examined outcomes and transcriptomic profiles of early-case biopsies diagnosed as borderline changes in different donor categories. In this single-center, retrospective, observational study, we compared midterm outcomes of kidney transplant recipients with early borderline changes as a first pathology between ECD (n = 109), standard criteria donor (SCDs, n = 109), and living donor (LD, n = 51) cohorts. Intragraft gene expression profiling by microarray was performed in part of these ECD, SCD, and LD cohorts. Although 5 year graft survival in patients with borderline changes in early-case biopsies was not influenced by donor category (log-rank P = 0.293), impaired kidney graft function (estimated glomerular filtration rate by Chronic Kidney Disease Epidemiology Collaboration equation) at M3, 1, 2, and 3 years was observed in the ECD cohort (P < 0.001). Graft biopsies from ECD donors had higher vascular intimal fibrosis and arteriolar hyalinosis compared to SCD and LD (P < 0.001), suggesting chronic vascular changes. Increased transcripts typical for ECD, as compared to both LD and SCD, showed enrichment of the inflammatory, defense, and wounding responses and the ECM-receptor interaction pathway. Additionally, increased transcripts in ECD vs. LD showed activation of complement and coagulation and cytokine-cytokine receptor pathways along with platelet activation and cell cycle regulation. Comparative gene expression overlaps of ECD, SCD, and LD using Venn diagrams found 64 up- and 16 down-regulated genes in ECD compared to both LD and SCD. Shared increased transcripts in ECD vs. both SCD and LD included thrombospondin-2 (THBS2), angiopoietin-like 4 (ANGPTL4), collagens (COL6A3, COL1A1), chemokine CCL13, and interleukin IL11, and most significantly, down-regulated transcripts included proline-rich 35 (PRR35) and fibroblast growth factor 9. Early borderline changes in ECD kidney transplantation are characterized by increased regulation of inflammation, extracellular matrix remodeling, and acute kidney injury transcripts in comparison with both LD and SCD grafts.

Successful kidney transplantation from an expanded criteria donor with long-term extracorporeal membrane oxygenation treatment: A case report

BACKGROUND

Due to a shortage of donor kidneys, many centers have utilized graft kidneys from brain-dead donors with expanded criteria. Kidney transplantation (KT) from donors on extracorporeal membrane oxygenation (ECMO) has been identified as a successful way of expanding donor pools. However, there are currently no guidelines or recommendations that guarantee successful KT from donors undergoing ECMO treatment. Therefore, acceptance of appropriate allografts from those donors is solely based on clinician decision.

CASE SUMMARY

We report a case of successful KT from a brain-dead donor supported by ECMO for the longest duration to date. A 69-year-old male received a KT from a 63-year-old brain-dead donor who had been on therapeutic ECMO treatment for the previous three weeks. The recipient experienced slow recovery of graft function after surgery but was discharged home on post-operative day 17 free from hemodialysis. Allograft function gradually improved thereafter and was comparatively acceptable up to the 12 mo follow-up, with serum creatinine level of 1.67 mg/dL.

CONCLUSION

This case suggests that donation even after long-term ECMO treatment could provide successful KT to suitable candidates.

The evolution of donation after circulatory death renal transplantation: a decade of experience

BACKGROUND

This study compared long-term outcomes of renal transplantation from donors following donation after circulatory death (DCD) with those following donation after brain death (DBD) from one of the largest centres in the UK.

METHOD

Recipients of renal transplants from deceased donors between 2002 and 2014 were identified from a prospectively maintained database. Outcomes were compared between DCD (468) and DBD (905) donors and between standard criteria donors (SCDs) and extended criteria donors (ECDs).

RESULTS

Graft survival (GS) and patient survival (PS) from DCD and DBD donors were comparable up to 10 years (GS: 61 versus 55%, P = 0.780; PS: 78 versus 71%, P = 0.285, respectively). Graft function was comparable after 3 months. GS and function were worse in the ECD groups, with no difference between EC-DBD and EC-DCD. PS in the ECD groups was worse than the SCD groups and PS in the EC-DCD group was worse than in the EC-DBD group. DCD donors were an independent risk factor for delayed graft function. Post-operative complications and EC-DCD donation were independent risk factors for reduced GS and PS.

CONCLUSION

This study supports the use of DCD renal grafts with comparable long-term survival and function to DBD grafts. The use of EC-DCD grafts is justified in selected recipients and provides acceptable function and survival advantages over dialysis.

VI consensus document by the Spanish Liver Transplantation Society

The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.

Kidney Donation From a Patient Who Underwent Endovascular Aneurysm Repair

Organ shortage is the greatest challenge facing the field of organ transplantation in Korea. There are no reports of patients who have undergone endovascular aneurysm repair being considered as kidney donors. We successfully performed kidney transplant procedures in a 62-year-old man and a 57-year-old man using kidneys recovered from a 67-year-old female brain-dead donor who underwent endovascular aneurysm repair 6 months before organ retrieval. To the best of our knowledge, this is the first report of transplants performed with organs from a donor who previously underwent endovascular aneurysm repair.

VI consensus document by the Spanish Liver Transplantation Society

The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.

Impact of Korea Network for Organ Sharing Expanded Donor Criteria on Delayed Graft Fuction in Kidney Transplantation: A Single-Center Experience

BACKGROUND

The shortage of donor organs has been a major challenge in transplantation. In an effort to reduce the donor shortage, kidney transplantation (KT) using expanded criteria donors (ECD) was encouraged. In Korea, transplantation centers used the Korea Network for Organ Sharing (KONOS) ECD criteria, which is different from the United Network for Organ Sharing (UNOS) criteria. The aim of this study is to evaluate the predictive power of KONOS criteria on delayed graft function (DGF) in comparison to UNOS criteria.

METHODS

A total of 376 recipients who underwent deceased donor kidney transplantation between January 2005 and December 2014 at Severance Hospital were retrospectively reviewed. Of these, 130 cases satisfied KONOS ECD, while the others followed KONOS standard criteria donor (SCD).

RESULTS

Donor age and history of hypertension was significantly higher with KONOS ECD than with KONOS SCD. In KONOS subgroup analysis, donor characteristics were different than with UNOS criteria. The incidence of DGF was higher in the KONOS ECD group than in the KONOS SCD group. However, UNOS ECD showed a high incidence of DGF compared to UNOS SCD with the same KONOS criteria. UNOS ECD was an independent risk factor for DGF in multivariate analysis. However, KONOS ECD was not a risk factor for DGF. Although glomerular filtration rate was inferior in the KONOS ECD group compared to the KONOS SCD group, the UNOS SCD group within the KONOS ECD group showed similar graft function compared to the KONOS SCD group.

CONCLUSION

KONOS criteria have a lower predictive power for DGF than UNOS criteria.

Receiving Hypertensive Donor Grafts Is Associated with Inferior Prognosis in Simultaneous Liver-Kidney Transplantation Recipients

Background

The impact of hypertensive (HTN) donor grafts on the prognosis of simultaneous liver-kidney transplantation (SLKT) patient is not known, and an applicable risk scoring system for SLKT patient survival is lacking. This study aimed to evaluate the impact of donor HTN on patient survival of SLKT recipients and to identify independent risk factors.

Material/Methods

Data from 3844 adult SLKT recipients receiving deceased donor grafts from March 2002 to December 2014 in the Scientific Registry of Transplant Recipients (SRTR) database were retrospectively analyzed. Kaplan-Meier analysis was used to compare patient and graft survival. Multivariate Cox proportional hazard models were built to identify independent risk factors associated with patient and graft survival.

Results

SLKT patients receiving HTN donor grafts had significantly shorter 5-year patient survival and kidney graft survival rates than did those receiving non-HTN donor grafts (50.1% vs. 63.2%, p<0.0001 and 45.4% vs. 67.8%, p<0.0001, respectively). Multivariate analysis identified HTN donor, donor age, donation after cardiac death, cold ischemia time, recipient age, recipient condition at transplant, recipient hepatitis C infection, need for life support, and recipient pre-transplant albumin level as independent risk factors associated with inferior patient survival in SLKT recipients. A risk scoring model that predicted excellent stratification of prognostic subgroups was established (AUC, 0.762; 95% CI, 0.739–0.785).

Conclusions

An SLKT patient receiving a graft from an HTN donor has an inferior prognosis. A risk scoring system applicable to patient survival in SLKT recipients was developed.

Analysis of Distribution of Expanded- and Standard-Criteria Donors and Complications Among Polish Recipients by Kidney Donor Risk Index Value

INTRODUCTION

The approach toward transplanting kidneys from expanded-criteria donors (ECDs) in Poland is largely site-dependent. The Kidney Donor Risk Index (KDRI) allows for obtaining a more precise characteristic of ECDs and further stratification into "better" and "worse" quality grafts.

METHODS

Comparison of the incidence of delayed graft function (DGF) and biopsy-proven acute rejection (BPAR), median of hospitalization time and median of estimated glomerular filtration rate (eGFR) at 1 year after transplantation among kidney graft recipients (n = 468), divided by donor status (ECD/standard-criteria donor [SCD]) and KDRI value (I: 0.67-1.2, II: 1.21-1.6, III: 1.61-2.0, IV: 2.01-3.48).

RESULTS

ECD kidneys have been transplanted to 32.47% of recipients. There were no ECD recipients in KDRI compartment I, 16.55% in compartment II, 79.22% in compartment III, and 100% in IV. In KDRI compartment II, DGF was diagnosed in 34.9% of SCDs and 56% of ECDs (P = .003), BPAR occurred in 7.8% of SCDs and 16% of ECDs (P = .073), median hospital stay was 12 days for SCDs and ECDs (P = 1), and eGFR was 50.7 mL/min for SCDs and 49.4 mL/min for ECDs (P = .734). In KDRI compartment III, DGF was diagnosed in 43.8% of SCDs and 49.2% of ECDs (P = .139), BPAR occurred in 6.3% of SCDs and 31.7% of ECDs (P = .001), median hospital stay was 10 days for SCDs and 12 days for ECDs (P = .634), and eGFR was 49.5 mL/min for SCDs and 45.2 mL/min for ECDs (P = .382). Among ECD recipients, DGF was diagnosed in 56.0%, 49.2%, and 47.7% of patients for KDRI compartments II, III, and IV respectively (P = .776); BPAR occurred in 16% (compartment II), 31.7% (compartment III), and 23.1% (compartment IV) (P = .273); the median hospital stay was 12 days (compartment II), 12 days (compartment III), and 12.5 days (compartment IV) (P = 1); and eGFR was 49.5 mL/min (compartment II), 45.4 mL/min (compartment III), and 36.1 mL/min (compartment IV) (P = .002).

CONCLUSION

Assessment using both the ECD and KDRI systems allows for a more precise evaluation of prognosis and predicting complications among recipients.

Increased risk of graft failure and mortality in Dutch recipients receiving an expanded criteria donor kidney transplant

Survival of expanded criteria donor (ECD) kidneys and their recipients has not been thoroughly evaluated in Europe. Therefore, we compared the outcome of ECD and non-ECD kidney transplantations in a Dutch cohort, stratifying by age and diabetes. In all first Dutch kidney transplants in recipients ≥18 years between 1995 and 2005, both relative risks (hazard ratios, HR) and adjusted absolute risk differences (RD) for ECD kidney transplantation were analysed. In 3062 transplantations [recipient age 49.0 (12.8) years; 20% ECD], ECD kidney transplantation was associated with graft failure including death [HR 1.62 (1.44-1.82)]. The adjusted HR was lower in recipients ≥60 years of age [1.32 (1.07-1.63)] than in recipients 40-59 years [1.71 (1.44-2.02) P = 0.12 for comparison with ≥60 years] and recipients 18-39 years [1.92 (1.42-2.62) P = 0.03 for comparison with ≥60 years]. RDs showed a similar pattern. In diabetics, the risks for graft failure and death were higher than in the nondiabetics. ECD kidney grafts have a poorer prognosis than non-ECD grafts, especially in younger recipients (<60 years), and diabetic recipients. Further studies and ethical discussions should reveal whether ECD kidneys should preferentially be allocated to specific subgroups, such as elderly and nondiabetic individuals.

The Need for New Donor Stratification to Predict Graft Survival in Deceased Donor Kidney Transplantation

PURPOSE

The aim of this study was to determine whether stratification of deceased donors by the United Network for Organ Sharing (UNOS) criteria negatively impacts graft survival.

MATERIALS AND METHODS

We retrospectively reviewed deceased donor and recipient pretransplant variables of kidney transplantations that occurred between February 1995 and December 2009. We compared clinical outcomes between standard criteria donors (SCDs) and expanded criteria donors (ECDs).

RESULTS

The deceased donors consisted of 369 patients. A total of 494 transplant recipients were enrolled in this study. Mean age was 41.7±11.4 year (range 18-69) and 273 patients (55.4%) were male. Mean duration of follow-up was 8.8±4.9 years. The recipients from ECD kidneys were 63 patients (12.8%). The overall mean cold ischemia time was 5.7±3.2 hours. Estimated glomerular filtration rate at 1, 2, and 3 years after transplantation were significantly lower in ECD transplants (1 year, 62.2±17.6 vs. 51.0±16.4, p<0.001; 2 year, 62.2±17.6 vs. 51.0±16.4, p=0.001; 3 year, 60.9±23.5 vs. 54.1±18.7, p=0.047). In multivariate analysis, donor age (≥40 years) was an independent risk factor for graft failure. In Kaplan-Meier analyses, there was no significant difference in death-censored graft survival (Log rank test, p>0.05), although patient survival was lower in ECDs than SCDs (Log rank test, p=0.011).

CONCLUSION

Our data demonstrate that stratification by the UNOS criteria does not predict graft survival. In order to expand the donor pool, new criteria for standard/expanded donors need to be modified by regional differences.

Suggestions on how to make suboptimal kidney transplantation an ethically viable option

To overcome kidney donation, the pool of potentially eligible donors has been widened by using suboptimal organs harvested from living donors or cadavers. These organs may engender health complications as age, risk factors, and pathologies of donors fail to meet the standard donor criteria. After examining a wide array of literature on suboptimal kidney transplants, we evidenced two major issues: the lack of standardized terminology and the lack of longterm data on the health outcomes of both suboptimal living donors and recipients. Consequently, surgeons are still unable to provide patients with thorough information to obtain a well-informed consent. Suboptimal kidney transplantation still remains in its experimental stage, thereby raising many ethical and medico-legal concerns. We suggest that one possible solution to overcome some of the ethical shortcomings of suboptimal kidney donations is to provide living donors and recipients honest, accurate, and thorough information about its health risks. To this aim, we advocate adopting a widely standardized terminology that would embrace the whole concept of suboptimal kidney transplantation, increasing the number of future publications on the health outcomes of living donors and recipients, spurring ethical reflection to improve the experience of suboptimal kidney transplantation and reduce the waiting-list for kidney transplantation.

[Deceased donation in renal transplantation]

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis

In 2002, the United Network for Organ Sharing proposed increasing the pool of donor kidneys to include Expanded Criteria Donor (ECD). Outside the USA, the ECD definition remains the one used without questioning whether such a graft allocation criterion is valid worldwide. We performed a meta-analysis to quantify the differences between ECD and Standard Criteria Donor (SCD) transplants. We paid particular attention to select studies in which the methodology was appropriate and we took into consideration the geographical area. Thirty-two publications were included. Only five studies, all from the USA, reported confounder-adjusted hazard ratios comparing the survival outcomes between ECD and SCD kidney transplant recipients. These five studies confirmed that ECD recipients seemed to have poorer prognosis. From 29 studies reporting appropriate survival curves, we estimated the 5-year pooled nonadjusted survivals for ECD and SCD recipients. The relative differences between the two groups were lower in Europe than in North America, particularly for death-censored graft failure. It is of primary importance to propose appropriate studies for external validation of the ECD criteria in non-US kidney transplant recipients.

Impact of Early Low-Grade Proteinuria and Allograft Dysfunction on Survival in Expanded Criteria Donor Kidney Transplant Recipients

INTRODUCTION

Recent studies have demonstrated a relationship between low-grade proteinuria and worse graft survival, but this has not been fully studied in expanded criteria donor (ECD) kidney transplant recipients.

AIM

The aim of this study was to assess whether the combination of early low-grade proteinuria (<1 g/d) and allograft dysfunction at the third month post-transplantation predicts outcomes in terms of survival in ECD kidney transplant recipients.

MATERIAL AND METHODS

We studied a cohort of 269 ECD kidney transplant recipients subdivided into 4 groups according to clinically relevant proteinuria (300 mg/d) and median creatinine (Cr; 1.7 mg/dL; interquartile range, 1.4-2.1 mg/dL) at the third month post-transplantation: Group A (Cr <1.7 mg/dL and proteinuria <300 mg/24 h; n = 97), Group B (Cr <1.7 mg/dL and proteinuria ≥300 mg/24 h; n = 38), Group C (Cr ≥1.7 mg/dL and proteinuria <300 mg/24 h; n = 79), and Group D (Cr ≥1.7 mg/dL and proteinuria ≥300 mg/24 h; n = 55).

RESULTS

Death-censored graft survival was significantly lower in Group D compared with the rest (P < .007). Multivariate Cox regression analysis using fixed covariates showed that the combination of low-grade proteinuria and a lower estimated glomerular filtration rate (eGFR) as associated with graft failure (hazard rate [HR] 2.5, 95% confidence interval [CI], 1.09-5.97; P = .03).

CONCLUSIONS

The early association of low-grade proteinuria and allograft dysfunction represents an important risk factor for graft loss in ECD kidney transplant recipients. Strategies to optimize renal function could improve the outcome in this specific population.

Outcomes of expanded-criteria deceased donor kidney transplantation in a single center

BACKGROUND

In an effort to expand the deceased donor pool, transplant centers have accepted expanded-criteria donors as appropriate for many of the patients in the deceased donor pool. We investigated expanded-criteria deceased donor kidney transplantation and compared the outcomes of kidney transplantation according to donor types.

METHODS

We retrospectively analyzed 88 kidney transplantations performed between June 2006 and December 2012. We divided the patient into 4 groups: SCDD, standard-criteria deceased donor; ECDD, expanded-criteria deceased donor; ECMO, donor under extracorporeal membrane oxygenation support; living donor.

RESULTS

Deceased and living donor kidney transplantations were performed in 52 (59.1%) and 36 (40.9%) cases, respectively. Among deceased donors, 31 (35.2%) were standard-criteria donors and 14 cases (15.9%) were expanded-criteria donors. Seven (8.0%) donors were under extracorporeal membrane oxygenation support. Mean follow-up was 26.1 ± 20 months. Average number of HLA mismatches among the donor types was 3.39, 3.07, 3.0, and 2.94 in SCDD, ECDD, ECMO, and living donor groups, respectively (P = .708). Delayed graft function occurred in 2 (6.9%), 3 (21.4%), 3 (42.9%), and 3 (8.3%) patients in the SCDD, ECDD, ECMO, and living donor groups, respectively (P = .043). Episodes of acute rejection within a year occurred in 14 (45.2%), 2 (14.3%), 1 (14.3%), and 6 (16.7%) patients in the SCDD, ECDD, ECMO, and living donor groups, respectively (P = .029). Renal functions after kidney transplantation at 3 months, 6 months, 9 months, and 1 year were not significantly different according to donor types. Graft survival was not different among the different donor types (87.1%, 92.8%, 85.7%, 91.7% in SCDD, ECDD, ECMO, and living donor groups, respectively; P = .67). Patient survival was not different among the different donor types (87.1%, 92.9%, 100%, 97.2% in SCDD, ECDD, ECMO, and living donor group, respectively; P = .36).

CONCLUSION

The use of expanded-criteria deceased donor had no impact on graft or patient survival after kidney transplantation.

Long-term impact of human leukocyte antigen mismatches combined with expanded criteria donor on allograft outcomes in deceased donor kidney transplantation

The long-term impact of human leukocyte antigen (HLA) mismatches combined with expanded criteria donors (ECD) on clinical outcomes has not been fully evaluated in recipients of deceased donor (DD) kidney transplantations. Of 595 DD renal transplant recipients in our center between 1991 and 2011, 210 recipients (36%) had 0-3 HLA mismatches/standard criteria donor (SCD), 353 (59%) had 4-6 HLA mismatches/SCD or 0-3 HLA mismatches/ECD, and 32 (5%) had 4-6 HLA mismatches/ECD. The mortality rate was significantly highest in the patients with 4-6 HLA mismatches/ECD (p = 0.040). The most common cause of death in this group was infection (50%). There were no significant differences in overall graft survival and death-censored graft survival. The biopsy-proven acute rejection rate was significantly higher in the 4-6 HLA mismatches/ECD group (p = 0.011). Cox-regression multivariate analyses showed that 4-6 HLA mismatches plus ECD (adjusted hazard ratio [AHR], 3.2; 95% confidence interval [CI], 1.17-10.56) and diabetes (AHR, 4.3; 95% CI, 1.50-12.28) were significant predictors of recipient mortality. In conclusion, ≥4 HLA mismatches plus ECD were associated with significantly higher rates of biopsy-proven acute rejection and mortality compared with other groups undergoing DD kidney transplantation.

Proposal of categorization of expanded criteria donors in renal transplantation

INTRODUCTION

Transplantation of renal allografts that have been procured from expanded criteria donors (ECD) have prevailed in an attempt to expand the donor pool. Even though ECD is an acceptable source of donors, the wide range of age along with the presence or not of risk factors necessitates further categorization. The aim of this study was to analyze the allograft and recipient survival of the ECD renal grafts and to propose an ECD categorization model.

PATIENTS AND METHODS

We reviewed the medical records of renal transplant recipients from January 2002 to July 2012, who received renal allografts from expanded and standard criteria donors (SCD) without risk factors such as hypertension, cerebrovascular disease or impaired renal function.

RESULTS

During the study period, 310 renal transplantations were performed in our Transplant Unit, of which 86 and 114 renal grafts were procured from ECD and SCD respectively. ECD renal graft survival the first, third and fifth year was 92%, 82% and 70% while respective recipient survival was 95%, 87% and 82%. Comparison with the control group of SCD showed that ECD renal graft survival after the third post-transplant year was significantly inferior (P < .0001). Donor age was a considerable prognostic factor of long-term renal graft function. Serum creatinine of ECD grafts was the first and third year 1.86 ± 0.6 mg/dL and 1.91 ± 0.8 mg/dL, respectively, showing significant difference to that of SCD grafts (P < .0001). Further categorization of ECD showed that renal allografts procured from donors above 60 years old without risk factors had better renal graft survival and function compared to grafts procured from donors aged 50-59 with 2 or 3 risk factors.

CONCLUSIONS

Renal transplantation from ECD offers acceptable graft survival rates, however they are inferior compared to renal grafts from optimal kidney donors. ECD kidney grafts have to be categorized, taking into consideration the independent risk factors.

Preoperative assessment of the deceased-donor kidney: from macroscopic appearance to molecular biomarkers

Variation in deceased-donor kidney quality can significantly affect outcomes after kidney transplantation. Suboptimal organ selection for a given recipient can result in primary nonfunction, premature graft failure, or inappropriate discard of a suitable organ. Appraisal and appropriate selection of deceased-donor kidneys for use in transplantation is therefore critical. A number of predictive tools have been developed to assist the transplant team in evaluating the suitability of a deceased-donor kidney for transplantation to a given recipient. These include stratification of donors into "standard-" or "expanded-criteria" categories based on clinical parameters, pre-implantation biopsy scores, donor risk scores, machine perfusion characteristics, functional kidney weight, donor biomarkers and molecular diagnostic tools, ex vivo viability assessment using postmortem normothermic perfusion, and overall macroscopic appraisal by the surgical team. Consensus as to the role and predictive value of each of these tools is lacking and clinical practice regarding evaluation and selection of kidneys varies considerably.In this review, we seek to critically appraise the literature and evaluate the levels of evidence for tools used to assess deceased-donor kidneys. Although a plethora of appraisal tools exist, very few demonstrate desirable predictive power to be useful in clinical decision-making. Further research using large, well-designed prospective studies is urgently needed to advance this important field of transplantation science.

Restored kidney graft from urologist referrals for renal transplantation

BACKGROUND

A new transplantation program using kidneys after a small tumor excision was initiated in Western Australia in February 2007. The aim of this study was to report the outcomes over 5 years.

METHODS

Local urologists were encouraged to refer the kidney to the transplantation service when considering a radical nephrectomy. Recipients are selected according to strict criteria. Between February 2007 and February 2012 24 of 30 referred kidneys were restored for transplantation. Average donor age was 53.4 (range, 32-75) years while the recipients were 66.3 (range, 57-80) years. Twenty-one kidneys were restored after excision of a small tumor (<3.3 cm) and 3 kidneys were restored after being obtained from patients who had experienced complicated ureteric injuries secondary to laparotomy and colectomy.

RESULTS

Nineteen of 24 grafts displayed immediate function, 4 had delayed function, and 1 had nonfunction. The first 3 patients developed urinary leakages, which all resolved by subsequent management. One graft showed a pseudoaneurysm on the day 1 Doppler ultrasound, requiring interventional embolization. All patients but 1 have been off dialysis with satisfactory graft function; creatinine (Cr) levels ranged from 70 μmol/L to 330 μmol/L. There was no tumor recurrence on close follow-up from 6 to 55 months (median, 26). Three patients died due to other medical issues.

CONCLUSION

Kidneys could be restored from urologic disease for transplantation after excision of a small tumor with satisfactory outcomes at an average follow-up of 26 months. Frozen section is necessary to ensure the clearance of the tumor prior to transplantation. A modification of the surgical technique has minimized urine leakage and pseudoaneurysm formation after tumor resection.

Induction with interleukin-2 antagonist for transplantation of kidneys from older deceased donors: an observational study

Background

The most important limiting factor in kidney transplantation is the scarcity of donor organs. Consequently, there is an increased use worldwide of kidneys from older deceased donors. High donor age is a known risk factor for acute cellular rejection and premature graft failure, and the optimal immunosuppressive regimen in these circumstances remains to be established.

Methods

We investigated whether induction treatment with an interleukin 2 (IL-2) receptor antagonist improves graft survival and reduces rejection episodes in recipients of kidneys from deceased donors aged ≥ 60 years. Data were retrieved for all recipients transplanted at our center from 2004 to 2009 with a kidney from a deceased donor aged > 60 years. The outcome was compared between recipients treated with (IL-2 plus) or without (IL-2 minus) an IL-2 receptor antagonist. All recipients received a calcineurin inhibitor, steroids and mycophenolate.

Results

A total of 232 first-transplant recipients were included (IL-2 plus = 149, IL-2 minus = 83). IL-2 minus was associated with increased risk of early acute rejection (OR 2.42; 95% CI 1.25 to 4.68, P = 0.009) and steroid-resistant rejection (OR 8.04; 2.77 to 23.25, P< 0.001). IL-2 plus patients had superior two-year estimated uncensored (87% versus 70%, P = 0.001) and death-censored (95% versus 79%, P< 0.001) graft survival.

Conclusions

Induction treatment with IL-2 receptor antagonist was associated with a reduction in acute rejection episodes and improved two-year graft survival in patients transplanted with kidneys from older deceased donors.

Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients

Kidney transplantation (KT) is the therapy of choice for end-stage renal disease (ESRD). The ESRD population is aging and so are patients waiting for KT. New strategies have been made for increasing the donor and recipient pools, and as a consequence kidneys from older donors or donors with significant comorbidities, the so-called “expanded criteria donor” (ECD) kidneys, are used for transplantation. Although good outcomes have been achieved from ECD, several issues are still waiting for clarification and need to be discussed. The concept of age matching is accepted as a method to ameliorate utilization of these allografts, but an optimal and widely accepted strategy is still not defined. The development of machine perfusion and the dual kidney transplantation are techniques which further improve the outcome of transplants from ECD, but the described experiences are scarce or coming from small single institutional reports. Also due to age-related immune dysfunction and associated comorbidities, the elderly recipients are more susceptible to immunosuppression related complications (e.g., infections and malignancy), although a widely accepted and validated immunosuppressive regimen is still lacking. In this paper, we review the issues related to KT employing allografts from marginal donors with a particular interest for the elderly patients.

Pretransplant transcriptome profiles identify among kidneys with delayed graft function those with poorer quality and outcome

Robust biomarkers are needed to identify donor kidneys with poor quality associated with inferior early and longer-term outcome. The occurrence of delayed graft function (DGF) is most often used as a clinical outcome marker to capture poor kidney quality. Gene expression profiles of 92 preimplantation biopsies were evaluated in relation to DGF and estimated glomerular filtration rate (eGFR) to identify preoperative gene transcript changes associated with short-term function. Patients were stratified into those who required dialysis during the first week (DGF group) versus those without (noDGF group) and subclassified according to 1-month eGFR of >45 mL/min (eGFR(hi)) versus eGFR of ≤45 mL/min (eGFR(lo)). The groups and subgroups were compared in relation to clinical donor and recipient variables and transcriptome-associated biological pathways. A validation set was used to confirm target genes. Donor and recipient characteristics were similar between the DGF versus noDGF groups. A total of 206 probe sets were significant between groups (P < 0.01), but the gene functional analyses failed to identify any significantly affected pathways. However, the subclassification of the DGF and noDGF groups identified 283 probe sets to be significant among groups and associated with biological pathways. Kidneys that developed postoperative DGF and sustained an impaired 1-month function (DGF(lo) group) showed a transcriptome profile of significant immune activation already preimplant. In addition, these kidneys maintained a poorer transplant function throughout the first-year posttransplant. In conclusion, DGF is a poor marker for organ quality and transplant outcome. In contrast, preimplant gene expression profiles identify "poor quality" grafts and may eventually improve organ allocation.