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Gaspar A, Gama M, de Jesus GN, Querido S, Damas J, Oliveira J, Neves M, Santana A, Ribeiro JM. Major determinants of primary non function from kidney donation after Maastricht II circulatory death: A single center experience. J Crit Care 2024; 82:154811. [PMID: 38603852 DOI: 10.1016/j.jcrc.2024.154811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/31/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE Organ shortage greatly limits treatment of patients with end-stage chronic kidney. Maastricht type 2 donation after circulatory death (DCD) has been shown to have similar results in long term outcomes in kidney transplantation, when compared with brain dead donation. Our main goal was to assess Maastricht type 2 DCD and evaluate factors that impact on early graft function. METHODS A retrospective study was conducted in an ECMO Referral Centre. All patients who received a kidney transplant from Maastricht type 2 DCD were included in study. Early graft function and short term outcomes were assessed. RESULTS From October 2017 to December 2022, 47 renal grafts were collected from 24 uDCD donors. Median warm ischemia time was 106 min (94-115), cannulation time was 10 min (8; 20) and duration of extracorporeal reperfusion (ANOR) was 180 min (126-214). Regarding early graft function, 25% had immediate graft function, 63.6% had delayed graft function and 11.4% had primary non-function (PNF). There was a correlation between cannulation time (p = 0.006) and ANOR with PNF (p = 0.016). CONCLUSIONS Cannulation time and ANOR were the main factors that correlated with PNF. Better understanding of underlying mechanisms should be sought in future studies to reduce the incidence of PNF.
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Affiliation(s)
- Ana Gaspar
- Intensive Care Department, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal; ECMO Referral Centre, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal.
| | - Madalena Gama
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Gustavo Nobre de Jesus
- Intensive Care Department, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal; ECMO Referral Centre, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal; Clínica Universitária de Medicina Intensiva, Faculdade de Medicina da Universidade de Lisboa, Portugal; Transplant Coordination Department, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal
| | - Sara Querido
- Nephrology and Transplantation Department, Unidade Local de Saúde Lisboa Ocidental EPE, Lisbon, Portugal
| | - Juliana Damas
- Nephrology and Transplantation Department, Unidade Local de Saúde São José EPE, Lisbon, Portugal
| | - João Oliveira
- Nephrology and Transplantation Department, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal
| | - Marta Neves
- Nephrology and Transplantation Department, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal
| | - Alice Santana
- Nephrology and Transplantation Department, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal
| | - João Miguel Ribeiro
- Intensive Care Department, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal; ECMO Referral Centre, Unidade Local de Saúde Santa Maria EPE, Lisbon, Portugal
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2
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Molina M, Fernández-Ruiz M, Gonzalez E, Cabrera J, Praga M, Rodriguez A, Tejido-Sánchez A, Medina-Polo J, Mateos A, Rubio-Chacón C, Sanchez A, Pla A, Andrés A. Prophylactic Anticoagulation Reduces the Risk of Kidney Graft Venous Thrombosis in Recipients From Uncontrolled Donation After Circulatory Death Donors With High Renal Resistive Index. Transplant Direct 2024; 10:e1649. [PMID: 38817627 PMCID: PMC11139466 DOI: 10.1097/txd.0000000000001649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 06/01/2024] Open
Abstract
Background Uncontrolled donation after circulatory death (uDCD) increases organ availability for kidney transplantation (KT) at the expense of a higher risk of primary graft nonfunction (PNF). At least half of the cases of PNF are secondary to graft venous thrombosis. The potential benefit from prophylactic anticoagulation in this scenario remains unclear. Methods In this single-center retrospective study we compared 2 consecutive cohorts of KT from uDCD with increased (≥0.8) renal resistive index (RRI) in the Doppler ultrasound examination performed within the first 24-72 h after transplantation: 36 patients did not receive anticoagulation ("nonanticoagulation group") and 71 patients underwent prophylactic anticoagulation until normalization of RRI in follow-up Doppler examinations ("anticoagulation group"). Results Anticoagulation was initiated at a median of 2 d (interquartile range, 2-3) after transplantation and maintained for a median of 12 d (interquartile range, 7-18). In 4 patients (5.6%), anticoagulation had to be prematurely stopped because of the development of a hemorrhagic complication. In comparison with the nonanticoagulation group, recipients in the anticoagulation group had a lower 2-wk cumulative incidence of graft venous thrombosis (19.4% versus 0.0%; P < 0.001) and PNF (19.4% versus 2.8%; P = 0.006). The competing risk analysis with nonthrombotic causes of PNF as the competitive event confirmed the higher risk of graft thrombosis in the nonanticoagulation group (P = 0.0001). The anticoagulation group had a higher incidence of macroscopic hematuria (21.1% versus 5.6%; P = 0.049) and blood transfusion requirements (39.4% versus 19.4%; P = 0.050) compared with the nonanticoagulation group. No graft losses or deaths were attributable to complications potentially associated with anticoagulation. Conclusions Early initiation of prophylactic anticoagulation in selected KT recipients from uDCD with an early Doppler ultrasound RRI of ≥0.8 within the first 24-72 h may reduce the incidence of graft venous thrombosis as a cause of PNF.
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Affiliation(s)
- Maria Molina
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain
- Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Badalona, Spain
- Department of Medicine, School of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
- RICORS2040 (Kidney Disease), Badalona, Barcelona, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Esther Gonzalez
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain
- Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Jimena Cabrera
- Programa de Prevención y Tratamiento de las Glomerulopatías, Centro de Nefrología, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
- Department of Nephrology, Hospital Evangelico, Montevideo, Uruguay
| | - Manuel Praga
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Alfredo Rodriguez
- Department of Urology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Angel Tejido-Sánchez
- Department of Urology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Jose Medina-Polo
- Department of Urology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Alonso Mateos
- Servicio de Urgencia Médica de la Comunidad de Madrid, SUMMA 112
- Facultad de medicina, Universidad Francisco de Vitoria, Madrid, Spain
| | | | - Angel Sanchez
- Department of Interventional Radiology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Ana Pla
- Department of Interventional Radiology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Hospital “12 de Octubre” (imas12), Madrid, Spain
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3
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Vijayan K, Schroder HJ, Hameed A, Hitos K, Lo W, Laurence JM, Yoon PD, Nahm C, Lim WH, Lee T, Yuen L, Wong G, Pleass H. Kidney Transplantation Outcomes From Uncontrolled Donation After Circulatory Death: A Systematic Review and Meta-analysis. Transplantation 2024; 108:1422-1429. [PMID: 38361237 DOI: 10.1097/tp.0000000000004937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Uncontrolled donation after circulatory death (uDCD) is a potential additional source of donor kidneys. This study reviewed uDCD kidney transplant outcomes to determine if these are comparable to controlled donation after circulatory death (cDCD). METHODS MEDLINE, Cochrane, and Embase databases were searched. Data on demographic information and transplant outcomes were extracted from included studies. Meta-analyses were performed, and risk ratios (RR) were estimated to compare transplant outcomes from uDCD to cDCD. RESULTS Nine cohort studies were included, from 2178 uDCD kidney transplants. There was a moderate degree of bias, as 4 studies did not account for potential confounding factors. The median incidence of primary nonfunction in uDCD was 12.3% versus 5.7% for cDCD (RR, 1.85; 95% confidence intervals, 1.06-3.23; P = 0.03, I 2 = 75). The median rate of delayed graft function was 65.1% for uDCD and 52.0% for cDCD. The median 1-y graft survival for uDCD was 82.7% compared with 87.5% for cDCD (RR, 1.43; 95% confidence intervals, 1.02-2.01; P = 0.04; I 2 = 71%). The median 5-y graft survival for uDCD and cDCD was 70% each. Notably, the use of normothermic regional perfusion improved primary nonfunction rates in uDCD grafts. CONCLUSIONS Although uDCD outcomes may be inferior in the short-term, the long-term outcomes are comparable to cDCD.
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Affiliation(s)
- Keshini Vijayan
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Hugh J Schroder
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Ahmer Hameed
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Kerry Hitos
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Warren Lo
- Institute of Urology and Nephrology, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Jerome M Laurence
- Central Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Peter D Yoon
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Christopher Nahm
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Taina Lee
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Lawrence Yuen
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Germaine Wong
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Renal Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Henry Pleass
- Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
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Zhang P, Sun C, Mo S, Hu C, Ning Y, Liang H, Liu Z, Fan X, Wang Y. Salvaging donated kidneys from prolonged warm ischemia during ex vivo hypothermic oxygenated perfusion. Kidney Int 2024:S0085-2538(24)00337-5. [PMID: 38789038 DOI: 10.1016/j.kint.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 03/28/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Abstract
Prolonged warm ischemic is the main cause discarding donated organs after cardiac death. Here, we identified that prolonged warm ischemic time induced disseminated intravascular coagulation and severe capillary vasospasm after cardiac death of rat kidneys. Additionally, we found a significant accumulation of fibrinogen in a hypoxic cell culture of human umbilical vein epithelial cells and in isolated kidneys exposed to prolonged warm ischemic following flushing out of blood. However, pre-flushing the kidney with snake venom plasmin in a 90-minute warm ischemic model maximized removal of micro thrombi and facilitated the delivery of oxygen and therapeutic agents. Application of carbon monoxide-releasing CORM-401 during ex vivo hypothermic oxygenated perfusion achieved multipath protective effects in prolonged warm ischemic kidneys. This led to significant improvements in perfusion parameters, restoration of the microcirculation, amelioration of mitochondrial injury, oxidative stress, and apoptosis. This benefit resulted in significantly prolonged warm ischemic kidney recipient survival rates of 70%, compared with none in those receiving ex vivo hypothermic oxygenated perfusion alone. Significantly, ex vivo hypothermic oxygenated perfusion combined with cytoprotective carbon monoxide releasing CORM-401 treatment meaningfully protected the donated kidney after cardiac death from ischemia-reperfusion injury by reducing inflammation, oxidative stress, apoptosis, and pathological damage. Thus, our study suggests a new combination treatment strategy to potentially expand the donor pool by increasing use of organs after cardiac death and salvaging prolonged warm ischemic kidneys.
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Affiliation(s)
- Peng Zhang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China
| | - Chao Sun
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China
| | - Shuyong Mo
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China
| | - Chaoyu Hu
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China
| | - Yuxiang Ning
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China
| | - Han Liang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Zhongzhong Liu
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China
| | - Xiaoli Fan
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China
| | - Yanfeng Wang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Wuhan, Hubei, P.R. China; Zhongnan Hospital of Wuhan University, Transplant Center of Wuhan University, Wuhan, Hubei, P.R. China.
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5
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 2023; 148:e120-e146. [PMID: 37551611 DOI: 10.1161/cir.0000000000001125] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2023; 190:109864. [PMID: 37548950 DOI: 10.1016/j.resuscitation.2023.109864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Nagaraju S, Savilla R, Moore M, Jones A, Africa J. Successful transplantation of LUCAS device assisted uncontrolled DCD kidneys with prolonged relative warm ischemia time: An underutilized option in North America. Clin Transplant 2023; 37:e15058. [PMID: 37421597 DOI: 10.1111/ctr.15058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/27/2023] [Accepted: 06/11/2023] [Indexed: 07/10/2023]
Abstract
Approximately 25% of deceased donors in the United States are procured in a donation after circulatory death (DCD) setting. Successful transplant outcomes from uncontrolled DCD (uDCD) practices have been reported in multiple European programs. They utilize established protocols for uDCD procurement with normo-thermic or hypothermic regional perfusion to reduce ischemic damage. Further, manual or mechanical chest compressions using extrinsic devices, such as the LUCAS device, are implemented to maintain circulation before organ retrieval. Currently, uDCDs are not a major part of DCD organ utilization in the United States. We report our experience with utilization of kidneys from uDCD with the use of the LUCAS device without normothermic or hypothermic regional perfusion. We transplanted four kidneys from three uDCD donors without utilization of in situ regional perfusion and with prolonged relative warm ischemia time (rWIT) (>100 min). All recipients had functional renal allografts and improved renal function after the transplant. To our knowledge, this is the 1st successful series reported in the United States of the utilization of kidneys from uDCDs without the utilization of in situ perfusion to maintain organ preservation with prolonged rWIT.
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Affiliation(s)
- Santosh Nagaraju
- Renal Transplant Program, Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Rachel Savilla
- Renal Transplant Program, Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Myla Moore
- Renal Transplant Program, Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Alice Jones
- Renal Transplant Program, Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Joseph Africa
- Renal Transplant Program, Charleston Area Medical Center, Charleston, West Virginia, USA
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Rubio-Chacón C, Mateos-Rodríguez A, Neria-Serrano F, Del Rio-Gallegos F, Andrés-Belmonte A. Influence of donor capnometry on renal graft evolution in uncontrolled donation after circulatory death. Resuscitation 2023:109863. [PMID: 37302687 DOI: 10.1016/j.resuscitation.2023.109863] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023]
Abstract
AIM To analyse the association between donor capnometry data and the short-term evolution of kidney grafts in cases of uncontrolled donation after circulatory death (uDCD). METHOD We used an ambispective observational study design, conducted in the Community of Madrid between January and December 2019, inclusive. Patients who suffered out-of-hospital cardiac arrest (CA) with no response to advanced cardiopulmonary resuscitation (CPR) were selected as potential donors. Donor capnometry levels were measured at the start, midpoint and transfer to hospital then compared with indicators of renal graft evolution. RESULTS The initial selection included 34 possible donors, of which 12 (35.2%) were viable donors from whom 22 (32.3%)kidneys were recovered. There was a correlation between the highest capnometry values and less need for post-transplant dialysis (≥24 mmHg, p< 0.017), fewer dialysis sessions and fewer days to recover correct renal function (Rho -0.47, p< 0.044). There was a significant inverse correlation between the capnometry values at transfer and 1-month post-transplant creatinine levels (Rho -0.62, p< 0.033). There were no significant differences between the capnometry values at transfer and primary nonfunction (PNF) or warm ischaemia time. One-year patient survival was 100% for patient receiving organ donation, while graft survival was 95%. CONCLUSIONS Capnometry levels at transfer are a useful predictor of the short-term function and viability of kidney transplants from uncontrolled donations after circulatory death.
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Affiliation(s)
| | - Alonso Mateos-Rodríguez
- Community of Madrid Emergency Medical Service, SUMMA 112, Madrid, Spain; Community of Madrid Regional Transplant Office, Madrid, Spain
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9
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Campi R, Pecoraro A, Sessa F, Vignolini G, Caroti L, Lazzeri C, Peris A, Serni S, Li Marzi V. Outcomes of kidney transplantation from uncontrolled donors after circulatory death vs. expanded-criteria or standard-criteria donors after brain death at an Italian Academic Center: a prospective observational study. Minerva Urol Nephrol 2023; 75:329-342. [PMID: 36946717 DOI: 10.23736/s2724-6051.23.05098-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The use of kidneys from "expanded criteria" donors after brain death (ECD) and uncontrolled donors after circulatory death (uDCD) has been warranted to increase the pool of donors for kidney transplantation (KT). However, there is lack of evidence on the feasibility and safety of KT from such donors in the Italian setting. METHODS We queried our prospectively KT database to select patients undergoing KT from deceased donors (uDCDs, ECDs, and standard-criteria donors [SCD] after brain death) from January 2017 to December 2020, comparing the perioperative and mid-term functional outcomes. RESULTS Overall, 172 KTs were included. The donor's profile was different among the study groups, while recipients' characteristics were similar expect for median age. Grafts from uDCDs and ECDs had longer median cold ischemia times as compared to grafts from SCDs. The proportion of patients experiencing DGF, the median hospitalization, as well as the overall and major complications rate, were significantly higher among recipients from uDCDs. The proportion of patients needing dialysis at last follow-up was significantly higher among recipients from uDCDs (33.3% vs. 8.5% vs. 5.4%, P<0.001). However, the median eGFR at the last follow-up was lower for recipients from ECDs compared to those from uDCDs and SCDs, respectively (P<0.001). CONCLUSIONS While "marginal" donors represent a relevant source of organs, KTs from uDCDs carry higher risks of major surgical complications, DGF, and worse graft survival as compared to KT from both ECDs and SCDs. As such, the use of grafts from uDCDs should be carefully assessed balancing the potential benefits with the risk of primary no function and the subsequent immunological sensitization.
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Affiliation(s)
- Riccardo Campi
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, University of Florence, Florence, Italy -
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy -
| | - Alessio Pecoraro
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, University of Florence, Florence, Italy
| | - Francesco Sessa
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, University of Florence, Florence, Italy
| | - Graziano Vignolini
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, University of Florence, Florence, Italy
| | - Leonardo Caroti
- Unit of Nephrology, Dialysis and Transplant, Careggi University Hospital, Florence, Italy
| | - Chiara Lazzeri
- Regional and Intensive Care Unit, ECMO Referral Center, Careggi University Hospital, Florence, Italy
| | - Adriano Peris
- Regional and Intensive Care Unit, ECMO Referral Center, Careggi University Hospital, Florence, Italy
| | - Sergio Serni
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, University of Florence, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Vincenzo Li Marzi
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, University of Florence, Florence, Italy
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Akalay S, Hosgood SA. How to Best Protect Kidneys for Transplantation-Mechanistic Target. J Clin Med 2023; 12:jcm12051787. [PMID: 36902572 PMCID: PMC10003664 DOI: 10.3390/jcm12051787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
The increasing number of patients on the kidney transplant waiting list underlines the need to expand the donor pool and improve kidney graft utilization. By protecting kidney grafts adequately from the initial ischemic and subsequent reperfusion injury occurring during transplantation, both the number and quality of kidney grafts could be improved. The last few years have seen the emergence of many new technologies to abrogate ischemia-reperfusion (I/R) injury, including dynamic organ preservation through machine perfusion and organ reconditioning therapies. Although machine perfusion is gradually making the transition to clinical practice, reconditioning therapies have not yet progressed from the experimental setting, pointing towards a translational gap. In this review, we discuss the current knowledge on the biological processes implicated in I/R injury and explore the strategies and interventions that are being proposed to either prevent I/R injury, treat its deleterious consequences, or support the reparative response of the kidney. Prospects to improve the clinical translation of these therapies are discussed with a particular focus on the need to address multiple aspects of I/R injury to achieve robust and long-lasting protective effects on the kidney graft.
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Affiliation(s)
- Sara Akalay
- Department of Development and Regeneration, Laboratory of Pediatric Nephrology, KU Leuven, 3000 Leuven, Belgium
| | - Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence:
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11
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Influence of Basic Life Support on Donor Organs in Uncontrolled Donors After Cardiac Death. Transplant Proc 2023; 55:53-55. [PMID: 36690504 DOI: 10.1016/j.transproceed.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/22/2022] [Accepted: 11/16/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND The aim of this study was to determine whether the application of basic life support (BLS) in patients who have experienced cardiac arrest and are subsequently referred to as uncontrolled asystole donors has any influence on the achievement of organs for subsequent transplantation. METHODS Demographic data, BLS, cause of death, emergency response times, and organ donations were collected. The analysis of quantitative variables following normal distribution is shown as mean (SD), and Student t distribution was used for comparison purposes. The analysis of variables that did not follow the normal distribution is shown as median (IQR), and Wilcoxon test was applied for comparison purposes. RESULTS A total of 91 cases of possible uncontrolled donor transfers were analyzed. Basic life support was provided to 61 patients (67.7%), whereas no BLS was provided to 27 patients (23.3%). Of the group that received BLS, 39 (73.6%) were effective donors compared with the non-BLS group, in which 22 (62.9%) were effective donors (P = .28). CONCLUSIONS We did not find an association between performing BLS compared with non-BLS and organ donation.
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12
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Olausson M, Antony D, Travnikova G, Johansson M, Nayakawde NB, Banerjee D, Søfteland JM, Premaratne GU. Novel Ex-Vivo Thrombolytic Reconditioning of Kidneys Retrieved 4 to 5 Hours After Circulatory Death. Transplantation 2022; 106:1577-1588. [PMID: 34974455 PMCID: PMC9311461 DOI: 10.1097/tp.0000000000004037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Due to organ shortage, many patients do not receive donor organs. The present novel thrombolytic technique utilizes organs from donors with uncontrolled donation after circulatory deaths (uDCD), with up to 4-5 h warm ischemia, without advanced cardiopulmonary resuscitation (aCPR) or extracorporeal circulation (EC) after death. METHODS The study group of pigs (n = 21) underwent simulated circulatory death. After 2 h, an ice slush was inserted into the abdomen. Kidneys were retrieved 4.5 h after death. Lys-plasminogen, antithrombin-III (ATIII), and alteplase (tPA) were injected through the renal arteries on the back table. Subsequent ex vivo perfusion at 15 °C was continued for 3 h, followed by 3 h with red blood cells (RBCs) at 32 °C. Perfusion outcome and histology were compared between uDCD kidneys, receiving no thrombolytic treatment (n = 8), and live donor kidneys (n = 7). The study kidneys were then transplanted into pigs as autologous grafts with a single functioning autologous kidney as the only renal support. uDCD control pigs (n = 8), receiving no ex vivo perfusion, served as controls. RESULTS Vascular resistance decreased to <200 mmHg/mL/min ( P < 0.0023) and arterial flow increased to >100 mL/100 g/min ( P < 0.00019) compared to controls. In total 13/21 study pigs survived for >10 days, while all uDCD control pigs died. Histology was preserved after reconditioning, and the creatinine level after 10 days was next to normal. CONCLUSIONS Kidneys from extended uDCD, not receiving aCPR/EC, can be salvaged using thrombolytic treatment to remove fibrin thrombi while preserving histology and enabling transplantation with a clinically acceptable early function.
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Affiliation(s)
- Michael Olausson
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Deepti Antony
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Galina Travnikova
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Martin Johansson
- Department of Laboratory Medicine, Sahlgrenska Academy, University of Gothenburg, SE-41345 Göteborg, Sweden
| | - Nikhil B. Nayakawde
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Debashish Banerjee
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - John Mackay Søfteland
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Goditha U. Premaratne
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
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13
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Lim WH, Dominguez-Gil B. Ethical Issues Related to Donation and Transplantation of Donation After Circulatory Determination of Death Donors. Semin Nephrol 2022; 42:151269. [PMID: 36577644 DOI: 10.1016/j.semnephrol.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With the continuing disparity between organ supply to match the increasing demand for kidney transplants in patients with renal failure, donation after the circulatory determination of death (DCDD) has become an important and increasing global source of kidneys for clinical use. The concern that the outcomes of controlled DCDD donor kidney transplants were inferior to those obtained from donors declared dead by neurologic criteria has largely diminished because large-scale registry and single-center reports consistently have reported favorable outcomes. For uncontrolled DCDD kidney transplants, outcomes are correspondingly acceptable, although there is a greater risk of primary nonfunction. The potential of DCDD remains unrealized in many countries because of the ethical concerns and resource implications in the utilization of these donor kidneys for transplantation. In this review, we discuss the origin and definitions of DCDD donors, and examine the long-term outcomes of transplants from DCDD donor kidneys. We discuss the controversies, challenges, and ethical and legal barriers in the acceptance of DCDD, including the complexities of implementing and sustaining controlled and uncontrolled DCDD donor programs. The lessons learned from global leaders will assist a wider international recognition, acceptance, and development of DCDD transplant programs that will noticeably facilitate and address the global shortages of kidneys for transplantation, and ensure the opportunity for people who had indicated their desires to become organ donors fulfill their final wishes.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; Internal Medicine, University of Western Australia Medical School, Perth, Australia.
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14
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King KL, Husain SA, Cohen DJ, Schold JD, Mohan S. The role of bypass filters in deceased donor kidney allocation in the United States. Am J Transplant 2022; 22:1593-1602. [PMID: 35090080 DOI: 10.1111/ajt.16967] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
Kidney transplant centers set organ offer filters enabling all candidates at their center to be bypassed during allocation of deceased donor kidneys from the UNOS Organ Center. These filters aim to increase allocation efficiency by preemptively screening out offers unlikely to be accepted. National data were used to compare filter settings of 175 centers in 2007 and in 2019. We examined characteristics of centers whose settings became increasingly restrictive over time, and associations between filter settings and organ offer acceptance. Overall, centers became more open to receiving offers over time, from a median 62% of filters open to receiving national offers in 2007 to 73% in 2019. Intravenous drug use filter settings changed most, from 63 to 153 willing centers. Centers with more open filter settings had higher transplant volume and offer acceptance ratios across all risk categories despite preemptively screening out fewer offers compared to centers with less open settings, but similar transplant rates. There was significant geographic heterogeneity in the distribution of centers with more open filter settings. Current center bypass filters may impact patients' access to transplantation without achieving their full potential for improving allocation efficiency.
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Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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15
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Rapid Access in Donation After Circulatory Death (DCD): The Single-Center Experience With a Classic Pathway in Uncontrolled DCD Algorithm. Transplant Proc 2022; 54:595-599. [DOI: 10.1016/j.transproceed.2021.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/13/2021] [Accepted: 11/18/2021] [Indexed: 11/24/2022]
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16
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Potential of Donation After Unexpected Circulatory Death Programs Defined by Their Demographic Characteristics. Transplant Direct 2021; 8:e1263. [PMID: 34966838 PMCID: PMC8710346 DOI: 10.1097/txd.0000000000001263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022] Open
Abstract
Background. Donation after unexpected circulatory death (uDCD) donors are often suggested to increase the number of donor organs. In 2014, a uDCD protocol was implemented in three transplant centers in the Netherlands which unfortunately did not result in additional transplantations. This study was initiated to identify demographic factors influencing the potential success of uDCD programs. Methods. Dutch resuscitation databases covering various demographic regions were analyzed for potential donors. The databases were compared with the uDCD implementation project and successful uDCD programs in Spain, France, and Russia. Results. The resuscitation databases showed that 61% of all resuscitated patients were transferred to an emergency department. Age selection reduced this uDCD potential to 46% with only patients aged 18–65 years deemed eligible. Of these patients, 27% died in the emergency department. The urban region of Amsterdam showed the largest potential in absolute numbers (52 patients/y). Comparison with the uDCD implementation project showed large similarities in the percentage of potential donors; however, in absolute numbers, it showed a much smaller potential. Calculation of the potential per million persons and the extrapolation of the potential based on the international experience revealed the largest potential in urban regions. Conclusions. Implementation of a uDCD program should not only be based on the number of potential donors calculated from resuscitation databases. They show promising potential uDCD percentages for large rural regions and small urban regions; however, actual numbers per hospital are low, leading to insufficient exposure rates. It is, therefore, recommendable to limit uDCD programs to large urban regions.
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Valdés Francí E, Perez Flores I, Candel FJ, Moreno de la Higuera MA, Romero NC, Rodríguez Cubillo B, Lucena Valverde R, Sánchez Fructuoso AI. Hemophagocytic syndrome triggered by donor-transmitted toxoplasmosis as a complication in same-donor recipients of renal transplantation: Case report and review of the literature. Transpl Infect Dis 2021; 23:e13732. [PMID: 34533259 DOI: 10.1111/tid.13732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 07/16/2021] [Accepted: 09/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hemophagocytic syndrome (HPS) is an infrequent complication of transplantation caused by an inflammatory response with a benign proliferation of macrophages and defective lytic capability of T lymphocytes and NK cells that can lead to multiorgan failure. Transplant patients are particularly exposed as a result of the increased risk of both infections and malignancies derived from immunosuppressive drugs. There is no consensus for therapy or immunosuppression; mortality is high. We report a case and present a review of all cases of HPS occurring in solid organ transplant recipients. CASE REPORT: We report two cases of infection by Toxoplasma gondii transmitted by the kidney allograft. One of the recipients was seronegative before transplantation and developed disseminated primary toxoplasmosis. An immune reaction compatible with an HPS ensued. Both were treated with Trimethoprim/sulfamethoxazole, immunosuppression was tapered, and after a 2-week period a complete response was obtained. CONCLUSION HPS presents therapeutic challenges in the context of transplantation. If HPS is suspected, the search of a very likely underlying infection should be central to the management.
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Affiliation(s)
- Elena Valdés Francí
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Isabel Perez Flores
- Nephrology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Francisco Javier Candel
- Department of Clinical Microbiology and Infectious Diseases, Clínico San Carlos University Hospital, Madrid, Spain
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18
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Abstract
PURPOSE OF REVIEW To summarise recently published studies of donor pretreatment and machine perfusion strategies in kidney transplantation. RECENT FINDINGS The sparsity of donor pretreatment trials has resulted in the re-analysis of already existing data, and RCTs are urgently needed to reinvigorate this aspect of donor research. Uncontrolled donation after circulatory death kidney transplantation has the highest risk of delayed graft function and graft failure, and recent studies have reported that normothermic regional perfusion improves graft function and survival in this setting. Hypothermic machine perfusion reduces delayed graft function following deceased donor kidney transplantation across donor types but unanswered questions still remain regarding its use. The use of oxygenated hypothermic machine perfusion appears to improve graft function in controlled donation after circulatory death mediated by a reduction in acute rejection. Ex-situ normothermic perfusion is emerging and while technically challenging it may facilitate the delivery of pretreatments. SUMMARY RCTs are urgently needed to reinvigorate research into donor pretreatment and to establish the place of specific preservation techniques in deceased donor kidney transplantation.
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19
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Coll E, Miñambres E, Sánchez-Fructuoso A, Fondevila C, Campo-Cañaveral de la Cruz JL, Domínguez-Gil B. Uncontrolled Donation After Circulatory Death: A Unique Opportunity. Transplantation 2020; 104:1542-1552. [PMID: 32732830 DOI: 10.1097/tp.0000000000003139] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.
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Affiliation(s)
| | - Eduardo Miñambres
- Intensive Care Unit and Donor Coordination Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Ana Sánchez-Fructuoso
- Nephrology Department, Hospital Universitario Clínico San Carlos, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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20
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Miñambres E, Rodrigo E, Suberviola B, Valero R, Quintana A, Campos F, Ruiz-San Millán JC, Ballesteros MÁ. Strict selection criteria in uncontrolled donation after circulatory death provide excellent long-term kidney graft survival. Clin Transplant 2020; 34:e14010. [PMID: 32573027 DOI: 10.1111/ctr.14010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND We aimed to report our experience in uncontrolled donation after circulatory death (uDCD) kidney transplantation applying a strict donor selection and preservation criteria. METHODS All kidney recipients received a graft from a local uDCD. As controls, we included all renal transplants from local standard criteria donation after brain death (SDBD) donors. Normothermic regional perfusion was the preservation method in all cases. RESULTS A total of 19 kidneys from uDCD donors were included and 67 controls. Delayed graft function (DGF) was higher in the uDCD group (42.1% vs 17.9%; P = .033), whereas no differences were observed in primary nonfunction (0% cases vs 3% controls; P = .605). The estimated glomerular filtration rate was identical in both groups. No differences were observed in graft survival censored for death between the uDCD and the SDBD groups at 1-year (100% vs 95%) or 5-year follow-up (92% vs 91%). uDCD kidney recipients did not have higher risk of graft loss in the multivariate analysis adjusted by recipient age, cold ischemic time, presence of DGF, and second kidney transplant (HR: 0.4; 95% CI 0.02-6; P = .509). CONCLUSIONS Obtaining renal grafts from uDCD is feasible in a small city and provides similar outcomes compared to standard DBD donors.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
| | - Emilio Rodrigo
- School of Medicine, University of Cantabria, Santander, Spain.,Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Rosalía Valero
- Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Alfredo Quintana
- Extrahospitalary Emergency, Gerencia de Atención Primaria-061, Santander, Spain
| | - Félix Campos
- Service of Urology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Juan Carlos Ruiz-San Millán
- School of Medicine, University of Cantabria, Santander, Spain.,Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - María Á Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
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21
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Kidney transplantation following uncontrolled donation after circulatory death. Curr Opin Organ Transplant 2020; 25:144-150. [DOI: 10.1097/mot.0000000000000742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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23
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Normothermic and hypothermic oxygenated perfusion for donation after circulatory death in kidney transplantation: do we pay higher risk of severe infection after transplantation?: a case report. BMC Infect Dis 2020; 20:115. [PMID: 32041547 PMCID: PMC7011237 DOI: 10.1186/s12879-020-4835-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 01/28/2020] [Indexed: 01/16/2023] Open
Abstract
Background Normothermic and hypothermic oxygenated perfusion for donation after circulatory death in kidney transplantation are becoming popular in Italy, with the purpose of reducing the risk of primary non function and delayed graft function due to the prolonged warm ischemia time. Potential complications related to these procedures are currently under investigation and are continuously emerging with the increasing experience. Post-operative infections - in particular graft arteritis - are a rare complication but determine high risk of mortality and of graft loss. The acute onset of the arterial complications makes it very difficult to find an effective treatment, and early diagnosis is crucial for saving both patient and graft. Prevention of such infections in this particular setting are advisable. Case presentation We present a patient with an acute arterial rupture after transplantation of a DCD graft treated in-vivo hypothermic oxygenated perfusion. The cause was a severe arteritis of the renal artery caused by Candida krusei and Pseudomonas aeruginosa. We discussed our treatment and we compared it to the other reported series. Conclusion Fungal infections in DCD transplant may be treacherous and strategies to prevent them should be advocated.
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Comparison of Graft Outcome Between Donation After Circulatory Death and Living-Donor Kidney Transplantation. Transplant Proc 2019; 52:111-118. [PMID: 31787324 DOI: 10.1016/j.transproceed.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/19/2019] [Accepted: 10/06/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Donation after cardiac death (DCD) and living-donor (LD) kidney transplantation are the main kidney transplantation types in China. But the outcome of DCD kidney transplantation compared with LD kidney transplantation remains unclear. METHODS In this study, 325 DCD and 409 LD kidney transplantations were included. We retrospectively compared 3-year graft survival, death-censored graft survival, recipient survival, and graft function. All kidneys of the DCD group were procured from voluntary donation after the citizens' death by the Organ Procurement Organization (OPO) in the presence of the Red Cross, and the transplantation application was approved by the Organ Transplant Ethics Committee. RESULTS The graft function at year 3 in the DCD group was superior to that of the LD group (eGFR: 71.14±22.28 vs 64.29±16.76 mL/min/1.73 m2; P < .001). After matching donor age, there was no significant difference between the paired DCD and LD group (eGFR: 62.22±18.50 vs 66.99±17.81 mL/min/1.73 m2; P = .068). The 3-year graft survival (94.7% vs 97.4%; P = .041) and recipient survival (97.2% vs 99.5%; P = .011) were a little worse in the total DCD group. However, once the DCD kidney transplantation recipients survived more than 2 months, graft and recipient survival rates were similar between the DCD and LD groups (97.7% vs 97.4%, P = .866 and 99.5% vs 99.0%, P = .466). These results were confirmed in an age-paired groups study. Severe infection was the main cause of graft loss and recipient death in the early stage of DCD transplantation. CONCLUSIONS Medium- and long-term graft function of DCD kidney transplantation were comparable to LD kidney transplantation. Our results supported the continued use of DCD kidneys.
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25
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Lomero M, Gardiner D, Coll E, Haase‐Kromwijk B, Procaccio F, Immer F, Gabbasova L, Antoine C, Jushinskis J, Lynch N, Foss S, Bolotinha C, Ashkenazi T, Colenbie L, Zuckermann A, Adamec M, Czerwiński J, Karčiauskaitė S, Ström H, López‐Fraga M, Dominguez‐Gil B, Sarkissian A, Liashchuk S, Tsvetkova E, Bušić M, Michael N, Ilkjaer LB, Dmitriev P, Makisalo H, Rahmel A, Tomadze G, Ioannis B, Mihály S, Carella C, Codreanu I, Jansen N, Konijn C, França A, Zota V, Žilinská Z, Avsec D, Gautier S, Sánchez‐Ibáñez J, Terrón C, Vidal C, Beyeler F, Weiss J, Ilbars T, Forsythe J, Johnson R, Enckevort A. Donation after circulatory death today: an updated overview of the European landscape. Transpl Int 2019; 33:76-88. [DOI: 10.1111/tri.13506] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/28/2019] [Accepted: 08/26/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Mar Lomero
- European Directorate for the Quality of Medicines & Healthcare/Council of Europe Strasbourg France
| | - Dale Gardiner
- National Clinical Lead for Organ Donation NHS Blood and Transplant Watford UK
| | | | | | - Francesco Procaccio
- Italian National Transplant Centre Italian National Institute of Health Rome Italy
| | - Franz Immer
- Swisstransplant The Swiss National Foundation for Organ Donation and Transplantation Bern Switzerland
| | - Lyalya Gabbasova
- Ministry of Health of the Russian Federation Moscow Russian Federation
| | | | | | - Nessa Lynch
- Organ Donation Transplant Ireland Dublin Ireland
| | | | - Catarina Bolotinha
- National Transplantation Coordination Instituto Português do Sangue e da Transplantação Lisboa Portugal
| | - Tamar Ashkenazi
- Israel Transplant Center State of Israel Ministry of Health Tel‐Aviv Israel
| | - Luc Colenbie
- DG Health Care Organs Embryo's and Bio‐Ethics Brussels Belgium
| | | | - Miloš Adamec
- Koordinační Středisko Transplantací Prague Czech Republic
| | | | - Sonata Karčiauskaitė
- National Transplant Bureau Under the Ministry of Health of the Republic Lithuania Vilnius Lithuania
| | - Helena Ström
- Department for Knowledge‐Based Policy of Health Care National Donation Centre Stockholm Sweden
| | - Marta López‐Fraga
- European Directorate for the Quality of Medicines & Healthcare/Council of Europe Strasbourg France
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