Donation after cardiac death kidneys with low severity pre-arrest acute renal failure

Single center experience and literature review of kidney transplantation from non-ideal donors with acute kidney injury: Risk and reward

INTRODUCTION

There is limited experience transplanting kidneys from either expanded criteria donors (ECD) or donation after circulatory death (DCD) deceased donors with terminal acute kidney injury (AKI).

METHODS

AKI kidneys were defined by a donor terminal serum creatinine level >2.0 mg/dL whereas non-ideal deceased donor (NIDD) kidneys were defined as AKI/DCD or AKI/ECDs.

RESULTS

From February 2007 to March 2023, we transplanted 266 single AKI donor kidneys including 29 from ECDs, 29 from DCDs (n = 58 NIDDs), and 208 from brain-dead standard criteria donors (SCDs). Mean donor age (43.7 NIDD vs. 33.5 years SCD), KDPI (66% NIDD vs. 45% SCD), and recipient age (57 NIDD vs. 51 years SCD) were higher in the NIDD group (all p < .01). Mean waiting times (17.8 NIDD vs. 24.2 months SCD) and dialysis duration (34 NIDD vs. 47 months SCD) were shorter in the NIDD group (p < .05). Delayed graft function (DGF, 48%) and 1-year graft survival (92.7% NIDD vs. 95.9% SCD) was similar in both groups. Five-year patient and kidney graft survival rates were 82.1% versus 89.9% and 82.1% versus 75.2% (both p = NS) in the NIDD versus SCD groups, respectively.

CONCLUSIONS

The use of kidneys from AKI donors can be safely liberalized to include selected ECD and DCD donors.

Long-term outcomes of kidney transplantation from deceased donors with terminal acute kidney injury: Single center experience and literature review

INTRODUCTION

Long-term outcomes of kidney transplantation from deceased donors (DDKTs) with terminal acute kidney injury (AKI) are not well defined.

METHODS

Single center retrospective review of DDKTs from 1/31/07-12/31/19. AKI kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level AND a terminal SCr ≥2.0 mg/dl.

RESULTS

A total of 188 AKI DDKTs were performed, including 154 from brain-dead standard criteria donors (SCD). Mean donor age was 36 years and mean Kidney Donor Profile Index was 50%; mean admission and terminal SCr levels were 1.3 and 3.1 mg/dl, respectively. With a mean follow-up of 94 months (median 89 months), overall patient (both 71.3%) and graft survival (54% AKI vs. 57% non-AKI) rates were comparable to concurrent DDKTs from brain-dead non-AKI SCDs (n = 769). Delayed graft function (DGF) was higher in AKI kidney recipients (47% vs. 20% non-AKI DDKTs, p < .0001). DGF was associated with lower graft survival in recipients of both AKI and non-AKI SCD kidneys but the impact was earlier and more pronounced in non-AKI recipients.

CONCLUSIONS

Despite having more than twice the incidence of DGF, kidneys from deceased donors with terminal AKI have long-term outcomes comparable to non-AKI SCD kidneys and represent a safe and effective method to expand the donor pool.

Is prolonged cold ischemia a contraindication to using kidneys from acute kidney injury donors?

To determine the impact of prolonged cold ischemia time (CIT) on the outcome of acute kidney injury (AKI) renal grafts, we therefore performed a single-center retrospective analysis in adult patients receiving kidney transplantation (KT) from AKI donors. Outcomes were stratified according to duration of CIT. A total of 118 patients receiving AKI grafts were enrolled. Based on CIT, patients were stratified as follows: (i) <20 hours, 27 patients; (ii) 20-30 hours, 52 patients; (iii) 30-40 hours, 30 patients; (iv) ≥40 hours, nine patients. The overall incidence of delayed graft function DGF was 41.5%. According to increasing CIT category, DGF rates were 30%, 42%, 40%, and 78%, respectively (P = .03). With a mean follow-up of 48 months, overall patient and graft survival rates were 91% and 81%. Death-censored graft survival (DCGS) rates were 84% and 88% for patients with and without DGF (P = NS). DCGS rates were 92% in patients with CIT <20 hours compared to 85% with CIT >20 hours (P = NS). In the nine patients with CIT >40 hours, the 4-year DCGS rate was 100%. We conclude that prolonged CIT in AKI grafts may not adversely influence outcomes and so discard of AKI kidneys because of projected long CIT is not warranted when donors are wisely triaged.

Risk factors of acute kidney injury after orthotopic liver transplantation in China

In this study, we determined the risk factors for acute kidney injury (AKI) following orthotopic liver transplantation (OLT) in China. We collected 5074 donation after cardiac death (DCD) OLT recipients who underwent surgery between January 1, 2010, and December 31, 2015, in 86 academic hospitals or transplant centers in China. Univariate and multivariate analyses were used to investigate the criticality of donor, graft, or recipient variables in the development of post-OLT AKI. In all, 4482 patients were included (median age, 49.31 years). Post-OLT AKI occurred in 3.97% patients, and 73.6% of all OLT patients were male. The 1- and 5-year cumulative survival rates (CSRs) of the AKI group were 33.95% and 25.24%, respectively, compared with 86.34% and 70.05%, respectively, of the non-AKI group (P < 0.001). The independent risk factors for post-OLT AKI were blood loss, cold ischemia time, warm ischemia time, preoperative serum creatinine, the treatment period with dopamine, overexposure to calcineurin inhibitor, and combined mycophenolate mofetil use (P < 0.05). These had a high prediction accuracy for post-OLT AKI (area under the curve [AUC] = 0.740).

WITHDRAWN: Risk factors of acute kidney injury after orthotopic liver transplantation in China

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Outcomes of kidneys utilized from deceased donors with severe acute kidney injury

BACKGROUND

Significant numbers of kidneys are discarded due to raised terminal creatinine of the donor.

AIM

To determine long-term outcomes of kidneys utilized from donors with severe acute kidney injury (AKI).

METHODS

In this retrospective study, we included all patients who received kidneys from deceased donors between years 2000 and 2012. AKI was defined according to the acute kidney injury network (AKIN) classification. The primary outcomes were patient and graft survival and secondary outcomes were renal function at different time points, delayed graft function, acute rejection and length of hospital stay.

RESULTS

Two hundred and eighty-four recipients received kidneys from 261 deceased donors. One hundred and fourteen patients (40%) received kidneys from the donors with AKI. Forty-two patients received kidneys from the donors with severe AKI (AKIN-3 category). Mean age of the donor and recipient was 36 and 37 years, respectively. Main cause of death in donors was road traffic accident (34%) followed by cerebrovascular accident (33%). Terminal creatinine was 85 and 262 μmol/l in non-AKI and AKI groups, respectively (P < 0.001). Significantly more patients in the AKI group had delayed graft function (P = 0.006), prolonged hospital stay (P < 0.001) and high creatinine at discharge (P = 0.002). However, acute rejection rates (P = 0.25), 1-, 5- and 10-year graft survival (P = 0.57) and patient survival (P = 0.77) were not different between AKI and non-AKI groups. The outcomes in the AKIN-3 category were comparable with the non-AKI group.

CONCLUSIONS

This study has shown favorable long-term outcomes of kidneys utilized from donors with severe AKI. This study may encourage healthcare professionals to consider accepting such kidneys.

Kidneys from standard-criteria donors with different severities of terminal acute kidney injury

OBJECTIVES

High terminal serum creatinine level in a deceased donor has been reported as the second most frequent cause of refusal for kidney transplantation. A growing body of evidence has shown a comparable outcome of kidney transplantation from deceased donors with acute kidney injury (AKI). However, the influence of the severity of AKI on graft outcomes remains to be elucidated.

METHODS

In this retrospective cohort study, 84 consecutive kidney transplants from 57 standard-criteria donors were classified into 4 groups by RIFLE (Risk, Injury, Failure, Loss of function, and End-stage renal disease) classification according to donor AKI severity before kidney procurement. The donor and recipient characteristics and graft outcomes were compared.

RESULTS

Of 84 kidney transplants, 56, 11, 10, and 7 recipients were in the Non-AKI, Risk, Injury, and Failure groups. The mean terminal creatinine was 1.1, 1.6, 2.3, and 4.4 mg/dL in these 4 groups. However, the graft outcomes, including primary nonfunction rate, delayed graft function rate, acute rejection rate, renal function, graft survival and overall survival over the first 5 years had no statistical difference. A trend toward increasing delayed graft function rate as the severity of AKI increased was observed (Non-AKI, Risk, Injury, and Failure: 26.8%, 36.4%, 60.0%, and 57.1%, P = .099).

CONCLUSIONS

Our study demonstrates that AKI before procurement does not cause adverse long-term graft outcomes. Standard-criteria donors with AKI are suitable for kidney transplantation, even with a high severity of AKI.

Evolving experience using kidneys from deceased donors with terminal acute kidney injury

BACKGROUND

Kidney transplantation from deceased donors with terminal acute kidney injury (AKI) is not widely accepted.

STUDY DESIGN

Acute kidney injury donor kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level and a terminal SCr level >2.0 mg/dL before organ recovery.

RESULTS

Over 5.5 years, we transplanted 84 AKI donor kidneys, including 64 kidneys from standard criteria donors (SCD), 11 from expanded criteria donors (ECD), and 9 from donation after cardiac death (DCD) donors. Mean donor age was 36 years (range 15 to 68 years); mean admission and terminal donor SCr levels were 1.25 mg/dL and 3.2 mg/dL, respectively (mean terminal estimated glomerular filtration rate 25.5 mL/minute). With a mean follow-up of 35 months (range 6 to 70 months), actual patient and graft survival rates are 98% and 89%, respectively, which are numerically, but not statistically, higher than concurrent kidney transplants from brain-dead (non-AKI) SCDs at our center. Delayed graft function (DGF) occurred in 34 patients (40%). Mean 1-, 12-, and 24-month SCr levels were 1.8, 1.6, and 1.7 mg/dL, respectively. Delayed graft function was associated with lower 3-year graft survival for non-AKI SCD transplants (68% vs 90%, with and without DGF), but there was no impact of DGF on graft survival for AKI donor kidneys (89% vs 91%).

CONCLUSIONS

Although AKI donor kidneys more commonly have DGF, the higher rate of DGF does not worsen graft outcomes. Kidneys from deceased donors with terminal AKI transplanted into appropriately selected patients have excellent medium-term outcomes and represent a method to safely expand the donor pool.

Kidney donation after cardiac death

There is continuing disparity between demand for and supply of kidneys for transplantation. This review describes the current state of kidney donation after cardiac death (DCD) and provides recommendations for a way forward. The conversion rate for potential DCD donors varies from 40%-80%. Compared to controlled DCD, uncontrolled DCD is more labour intensive, has a lower conversion rate and a higher discard rate. The super-rapid laparotomy technique involving direct aortic cannulation is preferred over in situ perfusion in controlled DCD donation and is associated with lower kidney discard rates, shorter warm ischaemia times and higher graft survival rates. DCD kidneys showed a 5.73-fold increase in the incidence of delayed graft function (DGF) and a higher primary non function rate compared to donation after brain death kidneys, but the long term graft function is equivalent between the two. The cold ischaemia time is a controllable factor that significantly influences the outcome of allografts, for example, limiting it to < 12 h markedly reduces DGF. DCD kidneys from donors < 50 function like standard criteria kidneys and should be viewed as such. As the majority of DCD kidneys are from controlled donation, incorporation of uncontrolled donation will expand the donor pool. Efforts to maximise the supply of kidneys from DCD include: implementing organ recovery from emergency department setting; improving family consent rate; utilising technological developments to optimise organs either prior to recovery from donors or during storage; improving organ allocation to ensure best utility; and improving viability testing to reduce primary non function.

Expanding the criteria of renal kidneys for transplantation: use of donors with acute renal failure

BACKGROUND

Increased numbers of patients waiting for renal transplantation have led to widening selection criteria for grafts. Thus, we have evaluated the outcome of transplanted kidneys procured in the presence of acute renal failure (ARF).

METHODS

Transplant patients (n = 52) with a kidney procured with ARF were studied. Clinical data from donors and recipients, serum creatinine (SCr), creatinine clearance [estimated glomerular filtration rate (eGFR)], cold ischaemia duration, time to urine flow recovery or renal function recovery, and the number of haemodialysis sessions, were collected retrospectively.

RESULTS

Mean donor age was 45.7 +/- 12.7 years, and the mean SCr at the time of harvesting was 276.3 +/- 104.2 micromol/l. Recipients' mean age was 51.1 +/- 12.1 years. After transplantation, recovery of renal function was observed after 7.6 +/- 7.1 days, and required 1.9 +/- 3.0 haemodialysis sessions. SCr was 124.6 +/- 49.5 micromol/l, and eGFR was 56.2 +/- 19.8 ml/min at last follow-up. eGFR was significantly lower if the donor's death was due to stroke or cerebral haemorrhage (CH), or if the donors had previous cardiovascular disease (CVD) (P < 0.02). Patients with eGFR of <50 ml/min (n = 23) had donors who were older, and whose cause of death was more frequently related to CVD factors or to CH/stroke (P < 0.03). There were no significant differences between the two groups regarding age of recipient, gender of the donor or recipient, cold ischaemia time, occurrence of cardiac arrest, collapse or acute rejection. Linear regression analysis indicated that donor age and occurrence of acute rejection were independent factors associated with eGFR.

CONCLUSIONS

ARF before organ procurement does not have a negative effect on subsequent renal function. However, old age, CVD risk factors or CH, and late renal function recovery after transplantation are correlated with subsequent lower renal function. Thus, renal grafts with ARF can be used for renal transplantations.