1
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Nemeth DV, Iannelli L, Gangitano E, D’Andrea V, Bellini MI. Energy Metabolism and Metformin: Effects on Ischemia-Reperfusion Injury in Kidney Transplantation. Biomedicines 2024; 12:1534. [PMID: 39062107 PMCID: PMC11275143 DOI: 10.3390/biomedicines12071534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Metformin (MTF) is the only biguanide included in the World Health Organization's list of essential medicines; representing a widespread drug in the management of diabetes mellitus. With its accessibility and affordability being one of its biggest assets, it has become the target of interest for many trying to find alternative treatments for varied pathologies. Over time, an increasing body of evidence has shown additional roles of MTF, with unexpected interactions of benefit in other diseases. Metformin (MTF) holds significant promise in mitigating ischemia-reperfusion injury (IRI), particularly in the realm of organ transplantation. As acceptance criteria for organ transplants expand, IRI during the preservation phase remain a major concern within the transplant community, prompting a keen interest in MTF's effects. Emerging evidence suggests that administering MTF during reperfusion may activate the reperfusion injury salvage kinase (RISK) pathway. This pathway is pivotal in alleviating IRI in transplant recipients, potentially leading to improved outcomes such as reduced rates of organ rejection. This review aims to contextualize MTF historically, explore its current uses, pharmacokinetics, and pharmacodynamics, and link these aspects to the pathophysiology of IRI to illuminate its potential future role in transplantation. A comprehensive survey of the current literature highlights MTF's potential to recondition and protect against IRI by attenuating free radical damage, activating AMP-activated protein kinase to preserve cellular energy and promote repair, as well as directly reducing inflammation and enhancing microcirculation.
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Affiliation(s)
- Denise V. Nemeth
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX 78235, USA
| | - Leonardo Iannelli
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Elena Gangitano
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Vito D’Andrea
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
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2
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Mella A, Calvetti R, Barreca A, Congiu G, Biancone L. Kidney transplants from elderly donors: what we have learned 20 years after the Crystal City consensus criteria meeting. J Nephrol 2024; 37:1449-1461. [PMID: 38446386 PMCID: PMC11473582 DOI: 10.1007/s40620-024-01888-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/03/2024] [Indexed: 03/07/2024]
Abstract
Based on the current projection of the general population and the combined increase in end-stage kidney disease with age, the number of elderly donors and recipients is increasing, raising crucial questions about how to minimize the discard rate of organs from elderly donors and improve graft and patient outcomes. In 2002, extended criteria donors were the focus of a meeting in Crystal City (VA, USA), with a goal of maximizing the use of organs from deceased donors. Since then, extended criteria donors have progressively contributed to a large number of transplanted grafts worldwide, posing specific issues for allocation systems, recipient management, and therapeutic approaches. This review analyzes what we have learned in the last 20 years about extended criteria donor utilization, the promising innovations in immunosuppressive management, and the molecular pathways involved in the aging process, which constitute potential targets for novel therapies.
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Affiliation(s)
- Alberto Mella
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Ruggero Calvetti
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Congiu
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center" A. Vercellone," Nephrology, Dialysis, and Renal Transplant Division, "Città Della Salute e Della Scienza" Hospital, Department of Medical Sciences, University of Turin, Corso Bramante, 88, 10126, Turin, Italy.
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3
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Development and external validation study combining existing models and recent data into an up-to-date prediction model for evaluating kidneys from older deceased donors for transplantation. Kidney Int 2020; 99:1459-1469. [PMID: 33340517 DOI: 10.1016/j.kint.2020.11.016] [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: 07/02/2020] [Revised: 10/11/2020] [Accepted: 11/05/2020] [Indexed: 11/20/2022]
Abstract
With a rising demand for kidney transplantation, reliable pre-transplant assessment of organ quality becomes top priority. In clinical practice, physicians are regularly in doubt whether suboptimal kidney offers from older donors should be accepted. Here, we externally validate existing prediction models in a European population of older deceased donors, and subsequently developed and externally validated an adverse outcome prediction tool. Recipients of kidney grafts from deceased donors 50 years of age and older were included from the Netherlands Organ Transplant Registry (NOTR) and United States organ transplant registry from 2006-2018. The predicted adverse outcome was a composite of graft failure, death or chronic kidney disease stage 4 plus within one year after transplantation, modelled using logistic regression. Discrimination and calibration were assessed in internal, temporal and external validation. Seven existing models were validated with the same cohorts. The NOTR development cohort contained 2510 patients and 823 events. The temporal validation within NOTR had 837 patients and the external validation used 31987 patients in the United States organ transplant registry. Discrimination of our full adverse outcome model was moderate in external validation (C-statistic 0.63), though somewhat better than discrimination of the seven existing prediction models (average C-statistic 0.57). The model's calibration was highly accurate. Thus, since existing adverse outcome kidney graft survival models performed poorly in a population of older deceased donors, novel models were developed and externally validated, with maximum achievable performance in a population of older deceased kidney donors. These models could assist transplant clinicians in deciding whether to accept a kidney from an older donor.
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4
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Süsal C, Kumru G, Döhler B, Morath C, Baas M, Lutz J, Unterrainer C, Arns W, Aubert O, Bara C, Beiras-Fernandez A, Böhmig GA, Bösmüller C, Diekmann F, Dutkowski P, Hauser I, Legendre C, Lozanovski VJ, Mehrabi A, Melk A, Minor T, Mueller TF, Pisarski P, Rostaing L, Schemmer P, Schneeberger S, Schwenger V, Sommerer C, Tönshoff B, Viebahn R, Viklicky O, Weimer R, Weiss KH, Zeier M, Živčić-Ćosić S, Heemann U. Should kidney allografts from old donors be allocated only to old recipients? Transpl Int 2020; 33:849-857. [PMID: 32337766 DOI: 10.1111/tri.13628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/06/2019] [Accepted: 04/22/2020] [Indexed: 02/05/2023]
Abstract
In several deceased donor kidney allocation systems, organs from elderly donors are allocated primarily to elderly recipients. The Eurotransplant Senior Program (ESP) was implemented in 1999, and since then, especially in Europe, the use of organs from elderly donors has steadily increased. The proportion of ≥60-year-old donors reported to the Collaborative Transplant Study (CTS) by European centers has doubled, from 21% in 2000-2001 to 42% in 2016-2017. Therefore, in the era of organ shortage it is a matter of debate whether kidney organs from elderly donors should only be allocated to elderly recipients or whether <65-year-old recipients can also benefit from these generally as "marginal" categorized organs. To discuss this issue, a European Consensus Meeting was organized by the CTS on April 12, 2018, in Heidelberg, in which 36 experts participated. Based on available evidence, it was unanimously concluded that kidney organs from 65- to 74-year-old donors can also be allocated to 55- to 64-year-old recipients, especially if these organs are from donors with no history of hypertension, no increased creatinine, no cerebrovascular death, and no other reasons for defining a marginal donor, such as diabetes or cancer.
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Affiliation(s)
- Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gizem Kumru
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marije Baas
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jens Lutz
- Division of Nephrology and Infectious Diseases, Medical Clinic, Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany
| | | | - Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Center, Cologne, Germany
| | - Olivier Aubert
- Service de Transplantation Rénale et Unité de Soins Intensifs, AP-HP, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | - Christoph Bara
- Division of Thoracic Transplantation and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andres Beiras-Fernandez
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Johannes Gutenberg University, Mainz, Germany
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Claudia Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Fritz Diekmann
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Ingeborg Hauser
- Department of Nephrology, Medinizische Klinik III, UKF, Goethe University, Frankfurt, Germany
| | - Christophe Legendre
- Service de Transplantation Rénale et Unité de Soins Intensifs, AP-HP, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | - Vladimir J Lozanovski
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Thomas Minor
- Department of Surgical Research, Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Germany
| | - Thomas F Mueller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Przemyslaw Pisarski
- Department for General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Lionel Rostaing
- Service de Néphrologie, Dialyse, Aphérèses et Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Peter Schemmer
- Department of Surgery, General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Stefan Schneeberger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vedat Schwenger
- Department of Nephrology and Autoimmune Diseases, Transplantation Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Claudia Sommerer
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Richard Viebahn
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Rolf Weimer
- Department of Internal Medicine, University of Giessen, Giessen, Germany
| | - Karl-Heinz Weiss
- Department of Internal Medicine IV, Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stela Živčić-Ćosić
- Department of Nephrology, Dialysis and Kidney Transplantation, Faculty of Medicine, Clinical Hospital Center Rijeka, University of Rijeka, Rijeka, Croatia
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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5
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Hruba P, Krejcik Z, Dostalova Merkerova M, Klema J, Stranecky V, Slatinska J, Maluskova J, Honsova E, Viklicky O. Molecular Fingerprints of Borderline Changes in Kidney Allografts Are Influenced by Donor Category. Front Immunol 2020; 11:423. [PMID: 32269565 PMCID: PMC7109293 DOI: 10.3389/fimmu.2020.00423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 02/24/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Zdenek Krejcik
- Department of Genomics, Institute of Haematology and Blood Transfusion, Prague, Czechia
| | | | - Jiri Klema
- Department of Computer Science, Faculty of Electrical Engineering, Czech Technical University, Prague, Czechia
| | - Viktor Stranecky
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University, Prague, Czechia
| | - Janka Slatinska
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jana Maluskova
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Eva Honsova
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Ondrej Viklicky
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czechia.,Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czechia
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6
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Noble J, Jouve T, Malvezzi P, Süsal C, Rostaing L. Transplantation of Marginal Organs: Immunological Aspects and Therapeutic Perspectives in Kidney Transplantation. Front Immunol 2020; 10:3142. [PMID: 32082306 PMCID: PMC7005052 DOI: 10.3389/fimmu.2019.03142] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/24/2019] [Indexed: 12/14/2022] Open
Abstract
Recent data from the World Population Prospects projects that, by 2050, nearly all regions in the world will have a quarter or more of the population aged 60 and above. Chronic kidney disease (CKD) has a high global prevalence (~13%) worldwide, and the prevalence of chronic kidney disease and end-stage kidney disease increase with age. Kidney transplantation remains the best therapeutic option for end-stage kidney disease, offering a survival benefit in comparison with dialysis maintenance for most patients. This review focuses on immunological aspects of kidney transplantation in older patients and marginal donors, i.e., 60 years or older deceased kidney donors or 50–59 years old deceased kidney donors with comorbidities. Clinical outcomes of kidney recipients in terms of renal and patient survival are more than acceptable even for patients over 70. In this population, the first cause of graft loss is death with a functional graft. However, the inherent issues of these transplantations are the acceptance or refusal of frail kidney from an old donor and the increased immunogenicity of these organs in balance with potential frail and immunosenescent recipients. Finally, the immunosuppressive regimen itself is a challenge for the future of the transplant, to prevent adverse effects such as nephrotoxicity and higher risk of infections or cancer in a population already at risk. Belatacept may have a good place in the immunosuppressive strategy to improve efficacy and the safety posttransplantation.
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Affiliation(s)
- Johan Noble
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France
| | - Caner Süsal
- Collaborative Transplant Study, Institute of Immunology, Heidelberg University, Heidelberg, Germany
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphéréses et Transplantation Rénale, Centre Hospitalier Universitaire (CHU) de Grenoble-Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
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7
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Chen SS, Pankratz VS, Litvinovich I, Al-Odat RT, Unruh ML, Ng YH. Expanded Criteria Donor Kidneys With Kidney Donor Profile Index ≤ 85%: Are We Doing Enough to Counsel Our Patients? Transplant Proc 2020; 52:54-60. [PMID: 31901324 DOI: 10.1016/j.transproceed.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/02/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Kidneys at higher risk for allograft failure are defined by the Kidney Donor Profile Index (KDPI) > 85% in the current kidney allocation system (KAS), replacing the historical concept of expanded criteria donor (ECD) kidneys in the previous KAS. Discrepancies exist in the classification of "high-risk kidneys" between the 2 KAS. In the current KAS, only recipients of KDPI > 85% kidneys are counseled about the high risk of allograft failure and are required to sign a consent. In this study, we evaluated the outcomes and allocation of kidneys with discordant classification. METHODS Using the Scientific Registry of Transplant Recipients, kidneys transplanted between 01/2002 and 09/2016 were classified according to the old (standard criteria donor [SCD]/ECD) and current (KDPI) KAS. We then grouped them as concordant (KDPI ≤ 85% + SCD or KDPI > 85% + ECD) and discordant (KDPI ≤ 85% + ECD or KDPI > 85% + SCD) kidneys. RESULTS Approximately 11% of transplanted kidneys were discordant in classification. Among kidneys with KDPI ≤ 85%, ECD status conferred a 64% (95% CI: 56%-73%) higher risk of allograft failure compared to SCD status. However, SCD/ECD status was not associated with differential outcomes in KDPI > 85% kidneys. These ECD kidneys have KDPIs > 50% and have been transplanted across all estimated post-transplant survival (EPTS) deciles. CONCLUSION Adequate counseling about the risk and benefit of accepting ECD kidneys with KDPI ≤ 85% versus waiting on dialysis should be explored with the patients, especially those with lower EPTS.
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Affiliation(s)
- Shan Shan Chen
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - V Shane Pankratz
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Igor Litvinovich
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Rawan T Al-Odat
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Mark L Unruh
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA; Section of Nephrology, Medicine Service, New Mexico VA Health Care System, Albuquerque, NM
| | - Yue-Harn Ng
- Nephrology Division, Department of Medicine, University of New Mexico, Albuquerque, NM, USA.
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8
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Salvadori M, Tsalouchos A. Histological and clinical evaluation of marginal donor kidneys before transplantation: Which is best? World J Transplant 2019; 9:62-80. [PMID: 31523629 PMCID: PMC6715576 DOI: 10.5500/wjt.v9.i4.62] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/21/2019] [Accepted: 07/30/2019] [Indexed: 02/05/2023] Open
Abstract
Organ shortage represents one of the major limitations to the development of kidney transplantation. To increase the donor pool and to answer the ever increasing kidney request, physicians are recurring to marginal kidneys as kidneys from older donors, from hypertensive or diabetic donors and from non-heart beating donors. These kidneys are known to have frequently a worse outcome in the recipients. To date major problem is to evaluate such kidneys in order to use or to discard them before transplantation. The use of such kidneys create other relevant question as whether to use them as single or dual transplant and to allocate them fairly according transplant programs. The pre-transplant histological evaluation, the clinical evaluation of the donor or both the criteria joined has been used and according the time each criterion prevailed over the others. Aim of this review has been to examine the advantages and the drawbacks of any criterion and how they have changed with time. To date any criterion has several limitations and several authors have argued for the development of new guidelines in the field of the kidney evaluation for transplantation. Several authors argue that the use of omic technologies should improve the organ evaluation and studies are ongoing to evaluate these technologies either in the donor urine or in the biopsies taken before transplantation.
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Affiliation(s)
- Maurizio Salvadori
- Department of Transplantation Renal Unit, Careggi University Hospital, viale Pieraccini 18, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Via Cesare Battisti, Pescia (PT) 2-51017, Italy
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9
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Park WY, Choi MS, Kim YS, Choi BS, Park CW, Yang CW, Kim YS, Jin K, Han S, Chung BH. Impact of acute kidney injury in expanded criteria deceased donors on post-transplant clinical outcomes: multicenter cohort study. BMC Nephrol 2019; 20:39. [PMID: 30717699 PMCID: PMC6360778 DOI: 10.1186/s12882-019-1225-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 01/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background The problem of organ shortage is an important issue in kidney transplantation, but the effect of kidney donation on AKI is unclear. The aim of this study was to investigate the impact of acute kidney injury (AKI) on post-transplant clinical outcomes for deceased donor kidney transplantation (DDKT) using standard criteria donors (SCDs) versus expanded criteria donors (ECDs). Methods Five-hundred nine KT recipients receiving kidneys from 386 deceased donors (DDs) were included from three transplant centers. Recipients were classified into the SCD-KT or ECD-KT group according to corresponding DDs and both groups were divided into the AKI-KT or non-AKI-KT subgroups according to AKI in donor. We compared the clinical outcomes among those four groups and investigated the interaction between AKI in donors and ECD on allograft outcome. Results The incidence of delayed allograft function was higher when the donors had AKI within SCD-KT and ECD-KT groups. In allograft biopsies within 3 months, chronic change was more significant in the AKI-ECD-KT subgroup than in the non-AKI-ECD-KT subgroup, but it did not differ between AKI-SCD-KT and non-AKI-SCD-KT group. AKI-ECD-KT showed higher risk for death-censored allograft failure than the other three groups and a significant interaction was observed between AKI in donors and ECD on the allograft outcome. Conclusions The presence of AKI in ECDs significantly impacted the long-term allograft outcomes of kidney transplant recipients, but it did not in SCDs. Electronic supplementary material The online version of this article (10.1186/s12882-019-1225-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Woo Yeong Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea.,Keimyung University Kidney Institute, Daegu, South Korea
| | - Min-Seok Choi
- Transplant Research Center, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Young Soo Kim
- Division of Nephrology, Department of Internal Medicine, Uijeongbu St. Mary's hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, South Korea
| | - Bum Soon Choi
- Transplant Research Center, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Cheol Whee Park
- Transplant Research Center, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Transplant Research Center, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yong-Soo Kim
- Transplant Research Center, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea.,Keimyung University Kidney Institute, Daegu, South Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea.,Keimyung University Kidney Institute, Daegu, South Korea
| | - Byung Ha Chung
- Transplant Research Center, Seoul, South Korea. .,Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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10
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Clinical significance of the Kidney Donor Profile Index in deceased donors for prediction of post-transplant clinical outcomes: A multicenter cohort study. PLoS One 2018; 13:e0205011. [PMID: 30289927 PMCID: PMC6173429 DOI: 10.1371/journal.pone.0205011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 09/18/2018] [Indexed: 12/11/2022] Open
Abstract
Background We investigated whether the Kidney Donor Profile Index (KDPI) system is useful in predicting clinical outcomes in deceased donor kidney transplantation (DDKT). Methods Four hundred sixty-nine kidney transplant recipients (KTRs) receiving kidneys from 359 deceased donors were included in this study, which involved three transplant centers. KTRs were divided into high and low KDPI KTR groups based on the median KDPI score of 67%. We compared clinical outcomes between the high KDPI and low KDPI groups. Results There were no significant differences in the incidence of delayed graft function and acute rejection between high and low KDPI KTR groups. In comparison with histologic findings in allograft tissues obtained within three months from KT, the proportion of glomerulosclerosis was significantly higher in the high KDPI KTR group than in the low KDPI KTR group. With Kaplan-Meier analysis, the graft survival rate was significantly lower in the high KDPI KTR group than in the low KDPI KTR group (Log rank, P = 0.017), and multivariate analysis also demonstrated that a high KDPI score was a significant risk factor for death censored allograft failure (HR 2.62, 95% CI, 1.29–5.33, P = 0.008). Conclusion The KDPI scoring system is useful in predicting allograft outcomes in a Korean DDKT cohort.
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Colussi G, Casati C, Colombo VG, Camozzi MLP, Salerno FR. Renal transplants from older deceased donors: Is pre-implantation biopsy useful? A monocentric observational clinical study. World J Transplant 2018; 8:110-121. [PMID: 30148077 PMCID: PMC6107519 DOI: 10.5500/wjt.v8.i4.110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/09/2018] [Accepted: 05/13/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare survival of kidney transplants from deceased extended criteria donors (ECD) according to: (1) donor graft histological score; and (2) allocation of high score grafts either to single (SKT) or dual (DKT) transplant.
METHODS Renal biopsy was performed as part of either a newly adopted DKT protocol, or of surveillance protocol in the past. A total 185 ECD graft recipients were categorized according to pre-implantation graft biopsy into 3 groups: SKT with graft score 1 to 4 [SKT(1-4), n = 102]; SKT with donor graft score 5 to 8 [SKT(> 4), n = 30]; DKT with donor graft score 5 to 7 (DKT, n = 53). Graft and patient survival were analyzed by Kaplan-Meier curves and compared by log-rank test. Mean number of functioning graft years by transplant reference, and mean number of dialysis-free life years by donor reference in recipients were also calculated at 1, 3 and 6 years from transplantation.
RESULTS There were no statistically significant differences in graft and patient survival between SKT(1-4) and SKT(> 4), and between SKT(> 4) and DKT. Recipient renal function (plasma creatinine and creatinine clearance) at 1 years did not differ in SKT(1-4) and SKT(> 4) (plasma creatinine 1.71 ± 0.69 and 1.69 ± 0.63 mg/dL; creatinine clearance 49.6 + 18.5 and 52.6 + 18.8 mL/min, respectively); DKT showed statistically lower plasma creatinine (1.46 ± 0.57, P < 0.04) but not different creatinine clearance (55.4 + 20.4). Due to older donor age in the DKT group, comparisons were repeated in transplants from donors older than 70 years, and equal graft and patient survival in SKT and DKT were confirmed. Total mean number of functioning graft years by transplant reference at 1, 3 and 6 post-transplant years were equal between the groups, but mean number of dialysis-free life years by donor reference were significantly higher in SKT (mean difference compared to DKT at 6 years: 292 [IQR 260-318] years/100 donors in SKT(1-4) and 292.5 [(IQR 247.8-331.6) in SKT(> 4)].
CONCLUSION In transplants from clinically suitable ECD donors, graft survival was similar irrespective of pre-implantation biopsy score and of allocation to SKT or DKT. These results suggest use of caution in the use of histology as the only decision criteria for ECD organ allocation.
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Affiliation(s)
- Giacomo Colussi
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
| | - Costanza Casati
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
| | - Valeriana Giuseppina Colombo
- Fabio Rosario Salereno, Division of Nephrology, Dialysis and Renal Transplantatation, ASST Grande Ospedale Territoriale Niguarda, Milan 20162, Italy
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Casati C, Colombo VG, Perrino M, Rossetti OM, Querques M, Giacomoni A, Binaggia A, Colussi G. Renal Transplants from Older Deceased Donors: Use of Preimplantation Biopsy and Differential Allocation to Dual or Single Kidney Transplant according to Histological Score Has No Advantages over Allocation to Single Kidney Transplant by Simple Clinical Indication. J Transplant 2018; 2018:4141756. [PMID: 29862061 PMCID: PMC5976897 DOI: 10.1155/2018/4141756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/21/2018] [Accepted: 04/10/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Grafts from elderly donors (ECD) are increasingly allocated to single (SKT) or dual (DKT) kidney transplantation according to biopsy score. Indications and benefits of either procedure lack universal agreement. METHODS A total of 302 ECD-transplants in period from Jan 1, 2000, to Dec 31, 2015, were allocated to SKT (SKTpre) on clinical grounds alone (before Dec 2010, pre-DKT era, n = 170) or according to a clinical-histological protocol (after Dec 2010, DKT era, n = 132) to DKT (n = 48), SKT biopsy-based protocol ("high-risk", SKThr, n = 51), or SKT clinically based protocol ("low-risk", SKTlr, n = 33). Graft and patient survival were compared between the two periods and between different transplant categories. RESULTS Graft and overall survival in recipients from ECD in pre-DKT and DKT era did not differ (5-year graft survival 87.7% and 84.2%, resp.); equal survival in the 2 ECD periods was shown in both donor age ranges of 60-69 and >70-years, and in low-risk or high-risk ECD categories. Within the DKT protocol SKThr showed worst graft and overall survival in the 60-69 donor age range; DKT did not result in significantly better outcome than SKT from ECD in either era. One-year posttransplant creatinine clearance in recipients did not differ between any ECD transplant category. At 3 and 5 years after transplantation there were significantly higher total dialysis-free recipient life years from an equal donor number in the pre-DKT era than in the DKT protocol. CONCLUSIONS Use of a biopsy-based protocol to allocate grafts from aged donors to SKT or DKT did not result in better short term graft survival than a clinically based protocol with allocation only to SKT and reduced overall recipient dialysis-free life years in time.
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Affiliation(s)
- Costanza Casati
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Valeriana Giuseppina Colombo
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marialuisa Perrino
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Marialuisa Querques
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Giacomoni
- Division of Transplant Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Agnese Binaggia
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Colussi
- Division of Nephrology, Dialysis and Kidney Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Analysis of Distribution of Expanded- and Standard-Criteria Donors and Complications Among Polish Recipients by Kidney Donor Risk Index Value. Transplant Proc 2018; 50:1686-1690. [PMID: 30056882 DOI: 10.1016/j.transproceed.2018.02.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 12/11/2022]
Abstract
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.
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Chen G, Wang C, Ko DSC, Qiu J, Yuan X, Han M, Wang C, He X, Chen L. Comparison of outcomes of kidney transplantation from donation after brain death, donation after circulatory death, and donation after brain death followed by circulatory death donors. Clin Transplant 2017; 31. [PMID: 28886219 DOI: 10.1111/ctr.13110] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are three categories of deceased donors of kidney transplantation in China, donation after brain death (DBD), donation after circulatory death (DCD), and donation after brain death followed by circulatory death (DBCD) donors. The aim of this study was to compare the outcomes of kidney transplantation from these three categories of deceased donors. METHODS We retrospectively reviewed 469 recipients who received deceased kidney transplantation in our hospital from February 2007 to June 2015. The recipients were divided into three groups according to the source of their donor kidneys: DBD, DCD, or DBCD. The primary endpoints were delayed graft function (DGF), graft loss, and patient death. RESULTS The warm ischemia time was much longer in DCD group compared to DBCD group (18.4 minutes vs 12.9 minutes, P < .001). DGF rate was higher in DCD group than in DBD and DBCD groups (22.5% vs 10.2% and 13.8%, respectively, P = .021). Urinary leakage was much higher in DCD group (P = .049). Kaplan-Meier analysis showed that 1-, 2-, and 3-year patient survivals were all comparable among the three groups. CONCLUSION DBCD kidney transplantation has lower incidences of DGF and urinary leakage than DCD kidney transplant. However, the overall patient and graft survival were comparable among DBD, DCD, and DBCD kidney transplantation.
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Affiliation(s)
- Guodong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Chang Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dicken Shiu-Chung Ko
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jiang Qiu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaopeng Yuan
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lizhong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Cuna V, Comai G, Cappuccilli M, Baraldi O, Capelli I, De Liberali M, Gasperoni L, Conte D, Ravaioli M, Pinna AD, La Manna G. Fifteen-Year Analysis of Deceased Kidney Donation: A Single Transplant Center Experience in a Region of Northern Italy. Med Sci Monit 2017; 23:4482-4489. [PMID: 28919594 PMCID: PMC5616149 DOI: 10.12659/msm.903513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The rising number of patients on waiting lists for kidney transplant and the shortage of available organs has intensified efforts to increase the number of potential donors. Material/Methods This study investigated changes in clinical parameters among potential deceased donors in the 15-year period between 1999 and 2013 and their impact on transplantation procedure and outcomes. A total of 1634 potential deceased donors were examined and divided into 2 groups: 707 of them identified from 1999 to 2005 (Group A), and 927 from 2006 to 2013 (Group B). Results The comparison between the potential donors in Group A vs. Group B revealed an increase over time in donor age (54.6±17.2 vs. 58.8±16.3, p<0.001), a reduction in the percentage of standard donors (52.3% vs. 39.8%, p<0.001), a broader utilization of organs from expanded criteria donors, and a greater number of comorbidities, particularly cardiovascular disease and dyslipidemia. However, renal function parameters and the bioptic scores did not change significantly over the years. Conclusions These results suggest the usefulness of strategies to increase the number of potential donors suitable for organ donation, especially among elderly and marginal donors.
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Affiliation(s)
- Vania Cuna
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
| | - Maria Cappuccilli
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
| | - Olga Baraldi
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
| | - Irene Capelli
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
| | - Matteo De Liberali
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
| | - Lorenzo Gasperoni
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
| | - Diletta Conte
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, Universita degli Studi di Bologna, Bologna, Italy
| | - Matteo Ravaioli
- Department of General Surgery and Transplantation, University of Bologna, Bologna, Italy
| | - Antonio D Pinna
- Department of General Surgery and Transplantation, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Experimental, Diagnostic, and Specialty Medicine (DIMES) - Nephrology, Dialysis, and Transplantation Unit, University of Bologna, Bologna, Italy
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16
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De Meester J. The expanded criteria donor for kidney transplant: not a nearly new car. Transpl Int 2016; 30:11-13. [DOI: 10.1111/tri.12880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/20/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Johan De Meester
- Department of Nephrology, Dialysis and Hypertension; AZ Nikolaas; Sint-Niklaas Belgium
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