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Urbanellis P, Mazilescu L, Kollmann D, Linares-Cervantes I, Kaths JM, Ganesh S, Oquendo F, Sharma M, Goto T, Noguchi Y, John R, Konvalinka A, Mucsi I, Ghanekar A, Bagli D, Robinson LA, Selzner M. Prolonged warm ischemia time leads to severe renal dysfunction of donation-after-cardiac death kidney grafts. Sci Rep 2021; 11:17930. [PMID: 34504136 PMCID: PMC8429572 DOI: 10.1038/s41598-021-97078-w] [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: 03/19/2021] [Accepted: 08/09/2021] [Indexed: 12/26/2022] Open
Abstract
Kidney transplantation with grafts procured after donation-after-cardiac death (DCD) has led to an increase in incidence of delayed graft function (DGF). It is thought that the warm ischemic (WI) insult encountered during DCD procurement is the cause of this finding, although few studies have been designed to definitely demonstrate this causation in a transplantation setting. Here, we use a large animal renal transplantation model to study the effects of prolonged WI during procurement on post-transplantation renal function. Kidneys from 30 kg-Yorkshire pigs were procured following increasing WI times of 0 min (Heart-Beating Donor), 30 min, 60 min, 90 min, and 120 min (n = 3-6 per group) to mimic DCD. Following 8 h of static cold storage and autotransplantation, animals were followed for 7-days. Significant renal dysfunction (SRD), resembling clinical DGF, was defined as the development of oliguria < 500 mL in 24 h from POD3-4 along with POD4 serum potassium > 6.0 mmol/L. Increasing WI times resulted in incremental elevation of post-operative serum creatinine that peaked later. DCD120min grafts had the highest and latest elevation of serum creatinine compared to all groups (POD5: 19.0 ± 1.1 mg/dL, p < 0.05). All surviving animals in this group had POD4 24 h urine output < 500 cc (mean 235 ± 172 mL) and elevated serum potassium (7.2 ± 1.1 mmol/L). Only animals in the DCD120min group fulfilled our criteria of SRD (p = 0.003), and their renal function improved by POD7 with 24 h urine output > 500 mL and POD7 serum potassium < 6.0 mmol/L distinguishing this state from primary non-function. In a transplantation survival model, this work demonstrates that prolonging WI time similar to that which occurs in DCD conditions contributes to the development of SRD that resembles clinical DGF.
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Affiliation(s)
- Peter Urbanellis
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Laura Mazilescu
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Dagmar Kollmann
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada.,Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Ivan Linares-Cervantes
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - J Moritz Kaths
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Sujani Ganesh
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada
| | - Fabiola Oquendo
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada
| | - Manraj Sharma
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada
| | - Toru Goto
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada
| | - Yuki Noguchi
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada
| | - Rohan John
- Laboratory Medicine and Pathobiology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ana Konvalinka
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
| | - Istvan Mucsi
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.,Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
| | - Anand Ghanekar
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada
| | - Darius Bagli
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Departments of Surgery (Urology) and Physiology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Program in Developmental and Stem Cell Biology, The Hospital For Sick Children Research Institute, Toronto, ON, Canada
| | - Lisa A Robinson
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada. .,Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
| | - Markus Selzner
- Soham and Shaila Ajmera Family Transplant Centre, University of Toronto General Surgery and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, 585 University Avenue, 11 PMB-178, Toronto, ON, M5G 2N2, Canada. .,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.
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Favi E, James A, Puliatti C, Whatling P, Ferraresso M, Rui C, Cacciola R. Utility and safety of early allograft biopsy in adult deceased donor kidney transplant recipients. Clin Exp Nephrol 2019; 24:356-368. [PMID: 31768863 DOI: 10.1007/s10157-019-01821-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Delayed graft function (DGF) is considered a risk factor for rejection after kidney transplantation (KTx). Clinical guidelines recommend weekly allograft biopsy until DGF resolves. However, who may benefit the most from such an aggressive policy and when histology should be evaluated remain debated. METHODS We analyzed 223 biopsies in 145 deceased donor KTx treated with basiliximab or anti-thymocyte globulin (rATG) and calcineurin inhibitor-based maintenance. The aim of the study was to assess the utility and safety of biopsies performed within 28 days of transplant. Relationships between transplant characteristics, indication, timing, and biopsy-related outcomes were evaluated. RESULTS Main indication for biopsy was DGF (87.8%) followed by lack of improvement in graft function (9.2%), and worsening graft function (3.1%). Acute tubular necrosis was the leading diagnosis (89.8%) whereas rejection was detected in 8.2% specimens. Rejection was more frequent in patients biopsied due to worsening graft function or lack of improvement in graft function than DGF (66.7% vs. 3.5%; P = 0.0075 and 33.3% vs. 3.5%; P = 0.0104, respectively) and in biopsies performed between day 15 and 28 than from day 0 to 14 (31.2% vs. 3.7%; P = 0.0002). Complication rate was 4.1%. Management was affected by the information gained with histology in 12.2% cases (7% considering DGF). CONCLUSIONS In low-immunological risk recipients treated with induction and calcineurin inhibitors maintenance, protocol biopsies obtained within 2 weeks of surgery to rule out rejection during DGF do not necessarily offer a favourable balance between risks and benefits. In these patients, a tailored approach may minimize complications thus optimizing results.
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Affiliation(s)
- Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy.
| | - Ajith James
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Carmelo Puliatti
- Organ Transplantation, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy
| | - Phil Whatling
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Chiara Rui
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
| | - Roberto Cacciola
- HPB and Transplant Unit, Department of Surgery, Tor Vergata University, Viale Oxford 81, 00133, Rome, Italy
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