Assessment of donors with sub-optimal kidney function/structure (original) (raw)
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Nephrology, 2005
GUIDELINES No recommendations possible based on Level I or II evidence. Deceased Kidney Donor Suitability Guidelines S117 3. Age limit 65 years 4. No signs of IV drug use 5. No systemic infection/sepsis 6. No history of kidney disease, uncontrolled hypertension, or malignancy other than primary, non-metastasizing CNS tumours. Preservation of organs should take place soon after the declaration of death to limit ischaemic damage. When death is declared on cardiac criteria, a period of non-action is observed before commencing mechanical resuscitation and preservation of the kidneys by in-situ cooling. There is variation between units in how this is performed. 4 Categories of NHB donors (Maastricht) The common situation is that all NHB donors have sustained irreversible cardiac arrest. Category 1: 'Dead-on-arrival' at hospital-cause of death is obvious (e.g. serious head injury) and no resuscitation is given. This is an unusual event and rare source of NHB donors. Category 2: 'Unsuccessful resuscitation'-an individual is brought to Accident & Emergency while being resuscitated but this is not effective or arrest occurs on the hospital ward and they are unable to be resuscitated. These are relatively common events and represent the largest potential pool of NHB donors. Category 3: 'Awaiting cardiac arrest'-e.g. severe brain damage without brain death has occurred. Patients are mostly ventilator-dependent and after consent from relatives, the ventilator is switched off and cardiac arrest awaited. The agonal period is limited to 2 hours to avoid damage from hypotension and hypoxia. Category 4: 'Cardiac arrest while brain dead'-these patients are in the process of being diagnosed brain dead and do not respond to cardiopulmonary resuscitation. SEARCH STRATEGY Databases searched: MeSH terms and text words for kidney transplantation and cadaveric organs were combined with MeSH terms and text words for diabetes, hypertension, viruses, bacterial infections, non-heart beating, marginal donor, paediatric donor, aged donor, and donor with prior cancer. These were then combined with the Cochrane highly sensitive search strategy for randomised controlled trials and search filters for identifying prognosis and aetiology studies. The search was carried out in Medline (1966-November Week 2 2003). The Cochrane Renal Group Trials Register was also searched for trials not indexed in Medline. Date of searches: 12 December 2003. WHAT IS THE EVIDENCE? There are no randomised controlled trials for this subject and they would be difficult to perform. The information comes from individual centre reports and Registry reports and the numbers are small.
Donation after Cardiac Death Kidneys with Low Severity Pre-Arrest Acute Renal Failure
American Journal of Transplantation, 2007
The widening gap between supply and demand for renal transplantation has prompted many centers to use donors after cardiac death. Some of these donors exhibit signs of acute renal failure (ARF) prior to cardiac arrest. Concern has been expressed about poor quality of graft function from such donors. In response to this perception, we reviewed 49 single renal transplant recipients from category III donors after cardiac death between 1998 and 2005, at out center. All kidneys but one had hypothermic machine perfusion and viability testing prior to transplantation. According to the RIFLE criteria, nine recipients had kidneys from donors with "low severity pre-arrest ARF". The remainder of the recipients were used as control group. There was no statistical significant difference in delayed graft function and rejection rates between these two groups. Recipients GFR at 12 months was 44.4 ± 17.1 and 45.2 ± 14.7 (mL/min/1.73m 2 ) from donors with ARF and without ARF, respectively (p = 0.96). In conclusion, low severity ARF in kidneys from controlled after cardiac death donors can be a reversible condition after transplantation. Short-term results are comparable to the kidneys from same category donors without renal failure, providing that some form of viability assessment is implemented prior to transplantation.
Nephrology Dialysis Transplantation, 2012
Background. Donation after circulatory determination of death (DCDD), formerly non-heart-beating donation and donation after cardiac death, has been re-introduced into clinical practice in France since June 2006 as a potential solution to organ shortage, but this kidney transplantation programme is not popular yet, mainly because of logistical concerns and uncertainty about the long-term warm ischaemia impact on transplanted kidneys. Methods. Our institution started the DCDD programme in January 2007, following the national 'BioMedicine Agency' protocol. We only considered uncontrolled donors with an initial no-flow period (i.e. delay between collapse and external cardiac massage start) <30 min. A 5-min stand-off period was observed before declaring the death and performing in situ cold perfusion, and since January 2010, normothermic subdiaphragmatic extracorporeal membrane oxygenation. All kidneys were machine-perfused using the hypothermic pulsatile preservation system before transplantation. Morphologic assessment and perfusion indexes were used to assess the suitability for transplantation. Results. From January 2007 to December 2010, our team performed 58 kidney transplantations from uncontrolled Maastricht Category I and II donors. Mean recipient age was 47 6 9 years. Male/female ratio was 45/13. Mean waiting time on transplantation registry was 30 months (4-180). Mean cold ischaemia time was 13 h 40 min (7-18) and pulsatile perfusion time 8 h (1-16). We had three cases (5%) of primary non-function (PNF) and 95% of delayed graft function. There was no increase in biopsyproven acute rejection incidence (12.7%). Patient and graft survivals were 98 and 91.4%, respectively, at 1 year and 98 and 88%, respectively, at last follow-up. Estimated glomerular filtration rate ( Modification of Diet in Renal Disease formula) was 48 6 16 mL/min/1.73m 2 at 1 year and 48 6 15 mL/min/1.73m 2 at the last follow-up. Conclusions. DCDD kidneys are a valuable additional source of organs for transplantation. Our results show encouraging outcomes, which give rise to further interest in this donor pool. Respecting the national protocol is crucial to prevent PNF and deleterious warm ischaemia effect on transplanted kidney.
Preservation techniques for donors after cardiac death kidneys
Current opinion in organ transplantation, 2011
The purpose of the present review is to describe the techniques currently used to preserve kidneys from donors after cardiac death. Automated chest compression devices may be used to improve organ perfusion between cardiac death and preservation measures. Normothermic extracorporeal membrane oxygenation reduces warm ischemic injury and has the ability to improve organ viability in donors after cardiac death. Kidneys from donors after cardiac death expand the donor pool but are inevitably subjected to a period of warm ischemia. Reduction of warm ischemic injury to the organs improves transplant outcome. To reduce this injury in organs from donors after cardiac death, different preservation techniques are used. Automated chest compression devices improve organ perfusion between cardiac death and the start of organ preservation. In-situ preservation with double-balloon triple-lumen catheter is an easy technique to preserve organs in uncontrolled donors and is used in many centers to co...
Kidneys from Donors after Cardiac Death Provide Survival Benefit
Journal of the American Society of Nephrology, 2010
The continuing shortage of kidneys for transplantation requires major efforts to expand the donor pool. Donation after cardiac death (DCD) increases the number of available kidneys, but it is unknown whether patients who receive a DCD kidney live longer than patients who remain on dialysis and wait for a conventional kidney from a brain-dead donor (DBD). This observational cohort study included all 2575 patients who were registered on the Dutch waiting list for a first kidney transplant between January 1, 1999, and December 31, 2004. From listing until the earliest of death, living-donor kidney transplantation, or December 31, 2005, 459 patients received a DCD transplant and 680 patients received a DBD transplant. Graft failure during the first 3 months after transplantation was twice as likely for DCD kidneys than DBD kidneys (12 versus 6.3%; P ϭ 0.001). Standard-criteria DCD transplantation associated with a 56% reduced risk for mortality (hazard ratio 0.44; 95% confidence interval 0.24 to 0.80) compared with continuing on dialysis and awaiting a standard-criteria DBD kidney. This reduction in mortality translates into 2.4-month additional expected lifetime during the first 4 years after transplantation for recipients of DCD kidneys compared with patients who await a DBD kidney. In summary, standard-criteria DCD kidney transplantation associates with increased survival of patients who have ESRD and are on the transplant waiting list.
Preservation of kidneys from controlled donors after cardiac death
British Journal of Surgery, 2011
Background: Donation after cardiac death (DCD) expands the pool of donor kidneys, but is associated with warm ischaemic injury. Two methods are used to preserve kidneys from controlled DCD donors and reduce warm ischaemic injury: in situ preservation using a double-balloon triple-lumen catheter (DBTL) inserted via the femoral artery and direct cannulation of the aorta after rapid laparotomy. The aim of this study was to compare these two techniques.