Abstract
The final decision to accept an organ for transplantation remains a subjective one. With “poor organ quality” commonly cited as a major reason for kidney discard, accurate, objective, and reliable quality assessment is essential. In an era of increasingly higher-risk deceased donor kidneys, the catch is to accept those where the risk–benefit scale will tip in the right direction. Currently available assessment tools, such as risk-scores predicting outcome and zero-time biopsy, perform unsatisfactory, and assessment options during static cold storage are limited. Kidney perfusion technologies are finding their way into clinical practice, and they bring a new opportunity to assess kidney graft viability and quality, both in hypothermic and normothermic conditions. We give an overview of the current understanding of kidney viability assessment during ex situ kidney perfusion. A pragmatic framework to approach viability assessment is proposed as an interplay of three different compartments: the nephron, the vascular compartment, and the immune compartment. Although many interesting ways to assess kidney injury and function during perfusion have been proposed, none have reached the stage where they can reliably predict posttransplant outcome. Larger well-designed studies and validation cohorts are needed to provide better guidance.
Highlights
Data from Eurotransplant, the United Kingdom, and the United States of America show that, every year, about 15% of kidney transplant candidates die on the waiting list while 15 to 20% of deceased donor kidneys offered are not transplanted [1,2,3,4,5]
With “poor organ quality” commonly cited as a major reason for kidney discard [2,5,6], it is clear that accurate, objective, and reliable quality assessment is essential. This is especially important in an era with increasingly higher-risk deceased donor kidneys of advanced age and increasing comorbidities that are more susceptible to ischemia reperfusion injury
Biomarkers determined in the perfusate of pig kidneys undergoing 8 hours of normothermic perfusion after exposure to 0, 30, or 60 minutes of warm ischemia showed that markers of acid-base homeostasis correlated with posttransplant renal function [50]
Summary
Data from Eurotransplant, the United Kingdom, and the United States of America show that, every year, about 15% of kidney transplant candidates die on the waiting list while 15 to 20% of deceased donor kidneys offered are not transplanted [1,2,3,4,5]. With “poor organ quality” commonly cited as a major reason for kidney discard [2,5,6], it is clear that accurate, objective, and reliable quality assessment is essential. This is especially important in an era with increasingly higher-risk deceased donor kidneys of advanced age and increasing comorbidities that are more susceptible to ischemia reperfusion injury. Severe ischemia reperfusion injury is associated with primary non-function (PNF) and cortical necrosis on biopsy [7,8,9]. Ischemia reperfusion injury might take a milder course with kidney function recovering over time. In this rreevviieeww,,wweeggiviveeananovoevrevriveiwewofotfhtehecucrurerrnetnktnkonwolwedlegdegoenoknidknidenyevyiavbiialbitiylitayssaessssemssemntent during kidnneeyy ppeerrffuussiioonnssttrraatteeggieiess. .WWeefofoccuussoonnclcilniniciacladl adtaataorodr adtatagegneenrearteadtedinilnarlgaregaenaimniaml satlusdtuiedsies or studies making use of kidneys that were not suitable forr ttrraannssppllaannttaattiioonn
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