Le donneur « marginal »: Le parcours de l’insuffisant rénal chronique

Abstract

The ECD Donor[Definition of an ECD donor, epidemiology, substantiation of results, evaluating an ECD donor, optimizing the EDC organ] Definitions The “marginal” donor, or ECD donor (ECD : Expanded Criteria Donor) is a donor that implies risks for the recipient. The DDS ( Deceased Donor Score), an American scoring system, allows for an assessment of the graft, according to the age, hypertension, creatinine clearance, number of HLA mismatches, reasons for decease. If, in actual facts, it appears that there is a continuum between the ideal donor and the donor to be rejected, the ECD definition and DDS score are well correlated with the renal function. Epidemiology The increase in the age of the average donor (since 2002 some donors over 75 years of age have appeared) and the evolution of the reasons for decease mean that, to date, one patient out of three from whom an organ is removed in France is an ECD donor. Substantiation The patients transplanted using marginal kidneys, following a phase of excess post-transplant mortality in relation with the graft, have a life expectancy gain of 5 years as compared to the wait-listed transplant candidates, versus 13 years in the case of an optimal donor. Nonetheless, the mortality risk in the case of ECD transplantation is decreased by 17 % as compared to the standard treatment (wait-listed patients and optimal graft), and 60 % should the patient remain on the waiting list. An algorithm is available so as to adapt and guide the decision-making process depending on the recipient. Assessment A correct assessment of donor kidneys, beyond the DDS system, also requires using Remuzzi's histological score (on glomerular, tubulointerstitial and vascular compartments), and a follow-up on the decrease of its ATP. Using a pulsatile infusion device makes it possible to reduce the delay in functional resumption, and to monitor the organ ex vivo. Optimization This involves having a reliable and available score in “ Cristal” ; possible recourse to a biopsy at the time of organ removal ; saving time on the deadlines ; improving the conditions for infusion ; selecting the recipient and adapting his/her immunosuppressive treatment. The key issue in optimizing an ECD/marginal graft is that of reducing the ischemic time to less than 10 hours of ischemia, as marginal donor kidneys can give identical and excellent results on a controlled population. Conclusion Still, it is essential to have a transparent approach towards the patient via, for example, an approved consent process.