Expanded Criteria Donors Donors Research Articles

MP36-20 MULTI-PHOTON MICROSCOPY FOR THE EVALUATION OF INTERSTITIAL FIBROSIS IN EXTENDED CRITERIA DONOR KIDNEYS: A PROOF-OF-CONCEPT PILOT STUDY

You have accessJournal of UrologyCME1 May 2022MP36-20 MULTI-PHOTON MICROSCOPY FOR THE EVALUATION OF INTERSTITIAL FIBROSIS IN EXTENDED CRITERIA DONOR KIDNEYS: A PROOF-OF-CONCEPT PILOT STUDY Wei Zheng So, Jirong Lu, Benjamin Yen Seow Goh, Rachel Zui Chih Teo, Anantharaman Vathsala, and Ho Yee Tiong Wei Zheng SoWei Zheng So More articles by this author , Jirong LuJirong Lu More articles by this author , Benjamin Yen Seow GohBenjamin Yen Seow Goh More articles by this author , Rachel Zui Chih TeoRachel Zui Chih Teo More articles by this author , Anantharaman VathsalaAnantharaman Vathsala More articles by this author , and Ho Yee TiongHo Yee Tiong More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002590.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This study evaluated the initial use of label free second harmonic generation (SHG) imaging with two photon excitation (2PE) auto-fluorescence for the quantification of collagen/fibrosis on pre-implantation biopsies of expanded criteria donors (ECD). METHODS: A total of 22 core ECD kidney transplant biopsy specimen tissues from 7 ECD donors, taken at the time of pre-implantation were retrieved, cut into 5-micron sections, mounted on slides and deparaffinized. The core needle biopsies were imaged with 2X and 20X objective using the commercially available laser-based Genesis® 200 (Histoindex Pte Ltd and Clinnovate Pte Ltd, Singapore). The entire core was selected as the Region of Interest (ROI). Corresponding clinical information from transplant donors were retrieved. Pathological review was performed, and all biopsies had Interstitial Fibrosis (IF)/Tubular Atrophy (TA) scores > 0. Collagen parameters measured included quantification by the Collagen Area Ratio in Tissue (CART), and qualitative measurements by Collagen Reticulation Index (CRI). RESULTS: 22 core biopsies were extracted from 14 donor kidney samples, of which originated from 7 donors. Table 1 depicts the baseline ECD characteristics of the donors. For the 8 kidneys with multiple biopsies done, we obtained an average score of the collagen parameters across the different samples. Biopsies classified with >85% KDPI score had significantly higher CAR and CART than biopsies with ≤85% KDPI score (Table 2). CONCLUSIONS: MPM is an evolving technology that enables the quantification of the amount (CART) and quality (CRI) of collagen deposition in unstained explant biopsies of ECD kidneys. This initial evaluation found significant difference in both parameters between ECD donors with more or less than 85% KDPI. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e605 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wei Zheng So More articles by this author Jirong Lu More articles by this author Benjamin Yen Seow Goh More articles by this author Rachel Zui Chih Teo More articles by this author Anantharaman Vathsala More articles by this author Ho Yee Tiong More articles by this author Expand All Advertisement PDF DownloadLoading ...

Kidney transplantation from expanded criteria donors: an increased risk of urinary complications - the UriNary Complications Of Renal Transplant (UNyCORT) study.

To assess the impact of expanded criteria donors (ECD) on urinary complications in kidney transplantation. The UriNary Complications Of Renal Transplant (UNyCORT) is a cohort study based on the French prospective Données Informatisées et VAlidées en Transplantation/Computerized and VAlidated Data in Transplantation (DIVAT) cohort. Data were extracted between 1 January 2002 and 1 January 2018 with 1-year minimum follow-up, in relation to 44 pre- and postoperative variables. ECD status was included according to United Network for Organ Sharing (UNOS) definition. The primary outcome of the UNyCORT study was the association between the donor's ECD/standard criteria donors (SCD) status and urinary complications at 1 year in uni- and multivariate analysis. Sub-group analysis, stratified analysis on ECD/SCD donor's status and transplant failure analysis were then conducted. Between 1 January 2002 and 1 January 2018, 10 279 kidney transplants in adult recipients were recorded within the DIVAT network. A total of 8559 (83.4%) donors were deceased donors and 1699 (16.6%) were living donors (LD). Among donation after circulatory death (DCD) donors, 224 (2.85%) were uncontrolled DCD and 93 (1.09%) were controlled DCD donors. A total of 3617 (43.9%) deceased donors were ECD. The overall urological complication rate was 16.26%. The donor's ECD status was significantly associated with an increased risk of urological complications at 1 year in multivariate analysis (odds ratio: 1.50, 95% CI 1.31-1.71; P < 0.001) and especially with stenosis and ureteric fistulae at 1 year. There is no association with LD, uncontrolled and controlled DCD. The placement of an endo-ureteric stent was beneficial in preventing urinary complications in all donors and particularly in ECD donors. The donor's ECD status is associated with a higher likelihood of stenosis and ureteric fistulae at 1 year. Recipients of grafts from ECD donors should probably be considered for closer urological monitoring and systematic preventive measures.

Molecular Fingerprints of Borderline Changes in Kidney Allografts Are Influenced by Donor Category.

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.

Perirenal Adipose Tissue Displays an Age-Dependent Inflammatory Signature Associated With Early Graft Dysfunction of Marginal Kidney Transplants.

Background: Better understanding of the contribution of donor aging and comorbidity factors of expanded criteria donors (ECD) to the clinical outcome of a transplant is a challenge in kidney transplantation. We investigated whether the features of donor-derived stromal vascular fraction of perirenal adipose tissue (PRAT-SVF) could be indicative of the deleterious impact of the ECD microenvironment on a renal transplant.Methods: A comparative analysis of cellular components, transcriptomic and vasculogenic profiles was performed in PRAT-SVF obtained from 22 optimal donors and 31 ECD deceased donors. We then investigated whether these parameters could be associated with donor aging and early allograft dysfunction.Results: When compared with the PRAT-SVF of non-ECD donors, ECD PRAT-SVF displayed a lower proportion of stromal cells, a higher proportion of inflammatory NK cells. The global RNA sequencing approach indicated a differential molecular signature in the PRAT-SVF of ECD donors characterized by the over-expression of CXCL1 and IL1-β inflammatory transcripts. The vasculogenic activity of PRAT-SVF was highly variable but was not significantly affected in marginal donors. Periorgan recruitment of monocytes/macrophages and NK cells in PRAT-SVF was associated with donor aging. The presence of NK cell infiltrates was associated with lower PRAT-SVF angiogenic activity and with early allograft dysfunction evaluated on day 7 and at 1 month post-transplant.Conclusions: Our results indicate that human NK cell subsets are differentially recruited in the periorgan environment of aging kidney transplants. We provide novel evidence that PRAT-SVF represents a non-invasive and timely source of donor material with potential value to assess inflammatory features that impact organ quality and function.

Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis

In 2002, the United Network for Organ Sharing proposed increasing the pool of donor kidneys to include Expanded Criteria Donor (ECD). Outside the USA, the ECD definition remains the one used without questioning whether such a graft allocation criterion is valid worldwide. We performed a meta-analysis to quantify the differences between ECD and Standard Criteria Donor (SCD) transplants. We paid particular attention to select studies in which the methodology was appropriate and we took into consideration the geographical area. Thirty-two publications were included. Only five studies, all from the USA, reported confounder-adjusted hazard ratios comparing the survival outcomes between ECD and SCD kidney transplant recipients. These five studies confirmed that ECD recipients seemed to have poorer prognosis. From 29 studies reporting appropriate survival curves, we estimated the 5-year pooled nonadjusted survivals for ECD and SCD recipients. The relative differences between the two groups were lower in Europe than in North America, particularly for death-censored graft failure. It is of primary importance to propose appropriate studies for external validation of the ECD criteria in non-US kidney transplant recipients.

Outcomes Following Transplantation of ECD and SCD Kidneys After Circulatory Death With or Without Acute Kidney Injury.

Aim: Expanded criteria donors (ECDs) and acute kidney injury (AKI) result in high discard rates for kidneys from deceased donors. In contrast, we have consistently used kidneys from such marginal donors, especially in donation after cardiac death (DCD) donors. The aim of this study is to compare the outcomes in recipients of ECD vs. standard criteria donors (SCD) DCD kidney transplants (KTx) with/without AKI. Methods: One hundred and twenty adult recipients from DCD donors were enrolled in this study. The recipients were divided into four groups according to the type of donor and AKI status as follows: ECD with AKI (Group 1), ECD without AKI (Group 2), SCD with AKI (Group 3), and SCD without AKI (Group 4). The recipients were followed up for an average of 6.3 ± 3.4 years after KTx. Results: Of the 120 DCD grafts, primary non-function was noted in 10 (8%), and 13 (11%) functioned immediately after KTx. The incidence of delayed graft function was 97 (81%). The overall graft survival rates at 1, 5, and 10 years were 88%, 83% and 75%, respectively. The graft survival rate in Group 1 was significantly poorer than that of Groups 3 and 4 (Log-rank test, p < 0.05). The graft survival rate in Group 2 tended to be poorer than that of Groups 3 and 4, but was not significantly different.Figure: No Caption available.In Group 1, the graft survival rates at 1, 5, and 10 years were 77%, 69% and 69%, respectively. A multivariate Cox regression analysis showed that donor age was independently associated with graft outcome. Conclusion: Although the graft survival rate in recipients of ECD kidneys with AKI was inferior to SCD grafts, ECD DCD donors with AKI could be a valuable source of kidneys for KTx with promising long-term outcomes.

Dual Kidney Transplants From Adult Marginal Donors: Double or Nothing.

Dual kidney transplantation (DKT) may reduce organ discard and optimize the use of kidneys from adult marginal donors. Methods: We retrospectively reviewed outcomes in DKT; if the donor creatinine clearance was <65 ml/min, then the kidneys were considered for DKT. Low risk patients (pts) were chosen with informed consent; all received either r-ATG or alemtuzumab induction with tacrolimus/mycophenolate ± steroids. Results: From 11/01-3/13, 72 DKTS were performed including 46 from expanded criteria donors (ECDs), 17 (5 ECD) from donation after cardiac death (DCD) donors, and 9 from standard criteria donors (SCD). A total of 31 kidney pairs (43%) were imported from other donor service areas; cold ischemia times were ≥30 hours in 22 cases (31%). Nearly all kidneys were refused by multiple centers and many were targeted for discard. Mean donor and recipient ages were 60 and 59 years, respectively, including 15 donors and recipients ≥70 years of age. Mean pre-KT waiting and dialysis vintage times were 12 months and 24 months, respectively. Pt and graft survival rates were 85% and 71% with a mean follow-up of 4 years. One year and death-censored graft survival rates were 90% and 80%. Outcomes did not differ by donor source or recipient age. 11 pts died at a mean of 36 months post-DKT (8 with functioning grafts) and 13 experienced graft loss at a mean of 34 months. The incidence of delayed graft function (DGF) was 24%; there were 2 cases (2.8%) of primary nonfunction. Mean length of initial hospital stay was 7.6 days. The 12 month incidences of surgical complications, acute rejection (AR), and major infection were each 17%. Mean serum creatinine and aMDRD GFR levels at 24 months were 1.5 mg/dl and 51 ml/min. Graft survival was comparable to concurrent single ECD and graft function comparable to concurrent SCD KTs. In the absence of DGF or AR, the proportionate nephron mass transplanted from donor to DKT recipient was 77% compared to 55-58% for pts receiving single KTs from SCD, ECD, or DCD donors. Conclusions: DKT using kidneys from marginal donors that otherwise might be discarded offer a viable option to counteract the growing shortage of single kidneys. Acceptable medium-term outcomes can be achieved with limited nephron mass donors with appropriate donor and recipient selection.

Hypothermic Machine Perfusion Reduces Delayed Graft Function and Improves One-Year Graft Survival of Kidneys from Expanded Criteria Donors: A Meta-Analysis

BackgroundExpanded criteria donors (ECDs) are currently accepted as potential sources to increase the donor pool and to provide more chances of kidney transplantation for elderly recipients who would not survive long waiting periods. Hypothermic machine perfusion (HMP) is designed to mitigate the deleterious effects of simple cold storage (CS) on the quality of preserved organs, particularly when the donor is in a marginal status.MethodsWe compared the transplant outcomes in patients receiving ECD kidneys with either HMP or CS graft preservation. Articles from the MEDLINE, EMBASE and Cochrane Library databases were searched and all studies reporting outcomes from HMP versus CS methods of kidney preservation were included in this meta-analysis. The parameters analyzed included the incidence of delayed graft function (DGF), primary non-function (PNF) and one-year graft and patient survival.ResultsA total of seven studies qualified for the review, involving 2374 and 8716 kidney grafts with HMP or CS preservation respectively, all from ECD donors. The incidence of delayed graft function (DGF) was significantly reduced with an odd ratio(OR) of 0.59 (95% CI 0.54–0.66, P<0.001) and one-year graft survival was significantly improved with an OR of 1.12 (95% CI 1.03–1.21, P = 0.005) in HMP preservation compared to CS. However, there was no difference in the incidence of PNF (OR 0.54, 95% CI 0.21–1.40, P = 0.20), and one-year patient survival (OR 0.98, 95% CI 0.94–1.02, P = 0.36) between HMP and CS preservation.ConclusionsHMP was associated with a reduced incidence of DGF and an with increased one-year graft survival, but it was not associated with the incidence of PNF and one-year patient survival.

Identification of Expanded-Criteria Donor Kidney Grafts at Lower Risk of Delayed Graft Function

Organ shortage leads to the increased use of expanded-criteria donor (ECD) kidneys, which contribute to a higher risk of delayed graft function (DGF) after transplantation. The aim of this study was to determine factors that may better predict the risk of DGF. Histologic assessments of donor renal biopsy were used with other clinical variables to predict the risk of DGF after kidney transplantation. The total Banff score equaled the sum of interstitial fibrosis (CI), tubular atrophy, arteriolar hyaline thickening, fibrous intimal thickening (CV), and fraction of sclerotized glomeruli. In total, 126 of 344 patients developed DGF after kidney transplantation. The histologic score for CI, tubular atrophy, and CV and the total Banff score were increased in patients with DGF. Only CI and CV were independent predictors of DGF (P<0.01). A CIV score (CI+CV; odds ratio, 2.68; 95% confidence interval, 1.55-4.66; P<0.001) was superior to the combination of the total Banff score (odds ratio, 1.48; 95% confidence interval, 0.85-2.55; P=NS). A CIV score≥1, donor age more than 51 years, and anoxia donor brain injury were associated with the highest risk of DGF. A CIV<1 identified a subgroup of ECDs at a lower risk of DGF comparable with standard-criteria donors (29.3% vs. 28.4%). Composite CIV score better identifies ECD kidneys with a lower risk of developing DGF. Morphologic evaluation of ECD kidneys and donor characteristics may improve kidney allocation.

Impact of Expanded Criteria Donors on Outcomes of Recipients After Kidney Transplantation

BackgroundAge and comorbidities of brain-dead donors have increased throughout the last decade. The use of expanded criteria donors (ECD) has become a common clinical practice. The objective of the present study was to compare outcomes of patients who underwent kidney transplantation from ECD versus standard criteria donors (SCD). MethodsWe studied 1375 adult recipients of kidney transplantations from 792 deceased donors in six Quebec centers between 2003 and 2009. Patient and graft survivals were analyzed using uni- and multivariate methods in regard to the effects of donor and recipient characteristics. ECD were defined per United Network for Organ Sharing: criteria age >60 years of age or age 50 to 59 years with two of three associated risk factors—history of cerebrovascular accident, hypertension, or elevated serum creatinine Mean follow-up was 3.5 ± 2 years. ResultsAmong the 792 donors, 510 SCD (64%) and 282 ECD (36%) were used for 1375 kidney transplant recipients. ECD had no effect on patient (P = .47) or graft (P = .28) survival. Cox proportional hazards regression analysis showed female donors (relative risk [RR] 1.75, P = .008), recipient age (RR 1.07, P = .0001), and waiting time be for transplantation (RR 1.000, P = .0001) to be associated with a greater risk of death after transplantation. Donor (RR 1.018, P = .0099) and recipient (RR 1.013, P = .0387) age and recipient waiting time for transplantation (RR 1.000, P = .0048) were also associated with a greater risk of graft loss. ConclusionThe use of SCD or ECD had no impact on patient or graft survival after kidney transplantation. Donor and recipient ages as well as waiting time for transplantation were related to graft loss. Waiting time remains a significant factor affecting outcomes; efforts should aim to decrease this period.

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European senior programme (ESP) is well known for acceptable outcomes using expanded criteria donor (ECD) kidneys from donors older than 65 years for recipients older than 65 years. The incidence of end-stage renal disease (ESRD) is 229/million in India with a mean age of 45 years. We performed a retrospective analysis of transplantation of ECD versus standard criteria donor (SCD) kidneys into younger recipients.Forty-three ECD transplantations among 158 deceased donor organ transplantation (DDOT) were performed between January 2006 and December 2009. Among 43 transplantation from 30 donors, 14 were dual kidney transplantations (DKT) performed based upon biopsy evaluation. All recipients received thymoglobulin (rATG) induction followed by immunosuppression with a steroid, mycophenolate mofetil (MMF), and a calcineurin inhibitor. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis.For ECD the mean donor age was 64 ± 11 years. Cerebrovascular accidents (CVA) were the cause of death among 60% of donors, 73.13% of whom were hypertensive and 23.13% diabetic.Mean DKT donor age was 75 ± 9.17 years versus 60 ± 8.0 years for single kidney transplantation (SKT). Mean recipient age of DKT versus SKT was 44 ± 12.4 years versus 43 ± 14 years. Mean serum creatinine (SCr; mg/dL) of SKT patients was 1.64 ± 0.75 versus 1.68 ± 0.46 in DKT. Mean follow-up was 455 ± 352 days. Mean SCr of 43 ECD recipients of mean age, 43.4 ± 14.2 years was 1.61 ± 0.61 mg/dL. Among 43 recipients, 23.25% were diabetic, 41.86% displayed delayed graft function (DGF), and 23.25% experienced biopsy-proven acute rejection (BPAR). Patient survival rate was 72.09% and graft survival rate was 67.44%. For SCD transplantations (n = 115), the mean donor age was 36 ± 14 years and recipient mean age was 32.8 ± 14.07 years. Mean SCr was 1.32 ± 0.46 mg/dL with 26.95% recipients displaying DGF, whereas 20.86% had BPAR. In the SCD group the patient survival rate was 79.13% and the graft survival rate was 72.17%. Thus, although the ECD group showed poor graft function (P = .042), they had acceptable patient and graft survivals (P = .34 and P = .56, respectively).Because of the organ shortage, DDOT using ECD transplants for younger recipients is a feasible option with acceptable outcomes.

Significance of Preimplantation Analysis of Kidney Biopsies From Expanded Criteria Donors in Long-Term Outcome

The shortage of organs has led to expanding the criteria for donors. Histologic evaluations before transplantation may enable the identification of organs unsuitable for single implantation. The aim of this study was to evaluate the histologic findings as prognostic factors of allograft survival from expanded criteria donors (ECDs). We included a cohort of 136 single transplantations with kidneys from ECD and correlated the preimplantation pathologic findings with graft failure. Renal structures from ECD older (n=104) or younger (n=32) than 60 years were evaluated histologically for renal senescence and rated with a total histologic score. A multivariate Cox analysis was performed to identify predictors of graft failure. Glomerulosclerosis was the most prevalent lesion in biopsies from donors older and younger than 60 years (P=0.002); interstitial fibrosis was more severe in biopsies from older donors (P=0.001); older donors showed a higher prevalence of tubular atrophy (P=0.022), and vascular compartment showed no significant differences. Kidney biopsy-based scoring system ranged from 0 to 15 points, indicating the presence of changes in the renal parenchyma. Biopsies with total histologic scores less than or equal to 5 showed significantly better 5-year graft survival than those with scores more than 5 (P<0.001). A preimplantation score more than 5 points remained an independent predictor of graft failure (hazard ratio 6.95; 95% confidence interval 1.57-30). Histologic analysis of kidney biopsies before transplantation is a valuable tool for facilitating the selection of viable grafts from ECD donors. When the total score is more than 5, single kidney transplantation from ECD should not be recommended for patients similar to this study population.

Expanded Criteria Donor Kidneys for Younger Recipients: Acceptable Outcomes

Introduction European senior programme (ESP) is well known for acceptable outcomes using expanded criteria donor (ECD) kidneys from donors older than 65 years for recipients older than 65 years. The incidence of end-stage renal disease (ESRD) is 229/million in India with a mean age of 45 years. We performed a retrospective analysis of transplantation of ECD versus standard criteria donor (SCD) kidneys into younger recipients. Methods Forty-three ECD transplantations among 158 deceased donor organ transplantation (DDOT) were performed between January 2006 and December 2009. Among 43 transplantation from 30 donors, 14 were dual kidney transplantations (DKT) performed based upon biopsy evaluation. All recipients received thymoglobulin (rATG) induction followed by immunosuppression with a steroid, mycophenolate mofetil (MMF), and a calcineurin inhibitor. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis. Results For ECD the mean donor age was 64 ± 11 years. Cerebrovascular accidents (CVA) were the cause of death among 60% of donors, 73.13% of whom were hypertensive and 23.13% diabetic. Mean DKT donor age was 75 ± 9.17 years versus 60 ± 8.0 years for single kidney transplantation (SKT). Mean recipient age of DKT versus SKT was 44 ± 12.4 years versus 43 ± 14 years. Mean serum creatinine (SCr; mg/dL) of SKT patients was 1.64 ± 0.75 versus 1.68 ± 0.46 in DKT. Mean follow-up was 455 ± 352 days. Mean SCr of 43 ECD recipients of mean age, 43.4 ± 14.2 years was 1.61 ± 0.61 mg/dL. Among 43 recipients, 23.25% were diabetic, 41.86% displayed delayed graft function (DGF), and 23.25% experienced biopsy-proven acute rejection (BPAR). Patient survival rate was 72.09% and graft survival rate was 67.44%. For SCD transplantations (n = 115), the mean donor age was 36 ± 14 years and recipient mean age was 32.8 ± 14.07 years. Mean SCr was 1.32 ± 0.46 mg/dL with 26.95% recipients displaying DGF, whereas 20.86% had BPAR. In the SCD group the patient survival rate was 79.13% and the graft survival rate was 72.17%. Thus, although the ECD group showed poor graft function ( P = .042), they had acceptable patient and graft survivals ( P = .34 and P = .56, respectively). Conclusion Because of the organ shortage, DDOT using ECD transplants for younger recipients is a feasible option with acceptable outcomes.

The Cost-Effectiveness of Organ Preservation Methods in Renal Transplantation: US Projections Based on the Machine Preservation Trial

Introduction The European Machine Preservation Trial (MPT) found a significantly lower rate of delayed graft function and improved graft survival in machine-perfused kidneys compared to cold-stored kidneys in the first year following kidney transplantation. Little is known about the cost-effectiveness of various organ preservation methods. Methods Outcome data from the MPT have been used to conduct a comparative cost-effectiveness analysis based on preservation method for both standard criteria (SCD) and expanded criteria donor (ECD) kidney transplants in the United States. Using graft survival as the primary outcome measure, a cost-effectiveness model was developed using Medicare and private payer cost/payment data, as well as clinical transition probabilities based on the MPT and other studies. Results At 1-year posttransplant, machine perfusion is a more cost-effective option than cold storage for organ preservation in transplants involving either SCD ($92,561 vs $104,118) or ECD ($106,012 vs $114,530) kidneys. Moreover, the cost-effectiveness ratios for transplants involving machine-perfused ECD kidneys ($106,012) are similar to those for transplants using cold-stored SCD kidneys ($104,118). Conclusion Machine perfusion is preferable to cold storage for organ preservation in both SCD and ECD donor kidney transplants. Not only is it more cost-effective, but from all relevant perspectives it adds substantial value.

Predictive Characteristics of Delayed Graft Function After Expanded and Standard Criteria Donor Kidney Transplantations

Delayed graft function (DGF) represents one of the most common complications after kidney transplantation. The increased use of expanded criteria donors (ECD) is related to a greater risk for DGF. The objective of our study was to analyze the incidence of DGF among ECD versus standard criteria donors (SCD). Among 121 cases we obtained 2 groups: group A (SCD; n = 75) and group B (ECD; n = 46). Group B was composed of older donors ( P < .0001), with an increased incidence of diabetes mellitus (DM; P < .0001), arterial hypertension (AH; P < .0001), cerebrovascular accidents ( P = .013), and lower creatinine clearances (CrCl; P = .008). Recipient age was significantly lower among group A ( P < .0001), with an increased incidence of donor hypotensive episodes ( P = .016). The global incidence of DGF was 40 patients (33%), who were mainly in group B ( P = .004). Analyzing the entire population, donor age ≥ 60 years ( P = .005), CrCl < 40 mL/min ( P = .025), donor history of DM ( P = .026) and AH ( P = .017), and cold ischemia time > 15 hours ( P < .0001) were parameters related to increased incidences of DGF. A biopsy score of 3 was not significantly associated with DGF. The results of our study underlined the increased risk for DGF related to the use of ECD. Donor age ≥ 60 years and cold ischemia time > 15 hours showed strong associations with this complication.

Outcomes of Transplantation Using Kidneys From Donors Meeting Expanded Criteria in Australia and New Zealand, 1991 to 2005

Kidneys from expanded criteria donors (ECD) are reported to have inferior transplant outcomes. Using the Australia and New Zealand Dialysis and Transplant Registry, we reviewed deceased donor kidneys transplanted from 1991 to 2005 in Australia and New Zealand, followed until December 2006. ECD was defined using United Network for Organ Sharing criteria. Graft and patient outcomes, estimated glomerular filtration rates (eGFR), acute rejection, and delayed graft function were analyzed by donor-age and ECD status, with adjustment for important covariates. There were 3248 recipients of non-ECD kidneys and 781 recipients of ECD kidneys. Compared with donors aged less than 50 years, adjusted hazard ratios for graft failure (GF) at 0 to 1 and 1 to 5 years for ECD kidneys from donors aged 60 years or above were 1.92 (1.48-2.49; P<0.001) and 2.52 (1.97-3.23; P<0.001). The hazard ratios for GF were 1.87 (1.31-2.70; P<0.05) for ECD kidneys from donors aged 50 to 59 years in the first year but were not increased subsequently. Mean eGFR at 1 year decreased with increasing donor age and ECD status (56.4 [53.8-58.9] mL/min for kidneys from donors aged <50, 46.6 [45.0-48.3] and 43.5 [41.1-45.9] for non-ECD and ECD donors aged 50 to 59 years, respectively, and 38.6 [36.9-40.4] for donors > or =60; P<0.001) but subsequent eGFR loss was similar except for donors aged 60 years or above (P=0.021). Acute rejection and delayed graft function were more frequent in ECD kidney recipients, but the associations between GF and donor age/ECD status were independent of these factors. For recipients of ECD kidneys, donor age 60 years or above is the most significant determinant of poor outcome; donor age 50 to 59 years represents a category of intermediate risk.