Heart-beating Donor Kidneys Research Articles

Non–Heart-Beating Donor Kidney Transplantation Survival Is Similar to Donation After Brain Death: Comparative Study With Controls in a Regional Program

Non–heart-beating donors (NHBD) are an increasing source of organs for kidney transplantation (KT) compared with donation after brain death (DBD), but the results in each regional transplantation program require local analysis. We compared 164 KT from NHBD (83 Maastrich type II A-B [T2] and 81 type III [T3]) with 328 DBD controls. NHBD kidneys were implanted with less cold ischemia, mean time on renal replacement therapy for NHBD recipients before transplantation was less too, and a higher proportion of thymoglobulin was also used. Besides NHBD-T2 more frequently showing the A group and patients being younger (48.9 ± 11 vs DBD 55.2 ± 15 years old; P < .001), there was a lower proportion of retransplant recipients and HLA sensitization; HLA-DR compatibility was slightly worse. Proportion of nonfunctioning allograft and necessity of dialysis after transplantation for NHBD were 4.9 and 68.3% versus DBD 4.3 and 26.9% (P < .001); renal function after a year was significantly less in NHBD (serum creatinine 1.79 ± 0.9 mg/dL vs 1.46 ± 0.5 in DBD; P < .001). NHBD recipient survival rates were 96% and 96% for the 1st and 3rd years, respectively, versus 96% and 94% for DBD, respectively (not significant [NS]). Graft survival rates censored by death were 91% and 89% (1st and 3rd years, respectively) versus 95% and 94% for DBD, respectively (NS). We did not find significant differences about survival between NHBD-T2 and T3. In the multivariable survival study (Cox, covariables with statistical significance demonstrated previously in our region), NHBD is not a prognosis factor for recipient or graft survival. Regarding current criteria for choosing donors and the graft allocation applied in Andalusia, short-term survival for NHBD transplantation is similar to DBD. Renal function in the short term is slightly worse, which is why it is important to monitor results over a long term, especially those from NHBD-T2.

Impact of static cold storage VS hypothermic machine preservation on ischemic kidney graft: inflammatory cytokines and adhesion molecules as markers of ischemia/reperfusion tissue damage. Our preliminary results

AbstractAt the present time, deceased heart-beating donor kidney allografts are usually stored cold. Extended-criteria donor (ECD) grafts show higher sensitivity to ischemia–reperfusion damage than standard kidneys. The increasing use of marginal organs in clinical transplantation urgently requires a more effective preservation system. Pulsatile hypothermic machine perfusion has shown major advantages over static cold storage in terms of reduced organ injury during preservation and improved early graft function. This preliminary study aims to compare pulsatile hypothermic machine perfusion and static cold storage of kidney allografts, outlining differences in the levels of early inflammatory cytokines (TNF-α, IL-2 and IL-1β) and soluble intracellular adhesion molecule (sICAM-1) in perfusion and preservation liquid.

Obstacles of Non–heart-beating Donor Kidney Transplantation in Japan to Date and Future Perspectives

In Japan, multiple organ retrieval from brain-dead heart-beating donors has been gradually increasing since the law was adopted in 1997 and amended in 2009. However, almost more than 90% of total deceased donor kidney transplantation (DDKT) in Japan are still obtained from non–heart-beating donors (NHBD). The majority of NHBD are Maastricht categories IV and III. In category IV, we usually place a double balloon arterial and a venous drainage catheter via the femoral vessels after the diagnosis of clinical brain death and acquisition of informed consent from the family. After controlled cardiac arrest, the double balloons are inflated and in situ cold perfusion started as soon as possible to minimize warm ischemic time (WIT), seeking to achieve a zero to within a few minutes WIT in most cases. In category III, it is impossible to place the device prior to cardiac arrest. In these cases, after declaration of cardiac death, cardiopulmonary compression is accompanied by systemic heparinization, immediate laparotomy, and insertion of a cold perfusion catheter at the aortic and caval bifurcations to minimize WIT. NHBD kidney retrieval is critical; extirpation must be performed as rapidly as possible. The results of NHBD kidney transplantation in Japan are excellent, according to the advancement and utilization of in situ cannulation, organ perfusion, and sophisticated retrieval techniques. The patient and graft survival rates of DDKT at 1, 3, and 5 years in most recent 2001 to 2007 era were 95.4%, 92.2%, 89.1% (n = 945) and 89.2%, 83.7%, 77.8% (n = 919), respectively.

Minimal Access Kidney Transplant: A Novel Technique To Reduce Surgical Tissue Trauma

Minimally invasive surgery and minimal access surgery has replaced conventional surgical procedures during the last 15 years with benefits including a decrease in postoperative pain, time spent convalescing, early return to normal activities, and pleasing cosmetic results. Many centers perform kidney transplant through an oblique or J-shaped approach deep into the iliac fossa. Both approaches have possible disadvantages regarding the extent of tissue trauma. Therefore, we introduced a new minimal access kidney transplant technique in our kidney transplant program in 2008 and report the outcomes of the first 10 patients transplanted with this technique. Between November 2008 to May 2009, ten kidney recipients were subjected to the minimal access kidney transplant technique. These patients represent a consecutive series of kidney transplants performed by the senior surgeon or under the supervision of the senior surgeon of transplant surgery. The mean (± SD) age of the recipients was 47 ± 14.7 years (range, 28-67 y), the body mass index was 25 ± 2.02 (range, 23-30), the time of procedure was 126.2 ± 27.5 minutes (range, 90-165 min) with a mean (± SD) anastomoses time of 27.7 ± 8.4 minutes (range, 19-45 min). Follow-up for all recipients was at least 18 months. There was no reintervention necessary, no wound infections, no primary nonfunction or a delayed graft function, no need for dialysis, no acute rejection episodes, no graft loss, no wound dehiscence, no incisional hernia, or lymphocele. Furthermore, no urologic complications or vascular complications were observed. Our reported technique was used on heart-beating donor kidneys as well as on living-donor organs and is safe with less comorbidity. This minimal access kidney transplant technique might be an alternative procedure for avoiding some of the disadvantages of conventional approaches used for kidney transplant.

Optimizing Outcomes by Preconditioning the Donor

The criteria that define a so-called “marginal donor” kidney have been standardized since 2002. However, every transplant center must establish its own guidelines on organ acceptability. An expanded criteria donor (ECD) kidney is age at least 60 years, or 50 to 59 years with at least two of three specified comorbidities. Cadaveric kidneys have shown worse functional and survival outcomes compared with those from living donors. Thus, all efforts should be made to minimize the effects of ischemia on standard, non–heart-beating or ECD cadaveric donor kidneys. Because of an increasing shortfall between the diminishing number of deceased donor organs available and the increasing waiting lists, an increasing number of living donor transplantations are being performed in Europe. Among deceased donor kidneys, the largest percentage corresponds to ECD—aged or comorbidity donors—and donors after cardiac death. The results of transplants with kidneys from donors over 65 years are 10% to 15% lower than those from younger donors. Older donors present more comorbidities; however, acceptable results may be obtained with careful selection and shortened cold ischemic times. If the transplant center uses these donors to expand the pool of available organs, the donor must be evaluated according to age, vascular condition, renal function, and comorbidity. If the donor is accepted, suitable questions are: Has the potential donor undergone maneuvers to improve the quality of the kidneys? Which kind of approaches should we perform? Should we only use the biopsy information for a decision?

Impact of the 1998 UK National Allocation Scheme for Deceased Heartbeating Donor Kidneys

National and regional strategies for allocating deceased heartbeating (DHB) donor kidneys to patients awaiting transplant are of great importance and have major implications for patients and healthcare systems. We describe the rationale for the 1998 National Kidney Allocation Scheme (1998 NKAS) and its impact on renal transplantation in the United Kingdom over 5 years. The 1998 NKAS was based on three tiers of patients defined by human leukocyte antigen (HLA) mismatch. This involved national allocation of well-matched kidneys in tiers 1 and 2, with regional allocation for less well-matched patients in tier 3. Pediatric patients (younger than 18 years) and regional patients were prioritized in tiers 1 and 2, with a points score based on six factors determining the specific priority order for allocation. The 1998 NKAS allocated approximately half the kidneys from DHB donors to the national transplant list and resulted in significantly improved HLA matching, more than doubling the proportion of transplants that were 000 HLA-A, -B, and -DR mismatched from 7% to 16% for adults. Pediatric patients achieved comparable levels of HLA matching to adult patients for the first time in the United Kingdom through improved access to adult donor organs. The scheme also benefited highly sensitized patients and improved equity with regard to patient blood group, rareness of HLA type, and HLA homozygosity. The 1998 NKAS represented a significant advance for the allocation of DHB donor kidneys in the United Kingdom and, while not addressing inequities in access to transplant, it did largely achieve the principal goal of improving HLA matching.

Factors Influencing Outcome After Deceased Heart Beating Donor Kidney Transplantation in the United Kingdom: An Evidence Base for a New National Kidney Allocation Policy

Outcomes after deceased heart beating donor kidney transplantation are good, but survival rates vary according to a number of donor-, recipient-, and transplant-related factors. This comprehensive analysis of transplant outcomes was undertaken to inform development of a new Kidney Allocation Scheme. A complete case analysis of the outcome of kidney-only transplants in the United Kingdom, 1995 to 2001, was undertaken using Cox regression modeling. Seven thousand three hundred eighty-five (77%) of the 9585 transplants reported to the UK Transplant Registry were primary transplants in adults. Regrafts and pediatric patients (age <18 years) were analyzed separately. Transplant and patient survival over 5 years were investigated in addition to causes of prolonged cold ischemia time (CIT). A variety of factors significantly adversely influenced kidney transplant and patient outcome, including older donor age, older recipient age, waiting time to transplant over 2 years, diabetes, and earlier year of transplant. Human leukocyte antigen mismatch and CIT were significant in analyses of transplant but not in patient outcome, and an increased graft failure rate was also identified in adolescent patients. CIT was prolonged by long-distance kidney exchanges between centers (2 hr) and reallocation of kidneys for alternative patients (7 hr). This study identified a number of factors that influence transplant outcome after deceased heart beating donor kidney transplant in the United Kingdom. The findings suggest that the influences of human leukocyte antigen mismatch and CIT are most relevant in considering a revised kidney allocation scheme.

A New UK 2006 National Kidney Allocation Scheme for Deceased Heart-Beating Donor Kidneys

In 2004, it was agreed that a new allocation scheme for kidneys from deceased heart-beating donors was required in the United Kingdom to address observed inequities in access to transplant. The 2006 National Kidney Allocation Scheme (2006 NKAS) was developed to meet agreed objectives and preparatory work included a review of the criteria for human leukocyte antigen (HLA) matching and simulation evidence about the effectiveness of alternative schemes. ALGORITHM FOR 2006 NKAS: The 2006 NKAS gives absolute priority to all 000 HLA-A, -B, -DR-mismatched patients and well-matched pediatric patients (<18 years), and then a points score defines priorities for allocation with waiting time being most influential. Points for age and HLA mismatch are linked in a novel approach to ensure well-matched transplants for younger patients while recognizing that HLA matching is less important for older patients as retransplantation is less likely to be required. To improve equity for difficult to match patients, rare HLA specificities were defaulted to more common, related specificities. IMPACT OF 2006 NKAS: After 3 years, the scheme is already making good progress in achieving its objectives, with overall results similar to those observed in the simulations. There has been a significant benefit for patients waiting more than 5 years for transplant. A number of other advantages of the scheme are also apparent with equity of access improving in many respects, including the achievement of equity of access to transplant for HLA-DR homozygous patients, but geographical inequity of access will take a number of years to address fully.

Outcome and Allocation of Deceased Heart-Beating Donor Kidneys in the United Kingdom

Outcome and Allocation of Deceased Heart-Beating Donor Kidneys in the United Kingdom

A Pilot Study Assessing the Feasibility of a Short Period of Normothermic Preservation in an Experimental Model of Non Heart Beating Donor Kidneys

Restoring metabolism to an organ after hypothermic storage and before transplantation could reverse some of the detrimental effects of ischemic injury. This may be particularly beneficial for kidneys from non-heart-beating (NHBD) donors that sustain significant periods of warm and cold ischemic injury. This pilot study assessed the feasibility of a short period of normothermic preservation (NP) in a porcine autotransplant model. Kidneys were subjected to 30 min of warm ischemia, then preserved by hypothermic machine perfusion (HMP) for 22 h or 20 h HMP followed by 2 h of NP using autologous blood. Kidneys were then re-implanted, a contralateral nephrectomy performed, and renal function measured over 10 d. Post-transplant, 4/6 animals survived in the NP group compared with 5/6 in the HMP group (P = 1.00). Creatinine levels fell below 250 μmol/L in all four of the surviving animals in the NP group compared with 2/5 in the HMP group (P = 0.608). There was no difference in levels of renal function (peak creatinine, HMP = 1736 ± 866 versus NP = 1553 ± 516 μmol/L; P ≥ 0.990). Levels of lipid peroxidation were significantly lower 60 min post-transplant in the NP group (NP = 477 ± 118.0 versus HMP = 671 ± 99.4 pg/mL; P = 0.026). A period of NP at the end of the renal preservation period in NHB kidneys is a feasible method of kidney preservation. NP could prove to be a useful technique to predetermine graft function and allow pre-transplant modification of organs.

Prélèvements d’organes sur donneurs décédés après arrêt cardiaque

The transplant of an allograft after cardiac arrest has been allowed in France since 2005 (decree of 2 august 2005: art R.1232-4-1, 2 and 3 of the public health code). Recently, according to the international scale, 4 situations that could lead to the realization of transplantable organs after cardiac arrest were identified according to a classification called "Maastricht" which describes the potential donors. In France the donors of class III (cessation of all medical care) were excluded. Ethical questions concerning this new practice come up. Are criteria adopted to define death enough sure? What is the place of non-heart beating donor transplantation with new technical resuscitation as extracorporeal life support for prolonged cardiac arrest? How does family and medical staff live this protocol? Despite this, non heart-beating donor kidney transplants offer the opportunity to compensate for the growing discrepancy between supply and demand for donor kidneys. Results from foreign studies have shown that they have the same survival and long term function as kidneys from traditional brain-stem dead donors. This practice is defined by legislation and supervised by the "Agence de la biomédecine" which guarantees technical efficiency and respect of ethics.

Recipient Hemodynamics During Non-Heart-Beating Donor Kidney Transplantation Are Major Predictors of Primary Nonfunction

Non-heart-beating donor (NHBD) kidneys may substantially expand the donor pool, but many transplant centers are reluctant to use these kidneys because of the relatively high incidence of primary nonfunction (PNF). In heart-beating donor kidneys, intravascular fluid depletion during transplant surgery is associated with delayed graft function (DGF). Therefore, we studied the effect of the recipients' hemodynamic status on the outcome of 177 NHBD kidney transplantations. Independent statistically significant predictors of PNF were average central venous pressure (CVP) below 6 cmH(2)O (adjusted odds ratio (AOR) 3.1 (95% CI: 1.4-7.1), p=0.007), average systolic blood pressure below 110 mmHg (AOR 2.6 (95% CI: 1.1-5.9), p=0.03) and pre-operative diastolic blood pressure below 80 mmHg (AOR 2.4 (95% CI: 1.0-5.9), p=0.05). Donor characteristics were not independently associated with PNF (p>0.10). In a subgroup analysis of 56 paired kidneys, 29% of the recipients with the lower CVP of the pair experienced PNF compared with 11% of their counterparts with higher CVP (p=0.09). Our study indicates that recipient hemodynamics during transplant surgery are major predictors of PNF. Therefore, improving recipient hemodynamics by expansion of the intravascular volume is expected to enhance the results of NHBD kidney transplantations and may enlarge the donor pool by increasing the acceptance of NHBD kidneys.

Redox-Active Iron Released During Machine Perfusion Predicts Viability of Ischemically Injured Deceased Donor Kidneys

Redox-active iron, catalyzing the generation of reactive oxygen species, has been implicated in experimental renal ischemia-reperfusion injury. However, in clinical transplantation, it is unknown whether redox-active iron is involved in the pathophysiology of ischemic injury of non-heart-beating (NHB) donor kidneys. We measured redox-active iron concentrations in perfusate samples of 231 deceased donor kidneys that were preserved by machine pulsatile perfusion at our institution between May 1998 and November 2002 using the bleomycin detectable iron assay. During machine pulsatile perfusion, redox-active iron was released into the preservation solution. Ischemically injured NHB donor kidneys had significantly higher perfusate redox-active iron concentrations than heart-beating (HB) donor kidneys that were not subjected to warm ischemia (3.9 +/- 1.1 vs. 2.8 +/- 1.0 micromol/L, p = 0.001). Moreover, redox-active iron concentration was an independent predictor of post-transplant graft viability (odds ratio 1.68, p = 0.01) and added predictive value to currently available donor and graft characteristics. This was particularly evident in uncontrolled NHB donor kidneys for which there is the greatest uncertainty about transplant outcomes. Therefore, perfusate redox-active iron concentration shows promise as a novel viability marker of NHB donor kidneys.

Non–Heart-Beating Donor Kidneys in The Netherlands: Allocation and Outcome of Transplantation

Non–Heart-Beating Donor Kidneys in The Netherlands: Allocation and Outcome of Transplantation

Anti-vimentin Antibody Detection in Recipients of Heart-Beating and Non–Heart Beating Donor Kidneys

Alternative donor sources include non–heart-beating donors (NHBDs). There donors have been exposed to significant ischemia, so that it is common to utilize machine perfusion to either improve the organs or at least assess their viability. Both prolonged warm ischemia and machine perfusion can potentially damage the vascular endothelium, thereby exposing vimentin to antigenic recognition. The aim of this study was to determine whether anti-vimentin antibodies could be detected in the blood of renal transplant recipients at specific time points after transplant and whether they could be related to the donor source. Fifty-one recipients of NHBD kidneys were compared to 52 recipients of heart-beating donor (HBD) kidneys. All recipients had similar anti-vimentin levels pretransplant. However, at 1 month those kidneys from Maastricht category II NHB donors showed significantly higher levels. At 6 months both Maastricht category II and category III NHB donor recipients displayed significantly higher levels than recipients of HBD kidneys.

Non???Heart-Beating Donor Kidneys in The Netherlands: Allocation and Outcome of Transplantation

Since February 1, 2001, kidneys from both heart-beating (HB) and non-heart-beating (NHB) donors in The Netherlands have been indiscriminately allocated through the standard renal-allocation system. Renal function and allograft-survival rate for kidneys from NHB and HB donors were compared at 3 and 12 months. The outcomes of 276 renal transplants, 176 from HB donors and 100 from NHB III donors, allocated through the standard renal allocation system, Eurotransplant Kidney Allocation System, and performed between February 1, 2001 and March 1, 2002 were compared. Three months after transplantation, graft survival was 93.7% for HB kidneys and 85.0% for NHB kidneys (P<0.05). At 12 months, graft survival was 92.0% and 83.0%, respectively (P<0.03). Serum creatinine levels in the two groups were comparable at both 3 and 12 months. Multivariate analysis identified previous kidney transplantation (relative risk [RR] 3.33; P<0.005), donor creatinine (RR 1.01; P<0.005), and NHB (RR 2.38; P<0.05) as independent risk factors for transplant failure within 12 months. In multivariate analysis of NHB data, a warm ischemia time (WIT) of 30 minutes or longer (P<0.005; RR 6.16, 95% confidence interval 2.11-18.00) was associated with early graft failure. No difference in 12-month graft survival was seen between HB and NHB kidneys after excluding the kidneys that failed in the first 3 months. Early graft failure was significantly more likely in recipients of kidneys from NHB donors. A prolonged WIT was strongly associated with this failure. Standard allocation procedures do not have a negative effect on outcome, and there is no reason to allocate NHB kidneys differently from HB kidneys.

GRAFT FUNCTION AFTER KIDNEY TRANSPLANTATION FROM NON-HEARTBEATING DONORS ACCORDING TO MAASTRICHT CATEGORY

Donor shortages have led to some groups using alternative sources such as non-heartbeating donors (NHBDs). Kidneys from NHBDs suffer from warm ischemia at cardiac arrest which is reflected by acute tubular necrosis of the allograft, resulting in a period of delayed graft function. NHBDs are categorized by the circumstances surrounding the agonal events of death which reflect differences in the likelihood of ischemic injury to the kidney. In this study we determined the impact of ischemic injury on the renal function of kidneys procured from different categories of NHBDs. From 1998 to 2003, 144 kidneys were procured from 72 NHBDs resulting in 93 transplants characterized into Maastricht categories II, III and IV NHBD renal transplants. Renal function after transplant was evaluated from the last dialysis until discharge from hospital, and then at 3 monthly intervals thereafter. Primary warm ischemic time is more prolonged in the uncontrolled donor (category II) than controlled donor (category III greater than IV). Delayed graft function occurs more frequently (Maastricht category II 83.8%, III 67.4% and IV 0%, ANOVA p <0.05) and the return to normal function is more prolonged in uncontrolled donors. This is illustrated by the greater incidence of acute tubular necrosis (Maastricht category II 81.1%, III 65.2% and IV 50.0%, ANOVA p = nonsignificant) in the kidney allograft. There was no difference in year 1 allograft survival (Maastricht category II 83.9%, III 92.5% and IV 100%, ANOVA p = nonsignificant). Early graft function is poorest in kidneys derived from Maastricht category II donors and best in category IV with III in-between. However, after 3 months the function of kidneys from all donors is the same.

CAN SERUM CREATININE IN THE FIRST YEAR AFTER TRANSPLANT PREDICT LONG-TERM RENAL TRANSPLANT OUTCOME?

P349 Aims: As short-term renal transplant survival continues to improve, with known risk factors having a diminishing effect, attention is increasingly focussing on alternative measures of outcome such as renal function. This study explores the relationship between renal function in the first year after transplant and long-term kidney transplant survival in the UK. Methods: Cadaveric heartbeating donor kidney only transplants in adult patients in the UK between 1983 and 1987 were analysed. Transplants failing in the first year were excluded. For 75% of the remaining cohort, both 3 and 12-month serum creatinine measures were recorded on the UK’s national transplant database. Transplant survival analysis (death with function counted as a failure) considered the influence on ten-year outcome of 3 and 12-month serum creatinine; the change between 3 and 12 month serum creatinine (Δ creatinine) and other potential risk factors recorded. Data were available for 2766 transplants with 97% 10-year follow-up including 17% regrafts, which were analysed separately. Results: Analysis of first transplants showed a highly statistically significant association between ten-year transplant survival and 12-month creatinine, Δ creatinine and an interaction of the two (p<0.0001). Unadjusted 10-year transplant survival estimates ranged from 62% (95% confidence interval (CI) 58-65%) for transplants with 12-month serum creatinine <120 μmol/l to 13% (95% CI 9-18%) for those with 12-month creatinine >= 265 μmol/l. There was a negative association between outcome and Δ creatinine, which was greatest for those with poor function at 12-months. Other factors adjusted for were recipient age (p<0.0001), blood group (p<0.001) and HLA match (p<0.1). Univariately, donor age and donor-recipient gender match were significant, but these effects disappeared with the introduction of measures of post-transplant renal function. Analysis of regrafts and of graft (death-censored) survival both showed comparable results. The relevance of findings to more recent data was validated by analysis of 3-year outcome of a recent cohort. Conclusions: For transplants functioning after the first post-operative year, 12-month serum creatinine and Δ creatinine were highly predictive of 10-year transplant survival. There was a 49% survival difference at 10-years post-transplant between the group with the poorest renal function at one year and the group with the best function.

Non-Heart Beating Donor Kidneys with Delayed Graft Function Have Superior Graft Survival Compared with Conventional Heart-Beating Donor Kidneys That Develop Delayed Graft Function

Delayed graft function may have an association with reduced graft survival, and nonheart-beating donor (NHBD) kidneys have higher rates of delayed graft function (DGF) than heart-beating donor (HBD) kidneys. This study compared outcome of renal transplants from HBDs who developed DGF, with NHBDs who developed DGF. All recipients of HBD and NHBD kidneys who developed DGF were identified during a 10-year period. All patients with graft primary nonfunction were excluded from analysis. Four hundred and fifty-six functioning transplants were performed. Delayed graft function occurred in 69 (17%) HBD and 55 (93%) NHBD kidneys. The grafts developing DGF were well matched for donor and recipient age. The rate of acute rejection was similar; [n = 16/69 (23%) HBD vs. n = 13/55 (24%) NHBD]. Cold ischaemia was 21 h in the HBD group and 17 h in NHBD group (p > 0.05). Serum creatinine was similar for both groups at 1.3 and 6 years (p > 0.05 for all time points). Graft survival in the NHBD recipients with DGF was significantly better at 3 years (84%) compared with recipients of a HBD renal transplant that developed DGF (73%) (p < 0.05), and at 6 years (62% survival for HBDs and 84% survival for NHBDs). This study shows that graft survival was better for NHBD kidneys up to 6 years after transplantation.

Long-term renal function after transplantation from non–heart-beating donor kidneys

Long-term renal function after transplantation from non–heart-beating donor kidneys