Post-transplant Need For Dialysis Research Articles

Influence of donor capnometry on renal graft evolution in uncontrolled donation after circulatory death

AimTo analyse the association between donor capnometry data and the short-term evolution of kidney grafts in cases of uncontrolled donation after circulatory death (uDCD). MethodWe used an ambispective observational study design, conducted in the Community of Madrid between January and December 2019, inclusive. Patients who suffered out-of-hospital cardiac arrest (CA) with no response to advanced cardiopulmonary resuscitation (CPR) were selected as potential donors. Donor capnometry levels were measured at the start, midpoint and transfer to hospital then compared with indicators of renal graft evolution. ResultsThe initial selection included 34 possible donors, of which 12 (35.2%) were viable donors from whom 22 (32.3%) kidneys were recovered. There was a correlation between the highest capnometry values and less need for post-transplant dialysis (≥24 mmHg, p < 0.017), fewer dialysis sessions and fewer days to recover correct renal function (Rho −0.47, p < 0.044). There was a significant inverse correlation between the capnometry values at transfer and 1-month post-transplant creatinine levels (Rho −0.62, p < 0.033). There were no significant differences between the capnometry values at transfer and primary nonfunction (PNF) or warm ischaemia time. One-year patient survival was 100% for patient receiving organ donation, while graft survival was 95%. ConclusionsCapnometry levels at transfer are a useful predictor of the short-term function and viability of kidney transplants from uncontrolled donations after circulatory death.

Renal Function at Discharge Among Kidney Recipients Experiencing Delayed Graft Function and Its Associations With Long-term Outcomes.

Using Organ Procurement and Transplantation Network data, we examined DGF, and used recipient serum creatinine at discharge as a correlate of renal function and DGF severity (mild: <2.5 mg/dL; severe: ≥2.5 mg/dL). The associations between donor and recipient factors and DGF severity were quantified using logistic regression. We also examined the associations between DGF severity and long-term recipient outcomes, adjusting for potential confounders. A predictive model using donor and recipient factors had a reasonably good ability to discriminate mild (low creatinine) versus severe (high creatinine) DGF (c-statistic of 0.70). In Cox regression, DGF and creatinine at discharge were both independently associated with long-term outcomes, yet their effects differed depending on the outcome (graft function, death-censored graft function, recipient mortality). Our findings suggest that having DGF, but with relatively good renal function (creatinine <2.5) at discharge, may be less deleterious on graft and recipient survival compared with severe, prolonged DGF, which was associated with a decreased median graft survival of ~2.6 y compared with no DGF with low creatinine at discharge. Our novel DGF severity stratification identified unique factors associated with DGF severity, along with DGF's association with long-term graft and patient survival. The adverse cost and outcome implications of severe DGF warrant additional investigation to improve kidney transplantation practice.

Protection From the Second Warm Ischemic Injury in Kidney Transplantation Using an Ex Vivo Porcine Model and Thermally Insulating Jackets

BackgroundKidney transplantation is the optimum treatment for kidney failure in carefully selected patients. Technical surgical complications and second warm ischemic time (SWIT) increase the risk of delayed graft function (DGF) and subsequent short- and long-term graft outcomes including the need for post-transplant dialysis and graft failure. Intraoperative organ thermal regulation could reduce SWIT, minimizing surgical complications due to time pressure, and limiting graft ischemia-reperfusion injury. MethodsA novel ischemic-injury thermal protection jacket (iiPJ) was designed and fabricated in silicone composite and polyurethane (PU) elastomer prototypes. Both were compared with no thermal insulation as controls. Time to reach ischemic threshold (15°C) and thermal energy transfer were compared. A water bath model was used to examine the thermal protective properties of porcine kidneys, as a feasibility study prior to in vivo translation. ResultsIn both iterations of the iiPJ, the time taken to reach the warm ischemia threshold was 35.2 ± 1.4 minutes (silicone) and 38.4 ± 3.1 minutes (PU), compared with 17.2 ± 1.5 minutes for controls (n = 5, P < .001 for both comparisons). Thermal energy transfer was also found to be significantly less for both iiPJ variants compared with controls. There was no significant difference between the thermal performance of the 2 iiPJ variants. ConclusionProtection from SWIT by using a protective insulation jacket is feasible. With clinical translation, this novel strategy could facilitate more optimal surgical performance and reduce transplanted organ ischemia-reperfusion injury, in particular the SWIT, potentially affecting delayed graft function and long-term outcomes.

Pre-Transplant Plasma Potassium as a Potential Risk Factor for the Need of Early Hyperkalaemia Treatment after Kidney Transplantation: A Cohort Study

Introduction: Plasma potassium (K⁺) abnormalities are common among patients with chronic kidney disease and are associated with higher rates of death, major adverse cardiac events, and hospitalization in this population. Currently, no guidelines exist on how to handle pre-transplant plasma K+ in renal transplant recipients (RTR). Objective: The aim of this study is to examine the relation between pre-transplant plasma K⁺ and interventions to resolve hyperkalaemia within 48 h after kidney transplantation. Methods: In a single-centre cohort study, we addressed the association between the last available plasma K⁺ level before transplantation and the post-transplant need for dialysis or use of K⁺-lowering medication to resolve hyperkalaemia within 48 h after renal transplantation using multivariate logistic regression analysis. Results: 151 RTR were included, of whom 51 (33.8%) patients received one or more K⁺ interventions within 48 h after transplantation. Multivariate regression analysis revealed that a higher pre-transplant plasma K⁺ was associated with an increased risk of post-transplant intervention (odds ratio 2.2 [95% CI: 1.1–4.4]), independent of donor type (deceased or living) and use of K⁺-lowering medication within 24 h prior to transplantation). Conclusions: This study indicates that a higher pre-transplant plasma K⁺ is associated with a higher risk of interventions necessary to resolve hyperkalaemia within 48 h after renal transplantation. Further research is recommended to determine a cutoff level for pre-transplant plasma K⁺ that can be used in practice.

Predictors of Mortality Post Lung Transplantation: Systematic Review and Meta-Analysis

Purpose In the field of lung transplantation , prognostic factors help in identifying characteristics of recipients and donors that may influence the survival of the transplanted organ or the patient's life. Understanding such factors can guide clinical decision making and better matching of recipients and donors. Our systematic review and meta-analysis aimed to provide best estimates of the association between possible predictors and 1-year all-cause mortality in adult primary lung transplant recipients. Methods We systematically searched 5 bibliographic databases for eligible primary studies assessing the association between any potential risk factor (related to lung donor, recipient, or the transplant operation), and 1-year recipient mortality. We pooled effect estimates using a random effects or fixed effects framework, as appropriate, according to a pre-specified protocol. This review utilized the GRADE approach to assess the quality of the evidence. Results High quality evidence identified older recipient age (HR 1.19 per 10-year increase, 95% CI 1.12 to 1.26), higher recipient BMI (HR 1.05 per 5-kg/m2 increase, 95% CI 1.01 to 1.10), female donor sex (HR 1.09, 95% CI 1.01 to 1.18), single vs bilateral lung transplant (HR 1.25, 95% CI 1.19 to 1.32) and post-transplant use of dialysis (HR 7.96, 95% CI 6.87 to 9.22) as predictors of 1-year mortality (Table 1). High quality evidence also excluded associations of pre-transplant lung disease etiology, recipient diabetes , pre-transplant systolic pulmonary artery pressure (PAP), pre-transplant mean PAP, donor age, blood type compatibility, and height mismatch between recipient and donors with 1-year mortality. Conclusion Recipient age, recipient BMI, post-transplant dialysis, donor sex, and transplant type predict 1-year graft survival . With the exception of post-transplant need for dialysis, the impact of each factor is, however, modest, suggesting the potential value for a predictive model that would incorporate multiple factors.

Extracorporeal membrane oxygenation following lung transplantation: indications and survival

Extracorporeal membrane oxygenation (ECMO) is employed to rescue patients with early graft dysfunction after lung transplantation (LTx). Rates of post-LTx ECMO and subsequent outcomes have been limited to single-center reports. UNOS registry was queried for LTx recipients from March 2015 to March 2016; 2,001 recipients were identified and stratified by need for post-LTx ECMO. Logistic regression was used to determine variables associated with post-LTx ECMO. Cox proportional hazards modeling identified factors associated with survival. Kaplan-Meier analysis with log-rank testing was employed for survival analysis. Of 2,001 recipients identified, 107 required post-LTx ECMO (5.1%). Recipients requiring ECMO were younger (56 vs 60 years, p = 0.007) and had higher body mass index (27.2 vs 25.8, p = 0.012). Recipients requiring post-LTx ECMO were more likely to have required mechanical ventilation before transplant (9.3% vs 4.9%, p = 0.049) and were more likely to have required pre-transplant ECMO (15% vs 3.7%, p < 0.001). On multivariable analysis, pre-transplant ECMO and increasing ischemic time were associated with post-LTx ECMO. Six-month survival for recipients requiring ECMO was 62.2%. On multivariable analysis, need for post-transplant dialysis was associated with mortality. Six-month survival for recipients requiring ECMO with and without dialysis was 25.8% and 86.7% (p < 0.001). In a nationally representative database, ischemic time and pre-transplant ECMO and/or ventilator requirement were associated with need for post-LTx ECMO. Need for post-transplant dialysis was associated with mortality in patients requiring post-LTx ECMO. These data may permit improved prediction of graft dysfunction. Strategies to minimize renal toxicity in the perioperative phase may lead to improved early survival post-LTx.

(527) - Does ACE Inhibitor Use in Heart Transplantation Decrease the Development of Cardiac Allograft Vasculopathy?

The use of angiotensin converting enzyme (ACE) inhibitors in heart transplant has been reported to decrease development of cardiac allograft vasculopathy (CAV). ACE inhibition is also used for diabetics to protect their renal function. We chose to evaluate our heart transplant patients on ACE inhibition during the first year post-transplant to assess development of CAV and to assess its impact on first-year rejection and other complications. Between 2010 and 2012, we assessed 154 heart transplant patients for the use of ACE inhibitors. Patients were divided between those treated for hypertension with ACE inhibitors within the first 3-months post-transplant for a duration of at least 2 years compared to those not treated with ACE inhibitors. 3-year outcomes were assessed for survival, freedom from CAV and Non-Fatal Major Adverse Cardiac Events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke). 1-year outcomes included freedom from acute cellular rejection, antibody-mediated rejection and need for post-transplant dialysis. There was no significant difference between the group treated with ACE inhibitors and the group that was not treated with ACE inhibitors for 3-year survival and freedom from CAV and NF-MACE. There was also no difference between the two groups for 1-year freedom from cellular or antibody-mediated rejection, infection, or need for dialysis. (See table) ACE inhibitor use does not appear to provide protection against the development of CAV. Nonetheless, these drugs are important anti-hypertensive medications and there were no significant adverse effects from the use of these drugs.Tabled 1EndpointsNo ACE Inhibitor Use (N=110)ACE Inhibitor Use ≥ 2 Year(N=44)P-Value3-Year Survival95.1%97.6%0.4983-Year Freedom from CAV77.7%80.9%0.6743-Year Freedom from NF-MACE89.0%90.6%0.6961-Year Freedom from Acute Cellular Rejection91.3%93.1%0.7251-Year Freedom from Antibody Mediated Rejection95.2%95.4%0.9311-Year Freedom from Infection45.50%61.40%0.108Post-Transplant Dialysis10.0% (11/110)2.3% (1/44)0.181 Open table in a new tab

Epsilon-Aminocaproic Acid Has No Association With Thromboembolic Complications, Renal Failure, or Mortality After Liver Transplantation.

To examine the role of epsilon-aminocaproic acid (EACA) administered after reperfusion of the donor liver in the incidences of thromboembolic events and acute kidney injury within 30 days after orthotopic liver transplantation. One-year survival rates between the EACA-treated and EACA-nontreated groups also were examined. Retrospective, observational, cohort study design. Single-center, university hospital. The study included 708 adult liver transplantations performed from 2008 to 2013. None. EACA administration was not associated with incidences of intracardiac thrombosis/pulmonary embolism (1.3%) or intraoperative death (0.6%). Logistic regression (n = 708) revealed 2 independent risk factors associated with myocardial ischemia (age and pre-transplant vasopressor use) and 8 risk factors associated with the need for post-transplant dialysis (age, female sex, redo orthotopic liver transplantation, preoperative sodium level, pre-transplant acute kidney injury or dialysis, platelet transfusion, and re-exploration within the first week after transplant); EACA was not identified as a risk factor for either outcome. One-year survival rates were similar between groups: 92% in EACA-treated group versus 93% in the EACA-nontreated group. The antifibrinolytic, EACA, was not associated with an increased incidence of thromboembolic complications or postoperative acute kidney injury, and it did not alter 1-year survival after liver transplantation.

Pulsatile Perfusion of Kidney Allografts With Celsior Solution

Background Use of pulsatile perfusion (PP) to optimize outcomes in deceased donor renal transplantation remains controversial. This prospective analysis describes all cadaveric renal allografts transplanted at our center that were preserved with PP using Celsior solution. Methods We used the LifePort Kidney Transporter (Organ Recovery Systems) perfusion machine. Study outcomes included 1-year graft and patient survivals as well as rates of delayed graft function and need for posttransplant dialysis. Results Graft survival for PP was 90% and patient survival 100%. The incidences of delayed graft function was 10% and of posttransplant dialysis, 10%. Conclusion These data support the use of PP with Celsior solution.

Comparison of Pulsatile Perfusion and Cold Storage for Paired Kidney Allografts

Use of pulsatile perfusion to optimize outcomes in deceased donor kidney transplantation remains controversial. This study is a retrospective analysis of all cadaveric renal allografts procured locally by our center over a 3-year period. Kidney pairs were identified in which one kidney underwent pulsatile perfusion and transplantation at our center, whereas the contra-lateral kidney underwent cold storage and transplantation at another center. Eighty-eight percent of the exported kidneys were six-antigen matches. Study outcomes included 1-year graft and patient survival, delayed graft function, and need for posttransplant dialysis. Recipients had similar demographic and disease characteristics. Survival for pulsatile perfusion and cold storage were 95% and 88% (graft, P=0.43) and 98% and 90% (patient, P=0.36), respectively. The incidence of delayed graft function was 5% and 35% (P<0.01), whereas posttransplant dialysis was 5% and 30% (P<0.01), for pulsatile perfusion and cold storage, respectively. These data support routine use of pulsatile perfusion.

Calcineurin inhibitor nephrotoxicity: longitudinal assessment by protocol histology.

The role and burden of cyclosporine (CsA) nephrotoxicity in long-term progressive kidney graft dysfunction is poorly documented. The authors evaluated 888 prospective protocol kidney biopsy specimens from 99 patients taken regularly until 10 years after transplantation for evidence of CsA nephrotoxicity. The most sensitive histologic marker of CsA nephrotoxicity was arteriolar hyalinosis, predicted by CsA dose and functional CsA nephrotoxicity. Striped fibrosis was associated with early initiation of CsA and the need for posttransplant dialysis (both P < 0.05). The 10-year cumulative Kaplan-Meier prevalence of arteriolar hyalinosis, striped fibrosis, and tubular microcalcification was 100%, 88.0%, and 79.2% of kidneys, respectively. Beyond 1 year, 53.9% had two or more lesions of CsA nephrotoxicity. Structural CsA nephrotoxicity occurred in two phases, with different clinical and histologic characteristics. The acute phase occurred with a median onset 6 months after transplantation, was usually reversible, and was associated with functional CsA nephrotoxicity (P < 0.05), high CsA levels (P < 0.05), and mild arteriolar hyalinosis (P < 0.001). The chronic phase of CsA nephrotoxicity persisted over several biopsies, occurred at a median onset of 3 years, and was associated with lower CsA doses and trough levels (both P < 0.05). It was largely irreversible and accompanied by severe arteriolar hyalinosis and progressive glomerulosclerosis (both P < 0.001). A threshold CsA dose of 5 mg/kg/day predicted worsening of arteriolar hyalinosis on sequential histology. Pathologic changes of CsA nephrotoxicity were virtually universal by 10 years and exacerbated chronic allograft nephropathy. CsA is unsuitable as a universal, long-term immunosuppressive agent for kidney transplantation. Strategies to ameliorate or avoid nephrotoxicity are thus urgently needed.

A tale of two kidneys--how long can a kidney transplant wait?

This paper compares early graft function (EGF) of the first transplanted kidney (group 1) with the kidney transplanted second (group 2) in kidney pairs from the same cadaver donor. Thirty-one pairs of kidneys were harvested from cadaver donors between January 1997 and October 1998. Each pair was transplanted using a standard technique by the same team of surgeons, one after the other, as a result of limitations in theatre time and staff availability. Incidence of acute rejection (AR), acute tubular necrosis (ATN) and need for post-transplant dialysis was recorded for both groups, and was compared using the relevant statistical methods. Patients in both groups were well matched for age, gender and mode of dialysis pre-transplant. Human leucocyte antigen (HLA) matching and panel reactive antibody (PRA) status were similar in the two groups (p > 0.05). Cold ischaemia time (CIT) in the two groups was 14.1 +/- 5.7 and 19.2 +/- 6.9 h, respectively, the difference being statistically significant (p < 0.05). The incidence of AR was similar in the two groups. However, ATN (on renogram) was significantly more common in group 2 (p < 0.05; 12 patients versus 5 patients in group 1). All patients with ATN required post-transplant dialysis. Hospital stay was significantly prolonged in group 2 patients (p < 05; 20 +/- 10.6 versus 16.3 + 6.2 d for group 1). Even a relatively short increase in CIT can cause the second transplanted kidney of a pair to have a significantly higher incidence of ATN, resulting in need for dialysis and prolongation of hospital stay. Simultaneous transplantation, in areas lacking organ sharing networks, would not only improve EGF, but also improve long term graft survival. In addition, the reduced requirement for post-transplant dialysis and a shorter hospital stay would balance any increased demand on resources.

National Impact of Pulsatile Perfusion on Cadaveric Kidney Transplantation

Background The simplicity and success of cold storage of cadaveric kidneys have led to the infrequent use of pulsatile perfusion. However, there may be advantages to pulsatile perfusion for less optimal donors. Methods. United Network for Organ Sharing data were analyzed retrospectively to determine the impact of pulsatile perfusion on initial function and 1-year graft survival. The analysis included 60,827 cadaveric kidney transplants performed between 1988 and 1995. Multivariate logistic regression analyses were used to determine the effect of preservation method on both early kidney function (need for first-week dialysis after transplant) and 1-year graft survival, after adjusting for other known risk factors. Results. The preservation method exhibited a highly significant impact on the need for first-week dialysis. Ice-preserved kidneys were associated with a 2.13-fold increase in the odds of requiring dialysis compared with perfused kidneys. If the donor age was <55 years, the odds were 2.33-fold higher for ice-preserved as compared with perfused. If cold ischemic time was <24 hr, there was a 2.19-fold increase in the odds of dialysis for ice-preserved kidneys. African-American recipients of cold-stored kidneys had a 2.29-fold greater odds of first-week dialysis. Conclusions. Based on there findings, it was estimated that the increased cost of perfusing kidneys from all donors <55 years of age would be balanced by the decreased need for posttransplant dialysis if the cost related to dialysis were $14,700 or greater per patient. These facts, coupled with the ability to assess an older donor kidney before transplant, could make pulsatile perfusion for the expanded donor financially as well as medically desirable.

National impact of pulsatile perfusion on cadaveric kidney transplantation.

The simplicity and success of cold storage of cadaveric kidneys have led to the infrequent use of pulsatile perfusion. However, there may be advantages to pulsatile perfusion for less optimal donors. United Network for Organ Sharing data were analyzed retrospectively to determine the impact of pulsatile perfusion on initial function and 1-year graft survival. The analysis included 60,827 cadaveric kidney transplants performed between 1988 and 1995. Multivariate logistic regression analyses were used to determine the effect of preservation method on both early kidney function (need for first-week dialysis after transplant) and 1-year graft survival, after adjusting for other known risk factors. The preservation method exhibited a highly significant impact on the need for first-week dialysis. Ice-preserved kidneys were associated with a 2.13-fold increase in the odds of requiring dialysis compared with perfused kidneys. If the donor age was > or =55 years, the odds were 2.33-fold higher for ice-preserved as compared with perfused. If cold ischemic time was > or =24 hr, there was a 2.19-fold increase in the odds of dialysis for ice-preserved kidneys. African-American recipients of cold-stored kidneys had a 2.29-fold greater odds of first-week dialysis. Based on these findings, it was estimated that the increased cost of perfusing kidneys from all donors > or =55 years of age would be balanced by the decreased need for posttransplant dialysis if the cost related to dialysis were $14,700 or greater per patient. These facts, coupled with the ability to assess an older donor kidney before transplant, could make pulsatile perfusion for the expanded donor financially as well as medically desirable.

Impaired renal artery blood flow at transplantation is correlated to delayed onset of graft function.

The aim of this prospective study was to evaluate a transit time flowmeter (Transonic, USA) in renal transplantation with respect to feasibility and estimation of graft circulation. Subsequently, the measurements were evaluated for their ability to predict delayed onset of function, occurrence of acute rejection or graft loss within 3 months after transplantation. Renal artery blood flow was measured and resistance calculated in 100 transplants-62 cadaveric donor (CD) and 38 living donor (LD)-immediately after restoration of graft circulation and before wound closure. Low blood flow (< 250 ml/min) and high resistance (> 392 mPRU) correlated positively with a long cold ischemia time and delayed onset of graft function, including the need for post-transplant dialysis. No correlation with rejection or graft loss was found. Blood flow measurements with the transit time flowmeter were easy to perform and immediate estimation of transplant circulation was achieved. Transplants at risk for delayed onset of function were identified.

Impaired renal artery blood flow at transplantation is correlated to delayed onset of graft function

Abstract The aim of this prospective study was to evaluate a transit time flowmeter (Transonic, USA) in renal transplantation with respect to feasibility and estimation of graft circulation. Subsequently, the measurements were evaluated for their ability to predict delayed onset of function, occurrence of acute rejection or graft loss within 3 months after transplantation. Renal artery blood flow was measured and resistance calculated in 100 transplants -62 cadaveric donor (CD) and 38 living donor (LD) - immediately after restoration of graft circulation and before wound closure. Low blood flow (> 250 ml/min) and high resistance (> 392 mPRU) correlated positively with a long cold ischemia time and delayed onset of graft function, including the need for post-transplant dialysis. No correlation with rejection or graft loss was found. Blood flow measurements with the transit time flowmeter were easy to perform and immediate estimation of transplant circulation was achieved. Transplants at risk for delayed onset of function were identified.

Kidney preservation for transportation. 6. A new perfusate applied to human cadaveric kidneys.

A new perfusate (solution C3) was applied to the hypothermic preservation of human cadaveric kidneys before transplantation, with excellent results. Twelve of the kidneys so preserved with storage times up to 9 hours 27 minutes manifested immediate adequate function, avoiding the need for post-transplant dialysis. Two kidneys stored for longer than 12 hours suffered acute tubular necrosis, as did four others in which buffered Hartmann's solution was used as the perfusate.