Non-heart-beating Donors Kidneys Research Articles

The non heart-beating donor.

Given the shortage of donor kidneys for transplantation, we have focused on the use of non heart-beating (NHB) donor kidneys since 1982. The major drawback for the use of NHB donor kidneys is the inherent possibility of severe ischaemic damage leading to primary non function. Thus viability assessment of ischaemically damaged kidneys is crucial, and, therefore, a machine perfusion programme was reinstituted in 1993. Machine perfusion (MP) enables viability assessment through analysis of perfusion characteristics and measurement of enzyme release into the perfusate. Of the last 100 consecutive MP NHB donor kidneys, 71 kidneys were transplanted and 29 kidneys were discarded. Nine kidneys started functioning immediately, 51 kidneys showed delayed function and 11 kidneys never functioned. When analysing in retrospect different parameters for viability assessment, only alpha-GST, an enzyme specific for damage of proximal tubular cells within the kidney, could discriminate between functioning and non-functioning kidneys. With this promising viability assessment, the large NHB donor potential and the good transplant results, we recommend the use of these donors.

Glutathione S-transferase as predictor of functional outcome in transplantation of machine-preserved non-heart-beating donor kidneys.

Non-heart-beating (NHB) donors are a valuable source of kidneys for transplantation. The organs, however, sustain substantial warm ischemic damage that may jeopardize the transplantability and result in nonfunction of the grafts. Quantification of warm ischemic time (WIT) and prediction of transplant outcome are essential for the use of NHB donor organs. During machine preservation (MP) the viability of NHB donor kidneys was evaluated through calculating intrarenal vascular resistance and determining lactate dehydrogenase and alpha-glutathione S-transferase (alphaGST) in the perfusate. Thirty-seven functioning (F) and nine nonfunctioning kidneys (NF) were compared. WIT was longer in NF; serum creatinine, donor age, and preservation time were not different. WIT correlated well with alphaGST after 4 and 8 hr of MP (r=0.353, P=0.009, and r=0.346, P=0.011, respectively). When compared with F, intrarenal vascular resistance was increased in NF after 4 and 8 hr of perfusion (P<0.05); at all time points, alphaGST levels were elevated in NF (P<0.05). Lactate dehydrogenase activity was not different between the groups, but could identify immediate functioning grafts within the F group. In conclusion, alphaGST levels correlated strongly with WIT and were also able to distinguish NF from F grafts. alphaGST can adequately predict the functional outcome of NHB donor grafts before transplantation; levels of alphaGST can be used to define reliable safety margins for viability. Therefore, MP is useful in evaluating the viability of NHB donor kidneys, and the parameters discussed will help to select nonviable grafts from this valuable pool of kidneys for transplantation.

Work-load generated by the establishment of a non-heart beating kidney transplant programme.

The work-load generated by a non-heart-beating donor (NHBD) kidney transplant programme over a 3-year period is reported. A total of 73 referrals were made, 64 from the Accident department and 9 from the wards. Organ procurement was performed in 24 cases (33%) and resulted in the retrieval of 44 kidneys. Reasons for failure to achieve organ procurement were; refused consent (n = 13; 18%), relatives unavailable to ask for consent (n = 9; 12%), technical problems with catheter insertion or perfusion (n = 10; 14%), transplant staff unavailable (n = 1; 1%), long asystolic period (n = 8; 11%) and donor unsuitable for other reasons (n = 8; 11%). Of the 44 kidneys retrieved, 30 were transplanted locally, 8 were transplanted at other United Kingdom centres and 6 were discarded. Locally transplanted NHBD kidneys represented 21% of the total transplant programme during the time period under study. We conclude that NHBD kidneys are a good source of additional organs for transplantation, but only one-third of referrals result in a successful procurement procedure. Moreover, the setting up of a successful programme is labour-intensive and requires a highly committed staff.

Transplantation of kidneys harvested from non-heart-beating donors: early and long-term results

Abstract The purpose of this retrospective study was to evaluate results of non-heart-beating donor (NHBD) kidney transplantation. Between Jan 1986 and Dec 1994,80 out of 582 cadaveric kidneys were harvested from NHBD (31.9 min ± 24 after cardiac arrest). The results in the NHBD group (76 recipients) were compared with those obtained after transplantation of kidneys harvested from heart-beating donors (HBD) with respect to early graft function, and the graft and recipient's survival. Both groups were matched for sex, age, PRA level, number of HLA mismatches, and cold ischemia time. Triple immunosuppression therapy was used in both groups. Acute tubular necrosis (ATN) was observed significantly more frequently in the NHBD group (50 of 76 recipients vs 33 of 100 in the HBD group). The striking finding of this study was that the occurrence of primary non-function was the same in both groups and that the main cause of it was acute rejection. The 1-year patient and graft survival rates were 98.7 % and 81.6 % for the NHBD group and 99 % and 90 % for the HBD group, respectively. There was also no statistical difference in the serum creat-inine concentration in both groups. We concluded that despite an increased incidence of ATN in the NHBD kidney recipients, the long-term results are good and comparable with those in the HBD group.

Advances in the diagnosis of renal transplant rejection

This review attempts to cover the main areas of recent development in renal transplantation, from the viewpoint of the renal histopathologist. There are various different types of donor kidney, including the ‘non-heart beating donor' and the possibility of xenotransplantation. These pose differing problems in biopsy interpretation. Non-heart beating donor kidneys always develop severe acute tubular necrosis in the early weeks; this causes difficulty in the detection of acute rejection at this stage, which may be resolved by fine needle aspiration biopsy, urine cytology and/or repeated ‘protocol' needle core biopsy. Recent developments have improved the performance of each method, but the best course remains a subject for debate. For renal transplant pathologists, the Banff classification of renal transplant pathology is perhaps the most important practical development in recent years. This scheme has a proven use in research projects, but its role in routine practice is not yet universally accepted. It has allowed the development of the histological criteria of rejection to become an ongoing process of refinement, facilitated by wide electronic discussion through the Internet. Prospects for predicting long-term graft survival from early transplant biopsies are discussed, including the development of a ‘chronic allograft damage index'. Other areas where developments may come in the near future include studies of cytokines and adhesion molecules, lymphocyte markers, semi-automated morphometric evaluation of biopsies and monitoring the effects of novel immunosuppressive drugs.

Short-term outcome of kidney transplants from non-heart-beating donors after preservation by machine perfusion.

In this study, the short-term outcome of renal transplants from non-heart-beating donors (NHBD) preserved by machine perfusion (MP) is evaluated and compared to preservation by cold storage (CS). Twenty-two NHBD kidneys were procured during 1993 and 1994 after in situ perfusion with histidine-tryptophan ketoglutarate and preserved by continuous perfusion using University of Wisconsin organ preservation solution for MP as a perfusate. Between 1980 and 1992, 57 NHBD kidneys were procured and preserved by CS. Donors in the MP group sustained increased first warm ischemia times (WIT1) (P < 0.1) and recipients in the MP group suffered longer anastomosis time, worse HLA-DR mismatch, and more initial use of cyclosporin as immunosuppressant; all these factors are known to be deleterious to short-term outcome. Despite these unfavorable conditions, delayed function (DF) rate was decreased in the MP group, although not significantly. However, when considering only kidneys with WIT1 > or = 45 min, short-term outcome was significantly better in the MP group (P < 0.05). We conclude that MP is superior for the preservation of NHBD kidneys, especially after prolonged warm ischemia.

Transplantation of kidneys harvested from non-heart-beating donors: early and long-term results.

The purpose of this retrospective study was to evaluate results of non-heart-beating donor (NHBD) kidney transplantation. Between Jan 1986 and Dec 1994, 80 out of 582 cadaveric kidneys were harvested from NHBD (31.9 min +/- 24 after cardiac arrest). The results in the NHBD group (76 recipients) were compared with those obtained after transplantation of kidneys harvested from heart-beating donors (HBD) with respect to early graft function, and the graft and recipient's survival. Both groups were matched for sex, age, PRA level, number of HLA mismatches, and cold ischemia time. Triple immunosuppression therapy was used in both groups. Acute tubular necrosis (ATN) was observed significantly more frequently in the NHBD group (50 of 76 recipients vs 33 of 100 in the HBD group). The striking finding of this study was that the occurrence of primary non-function was the same in both groups and that the main cause of it was acute rejection. The 1-year patient and graft survival rates were 98.7% and 81.6% for the NHBD group and 99% and 90% for the HBD group, respectively. There was also no statistical difference in the serum creatinine concentration in both groups. We concluded that despite an increased incidence of ATN in the NHBD kidney recipients, the long-term results are good and comparable with those in the HBD group.

In situ preservation of kidneys from non-heart-beating donors--a proposal for a standardized protocol.

The growing success in renal transplantation has resulted in an increase in the need for donor organs. Procurement of kidneys from heart-beating (HB) donors is unlikely ever to meet this demand. Non-heart-beating (NHB) donors offer a yet untapped source of renal grafts. Cadaver kidneys from patients who have sustained cardiac standstill are often considered unsuitable for transplantation due to prolonged warm ischemia time. Using an emergency in situ perfusion technique it is possible to limit warm ischemic damage and to salvage these kidneys for transplantation. The procedure requires prompt action and cooperation of emergency service personnel. This report presents a protocol for the emergency in situ preservation procedure that can be practiced in most hospitals. At the University Hospital of Maastricht, The Netherlands, implementation of this procedure resulted in 20% more kidneys available for transplantation. Although NHB donor kidneys showed a higher rate of delayed function compared with a matched HB donor kidney population, there was no significant difference in long-term graft survival between the two groups.