Rate Of Primary Nonfunction Research Articles

Effect of preservation solutions for static cold storage on kidney transplantation outcomes: A National Registry Study.

This study aimed to evaluate how 5 preservation solutions for static cold storage affected kidney transplant outcomes. It included all first single kidney transplants during 2010-2014 from donations after brain death in the French national transplant registry, excluding preemptive transplants and transplants of kidneys preserved with a hypothermic perfusion machine. The effects of each preservation solution on delayed graft function (DGF) and 1-year transplant failure were evaluated with hierarchical multivariable logistic regression models. The study finally included 7640 transplanted kidneys: 3473 (45.5%) preserved with Institut Georges Lopez-1 solution (IGL-1), 773 (10.1%) with University of Wisconsin solution, 731 (9.6%) with Solution de Conservation des Organes et Tissus (SCOT, organ and tissue preservation solution), 2215 (29.0%) with Celsior, and 448 (5.9%) with histidine-tryptophan-ketoglutarate. Primary nonfunction rates did not differ by solution. After adjustment for donor, recipient, and transplant characteristics, the DGF risk was significantly lower with IGL-1 than with all other solutions (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.48-0.64). Conversely, SCOT was associated with a DGF risk significantly higher than the other solutions (OR 2.69, 95% CI 2.21-3.27) and triple that of IGL-1 (OR 3.37, 95% CI 2.72-4.16). One year after transplantation, the transplant failure rate did not differ significantly by preservation solution. The difference between the groups for 1-year mean creatinine clearance was not clinically relevant.

Kidney transplant outcomes from donation after circulatory death donors of advanced age.

Continued comparison of kidney transplant outcomes between older DCD and donation after brain death (DBD) donors is needed to safely expand the deceased donor pool. We performed a retrospective cohort study using the UNOS/OPTN transplant registry from donors >50years old between 1994 and 2016. Donor age was stratified into 4 groups: 50-54, 55-59, 60-64, and >65years old. Rates of delayed graft function (DGF) and primary non-function (PNF) were compared. Multivariable Cox regression models were constructed to identify factors associated with time to graft failure. The DCD donors within each age group had fewer comorbidities than the DBD donors. Graft survival for DCD kidneys was equivalent or superior to DBD kidneys in all donor age groups. DGF rates were significantly greater for DCD kidneys in all age groups. PNF rates across all groups were similar. In multivariable analysis, DCD status was not independently associated with time to all-cause graft failure in the 50-54 donor age group (HR=1.02, 95% CI=0.93-1.13), 55-59 donor age group (HR=1.07, 95% CI=0.96-1.19), or 60-64 donor age group (HR=1.135, 95% CI=0.97-1.32). Kidneys from carefully selected older DCD donors, particularly ages 50-64, are a potential means to safely expand the deceased donor pool.

A systematic review to identify whether perfusate biomarkers produced during hypothermic machine perfusion can predict graft outcomes in kidney transplantation.

There is good evidence to support the use of hypothermic machine perfusion (HMP) over static cold storage as the favoured preservation method for deceased donor kidneys. However, the utility of HMP as a tool to assess the viability of kidneys for transplant is unclear. There is a need to determine whether perfusate biomarkers produced during HMP can predict post-transplant outcomes and assess the suitability of organs for transplantation. Three different databases (MEDLINE, Embase, Transplant Library) were screened to 31 May 2019. Articles were included if a relationship was reported between one or more perfusate biomarkers and post-transplant outcomes. Studies were assessed and graded for methodological quality and strength of evidence. Glutathione S-transferase was the most promising biomarker for predicting delayed graft function, but its predictive ability was at best moderate. Analysis of primary nonfunction rates was challenging due to low occurrence rates and small sample sizes. Existing studies are limited in quality and have not yielded biomarkers for kidneys undergoing HMP that are able to predict post-transplant outcomes with sufficient accuracy to support routine clinical use. Further studies with larger samples and more robust methodology are needed. (PROSPERO registration: CRD42019121161).

Early graft losses in paired kidney exchange: Experience from 10years of the National Kidney Registry.

Cooperative kidney paired donation (KPD) networks account for an increasing proportion of all living donor kidney transplants in the United States. There are sparse data on the rate of primary nonfunction (PNF) losses and their consequences within KPD networks. We studied National Kidney Registry (NKR) transplants (February 14, 2009 to December 31, 2017) and quantified PNF, graft loss within 30days of transplantation, and graft losses in the first-year posttransplant and assessed potential risk factors. Of 2364 transplants, there were 38 grafts (1.6%) lost within the first year, 13 (0.5%) with PNF. When compared to functioning grafts, there were no clinically significant differences in blood type compatibility, degree of HLA mismatch, number of veins/arteries, cold ischemia, and travel times. Of 13 PNF cases, 2 were due to early venous thrombosis, 2 to arterial thrombosis, and 2 to failure of desensitization and development of antibody-mediated rejection (AMR). Given the low rate of PNF, the NKR created a policy to allocate chain-end kidneys to recipients with PNF following event review and attributable to surgical issues of donor nephrectomy. It is expected that demonstration of low incidence of poor early graft outcomes and the presence of a "safety net" would further encourage program participation in national KPD.

Clinical Implications of Donor Warm and Cold Ischemia Time in Donor After Circulatory Death Liver Transplantation.

The use of donation after circulatory death (DCD) liver allografts has been constrained by limitations in the duration of donor warm ischemia time (DWIT), donor agonal time (DAT), and cold ischemia time (CIT). The purpose of this study is to assess the impact of longer DWIT, DAT, and CIT on graft survival and other outcomes in DCD liver transplants. The Scientific Registry of Transplant Recipients was queried for adult liver transplants from DCD donors between 2009 and 2015. Donor, recipient, and center variables were included in the analysis. During the study period, 2107 patients underwent liver transplant with DCD allografts. In most patients, DWIT and DAT were <30 minutes. DWIT was <30 minutes in 1804 donors, between 30 and 40 minutes in 248, and >40 minutes in 37. There was no difference in graft survival, duration of posttransplant hospital length of stay, and readmission rate between DCD liver transplants from donors with DWIT <30 minutes and DWIT between 30 and 40 minutes. Similar outcomes were noted for DAT. In the multivariate analysis, DAT and DWIT were not associated with graft loss. The predictors associated with graft loss were donor age, donor sharing, CIT, recipient admission to the intensive care unit, recipient ventilator dependence, Model for End-Stage Liver Disease score, and low-volume transplant centers. Any CIT cutoff >4 hours was associated with increased risk for graft loss. Longer CIT was also associated with a longer posttransplant hospital stay, higher rate of primary nonfunction, and hyperbilirubinemia. In conclusion, slightly longer DAT and DWIT (up to 40 minutes) were not associated with graft loss, longer posttransplant hospitalization, or hospital readmissions, whereas longer CIT was associated with worse outcomes after DCD liver transplants.

The Impact of Steatosis on the Outcome of Liver Transplantation: A Meta-Analysis

Background and Aims Liver transplantation is one of the most effective treatments for end-stage liver disease as well as for cases of acute liver failure. Facing organ donor shortage, liver transplant teams had to use marginal organs. Thus, increasing availability is a key concern of donor liver grafts including steatotic livers. However, the use of steatotic liver is still controversial. The aim of this systematic review and meta-analysis was to analyze the impact of steatosis on the outcome of liver transplantation. Methods We searched PubMed, Cochrane Library, Embase, Web of knowledge, and so on for studies published through May 31, 2018, in which patients experienced liver transplantation using fatty liver. All studies extracted outcome indicators, and we draw conclusions by contrasting outcome indicators in different groups of steatosis. Odds ratios and 95% confidence intervals were calculated. P<0.05 was considered as statistically significant difference. Results 19 publications were included. There was no significant difference between the group of no steatosis and mild group in primary nonfunction rate (P=0.605) or early graft dysfunction rate (P=0.44). The PNF rate was significantly higher in moderate group (P=0.003) and severe group (P <0.001) compared with that in no steatosis group. The same results were seen in early graft dysfunction rate. However, graft survival rate and patient survival rate did not differ between groups. Conclusions Livers with mild steatosis, even with moderate or severe steatosis, could be suitable donor under strict control of transplant conditions.

The “Skinny” on Assessment and Utilization of Steatotic Liver Grafts: A Systematic Review

The frequency at which steatotic deceased donor liver grafts are encountered will likely continue to increase. Utilization of liver grafts with moderate-to-severe steatosis for liver transplantation (LT) has been previously shown to be associated with increased rates of primary nonfunction and decreased recipient survival. In order to better inform clinical decision making and guide future research, critical evaluation of the literature on donor liver steatosis and posttransplantation outcome is needed. This literature review aims to provide the "skinny" on using deceased donor steatotic livers for LT.

Steatosis in Liver Transplantation: Current Limitations and Future Strategies.

In parallel with the pandemic of obesity and diabetes, the prevalence of nonalcoholic fatty liver disease has progressively increased. Nonalcoholic steatohepatitis (NASH), a subtype of nonalcoholic fatty liver disease has also augmented considerably being currently cirrhosis due to NASH the second indication for liver transplantation in the United States. Innovative treatments for NASH have shown promising results in phase 2 studies and are being presently evaluated in phase 3 trials. On the other hand, the high mortality on the liver transplant waitlist and the organ shortage has obligated the transplant centers to consider suboptimal grafts, such as steatotic livers for transplantation. Fatty livers are vulnerable to preservation injury resulting in a higher rate of primary nonfunction, early allograft dysfunction and posttransplant vascular and biliary complications. Macrosteatosis of more than 30% in fact is an independent risk factor for graft loss. Therefore, it needs to be considered into the risk assessment scores. Growing evidence supports that moderate and severe macrosteatotic grafts can be successfully used for liver transplantation with careful recipient selection. Protective strategies, such as machine-based perfusion have been developed in experimental setting to minimize preservation-related injury and are now on the verge to move into the clinical implementation. This review focuses on the current and potential future treatment of NASH and the clinical practice in fatty liver transplantation, highlights its limitations and optimal allocation, and summarizes the advances of experimental protective strategies, and their potential for clinical application to increase the acceptance and improve the outcomes after liver transplantation with high-grade steatotic livers.

The effect on early renal function of various dynamic preservation strategies in a preclinical pig ischemia-reperfusion autotransplant model.

The aims of this study were to determine the most optimal timing to start machine perfusion during kidney preservation to improve early graft function and to evaluate the impact of temperature and oxygen supply during machine perfusion in a porcine ischemia-reperfusion autotransplant model. The left kidney of an approximately 40-kg female Belgian Landrace pig was exposed to 30 minutes of warm ischemia via vascular clamping and randomized to 1 of 6 study groups: (1) 22-hour static cold storage (SCS) (n = 6), (2) 22-hour hypothermic machine perfusion (HMP) (n = 6), (3) 22-hour oxygenated HMP (n = 7), (4) 20-hour HMP plus 2-hour normothermic perfusion (NP) (n = 6), (5) 20-hour SCS plus 2-hour oxygenated HMP (n = 7), and (6) 20-hour SCS plus 2-hour NP (n = 6). Graft recovery measured by serum creatinine level was significantly faster for continuous HMP preservation strategies compared with SCS alone and for all end-ischemic strategies. The active oxygenated 22-hour HMP group demonstrated a significantly faster recovery from early graft function compared with the 22-hour nonactive oxygenated HMP group. Active oxygenation was also found to be an important modulator of a faster increase in renal flow during HMP preservation. Continuous oxygenated HMP applied from the time of kidney procurement until transplant might be the best preservation strategy to improve early graft function.

Impact of In Situ Cold Perfusion of Kidney Grafts during Vascular Anastomosis

This study investigated simple in situ perfusion of a kidney to reduce its susceptibility to warm ischemia in rodent and porcine ischemic kidney models. Organ temperature was managed via simple continuous perfusion using newly developed thermal barrier sheet (TBS). ATP retention following cold perfusion with extracellular-trehalose-Kyoto (ETK) solution was investigated in a rat model. Materials and Methods Kidneys from adult male genetically modified luciferase transgenic (Luc Tg) rats were removed. The renal artery/vein underwent simple cold preservation at 4°C for 5 to 18 hours using ETK solution. After cold storage, the kidney was transplanted into a dummy living body that was heated to 37°C and perfused with ETK solution using a drip. The surface temperature (Ts) was measured with an infrared camera and ATP luminescence in organs was observed for 60 minutes. In porcine, the renal artery and vein were clamped within the abdominal cavity and the left kidney was prepared as a donor organ after 25 minutes of exposure to warm ischemia. The kidney was perfused via the renal artery at 4°C using ETK solution and subsequently underwent cold preservation (Fig1.a). We continued the surgery, while the kidney continued to undergo cold perfusion (Fig2.b) using a TBS. Continuous suturing was performed and the cannula was removed immediately after reflux. Blood flow then resumed. Control kidneys were sutured without undergoing perfusion. The time required for anastomosis was 1 hour, during which time the Ts of the kidney was measured. After resuming blood flow, the right kidney was removed. Following transplantation, blood and tissue were collected. Results Using a TBS and cold reflux in the dummy body, the rodent kidney Ts was maintained at 15°C or less for more than 30 minutes. During perfusion with the conventional method, the kidney Ts was at least 28°C immediately following removal. In the case of cold perfusion and TBS, the ATP level was elevated by approximately 4-fold that of pre-removal levels during preservation. Meanwhile, while using the conventional method, the ATP level was 0.9-fold of the pre-removal level during cold preservation. The porcine kidney Ts in the control group increased to 32°C during transplantation. Whereas, in the cold perfusion group, transplantation was performed while the kidney Ts was maintained at 24°C. The primary non-function rate after transplantation was 60% in the control group and 25% in the cold perfusion group. Discussion The cold perfusion method using a TBS can maintain the temperature and ischemic time in all organs obtained after cardiac death. In addition, the preclinical porcine model is a useful renal transplantation graft model that does not exhibit rejection and can be used to identify appropriate constant temperature perfusion solutions. Conclusions By developing this perfusion system, we believe that we can promote research toward practical application of machine perfusion.

Liver Transplant From Controlled Cardiac Death Donors Using Normothermic Regional Perfusion: Comparison With Liver Transplants From Brain Dead Donors

BackgroundLiver transplantation from donors after either controlled or uncontrolled cardiac death (DCD) is associated with considerable rates of primary nonfunction (PNF) and ischemic cholangiopathy (IC). Normothermic regional perfusion (NRP) could significantly reduce such rates. MethodsRetrospective study to analyze short-term (mortality, PNF, vascular complications) and long-term (IC, survival) complications in 11 liver transplants from controlled DCDs using NRP with extracorporeal membrane oxygenation (ECMO) (group 1). They were compared with 51 patients transplanted with grafts from donors after brain death (DBD) (group 2). Mean recipient age, sex, and Model for End-stage Liver Disease (MELD) score were not significantly different. ResultsIn group 1, mean functional warm ischemia time was 15.8 (range, 7–40) minutes and 94.1 (range, 20–150) minutes on NRP. The ischemic damage was minimal, as shown by the slight alanine aminotransferase (ALT) and aspartate aminotransferase (AST) rises in the donor serum after 1 hour on NRP and similar rises 24 hours after transplantation in both groups. No patient had IC or acute renal failure. No significant difference was found between the groups for vascular or biliary complications. One group 1 patient had PNF (9.1%), resulting in death. Overall retransplantation and in-hospital death rates were 8.1% and 4.8%, respectively, with no significant difference between groups. Estimated mean survival was 24.6 (95% confidence interval [CI], 20.2–29.1) months in group 1 and 32.3 (95% CI, 30.4–34.2) months in group 2 (not a statistically significant difference). ConclusionIn our experience, liver transplants from controlled DCDs using NRP with ECMO is associated with a low risk of PNF and IC, with short- and long-term results comparable to those in DBD transplants.

Donation After Cardiac Death in Liver Transplantation: An Additional Source of Organs With Similar Results to Donation After Brain Death

BackgroundAs new sources of organs are needed, liver transplantation using donors after cardiac death (DCD) is progressively increasing, but outcomes with this method are still questioned. This study was accomplished to verify that DCD outcomes are comparable to those seen in donation after brain death (DBD). MethodsThis was a prospective cohort study including 100 liver transplantation performed between 2014 and 2017, divided according to donor type in 75 DBD and 25 DCD. ResultsDCD donors were younger (mean age: DCD 56 years, DBD 59 years; P = .009). Mean Modified End-stage Liver Disease (MELD) score was lower for DCD (DCD 16, DBD 19; P < .001). No differences were found regarding ischemia times and development of postreperfusion syndrome or coagulopathy. Primary graft dysfunction was more frequent in DCD (60%, DCD 29.3%; P = .006). Rates of primary graft nonfunction (DCD 0%, DBD 1.3%; P = .562) and acute rejection (DCD 20%, DBD 16.4%; P = .685) were similar. Acute kidney injury occurred more often in DBD (DCD 32%, DBD 12%; P = .051). Length of stay was comparable. Rates of biliary complications (DCD 20%, DBD 26.7%; P = .505) were similar, unlike ischemic cholangiopathy (DCD 12%, DBD 1.3%; P = .018). Retransplantation rates were also similar (DCD 8%, DBD 4%; P = .427) as was survival rate after 3 years (DCD 84%, DBD 86.7%; P = .739). ConclusionDCD represents an additional graft source with results that are encouraging and may be comparable to DBD with a careful donor and recipient selection.

DCD donor hemodynamics as predictor of outcome after kidney transplantation.

Insufficient hemodynamics during agonal phase-ie, the period between withdrawal of life-sustaining treatment and circulatory arrest-in Maastricht category III circulatory-death donors (DCD) potentially exacerbate ischemia/reperfusion injury. We included 409 Dutch adult recipients of DCD donor kidneys transplanted between 2006 and 2014. Peripheral oxygen saturation (SpO2-with pulse oximetry at the fingertip) and systolic blood pressure (SBP-with arterial catheter) were measured during agonal phase, and were dichotomized into minutes of SpO2>60% or SpO2<60%, and minutes of SBP > 80mmHg or SBP < 80mmHg. Outcome measures were and primary non-function (PNF), delayed graft function (DGF), and three-year graft survival. Primary non-function (PNF) rate was 6.6%, delayed graft function (DGF) rate was 67%, and graft survival at threeyears was 76%. Longer periods of agonal phase (median 16min [IQR 11-23]) contributed significantly to an increased risk of DGF (P=.012), but not to PNF (P=.071) and graft failure (P=.528). Multiple logistic regression analysis showed that an increase from 7 to 20minutes in period of SBP < 80mmHg was associated with 2.19 times the odds (95% CI 1.08-4.46, P=.030) for DGF. In conclusion, duration of agonal phase is associated with early transplant outcome. SBP < 80mmHg during agonal phase shows a better discrimination for transplant outcome than SpO2<60% does.

Continuous Ambulatory Peritoneal Dialysis Catheter Insertion Technique: A Comparative Study of Percutaneous versus Surgical Insertion.

Continuous ambulatory peritoneal dialysis (CAPD) is a standard renal replacement therapy, but there is a lack of consensus for catheter insertion method and type of catheter used. We retrospectively analyzed 140 peritoneal dialysis catheters (PDC) inserted in 139 CAPD patients by two methods; percutaneous (Group “P,” n = 47) and surgical mini laparotomy (Group “S,” n = 93) technique over a 39-month period, with cumulative experience of 2415 catheter-months: 745 catheter-months for Group “P” and 1670 catheter-months for Group “S.” Break-in period was shorter in Group “P” (P = 0.002) whereas primary nonfunction rate was comparable (P = 0.9). The mean catheter survival was better in Group “S” (17.95 ± 10.96 months vs. 15.85 ± 9.41 months in “P” group, P = 0.05) whereas the death-censored and overall catheter survival was comparable in both groups. PDC removal due to refractory peritonitis was also comparable. Mechanical complications were more in “P” group (P = 0.049), leading to higher catheter removal (P = 0.033). The peritonitis rates were higher in “P” group (1 episode per 24.8 catheter-months vs. 1 episode per 34.8 catheter-months in “S” group, P = 0.026) and related to a higher number of rural patients in the group (P = 0.04). Patient survival was comparable. There was no effect on episodes of peritonitis in those CAPD patients who had diabetic etiology or prior hemodialysis catheter-related sepsis, age, and PDC insertion method.

A systematic review and meta-analysis of cold in situ perfusion and preservation of the hepatic allograft: Working toward a unified approach.

The efficacy of cold in situ perfusion and static storage of the liver is a possible determinant of transplantation outcomes. The aim of this study was to determine whether there is evidence to substantiate a preference for a particular perfusion route (aortic or dual) or perfusion/preservation solution in donation after brain death (DBD) liver transplantation. The Embase, MEDLINE, and Cochrane databases were used (1980‐2017). Random effects modeling was used to estimate effects on transplantation outcomes based on (1) aortic or dual in situ perfusion and (2) the use of University of Wisconsin (UW), histidine tryptophan ketoglutarate (HTK), Celsior, and/or Institut Georges Lopez–1 (IGL‐1) solutions for perfusion/preservation. A total of 22 articles were included (2294 liver transplants). The quality of evidence ranged from very low to moderate Grading of Recommendations, Assessment, Development and Evaluations score. Meta‐analyses were conducted for 14 eligible studies. Although there was no difference in the primary nonfunction (PNF) rate, a higher peak alanine aminotransferase (ALT) was recorded in dual compared with aortic‐only UW‐perfused livers (standardized mean difference, 0.24; 95% confidence interval, 0.01‐0.47); a back‐table portal venous flush was undertaken in the majority of aortic‐only perfused livers. There were no relevant differences in peak enzymes, PNF, thrombotic graft loss, biliary complications, or 1‐year graft survival in comparisons between dual‐perfused livers using UW, HTK, Celsior, or IGL‐1. In conclusion, there is no significant evidence that aortic‐only perfusion of the DBD liver compromises transplantation outcomes, and it may be favored because of its simplicity. However, there is currently insufficient evidence to advocate for the use of any particular perfusion/preservation fluid over the others. Liver Transplantation 23 1615–1627 2017 AASLD.

Does Low Hepatic Artery Flow Increase Rate of Biliary Strictures in Deceased Donor Liver Transplantation?

We read the article by Kim et al,1 which was recently published in Transplantation, with great interest. In the study, the authors found that HA flow lower than 400 mL/min was associated with an increased rate of biliary strictures in younger donors (<50 years) and in patients with duct-to-duct anastomoses (P = 0.028). Lower HA flow was also associated with decreased graft survival (P = 0.013). Nevertheless, only donor age and HCC as the primary diagnosis were related to biliary strictures in the first 24 months based on multivariate analysis. HA flow lower than 400 mL/min was associated with biliary strictures (hazard ratio, 1.53; 95% confidence interval, 1.04-2.24; P = 0.0297) but only in univariate and not multivariate analysis. In addition, HA flow lower than 400 mL/min was also related to graft failure in univariate analysis. The authors conclude that increasing HA flow in patients receiving grafts from younger donors and with low HA flows should be considered. Recently, we conducted a retrospective observational study over a prospective database analyzing 333 consecutive orthotopic liver transplants performed between January 2007 and October 2012. Two groups were established per HA flow (216 patients with HA flow <200 mL/min and 117 patients with HA flow ≥200 mL/min). Lower HA flow was significantly associated with female donors (37.6% vs 24.5%, P = 0.012) and with lower body weight (73.2 ± 11.8 vs 76.2 ± 12.4 kg, P = 0.011). No differences between groups were observed in recipient parameters. Longer intensive care unit and hospital stays after transplantation were observed in the lower-HA-flow group compared with the higher-HA-flow group: 5 versus 4 days (P = 0.03) and 20 versus 16 days (P = 0.004), respectively. No significant differences in vascular complication (9.4% vs 6.9%, P = 0.425) and biliary complication rate (12.8% vs 8.3%, P = 0.191) were found. Moreover, 5-year graft survival was comparable between both groups (70.8% vs 70.8%, P = 0.224). We also studied 100 mL/min as the HA flow threshold (12 patients with HA flow <100 mL/min and 321 patients with HA flow ≥100 mL/min). Significantly, lower graft survival was observed in the lower-HA-flow group at 5 years (54.6% vs 70.8%, P = 0.006), but no differences were found in arterial (8.3% vs 8.1%, P = 0.999) or biliary complications (8.3% vs 10%, P = 0.999). The lack of a direct relationship between HA flow and biliary complications has also been observed by Pratschke et al,2 who reported that HA flow under a cutoff point of 240 mL/min was related to impaired postoperative organ function and higher rates of primary nonfunction after liver transplantation. Moreover, lower HA flow was an independent factor of lower organ survival in univariate and multivariate analyses. Of note, biliary complications were not affected by HA flow in this study. In summary, recent studies have failed to define a threshold for HA flow that could be related to biliary complications after LT. Finally, we agree with the authors when they suggest that the relationship between biliary strictures and HA flow may be an association but not a causality.

Impact of Cold Ischemia Time in Kidney Transplants From Donation After Circulatory Death Donors.

BackgroundDeceased-donor kidneys are exposed to ischemic events from donor instability during the process of donation after circulatory death (DCD). Clinicians may be reluctant to transplant DCD kidneys with prolonged cold ischemia time (CIT) for fear of an additional deleterious effect.MethodsWe performed a retrospective cohort study examining US registry data between 1998 and 2013 of adult first-time kidney-only recipients of paired kidneys (derived from the same donor transplanted into different recipients) from DCD donors.ResultsOn multivariable analysis, death-censored graft survival (DCGS) was comparable between recipients of kidneys with higher CIT relative to paired donor recipients with lower CIT when the CIT difference was 1 hour or longer (adjusted hazard ratio, [aHR], 1.02; 95% confidence interval [CI], 0.88-1.17; n = 6276), 5 hours or longer (aHR, 0.98; 95% CI, 0.80-1.19; n = 3130), 10 hours or longer (aHR, 1.15; 95% CI, 0.82-1.60; n = 1124) or 15 hours (aHR, 1.15; 95% CI, 0.66-1.99; n = 498). There was a higher rate of primary non function in the long CIT groups for delta 1 hour or longer (0.89% vs 1.63%; P = 0.006), 5 hours (1.09% vs 1.67%, P = 0.13); 10 hours (0.53% vs 1.78%; P = 0.03), and 15 hours (0.40% vs 1.61%; P = 0.18), respectively. Between each of the 4 delta CIT levels of shorter and longer CIT, there was a significantly and incrementally higher rate of delayed graft function in the long CIT groups for delta 1 hour or longer (37.3% vs 41.7%; P < 0.001), 5 hours (35.9% vs 42.7%; P < 0.001), 10 hours (29.4% vs 44.2%, P < 0.001), and 15 hours (29.6% vs 46.1%, P < 0.001), respectively. Overall patient survival was comparable with delta CITs of 1 hour or longer (aHR, 0.96; 95% CI, 0.84-1.08), 5 hours (aHR, 1.01; 95% CI, 0.85-1.20), and 15 hours (aHR, 1.27; 95% CI, 0.79-2.06) but not 10 hours (aHR, 1.47; 95% CI, 1.09-1.98).ConclusionsThese results suggest that in the setting of a prior ischemic donor event, prolonged CIT has limited bearing on long-term outcomes.

Gender disparity in fistula use at initiation of hemodialysis varies markedly across ESRD networks-Analysis of USRDS data.

Gender disparities had been noted in the care of women with end stage renal disease (ESRD) in the early 2000's, including less frequent initiation of hemodialysis utilizing a fistula but more recent data have not been examined and underlying factors have not been extensively studied. Data from the United States Renal Data System (USRDS) were examined, including 202,999 hemodialysis patients. Only those who had received prior nephrology care were included. Multiple logistic regression was used, adjusted for possible confounders, including age, race, cause of ESRD, BMI, height, history of alcohol or drug abuse, medical comorbidities, ability to ambulate, time of nephrology care, type of insurance, and ESRD network. The odds of arteriovenous fistula (AVF) use at initiation of hemodialysis were significantly lower in women compared to men (OR = 0.69, 95% CI 0.67-0.71, P < 0.0001). The gender gap in AVF use at initiation was highest in New York and the upper Midwest (networks 2 and12) and smallest for Southern California and the Pacific Northwest and Alaska (18 and 16). Gender disparity was more pronounced for black women, with odds ratios for AVF use at initiation of dialysis (OR = 0.66, 95% CI 0.62-0.69), P < 0.0001 as compared to non-black (OR 0.70, 95% CI 0.68-0.73), P ≤ 0.0001. Limitations include use of USRDS data. Data misclassification or errors in data reporting may exist and certain comorbid conditions may be underreported. Data regarding rate of primary fistula non-function are also not available. Adjusted odds ratio for AVF use was significantly lower in women compared to men, independent of time of nephrology care and other predictors. The gender disparity was most pronounced for black women and also varied from 20% to 46% lower odds for AVF use in women for different ESRD networks, after controlling for possible confounding variables, suggesting that practice based factors may be of importance in explaining this important finding.

UK National Registry Study of Kidney Donation After Circulatory Death for Pediatric Recipients.

Donation after circulatory death (DCD) kidney transplantation has acceptable renal allograft survival in adults but there are few data in pediatric recipients. The aim of this study was to determine renal allograft outcomes for pediatric recipients of a DCD kidney. Data were collected from the UK Transplant Registry held by National Health Service Blood and Transplant. Kidney transplants performed for pediatric recipients (age, <18 years) in the United Kingdom from 2000 to 2014 were separated into DCD, donation after brain death (DBD), and living donor (LD) transplants, analyzing 3-year patient and renal allograft survival. One thousand seven hundred seventy-two kidney only transplants were analyzed. Twenty-one (1.2%) of these were from DCD donors, 955 (53.9%) from DBD donors, and 796 (44.9%) from LDs. Patient survival is 100% in the DCD group, 98.7% in the DBD group, and 98.9% in the LD group. Three-year renal allograft survival was 95.2% in the DCD group, 87.1% in the DBD group, and 92.9% in the LD group. There was no significant difference in 3-year renal allograft survival between the DCD and DBD groups (P = 0.42) or DCD and LD groups (P = 0.84). For DCD, the primary nonfunction rate was 5% and delayed graft function was 25%. Children receiving a DCD kidney transplant have good renal allograft survival at 3-year follow-up, comparable to those receiving a kidney from a DBD donor or a LD. This limited evidence encourages the use of selected DCD kidneys in pediatric transplantation, and DCD allocation algorithms may need to be reviewed in view of this.

Safety and Outcomes in 100 Consecutive Donation After Circulatory Death Liver Transplants Using a Protocol That Includes Thrombolytic Therapy.

Donation after circulatory death (DCD) liver transplantation (LT) reportedly yields inferior survival and increased complication rates compared with donation after brain death (DBD). We compare 100 consecutive DCD LT using a protocol that includes thrombolytic therapy (late DCD group) to an historical DCD group (early DCD group n = 38) and a cohort of DBD LT recipients (DBD group n = 435). Late DCD LT recipients had better 1- and 3-year graft survival rates than early DCD LT recipients (92% vs. 76.3%, p = 0.03 and 91.4% vs. 73.7%, p = 0.01). Late DCD graft survival rates were comparable to those of the DBD group (92% vs. 93.3%, p = 0.24 and 91.4% vs. 88.2%, p = 0.62). Re-transplantation occurred in 18.4% versus 1% for the early and late DCD groups, respectively (p = 0.001). Patient survival was similar in all three groups. Ischemic-type biliary lesions (ITBL) occurred in 5%, 3%, and 0.2% for early DCD, late DCD, and DBD groups, respectively, but unlike in the early DCD group, in the late DCD group ITBL was endoscopically managed and resolved in each case. Using a protocol that includes a thrombolytic therapy, DCD LT yielded patient and graft survival rates comparable to DBD LT.