Standard Criteria Donor Research Articles

Does Rapid Growth in the Number of Donation after Circulatory Death Donors Equate to Fewer Brain Dead Donors and Fewer Organs Transplanted?

Background One U.S. organ procurement organization (OPO) saw a significant growth in donation after circulatory death (DCD) as a percentage of its overall deceased donor population between 2012 and 2017. Growing the number of DCD donors recovered was a strategy undertaken in 2012 to increase overall OPO performance. The OPO sought to identify whether the DCD increase had unintentionally impacted brain dead donors (DBD) recovered and/or the total number of organs transplanted. Method A retrospective review of donation activity was performed from 2012-2017 (2017 annualized based upon 10 months’ data). Donor types and organs transplanted were analyzed. Trends in data were analyzed both year-to-year and by comparing 2017 to mean data over the OPO's growth cycle (defined as 2014 to 2017). Results From 2012 to 2017, the OPO experienced an increase in total deceased organ donors from 94 to 178 (+89.4%) with a peak of 180 donors in 2016. For the same period, total DBD increased from 84 to 109 (+29.8%) with a peak of 132 in 2015. DCD increased from 10 to 68 (+680%), peak=68 in 2017. With DBD donors subdivided into standard criteria donors (SCD) and extended criteria donors (ECD), results are: SCD increased from 66 to 91 (+37.9%) with a peak of 102 SCD in 2015 while ECD remained flat at 18 in both 2012 and 2017 with a peak of 30 ECD in 2015.Similarly, organs transplanted (OTx) from all deceased donors increased from 323 to 509 (+57.6%), peak=509 in 2017; from DCD OTx increased from 20 to 132 (+660%), peak=132 in 2017; from SCD OTx increased from 262 to 343 (+30.9%), peak=361 in 2014; and from ECD OTx decreased from 41 to 34 (-17.1%), peak=54 in 2015.Discussion In this OPOs experience, accomplishing significant growth in DCD was initially (through 2015) accomplished in parallel with increases in both SCD and ECD. However, in the most recent two years, both SCD and ECD have declined from 2015 peaks (-10.8% and -40.0% respectively). SCD have remained relatively in-line with a four year (2014-2017) mean of 94 (-3.2%) but ECD have declined from a four year mean of 24.5 to 18 (-26.5%). Similarly, OTx from SCD have remained relatively in line with a four year mean of 349.6 (-1.9%) whereas ECD OTx have decreased from a four year mean of 43.3 (-21.5%). Though total deceased donors and OTx have been steadily up, recently DCD donors and OTx continue to increase as DBD have been declining, especially in the ECD population. While the OPO authorizes all DCD donors for DBD also, and routinely some DCD progress to DBD prior to recovery (at which time organs are re-allocated), the overall DBD decrease and the profound ECD decrease could result from a variety of variables such as more rapid deceleration of care and bears further study. A broader, multi-OPO study is also indicated to determine if this is a national trend, and whether local and regional variables impacting any trend are unique depending on donor locale.

Renal Transplantation of Discolored Kidneys from Donors with Rhabdomyolysis and Acute Kidney Injury

Background Rhabdomyolysis is common in trauma patients with acute renal injury (AKI). The kidneys from donors with rhabdomyolysis and AKI may show discolored appearance. The transplant surgeons may be unwilling to accept a kidney with AKI and black appearance, especially when the kidney is anuric. Method Fourteen discolored (from brown to glossy black) kidneys from 7 deceased donors with severe rhabdomyolysis and AKI (defined as Kidney Disease Improving Global Outcomes (KDIGO) AKI Stage 1 - 3) were accepted for transplantation at our centers. Generally, we accept kidneys with a resistance < 0.4 mmHg/mL/min in pump perfusion when an preimplant biopsy excludes cortical necrosis and chronic lesions (>10% glomerulosclerosis, interstitial fibrosis, tubular atrophy). The kidney transplant results of 14 black kidneys from rhabdomyolysis donors were compared with those of 30 renal grafts from standard criteria donors (SCD). Results Two donors received continuous renal replacement therapy due to anuria. The peak serum creatinine kinase, myoglobin, and serum creatinine of the these donors was 27738 ± 7394 U/L, 76003 ± 50708 μg/L, and 442 ± 214 μmol/L, respectively. Pathological examination showed massive casts in the distal convoluted tubules. Immunohistochemically stained for myoglobin showed luminal myoglobin casts or prominent tubular epithelial cell reaction for myoglobin in the absence of luminal casts. Electron microscopy showed electron-dense casts consistent with myoglobin within tubular lumens. The estimated glomerular filtration rate (by the CKD-EPI Creatinine 2009 equation) at 1 years post-transplantation was similar between black kidneys from donors with rhabdomyolysis and SCD (69.8 ± 13.6 ml/min/1.73m2 vs. 71.2 ± 15.1 ml/min/1.73m2, P = 0.56). Conclusion If the rhabdomyolysis donor has a peak serum creatinine kinase level higher than 20 000 U/L and has tea- colored urine, the kidneys are likely to have a black appearance after in situ cold perfusion. Discolored kidneys from rhabdomyolysis donors with AKI can achieve excellent graft function, even when the kidneys are anuric. Routine screening for rhabdomyolysis should be performed in donors with AKI.

A New Risk Stratification Score for Deceased Donor Kidneys in Korea

Organ shortages have led to expansions in the criteria for deceased donors. Although the expanded criteria donor (ECD)/standard criteria donor (SCD) dichotomous criteria have been useful for making decisions about accepting organ offers, several studies reported that these criteria are too simple to predict prognosis sufficiently. The Kidney Donor Risk Index (KDRI) is based on 10 donor factors, therefore providing a finely granulated evaluation of donor kidney quality. Kidney Donor Profile Index (KDPI) that was derived from KDRI, was newly adopted as an alternative to ECD/SCD in the US. However, the KDPI based on US data may not have similar prognostic values in other countries. Here, we developed a Korean risk stratification score for deceased donor kidney using data obtained from the KONOS (Korean Network for Organ Sharing) and KOTRY (Korean Organ Transplantation RegistrY), and investigated its prognostic values. We analyzed 5,524 first-time, deceased donor adult kidney transplants between 2000 and 2016. A Cox regression model was used to find out independent risk factors among donor and transplant-related factors for graft failure, adjusted for recipient characteristics. There were 426 deaths and 483 graft loss during median follow-up of 49 months. The mean age of donors were 44 years old, and 32% of donor were females. Nine hundred seventeen donors had history of hypertension, and the cause of death was cerebrovascular event in 2,597 donors. Fifty-three donated organ after cardiac death, and mean cold ischemic time was 322 minutes. Twenty-three percent belonged to ECD. Median KDRI was 1.18 and KDPI was 67. A New Korean Kidney Donor Risk Index (K-KDRI) includes 6 donor and transplant factors, each found to be independently associated with graft failure: donor age, weight, history of diabetes, serum creatinine, cerebrovascular cause of death, and HLA mismatch. Median K- KDRI was 1.5. A New Korean Kidney Donor Profile Index (K-KDPI) is a remapping of the K-KDRI onto a cumulative percentage scale. The lowest K-KDPI group (<20%) showed better graft survival than the higher K-KDPI groups (20-80%, ≥80%, respectively) (p<0.001). Even within the ECD group, higher K-KDPI values were significantly associated with lower graft survival rate. In contrast, in the same K-KDPI group, there was no difference in graft survival rate between ECD and SCD. These data suggested that K-KDPI is a better prognostic tool for graft outcomes than the previous ECD/SCD criteria. The new K-KDPI criteria based on the Korean data are expected to give better information about graft prognosis and assist decision making for deceased donor kidney utilization in Korea. KONOS (Korean Network for Organ Sharing). KOTRY (Korean Organ Transplantation Registry).

Altered Expression of Inflammation Genes in Preimplantation Kidney Biopsies of Extended Criteria Donors

Background Changes to an organ can occur at the time of brain death and a series of inflammatory proteins are generated within the organ. It is not known whether this inflammatory similarly affects the kidneys from extended (ECD) and standard (SCD) criteria donors and because we have previously reported that preimplantation kidney biopsies from ECD donors have a heavier inflammatory profile when compared with SCD donors. In the present study we extended our results using great number of genes and seeking to identify some immunologic pathways involved in the mechanism of sterile inflammation. Methods Pretransplant kidney biopsies (Bx) were obtained from ECD (n=40) and SCD (n=40). Gene expression profile measured by Real Time qPCR Array representing expression levels of genes indicative of inflammation (IL-10, IL-1b, TNF-α, MCP-1, NFK-b, TLR-4, HMGB1, IFN-gamma, TGF-b, Myd-88), cytoprotection (HO-1, HIF-1a), apoptose (CASP-1) and intercellular adhesion (ICAM-1) and correlated with donor variables. Results ECD donors were older had more cerebrovascular accident, arterial hypertension and diabetes (p<0.01) and recipients of ECD kidneys had renal function and 24h proteinuria worst 1 year after transplantation (p<0.006). Genes IL-10, IL-1 β, TLR-4, HMGB-1, HIF-1 and CASP-1 were significantly more expressed in biopsies from ECD than SCD. Presence of DGF, acute rejection, was not associated with any individual transcript. Conclusions The present results confirm and expand our previous findings that ECD kidney is highly inflamed when compared with SCD and that a Myd-88 independent pathway of innate immunity may be activated. We appreciate the FAPESP (#2014/25831-5) for the financial support.

Kidney Transplantation from Uncontrolled Donation after Circulatory Death, our Outcomes Compared to Donation after Brain Death after Very Long Time

Introduction Kidney transplantation (KT) is the best renal replacement therapy but the shortage of organ is the main limitation. Uncontrolled Donation after Circulatory Death (uDCD) increases the available organs with similar outcomes than donors after brain death (DBD). The long-term outcome of uDCD compared to standard criteria donors after DBD KT is unknown. Methods We compared the long-term follow-up (10 y) of all uDCD KT procured since June 2005 to December 2013 (n=237) with a cohort of first KT of DBD performed between 2004 and 2014 (237) in the same institution. We review renal function, graft and recipient survival. We studied factors related with graft survival. Results Primary non-function was similar between both groups (uDCD 6.8% vs. 4.2%, p=0.16). Despite the higher delayed graft function (DGF) in uDCD (73.4% vs. 46.4%, p<0.01), renal function was similar between the two groups in the follow-up with exception the first six months (FG 51±17 ml/min vs 55±19 ml/min, p=0.04), Figure 1. Graft and recipient survival were equivalent in both groups after 10 years (82% vs. 80%, p=0.6 and 86% vs 88%, p=0.45, respectively), Figure 2. In multivariable analysis, proteinuria >0.5 after 3, 6 and 12 months (HR 5.1 CI 1.2-5.4, p<0.05) and GFR < 45 ml/min (HR 6.2 CI 1.8-21.5, p<0.05) had a deleterious impact in uDCD donors (HR 2.5 CI 1.01-6.3, p=0.04) while DGF had any impact (p>0.05). Conclusions KT from uDCD has similar renal function, graft and recipient survival than DBD after long-term of follow-up. The main factors related with graft survival were proteinuria > 0.5 g/day at 3, 6 and 12 months and GFR < 45 ml/min at 12 months.

The evolution of donation after circulatory death renal transplantation: a decade of experience

This study compared long-term outcomes of renal transplantation from donors following donation after circulatory death (DCD) with those following donation after brain death (DBD) from one of the largest centres in the UK. Recipients of renal transplants from deceased donors between 2002 and 2014 were identified from a prospectively maintained database. Outcomes were compared between DCD (468) and DBD (905) donors and between standard criteria donors (SCDs) and extended criteria donors (ECDs). Graft survival (GS) and patient survival (PS) from DCD and DBD donors were comparable up to 10 years (GS: 61 versus 55%, P = 0.780; PS: 78 versus 71%, P = 0.285, respectively). Graft function was comparable after 3 months. GS and function were worse in the ECD groups, with no difference between EC-DBD and EC-DCD. PS in the ECD groups was worse than the SCD groups and PS in the EC-DCD group was worse than in the EC-DBD group. DCD donors were an independent risk factor for delayed graft function. Post-operative complications and EC-DCD donation were independent risk factors for reduced GS and PS. This study supports the use of DCD renal grafts with comparable long-term survival and function to DBD grafts. The use of EC-DCD grafts is justified in selected recipients and provides acceptable function and survival advantages over dialysis.

Impact of Korea Network for Organ Sharing Expanded Donor Criteria on Delayed Graft Fuction in Kidney Transplantation: A Single-Center Experience

BackgroundThe shortage of donor organs has been a major challenge in transplantation. In an effort to reduce the donor shortage, kidney transplantation (KT) using expanded criteria donors (ECD) was encouraged. In Korea, transplantation centers used the Korea Network for Organ Sharing (KONOS) ECD criteria, which is different from the United Network for Organ Sharing (UNOS) criteria. The aim of this study is to evaluate the predictive power of KONOS criteria on delayed graft function (DGF) in comparison to UNOS criteria. MethodsA total of 376 recipients who underwent deceased donor kidney transplantation between January 2005 and December 2014 at Severance Hospital were retrospectively reviewed. Of these, 130 cases satisfied KONOS ECD, while the others followed KONOS standard criteria donor (SCD). ResultsDonor age and history of hypertension was significantly higher with KONOS ECD than with KONOS SCD. In KONOS subgroup analysis, donor characteristics were different than with UNOS criteria. The incidence of DGF was higher in the KONOS ECD group than in the KONOS SCD group. However, UNOS ECD showed a high incidence of DGF compared to UNOS SCD with the same KONOS criteria. UNOS ECD was an independent risk factor for DGF in multivariate analysis. However, KONOS ECD was not a risk factor for DGF. Although glomerular filtration rate was inferior in the KONOS ECD group compared to the KONOS SCD group, the UNOS SCD group within the KONOS ECD group showed similar graft function compared to the KONOS SCD group. ConclusionKONOS criteria have a lower predictive power for DGF than UNOS criteria.

Normothermic ex-vivo preservation with the portable Organ Care System Lung device for bilateral lung transplantation (INSPIRE): a randomised, open-label, non-inferiority, phase 3 study

Severe primary graft dysfunction (PGD) of grade 3 (PGD3) is a common serious complication following lung transplantation. We aimed to assess physiological donor lung preservation using the Organ Care System (OCS) Lung device compared with cold static storage. In this non-inferiority, randomised, controlled, open-label, phase 3 trial (INSPIRE) recipients were aged 18 years or older and were registered as standard criteria primary double lung transplant candidates. Eligible donors were younger than 65 years old with a ratio of partial pressure of oxygen in arterial blood to the fraction of inspired oxygen of more than 300 mm Hg. Transplant recipients were randomly assigned (1:1) with permuted blocks, stratified by centre, to receive standard criteria donor lungs preserved in the OCS Lung device (OCS arm) or cold storage at 4°C (control arm). The composite primary effectiveness endpoint was absence of PGD3 within the first 72 h after transplant and 30-day survival in the per-protocol population, with a stringent 4% non-inferiority margin. Superiority was tested upon meeting non-inferiority. The primary safety endpoint was the mean number of lung graft-related serious adverse events within 30 days of transplant. We did analyses in the per-protocol and intention-to-treat populations. This trial is registered with ClinicalTrials.gov, number NCT01630434. Between Nov 17, 2011, and Nov 24, 2014, we randomly assigned 370 patients, and 320 (86%) underwent transplantation (n=151 OCS and n=169 control); follow-up was completed in Nov 24, 2016. The primary endpoint was met in 112 (79·4%) of 141 patients (95% CI 71·8 to 85·8) in the OCS group compared with 116 (70·3%) of 165 patients (62·7 to 77·2) in the control group (non-inferiority point estimate -9·1%; 95% CI -∞ to -1·0; p=0·0038; and superiority test p=0·068). Patient survival at day 30 post-transplant was 135 (95·7%) of 141 patients (95% CI 91·0-98·4) in the OCS group and 165 patients (100%; 97·8-100·0) in the control group (p=0·0090) and at 12 months was 126 (89·4%) of 141 patients (83·1-93·9) for the OCS group compared with 146 (88·1%) of 165 patients (81·8-92·8) for the control group. Incidence of PGD3 within 72 h was reported in 25 (17·7%) of 141 patients in the OCS group (95% CI 11·8 to 25·1) and 49 (29·7%) of 165 patients in the control group (22·8 to 37·3; superiority test p=0·015). The primary safety endpoint was met (0·23 lung graft-related serious adverse events in the OCS group compared with 0·28 events in the control group [point estimate -0·045%; 95% CI -∞ to 0·047; non-inferiority test p=0·020]). In the intention-to-treat population, causes of death at 30 days and in hospital were lung graft failure or lung infection (n=2 for OCS vs n=7 for control), cardiac causes (n=4 vs n=1), vascular or stroke (n=3 vs n=0), metabolic coma (n=0 vs n=2), and generalised sepsis (n=0 vs n=1). The INSPIRE trial met its primary effectiveness and safety endpoints. Although no short-term survival benefit was reported, further research is needed to see whether the reduced incidence of PGD3 within 72 h of a transplant might translate into earlier recovery and improved long-term outcomes after lung transplantation. TransMedics Inc.

Influence of Sudden Cardiac Arrest in Deceased Kidney Donors on Organ Function After Transplantation

IntroductionDue to the increasing number of organ recipients, expanded criteria donors (ECD) are qualified for transplantation, including donors after sudden cardiac arrest (SCA). The aim of this study was to evaluate the influence of SCA on kidney function immediately after transplantation. Patients and MethodsThe analysis includes 186 kidney recipients, mean age 49 years (19–74), who were transplanted between January 2014 to July 2015. In 44 cases, kidneys were retrieved from donors after SCA (23.6%). Delayed graft function (DGF) was recognized if the patient needed at least one hemodialysis after the kidney transplant. Acute rejection (AR) was confirmed by biopsy. ResultsSixty-five (34.9%) patients presented with DGF, 14 of them received kidneys from donors after SCA (31.8% of the SCA group), and 51 of them are from donors without SCA (35.9% of the non-SCA group). Eleven AR episodes were observed in the first month, including 4 cases in the SCA group. The study revealed no influence of donors' SCA on the frequency of DGF and AR or high creatine level after transplantation. The differences between both groups were not significant (P > .05). ConclusionsSCA episodes in donors during ICU treatment before organ retrieval had no influence on immediate kidney function after kidney transplant. There is no correlation between SCA and episodes of DGF or AR. SCA donors should be considered as standard criteria donors.

Similar Outcomes of Kidney Transplantations Using Organs From Donors After Cardiac Death and Donors After Brain Death

BackgroundTo increase the number of cadaveric kidney transplants in Japan, it is necessary to proactively use organs from all donors. Since the revision of the Organ Transplant Law, the number of organ donors after cardiac death (DCD) has decreased but the number of organ donors after brain death (DBD) has increased; however, the number of donor organs and awareness of cadaveric transplantation have increased. MethodsAt our institution, 28 patients underwent cadaveric kidney transplantation from January 2001 to December 2016. These patients were classified into 2 groups according to DBD or DCD. Furthermore, 10 patients received transplants from expanded criteria donors (ECD) and 18 received them from standard criteria donors (SCD). ResultsKidney graft survival and engraftment were observed for all patients. There were no significant differences in renal function at 6 months for DBD and DCD transplant recipients. Renal function at 1, 3, and 5 years and serum creatinine levels were better for the ECD group. Renal function at 5 years after transplantation was significantly better for the SCD group than for the ECD group; however, there was no difference in delayed graft function between the SCD and ECD groups. Comparisons of the 3 groups showed good renal function for transplants from DBDs, but there was no significant difference in survival rates. ConclusionsResults were good for all patients. There were no significant differences in outcomes of our patients who received transplants from ECD or SCD.

Analysis of Distribution of Expanded- and Standard-Criteria Donors and Complications Among Polish Recipients by Kidney Donor Risk Index Value

IntroductionThe approach toward transplanting kidneys from expanded-criteria donors (ECDs) in Poland is largely site-dependent. The Kidney Donor Risk Index (KDRI) allows for obtaining a more precise characteristic of ECDs and further stratification into “better” and “worse” quality grafts. MethodsComparison of the incidence of delayed graft function (DGF) and biopsy-proven acute rejection (BPAR), median of hospitalization time and median of estimated glomerular filtration rate (eGFR) at 1 year after transplantation among kidney graft recipients (n = 468), divided by donor status (ECD/standard-criteria donor [SCD]) and KDRI value (I: 0.67–1.2, II: 1.21–1.6, III: 1.61–2.0, IV: 2.01–3.48). ResultsECD kidneys have been transplanted to 32.47% of recipients. There were no ECD recipients in KDRI compartment I, 16.55% in compartment II, 79.22% in compartment III, and 100% in IV. In KDRI compartment II, DGF was diagnosed in 34.9% of SCDs and 56% of ECDs (P = .003), BPAR occurred in 7.8% of SCDs and 16% of ECDs (P = .073), median hospital stay was 12 days for SCDs and ECDs (P = 1), and eGFR was 50.7 mL/min for SCDs and 49.4 mL/min for ECDs (P = .734). In KDRI compartment III, DGF was diagnosed in 43.8% of SCDs and 49.2% of ECDs (P = .139), BPAR occurred in 6.3% of SCDs and 31.7% of ECDs (P = .001), median hospital stay was 10 days for SCDs and 12 days for ECDs (P = .634), and eGFR was 49.5 mL/min for SCDs and 45.2 mL/min for ECDs (P = .382). Among ECD recipients, DGF was diagnosed in 56.0%, 49.2%, and 47.7% of patients for KDRI compartments II, III, and IV respectively (P = .776); BPAR occurred in 16% (compartment II), 31.7% (compartment III), and 23.1% (compartment IV) (P = .273); the median hospital stay was 12 days (compartment II), 12 days (compartment III), and 12.5 days (compartment IV) (P = 1); and eGFR was 49.5 mL/min (compartment II), 45.4 mL/min (compartment III), and 36.1 mL/min (compartment IV) (P = .002). ConclusionAssessment using both the ECD and KDRI systems allows for a more precise evaluation of prognosis and predicting complications among recipients.

Real world data in health technology assessments in kidney transplants in Germany: use of routinely collected data to address epidemiologic questions in kidney transplants in the AMNOG process in Germany.

Introduction: It is discussed whether real world data can be used in health technology assessment. Following it is of interest whether routinely collected data for quality assurance (QA) in the hospital sector is feasible to address epidemiologic questions in kidney transplantation in the AMNOG process in Germany. Objectives: To investigate the proportion of kidney transplants classified as from so-called standard criteria donors (SCD) and from expanded criteria donors (ECD) in Germany and to study the age distribution.Methods: After granted use by the Federal Joint Committee (G-BA), the data analysis was carried out by the AQUA institute, and a SPSS code was developed. Special challenge was the complex definition of SCD/ECD criteria that, in addition to donor age, takes into account combinations of donor diagnoses, creatinine, and cold ischemia time.Results: Age analyses could be performed in all patients. Median age of the adult transplant recipients in Germany was 54 years in 2012 as well as in 2013, range 18–85 and 18–82 years and a mean (SD) of 53 (14) and 52 (14) years, respectively. 63.5% (2012) and 62.5% (2013) of recipients were male. Classification in SCD/ECD transplants could be performed for 2,083 of 2,461 patients (85%; 2012) and for 1,795 of 2,079 patients (86%; 2013). Of all classifiable transplants 61.4% (2012) and 66.5% (2013) were SCD transplants. Total project time from the request to results was <6 months.Conclusions: The use of data routinely collected for QA in the hospital sector is feasible to address epidemiologic questions in kidney transplantation in the AMNOG process in Germany, which is basically following the systematic of an HTA process. All patients with kidney transplants are represented thus avoiding sampling error. Limitations include the availability of all necessary data in the QA data set. Within <6 months’ time with reasonable resources it was possible to meet timelines. The analyses were accepted by the authorities.

Kidney transplantation using expanded criteria deceased donors with terminal acute kidney injury: a single center experience in Korea.

PurposeWe investigated the clinical outcomes of deceased donor kidney transplantation (KT) using kidneys with terminal acute kidney injury (AKI).MethodsBetween February 2000 and December 2013, we performed 202 deceased donor renal transplants from 159 brain dead donors. According to the expanded criteria donor (ECD) and AKI network criteria, we divided 202 recipients into 4 groups: Group I: Non-AKI & standard criteria donor (SCD) (n = 97); group II: Non-AKI & ECD (n = 15); group III: AKI & SCD (n = 52); and group IV: AKI & ECD (n = 38).ResultsThe incidence of delayed graft function (DFG) was significantly higher in patients with AKI than it was in the non-AKI group (P = 0.008). There were no significant differences among the 4 groups in graft survival (P = 0.074) or patient survival (P = 0.090). However, the long-term allograft survival rate was significantly lower in group IV than it was in other groups (P = 0.024).ConclusionAllografts from deceased donors with terminal AKI had a higher incidence of DGF than did those from donors without AKI. However, there is no significant difference in graft and patient survival rates among the groups. So, the utilization of renal grafts from ECDs with terminal AKI is a feasible approach to address the critical organ shortage.

Effects of Cold Ichemic Time on Allograft Survival in Kidney Transplantation From Expanded Criteria Donor

Backgrounds Kidney organ shortage is a major problem for transplant communities around the world. Kidneys from expanded criteria donors (ECD) is increasingly accepted and widely used by many transplant programs. However, kidney allograft survivals from ECD is believed to be lower compared to standard criteria donors (SCD) due to lower nephron numbers. Objectives To demonstrate factors correlated with poor allograft survival from ECD. Methods Using Thai transplantation registry data from 1994 to 2016, 2,886 adults (>18 years) first deceased donor kidney transplant recipients were included into the study. Of those, 242 (8.39%) were kidney transplantation from expanded criteria donor which was defined as donor age of more than 60 year or donor age between 50 to 60 years with two of the following characteristics including history of hypertension, last serum creatinine of more than 1.5 mg/dl, and death from stroke. Results Mean recipient age and donor age were significantly higher in ECD group (for recipient age, 48.6±11.8 vs 44.7±11.3 years in SCD group, p<0.001; for donor age, 60.1±5.7 vs 34.5±13.0 years in SCD group, p<0.001). Not surprisingly, cold ischemic time (CIT) is longer in ECD group (20.2±5.0 vs 19.0±6.5 hours in SCD group, p=0.006) and delayed graft function is higher (59.7% vs 42.4%, p<0.001). ECD group increased risk of allograft loss when compared to SCD group (HR 2.19, 95% CI 1.65 to 2.91, p <0.001). However, in patients with CIT of less than 18 hours, the effects of ECD was disappeared (HR 1.58, 95% CI 0.83 to 3.01, p=0.165), compared to group of patients with CIT of more than 18 hours (HR 2.29, 95% CI 1.61 to 3.24, p <0.001) as shown in the figure. Conclusions Kidney transplantation from ECD increases the risk of allograft failure. However, this effect is vanished if CIT is less than 18 hours. Transplant coordinators from 31 kidney transplant centers across Thailand.

Comparison of Clinical Outcomes of Deceased Donor Kidney Transplantation according to Donor Evaluation Criteria

Introduction Deceased donor kidney transplantation (DDKT) in Korea has been activated recently. However, discrepancies between needs and supply are still increasing, and the use of donors with acute kidney injury (AKI), expanded criteria (ECD), or high kidney donor profile index (KDPI) is also increasing. We investigated the clinical outcomes of DDKT in relation to AKI, ECD, and KDPI. Methods We retrospectively analyzed DDKT performed at Keimyung University hospital between 2010 and 2014. Ninetyfour DD and their corresponding 95 KT recipients were included in this study. Results The mean follow-up period was 42.6 ± 17.4 months (range 2‐81). Patients belonging to the AKI group were 42 (44.2%), ECD group were 23 (24.2%), and high KDPI (>85%) group were 16 (16.8%). The incidence of delayed graft function (DGF) was significantly higher in the AKI group than in the non-AKI group (P = 0.011), but not in the ECD group and the high KDPI group. The estimated glomerular filtration rate (eGFR) of the AKI group was significantly lower at 1 week, 2 weeks and 1 month after KT compared to the non-AKI group. After 3 months of KT, there was no significant difference in eGFR between the AKI group and non-AKI group, the ECD group and standard criteria donor group, and the high KDPI group and low KDPI group. Allograft survival rate showed no significant difference in the AKI, ECD, and high KDPI groups compared with the control groups. However, allograft survival rate was significantly lower only in the group with acute rejection (AR) than in the group without AR (P < 0.001). Patient survival rate showed no significant difference, according to donor AKI, ECD, or high KDPI. In multivariate analysis, AR was an independent risk factor for graft failure (hazard ratio 85.75, 95% confidence interval, 7.02-1047.77, P < 0.001), but AKI, ECD, or high KDPI were not. Conclusion Donors with AKI showed significant association with incidence of DGF. However, kidneys with AKI, ECD, or high KDPI performed similarly to the control group in terms of graft function, graft survival, and patient survival. More detailed criteria for selecting a proper donor will be needed.

Active Donor Management During the Hospital Phase of Care Is Associated with More Organs Transplanted per Donor

Meeting donor management goals when caring for potential organ donors has been associated with more organs transplanted per donor (OTPD). Concern persists, however, as to whether this indicates that younger/healthier donors are more likely to meet donor management goals or whether active management affects outcomes. A prospective observational study of all standard criteria donors was conducted by 10 organ procurement organizations across United Network for Organ Sharing Regions 4, 5, and 6. Donor management goals representing normal critical care end points were measured at 2 time points: when a catastrophic brain injury was recognized and a referral was made to the organ procurement organization by the DH; and after brain death was declared and authorization for organ donation was obtained. Donor management goals Bundle "met" was defined as achieving any 7 of 9 end points. A positive Bundle status change was defined as not meeting the Bundle at referral and subsequently achieving it at authorization. The primary outcomes measure was having ≥4 OTPD. Data were collected for 1,398 standard criteria donors. Of the 1,166 (83%) who did not meet the Bundle at referral, only 254 (22%) had a positive Bundle status change. On adjusted analysis, positive Bundle status change increased the odds of achieving ≥4 OTPD significantly (odds ratio 2.04; 95% CI 1.49 to 2.81; p < 0.001). A positive donor management goal Bundle status change during donor hospital management is associated with a 2-fold increase in achieving ≥4 OTPD. Active critical care management of the potential organ donor, as evidenced by improvement in routinely measured critical care end points can be a means by which to substantially increase the number of organs available for transplantation.

Preimplantation Kidney Biopsies of Extended Criteria Donors Have a Heavier Inflammatory Burden Than Kidneys From Standard Criteria Donors.

BackgroundDonors after brain death develop a systemic proinflammatory state that may predispose the kidneys to injury after transplantation. Because it is not known whether this inflammatory environment similarly affects the kidneys from expanded criteria donor (ECD) and standard criteria donors (SCD), we sought to evaluate differences in the gene expression of inflammatory cytokines in preimplantation biopsies (PIBx) from ECD and SCD kidneys.MethodsCytokines gene expression was measured in 80 PIBx (SCD, 52; ECD, 28) and associated with donor variables.ResultsNormal histology and chronic histological lesions were not different between both types of kidneys. ECD kidneys showed significant increase in the transcripts of MCP-1, RANTES, TGF-β1, and IL-10 when compared with SCD. Kidneys presenting normal histology had similar inflammatory profile except by a higher expression of RANTES observed in ECD (P = 0.04). Interstitial fibrosis and tubular atrophy (interstitial fibrosis and tubular atrophy ≥ 1) were associated with higher expression of TGF-β1, RANTES, and IL-10 in ECD compared with SCD kidneys. Cold ischemia time of 24 hours or longer was significantly associated with upregulation of FOXP3, MCP-1, RANTES, and IL10, whereas longer duration of donor hospitalization significantly increased gene expression of all markers. High FOXP3 expression was also associated with lower level of serum creatinine at 1 year. Donor age was not associated with any of the transcripts studied.ConclusionsPIBx of ECD exhibit a higher gene expression of inflammatory cytokines when compared with SCD kidneys. This molecular profile may be a specific ECD kidney response to brain death and may help to predict the posttransplant outcomes of ECD recipients.

Kidney transplantation from donors with rhabdomyolysis and acute renal failure.

Rhabdomyolysis in deceased donors usually causes acute renal failure (ARF), which may be considered a contraindication for kidney transplantation. From January 2012 to December 2016, 30 kidneys from 15 deceased donors with severe rhabdomyolysis and ARF were accepted for transplantation at our center. The peak serum creatinine (SCr) kinase, myoglobin, and SCr of the these donors were 15569±8597U/L, 37092±42100μg/L, and 422±167μmol/L, respectively. Two donors received continuous renal replacement therapy due to anuria. Six kidneys exhibited a discolored appearance (from brown to glossy black) due to myoglobin casts. The kidney transplant results from the donors with rhabdomyolysis donors were compared with those of 90 renal grafts from standard criteria donors (SCD). The estimated glomerular filtration rate at 2years was similar between kidney transplants from donors with rhabdomyolysis and SCD (70.3±14.6mL/min/1.73m2 vs 72.3±15.1mL/min/1.73m2 ). We conclude that excellent graft function can be achieved from kidneys donors with ARF caused by rhabdomyolysis.

Pre-Procurement Donor Asystole Common in Intestine Donors

Introduction: Intestine transplantation has a high risk of post-transplant complications. For this reason, many intestine transplant centers are conservative in their choice of deceased donors, using only standard criteria donors. One reason to exclude a deceased donor intestine graft is because of donor asystole time. This paper reports the routine use of intestine and multivisceral grafts from deceased donors with prolonged asystole. Methods: The study reviewed the records of all intestine transplant patients from a single center from 2003 to 2015. All donor records were reviewed in detail. Donor asystole was recorded as donor “down time” which comprised the total cumulative number of minutes that the donor received chest compressions during resuscitation before stabilizing to proceed to organ procurement. Clinical graft outcomes included early graft loss and graft complications. Results: There were 246 transplants included in this study. There were 39% of donors overall with some asystole time recorded, 23% among adult and 62% among pediatric recipients (p<0.01). Asystole time ranged from 1 minute to 60 minutes (2 patients). Median donor age was 18 years. The median donor age decreased with increasing asystole time: 1–14 minutes, 18 years; 15–30 minutes, 15 years; and 30–60 minutes, 3 years. Among pediatric recipients, 22% of donors had asystole time more than 30 minutes. At 1-year post transplant, there was no difference in graft survival when stratified by donor asystole. There was also no difference in recipient length of hospital stay post-transplant. Conclusions: Donor asystole time alone should not be used to exclude the intestine or multivisceral graft from transplantation. At our center, there is an increased willingness to tolerate donor asystole time with decreasing donor age. Donor asystole is not associated with worse graft survival or longer hospital stay in pediatric or adult patients.

Long-Term Outcomes of Kidney Transplantation From Expanded-Criteria Deceased Donors: A Single-Center Experience

BackgroundOrgan shortage has prompted the use of expanded-criteria donors (ECDs). Our objective was to compare long-term outcomes of kidney transplants from ECDs with those from concurrent standard-criteria donors (SCDs). In addition, we evaluated variables associated with graft survival in both groups. MethodsWe retrospectively reviewed all 617 deceased-donor kidney transplantations performed from 2005 to 2009 in our department. The population was divided according to donor status into ECD or SCD. Patients were followed until 5 years after transplantation, death, graft failure, or loss to follow-up. ResultsWe transplanted 150 deceased-donor kidneys from ECDs and 467 from SCDs. ECD were older, more frequently women, had a lower pre-retrieval glomerular filtration rate, and more frequently died due to cerebrovascular accident. ECD recipients were older, presented a lower proportion of black race, more frequently were on hemodialysis, and presented a higher rate of first kidney transplants. Mean glomerular filtration rate was consistently lower in the ECD group. Patient and graft survivals were lower in the ECD group, but statistical significance was present only in graft survival censored for death with a functioning graft at 3 years and graft survival noncensored for death with a functioning graft at 5 years. Younger recipient ages, longer time on dialysis, acute rejection episodes, and glomerular filtration rate at 1 year after transplantation were independent risk factors for lower graft survival. ConclusionsTransplantation with the use of ECD kidneys provide quite satisfactory patient and graft survival rates despite their poorer long-term outcomes.