End stage kidney disease increases the risk of COVID-19 related death but how the kidney replacement strategy should be adapted during the pandemic is unknown. Chronic hemodialysis makes social distancing difficult to achieve. Alternatively, kidney transplantation could increase the severity of COVID-19 due to therapeutic immunosuppression and contribute to saturation of intensive care units. For these reasons, kidney transplantation was suspended in France during the first epidemic wave. Here, we retrospectively evaluated this strategy by comparing the overall and COVID-19 related mortality in kidney transplant recipients and candidates over the last three years. Cross-interrogation of two national registries for the period 1 March and 1 June 2020, identified 275 deaths among the 42812 kidney transplant recipients and 144 deaths among the 16210 candidates. This represents an excess of deaths for both populations, as compared with the same period the two previous years. This difference was integrally explained by COVID-19, which caused the death of 44% of recipients and 42% of candidates. Taking into account the size of the two populations and the geographical heterogeneity of virus circulation, we found that the excess of risk of death due to COVID-19 was similar for recipients and candidates in high viral risk area but four-fold higher for candidates in the low viral risk area. Thus, in case of a second epidemic wave, kidney transplantation should be suspended in high viral risk areas but maintained outside those areas, both to reduce the excess of deaths of candidates and avoid wasting precious resources.
It has been suggested that dual kidney transplantation (DKT) improves outcomes for expanded criteria donor (ECD) kidneys. However, no criteria for allocation to single or dual transplantation have been assessed prospectively. The strategy of DKT remains underused and potentially eligible kidneys are frequently discarded. We prospectively compared 81 DKT and 70 single kidney transplant (SKT) receiving grafts from ECD donors aged >65 years, allocated according to donor estimated glomerular filtration rate (eGFR): DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min. Patient and graft survival were similar in the two groups. In the DKT group, 13/81 patients lost one of their two kidneys due to hemorrhage, arterial or venous thrombosis. Mean eGFR at month 12 was similar in the DKT and SKT groups (47.8 mL/min and 46.4 mL/min, respectively). Simulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to our allocation based on donor eGFR.
Background. The French uncontrolled donors after circulatory death (DCD) protocol restricts donor age to <55 years, no-flow time to <30 minutes, and functional warm ischemia time to <150 minutes. In situ kidney perfusion can be performed at either 4°C (in situ cooling [ISC]) or 33–36°C (normothermic regional perfusion [NRP]). Hypothermic machine perfusion is systematically used. Only nonimmunized first transplant recipients were eligible. To improve the management of uncontrolled DCD, we tried to identify factors predictive of outcome. Methods. We identified all kidney transplants from uncontrolled DCD between 2007 and 2014 from the French Transplant Registry. Risk factors for primary nonfunction (PNF; n = 37) and poor renal function (estimated glomerular filtration rate < 30 mL/min or graft loss at 1 y, n = 66) were analyzed by using a multivariate logistic model. Results. This study analyzed 499 kidney transplantations, 50% of which were performed with NRP. Mean functional warm ischemia time was 135 minutes. Mean cold ischemia time was 14 hours. The principal PNF risk factor was young donor age (odds ratio [OR] = 0.95; P = 0.002). A sensitivity analysis showed a higher risk of PNF with ISC than with NRP (OR = 4.5; P = 0.015). Risk factors for poor renal function were donor body mass index (OR = 1.2; P < 0.001) and ISC versus NRP. Univariate analysis of uncontrolled DCD–specific risk factors showed no-flow time, functional warm time, and cold ischemia time did not affect the risk of PNF or poor renal function. Conclusions. Uncontrolled DCD kidneys are an additional source of valuable transplants. NRP appears to decrease graft failure by restoring oxygenated blood as the first step of preconditioning.
In elderly patients, transplantation with an ECD kidney was associated with higher survival rates than remaining on the waiting list. This result suggests that the identification and use of ECD kidney grafts should be optimized, given changes in the characteristics of potential donors and recipients.
Transplanted children, particularly girls and patients with low parental educational levels, require optimized educational, psychologic, and social support to reach the educational level of their peers. This support should be maintained during adulthood to help them integrate into the working population and build a family.
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