Kidney transplantation with donors in severe acute kidney injury. Should we use these organs? Retrospective Case Series

Abstract

Introduction: The number of incident and prevalent patients on dialysis has increased, as well as the number of candidates for renal transplantation in Brazil, without a proportional increase in the number of organ donors. The use of expanded kidneys, as to renal function, may be an alternative to increase the supply of organs. Objective: to discuss the feasibility of using expanded kidneys for renal function, which are in severe acute renal injury. Methods: All cases of renal transplantation of deceased donors performed at the Hospital das Clínicas de Botucatu of UNESP, from January 2010 to June 2018, totaling 732 cases were evaluated. Cases with final donor creatinine greater than 6 mg/dL were selected. Results: four patients were selected, of whom all donors were in severe acute kidney injury (AKI). These donors presented rhabdomyolysis as a probable cause of severe AKI, were young, with no comorbidities and had decreased urinary volume in the last 24 hours. The clinical evolution of all the recipients was satisfactory, with a glomerular filtration rate after transplantation ranging from 48 to 98 mL/min/1.73 m2. Conclusion: this series of cases shows the possibility of using renal donors in severe AKI, provided the following are respected: donor age, rhabdomyolysis as the cause of AKI, and implantation-favorable biopsy findings. Additional studies with better designs, larger numbers of patients and longer follow-up times are needed.

Donor rhabdomyolysis, acute kidney injury, and kidney transplant outcomes

“…Our findings of an absence of effect of CPK and AKI on shortterm graft survival aligns with 6 prior small case series [6][7][8][9][10]12 and one between-group study from China. 11 However, these previous studies found 100% graft survival among KTX recipients of high-CPK kidneys with AKI (Table 1), possibly representing negative reporting bias.…”

“…In terms of graft function, we found favorable 1‐year eGFR between high and low CPK groups and no significant effect by the combination of high CPK and AKI. Our findings concur with prior studies where graft functional parameters at 1–2 years follow‐up were consistently excellent 6–8,10–12 . Since 1‐year eGFR is highly correlated and predictive of long‐term graft function, 22 long‐term graft survival will likely be acceptable; however, further research is needed to confirm this.…”

“…Prior studies have reported delayed graft function occurrence as high as 100% among patients with rhabdomyolysis and AKI. [6][7][8][9][10][11][12] The increased initial burden of care and morbidity associated with DGF may preclude some centers from accepting kidneys at risk for DGF, and the close relationship between rhabdomyolysis and AKI may compound this perceived risk.…”

“…In these studies, graft function was reported to be acceptable; however, most were small case series with a paucity of data from donors with extreme CPK levels, and the potential additive effect of AKI was not examined (Table 1). [6][7][8][9][10][11][12] As such, the question remains as to whether a threshold level of CPK precludes transplantation and whether the effect of rhabdomyolysis is different with or without AKI.…”

Viability assessment and utilization of declined donor kidneys with rhabdomyolysis using ex vivo normothermic perfusion without preimplantation biopsy

“…There are limited data on the outcomes of kidneys transplanted from deceased donors with AKI due to rhabdomyolysis. DGF is common, however, long‐term graft outcomes have been reported to be acceptable 14‐16 . Although preimplantation histological analysis may aid the decision‐making process, in many transplant centers, the resources are not in place to routinely perform preimplantation analysis.…”