Are We Frozen in Time? Analysis of the Utilization and Efficacy of Pulsatile Perfusion in Renal Transplantation

Abstract

Preservation techniques are crucial to deceased donor kidney transplantation (DDTx), but the efficacy of pulsatile perfusion (PP) versus cold storage (CS) remains uncertain. We describe patterns of PP use and explore four fundamental questions. What kidneys are selected for PP? How does PP affect utilization of donated kidneys? What effect does PP have on outcomes? When does PP appear to be most efficacious? We examined rates of PP in DDTx in the United States from 1994 to 2003. We generated models for organ utilization, delayed graft function (DGF) and for the use of PP. We analyzed the long-term effect of PP with multivariate Cox models. The utilization rates for nonexpanded criteria donors (ECDs) were similar by storage type, but for ECDs there was a significantly higher utilization rate with PP (70% with PP vs. 59% with CS, p < 0.001). Use of PP was widely variable across transplant centers. DGF rates were significantly lower with PP (27.6% vs. 19.6%). PP was associated with a mild benefit on death censored graft survival (adjusted hazard ratio = 0.88, 95% CI 0.85-0.91). Reduced DGF and significantly lower discard rates of ECDs associated with PP suggest an important utility of PP in renal transplantation. Additional evidence of improvement in graft survival, particularly in more recent years, provides further encouraging evidence for the use of PP.

Which Renal Transplant Candidates Should Accept Marginal Kidneys in Exchange for a Shorter Waiting Time on Dialysis?

“…This suggests a relatively equivalent magnitude of patients who may benefit from altering their therapeutic course associated with the timing and type of transplant while potentially extending long-term outcomes. Furthermore, the rate of organ discard for ECD kidneys, although improving, remains substantial, and further identification of potential recipients of ECD kidneys may have a marked effect on broadening the use of viable organs (21,22). A similar model, aimed at increasing the utilization of older donors and reducing waiting time for older recipients, is already being used in the voluntary Eurotransplant Senior Program (23).…”

Pulsatile Perfusion Reduces the Incidence of Delayed Graft Function in Expanded Criteria Donor Kidney Transplantation

“…This is the definition of DGF used by many papers comparing PP and CS (6)(7)(8)(9)(10)(14)(15)(16). However, this definition overestimates the true incidence of DGF, because it includes patients who underwent dialysis following transplantation for reasons such as electrolyte imbalances, vascular thrombosis, ureteral obstruction, etc.…”

“…There have been numerous studies comparing PP to cold storage (CS) in donor kidneys (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Early studies claimed there was no advantage of PP, finding no significant differences in DGF or graft survival between PP and CS (10,11,13).…”

Identifying Potential Kidney Donors Among Newborns Undergoing Circulatory Determination of Death

“…23 It also notably improves outcomes by decreasing the prevalence of delayed graft function. 24,25 Because prolonged cold ischemic time (up to 48 hours) is widely accepted, en bloc kidneys procured from donor newborns can be transported easily to specialized centers willing to transplant these small organs. Thus, implementation of NICU DCDD programs nationwide could feasibly provide donor kidneys for selected transplant centers even if local or regional programs elect not to transplant kidneys from infant donors.…”