Baseline Donor Chronic Renal Injury Confers the Same Transplant Survival Disadvantage for DCD and DBD Kidneys

Abstract

Histological assessment of baseline chronic kidney injury may discriminate kidneys that are suitable for transplantation, but has not been validated for appraisal of donation after circulatory death (DCD) kidneys. 'Time-zero' biopsies for 371 consecutive, solitary, deceased-donor kidneys transplanted at our center between 2006 and 2010 (65.5% DCD, 34.5% donation after brain death [DBD]) were reviewed and baseline chronic degenerative injury scored using Remuzzi's classification. High scores correlated with donor age and extended criteria donors (42% of donors), but the spectrum of scores was similar for DCD and DBD kidneys. Transplant outcomes for kidneys scoring from 0 to 4 were comparable (1 and 3 year graft survival 95% and 92%), but were much poorer for kidneys scoring !5, with 1 year graft survival only 73%, and 12.5% suffering primary nonfunction. Critically, high Remuzzi scores conferred the same survival disadvantage for DCD and DBD kidneys. On multi-variable regression analysis, time-zero biopsy score was the only independent predictor for graft survival, whereas one-year graft estimated glomerular filtration rate (eGFR) correlated with donor age and biopsy score. In conclusion, the relationship between severity of chronic kidney injury and transplant outcome is similar for DCD and DBD kidneys. Kidneys with Remuzzi scores of 4 can be implanted singly with acceptable results.

Successful Transplantation of Kidneys From Elderly Circulatory Death Donors by Using Microscopic and Macroscopic Characteristics to Guide Single or Dual Implantation

“…Biopsies were placed in formalin at the recovery of organ, prior to fixation in paraffin and graded according to the Remuzzi scoring system by consultant histopathologists, as described previously (7). Remuzzi proposed that kidneys with a score of 4-6 are implanted as a dual transplant (11), but in agreement with Fernandez-Lorente et al (12), analysis of our data suggests that kidneys with Remuzzi scores of 4 or less can be implanted singly with reasonable expectations of satisfactory outcomes (13). Thus, kidneys with scores of 4 were generally considered for single implantation, but this was influenced by other factors, such as consideration of the technical aspects of performing a dual transplant on a particular recipient and macroscopic appearance of the kidney; particularly severity of aortic patch and renal artery atherosclerosis, quality of perfusion and presence of kidney scaring.…”

“…Similarly, several dual implants were performed in our series using kidneys that could perhaps have provided satisfactory function and adequate outcomes if they had been transplanted singly. A cut-off value of a Remuzzi score of 4 that identifies kidneys to be implanted as a dual transplant has been questioned (12), and our analysis of the impact of Remuzzi scores on outcomes for all DCD kidney transplants suggests that kidneys with scores less than 5 can be implanted safely singly (13). Using this cut-off value, nine kidneys of the dual implant group could have theoretically been implanted singly, albeit in five of these, the partner kidney of the pair scored greater than 4, and it was, therefore, decided to implant the two kidneys together.…”

Donor Hemodynamics as a Predictor of Outcomes After Kidney Transplantation From Donors After Cardiac Death

“…Given that use of kidneys recovered from older DCD donors is expanding, determining predictors of graft failure in this cohort is of increasing importance (20)(21)(22)(23). Although studies have indicated that kidneys from older donors may be more vulnerable to injury during warm ischemia, other data suggest otherwise (12,18,24). Singh et al evaluated expanded criteria donor (ECD) status as an effect modifier of the association between DCD status and recipient outcome and found that combined DCD/ECD kidneys had survival comparable to DCD/non-ECD kidneys (12).…”

“…These results suggest that warm ischemia might not interact with other marginal donor characteristics, leading to worse outcomes; however, KDRI scores suggested DCD/ECD kidneys were selected for optimal characteristics, potentially masking interaction between DCD organ characteristics and donor age. Other studies also indicated that kidneys from older DCD donors do not lead to worse outcomes, at least when compared with those from brain-dead donors (18,24). Importantly, these studies were not designed to evaluate the importance of DWI variability among donors.…”

The influence of warm ischemia elimination on kidney injury during transplantation – clinical and molecular study

“…The most deleterious effect was described for donor age1, while the length and type of ischemia seem to be crucial after organ retrieval. Cold ischemia time (CIT) has been widely reported to affect renal allograft survival and function2.…”