Donation after Cardiac Death Kidneys with Low Severity Pre-Arrest Acute Renal Failure

Abstract

The widening gap between supply and demand for renal transplantation has prompted many centers to use donors after cardiac death. Some of these donors exhibit signs of acute renal failure (ARF) prior to cardiac arrest. Concern has been expressed about poor quality of graft function from such donors. In response to this perception, we reviewed 49 single renal transplant recipients from category III donors after cardiac death between 1998 and 2005, at out center. All kidneys but one had hypothermic machine perfusion and viability testing prior to transplantation. According to the RIFLE criteria, nine recipients had kidneys from donors with "low severity pre-arrest ARF". The remainder of the recipients were used as control group. There was no statistical significant difference in delayed graft function and rejection rates between these two groups. Recipients GFR at 12 months was 44.4 ± 17.1 and 45.2 ± 14.7 (mL/min/1.73m2 ) from donors with ARF and without ARF, respectively (p = 0.96). In conclusion, low severity ARF in kidneys from controlled after cardiac death donors can be a reversible condition after transplantation. Short-term results are comparable to the kidneys from same category donors without renal failure, providing that some form of viability assessment is implemented prior to transplantation.

Is prolonged cold ischemia a contraindication to using kidneys from acute kidney injury donors?

“…Recent expansion of deceased donors have been due to increased utilization of “marginal” kidneys procured from ECD, DCD, and AKI donors . Unfortunately, with liberalization of deceased donor criteria, the number of kidneys recovered with the intent to transplant and then ultimately discarded each year has nearly doubled .…”

“…Although regional and national sharing may provide the opportunity to place these kidneys at centers that are willing to transplant them, longer CIT may become a confounding factor. Both longer CIT and elevated terminal donor SCr have been identified in the past as strong independent risk factors for reduced graft survival and DGF . Until recently, the combined effect of these aggravating factors was believed to be a valid reason for kidney discard.…”

“…To increase the size of the pool of donors, initiatives such as the Organ Donor Breakthrough Collaborative and other national initiatives were implemented. As a result of these endeavors, an upturn in the number of “marginal” donors such as expanded criteria donors (ECD), donation after cardiac death (DCD) donors, high‐risk behavioral donors, donors with prolonged warm or cold ischemia time (CIT), dual kidneys from donors at the extremes of age, or donors with acute kidney injury (AKI) occurred . Commensurate with efforts to enlarge the donor pool and with changes in the Kidney Allocation System (KAS) including implementation of the Kidney Donor Profile Index (KDPI), the kidney discard rate increased from 10% in 1998 to 20% in 2015 .…”

Kidney donation after cardiac death

“…There was no statistically significant difference in delayed graft function (DGF) and rejection rates between the two groups. Sohrabi et al [32] concluded that low severity ARF in kidneys from controlled DCD can be a reversible condition after transplantation. It is noteworthy that all but one of those kidneys had hypothermic machine perfusion and viability testing prior to transplantation.…”

“…The major concern with such donors is about the expected poor quality of graft function. Sohrabi et al [32] reviewed 49 single renal transplant recipients from category Ⅲ donors after cardiac death between 1998 and 2005, at Newcastle, United Kingdom. According to the RIFLE criteria (risk, injury, failure, loss and end stage renal disease) [33] , nine of these recipients had kidneys from donors with "low severity pre-arrest ARF".…”