Expanding the donor pool: use of renal transplants from non‐heart‐beating donors supported with extracorporeal membrane oxygenation

Abstract

In response to organ shortage, we used the renal grafts from non-heart-beating donors (NHBDs). Extracorporeal membrane oxygenation (ECMO) was used to maintain NHBDs before organ procurement. We compared the results of renal transplantation from different donors, including heart-beating donors (HBDs), living-related donors (LDs), and NHBDs supported with ECMO. From February 1998 to June 2003, we recruited 219 patients receiving renal transplantation at National Taiwan University Hospital. Among them, 31 received kidneys from NHBDs supported with ECMO, 120 from HBDs, and 68 from LDs. Multiple organ transplant recipients were not included in this study. We compared the graft survival, serum creatinine levels, and estimated glomerular filtration rates of the three groups. The rate of delayed graft function was higher in NHBD recipients (41.9%) than in HBD recipients (27.0%) and LD recipients (10.9%) (p = 0.003). In the NHBD group, the recipients of grafts with delayed function had significantly longer ECMO runs (63.1 +/- 3.0 min) than those without delayed function (53.7 +/- 2.5 min) (p = 0.024). Estimated glomerular filtration rate (p = 0.472) and mean serum creatinine level (p = 0.286) were not significantly different between the three groups using a longitudinal approach. The 5-yr graft survival rates for NHBD (88.4%, 95% CI: 0.680-0.962), HBD (83.2%, 95% CI: 0.728-0.899), and LD transplant recipients (89.3%, 95% CI: 0.619-0.974) were not significantly different (p = 0.239). The 5-yr patient survival rates for NHBD, HBD, and LD transplant recipients were 100, 93.0 (95% CI: 0.859-0.966) and 100% respectively. The long-term allograft survival and function of kidneys from NHBDs supported by ECMO, HBD, and LD did not differ significantly. Long ECMO running time tended to delay graft function.

Outcome of Kidney Transplantation From Nonheart-Beating Versus Heart-Beating Cadaveric Donors

“…Eight studies (10 -12, 14, 17, 18, 21, 24) reported in situ cooling as the method of kidney preservation. Lee et al (16) used extracorporeal membrane oxygenation to decrease warm ischemic injury to the kidneys. Pokorny et al (19) did not have the need for in situ flush because of different legislation, which allowed them to proceed with renal procurement as soon as cardiac death was established.…”

Cold Ischaemic Injury in Kidney Transplantation

“…The incidence of DGF and PNF was reduced after normothermic recirculation compared to standard in situ or total body cooling. Gravel et al described a DGF rate of 11% in controlled DCD donors [92] and Lee et al found similar 5 year graft survival rates to DBD and living donors [93]. Maintaining circulation before retrieval is thought to condition the organs by up-regulating adenosine receptors which may protect against preservation injury [91].…”

Ethical Issues in the Use of Extracorporeal Membrane Oxygenation in Controlled Donation After Circulatory Determination of Death

“…Similarly, in the Henry Ford Health System (11) and at Wake Forest University (2), ECMO cannulas are inserted premortem, after informed consent. At National Taiwan University Hospital, the insertion of ECMO cannulas is conducted postmortem (9), with no mention of the requirement for informed consent.…”

“…Only a few cDCDD centers, however, have reported the use of extracorporeal membrane oxygenation (ECMO) to improve future graft outcome, including National Taiwan University Hospital, Taiwan (9); the University of Michigan, Ann Arbor, Michigan (10); the Henry Ford Health System, Detroit, Michigan (11); Wake Forest University, WinstonSalem, North Carolina (2); and three centers (Cambridge, Birmingham, and Edinburgh) in the United Kingdom (12).…”