Hypothermic pulsatile preservation of kidneys from uncontrolled deceased donors after cardiac arrest - a retrospective study

Abstract

Kidneys from uncontrolled donors after cardiac arrest (uDCD) suffer from a period of warm ischemia between cardiac arrest and cold flushing. Aim of the study was to evaluate renal outcomes of uDCD kidneys selected on the basis of renal Resistance Index (RI) and its influence on graft function and survival. The study included 44 kidneys procured from 26 uDCD starting 1.1.2006 until 12.31.2013. The donors (Maastricht category II) underwent cardiopulmonary resuscitation by assisted ventilation and chest compression; the organs were preserved with in situ cold perfusion or a normothermic regional perfusion. All kidneys were perfused on hypothermic (1-4 °C) pulsatile perfusion machine (RM3; Waters Medical System) and discarded when RI ≥0.5 mmHg/ml/min after 6 h of perfusion. There was one (2.2%) primary non function, while 37 recipients (84.1%) experienced delayed graft function. Graft survival was 97.6% at 1 and 3 post-transplantation years. Linear regression models showed that lower values of RI at the end of perfusion were associated with higher values of Modification of Diet in Renal Disease at 3 (P = 0.049) and 6 months after transplantation (P = 0.010) and with higher values of inulin clearance at 1 year (P = 0.030). RI showed to be a useful tool to select uDCD kidneys allowing to achieve good clinical results.

Strict selection criteria in uncontrolled donation after circulatory death provide excellent long‐term kidney graft survival

“…This observation is identical to all previous studies where DGF was higher in uDCD compared with DBD kidney transplantation, [10][11][12][13][14]16,24 though this had apparently no effect on graft survival in most studies. [12][13][14] Nevertheless, DGF remains a marker of injury for the renal graft during the donation procedure and therefore it might be seen as a marker reflecting the efficacy of the preservation strategy.…”

“…The long-term kidney survival rate was identical in both groups and far better than what had been recorded in most publications. [10][11][12][13][14]16,24 In fact, uDCD donation was not a risk factor for graft loss in the multivariate analysis. The evolution of kidney function postoperatively was also excellent in kidneys transplanted with uDCD donors.…”

“…In fact, our WIT is the lowest of all largest series. [10][11][12][13][14]16,24 All of our kidneys had been preserved with NRP, which has already been associated with lower rates of PNF as compared to the use of continuous cold flush via an intra-abdominal double-balloon catheter. 9,13,16 Although our median uDCD donor age was similar to that of most published series, no donor over 60 years was included, which is known to be a risk factor for the PNF 13,15 In our study, recipients transplanted from uDCD donors tripled the probability of developing DGF in the multivariate analysis.…”

“…At all time points, P > .05 observed in our series (42%) was much lower than that previously documented. [10][11][12][13][14]16,24 We would like to emphasize again the need for strict admission criteria and the reduction of WIT. The Spanish Registry showed that 46% of kidneys transplanted from uDCD donors had a WIT >130 minutes 13 which is similar to the recent French experience (135 minutes).…”

“…8 In terms of the outcomes obtained using organs procured from uDCD donors, excellent long-term kidney graft survival has been reported from uDCD procedures. 9,10 However, there is still some reluctance toward the use of uDCD kidneys due to higher rate of primary nonfunction (PNF) [11][12][13] and increased incidence of delayed graft function (DGF). High kidney discard rates also remain a challenge that lower the conversion rates of potential into utilized donors.…”