Improved Outcomes in Cadaveric Renal Allografts With Pulsatile Preservation.

Abstract

Background: Early immunologic and non‐immunologic injury of renal allografts adversely affects long‐term graft survival. Some degree of preservation injury is inevitable in cadaveric renal transplantation, and, with the reduction in early acute rejection, this non‐immunologic injury has assumed a greater relative importance. Optimal graft preservation will maximize the chances of early graft function and long‐term graft survival, but the best method of preservation – pulsatile perfusion (PP) versus cold storage (CS) – is debated. Methods: Primary cadaveric kidney recipients from January 1990 through December 1995 were evaluated. The effects of implantation warm ischemic time (WIT) (≤20 min, 21–40 min, or >40 min) and total ischemic time (TIT) (< or ≥20 h) on death‐censored graft survival were compared between kidneys preserved by PP versus those preserved by CS. The effect of preservation method on delayed graft function (DGF) was also examined. Results: There were 568 PP kidneys and 268 CS kidneys. Overall death‐censored graft survival was not significantly different between groups, despite worse donor and recipient characteristics in the PP group. CS kidneys with an implantation WIT >40 min had worse graft survival than those with <40 min (p=0.0004). Survival of PP kidneys and those transplanted into 2 DR‐matched recipients was not affected by longer implantation WIT. Longer TIT did not impact survival. DGF was more likely after CS preservation (20.2% versus 8.8%, p=0.001). Conclusions: Preservation with PP improves early graft function and lessens the adverse effect of increased warm ischemia in cadaveric renal transplantation. This method is likely associated with less preservation injury and/or increases the threshold for injury from other sources and is superior to CS.

Pulsatile Machine Perfusion With Vasosol Solution Improves Early Graft Function After Cadaveric Renal Transplantation

“…At 1 year posttransplant, only four grafts were lost in each group, reflecting 95% 1-year graft survival in each group. DISCUSSION MP is believed to improve early graft function compared with cold-stored kidneys and to permit extended preservation times with less risk of DGF (3)(4)(5). In addition to the vasomotor effects of pulsatile flow on the intrarenal arteriolar bed, other mechanistic factors leading to improved outcome have been suggested in MP kidneys, including promotion of integrity of the graft endothelium and attenuation of programmed cell death associated with mitochondrial membrane disruption.…”

“…In addition to the vasomotor effects of pulsatile flow on the intrarenal arteriolar bed, other mechanistic factors leading to improved outcome have been suggested in MP kidneys, including promotion of integrity of the graft endothelium and attenuation of programmed cell death associated with mitochondrial membrane disruption. Amelioration of theses injuries reduces both necrotic and apoptotic cell death with improvement in graft function after reperfusion, as evidenced by lower rates of DGF seen with MP in many series (3)(4)(5)(12)(13)(14). In large pooled data from the Organ Procurement and Transplantation Network database (2), the relative risk for DGF increased exponentially with increasing CIT in CS kidneys compared with a linear increase in kidneys undergoing MP.…”

“…Earlier randomized trials comparing CS and MP did not show a benefit for MP, whereas large registry data cautiously suggested an advantage for MP (2). The increased use of expanded criteria donors has lead to a renewed interest in ex vivo assessment and resuscitation of ischemically damaged organs, goals that are uniquely suited for MP (3)(4)(5)(6)(7)(8)(9)(10). Recent series have shown clear benefit to MP, especially in extended criteria donor kidneys (3)(4)(5)(6)(7).…”

“…The increased use of expanded criteria donors has lead to a renewed interest in ex vivo assessment and resuscitation of ischemically damaged organs, goals that are uniquely suited for MP (3)(4)(5)(6)(7)(8)(9)(10). Recent series have shown clear benefit to MP, especially in extended criteria donor kidneys (3)(4)(5)(6)(7). MP has several advantages: It (1) improves early function of renal allografts, (2) provides a delivery system for pharmacologic manipulation, and (3) permits real-time assessment of graft quality before transplantation.…”

Application of Machine Perfusion Preservation as a Viability Test for Marginal Kidney Graft

“…However, unlike the recipients with heart beating donor kidneys, recipients with NHBD experience a higher incidence of primary nonfunction and delayed graft function requiring postoperative hemodialysis (HD), prolonged hospitalization, and difficulties in the diagnosis of acute rejection. Ultimately, delayed graft function results in poorer long-term graft survival (1,2). Furthermore, primary nonfunction of kidney graft must be minimized as much as possible.…”