Kidney Transplant From Uncontrolled Donation After Circulatory Death: Contribution of Normothermic Regional Perfusion

Abstract

Background. The French uncontrolled donors after circulatory death (DCD) protocol restricts donor age to <55 years, no-flow time to <30 minutes, and functional warm ischemia time to <150 minutes. In situ kidney perfusion can be performed at either 4°C (in situ cooling [ISC]) or 33–36°C (normothermic regional perfusion [NRP]). Hypothermic machine perfusion is systematically used. Only nonimmunized first transplant recipients were eligible. To improve the management of uncontrolled DCD, we tried to identify factors predictive of outcome. Methods. We identified all kidney transplants from uncontrolled DCD between 2007 and 2014 from the French Transplant Registry. Risk factors for primary nonfunction (PNF; n = 37) and poor renal function (estimated glomerular filtration rate < 30 mL/min or graft loss at 1 y, n = 66) were analyzed by using a multivariate logistic model. Results. This study analyzed 499 kidney transplantations, 50% of which were performed with NRP. Mean functional warm ischemia time was 135 minutes. Mean cold ischemia time was 14 hours. The principal PNF risk factor was young donor age (odds ratio [OR] = 0.95; P = 0.002). A sensitivity analysis showed a higher risk of PNF with ISC than with NRP (OR = 4.5; P = 0.015). Risk factors for poor renal function were donor body mass index (OR = 1.2; P < 0.001) and ISC versus NRP. Univariate analysis of uncontrolled DCD–specific risk factors showed no-flow time, functional warm time, and cold ischemia time did not affect the risk of PNF or poor renal function. Conclusions. Uncontrolled DCD kidneys are an additional source of valuable transplants. NRP appears to decrease graft failure by restoring oxygenated blood as the first step of preconditioning.

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.…”

“…PNF is the main concern in uDCD kidney transplantation with a reported incidence ranging from 1.8% to 20% in the largest series. [11][12][13][14]16,25 Several factors such as donor age, prolonged WIT, or in situ cooling as preservation method have been related to high rates of PNF. 12,13,16 The primary reasons for our excellent results are most likely the strict admission criteria, keeping intrahospital logistics as simple as possible to minimize the WIT.…”

“…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.…”

“…14,15 Several factors such as donor age, the duration of the no-flow period, prolonged warm ischemic time (WIT), and the type of preservation have been linked to higher rates of PNF and graft loss. 13,15,16 Hence, a very restrictive protocol and strict adherence to national guidelines seems to be the best option to achieve an excellent longterm graft survival in order to fully exploit the potential contribution of uDCD to donation and transplantation activities.…”

Ethical and logistical concerns for establishing NRP-cDCD heart transplantation in the United States

“…NRP use might reduce the incidence of ischemic hepatic cholangiopathy in DCD livers . DCD kidneys placed on NRP have demonstrated graft survival equivalent to DBD and had earlier recovery of graft function when compared to standard DCD in situ cold perfusion preservation . NRP‐facilitated multiorgan procurements have already been performed in the United Kingdom demonstrating higher recovery rates compared to standard cDCD .…”