Machine perfusion use for combined staged kidney transplantation after heart re‐transplantation: keep calm and stabilize the recipient!

Hypothermic machine perfusion can safely prolong cold ischemia time in deceased donor kidney transplantation. A retrospective analysis on postoperative morbidity and graft function

“…Of course, minimizing the CIT time is still a key point for reducing the risk of DGF or other cold ischemia complications, 5,7 but there are several clinical circumstances in which such strategy may not be applicable. 12,13,[21][22][23] Distant organ procurement, delay in pathological examination response on scoring of ECD kidney grafts, combined liver-kidney or heart-kidney transplantation, or necessity of pre-KT dialysis, are all examples that belong to the routine clinical practice. The present study provided some new encouraging insight, but we hope that it will also trigger further analysis.…”

“…Nonetheless, the present findings as well as the pragmatic analysis of previously reported results from large clinical series or randomized trials do actually support the safety of using HMP to extend the CIT time, without any significant additional risk. Of course, minimizing the CIT time is still a key point for reducing the risk of DGF or other cold ischemia complications, 5,7 but there are several clinical circumstances in which such strategy may not be applicable 12,13,21‐23 . Distant organ procurement, delay in pathological examination response on scoring of ECD kidney grafts, combined liver‐kidney or heart‐kidney transplantation, or necessity of pre‐KT dialysis, are all examples that belong to the routine clinical practice.…”

“…[9][10][11] Even in combined liver-kidney or heart-kidney transplantation, a delayed kidney procedure has been recently advocated, aiming at stabilizing the recipient after the first organ implant and protecting the kidney graft from hemodynamic instability. 12,13 In these settings, the extension of CIT has been usually conditioned to the use of HMP, although the safety profile of this management has not been clearly and extensively demonstrated so far. Beside the cold ischemic injury and inherent risk of DGF, keeping the graft under prolonged HMP might potentially expose it to bacterial contamination or may increase the risk of vascular complications due to some endothelial injury caused by the shear stress of pulsatile cold perfusion.…”

“…However, in recent years, the prevalence of KT candidates with multiple comorbidities or advanced age has been increasing, and their pretransplant preparation may be complex and time‐consuming 9‐11 . Even in combined liver‐kidney or heart‐kidney transplantation, a delayed kidney procedure has been recently advocated, aiming at stabilizing the recipient after the first organ implant and protecting the kidney graft from hemodynamic instability 12,13 . In these settings, the extension of CIT has been usually conditioned to the use of HMP, although the safety profile of this management has not been clearly and extensively demonstrated so far.…”

Overcoming challenges in patient selection and monitoring in combined heart and kidney transplantation

“…On the one hand, this observation suggests that performing HKT in candidates who are not dialysis dependent, and with previous sternotomy, may lead to an inappropriate utilisation of kidneys, harming waiting times of patients listed for kidney transplant only. On the other hand, approaches considering a delayed kidney transplant by means of kidney machine perfusion may be a potential solution in surgically complex heart transplant settings [16 ▪ ], in view of the improved outcomes of kidney graft function demonstrated in the context of combined liver-kidney transplant [17]. This strategy permits a delay of kidney transplant for several hours, allowing both for the patient to stabilise after the first graft is implanted, and for a potential reallocation of kidney to a back-up recipient if the combined transplant candidate is unstable.…”