Missed opportunities for DCD kidney donors: Evaluation of warm ischemic time and associated functional warm ischemic time

Abstract

Introduction: Many transplant centers utilize a hard cutoff of 2 hours of warm ischemic time (WIT), defined as the time from withdrawal of life-sustaining measures to cold organ flush, to exclude donation after circulatory determination of death (DCD) kidney donation. As a result, almost a quarter of withdrawals to retrieve DCD organs fail to produce kidney transplants in Ontario. In order to assess our ability to increase organ yield, we wanted to characterize WIT and functional WIT (fWIT, time from systolic blood pressure <50 mm Hg to cold organ flush), as well as determine the time at which potential donors eventually die in those that did not become organ donors. Results:Of 350 DCD kidney donors analyzed, 46.9% had < 0.5 hours, 51.7% between 0.5 and 2 hours, and 1.4% >2 hours of WIT. In each of these categories (WIT <0.5 hours, 0.5-2 hours and >2 hours), the percentage of patients with fWIT <30 minutes was 100%, 94.4%, and 100%, respectively (P = NS). There were 106 potential donors who did not end up donating due to WIT >2 hours. Of these, 20.8% died between 2 and 4 hours, 10.4% between 4 and 6 hours, and 68.8% beyond 6 hours. Discussion:The percentage of donors with fWIT >30 minutes did not increase with increasing WIT in DCD donors that went on to donate organs. These data support assessment of waiting up to 4 hours for DCD kidney donation as long as fWIT remains low. K E Y W O R D Sdonation after circulatory determination of death, functional warm ischemic time, kidney transplantation, renal transplantation, warm ischemic time

Trajectories of Systolic Blood Pressure Decline in Kidney Donors After Circulatory Death and Delayed Graft Function

“…This novel nding differs from previous investigations, which reported a longer duration of functional warm ischemia, de ned as the rst recorded time of systolic BP less than 50 mmHg to cold perfusion, was associated with slow graft function, and premature graft loss in DCD kidneys 15 . Prior work have indicated that a longer agonal time was associated with a signi cantly increased risk of DGF and primary non-function by 50% 16 , particularly in donors where the duration of systolic BP less than 80 mmHg exceeded 20 minutes before cold perfusion, with this effect more apparent in younger donors (aged < 40 years) 5 .…”

DCD Renal Transplantation From Donors With Acute Kidney Injury

“…Recent study, however, demonstrates that the warm ischemic time has significant effects on DCD graft function. 19,20 When offered kidneys, it is important to consider just how dangerous it is to remain on the waitlist, waiting for a kidney. The overall 5-year survival rate for end-stage renal disease patients is 35%.…”

Kidney utilization in the Netherlands – do we optimally use our donor organs?

“…Around 20% of all potential DCD kidneys were never retrieved because the donor's agonal phase exceeded the 2-h national upper limit set for kidney donation. A Canadian retrospective study showed that 21% of potential DCD donors who did not end up donating due to an agonal phase >2 h did sustain cardiocirculatory arrest between 2 and 4 h after withdrawal of treatment [ 19 ]. The acceptable maximum duration of the agonal phase is still under debate, but several studies support a waiting time of up to 4 h for DCD kidney donation.…”