Optimizing utilization of kidneys from deceased donors over 60 years: Five-year outcomes after implementation of a combined clinical and histological allocation algorithm

Sefora, Pierobon Elisa; Sandrini, Silvio; Nicola, De Fazio; Rossini, Gian Paolo; Fontana, I.; Boschiero, Luigino; Gropuzzo, M; Eliana, Gotti; Donato, Daniel; Minetti, Enrico; Teresa, Gandolfo Maria; Brunello, Anna; Carmelo, Libetta; Secchi, Antonio; Chiaramonte, S; Rigotti, Paolo

doi:10.1111/tri.12135

Cited by 38 publications

(24 citation statements)

References 27 publications

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“…Others have also shown equal survival of SKT and DKT from donors in the same age ranges (i.e., 60–69 and 70–79) [ 28 ]. Equal outcome with worst graft histology is commonly assumed to support the validity of DKT allocation by score [ 8 , 14 , 28 ]; contrary to this assumption are reports of good outcome of grafts with bad preimplantation biopsy, which would have indicated DKT according to the NITp protocol and are allocated to SKT without knowledge of biopsy data ([ 12 , 13 , 29 ] and personal data). We show here that allocation to SKT without biopsy of grafts from high-risk, older than 70 years, donors achieves similar survival than DKT from equally comorbid donors, provided that clinical suitability is carefully sought.…”

Section: Discussionmentioning

confidence: 99%

“…The DKT program in our Centre complies with a protocol of the NITp, our interregional transplant agency [ 8 ], where it is publicly registered [ 16 , 17 ]; the following definitions are in use.…”

Section: Methodsmentioning

confidence: 99%

“…In our Renal Transplant Area (Nord Italia Transplant program, NITp), comprising 6 Northern Italy regions with a total of about 19 million inhabitants, a protocol for allocation of grafts from elderly donors to DKT or SKT according to biopsy indication has been available as an option to expand donor pool since early 2000s [ 8 ]. Our Centre joined the NITp DKT program in 2010; before that date, only SKT was considered for any donor, irrespective of age, provided that renal function and anatomy were permissive.…”

Section: Introductionmentioning

confidence: 99%

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Renal Transplants from Older Deceased Donors: Use of Preimplantation Biopsy and Differential Allocation to Dual or Single Kidney Transplant according to Histological Score Has No Advantages over Allocation to Single Kidney Transplant by Simple Clinical Indication

Casati¹,

Colombo²,

Perrino³

et al. 2018

Journal of Transplantation

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Background Grafts from elderly donors (ECD) are increasingly allocated to single (SKT) or dual (DKT) kidney transplantation according to biopsy score. Indications and benefits of either procedure lack universal agreement. Methods A total of 302 ECD-transplants in period from Jan 1, 2000, to Dec 31, 2015, were allocated to SKT (SKTpre) on clinical grounds alone (before Dec 2010, pre-DKT era, n = 170) or according to a clinical-histological protocol (after Dec 2010, DKT era, n = 132) to DKT (n = 48), SKT biopsy-based protocol (“high-risk”, SKThr, n = 51), or SKT clinically based protocol (“low-risk”, SKTlr, n = 33). Graft and patient survival were compared between the two periods and between different transplant categories. Results Graft and overall survival in recipients from ECD in pre-DKT and DKT era did not differ (5-year graft survival 87.7% and 84.2%, resp.); equal survival in the 2 ECD periods was shown in both donor age ranges of 60–69 and >70-years, and in low-risk or high-risk ECD categories. Within the DKT protocol SKThr showed worst graft and overall survival in the 60–69 donor age range; DKT did not result in significantly better outcome than SKT from ECD in either era. One-year posttransplant creatinine clearance in recipients did not differ between any ECD transplant category. At 3 and 5 years after transplantation there were significantly higher total dialysis-free recipient life years from an equal donor number in the pre-DKT era than in the DKT protocol. Conclusions Use of a biopsy-based protocol to allocate grafts from aged donors to SKT or DKT did not result in better short term graft survival than a clinically based protocol with allocation only to SKT and reduced overall recipient dialysis-free life years in time.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Renal Transplants from Older Deceased Donors: Use of Preimplantation Biopsy and Differential Allocation to Dual or Single Kidney Transplant according to Histological Score Has No Advantages over Allocation to Single Kidney Transplant by Simple Clinical Indication

Casati¹,

Colombo²,

Perrino³

et al. 2018

Journal of Transplantation

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“…In other countries, primarily Italy, the standardized assessment of a pre-transplant formalin-fixed biopsy is the key criterion by which the allocation of marginal donor organs is determined. It serves to establish which kidneys should be discarded or accepted, but also which kidneys should be allocated for dual transplantation [ 45 ]. Suitable kidneys from donors aged 65 years or above can be allocated to younger donors, within pre-defined limits of donor–recipient age difference (e.g.…”

Section: Strategies For Expanding the Deceased-donor Poolmentioning

confidence: 99%

Strategies to increase the donor pool and access to kidney transplantation: an international perspective

Maggiore¹,

Oberbauer²,

Pascual³

et al. 2014

Nephrology Dialysis Transplantation

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In this position article, DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) board members describe the current strategies aimed at expanding living and deceased donor kidney pools. The article focuses on the recent progress in desensitization and kidney paired exchange programmes and on the expanded criteria for the use of donor kidneys and organs from donors after circulatory death. It also highlights differences in policies and practices across different regions with special regard to European Union countries. Living donor kidney paired exchange, the deceased donor Acceptable Mismatch Programme and kidneys from donors after circulatory death are probably the most promising innovations for expanding kidney transplantation in Europe over the coming decade. To maximize success, an effort is needed to standardize transplant strategies, policies and legislation across European countries.

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“…In some countries (among which Italy), dual (DKT) rather than single kidney transplantation (SKT) from ECD has gained popularity as a means of limiting elderly organ discard[ 11 - 15 ]; a simplistic rational is that quantity of functioning nephrons in one kidney from elderly donors may be insufficient to sustain adequate function in recipients, while double such a quantity may provide adequate compensation. Moreover organ senescence and age-related pathology might also benefit from doubling tissue mass.…”

Section: Introductionmentioning

confidence: 99%

Renal transplants from older deceased donors: Is pre-implantation biopsy useful? A monocentric observational clinical study

Colussi¹,

Casati²,

Colombo³

et al. 2018

WJT

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AIMTo compare survival of kidney transplants from deceased extended criteria donors (ECD) according to: (1) donor graft histological score; and (2) allocation of high score grafts either to single (SKT) or dual (DKT) transplant.METHODSRenal biopsy was performed as part of either a newly adopted DKT protocol, or of surveillance protocol in the past. A total 185 ECD graft recipients were categorized according to pre-implantation graft biopsy into 3 groups: SKT with graft score 1 to 4 [SKT(1-4), n = 102]; SKT with donor graft score 5 to 8 [SKT(> 4), n = 30]; DKT with donor graft score 5 to 7 (DKT, n = 53). Graft and patient survival were analyzed by Kaplan-Meier curves and compared by log-rank test. Mean number of functioning graft years by transplant reference, and mean number of dialysis-free life years by donor reference in recipients were also calculated at 1, 3 and 6 years from transplantation.RESULTSThere were no statistically significant differences in graft and patient survival between SKT(1-4) and SKT(> 4), and between SKT(> 4) and DKT. Recipient renal function (plasma creatinine and creatinine clearance) at 1 years did not differ in SKT(1-4) and SKT(> 4) (plasma creatinine 1.71 ± 0.69 and 1.69 ± 0.63 mg/dL; creatinine clearance 49.6 + 18.5 and 52.6 + 18.8 mL/min, respectively); DKT showed statistically lower plasma creatinine (1.46 ± 0.57, P < 0.04) but not different creatinine clearance (55.4 + 20.4). Due to older donor age in the DKT group, comparisons were repeated in transplants from donors older than 70 years, and equal graft and patient survival in SKT and DKT were confirmed. Total mean number of functioning graft years by transplant reference at 1, 3 and 6 post-transplant years were equal between the groups, but mean number of dialysis-free life years by donor reference were significantly higher in SKT (mean difference compared to DKT at 6 years: 292 [IQR 260-318] years/100 donors in SKT(1-4) and 292.5 [(IQR 247.8-331.6) in SKT(> 4)].CONCLUSIONIn transplants from clinically suitable ECD donors, graft survival was similar irrespective of pre-implantation biopsy score and of allocation to SKT or DKT. These results suggest use of caution in the use of histology as the only decision criteria for ECD organ allocation.

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Optimizing utilization of kidneys from deceased donors over 60 years: Five-year outcomes after implementation of a combined clinical and histological allocation algorithm

Cited by 38 publications

References 27 publications

Renal Transplants from Older Deceased Donors: Use of Preimplantation Biopsy and Differential Allocation to Dual or Single Kidney Transplant according to Histological Score Has No Advantages over Allocation to Single Kidney Transplant by Simple Clinical Indication

Renal Transplants from Older Deceased Donors: Use of Preimplantation Biopsy and Differential Allocation to Dual or Single Kidney Transplant according to Histological Score Has No Advantages over Allocation to Single Kidney Transplant by Simple Clinical Indication

Strategies to increase the donor pool and access to kidney transplantation: an international perspective

Renal transplants from older deceased donors: Is pre-implantation biopsy useful? A monocentric observational clinical study

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