Non–Heart-Beating Donor Kidney Transplantation Survival Is Similar to Donation After Brain Death: Comparative Study With Controls in a Regional Program

doi:10.1016/j.transproceed.2016.07.036

Transplantation Proceedings

Volume 48, Issue 9, November 2016, Pages 2867-2870

https://doi.org/10.1016/j.transproceed.2016.07.036 Get rights and content

Highlights

•
The development of the NHBD program has been making it possible to maintain and even increase transplantation activity in our region in recent years.
•
The general impression until now has been that recipient and graft survival from NHBD is similar to DBD, at least over the short term.
•
A tendency toward shorter graft survival from NHBD T2 can be seen; its behavior tends to be similar to expanded criteria DBD.

Abstract

Non–heart-beating donors (NHBD) are an increasing source of organs for kidney transplantation (KT) compared with donation after brain death (DBD), but the results in each regional transplantation program require local analysis. We compared 164 KT from NHBD (83 Maastrich type II A-B [T2] and 81 type III [T3]) with 328 DBD controls. NHBD kidneys were implanted with less cold ischemia, mean time on renal replacement therapy for NHBD recipients before transplantation was less too, and a higher proportion of thymoglobulin was also used. Besides NHBD-T2 more frequently showing the A group and patients being younger (48.9 ± 11 vs DBD 55.2 ± 15 years old; P < .001), there was a lower proportion of retransplant recipients and HLA sensitization; HLA-DR compatibility was slightly worse. Proportion of nonfunctioning allograft and necessity of dialysis after transplantation for NHBD were 4.9 and 68.3% versus DBD 4.3 and 26.9% (P < .001); renal function after a year was significantly less in NHBD (serum creatinine 1.79 ± 0.9 mg/dL vs 1.46 ± 0.5 in DBD; P < .001). NHBD recipient survival rates were 96% and 96% for the 1st and 3rd years, respectively, versus 96% and 94% for DBD, respectively (not significant [NS]). Graft survival rates censored by death were 91% and 89% (1st and 3rd years, respectively) versus 95% and 94% for DBD, respectively (NS). We did not find significant differences about survival between NHBD-T2 and T3. In the multivariable survival study (Cox, covariables with statistical significance demonstrated previously in our region), NHBD is not a prognosis factor for recipient or graft survival. Regarding current criteria for choosing donors and the graft allocation applied in Andalusia, short-term survival for NHBD transplantation is similar to DBD. Renal function in the short term is slightly worse, which is why it is important to monitor results over a long term, especially those from NHBD-T2.

Section snippets

Methods

This was a retrospective study with data from a regional register (SICATA: Sistema de Información de la Coordinación Autonómica de Trasplantes de Andalucía. Regional Transplant Coordination Register from Andalucia), in 5 transplantation centers in Andalusia (Spain), from January 1, 2010 to December 31, 2014. In this study 164 KT from NHBD were compared with 328 KT from DBD controls (KT performed immediately before and after every NHBD transplantation in the same center in patients older than

Results

Donors characteristics are shown in Table 1 compared with controls. The number of men was significantly higher in both types of NHBD in comparison with controls. NHBD type II Maastricht (T2) showed an average age that was 10 years younger than controls and with a different distribution by age: almost all participants were younger than 60 years and there was double the proportion of people younger than 40 years compared with controls. NHBD type III Maastricht (T3) showed an average age similar

Discussion

The development of the NHBD program has been making it possible to maintain and even increase transplantation activity in our region in recent years. NHBD can show different characteristics from DBD, in particular NHBD T2 are younger and grafts are implanted faster than DBD. As a result of the length of warm ischemia, renal function could be delayed more frequently in NHBD and the optimal renal function reached during the first year is slightly worse than DBD. This fact could hypothetically

References (4)

M.A. Gentil et al.
Impact of asystolic donations in kidney transplant activity from cadaveric donors in Andalusia
Transplant Proc
(2015)
D.M. Summers et al.
Kidney donation after circulatory death: state of the art
Kidney Int
(2015)

There are more references available in the full text version of this article.

Cited by (9)

Implementation of donation after circulatory death kidney transplantation can safely enlarge the donor pool: A systematic review and meta-analysis
2021, International Journal of Surgery
Citation Excerpt :
Characteristics of the included studies are presented in Table 1. Twenty studies (39.2%) included only controlled DCD [7,24–42], 14 studies (27.5%) both controlled and uncontrolled DCD [43–56], and 2 studies (3.9%) included only uncontrolled DCD [57,58]. Fifteen studies (29.4%) did not state which donor type was included [10,59–72].
Donation after circulatory death (DCD) kidney transplantation has been introduced to address organ shortage. However, DCD kidneys are not accepted worldwide due to concerns about inferior quality. To investigate whether these concerns are justified, we performed a systematic review and meta-analysis to investigate DCD graft outcomes compared to donation after brain death (DBD).
EMBASE, Medline, Cochrane, Web of Science and Google Scholar were searched from database inception until September 2020. Exclusion criteria were studies reporting on pediatric/dual kidney transplants, multi-organ transplants or studies including normothermic perfusion techniques. The primary outcome was graft survival. Secondary outcomes were primary non-function (PNF), delayed graft function (DGF), 3-months biopsy-proven acute rejection (BPAR), 1-year estimated Glomerular Filtration Rate (eGFR), patient survival, and urologic complications. A random-effects model was used for meta-analysis. Meta-regression analysis was performed in case of high between-study heterogeneity.
Fifty-one studies were included, comprising 73,454 DCD and 518,229 DBD recipients. One-year graft loss was increased in DCD recipients (death-censored: risk ratio (RR) 1.10 (95%-confidence interval (CI) 1.04–1.16), all-cause: RR 1.13 (95%-CI 1.08–1.19)). Ten-year graft loss was similar to DBD (death-censored: RR 1.02 (95%-CI 0.92–1.13), all-cause: RR 1.03 (95%-CI 0.94–1.13)). DCD recipients had an increased risk of PNF (RR 1.43 (95%-CI 1.26–1.62)), DGF (RR 2.02 (95%-CI 1.88–2.16)), and 1-year mortality (RR 1.10 (95%-CI 1.01–1.21)). No differences were observed for 3-months BPAR, ureter stenosis/leakage, 1-year eGFR and 10-year mortality.
Long-term DCD kidney transplant outcomes are similar to DBD despite a higher risk of PNF, DGF, and a 13% increased risk of graft loss in the first year after transplantation. These results should encourage implementation of DCD programs.
Normothermic Regional Perfusion and Donation After Circulatory Death (Controlled and Uncontrolled): Metabolic Differences and Kidney Transplantation Evolution
2019, Transplantation Proceedings
Citation Excerpt :
However, there is a trend toward normalization of kidney function parameters during subsequent follow-up examination. These conclusions are in accordance with those of other studies conducted after the donation after brain death [7]. The metabolic alterations derived from DCD are more marked in the uDCD.
To analyze metabolic differences during normothermic regional perfusion (NRP) between the dissimilar types of donation after circulatory death, uncontrolled (uDCD) and controlled (cDCD), and the evolution of the transplanted kidneys.
Observational, prospective, cohort study. We included patients from uDCD and cDCD maintained with NRP in 2017. Six consecutive blood gases were collected with determination of pH and lactic acid. Creatinine levels were monitored at 24 hours, 3 months, and 6 months after transplant and the need for renal replacement therapy was evaluated. Descriptive statistical analysis was performed, presenting the qualitative variables as frequencies and percentages, and quantitative as mean ± SD or median (interquartile range [IQR]). We used χ² testing for bivariate analysis of qualitative variables.
We collected 18 donors. Fifteen out of 18 (83.3%) were men with a median of 51 years (IQR, 46-60). Eleven out of 18 (61.1%) were cDCD and 7 out of 18 (38.9%) were uDCD. The blood gas results are illustrated in Table 1. A total of 28 renal transplants were obtained with a median age of 47 years (IQR, 45-57); 83% were male. Ten out of 28 (35.7%) came from uDCD and 18 out of 28 (64.7%) from cDCD. Table 2 shows the monitoring of the creatinine values of the recipients after the transplantation.
There are more metabolic disorders in our series in uDCD organ donation compared with cDCD. The recovery of the renal function of organs from uDCD is slower than that of cDCD, however; the tendency is toward normality.
Optimizing Intraoperative Blood Pressure to Improve Outcomes in Living Donor Renal Transplantation
2020, Transplantation Proceedings
Adequate renal perfusion at the time of unclamping is important because it has been known to affect outcomes in renal transplantation. Nevertheless, the ideal intraoperative systolic arterial pressure (SAP) has not been well defined.
We performed a retrospective analysis of 106 living donor renal transplants performed at our center from June 2010 to May 2019. We divided the cohort into 2 groups according to our center’s goal SAP of ≥150 mm Hg: 57 patients had SAP ≥150 mm Hg and 49 patients had SAP <150 mm Hg. We analyzed pretransplant characteristics, intraoperative measurements, and postoperative laboratory values to validate our center’s target SAP at the time of reperfusion. This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor sources.
Patients with SAP ≥150 mm Hg had been on dialysis for a significantly shorter duration before transplant compared with those who had SAP <150 mm Hg. In the SAP ≥150 mm Hg group, urinary sodium excretion normalized earlier, and they had a significantly smaller stroke volume variation, higher cardiac output and cardiac index, earlier initial urination, and higher intraoperative urine output. There were no differences in intraoperative volume repletion, central venous pressure, or postoperative estimated glomerular filtration rate.
Achieving SAP ≥150 mm Hg at the time of reperfusion may be associated with early stabilization of graft function. Nevertheless, our data suggested that recipients with a prolonged dialysis history are less likely to achieve SAP ≥150 mm Hg at the time of unclamping in living donor renal transplantation.
Kidney transplantation in the Intensive Care Unit: Graft evaluation using imaging tests
2019, Medicina Intensiva
Kidney transplant from controlled donors following circulatory death: Results from the GEODAS-3 multicentre study
2019, Nefrologia
Citation Excerpt :
Renal function at the first year was close to 60 ml/min, so we could be expected good medium and long term survival. Our study does not allow a comparison with the results of the DBD donation, but a recent analysis of the Andalusian regional registry shows that renal function achieved after one year is better in transplants from DBD donors than from DCD (Crs 1.79 ± 0.90 vs. 1.46 ± 0.50 mg/dl; p < 0.001).22 Although we have collected cases with a follow-up of up to 5 years, our average follow up only allows us to analyze survival at the second year.
Many European countries have transplant programs with controlled donors after cardiac death (cDCD). Twenty-two centers are part of GEODAS group. We analyzed clinical results from a nephrological perspective.
Observational, retrospective and multicentre study with systematic inclusion of all kidney transplant recipients from cDCD, following local protocols regarding extraction and immunosuppression.
A total of 335 cDCD donors (mean age 57.2 years) whose deaths were mainly due to cardiovascular events were included. Finally, 566 recipients (mean age 56.5 years; 91.9% first kidney transplant) were analyzed with a median of follow-up of 1.9 years. Induction therapy was almost universal (thymoglobulin 67.4%; simulect 32.8%) with maintenance with prednisone-MMF-tacrolimus (91.3%) or combinations with mTOR (6.5%). Mean cold ischemia time (CIT) was 12.3 h. Approximately 3.4% (n = 19) of recipients experienced primary non-function, essentially associated with CIT (only CIT ≥ 14 h was associated with primary non-function). Delayed graft function (DGF) was 48.8%. DGF risk factors were CIT ≥ 14 h OR 1.6, previous haemodialysis (vs. peritoneal dialysis) OR 2.1 and donor age OR 1.01 (per year). Twenty-one patients (3.7%) died with a functioning graft, with a recipient and death-censored graft survival at 2-years of 95% and 95.1%, respectively. The estimated glomerular filtration rate at one year of follow-up was 60.9 ml/min.
CIT is a modifiable factor for improving the incidence of primary non-function in kidney transplant arising from cDCD. cDCD kidney transplant recipients have higher delayed graft function rate, but the same patient and graft survival compared to brain-dead donation in historical references. These results are convincing enough to continue fostering this type of donation.
Varios países europeos disponen de programas de donación tras parada cardiaca controlada (cDCD). Veintidós centros participan en el grupo GEODAS, cuyos resultados clínicos presentamos desde una perspectiva nefrológica.
Estudio multicéntrico retrospectivo observacional con inclusión sistemática de todos los trasplantes renales (TR) procedentes de cDCD, siguiendo protocolos locales de extracción e inmunosupresión.
Se incluyó a 335 donantes tras cDCD (edad media 57,2 años) fallecidos mayoritariamente por eventos cardiovasculares. Se analizan 566 receptores (edad media de 56,5 años; el 91,9% con primer trasplante renal), con una mediana de seguimiento de 1,9 años. La terapia de inducción fue casi universal (timoglobulina 67,4%; simulect 32,8%) con mantenimiento con prednisona-MMF-tacrolimus (91,3%) o combinaciones con mTOR (6,5%). El tiempo medio de isquemia fría (CIT) fue 12,3 h. Hubo un 3,4% de fallo primario del injerto (n = 19), asociado fundamentalmente al tiempo de isquemia fría (solo el CIT ≥ 14 h se asoció a fallo primario del injerto). La función retrasada del injerto (DGF) fue 48,8%. Los factores de riesgo para la DGF fueron: CIT ≥ 14 h OR 1,6, procedencia de hemodiálisis (vs. diálisis peritoneal) OR 2,1 y edad del donante OR 1,01 (por año). Veintiún pacientes fallecieron con injerto funcionante (3,7%), con una supervivencia de paciente e injerto (censurada para muerte) al segundo año del 95% y del 95,1%, respectivamente. El filtrado glomerular estimado al año de seguimiento fue 60,9 ml/min.
El CIT es un factor modificable para mejorar la incidencia del fallo primario del injerto en trasplante renal procedente de cDCD. El trasplante renal con cDCD tiene mayor incidencia en la función retrasada del injerto, pero igual supervivencia de paciente e injerto que la referencia histórica para donación en muerte encefálica. Los resultados son satisfactorios para continuar promoviendo este tipo de donación.
Is there decreasing public interest in renal transplantation? A google trends™ analysis
2020, Journal of Clinical Medicine

View all citing articles on Scopus

View full text

4th Congress of the Spanish Society of TransplantationOrgan donationNon–Heart-Beating Donor Kidney Transplantation Survival Is Similar to Donation After Brain Death: Comparative Study With Controls in a Regional Program

Highlights

Abstract

Section snippets

Methods

Results

Discussion

Transplant Proc

Kidney Int

4th Congress of the Spanish Society of Transplantation
Organ donation
Non–Heart-Beating Donor Kidney Transplantation Survival Is Similar to Donation After Brain Death: Comparative Study With Controls in a Regional Program