Comparison of outcomes of kidney transplantation from donation after brain death, donation after circulatory death, and donation after brain death followed by circulatory death donors


Abstract

Background

There are three categories of deceased donors of kidney transplantation in China, donation after brain death (DBD), donation after circulatory death (DCD), and donation after brain death followed by circulatory death (DBCD) donors. The aim of this study was to compare the outcomes of kidney transplantation from these three categories of deceased donors.

Methods

We retrospectively reviewed 469 recipients who received deceased kidney transplantation in our hospital from February 2007 to June 2015. The recipients were divided into three groups according to the source of their donor kidneys: DBD, DCD, or DBCD. The primary endpoints were delayed graft function (DGF), graft loss, and patient death.

Results

The warm ischemia time was much longer in DCD group compared to DBCD group (18.4 minutes vs 12.9 minutes, P < .001). DGF rate was higher in DCD group than in DBD and DBCD groups (22.5% vs 10.2% and 13.8%, respectively, P = .021). Urinary leakage was much higher in DCD group (P = .049). Kaplan‐Meier analysis showed that 1‐, 2‐, and 3‐year patient survivals were all comparable among the three groups.

Conclusion

DBCD kidney transplantation has lower incidences of DGF and urinary leakage than DCD kidney transplant. However, the overall patient and graft survival were comparable among DBD, DCD, and DBCD kidney transplantation.

The Search for a New Donor: Kidneys with Small Renal Masses


The Search for a New Donor: Kidneys with Small Renal Masses
Abstract
The gap between organ demand and supply is increasing gradually for both the developed and the
developing countries. Lack of deceased donors leads to kidney transplantationfrom cardiac death and
living donors. Recently, a new organ donor is added to the above mentioned options. This is the use of the
kidneys procured from the patients with small renal tumors. Many studies showed the possibility, feasibility
and safety of utilization of the restored or tumor excised kidneys in selective cases. Here, the important
point is that the ethical principles, the balance of risk and benefit for both donor as well as recipient
should take the priority. Long-term follow-up outcomes and further multicenter studies will be guiding in
determining the future of this approach.
 
Discussion

Organ shortage is an important problem in kidney transplantation. The gap between organ demand and supply is increasing gradually. Lack of deceased donors leads to use of expended criteria, cardiac death and living donors. Recently, a new organ sourcewas added to the above mentioned options. This is the use of the kidneys procured from the patients with small renal tumors. Incidental small renal tumors are detected more frequently by using imaging methods like US, CT scan, MRI. Nephron sparing partial nephrectomy is the gold standard treatment for the patients with small renal tumors (pT1a).[1] Thermal ablation and active follow up are recommended for the patients unfit for the surgery and with comorbid disease. [1] The studies conducted in the United States and England revealed that total nephrectomy is the most common treatment modality in practice (92.5%-96%).[2,3] Although the nephron sparing partial nephrectomy lately began to take place of total nephrectomy for the treatment of small  renal masses, it is still not common. Nowadays, the factors for universality of the total nephrectomy could be summarized as potential risks of partial  nephrectomy (bleeding, urinary leak, wound infection), experience of the surgeon and the request of the patients.

There are few reports about the use of kidneys with small renal masses in kidney transplantation. Brook et al. have compared the outcomes of kidney transplantations in patients with small renal tumors (renal cell carcinoma-pT1a-grade 1-3, papillary carcinoma-grade 1-2, chromophobe carcinomagrade 2, oncocytoma), live unrelated donors and dialysis wait-listed patients.[5] In a subsequent matched cohort analysis, kidney recipients from donors with excised renal tumors had comparable graft than the patient survival with the kidney recipients from live unrelated donors. Patient survival for excised tumor kidney recipients was better than those who did not receive a transplant.[5]Mannami et al reported the results by the use of not only kidneys with small renal tumors (renal cell carcinoma, pT1a, grade 1-2) but also kidneys with ureteral cancer(transitional cell carcinoma, pT1a,2,3 grade 1-3), benign diseases (angiomyolipoma, recurrent urinary tract infections, hydronephrosis due to retroperitoneal fibrosis after radiotherapy), aneurism and severe nephrotic syndrome.[4] In this study, the graft and patient survival for 5 years and 10 years were 51.8% and 42.7%, 79.3% and 63.8, respectively. In patients of the same age group on dialysis, patient survival was 72% and 52% at 5years and 10 years, respectively.[4] Beside the graft and patient survival, the improvement of the QoL is also another prominent benefit of the kidney transplantation.

Considering the tumor recurrence, Mannami et al reported no recurrence in the small renal tumor group but showed one at 15 months in ureteral cancer group.[4] Brook et al reported only one tumor recurrence at 9 years after the transplant of the kidney with excised renal tumor.[5]Sener et al reported the results of 5 kidney transplantations after tumor excision with the median 15 months (1 month to 41 months) follow up and there was no recurrence or metastatic disease in the recipients and the donors.[6]In another study it was revealed  that no recurrence of tumor by the median 69 months(14 months to 200 months) follow up of 14recipients with tumor excised kidney transplant. [7] These successive findings support the safe use of the kidneys from the patients with small renal  tumor after excision. Availability or lack of the data for long-term follow up should be kept in mind. Transplantation of these kidneys in high risk  recipients (like age over 60, no living donor, comorbid disease, estimated live expectancy in 5 years lower than 50%, with history of un successful transplantation) may be helpful to eliminate the concerns about the tumor recurrence.

The use of kidneys with incidentally detected small renal tumors during organ procurement or patient examination doesn’t prohibit the transplantation. Furthermore, earlier mentioned studies showed the possibility, feasibility and safety of utilization of the restored or tumorexcised kidneys in selective cases. When comparing with the wait-listed dialysis patients, kidney transplant recipients have the advantage of better survival and QoL, as well. In the light of this, utilization of the restored or tumor excised kidneys in selective group recipients may be helpful to expand the donor pool. In countries where the organ shortage is still a big problem,most of the transplantations are performed using organs from healthy live donors. The balance between risk and benefit for both donor and recipient should take the priority. The legislations as well as clinic protocols should be based on objective criteria and should be free from bias. Long-term followup outcomes and multicenter studies will guide the future of this approach.

References

  1. Thomas AA, Campbell SC. Small renal masses: toward more rational treatment. Cleve Clin J Med. August 2011; 78(8): 539-547.
  2. Hollenbeck BK, Taub DA, Miller DC, Dunn RL, Wei JT. National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization? Urology. 2006;67:254-259.
  3. Nuttall M, Cathcart P, van der Meulen J, et al. A description of radical nephrectomy practice and outcomes in England: 1995-2002. BJU Int. 2005;96:58-61.
  4. Mannami M, Mannami R, Mitsuhata N, et al. Last resort for renal transplant recipients, ‘restored kidneys’ from living donors/patients. Am J Transplant. 2008;8(4):811-818.
  5. Brook NR, Gibbons N, Johnson DW, Nicol DL. Outcomes of the transplants from patients with small renal tumours live unrelated donors and dialysis wait-listed patients. Transplant Int. May 2010;23(5): 476-483.
  6. Sener A, Uberoi V, Bartlett ST, Kramer AC, Phelon MW. Living donor renal transplantation of grafts with incidental renal masses after exvivo partial nephrectomy. BJU Int. December 2009;104(11): 1655-1660.
  7. Buell JF, Hanawway MT, Munda R, et al. Donor kidneys with small renal cell cancers: can they be transplanted? Transplant Proc. 2005 ;37: 581-582.

 

Intrarenal Resistive Index after Renal Transplantation.


BACKGROUND

The intrarenal resistive index is routinely measured in many renaltransplantation centers for assessment of renal-allograft status, although the value of the resistive index remains unclear.

METHODS

In a single-center, prospective study involving 321 renal-allograft recipients, we measured the resistive index at baseline, at the time of protocol-specified renal-allograft biopsies (3, 12, and 24 months after transplantation), and at the time of biopsies performed because of graft dysfunction. A total of 1124 renal-allograft resistive-index measurements were included in the analysis. All patients were followed for at least 4.5 years after transplantation.

RESULTS

Allograft recipients with a resistive index of at least 0.80 had higher mortality than those with a resistive index of less than 0.80 at 3, 12, and 24 months after transplantation (hazard ratio, 5.20 [95% confidence interval {CI}, 2.14 to 12.64; P<0.001]; 3.46 [95% CI, 1.39 to 8.56; P=0.007]; and 4.12 [95% CI, 1.26 to 13.45; P=0.02], respectively). The need for dialysis did not differ significantly between patients with a resistive index of at least 0.80 and those with a resistive index of less than 0.80 at 3, 12, and 24 months after transplantation (hazard ratio, 1.95 [95% CI, 0.39 to 9.82; P=0.42]; 0.44 [95% CI, 0.05 to 3.72; P=0.45]; and 1.34 [95% CI, 0.20 to 8.82; P=0.76], respectively). At protocol-specified biopsy time points, the resistive index was not associated with renal-allograft histologic features. Older recipient age was the strongest determinant of a higher resistive index (P<0.001). At the time of biopsies performed because of graft dysfunction, antibody-mediated rejection or acute tubular necrosis, as compared with normal biopsy results, was associated with a higher resistive index (0.87±0.12 vs. 0.78±0.14 [P=0.05], and 0.86±0.09 vs. 0.78±0.14 [P=0.007], respectively).

CONCLUSIONS

The resistive index, routinely measured at predefined time points after transplantation, reflects characteristics of the recipient but not those of the graft.

 

Souirce: NEJM

 

 

Patient Caught Rabies Through Organ Transplant, CDC Says.


A patient who recently died of rabies in Maryland contracted the illness from a kidney transplant received over a year ago, the CDC reported on Friday. The lengthy incubation period, while longer than the typical 1 to 3 months, is unusual but not unprecedented.

Tests on tissue samples from the patient and donor confirmed that they were both infected with raccoon-type rabies. The three other patients who received organs from the donor have been identified and are receiving anti-rabies shots.

The CDC notes: “If rabies is not clinically suspected [in a potential donor], laboratory testing for rabies is not routinely performed, as it is difficult for doctors to confirm results in the short window of time they have to keep the organs viable for the recipient.”

Source: CDC

Organs Wasted in Kidney Transplant Network .


The current system of allocating kidneys is flawed, with organs being discarded that might otherwise have benefited people — and the problem is growing — the New York Times reports.

The paper says that in 2011, some 2600 of 15,000 kidneys recovered for transplantation were discarded — many because recipients could not be found in time (the article notes that “it is not precisely clear” how many discarded kidneys might actually have been useful). The number of kidneys discarded has grown over 75% in the past decade, “more than twice as fast as the increase in kidney recoveries,” according to the Times.

Federal efforts to monitor the quality of transplantation programs may also inadvertently contribute to the problem. The effort to keep success rates high has made transplant surgeons “far more selective about the organs and patients they accepted, leading to more discards.”

New proposals for kidney allocation have been put forward, but remain similar to the system already in place.

Source:New York Times