1. You were offered kidneys from a 71-year-old DCD donor (donation after cardiac death) who suffered from SAH (grade 5). His BP was well controlled by one agent. He had mild DM diagnosed last year, S Cr 81 µmol/L with excellent urine output (100 mls/h during the last hour and 2.6 L over the last 24 hours).
- Would you accept this donor?
- If yes, how do you select the recipient(s) suitable for this case?
Thank you ALL for your replies
You have noticed that this donor is an ECD (very marginal, age 71, had DM and HT). A few of you mentioned DUAL KIDNEY TRANSPLANTATION (DKT).
Do you think that DKT could be a better option compared to transplanting these kidneys separately?
Dear Prof
DKT would be a better option compared to transplanting these kidneys separately since it will double the active nephron mass and reduce the complications associated with organs from ECDs like DGF and reduced graft survival.
I understand your viewpoint, Dr HUssain
Remuzzi G, Grinyo J, Reggenenti et al. 1999
Yes Dr Ben
Dual kidney transplantation is a better option as it will increase the nephron mass. Data showed that recipients of dual kidneys from elderly donors have a significantly decreased incidence of DGF and better renal function and graft survival than recipients of a single kidney harvested from donors of similar age.
Yes, Dr Huda.
DKT increases the nephron mass. Nephron mass is a determinant of CAF. Viable nephron mass by DKT is effectively prevents progressive deterioration in renal function compared with single transplant controls
I understand your viewpoint, Dr Abdallah
No global consensus regarding criteria for DKT but each center has his own experience for example, UNOS database published on 2008 that they were considering DKT if two criteria fulfilled from these criteria :
1-age greater than 60 years.
2-Creatinine clearance greater than 65 mL/min.
3-Rising serum creatinine greater than 2.5 mg/dL at retrieval.
4-Chronic hypertension or type 2 diabetes mellitus.
5-glomerulosclerosis on biopsy between 15% and 50%.
So our recipient here is old age , with HTN and DM and also we should match our recipient age and size which is so important because older recipient can tolerate nephron mass and expected life time and better to be low immunological risk as recipients without previous transplant and panel reactive antibody titer < 50% to avoid over immunosuppression and attacks of rejections.
I understand your viewpoint, Dr Saad.
Thanks, Mohamed
Would use these kidneys as DKT or separately?
Thanks , prof.
Its local center protocol but I will accept DKT if we are following
Sheffield center:
uses this approach. Kidneys with prolonged warm ischemia time, small kidneys, eGFR < 60 mL/min, kidneys with multiple cysts, and kidneys from elderly donors (> 70 y) are considered for DKTs, especially in association with donors who have a history of hypertension or type 2 diabetes mellitus.
Performing a dual kidney transplant (DKT) can be based on the pre-implantation biopsy Remuzzi score (0-3: single kidney transplant, 4-6 for DKT).
DKT would be definitely a better option due to increased nephron mass. But if the Remuzzi score is good, 2 recipients can get benefit of single kidneys instead of a single patient getting the benefit of DKT (in view of good renal function – S Cr 81 micromol/L and urine output 100 ml/hr).
Refrence:
Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
I understand your viewpoint, Dr Amit Sharma.
Well, it is dependent on what is seen on the biopsy and the function of the kidneys. however, DKT should be better since one can always compensate the other if there was an injury.
Yes, Dr Badal.
Thanks, Marius
Would use these kidneys as DKT or separately WITHOUT performing a pretransplantation biopsy?
Dear Dr Ahmed,
My answer is Yes. I will recommend DKT from this donor without waiting for a pretransplantation biopsy.
The reasons for my decision:
– Ageing per se is associated with a decline in the GFR, usually masked by the lower muscle mass in the elderly (1).
– This scenario describes a marginal kidney from ECD. Therefore, I will prefer not to waste time waiting for biopsy results as the prolonged cold ischaemia time can increase the risk of DGF and may negatively affect the long-term outcome of this allograft.
References:
1) Steddon S, Ashman N, Chesser A, et al. Oxford Handbook of Nephrology and Hypertension. Second edition, Oxford University Press, ISBN 978–0–19–965161–0, 2014.
yes, it is better to increase nephron mass and improve GFR and improve outcome
I understand your viewpoint, Dr Riham.
DKT is good to consider to increased nephron mass. However, since this patient has good kidney function with good urine output, I think personally is better to donate kidneys to 2 marginal recipients aged >60 years or patients with advanced diabetes or multiple comorbidities.
I understand your viewpoint, Dr Fakhriya. But, we need to be aware that marginal kidney in a marginal recipient is unsafe if there is primary non-function.
Its .
As the DKT would endowed the nephrone dose. translated into an improved GFR , reducing the hyperfiltration consequent on reduced nephrone dose.
Yes Dr Jebur
Dear prof Ahmed yes the option of DKT will be a good option compared to SKD from such marginal kidney in order to expand the functional nephron mass in single recipients preferred females age-matched and small size with limited access and BMI < 30 with low immunological risk with CNI free or minimization protocol
Thanks, Saja
Would use these kidneys as DKT or separately WITHOUT performing a pretransplantation biopsy?
Kidney biopsy pre-OP has its limitations being invasive with the associated risk of bleeding and AVF in addition to variation in reporting these biopsies might be misleading and result in unnecessary organ discard so alternative to that some centers use the clinical donor’s criteria along with e GFR level .in donors above the age of 65years with one or more of the medical comorbidities like HTN, type 2DM, death with CVA or CVD
GFR > 60ml/min for SKD
GFR 30-60ml/min allocation for DKT
GFR < 30ml/min the organ should be discarded .The above selection criteria were Studied by Snanoudj in 81 DKT with 2 years graft survival reached 90% however the Italian series of 100 DKT they do pre-OP biopsy using rummazzi scoring in ECD with age > 70 and serum creatinine > 1.5 donors with histological score between0-3 will go for SKD , 4-6 score for DKT and above 7 the kidney will be discarded with the 3 years graft survival from DKT was reached 90%. Till date we don’t have consensus about uniform protocol and each center they have their own selection criteria and hope no wrong answer done .
references
1.Dual Kidney Transplant Ahmed Hassan, Ahmed Halawa.
The decision is very challenging.
it depends on donor and recipient condition.
For donor, he has (expended criteria donor .)
we should evaluate proteinuria and it is better to perform renal biopsy and we can benefit from REMUZZI SCORE
0-3 single kidney
4-6 double kidney
In addition we can benefit KDRI
However, we should compare the mortality rate on waiting list and the mortality or morbidity after transplantation .
We can save two recipients on waiting list especially those who have best HLA matching – age match when possible- female- small patient
I still prefer transplant these kidney separately regarding to the shortage of donation unless there is a fit recipient has his priority or has high score points on waiting list
Thanks, Ghalia
What are the selection criteria for the 2 potential recipients of these kidneys?
You mentioned you would transplant them separately.
Dual renal transplants have been implemented to boost nephron bulk. If 2 marginal organs are donated to the same recipient, more working nephrons should be accessible compared to a single subpar organ or excellent kidney. Increasing the amount of viable nephron mass by transplanting 2 kidneys to the same recipient reduces gradual deterioration in renal function compared to single transplant controls.
Thanks, Weam
Dear ALL
Suppose you decided to transplant these kidneys separately into 2 different recipients.
What are the selection criteria for the 2 potential recipients of these kidneys?
I will select age matched recipients as these kidneys might have issues with long term graft outcomes due to senile glomerulosclerosis and likely unsuitable for young recipients
what are the selection criteria for the 2 potential recipient of these kidneys?
selection criteria for the recipient included
age more than 40 ,or has multi-access failure ,has low immunological risk ,long waiting time in transplant list more than 4 years and has no multiple comorbidies.
better to go for DKT in a single recipient to increased the volume of functional nephrons in a younger recipient with low immunological risk female with low mass and less comorbid disease ,on long waiting with limited access,and may be still consider this marginal kidney to SKD then I will select age matched recipient ( elderly female recipient , BMI < 30 and low immunological risk to allow for CNI minimization or CNI free protocol and use of NMP for renal preservation. the use of such marginal kidneys low nephron mass as separate SKD for younger recipient is unjustifiable and associated with poor graft survival .
Reference
Suppose you decided to transplant these kidneys separately into 2 different recipients.
What are the selection criteria for the 2 potential recipients of these kidneys?
In this specific scenario, I will recommend:
– Age-matched recipient.
– Small body surface area (i.e. less muscle mass)
– Preferably females (again due to the lower muscle mass)
– Low immunological risk.
– Adoption of CNI free protocol.
If we decided to transplant these kidneys separately into 2 recipients, the potential recipient’s criteria as the following:
small size recipient , ( female is better )
low immunological risk
age >40 yrs
immunosuppressive modulation
short CIT
pretransplant renal biopsy & scoring
a recipient with a long waiting time >4 yrs
a recipient with vascular dialysis access
Sir, Preferably yes if recipient is young but if recipient is also elderly then I will consider SKT
DKT or SKD selection criteria still variable and center depended
as the DKT has increasing use of marginal kidney,although it carries potentioal high risk of surgical complication because longer surgical procedure and 2 fold risk of vascular and ureteric anastomsis and many centre remain reluctant and lack of experence
but this pateint age more than 60 and been DM and HTN AND eGFR more than 60 so will benifit from DKT as it will increase nephron mass
References
1. Bunnapradist S, Gritsch HA, Peng A, Jordan SC, Cho YW. Dual kidneys from marginal adult donors as a source for cadaveric renal transplantation in the United States. J Am Soc Nephrol. 2003;14(4): 1031-1036. 2. Allen J, Hudson A. Dual kidney transplantation. Kidney Advisory Group. 2011;16(11):1-9. 3. Navarro AP, Sohrabi S, Reddy M, Carter N, Ahmed A, Talbot D. Dual transplantation of marginal kidneys from nonheart beating donors selected using machine perfusion viability criteria. J Urol. 2008;179(6):2305-2309; discussion 2309. 4. Remuzzi G, Grinyo J, Ruggenenti P, et al. Early e
this patient ECD, so better to choose DKT option. however; he had a good graft function
he is diabetic 1 year ago diagnosed, HTN controlled with only one agent
so we can use his kidneys to save 2 patients with the selected criteria of
if a pre-transplant biopsy of both kidneys is available and the results can be obtained quickly it would be better
my decision; I would go for 2 KT separate rather than DKT
Sir,
This would be donor for :
Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
DKT will offer more nephrons so may be associated with better outcome.
But we have to bear I mind that it is technically difficult, time consuming, associated with higher incidence of wound dehiscence, and associated with more post-operative complications especially vascular thrombosis and ureteric complications when compared to single kidney transplantation . so the patient should be average sized and fit for the operation
further assessment is needed before good decision including the presence of significant proteinuria, size of the kidneys, and GFR
So biopsy may help to avoid unwanted side effects and help our decision if GFR between 30-60 ml/min (< 30 ml/min I will discard the kidney and > 60 ml/min I will proceed for SKT)
So I will go for DKT only if GFR between 30-60 with a score of 4-6 on renal biopsy
Other option is going for DKT without biopsy to have more nephrons but recipient should have minimal comorbidities, average sized female or elderly and have low immunological risk
As ECD, dual kidney transplant is an option for better outcome.
Dual kidney transplant is better in this old age with creatinine clearance of <50 ml/min, had DM and mild HTN.
Dear Dr Ahmed,
This kidney is from an ECD due to the age and the associated co-morbidities. Furthermore, the normal serum Cr in the elderly does not necessarily mean normal GFR due to the low muscle mass in the elderly, which may mask the physiological decline of GFR with ageing (1).
Therefore, I will accept this donor for DKT.
References:
1) Steddon S, Ashman N, Chesser A, et al. Oxford Handbook of Nephrology and Hypertension. Second edition, Oxford University Press, ISBN 978–0–19–965161–0, 2014.
DKT would be a better option compared to transplanting these kidneys separately since it will increase the active nephron mass but more surgical wise challenge. and also, why to safe one soul if it’s possible to safe two potential recipients within the same age group as those on Euro transplant senior program (ESP) after good assessment based on clinical,lab,radiological,KDPI and KDRI
This patient has eGFR 95 ml/min/1.73 m² estimated GFR by 2021 CKD-EPI Creatinine. Transplanting his kidneys to separate old patients may be better, taking the complications of the operation (DKT) itself into consideration. Of course, he is expected to have a high Emuzzi score if biopsied by classic wedge biopsy.I may think about dual kidney Tx in case of donating it to young patient.
Dear prof
DKT in an ECD kidney is better than single KT in terms of increasing the nephrons & graft survival
Yes, dual kidney Transplantation is better option it has positive feedback on nephron mass with improving graft function and survival
Yes, dear prof. , Dual kidney transplantation will be better option if compared with transplanting these kidneys separately due to increase number of nephron mass so, increasing glomerular filtration rate, decreased complications from ECD donors.
Dual kidney transplantation is performed in marginal kidneys to increase nephron mass and number in these kidneys which are expected to be low.
References:
BTS guidelines for transplantation from DCD
Yes I will accept the donor..The donor is an ECD with age being 71 years with hypertension and death due to cerebrovascular causes….The donor is also DCD and a diabetic…there is normal creatinine and good urine output
The recipient should be selected carefully as there is increased risk of delayed graft function and reduced overall graft survival….The recipient should be of normal BMI, with low immunological risk, similar age, with poor vascular access when the survival on dialysis becomes questionable
This potential DCD donor is an extended criteria donor with proper KFTs and Urine output . Associated with mild HTN and DM
Accepting this donor is better than dialysis and staying on the waiting list
Extended criteria donors have a lower survival outcome for survival in comparison with standard donors that’s why selection of the recipient should be made accurately.
Recipients can include old patients or diabetics older than 40 years , small sized recipients especially females, low immunological risks , expected waiting time in waiting list is more than life expectancy.
Dual kidney transplant may be needed if Renuzzi score between 4-6
I think double kidney transplant is a better option
Yes.
Criteria for DKT
Donor
aged 70 years or over plus one or more of past hypertension, diabetes.
death due to CVA or retrieval creatinine > 150µM/L
Recipient
Potential transplant recipient on long waiting list with exhausted vasuclar access for HD or UF failure on CAPD.
Pt is extended criteria donor(DM,Age:71)
We can go for RUMMIZZI score:according to biopsy result and GFR ,proteinuria
0-3 single kidney transplant
4-6 dual kidney transplant
>or =7 discard kidneys
Would you accept this donor?
This is an ECD DCD (>60 years, diabetes, and hypertension). Considering the scarcity of organs and the rising waitlist in any kidney transplant program, I will accept this donor if:
Recipient selection:
Criteria for DKT:
I would prefer DKT if Remuzzi score between 4 to 6 and GFR between 30-60ml/min, otherwise single kidney transplant and benefitting two recipients
Reference:
Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015;13(6):500-9.
1- Yes i will accept him.
He fulfills the criteria of expanded criteria donars being
Dm, htn & 71 ys,
The suitable recipient will be :
■ Age above 40, better near to donar ‘s age
■ Recent DM
■ HTN.
■ Vascular access problems
■ Dialysis moree than 4 years
■ Low immunological risk
This ptn has a good Uop & good GFR
So can be taken.
Recipient should be educated about DGF , low graft survival.
DKT is a good option for optimizing the use of kidneys from the expanded criteria donors.
Dual kidney transplantation from expanded criteria brain dead donors has better graft and patient survival than from non heart beating donors.
it will double the nephron mass and hence the GFR
Would you accept this donor?
Yes, I will accept the donor
This scenario is ECD with DCD, with good renal function.
This kind of donation is a risk
Extended criteria donors are now accepted more frequently. Increasing number of elderly donors with age > 60 years, history of diabetes or hypertension, and clinical proteinuria are accepted as donor.
If yes, how do you select the recipient(s) suitable for this case?
Dual kidney transplantation (DKT) is also more frequently done and experience with this technique is slowly building up. DKT not only helps to reduce the number of patients on waiting list but also limits unnecessary discard of viable organs. Surgical complications of DKT are comparable to single kidney transplantation (SKT). Patient and graft survivals are also promising.
Generally, the recipients of DKT were older when compared to SKT. Results of most studies showed that elderly patients who had DKT tend to have lower metabolic rate and low body mass index than the average SKT patients. DKT is considered better for age and weight matched recipient. Greater number of nephrons in DKT is suitable for elderly patients with low basal metabolism and reduced body mass. The results of DKT in elderly were comparable with the younger SKT population .Theoretically elderly recipients tend to have blunted immunologic responses and, therefore, despite increased nephron mass, the chances of rejection are lower. Furthermore, there were promising results showing that DKT in a younger cohort (mean age 60 ± 5 years) from older donors (mean age 75 ± 7 years) had fewer episodes of acute rejection and good graft survival.
Int Sch Res Notices. 2017; 2017: 2693681.
Published online 2017 Jul 2. doi: 10.1155/2017/2693681
PMCID: PMC5511653
PMID: 28752128
Dual Kidney Transplantation: A Review of Past and Prospect for Future
Muhammad Abdul Mabood Khalil, Jackson Tan, Taqi F. Toufeeq Khan, Muhammad Ashhad Ullah Khalil, and Rabeea Azmat
Would u accept this donor?
In the world of transplantation where there is immense organ shortage such donors should be accepted however he fulfills the criteria of ECD
Age 71 yrs
Recent DM
HTN.
A suitable recipient for such donor should be
Age above 60
low immunological risk
vascular access issues
long waiting time
Recipient education about DGF , low graft survival should be done
Would you accept this donor?
This is an ECD (age:71, HTN, DM, SAH, good UOP, good GFR).
I would accept him for donation.
If yes, how do you select the recipient(s) suitable for this case?
Selection criteria for suitable recipients:
Old age, low immunological risk, low HLA mismatches, no DSA, Long duration on waiting list, multiple vascular access problems.
Single kidney donation is recommended for older age recipients, recipients with low body mass, and pre-transplant biopsy score 0-3.
Dual kidney donation is recommended to increase the nephron mass if biopsy score 4-6, experienced surgeons are available.
If biopsy score above 6, discard kidneys.
References:
BTS guidelines for transplantation from DCD.
I will accept him with considering the following items.This is an ECD or marginal donor with comorbidities like diabetes and HTN. These kidneys are used to increase donor’s pool. His KDPI is high. So, the proper recipient should be selected and informed about the high risk of DGF and probable low graft survival.
The recipient would be the same age or maximum 10 years younger than donor with low immunological risk, no DSA, small size, being for a long time on waiting list and vascular access problems.
References:
BTS guidelines for transplantation from DCD
Yes, He is considered an expanded criteria donor as age > 60 years, history of HTN and DM and death after cardiac death.
Recipients who may benefit after ECD kidney transplantation are recipients with age >40 years, long waiting tome on dialysis >4 years, those with HTN or DM and patients with exhausted vascular access.
patients with low immunological risk and those with life expectancy on dialysis lower than estimated waiting time for kidney transplantation.
Filiopoulos V, Boletis JN. Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression?. World journal of transplantation. 2016 Mar 24;6(1):103.
Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transplant International. 2008 Jan;21(1):11-7.
Yes, I would accept this kidney for extended criteria evaluation, focusing mainly on the biopsy result and the amount of glomerulosclerosis. Assistance is needed to reduce the risk of other injuries:
– Hypothermic perfusion machine
– induction with ATG and decrease in the use of CNI
As the criteria for donation would be quite borderline, perhaps choosing a recipient for a dual transplant would be indicated. Or a recipient who would benefit a lot from this kidney, for example, one with a long queue due to awareness or who, even with a shorter queue, had greater urgency due to lack of venous access.
According to this scenario, known 71 year old patient, DCD donor, with suggestive history of HTN, mild DM,is categorized under ECD extended donor criteria would be accepted for certain situations ; those with small lean mass, long duration for waiting list exceeding 4 years ,failed vascular access, old aged recipient ,and of low immunological risk .
Good induction therapy is indicated in such cases. Dual kidney transplant may be helpful to improve the prognosis of ECD.
Reference:
According to the British Transplant Society guidelines.
Aubert et al; BMJ; 101h; 1157 (2015)
Merion et al JAMA; 294; 2726 (2009)
yes I will accept.
DKT will be a better option.
in our center we didnt accept because the age,DM and HTN.
because our patient pedatric , the cahnce of ATN is very high compared to standatrd case
Yes, as the Survival advantage of ECD kidney transplant recipients over dialysis patients remaining on transplant
waiting list
Preferably to be given to:
• Patients older than 40 years
• Long median waiting time (> 4 years)
• Patients of low immunological risk
• Diabetics
• Dialysis patients with vascular access problems
• Dual ECD renal transplant for fit recipients
*Yes ,I will accept this 71 years old, DCD donor is considered as ECD extended criteria donor due to his age , DM, Hypertension. But he has good Kidney function with good urine output. Although ; the higher risk of DGF and less long term graft survival.
*Selection of the recipient(s) suitable for this case: Due to incidence of less graft survival so , It is better to select older recipients, low immunological risk, was on long waiting list for SCD kidney.
-Protocol of transplantation will include ATG induction , due to: the high risk of rejection and delayed graft function.
References :
1.Stallone G, Infante B, etal., Older donors and older recipients in kidney transplant. J Nephro. 2010;23:S98–S103
2.Remuzzi G., Grinyo J., et al., Early experience with DKT in adults using expanded donor criteria.(DKG) Journal of American Society of Nephrology.1999;10(12):2591–2598.
1. You were offered kidneys from a 71-year-old DCD donor (donation after cardiac death) who suffered from SAH (grade 5). His BP was well controlled by one agent. He had mild DM diagnosed last year, S Cr 81 µmol/L with excellent urine output (100 mls/h during the last hour and 2.6 L over the last 24 hours).
This is expanded criteria donor because:
1. Age above 50years
2. Diabetic
3. Hypertensive
4. Died because of SAH.
Howe ever the kidney is functioning well with good urine output. So, I will accept it. To give the recipient the best available result, considering dual kidney transplant may give better out come.
Suitable recipient should be of similar age or 5-10years younger.
The available donor is 71 years old DCD ( donation after cardiac death) with hypertension diabetic SAH grade 5. Excellent kidney function with good UOP
*I will accept this ECD.
* the recipient INSHALLAH should be 50 years old decreased immunological condition
Already on long waiting with little associated comorbiditis but with counselling regard last benefit risk for this donation.
Would you accept this donor?
71 year old DCD
Hypertensive
Mild diabetes
He can be accepted to increase donor pool
So I will accept him after proper counselling to recipient about possible outcomes. A Dual kidney transplant will increase the nephron mass and will be best option rather than single kidney transplant
If yes, how do you select the recipient(s) suitable for this case?
Age > 60 years
Long waiters
Low immunological risks
Those who have vascular access
Small recipients
Females
BTS Guidelines- Transplantation from DCD
sorry for the delay response
this donor considered under EDC
above 60
mild DM
controlled HTN by 1 agent
excellent renal function and UOP
so i will accept him
for the recipient either we can save 2 patient with single kidney transplant and we can select them according to following :
age matched or above 40
small size
female
low immunological risk
difficult and complicated access
long waiting list time or on dialysis >4 yrs
pretransplant renal biopsy is better to be done and short cold ischemia time with machine reperfusion to be obtained
better to use less immunosuppressant protocol or CNI free protocol post transplant
or save 1 patient with dual kidney transplant for more nephron mass and less DGF and better graft/patient survival
Would you accept this donor?
this donor is ECD ,71 years old ,hypertensive, recently diabetic with SAH ,urine out put was excellent till last hour ,no history of shock or hypotension, his creatinine 81mmol/L .
ECD donors was accepted to increase donor pool and decrease time on waiting list .
I will accept this donor with Proper selection of recipient for ECD and full information about the risk and benefit as it is very important to make recipients ready when the organ is avilable.
Using kidney donor risk index is a good tool
giving estimate of incidence if DGF ,graft survival.
it includes :age, sex, Race, history of medical conditions (hypertension and diabetes,s creatinine,viral infection),cause of death , DCD.
Pretransplant biopsy to determine glomerulosclerosis, ATN,cortical necrosis and other chronic pathological changes.
Biopsy will help to determine if donor is suitable for SKT ,DKT or the even to be discarded using Remuzzi score to help making decision.
Although some surgeons performe elliptical biopsy which gives higher percentage of glomerulosclerosis.
If yes, how do you select the recipient(s) suitable for this case?
Recipients mostly will be old age ,low immunological risk,with low mismatch and no DSA,diabetic ,female recipients are preferred.
Patient who needs urgent transplantation as being for long time on waiting list, out of vascular access .
Informed consent must be taken by recipient and early education about risks of DGF, episodes of rejection, and lower long term survival must be done.
-Decrease cold ischemia time and the use of oxygenated machine perfusion uf avilable to decrease IRI and DGF rate.
I will recommend ATG for induction and CNI minimization protocol to decrease CNI toxicity .
References:
BTS guidelines for transplantation from DCD.
I will accept the donor as ECK.
The recipient should be: older than 40 yrs, diabetic, on long waiting list, low immunological risk or dialysis patient with vascular access problems and females and small patients .
● This donor is elderly and have DM in addition to hypertention so he is ECD and he is agood option for DKT as
* He is older than 60 years
* History of hypertension
* History of diabetes
● The suitable recipient will be
* Older > 60 year
* Lower immunologic risk
* have minimal comorbidities
* BMI < 30 kg/m2.
* long waitting list
Would you accept this donor?
The donor DCD with ECD
Old age > 60
HTN and DM
with good kidney function
I will accept such donor
But I would like to perform DKT to increase healthy nephron mass
Survival advantage of ECD kidney transplant recipients over Dialysis patients remaining on transplant list
If yes, how do you select the recipient(s) suitable for this case
-Yes I would accept this offer as an extended criteria
(age more than 60 – HTN controlled by one agent- donation after cardiac death)
-suitable recipient older age (old for old
-female recipient (lower muscle mass)
low immunological risk (PRA<5%)
dual kidney transplant to increase nephron mass
I would accept this donor according to ECD.
The potential donor:
a) 71years old.
b) with mild DM and controlled HTN by one agent.
c) Excellent UOP and serum creatinine.
If yes, how do you select the recipient(s) suitable for this case?
I will select a recipient based on:
a) Matching age and size ( age for age).
b) DKT is considerable as the offered kidney is a marginal one(age >60).
c) BMI < 30.
d) Low immunological risk.
e) No or less comorbidities.
_ the current potential cadaveric donor is ECD (old age more than 60 years, with diabetes and hypertension). However, the long term outcome with ECD is better than waiting for transplantation on hemodialysis.
_ dual kidney transplantation can be used to increase nephron mass, as normal kidney function in such elderly patient with decreased muscle mass can be falsy overestimatin his GFR.
_ no consensus regarding the indication for DKT but GFR between 60-80 and Remuzzi score 4_7 generally considered for DKT.
_ still the choice of the recipient will be better of old age (old for old), as the longevity of the graft from such elderly donor will be suitable for old recipient with relatively lower muscle mass and shorter expected life span.
_ in addition, recipient with lower immunological risk will be better for such ECD.
1- for older & low immunological risk recipients , the outcome will be better
2- basically for patients who have been on waiting list for long time & /or failure of access for dialysis , so the outcome here will be compared to being on dialysis or on waiting list .
What do we do with this donor
Yes I would accept this donor.
The characteristics of this donor make him expanded criteria donor (ECD). He is elderly (71 years old), DCD, SAH grade 5, hypertension, mild DM.
Possible risks of using this donor :
However, despite all of these risks, survival advantage of ECD kidney over dialysis and patient remaining on transplant waiting list would facilitate the need to accept this donor.
DKT would be a good option for this donor-recipient pair. Outcome could possibly be better rather than conventional single kidney transplant. Major benefits associated with DKT would include increased active functioning nephron mass along with reduced risk of DGF. Good outcome is expected from this. In addition, since even the recipient is selected to be of age above 40, the expected life span is not more than 20 years and this raises the long term success rate of DKT.
Selecting recipient
The following recipients would fare better with this donor :
References :
Kidney transplantation is the best modality of RRT which associated with lower morbidity and mortality in comparison to dialysis. This donor is an extended criteria donor (age >60 years), controlled hypertension on one drug, controlled DM and after cardiac death (DCD) with good renal function in the form of serum creatinine 81 micromole/L, urine output 100 ml/hour).
Assessment of deceased kidney depends on main 6 parameters which includes
1. Clinical data
2. Laboratory and radiological assessment
3. Pre-implantation biopsy (Remuzzi score)
4. KDPI
5. KDRI
6. Viability assessed by perfusion machine
I will accept this donor as the outcomes of ECD transplant are better than remaining on wait-list but some data still needs to be fulfilled such urine PCR, kidneys ultrasound, blood group and HLA to compare with possible recipients on the waiting list.
Such a donor has increased risk of DGF, rejection and poor term graft survival (1).
Hanse that ECD kidneys have increased risk of DGF, rejection and poor term graft survival as compared to standard criteria donor kidneys. it is important to select the recipient appropriately based on immunological risk, age, body surface area matching and same demographic area to decrease CIT.
A small sized recipient (like females).
The recipient of matched age or more than 60 years old.
diabetic patient with age more than 40 years.
low immunological risk recipient
failing vascular access with urgent need to be transplanted.
Potential recipient on waiting time for long time.
same demographic area to decrease CIT
but some optimization of this kidney is needed by
References:
1) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 17, 2022.
2) Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transpl Int. 2008 Jan;21(1):11-7. doi: 10.1111/j.1432-2277.2007.00543.x. Epub 2007 Sep 10. PMID: 17850235.
3) Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3 Suppl 4:114-25. doi: 10.1034/j.1600-6143.3.s4.11.x. PMID: 12694055.
4) Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
Clinical data :
ECD of denotation with the age more than 60 years old
Hypertensive, DM, and After DCD
and fortunately good Kidney function with S Cr 81µmol/L excellent urine output (100 ml /h)
I will accept this donor due to transplants definitely have survival advantages over dialysis patients remaining on the transplant waiting list.
However, ECDs have a higher risk of delayed graft functions, and more risk of acute rejections with less graft long-term survival.
Most of the studies confirm that the grafts from ECD donors have worse survival and function compared to SCD grafts
So the recipients selection preferred to be
older patients
low body mass
low immunological risk,
prolonged waiting for an SCD kidney
multiple vascular access failure
In selecting the induction in these patients antithymocyte globulin or Alemtuzumab for ECD kidneys due to the high risk of rejection and delayed introduction of Tacrolimus or use of low dose.
Use of DKT vs SKT as there is now more evidence that DKT can achieve good long-term outcomes, often comparable to SKT as selection criteria were proposed and utilized. Various criteria are considered: age, comorbidity (diabetes or hypertension), cold ischemia time, creatinine clearance, and preimplantation biopsy finding for allocation.
in our situation, there are many risks as ECD, DM and HTN so we preferred of DKT to the marginal kidneys.
Remuzzi et alassessed their biopsies and used scores for glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arterial and arteriolar narrowing. The final score was labeled mild if the score was 0–3, moderate 4–6, and severe 7–12. The kidney with mild score was preferred for SKT and moderate grade (4–6) for DKT.
Ref :
Remuzzi G., Grinyo J., Ruggenenti P., et al. Early experience with dual kidney transplantation in adults using expanded donor criteria. double kidney transplant group (DKG) Journal of American Society of Nephrology. 1999;10(12):2591–2598.
Stallone G, Infante B, Gesualdo L. Older donors and older recipients in kidney transplantation. J Nephrol. 2010;23:S98–S103
Yes, I’ll accept this donor. As ECD still can prolong life in long awaited kidney recipient.
I’ll consider followings
yes I will accept this donor as ECD ,this can go for SKT as his age with two comorbidity
better to benefits for two recipients
we can choose the recipient who is old age with with mass match or who has vascular access problems
Also we can accept him fo DKT as well with greater nephrology mass
Would you accept this donor?
If yes, how do you select the recipient(s) suitable for this case?
1- elderly
2- with poor vascular access for hemodialysis and not candidate or peritoneal dialysis
3- HIV +ve patients.
4- patients with sickle cell anemia as their expected survival is about 3 years.
5- other less healthy patients.
Yes, I would accept him as a donor
This donor is ECD ; age: 71, HTN , DM
– Diabetic patient
– In long time waiting list (> 4 years)
– Female patient or small size recipient
– Age match if possible
Thanks, see my question above
Too short !
this kidney is expanded criteria donor with more than 70 years old. the kidneys increased glomerular, vascular, and tubular senescence. The survival benefits seen in recipients of marginal kidney transplants are inferior compared with those in recipients of standard criteria donor kidneys, but significantly better than in those remaining on hemodialysis.
This marginal kidneys are better transplanted to those who above 55 years old, those who has been on longer dialysis vintage, those recipient who has one or two co-morbids.
Dual Kidney transplant is better for those who has egfr 30-60 and single kidney transplant for those who more than 60. however Remuzzi score will aid in determining single or dual kidney transplant .
Paride De Rosa etval -Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients
Thanks, see my question above
Thankyou
This 71 years ,hypertension ,diabetes is ECD.
Yea can be accepted as potential donor ,with risk of delayed graft function and poor in
young recipient and high morbidity and mortality in old recipient
quality organ which may fail within a short time.(1)
older DCD donors (>60 years), particularly those with hypertension and/or
cardiovascular death, pre-implantation biopsy may identify kidneys with substantial
arterial disease or glomerulosclerosis that are likely to have poor long term outcome.
Donors with low GFR, elderly donor, diabetes, prolonged cold ischemia consider use of
dual kidney transplant.
if yes, how do you select the recipient(s) suitable for this case?
it is important to avoid exposing young patients to sensitization from a poorly matched,
poor quality organ which may fail within a short period of time. old for elderly is better ,
as marginal organs from marginal donors should be allocated to the oldest patients
because these organs will not last as long as others and may not need to, simply
because life expectancy is 73 years for men and 79 years for women.
References:
1-BTS 2013.
2-Henry B. Randall, Sean Cao, Michael E. de Vera. Transplantation in Elderly
Patients. Arch Surg. 2003;138(10):1089-1092. doi:10.1001/archsurg.138.10.1089.
Thank you. In this ECD marginal kidney, would you consider a dual donation? How do you decide that?
Thanks, see my question above
This is an ECD :
-71 years
-HTN , SAH and diabetic too
*Using kidney grafts from ECD donors has been shown to be beneficial for kidney transplant recipients, being especially beneficial if the recipient is properly selected.
In the United Kingdom, the percentage of donors from DCD, mostly controlled cDCD, increased six times between 2004 and 2013
In the Netherlands, 43% of the kidney transplants performed between 2000 and 2017 came from cDCD.
In Spain, cDCD accounted for 24% of all transplants performed in 2018 and 26% of transplants from deceased donors.
*This increase is due to evidence that cDCD grafts, despite the inherent risk of associated warm ischemia, have the same long-term graft survival as DBD grafts.
*Merion et al. showed that receiving a graft from a ECD donor reduced the recipient’s mortality by 17% compared to remaining on the transplant waiting list or subsequently receiving a transplant from a conventional donor.
A recent meta-analysis of 12 studies including 6008 DCD and 13,129 DBD transplants found no significant differences in graft survival at one, three, five, and 10 years.
The use of DCD has also been shown to reduce mortality significantly, by 56%, as compared to those who continued on the waiting list, even if they subsequently received a conventional DBD graft.
So i will accept this donor and with optimization of the ECD kidney through the following:
1-Short CIT
2-Low immunological risk recipient :
3-Small body sized recipients(females)
4-Machine perfusion -hypothermic -02 based with the following benefits :
A- lower the DGF rate significantly
B-lower the IRI
C-testing the viability of the kidneys
5-Preemptive biopsy and scoring
6-Dual kidney Tx for fit recipients
7-Proper recipient selection who will mostly benefit from the ECD kidney :
A-More than 40 years old
B-waiting list more than 4 years
C-low immunological risk
D-Diabetic
E-HDx with access problem
8-IS manipulation
References :
1-R.M. Merion, V.B. Ashby, R.A. Wolfe, D.A. Distant, T.E. Hulbert-Shearon, R.A. Metzger, et al.
Deceased-donor characteristics and the survival benefit of kidney transplantation.
JAMA, 294 (2005), pp. 2726-2733
2-A.B. Massie, X. Luo, E.K. Chow, J.L. Alejo, N.M. Desai, D.L. Segev.
Survival benefit of primary deceased donor transplantation with high-KDPI kidneys.
Am J Transplant, 14 (2014), pp. 2310-2316
3-M.J. Pérez-Sáez, E. Arcos, J. Comas, M. Crespo, J. Lloveras, J. Pascual.
Catalan Renal Registry Committee. Survival benefit from kidney transplantation using kidneys from deceased donors aged ≥75 years: a time-dependent analysis.
Am J Transplant, 16 (2016), pp. 2724-2733
4-D.M. Summers, C.J. Watson, G.J. Pettigrew, R.J. Johnson, D. Collett, J.M. Neuberger, et al.
Kidney donation after circulatory death (DCD): state of the art.
Kidney Int, 88 (2015), pp. 241-249
Thankyou Mohamed to decide SKT or DKT which method will you choose for this index case.
1-Nathan HM, Conrad SL, Held PJ, et al. Organ donation in the United States. Am J Transplant. 2003;3(S 4):29–40. [PubMed] [Google Scholar]
2. Žilinská Z, Sersenová M, Chrastina M, et al. Occurrence of malignancies after kidney transplantation in adults: Slovak multicenter experience. Neoplasma. 2017;64:311–17. [PubMed] [Google Scholar]
3. Metzger RA, Delmonico FL, Feng S, et al. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3(S 4):114–25. [PubMed] [Google Scholar]
4. Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA. 2005;294:2726–33. [PubMed] [Google Scholar]
Thankyou Manual in this index case he fits into ECD then how are you going to evaluate and decide is it SKT or DKT and how?
Risk factors associated with this case:
As per guidelines
Hence Age alone makes him a marginal donor. Therefore, I will accept him for donation and I will go ahead for single kidney transplant.
I will preferably select age matched donor for SKT as there will be definately some age related glomerulosclerosis and hence long term graft outcome may be guarded in young recipient
typo error “age matched recipient”
Thank you Yashu .In fact in your last line you mentioned that there are going to be chronic changes in this ECD kidney. So this is a case very fit for a Remuzzi score which really looks at chronic changes and then you can decide single or double. The rest is easy to choose the suitable recipient.
As risk of graft failure is >70 % being ECD when compared SCD, recipient could selected with age > 40 years , more than 4 years of wait listing ,low immunological risk ,DM ,Vascular access problems with preferably small sized body mass eg females.
Immunosuppression modulation is needed including induction with ATG or Alemtuzumab decreased CNI exposure or CNI free Belatacept protocol.
Thanks, Ahmed
Would use these kidneys as DKT or separately WITHOUT performing a pretransplantation biopsy?
– This donor is an ECD due to his age 71 y ,being DCD, he had DM and hypertension but his creatinine and urinary output are acceptable
So these kidneys had to be evaluated for their quality and NMP can be used and e GFR , CIT ,FWIT and biopsy will be needed to detect any histopathological affection so multiple factors need to be collectively scored to assess the quality of these organs and their fitness for transplantation.
With the available preliminary data I can accept this donor to a certain recipient.
– The recipient can be chosen with matching age and body weight so an old recipient with low immunological risk can be a better recipient and to increase the nephron mass and enhance the renal function DKT can be an appropriate option to reduce DGF and increase graft survival in an elderly with potential short life expectancy so the time for complications to occur could be shorter.
Well done this is a case that will benefit from a biopsy.
ECD donors used to expand deceased donor pools especially for elderly recipients.ECD donor with DCD associated with increase DGF rate, lower graft & patient survival, but it still better outcome than staying on dialysis or waiting list, 40-80% mortality rate lower in recipient with ECD than patient on waiting list.
This patient meet criteria of ECD, & can be accepted with emphasizing on reduction of CIT, using of pulsatile perfusion preservation & using of IS with less nephrotoxicity. This donor best to offer for elderly patient with DKT to increase number of functional nephrons.
References:
How can you decide SKT or DKT
criteria for DKT differ according center policy, but in general it needed for elderly donors(>70 years), presence of comorbidity as HT & DM, CIT & creatinine clearance.
Important information:
1) Age 71 years old DCD
2) Has a history of SAH grade 5
3) History of BP but using one medication
4) History of recently diagnosed DM
5) Normal kidney functions and excellent urine output
From the case presentation, I should think the patient can be a donor. However, he will fall under the extended criteria donor which is a person over the age of 60 years old or a donor over 50 years old with the following: elevated BP and a creatinine great or equal to 1.5 and or death resulting from stroke. The ECD is important given that it helps to provide recipients with a donor and as such reduces the waiting list. A kidney biopsy can be done to see the chronicity of the kidney and as such both kidneys can be donated to one individual. Also, the recipient has to be aware of the donor’s age and the risk and benefits of accepting the kidney. It must be also noted that the recipient must understand all the intricacies and sign legal documents that all were explained and accept the terms and conditions.
Now which group should receive the kidney? I should believe a recipient around the same age or one that ages around 40 and above years old. Now after deciding to donate the kidneys, there must be a protocol in place to ensure there are reduced chances of kidney rejection. So one must try to ensure cold ischemic time is reduced, ensure blood pressures and saturation maintain acceptably, an immunosuppressive medication to reduce early rejection, and ensure glucose levels are normal or acceptable.
Well done
This is an extended criteria donor (age >60 years) with donation after cardiac death (DCD) and good renal function (serum creatinine 81 micromol/L, urine output 100 ml/hour). In addition, the donor also had hypertension and mild diabetes.
Such a donor has increased risk of DGF (1).
But I will accept this donor as the outcomes of ECD transplant are better than remaining on wait-list (2).
The ECD kidneys have lower graft survival as compared to standard criteria donor kidneys (3). Hence it is important to select the recipient appropriately.
The recipient selection in this scenario would be based on age and body surface area matching (2). A small sized recipient (like females) would be better. The recipient should be more than 60 years old or diabetic patient with age more than 40 years, with low immunological risk, with failing vascular access and with expected waiting time on wait-list exceeding life expectancy on the waiting list without transplant (3).
Another aspect which needs to be dealt with is regarding using a single kidney or dual kidney transplant (DKT). A pre-implantation kidney biopsy will help in taking a decision in this regard (4). Kidney biopsy with a Remuzzi score of 4-6 (or glomerulosclerosis between 15-50%) should be used for DKT.
The prospective recipient should be informed about the graft outcomes in this scenario and an informed consent should be taken before proceeding with the transplant.
Peri- and post-transplantation management will include use of machine perfusion, induction therapy in form of either ATG or Alemtuzumab. Maintenance immunosuppression in form of Tacrolimus – with delayed introduction of Tacrolimus (to reduce the incidence of DGF), MMF and steroids (1).
References:
1) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 17, 2022.
2) Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transpl Int. 2008 Jan;21(1):11-7. doi: 10.1111/j.1432-2277.2007.00543.x. Epub 2007 Sep 10. PMID: 17850235.
3) Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3 Suppl 4:114-25. doi: 10.1034/j.1600-6143.3.s4.11.x. PMID: 12694055.
4) Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
Excellent also consider the UK Kidney advisory group score according to the eGFR