2. You were offered kidneys from a 21-year-old DCD donor who suffered from hypoxic brain damage (committed suicide by hanging). He had cardiac arrest for 45 mins before being revived. No history of hypertension or DM, S Cr 190 µmol/L before retrieval. He is still passing urine (40 mls/h during the last hour and 1.8 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
I have noticed many colleagues keen to biopsy these kidneys to inform decision-making. Are you expecting the biopsy of these ATN kidneys to show something else except ATN?
In other words, do you think the biopsy will add something or just may end to discarding the kidneys?
Thanks you alot Prof.Halawa
This donor 21 years old — young
A- AKI (Prerenal – hypoperfusion).
B-Still passing urine 40 ml/hours.
C- And non oliguric ATN
If desion about biopsy to make DD from ATN – ACN
What would be your :
perfusion plan
Immunosuppression plan for this grossly ischemic injury.
Thanks alot for you Prof.Dawlat
Two basic mechanisms play an important role in IRI:
Perfusion plan
Immunosuppression plan for this grossly ischemic injury.
—————————————————————————————
Refrence
Thank you Dr Wadi
I agree with you
I note your viewpoint, Dr Wadi.
prolonged cardiac arrest can lead to ATN or cortical necrosis. Even the degree of ATN will give an idea about the time of recovery post-transplant.
I note your concern, Dr Waem
The kidney biopsy will help nothing in making diagnosis of atn
But it help us to use the rimuzzie socre to no if we have to transplant one kidney or both kideny or exclude if more than 7
I like your approach but you have not mentioned any evidence to support your argument.
no need for kidney biopsy this is a typical prolonged ischemic hypo perfusion injury with non oliguric AKI in a previously healthy young donor we need to preserve the organs by using the normothermic or oxygenated hypothermic perfusion machine to avoid further ischemia time till getting a suitable recipient induction to depend on immunological risk could be still basiliximab vs almutezmab and delayed the introduction of CNI or use CNI free protocol
I like your approach but you have not mentioned any evidence to support your argument.
no need for biopsy as will not add anything
Your reply is too brief, dear Dr Riham
I don’t think the kidney biopsy will change the suspected diagnosis of ATN induced AKI.As far as its stage 2 AKI as per AKIN classification, I would recommend Machin cold solution infusion for procurement, to minimize the DGF and NFA . The allograft in this context ( young donor with no comrbidities , but with hypoxia and DCD) will be faring well and long term survival might be comparable to DSC..
Biopsy will add no thing and yes may increase the risk of discarding this kidneys
Really we had a similar case of non oliguric ATN of a young potential donor but DBD due to severe brain injury, patient had azotaemia and hyperkalemia and passing good UOP (even we did CRRT to correct hyperkalemia before retrieval).Transplant team decided to decline kidney transplantation and they proceed for liver transplantation. I think kidney biopsy in these cases can make more confusion.
The point for implantation biopsy that it helps the caregivers and patients to decide whether to accept a less than ideal kidney for transplantation. it is important to understand whether donor biopsies accurately predict posttransplant outcomes, or it provides a false sense of security in discarding kidneys based on misleading histological findings.
There is lack of evidence that implantation biopsies can reliably predict posttransplant outcome. Indeed, this issue has been debated in Europe, where procurement biopsies are used much less frequently than in the United States where deceased donor kidney biopsies are routinely performed to facilitate the decision of organ allocation.
Reference
Hopfer H, Kemeny E. Assessment of donor biopsies. Curr Opin Organ Transplant 2013; 18: 306–312
Haas M. Donor kidney biopsies: Pathology matters, and so does the pathologist. Kidney Int 2014; 85: 1016–1019
The donor is young, with no history of DM or HTN, and had renal hypoperfusion from cardiac arrest.
I think the biopsy in such a case will not add more information rather than ATN and will increase the discard rate.
Kidney biopsy may not give such details at this instance since it is an AKI and what the biopsy will reveal is acute changers found in AKI. If the cause was unknown then a biopsy would give a definitive diagnosis. currently not relavant.
Thank you, well done.
No.
Kidney biopsy will not add anything in this scenario.
It might be of value in someone who is older, history of hypertension, or with severe AKI (to look for cortical necrosis or signs of chronicity). Acute tubular injury in pre-implantation biopsy does not help in predicting transplant outcomes, although chronic injury correlates with the GFR and survival (1)
Reference:
1) Koyawala N, Parikh CR. A Review of Donor Acute Kidney Injury and Posttransplant Outcomes. Transplantation. 2020 Aug;104(8):1553-1559. doi: 10.1097/TP.0000000000003144. PMID: 32732831.
Thank you, well done.
if his baseline serum creatinine is normal then the biopsy is most likely ATN and biopsy will increase the tendency to discard the kidney
Would you accept this case:
This is a young donor with h/o cerebrovascular death >45 minutes – Marginal donor
The donor has AKI (Pre-renal) probably ATN
Still passing urine of 40ml/hr
Current evidence suggests that donor AKI may not impair transplant outcomes- The donor can be accepted.
There is hardly any role for biopsy in this case- nothing is expected than ATN
Suitable recipient would be:
Palmisano A, Gandolfini I, Delsante M, Cantarelli C, Fiaccadori E, Cravedi P, Maggiore U. Acute kidney injury (aki) before and after kidney transplantation: Causes, medical approach, and implications for the long-term outcomes. Journal of Clinical Medicine. 2021 Apr 2;10(7):1484.
Andrews PA, Burnapp L, Manas D. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70.
A previous study reported that the use of a kidney from donors who develop AKI is not associated with long term graft dysfunction even if CIT was prolonged except if the donor is ECD, subsequent studies reported increase in the risk of graft failure when using kidneys form donors who develop AKI when compared to non AKI donors and the risk increase with increasing the stage of AKI from 1 up to 3
So the authors recommended that it is safe to use kidneys form donors who develop AKI stage 1-2 provided they are SCD, while donors who have either severe AKI stage 3, or AKI ECD my benefit from further evaluation by biopsy to exclude cortical necrosis > 10 % and advanced glomerulosclerosis > 20%, respectively, and certain strategies such as the use of machine perfusion and/or minimization of CIT
So … I think it will add only in patient with AKI stage 3 (elevation of serum creatinine ≥3 times of the reference value or rise of creatinine > 4 mg/dl) to exclude the development of CAN, or if the donor is ECD to assess glomerulosclerosis
To conclude our patient is a SCD, who develop AKI stage 1-2 so no need for biopsy except if the creatinine continue to rise, other wise I will give the maximum care to adjust hemodynamics
Biopsy can be helpful distinguishing the extent of involvement, which guides discarding kidneys or not.
REMUZZI scoring system is made to diagnose chronicity lesions to decide SKT or DKT as long as the donor has no chronic kidney disease and his age is 21.biopsy pretransplant will not add a lot in decision making
I will not accept Kidney biopsy, it will add no additional benefit in AKI secondary to ATN
No, it seems that biopsy won’t show nothing except of ATN in a young donor with good urine output. To reduce ischemic damage, normothermic or oxygenated hypothermic perfusion machine is used. Selection of an appropriate recipient with low immunologic risk and delay CNI introduction will be a good option.
This is a young donor with cardiac arrest with no history of hypertension or diabetes…there is prolonged period of cardiac arrest before organ retrieval…The donor has high creatinine due to oliguric ATN from pre renal cause…Renal biopsy will not show any chronic changes apart from ATN…Renal biopsy can be done in those kidneys with underlying long standing changes, to decide on implantation based on Remuzzi score…
The recipient selection is important…A elderly recipient with low immunological risk whose life expectancy is more on transplant as compared to waiting time on hemodialysis should be chosen.. There is anticipated delayed graft function and prolonged dialysis dependency state in the post operative period which the patient should be counselled upon….The recipient should receive ATG as induction agent with CNI minimizing protocols…The kidney can be used for normothermic renal perfusion to maximize the outcome
This is a marginal criteria donor with age less than 50 years with donation after DCD with no history of DM and HTN . The DCD is non oliguric AKI With creat 190 . Yet the outcome post AKI and non AKI donors are not significantly different. But post AKI donors may have delayed graft function .
Asphyxiation shows similar results to that of other causes of death
So , I shall accept this donor .
Biopsy of the kidney is important, other wise it will be difficult to accept this as a dnor
Yes.
Recipient selection criteria.
Potential kidney transplant recipient on long waiting list with exhausted vascular access for HD or sign of UF failure for CAPD.
middle age
Non oliguric ATN
can be accepted as a donor
Would you accept this donor?
Donor AKI doesn’t impair transplant outcomes in standard-risk donors. (1) The evidence is less convincing for marginal donors like this index case. (1) He had AKI as a result of cardiac arrest and had no other comorbidities. I will accept this donation after receiving written informed consent of delayed graft function and less than favourable graft outcomes compared to standard-risk DCD donors due to the ever-increasing demand for organs, rising ESRD, and worse outcomes of dialysis compared to transplantation of a marginal donor DCD/DBD kidney. For such marginal DCD donors, protocols should be implemented for good organ retrieval, minimization of cold ischemia times, and the preferable use of machine perfusion.
Role of preimplantation biopsy
It will not add much and likely show features of ATN, which is not going to change the management plan.
Selection of recipient:
Induction and maintenance immunosuppression plan:
ATG induction followed by gradually start of CNI or CNI free protocol with use of belatacept or mTOR inhibitors (after ensuring wound healing)
Reference:
I would accept this donor
He has non oliguric ATN . Biopsy won’t add much so it is not needed.
Machine perfusion should be prefered as it can reduce the delayed graft function rate
Reduces ischemia reperfusion injury. Increases the transability of ECD.
Recipient should be Elderly
Small muscle mass
low immunological risk. long waiting time
Would you accept this donor?
I would accept this donor.
21 y old donor, not DM, not HTN, committed suicide by hanging –à> DCD marginal kidney.
Mostly he developed non-oliguric ATN after cardiac arrest.
If yes, how do you select the recipient(s) suitable for this case?
Recipients with best HLA match and low immunological risk.
Donor will need machine perfusion to improve UOP and serum creatinine.
IS: induction (ATG or Almetuzumab), delay starting CNI or use CNI free regimen.
yes I will accept, this a young donor without any history of chronic illness the only risk factor for DGF is prolong ischemia time due to cardiac arrest
should be old age without vascular problem
· I will accept him with considering the following items. This DCD donor is young with no comorbidity and non-oliguric AKI. So, I will accept him as a marginal donor for proper recipient after explaining the conditions.
The recipient should be older than 40, low immunological risk, diabetic, small size, remaining more than 4 years on waiting list and having vascular access problems. Dual kidney transplantation is recommended in these situations.
Induction with agents that could delay CNI introduction like ATG or alemtuzumab.
This kidney should not be discarded, several studies compared the effect of donor AKI on the outcome of transplantation versus non-AKI donors and showed that donor AKI is associated with increased incidence of delayed graft failure, however, there was no difference in acute rejection rate or long term graft function determined by eGFR or creatinine clearance and that graft survival was similar in the 2 groups.
There is a growing evidence suggests avoiding the decline of kidneys with AKI to increase available kidneys for transplantation to decrease the waiting list.
This kidney better to be offered to elderly recipient with low immunological risk, difficult vascular access, long waiting time on the waitlist.
Post transplant, CNI minimization may be preferred to avoid its nephrotoxic effect.
Koyawala N, Parikh CR. A review of donor acute kidney injury and posttransplant outcomes. Transplantation. 2020 Aug 1;104(8):1553-9.
Yes, I would receive this kidney, because:
– young patient
– No prior kidney disease
– Baseline renal function after injury without indication for hemodialysis;
I would select an older receiver because it has less metabolic demand, being able to adapt to a situation of an injured organ that does not fully recover.
This case of young age DCD donor with prolonged cardiac arrest, oliguric, no history suggestive of comorbidities as HTN or DM, (history of drug abuse or addiction or smoking should be excluded),considered as ECD with better outcome compared to remaining on waiting list or facing complications of prolonged dialytic support.
Can be accepted for donation in special situations including patients 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. Counselling the recipient for the high probability of delayed graft function is recommended in such situation.
Reference:
According to the British Transplant Society guidelines.
Aubert et al; BMJ; 101h; 1157 (2015)
Merion et al JAMA; 294; 2726 (2009)
A young DCD donor can be accepted as making a good urine output. despite, there is risk of DGF but can be accepted for donation.
No because this case devloped AKI its take long time to recovary and later if take ATN itvwill be there.
if take to spesfaic recipent should be clear from DSA and recipent might be need high dose of immunosuprssent ,because the chance of rejection is high
_ I will accept the current donor, as it is proven from many studies that transplantation of cadaveric kidney with AKI has comparable graft outcome after 3 months post transplantation. (despite having higher risk of DGF).
_ especially in such young age donor (SCD).
_ However, appropriate choice of the recipient and optimization of transplantation through:
_ small size or female recipient (Need smaller nephron mass)
_ shorten the cold ischemia time
_ use hypothermic perfusion machine rather than static or standard cold storage
_ optimization of hemodynamics prior to transplantation.
_ use of ATG or alemtuzimab induction to delay CNI introduction or use CNI free protocol through belatacept use or MMF and steroids.
_ NO added benefit to do allograft biopsy here, as it will show ATN (from ischemic injury)
*Yes, I will accept this ECD donor , DCD 21 years old with pre-renal AKI , passing urine out put 40 ml/hr. since ; AKI will not affect renal graft survival.
*Biopsy only needed to judge regarding Rumzei scoring system only if transplant SKT or DKT but no difference in diagnosis it is mostly ATN.
If accept this donor will need machine perfusion to decrease incidence of DGF.
*The suitable recipient for marginal donor will be:
1. Older age > 60 years.
2. Lower immunologic risk
3. On long time waiting list.
4. Long time hemodialysis and having vascular access failure.
5.small muscle mass recipient.
-References:
Andrews PA, Burnapp L,etal.,:Summary of BTS guidelines for transplantation from donors after deceased circulatory death. Transplant. 2014 Feb 15;97(3):265-70.
yes, young donor, with no co-morbidity, urine40 ml/hr
AKI mostly due to ATN , biopsy will not add to the diagnosis.
*Machine perfusion to reduce the DGF rate
*Immunosuppression : Induction with ATG withDelayed CNI introduction regimens
This is borderline or marginal kidney from young donor with AKI due to prerenal.
I will accept it but will inform the recipient about the risk of delayed graft function.
As this is marginal kidney, recipient is better to be above 40years with long dialysis duration and difficult dialysis access.
The available donor is 21 years old DCD with hypoxic brain injury , AKI but good UOP and no past medical history
* I will accept that donor it is considered better option than keeping another ESRD patient on waiting list and ongoing dialysis.
*the recipient INSHALLAH must
Old age> 60 years old
On long waiting list.
Decreased immunological condition
On dialysis with vascular access problem.
Would you accept this donor?
21 year old DCD
Hypoxic brain injury
No medical conditions
AKI but passing urine
Keeping in view the above findings he is a marginal donor and not ECD
So we can proceed with donation and transplantation. The graft outcome may be poor but still better than dialysis.
The diagnosis is clinical and biopsy will not add any thing extra.
Hypothermic machine perfusion may decreased DGF and also improve immune response.
Induction with ATG and Alemtuemab and maintenance MMF and steroids-CNI Free
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
sorry for the delay response
we have a young donor
with AKI due to hypoperfusion no other risk factors
has good UOP
AKI is no longer exclusion criteria for donation ,however if patient under EDC may need further work up like biospy , rumzzi scoring and oxygenated hypothermic reperfusion machine
i will accept him
i dont think biopsy will add any thing to my diagnosis(ATN) unless if i have urine analysis showed proteinuria / hematuria
Donors with AKI are more likely to undergo delayed graft function but have similar long-term outcomes as donors without AKI. The mechanism for similar graft survival is unclear. Some hypothesized mechanisms include (1) ischemic preconditioning; (2) posttransplant and host factors playing a greater role in long-term survival than donor factors; and (3) selection bias of transplanting only relatively healthy donor kidneys with AKI. Existing literature suggests transplanting more donor kidneys with stage 1 and 2 AKI, and cautious utilization of stage 3 AKI donors,
for recipient selection criteria ( as EDC recipient )
references :
https://pubmed.ncbi.nlm.nih.gov/32732831/
This young donor 21 years old who committed suicide, cardiac arrest for 45 minutes which resulted in non oliguric acute tubular necrosis ,s creatinine 190 µmol/L before retrieval.
He has no past known medical history.
The mode of death following ligature asphyxiation results in global tissue hypoxia and the effect that happens on end organ function following kidney transplantation has never been fully assessed.
The results of one cohort analysis clearly demonstrate that the outcomes for recipients of kidneys from both DBD and DCD donors who have died following ligature asphyxiation are comparable to those for recipients of kidneys from donors who have died from all other causes.
DGF and 12‐month eGFR were significantly better in recipients ftom DBD donors who died following ligature asphyxiation.
recipients of kidneys from DCD donors who died following ligature asphyxiation had superior transplant outcomes compared to those seen in recipients of kidneys from all other DCD donors.
May be explained by young age of donors and no other comorbidities.
The additional warm ischemic insult from ligature asphyxiation was not associated with an increase in either PNF or DGF.
The rates of DGF and risk of PNF increased significantly when kidneys from donors with AKI stage 3 are transplanted.
Kidney biopsy pretransplant will show the acute ischemic changes ,ATN.
These ischemic insult is still can be reversed by good perfusion to save the organ.
So i will accept this organ ,oxygenated machine perfusion if available will help to reduce IRI and DGF
dual kidney transplantation can be an option also due to the prolonged warm ischemia time.
If yes, how do you select the recipient(s) suitable for this case?
-Patients older than 40 years.
-Long waiting time on Dialysis.
-failed vascular access.
– low immunological risk, no DSA.
-Diabetics.
Informed consent must be taken with full information to recipient about potential risks of DFD ,acute rejection, graft failure.
Induction with ATG, and use of CNi free or low protocol , especially in elderly recipients to reduce drug toxicity.
Patrick B. Trotter, Ina Jochmans.Transplantation of kidneys from DCD and DBD donors who died after ligature asphyxiation: The UK experience.Am J Transplant. 2018 Nov; 18(11): 2739–2751.
● DCD young donor with AKI but still passing urine
biopsy will add nothing except ATN
I will accept this donor ( marginal kidney )
As AKI not affected graft survival
The suitable recipient will be
* Older > 60 year
* Lower immunologic risk
* long waitting list
* urgent recipiant
This patient has an eGFR of 44 ml/min, which is not expected to be a result of the scenario of low duration. He may had some form of medications or herbs that affected his kidney function otherwise. passing good urine will make me think of accepting him supposing AKI component, but I will not give his kidneys to young patients. DKT may be an option, but I prefer to give his kidneys to a very young patient. I will check for proteinuria (nephritic range is acceptable). But in the case of the nephrotic range I will discard this donor
I think taking a be biopsy will good for deciding on a management plan after transplantation. Nothing I lose If I take it. It may be kept for future evaluation anyhow.
Young DCD with hypoxic brain damage and WIT around 45 min with pre renal AKI but still passing urine (ATN) mostly
This donor is not meeting the definition of ECD and also not SCD
He is consider marginal donor and there is no absolute contraindications for preventing transplantation from such donor
So I will proceed for donation and my opinion with SKT
also it is still associated with improved outcomes compared with waitlist mortality.
NOTE THAT And according to British Transplantation Society Guidelines The use of kidneys with >30 minutes of total WIT should be restricted to programmes which are undertaking measures to ‘recondition’ organs via ex situ oxygenated normothermic perfusion, with the possibility of more predictive assessment of organ quality than appears possible with static cold storage or cold perfusion technologies.
Neither acute renal impairment nor haemodynamic instability during a prolonged period from withdrawal of life-sustaining treatment until cardiorespiratory arrest influence DCD kidney graft outcomes .
If yes, how do you select the recipient(s) suitable for this case
In general
>>> immunosuppressive treatment should be used in aim to reduce the incidence of rejection
As Kidneys retrieved from DCD donors will inevitably have suffered warm ischaemic damage and will be at increased risk of both PNF and DGF.
Widely favoured strategies to reduce the incidence of DGF and the risk of clinically silent rejection occurring during periods of DGF include the use of induction therapies to reduce the risk of rejection and the avoidance or delay in introduction of calcineurin inhibitors (CNIs).
I have gone through answers given by colleagues and would like to put my opinion to approach this case in a different way.
As per BTS guidelines following are absolute contraindications for transplanting kidneys from DCD donors.
But still Kidneys with WIT > 30 minutes can be considered at those centers /programs
which are undertaking measures to ‘recondition’ organs via ex situ oxygenated normothermic perfusion.
So in the light of above, for the above case there is no doubt that patient has suffered hypoxic renal injury (non -oliguric AKI) but still I will go ahead for pre implantation biopsy to differentiate whether it is ATN or ACN. Now,
I would accept this donor:
a) Although having high serum creatinine ,this donor is young and his suicidal attempt may give a clue to an underlying medical problem related to his psychiatric illness. Pre-suicidal poor oral intake and cardiac arrest may be behind the deterioration of kidney function that may improve in the post-transplant period.
b) I will consider the donor’s kidney as a marginal kidney which will be suitable for DKT rather than SKT.
If yes, how do you select the recipient(s) suitable for this case?
a) For DKT.
b) I will select a recipient with an old age as this kidney may have DGF and poor outcome in the post-transplant period. will be unwise to offer this marginal kidney to a young recipient with long life expectancy.
c) Low immunological risk.
d) No or less comorbidities.
Would you accept this case:
Yes I will accept
Young donor with cause of death CV cause ( marginal donor )
45 minutes of arrest causing ATN and still passing urine
Dual kidney may be taken
Suitable recipient would be:
Female or small muscle mass
Elderly
Diabetics
Low immunological risk
Multiple access failure
Age more than 40
On waiting list more than 4 years
basically, to recipient who have no available living donor with long time on waiting list or vascular accses failure on dialysis .
& Preferably to older patient , low immunological risk & low BMI
Kidney transplantation is the best modality of RRT which is associated with lower morbidity and mortality in comparison to dialysis. This donor is a DCD marginal kidney
Assessment of the donor’s kidney
So, I will accept this kidney but after optimization of this kidney as it controlled DCD so is better to wait until improvement of serum creatinine and urine output,
The question is to whom recipient can we offer a marginal kidney?
as mentioned before I will wait until the improvement of s.creatinine and UOP and optimization of this kidney then can be offered to any recipient with low immunological risk in the same demographic area to decrease CIT
but some optimization of this kidney is needed by
REFERENCES
Clinical data
Young donor with no history of DM or HTN
Presented with AKI (S Cr 190 µmol/L before retrieval, passing urine (40 mls/h during the last hour) expected to be ATN
I will accept the donor as
due to the shortage of donors available, in additional to transplants definitely have survival advantages over dialysis patients remaining on the transplant waiting list
However risk of delayed graft functions, acute rejection and maybe graft loss increase with donors associated with AKI .
the donor with AKI ( due to Ischemic and Toxic insults ) with normal baseline kidney functions, not DM and not HTN are usually associated with good graft outcome and are accepted to be a suitable donor
however, it might not to accepted if AKI stage 3 due to a higher risk of poor outcomes after kidney transplantation.
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
informing the recipient that transplantation may be associated with delayed graft functions with an increased risk of acute rejection
Some implementations may help graft outcome :
early introduction anti-thymocyte globulin or Alemtuzumab
decrease cold ischemia times
use of machine perfusion
References
Merion, R.M.; Ashby, V.B.; Wolfe, R.A.; Wolfe, R.A.; Distant, D.A.; Hulbert-Shearon, T.E.; Metzger, R.A.; Ojo, A.O.; Port, F.K.
Deceased-donor characteristics and the survival benefit of kidney transplantation.
Kilambi, V.; Bui, K.; Hazen, G.B.; Friedewald, J.J.; Ladner, D.P.; Kaplan, B.; Mehrotra, S. Evaluation of Accepting Kidneys of
Varying Quality for Transplantation or Expedited Placement With Decision Trees. Transplantation 2019, 103, 980–989.
This ECD is marginal but can be accepted in following settings:
– Elderly recipient
– Long transplant waiting list
– Recipients with dialysis vascular access problems
– Recipient with low muscle mass and small size
– Recipients with lower immunologic risks
– Induction agent should be potent eg. ATG / Alemtuzumab.
– Machine perfusion.
– Patients will benefit from delayed or low dose or CNI free regime as to avoid CNI toxicity.
I think we can accept this donor as he is young but the kidney has high chance of DGF ,AND risk of repercussion ischemic injury which increase the risk of rejection
we need to select the recipient with small size and and with low immunological risk
in this situation better to use ATG for induction and continue with CNI free regime
I don’t recommend kidney biopsy because it will not add ,and it could lead to unnecessary discord for the kidney
This is DCD kidney but from a young donor who had ishaemic brain injury and arrested for 45 minutes. His creatinine is 190 with possible AKI secondary to prerenal cause. urine output still good. the kidney is considered marginal but still can be donated to those as listed below:
Age > 40 years
Transplant waiting list > 4 years
Recipients with dialysis vascular access problems
Recipient with low muscle mass and small size
Recipients with lower immunologic risk (no previous transplant and PRA titer < 50%)
Diabetics
AKI stage 1 or 2 no statical significant difference between non AKI regarding long term graft function and acute rejection.
Induction agent should be potent IS such as ATG. the reason behind it because hypoxia might induce interleukin and cytokine activation. Ishaemic reperfusion injury too will lead to acute rejection.
Machine perfusion should be added to reduced the DGF rate.
Depending on the age and co morbidity of the recipient, the maintenance therapy should be planned. Elderly patients will benefit from CNI free regime as they are prone for infection and CNI toxicity.
Accepting such kidneys will still beneficial compared to remaining on dialysis. So the answer will be obviously, yes.
Role of kidney biopsy is not established in AKI and will not beneficial. ATN should already be suspected in clinical scenario, biopsy will not have added benefit.
This is a case of DCD from a donor with AKI.
The donor is still young with no past medical history. A study of DCD transplantation from a donor with AKI showed that DCD renal allografts from donors experiencing stage 1 and 2 AKI have a higher adjusted risk of death-censored graft failure than AKI stage-matched donation after brain death renal allografts. Their use, however, is still associated with improved outcomes compared with waitlist mortality.
Based on these findings, I will accept the offer to a recipient who is small in size, well-immunologically matched, has exhausted accesses, and waiting for a long time for transplantation.
The recipient should be informed about the nature of the offered graft and the risk of DGF, and the expected long-term outcome of such a graft.
Induction with ATG to provide a safe CNI-free period or a low CNI dose to avoid further damage to the transplanted kidney.
Reference:
Lia D, Singer P, Nair V, Yang J, Teperman L, Grodstein E. DCD Renal Transplantation From Donors With Acute Kidney Injury. Transplantation. April 2021; 105(4).
yes. young donor with ARF reversed after cardiac arrest.
deceased donors may also have greater repair potential because the donors are typically
younger and have fewer comorbidities.
Many clinical actions can lead to serum creatinine fluctuations (1)
leads to level that meet criteria for AKI in deceased donors who typically do not have
CKD, severe cardiovascular disease, or sepsis.
vasopressin fluctuations during brain death can contribute to fluid losses and a number
of hemodynamic changes, which do not necessarily lead to the intrinsic tissue injury
commonly associated with CKD development.
Repair biomarkers in the deceased donor setting suggests that donor injury can
initiate repair processes and ischemic preconditioning, which may be beneficial at the
time of transplant in the recipient.(2)
So kidneys from deceased donors with AKI could expand the pool of available kidneys
for transplants.
References:
1-Caroline Liu, Isaac E. Hall, MD, Sherry Mansour, DO, et al. Association of Deceased
Donor Acute Kidney Injury With Recipient Graft Survival. MA Newt.
Open. 2020;3(1):e1918634.
2-Caroline Liu, MHS; MS; Sherry Mansour et al. Association of Deceased Donor Acute
kidney injury With Recipient Graft Survival. AMA Newt Open. 2020; 3(1).
Would you accept this donor?
If yes, how do you select the recipient(s) suitable for this case?
A marginal donor can be accepted with counselling recipient and expected DGF.
Potential recipient more suitably to be age more than 40, diabetic, small size, waiting more than 4 y on dialysis ,low immunological risk recipient …Hypothermic perfusion of graft is needed.
Induction with ATG or Alemtuzumab with maintenance with CNI free regimen.
This patient is considered in the group of extended donor criteria ECD because of ATN; raised s. creat.
However; I would accept him as a donor
– Diabetic patient
– In long time waiting list (> 4 years)
– Female patient or small size recipient
– Age match if possible
– Choose Hypothermic Machine Perfusion (HMP)
Would you accept this donor?
Yes, I will accept him for donation.
Our donor is young age , no history of chronic diseases and has Ischemic AKI post arrest.
Many studies try to demonstrate effect of donor AKI on primary no function, DGF, and long-term graft dysfunction and some studies as ( Hall et al , Dube et al)shown that donor AKI might cause DGF but not necessarily increase the risk of early graft loss or graft failure in the long term.
If yes, how do you select the recipient(s) suitable for this case?
I think selection of the recipient depends on quality of our kidney and relay on it we will decide if we will go with SKT or DKT but still no global consensus regarding DKT and its local center protocol.
But, we can avoid biopsy based decision depending on e GFR ,donors with eGFR > 60 mL/min were considered for SKT. Kidneys were discarded when eGFR was < 30 mL/min, and eGFR between these results was an indicator for DKT.
Sheffield center using DKT in special criteria as patients with low immunological risk, who are less than 60 years old, and who have minimal comorbidities and body mass index < 30 kg/m2.
References:
1- Palmisano A, Gandolfini I, Delsante M, et al. Acute Kidney Injury (AKI) before and after Kidney Transplantation: Causes, Medical Approach, and Implications for the Long-Term Outcomes. J Clin Med. 2021;10(7):1484. Published 2021 Apr 2. doi:10.3390/jcm10071484.
2- Dube, G.K.; Brennan, C.; Husain, S.A.; Crew, R.J.; Chiles, M.C.; Cohen, D.J.; Mohan, S. Outcomes of kidney transplant from deceased donors with acute kidney injury and prolonged cold ischemia time—A retrospective cohort study. Transplant. Int. 2019, 32, 646–657.
3- Heilman, R.L.; Smith, M.L.; Smith, B.H.; Kumar, A.; Srinivasan, A.; Huskey, J.L.; Khamash, H.A.; Jadlowiec, C.C.; Mathur, A.K.; Moss, A.A.; et al. Long-term Outcomes Following Kidney Transplantation From Donors With Acute Kidney Injury. Transplantation 2019, 103, e263–e272
I will vote yes for acceptance of this Donor ( young , DCD , AKI mostly ATN)
Aim for optimization of the ECD kidney through
1-Immunosupression modulation aiming :
A:To reduce the incidence of rejection
B: minimizing CNI exposure through :
-Induction by ATG /Alemtuzumab
-CNI -free belatacept based regimen
-CNI free regimen :MMF and induction based
-reduced CNI exposure
-CNI free mTor based regimen
2-Short Cold ischemia time
3-Macine perfusion
4-Dual kidney Tx
5 proper selection of the recipients who would benefit the most :
-more the 40 years
-low immunological risk
-Waiting list more than 40 years
-Diabetics
-low body built-females
References :
1-R.L. Heilman, A. Mathur, M.L. Smith, B. Kaplan, K.S. Reddy.
Increasing the use of kidneys from unconventional and high-risk deceased donors.
Am J Transplant, 16 (2016), pp. 3086-3092
2-F.K. Port, J.L. Bragg-Gresham, R.A. Metzger, D.M. Dykstra, B.W. Gillespie, E.W. Young, et al.
Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors.
Transplantation, 74 (2002), pp. 1281-1286
3-A.H. Querard, Y. Foucher, C. Combescure, E. Dantan, D. Larmet, M. Lorent, et al.
Comparison of survival outcomes between Expanded Criteria Donor and Standard Criteria Donor kidney transplant recipients: a systematic review and meta-analysis.
Transpl Int, 29 (2016), pp. 403-415
4-A.H. Querard, F. Le Borgne, A. Dion, M. Giral, G. Mourad, V. Garrigue, et al.
Propensity score-based comparison of the graft failure risk between kidney transplant recipients of standard and expanded criteria donor grafts: Toward increasing the pool of marginal donors.
Am J Transplant, 18 (2018), pp. 1151-1157
-This donor is a marginal donor , DCD and ischemia time of 45 minutes ,serum creatinine level is 2.1 5 mg/dl indicating the occurrence of AKI ,ATN
So he is considered a marginal donor KDRI risk score need to be estimated.
If the donor baseline kidney function was normal, ischemic or toxic insults causing AKI do not generally hinder full recovery of kidney function.
Donor AKI can cause DGF but not necessarily increase the risk of early graft loss or graft failure on the long term.
For standard-risk donors, donor AKI does not impair transplantation outcomes.
That is why this donor can be acceptable for certain recipents.
-The recipient can be an elderly , having short life expectancy to stay dialysis independent as much as he can will have better outcome than remaining on the waiting list ,as patients on waiting list for long
time can be considered too ,as well as cases with failed vascular access and those with low immunological risks
Low-dose dopamine for donor pre-treatment before taking the organ can be done
Machine prefusion can be used to improve the kidney function along with multipotent adult progenitor cells (MAPC) if available perfusion to prevent DGF and fibrosis as this graft has an increased incidence of DGF
Reference
– Palmisano A et al. Acute Kidney Injury (AKI) before and after Kidney
Transplantation: Causes, Medical Approach, and Implications
for the Long-Term Outcomes J. Clin. Med. 2021, 10, 1484
-Liu C, Hall IE, Mansour S, Thiessen Philbrook HR, Jia Y, Parikh CR. Association of Deceased Donor Acute Kidney Injury With Recipient Graft Survival. JAMA Netw Open. 2020 Jan 3;3(1):e1918634.
Would you accept this donor?
Very young donor with with no comorbidities but prolonged cardiac arrest leading to AKI
I will accept this donor with marginal kidney (DCD/ATN) who is still passing urine and the cause is obvious (ATN) after discussion with the recipient
AKI, even that requiring dialysis for the donor, is not an absolute contraindication to kidney donation
The risk of DGF/PNF is expected to be high (DCD/AKI) but the risk of early graft loss or graft failure in the long term not necessarily increased. The long term outcome is related to donor factors (age and comorbidities), CIT and Remuzzi biopsy score
Rapid organ retrieval and minimization of CIT / use of machine perfusion and viability test
If yes, how do you select the recipient(s) suitable for this case?
Age > 40 years
Transplant waiting list > 4 years
Recipients with dialysis vascular access problems
Recipient with low muscle mass and small size
Recipients with lower immunologic risk (no previous transplant and PRA titer < 50%)
Diabetics
Induction immunosuppressant and omit or reduce the dose of CNIs
References
1. Palmisano A, Gandolfini I, Delsante M, Cantarelli C, Fiaccadori E, Cravedi P, Maggiore U. Acute Kidney Injury (AKI) before and after Kidney Transplantation: Causes, Medical Approach, and Implications for the Long-Term Outcomes. J Clin Med. 2021 Apr 2;10(7):1484. doi: 10.3390/jcm10071484. PMID: 33918444; PMCID: PMC8038198.
2. BTS guidelines. Transplantation from deceased donors after circulatory death. July 2013.
3. Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
Thankyou Mohamad but Remuzzi score looks for chronic lesions which you will not find here better go for the YK kidney group.
This donor is a standard criteria donor (age less than 50 years) with donation after cardiac death (DCD). There is no past history of hypertension or diabetes.
There is presence of non-oliguric AKI. As the serum creatinine is 190micromol/L, which should be less than 3 times the baseline, the AKI stage is stage 2 (1).
AKI is present in 50% of DCD donors (2). It has been shown that for standard risk donors, the transplantation outcomes are not affected by donor AKI (2). Kidneys from donors with AKI stage 3 have been shown to have poor outcomes, hence need to be more cautious in such transplants (3). Donor AKI has been shown to be associated with increased incidence of delayed graft function (DGF). There is no difference in acute rejection rates in kidneys from donors with AKI and donors without AKI (4). Moreover, it has been shown that outcome of kidneys from donors who have died after ligature asphyxiation (for example by suicide) is similar to those dying from other causes (5).
In view of these points, I would accept this donor.
This is standard criteria donor (SCD) with AKI. As such, there is no contraindication for using such a kidney in any recipient.
The prospective recipient should be informed about the graft outcomes, including increased risk of DGF 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 (6).
References:
1) Makris K, Spanou L. Acute Kidney Injury: Definition, Pathophysiology and Clinical Phenotypes. Clin Biochem Rev. 2016 May;37(2):85-98. PMID: 28303073; PMCID: PMC5198510.
2) Palmisano A, Gandolfini I, Delsante M, Cantarelli C, Fiaccadori E, Cravedi P, Maggiore U. Acute Kidney Injury (AKI) before and after Kidney Transplantation: Causes, Medical Approach, and Implications for the Long-Term Outcomes. J Clin Med. 2021 Apr 2;10(7):1484. doi: 10.3390/jcm10071484. PMID: 33918444; PMCID: PMC8038198.
3) Boffa C, van de Leemkolk F, Curnow E, Homan van der Heide J, Gilbert J, Sharples E, Ploeg RJ. Transplantation of Kidneys From Donors With Acute Kidney Injury: Friend or Foe? Am J Transplant. 2017 Feb;17(2):411-419. doi: 10.1111/ajt.13966. Epub 2016 Aug 25. PMID: 27428556.
4) Koyawala N, Parikh CR. A Review of Donor Acute Kidney Injury and Posttransplant Outcomes. Transplantation. 2020 Aug;104(8):1553-1559. doi: 10.1097/TP.0000000000003144. PMID: 32732831.
5) Trotter PB, Jochmans I, Hulme W, Robb M, Watson C, Neuberger J, Andrew Bradley J. Transplantation of kidneys from DCD and DBD donors who died after ligature asphyxiation: The UK experience. Am J Transplant. 2018 Nov;18(11):2739-2751. doi: 10.1111/ajt.14989. Epub 2018 Jul 30. PMID: 29947090; PMCID: PMC6221073.
6) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 18, 2022.
Thankyou Amit agree with all your steps and precautions but l would call him a marginal donor ,a step down from SCD
Ligature asphyxiation have a great impact on DCD organ & it may have a second period of warm ischemia injury between cardiac arrest & cold perfusion of the organ. Most of DCD died after asphyxiation were young without co-morbidities & considered as good donor pools, but this patient have cardiac arrest >45 min which can cause AKI like our patient.
It was found that DCD transplant recipient associated with PNF & DGF but the long term outcome was comparable to DBD transplantation, & DCD asphyxiation transplant have better outcome than other cause of DCD.
So Yes I will accept this donor, but the recipient should inform about the risk of DGF & slow recovery of graft function, this donor can offered for:
References:
Any precautions for retrieval and perfusion in this ischemic organ.
Using og UW solution & cold storage can be used to reduce ischemic injury.
This is a young donor aged 21 years old with AKI, most likely secondary to ATN due to hypoperfusion. He is still passing reasonable urine; 40 ml/hours.
Based on UK Registry analysis from 2003 to 2016, undertaken in 521 donors who died following ligature asphyxiation, to determine transplant outcomes in recipients. Of these, 409 (78.5%) donated kidneys for transplantation (46.9% donation after brain death [DBD] and 53.1% DCD donors) resulting in 650 kidney transplants. Compared to other deceased donors, Unadjusted patient and graft survival were superior for recipients of both DBD and DCD kidneys from donors dying after ligature asphyxiation, although after adjustment for donor/recipient variables, transplant outcomes were similar. A case–control matched analysis confirmed transplant outcomes for those who received kidneys from donors dying after ligature asphyxiation were similar to controls. Though kidneys from donors dying of ligature asphyxiation suffer an additional warm ischemic insult that does not apparently adversely influence transplant outcomes, even for kidneys from DCD.
So, I think these kidneys can be utilized normally. However, certain actions needed to improve kidney functions such as to reduce cold ischemia time and to use oxygenated machine perfusion to reduce the ischemia-reperfusion injury and to monitor recipients kidney function post transplant.
Ref.: Patrick B. Trotter. Transplantation of kidneys from DCD and DBD donors who died after ligature asphyxiation: The UK experience. Am J Transplant. 2018;1–13
Thankyou can you choose a recipient for optimal results
21-year-old DCD donor with hypoxic brain damage due to hanging and had cardiac arrest for 45 mins before revival. He had impaired renal functions (S. creatinine 190umol/l) but his kidneys are still perfused and still producing 1.8 liter of urine in last 24 hours. He does not have any other significant comorbid factors.
In This Scenario, we have two issues:
1) Effect of post hanging on Kidney donation :
There were reservations regarding the medical suitability of organ retrieval from hanging victims because hanging can cause global hypoxia due to warm ischemic injury that can potentially affect the transplantable organs(in our scenario >30 min).
·published data regarding outcomes from such transplantation are limited and conflicting. However an Australian New Zealand study(1) showed no difference in outcomes or in chronic allograft rejection, but there was a higher incidence of extracorporeal life support . A UK Registry analyzed transplant outcomes in kidney recipients from donors who died following ligature asphyxiation from 2003‐2016. The transplant outcomes were similar and these donors were younger, more often male, and had less hypertension(2)
2) This donor had AKI most likely due to ATN but still his kidneys are perfused with good urine output. AKI increases the risk of DGF and primary nonfunctioning graft and every effort should be done to reduce the cold ischemia time. Studies showed comparable graft survival between AKI and non-AKI donors, especially among stage 1 and 2 AKI donors with overall no significant difference in long term graft function and acute rejection episodes (3).
In view of the above, I will accept this young DCD donor who has no comorbidities but AKI as literature showed a comparable graft survival to non AKI donors. Utilizing this graft will be life saving for the people on the waiting list.
The suitable recipient should be:
· Age-matched recipient preferred > 40 years
· Low immunogenicity with absent DSA, so an adequate matching is required
· A recipient waiting a long time on the waiting list
· A recipient with problematic vascular access affecting his dialysis adequacy
· Diabetic recipients
The donor kidneys were affected by the prolonged WIT and AKI. Optimization of function is required by:
· Trials to reduce cold ischemia time(virtual cross match may help in that).
· Use of pulsatile oxygenated machine perfusion to reduce the ischemia-reperfusion injury and the DGF.
· Tailor immunosuppression(less immunosuppression in elderly recipients, delayed introduction or CNIs or CNI free regimens are preferred with a strong induction therapy preferably with ATG or Alemtuzumab.
References:
1) Fayed et al. Characteristics of Organ Donors Who Died From Suicide by Hanging in Australia and New Zealand: A Retrospective Study. Cureus . November 03, 2021 13(11).
2) Patrick B. Trotter. Transplantation of kidneys from DCD and DBD donors who died after ligature asphyxiation: The UK experience. Am J Transplant. 2018;1–13.
3) Koyawala N, Parikh CR. A Review of Donor Acute Kidney Injury and Posttransplant Outcomes. Transplantation. 2020 Aug;104(8):1553-1559.
Well done how do you in this index case tackle the option of duel donation.
Would you accept this donor?
Yes ,I would accept this donor .
If yes, how do you select the recipient(s) suitable for this case?
– Recipient-donor age match .
-Female recipient or a small patient .
-Recipient with low Immunologicl risk and used Low dose immunosuppression.
-Recipient with short CIT
-Kidney Donor Risk Index (KDRI) which is an estimate of the relative risk of post-transplant graft failure (in an average, adult recipient) from a particular deceased donor compared to a reference donor (age 40, non-diabetic, etc.).
-Dual renal transplant if recipients fit.
-Hypothermic Machine Perfusion (HMP): the use of machine perfusion
technology associated with improved DGF rates, particularly for DCD organs
Reference:
-Maria Irene Bellini et al . Cold Pulsatile Machine Perfusion versus Static Cold Storage in Kidney Transplantation: A Single Centre Experience .BioMed Research International Volume 2019, Article ID 7435248, 8 pages
-Prof Ahmed Halawa lecture on Expanded Criterial Donor
Can you assess the viability of the organ as well allthough theATN might give non conclusive results.