3. You were offered kidneys from 65-year-old male DBD (donor after brain death) donor who suffered from SAH (grade 5) complicating acute liver failure. This patient is known to have alcoholic liver cirrhosis for years. His baseline S Cr was 60 µmol/L. On admission S Cr was reported to be 300 µmol/L (3.4 mg/dl). Urine output was 20mls/h during the last hour and 1.1 L over the last 24 hours.
- Would you accept this DBD donor?
- Would you accept this donor if he was DCD?
- If yes, what is the prognosis?
- What are we dealing with?
Would you accept this DBD donor?
The donor has hepato-renal syndrome type 1 (HRS-1), which is the cause for AKI Graft survival of patients with HRS should be good.
Taking into consideration that the graft from 65 years old. therefore, it can be regarded as ECD. If hepatorenal syndrome is the only cause after ruling out infections and HCC, this donor is considered acceptable.
Would you accept this donor if he was DCD?
This donor will be controlled donor, with proper protocol regarding: timing for harvesting, haemodynamics, ventilation and hormonal replacement, This DCD kidneys should be good for procument
If yes, what is the prognosis?
What are we dealing with?
we are dealing with ECD/ marginal kidneys
Would you accept this DBD donor?
This DBD donor is an expanded criteria donor with age above 60 years , with a past history of Alcoholic liver cirrhosis complicated with liver faliure .
AKI is very common is DBD 20-30 % and higher with DCD 40 -50 % .
And studies showed no inferiority to receive a deceased-donor with AKI 3 despite high possibility of delayed graft function .
So we shall proceed with Tx better than the long waiting list .
Would you accept this donor if he was DCD?
Higher risk of AKI 3 with DCD 50 % but better than Tx waiting list after consenting the patient .
If yes, what is the prognosis?
Yes , relatively poor outcome with high incidence of delayed graft function . But no statistically significant difference between AKI or noAKI donors
Would you accept this DBD donor?
This DBD donor can be accepted As extended criteria because he has normal base line kidney function with acceptable urine output , his AKI is due to HRS secondary to liver cirrhosis , his cirrhosis is secondary to alcoholic not malignancy or infectious disease but there is low risk of DGF
At same time, causes of liver decompensation on baseline cirrhosis needs to be evaluated to rule any transmissible disease to the recipient.
Also, other nephrotoxic drugs or causes to precipitate further AKI in the donor should be evaluated.
Would you accept this donor if he was DCD?
Yes I would accept this donor if he was DCD. DCD kidneys are more prone to cold ischaemia than DBD kidneys however the long-term outcomes are similar between DBD recipients and DCD recipients.
If yes, what is the prognosis?
ECD is associated with higher incidence of delayed graft function
What are we dealing with?
DBD kidney donor, ECD who developed acute kidney injury mostly related to type 1 hepatorenal syndrome
The first codified classification of DD kidneys was implemented in October 2002 . Under this scheme, DD kidneys were classified into two groups: Standard-criteria donor (SCD) and expanded-criteria donor (ECD). This classification was meant to reflect the quality of the organ, and the definition was driven empirically by the risk for graft loss. An ECD kidney has a 70% greater risk for failure compared with an SCD kidney
Standard-Criteria Donor
The classic SCD is a 35-yr-old man who has no history of hypertension or diabetes and for whom the cause of death is a motor vehicle accident. In practice, all DDs who do not meet any of the criteria for an ECD and from whom donation occurred after brain death (donation after brain death [DBD]; are considered as an SCD.
Expanded-Criteria Donor
An ECD is one who, at the time of death, is aged ≥60 or aged 50 to 59 yr and has any two the following three criteria: (1) Cause of death is cerebrovascular accident; (2) preexisting history of systemic hypertension; and (3) terminal serum creatinine >1.5 mg/dl. The criterion for the definition of ECD was based on the presence of variables that increased the risk for graft failure by 70% (relative hazard ratio 1.70) compared with an SCD kidney.
Donation after Brain DeathDBD describe a donor who had primary brain death in whom cardiac circulation and respiration remain intact or are maintained by medical measures, including mechanical ventilation, drugs, intra-aortic balloon pump, or extracorporeal machine oxygenation device. A DBD could be an ECD or SCD depending on whether the ECD/SCD criteria are separately fulfilled.
Donation after Cardiac DeathThe donation after cardiac death (DCD) donor refers to the donor who does not meet the criteria for brain death but in whom cardiac standstill or cessation of cardiac function occurred before the organs were procured. The cessation of cardiac function could have occurred spontaneously or been initiated deliberately. The DCD donor was previously referred to as non–heart-beating donor. The DCD categories encompass four subgroups, depending on the circumstances and manner in which cardiac standstill occurred (Maastricht classification), but only two subtypes of DCD are in common usage (controlled DCD and uncontrolled DCD)
Controlled DCD.The OPTN defines a controlled DCD (cDCD) as “a donor whose life support will be withdrawn and whose family has given written consent for organ donation in the controlled environment of the operating room.” The cDCD describes a situation in which the donor’s hemodynamic stability and respiratory function were maintained until the decedent is extubated in a controlled environment of the operating room or in the intensive care unit.
Uncontrolled DCD.The OPTN defines uncontrolled DCD (uDCD) as “a candidate who expires in the emergency room or elsewhere in the hospital before consent for organ donation is obtained and catheters are placed in the femoral vessels and peritoneum to cool organs until consent can be obtained. Also, an uncontrolled Donation after Cardiac Death donor is a candidate who is consented for organ donation but suffers a cardiac arrest requiring CPR during procurement of the organs.”
The current donor is considered DBD / ECD donor and I would accept him.
Inherent to the definition of an ECD kidney is a 70% increased risk for graft failure compared with an SCD kidney . Nonetheless, diminished allograft survival does not suggest lack of therapeutic benefits. Although most studies of ECD kidney transplantation confirm lower allograft survival rates, recipients of ECD kidneys generally have improved survival compared with matched dialysis-treated patients . The improved recipient survival (relative to the dialysis-treated patient) is not uniform for all patient groups. On the basis of data from the US Scientific Registry of Transplant Recipients (SRTR), Merion et al.found that that long-term mortality among ECD kidney transplant recipients was 17% lower compared with recipients who did not accept an ECD kidney offer. The survival benefit was apparent only at 3.5 yr after transplantation and was further confined to recipients who were older than 40 yr, were non-Hispanic, did not have diabetes, and were awaiting kidney transplantation in an Organ Procurement Organization service area in which the average waiting time for a kidney was >1350 d (>45 calendar months). Also using US national transplant data (SRTR), Miles et al. found that repeat kidney transplant candidates who received an SCD kidney had better survival than comparable dialysis-treated patients but had no advantage in survival had they received an ECD kidney for the retransplantation. A useful statistic that can be given to transplant candidates is that the projected average added-life-years after an SCD kidney transplantation is 10 yr compared with 5.1 yr for an ECD kidney transplantation. ECD kidney transplantation is associated with a significantly increased risk for delayed graft function (need for dialysis treatment during the first week after transplantation).
Analysis of clinical outcomes from the US national data by Gagandeep et al. showed that both the allograft and the recipient survival are similar between DCD and DBD, but the risk for delayed graft function was 42 to 51% in DCD compared with 24% in DBD kidney transplant recipients. Similarly, Doshi and Hunsicker found no significant difference in the 5-yr patient (DCD versus DBD 81.3 versus 81.8%; P = 0.70) and allograft survival (DCD versus DBD 66.9 versus 66.5%; P = 0.52) when comparing DCD with DBD kidney transplantation, but there was a significantly higher risk for delayed graft function with DCD kidney transplantation (DCD versus DBD 41 versus 24%; P < 0.001). There seems to be no difference in the risk for acute rejection episodes between DBD and DCD kidney transplantation. Outcomes of DCD-ECD kidneys, however, are generally poor.
ECD in DBD versus DCD
Ref:
Panduranga S. Rao, Akinlolu Ojo, The Alphabet Soup of Kidney Transplantation: SCD, DCD, ECD—Fundamentals for the Practicing Nephrologist,CJASN Nov 2009, 4 (11) 1827-1831; DOI: 10.2215/CJN.02270409
1.yes, I will accept him,
the donor had AKI secondary to hepatorenal syndrome
A study compared out come of deceased kidney transplantation in two groups ,one with AKI and the other non AKI
AKI group presented more episodes of DGF compared to non AKI group , but there is no difference between two groups in the rate of acute rejection episodes, kidney function as well as patient and graft survival.
2.yes I will accept the donor if he was DCD
3.According to BTS guidelines, acute kidney injury is not contraindication to kidney donation in DCD. but there is increase in the risk of DGF to a greater degree than that associated with DBD donation.
4.Expanded criteria donor (ECD) older than 60 years and he had ARF
Domagala P, Gorski L, Wszola M, Kieszek R, Diuwe P, Goralski P, Drozdowski J, Ostaszewska A, Gozdowska J, Ciszek M, Trzebicki J, Durlik M, Paczek L, Chmura A, Kwiatkowski A. Successful transplantation of kidneys from deceased donors with terminal acute kidney injury. Ren Fail. 2019 Nov;41(1):167-174.
Would you accept this DBD donor?
I would accept this 65 year male , DBD donor with history of alcoholic liver cirrhosis and having grade V SAH with acute liver failure leading to AKI (previous creatinine-normal).The possible cause of AKI in this case is hepato-renal syndrome which does not preclude donation. And also death censored graft survival from DBD donors with kidney impairment is almost similar to those without renal impairment. And induction therapy with low dose ATG further can improve graft survival.Furthermore, recipient’s age, sex, muscle mass and renal biopsy with Remuzzi score will help in deciding whether single r dual kidney transplant is needed.
Would you accept this donor if he was DCD? If yes, what is the prognosis?
I will accept this donor if he was DCD only after counseling of the recipient as there are increase chances of DGF and rejection due to cold ischemia leading to worse graft survival in the short term. However, the long term outcomes are almost similar to DBD .Graft outcome depends on whether the graft is ECD or SCD rather than DBD or DCD.
What are we dealing with?
ECD donor with multiple comorbidities i.e., alcoholic lier cirrhosis,SAH ,fulminant liver failure and AKI likely because of HRS.
REFERENCES:
1-Kim, K.D., Lee, K.W., Kim, S.J. et al. Safety and effectiveness of kidney transplantation using a donation after brain death donor with acute kidney injury: a retrospective cohort study. Sci Rep 11, 5572 (2021
2-Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 12, 2022.
3- Koyawala N, Parikh CR. A Review of Donor Acute Kidney Injury and Post-transplant Outcomes. Transplantation. 2020 Aug;104(8):1553-1559
Would you accept this DBD donor?
I would accept this DBD donor. This donation offer is from an ECD aged 65 y, male, DBD, SAH grade 5, alcoholic liver disease and acute liver cell failure associated with acute renal failure mostly because of hepatorenal syndrome.
ECD can be used for donation either single kidney or better to use dual kidney transplant based on pre-donation biopsy using Remuzzi Score to decide about best donation option.
Death censored graft survival in transplant recipients from DBD donors with pre-donation AKI was similar outcome compared to recipients from DBD donors without pre-donation AKI. This single donation offer could be accepted for recipient with old age, small muscle mass. However, dual kidney donation can be offered for recipients with younger age with bigger muscle mass.
Would you accept this donor if he was DCD?
I would accept this donor if he was DCD. DCD kidneys are more prone to cold ischaemia than DBD kidneys however the long-term outcomes are similar between DBD recipients and DCD recipients.
If yes, what is the prognosis?
Death censored graft survival in transplant recipients from DBD donors with pre-donation AKI was similar outcome compared to recipients from DBD donors without pre-donation AKI. However, they have high risk of DGF.
What are we dealing with?
ECD from DBD with AKI secondary to type I HRS.
Q1: This is an example of ECD DBD with SAH and acute live
failure and high probability of hepatorenal syndrome and AKI.
This donor would be accepted in certain conditions:
-virology screening for HBS, HCV, and HIV
-kidney biopsy if possible before transplantation to rule out
ESKD ore chronic kidney disease stage 4or cortical necrosis.
If these condition were ok, I will proceed to transplantation.
Q2: Yes, if this donor was DCD, the same decision as DBD was
made.
Q3: DCD donors are associated with the similar long-term
outcome as DBD donor especially when standard criteria
donor is used.
But this a case of ECD DBD that makes the graft outcome
worse compared to SCD DBD or DCD.
In addition, DGF is seen more frequently in DCD donors
compared to DBD donors.
Q4: this is a case of ECD, DBD with high grades AH alcoholic
liver failure leading to hepatorenal syndrome.
The risk-benefit of remaining on waiting list on dialysis against
accepting an ECD DBD donor should be explained to the
recipient and consent.
Yes as AKI is mostly due to hepatorenal syndrome and is not a contraindication for transplantation and is considered as ECD
Yes because despite the increased risk of delayed graft function with DCD early, the graft outcome is similar to DBD
ECD is associated with higher incidence of delayed graft function
Extended criteria donor due to age >60, AKI due to hepatorenal syndrome.
BTS guidelines. Transplantation from deceased donors after circulatory death. July 2013.
This donor can be accepted after categorizing him as extended donor criteria for marginal kidneys based on his age exceeding 60 years , subarachnoid hemorrhage, renal impairment (AKI vs. prerenal insult ;either hepatorenal syndrome ,chronic alcoholism ,viral hepatitis ,drug intoxication).
Proper counselling of the recipient as this kidney will mostly face delayed graft function, incidence of acute rejection is high due to delayed CNI use which may require using other agents for induction as ATG or basiliximab.
DCD donors face more circulatory ischemia to organs as liver and kidney, making the prognosis worse compared to DBD donors.
The prognosis after DBD donation in the perioperative time after delayed graft function, baseline renal functions would be high; however after the passage of 3 months, renal functions improve to be matching to other deceased donors without marginal kidneys.
Even though this DBD donation will improve lifestyle and quality of life of the recipient as well as it is considered better option rather than maintaining dialytic support or remaining on the waiting list with the shortage of organs nowadays.
This case discusses the DBD donation of marginal kidneys, with extended donor criteria.
References:
Early Hypertransaminasemia after Kidney Transplantation: Significance and Evolution According to Donor Type
J. Clin. Med. 2021, 10(21), 5168; https://doi.org/10.3390/jcm10215168
Would you accept this DBD donor?
The donor is brain dead at the age of 65 years with no diabetes or hypertension…He has underlying alcoholic liver disease with SAH…He had a baseline normal creatinine and renal function has subsequently worsened…He maybe having Acute kidney injury due to hepato-renal syndrome or pre renal causes…He is an ECD (extended criteria donor) due to his age… And considering his hepatorenal syndrome which causes only ATN, it should recover….I would also pay attention to rule out viral etiologies to his liver disease apart from alcohol…
Yes I will accept the donor for transplantation…The recipient selection could be an elderly recipient if possible, else will counsel the recipient of the potential DGF and acute rejection but near equal 10-15 year graft survival as compared to normal criteria donor….I would use Induction agent and minimize the use of CNI in the beginning as there is ATN in the donor…
AKI in ECD are associated with more incidence of DGF, more hospitalizations and more cost as compared to those with no AKI and ECD….
Would you accept this donor if he was DCD?
Although the short term graft survival is poor with a DCD in a elderly donor with creatinine of 3mg% and oliguria, the overall graft survival is the same as DBD in elderly and the overall survival rate is definitely better than staying on the waitlist on hemodialysis…It is difficult decision to be taken..I would counsel the recipient and decide to proceed if he is young and with severe malnourishment on HD with poor vascular access, when the survival on HD becomes doubtful, I will counsel the recipient and proceed with high risk of DGF and primary non functioning if accepted… I would use CNI minimizing protocol and low dose ATG as induction if required…
Would you accept this DBD donor?
1st question needed to be answered
1. What is the impact of AKI on the prognosis??
A retrospective cohort study reviewed all patients who underwent KT from DBD donors between June 2003 & April 2016.
The cohort included 376 donors (no AKI group, n= 117 [31.1%]; AKI group n= 259 [68.9%]). And study showed
· Death-censored graft survival was similar as regards AKI irrespective of AKI severity.
· death-censored graft survival improved with the use of low-dose r-ATG
2nd question is needed to be answered
2. This is ECD as regards his age so, can we use his organs for a single kidney transplant or it’s better to use them as a dual kidney transplant?
The best answer it will be based on a biopsy interpreted by an expert pathologist and then using of Remuzzi score but unfortunately, this is not easily applicable in clinical practice
so, without a biopsy decision will be based on the recipient’s age, sex, and muscle mass
if the recipient female patient, with old age and low muscle mass so, a single kidney transplant will be a good option
if the potential recipient is male young or with a huge muscle mass so, a dual kidney transplant should be considered after discussion with your surgeon because its more difficult and needs a more experienced surgeon also, he needs to evaluate the available room in the recipient’s abdomen.
3rd question needed to be answered
3. Is there any difference if this donor was DCD, not DBD??
it is recognized that DCD kidneys appear to be more susceptible to cold ischemia, and the proposed national allocation scheme should take this into account. (B2) but as regards long-term outcomes, DCD recipients are similar to those DBD recipients.
So, as regards the answers to the previous questions, I would accept this donor either if he was DCD or DBD and I consider giving low dose induction ATG with delayed introduction of CNI .and pretransplant biopsy will be decided based on the availability of an expert pathologist and potential donors’ criteria.
=========================
If yes, what is the prognosis?
According to the above retrospective studies, the death-censored graft survival was similar as regards AKI but still high risk of PNK and DGF.
=========================
What are we dealing with?
DBD kidney donor, ECD who developed acute kidney injury mostly related to type 1 hepatorenal syndrome.
References
1. Kyeong Deok Kim et al. Safety and effectiveness of kidney transplantation using a donation after brain death donor with acute kidney injury:a retrospective
cohort study. Scientific Reports | (2021) 11:5572 | https://doi.org/10.1038/s41598-021-84977-1
2. Caroline C. Jadlowiec. Transplanting kidneys from donation after cardiac death donors with acute kidney injury. Am J Transplant. 2020;20:864–869.. DOI: 10.1111/ajt.15653
I will accept the donation,
this is ECD criteria donation, may he has pigment nephropathy(NON OLIGURIC ATN), prognosis is not good.
Dealing with AKI,ATN pigment nephropathy, acute hepatitis and HRS.
Would you accept this DBD donor?
Yes.
Would you accept this donor if he was DCD?
Yes
If yes, what is the prognosis?
Good
What are we dealing with?
kidney donation in DBD and DCD complicated with AKI due to hepatorenal disease.
Reference
1) British Transplantation Society
British Transplantation Society and Intensive Care Society Donation after circulatory death: report of a consensus meeting. 2010
2)Am J Transplant. 2013
Does expanded criteria donor status modify the outcomes of kidney transplantation from donors after cardiac death?.Singh S.K.Kim S.J. Am J Transplant. 2013; 13: 329-336
yes, but several laboratory test will be done prior such as virology, tumor markers
yes, as it is Expanded Criteria donor
to use Machine perfusion has reduced the DGF rate significantly compared to the standard cold storage, and appropriate immunosuppressent
(Induction with ATG/Delayed CNI introduction regimens)
# Would you accept this DBD donor?
*Yes, I would accept this DBD donor as extended criteria donors, after full virology and malignancy screening, the recipient is alcoholic abuse.
# Would you accept this donor if he was DCD?
*Yes, I would accept this donor if he was DCD. But the incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.(A1)
# If yes, what is the prognosis?
* Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account. (B2)
*Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2)
*Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required. (A1)
*AKI in DBD donors negatively affected the DGF rate. However, it did not affect long-term graft function or death-censored graft survival. The use of high dose-r-ATG as an induction agent, KDRI, and rejection episodes had a negative effect on death-censored graft survival. Low dose r-ATG may be considered as an induction immunosuppression in recipients receiving kidneys with AKI because it produced better graft survival than basiliximab.
# What are we dealing with?
*we dealing with ECD, DBD with alcoholic liver cirrhosis and AKI- HRS.
#Transplantation from deceased donors after circulatory death
The BTS July 2013
#Safety and effectiveness of kidney transplantation using a donation after brain death donor with acute kidney injury: a retrospective cohort study Article number: 5572 (2021)
This donor is an extended criteria donor (age more than 60 years) with donation after brain death (DBD). There is a past history of alcoholic liver cirrhosis and acute liver failure.
There is presence of non-oliguric AKI. As the serum creatinine is 300micromol/L, which is more than 3 times the baseline, the AKI stage is stage 3 (1).
AKI is present in 30% of DBD and 50% of DCD donors (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).
In view of these points, I would accept this donor as the outcomes of ECD transplant are better than remaining on wait-list (5).
As the risk of DGF is higher in DCD, such a kidney with AKI stage 3, can be used only after careful consideration. A dual kidney transplant would be an option in this donor.
The ECD kidneys have lower graft survival as compared to standard criteria donor kidneys (6). 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 (5). 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 (6).
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 (7).
Peri- and post-transplantation management in DCD 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 (7).
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).
We are dealing with ECD – DBD donor with AKI.
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) 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.
6) 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.
7) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 12, 2022.
The available donor is 6 5 years old male with DBD suffered from SAH grade 5 complicating acute liver failure and known to have alcoholic liver cirrhosis for year, his basal creatinine 60 ummol and on admission 300 ummol with UOP 1100 ml/24h
Yes, I will accept , patient developed acute kids injury secondary to hepato-renal syndrome but we must consider virology,.
.Would you accept this donor if he was DCD?
Yes, studies showed that both DCD and DBD have the same outcome.
this acceptance unless patients ESRD or CKD stage
IT is better than to keep patient on dialysis.
It way associated with delayed graft failure with rejection but better than to keep patient on dialysis.
Expanded creitaris donor with increased age and acute kidney injury
Would you accept this DBD donor?
This DBD donor can be accepted as
At same time, causes of liver decompensation on baseline cirrhosis needs to be evaluated to rule any transmissible disease to the recipient.
Also, other nephrotoxic drugs or causes to precipitate further AKI in the donor should be evaluated.
The donor kidney after retrieval should be assessed macroscopically and microscopically by graft biopsy. This may guide further prognosis of this graft.
Kim KD, Lee KW, Kim SJ, Lee O, Lim M, Jeong ES, Kwon J, Yang J, Oh J, Park JB. Safety and effectiveness of kidney transplantation using a donation after brain death donor with acute kidney injury: a retrospective cohort study. Scientific reports. 2021 Mar 10;11(1):1-1.
Would you accept this donor if he was DCD?
If yes, what is the prognosis?
Transplantation from deceased donors after circulatory death (BTS 2013 guidelines)
What are we dealing with?
We are dealing with DBD donor with AKI (probably recoverable) due to hepatorenal syndrome on baseline cirrhosis.
This DBD patient can be has no absolute contraindication for donation under ECD (age>60, high terminal creatinine and has SAH)
HRS is the diagnosis of exclusion and we need to do through assessment(history, examination and investigations) to exclude other causes of liver cirrhosis and reduce the risk of donor related infection and tumor transmission.
· We need to exclude other causes of liver decompensation:
-Infection screening (hepatitis, HIV)
– Malignancy screening with alpha feto protein (cirhossis in elderly patien)
– Septic screening as sepsis is a contraindication for donation
– GIT bleeding(coagulation profile, QFIT test and if feasible OGD)
· We need to exclude other causes of AKI:
– Other Pre-renal causes like intravascular volume depletion, reno-vascular causes and serum sodium level and urinary indices which may help to establish the diagnosis of HRS
– Intrinsic renal causes like nephrotoxins and drugs including diuretics.
– Post renal causes including bladder out flow obstruction
– Renal biopsy could provide valuable information about the histologic appearance and help to exclude acute cortical necrosis but it may be not feasible at the time of the offer.
– A careful inspection of the size and macroscopic appearance of the kidney at the time of harvesting.
The International Journal of Organ Transplantation medicine in 2015 stated that renal dysfunction in hepatorenal syndrome is likely reversible (normal renal histology) and different reports have suggested that the transplantation of kidneys from a dying patient who has HRS has been successful especially that this donor have a normal base line kidney function.
Donors with AKI are more likely to experience DGF but have similar long-term outcomes as donors without AKI. Moreover, existing literature suggests to transplant more donor kidneys (stage 1 and 2 AKI and cautious utilization of stage 3 AKI donors) to increase the pool of viable kidneys.
Yes, same consideration like DBD donor despite the fact that DCD are more liable to DGF, so every effort should be done to reduce the cold ischemia time. Additionally, a full explanation should be provided to the recipient prior to transplantation.
The prognosis is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD
Long term outcomes of DCD recipients are similar to those of DBD recipients with a median eGFR of 45 ml/min following DCD and 46 ml/min for DBD
This is an ECD, DBD who has a background of liver cirrhosis(mostly alcoholic) complicated by acute hepatic failure, AKI 3 mostly due to HRS and grade 5 SAH mostly due to coagulopathy
References:
1. BTS guidelines. Transplantation from deceased donors after circulatory death. July 2013.
2. Koyawala N, Parikh CR. A Review of Donor Acute Kidney Injury and Post-transplant Outcomes. Transplantation. 2020 Aug;104(8):1553-1559
3. Koyawala, Neel et al. A Review of Donor Acute Kidney Injury and Post-transplant Outcomes. Transplantation: August 2020 – Volume 104 – Issue 8 – p 1553-1559
– No absolute contraindication here to accept this DBD for donation but there are risk factors for delayed graft function & early rejection like AKI ( prerenal hepatorenal Vs ATN) ,Older age & possible prolonged hemodynamic instability 2ry to liver failure
– I will accept this DBD for donation with this precautaion:
1- Measures should obtained for hemodynamic stability to improve kidney perfusion targetin MAP >60 with inotropes (dobutamine ).
2- Pre implementation biopsy will be of value here to asses degree of glomerulosclerosis because of age & to exclude cortical necrosis
3- Explain to the potential recepient the risk of delayed graft fu=nction & early rejection & comparing this to being on waiting list & dialysis
4- If this case was DCD , also I will consider as a donor but with added risk factor for delayed graft function due to increase cold ischemia time but the long outcome is the same & at that case induction with AB induction therapy should be used .
Grade 5 subarachnoşid haemorrhage, which means coma is eligible for cadaveric transplantation after fulfilling the required criteria. basal cr 60 µmol/L (0.68 mg dl) increased to 300 µmol/L (equivalent to 3.39 mg/dl). We do not know when it will be raised because this increase in creatinine will affect our decision. There is a minimum of 24-48 hours needed for AKI to be reflected in serum creatinine, whatever the cause. This deceased donor may be accepted after evaluation of 0 points pretransplant biopsy. I will not accept a patient with probable TIN, even if acute. This will complicate my recipient. accompanying liver cirrhosis, which may lead to hepatorenal syndrome (reversible AKI), can be evaluated but taking into consideration the patient’s age and the muscle atrophy, even creatinine of 0.68 mg/dl reflects lower eGFR, Here I prefer creatinine clearance as a measurement of eGFR.
Both kidneys may be useful for one recipient (!)
You were offered kidneys from 65-year-old male DBD (donor after brain death) donor who suffered from SAH (grade 5) complicating acute liver failure. This patient is known to have alcoholic liver cirrhosis for years. His baseline S Cr was 60 µmol/L. On admission S Cr was reported to be 300 µmol/L (3.4 mg/dl). Urine output was 20mls/h during the last hour and 1.1 L over the last 24 hours.
Yes, will accept this donor as he has no contra indication for donation. He has alcoholic liver cirrhosis, not hepatitis related.
Also, he has AKI which is reversible as it is due to liver cirrhosis and mostly hepatorenal or pre renal.
Again yes. Just we will be anticipating more the risk of DGF.
The prognosis is good. Short term risk of DGF, more in DCD, but overall prognosis is good.
Potential kidney donor, ECD, with Liver cirrhosis and AKI
Could you accept this DBD donor?
Yes i will accept this old donor with DBD, AKI is related to liver failure and SAH, so it’s not contraindicated but should be counseling regarding delay graft function and should role out viral infection
Yes but should be counselling regarding possible delay graft function during first 3 months but on long term outcome similar between DBD and DCD
what is the prognosis? It’s good
*This potential DBD donor 65 years old ,acute liver cell failure SAH ,AKI mostly Pre-renal ( Hepato-renal ) so is considered ECD because his age is above 60 years , his creatinine > 1.5mg/dl.
Regarding renal donation: I will accept the donor with some precautions treatment of AKI to reach baseline creatinine, we have to exclude any viral infection as; HBV or HCV.
*Comparing DBD with DCD : In DCD , there is high incidence of DGF than in DBD donors, later after 3 months they are comparable. DCD kidneys are more vulnerable to warm ischemic injury leading to DGF.
*According to BTS guidelines; the long term graft outcomes of DCD recipients are closely comparable to DBD recipients . so, I will accept DCD donor after counselling and approval of recipient.
References:
1.BTS guidelines 2013.Transplantation from deceased donors after circulatory death.
Would you accept this DBD donor?
Yes I will accept him as AKI does not precludes donation. I will evaluate for liver infection and rule out liver malignancy.
Would you accept this donor if he was DCD?
He can be accepted after counselling . There will be delayed graft function but long term outcomes of DBD and DCD may be nearly similar.
If yes, what is the prognosis?
There can be better outcome if GFR is good and low immunological risk.
What are we dealing with?
Extended donor Criteria- EDC- DBD, Hepatorenal syndrome.
Reference
BTS Guidelines – Transplantation from deceased donors after circulatory death.
· Would you accept this DBD donor?
I will accept this donor
The imbalance between donors and recipients of kidney transplantation (KT) needs the increase of the potential donor pool for transplantation
So, the use of kidneys from expanded criteria donors (ECDs) in deceased donor (DD) KT has been proposed as an important strategy for solving this donor shortage
kidneys from deceased expanded criteria donor (ECD), defined by
donor age older than 60, or a donor older than 50 years with at least two of the following:
1- hypertension
2-stroke as a cause of death
3- serum creatinine greater than 1.5 mg/dL
Previous studies have demonstrated that the prognosis of KT from ECDs is not significantly different from that of KT from standard criteria donors (SCDs) . In contrast, other studies have reported that KT from ECDs yielded poorer clinical outcomes in terms of allograft survival rate compared with that from SCDs
The survival benefit in most patients even with the lowest quality donors can be achieved and it’s better than staying on waiting list on dialysis
AKI, which occurs in more than 25% of critically ill patients, depends on the following point :-
1-underlying disease
2-the duration of kidney impairment
3-the patient’s baseline kidney condition
If the patient baseline kidney function is normal, ischemic or toxic insults causing AKI do not generally hamper full recovery of kidney function
On this basis, it is widely accepted that kidneys from donors with AKI might represent a suitable and safe source for kidney transplantation.
the renal outcomes of AKI in underlying chronic kidney disease (CKD) are significantly worse than those of AKI in normal kidneys . Therefore, it is possible that AKI in ECDs, who might have underlying CKD, has a more significant impact on long-term allograft survival than AKI in SCDs, who might have less severe or no underlying CKD.
Potential recipient has to be well informed about the risks of transplant- ing grafts from ECD.
Transplantation of dual ECD kidneys is one of the possible ways to reduce the number of discarded kidneys and increase nephron mass of ‘marginal’ kidneys. It may be a good approach in expanding donor pool.
In order not to discard kidneys from ECD but improve their allocation and graft survival, Nyberg et al. developed a scoring system for these kidneys. Deceased donor score (DDS) includes scores for donor’s age, hypertension, creatinine clearance, HLA mismatch and cause of death.
If the score is higher than 20, 6-year graft survival is lower than 70%; if DDS is lower than 20, 6-year graft survival is higher than 80%
obvious absolute contraindications to the use of organs for DCD kidney transplantation are:
1-End-stage kidney disease (CKD stage 5, eGFR <15 ml/min)
2-CKD stage 4 (eGFR 15-30 ml/min)
3-Acute cortical necrosis on pre-implantation kidney biopsy
Acute kidney injury, even that requiring dialysis for the donor during the current hospital admission, is not an absolute contraindication to kidney donation. However, it is likely to increase the risk of DGF or primary non function (PNF) to a greater degree than that associated with DBD donation.
Before donation I will screen this donor for hepatitis C and B
CBP,bleeding profiles
· Would you accept this donor if he was DCD?
I will accept this donor
A recent, large, UK based cohort study has suggested that DCD donor kidneys are more susceptible to cold ischaemic injury, but there is no evidence that DCD ECD donor kidneys suffer from more long term graft dysfunction than equivalent DBD ECD donor kidneys
Patient survival following receipt of a DCD kidney seems to be similar to that of a patient receiving a DBD kidney. However, the increased risk of DGF and its consequences need to be discussed with the recipient
· If yes, what is the prognosis?
Regarding DGF
The DGF rate was significantly higher in recipients with donors in the AKI group (p < 0.001) and tended to increase with the AKI stage (5.1%, 17.6%, 15.5%, and 61.6%, for the No AKI and stage 1, 2, and 3 AKI groups, respectively p < 0.001) However, the DGF rate did not have a negative effect on death-censored graft survival in the univariate analysis (p = 0.126)
AKI in DBD donors negatively affected the DGF rate. However, it did not affect long-term graft function or death-censored graft survival.
Regarding Acute rejection
donor AKI did not affect the acute rejection rate or rejection-free survival.
Regarding HISTOLOGICAL OUTCOMES
Surveillance biopsy in the Mayo Clinic cohort demonstrated nodifference in the chronic allograft changes between the AKI and the control groups.
Regarding Graft survival
No significant difference in graft survival when comparing the AKI with the non-AKI group,
Patient survival following receipt of a DCD kidney seems to be similar to that of a patient receiving a DBD kidney. However, the increased risk of DGF and its consequences need to be discussed with the recipient
DCD donor kidneys are more susceptible to cold ischaemic injury and increased risk of DGF but there is no evidence that DCD ECD donor kidneys suffer from more long term graft dysfunction than equivalent DBD ECD donor kidneys
· What are we dealing with?
We are dealing with deceased donor with ECD,DBD,AKI(prerenal or HRS)
References
1-Safety and effectiveness of kidney transplantation using a donation after brain death donor with acute kidney injury: a retrospective cohort study
Kyeong Deok Kim 1, Kyo Won Lee 1*, Sang Jin Kim1, Okjoo Lee1, Manuel Lim1, Eun Sung Jeong1, Jieun Kwon1, Jaehun Yang1, Jongwook Oh2 & Jae Berm Park1. http://www.nature.com/scientificreports
(2021) 11:5572
2-Impact of acute kidney injury in expanded criteria deceased donors on post-transplant clinical outcomes: multicenter cohort study Woo Yeong Park4,5†, Min-Seok Choi1,2†, Young Soo Kim3, Bum Soon Choi1,2, Cheol Whee Park1,2, Chul Woo Yang1,2, Yong-Soo Kim1,2, Kyubok Jin4,5, Seungyeup Han4,5 and Byung Ha Chung
Park et al. BMC Nephrology (2019) 20:39 https://doi.org/10.1186/s12882-019-1225-1
3-REVIEW ARTICLEShould we use kidneys from donors with acute kidney injuryfor renal transplantation?Gordon C.-K. Chan | Kai Ming Chow
Asian Pacific Society of Nephrology 2019
KIDNEY TRANSPLANTATION FROM DECEASED DONORS
WITH HIGH TERMINAL SERUM CREATININE
IVA BAčAK KOCMAN, ŽELJKO KAšTELAN1, PETAR KES2, ELEONORA GOLuŽA, MLADEN PERIć3, IVAN KOCMAN2 and NIKOLINA BAšIć JuKIć2 Acta Med Croatica. Vol. 70 (2016) (Suppl. 2) 70-75
4- British Transplantation Society Guidelines.
Transplantation from deceased donors after circulatory death
Would you accept this DBD donor?
-Yes ,I will accept him.
Would you accept this donor if he was DCD?
Yes ,Iwill accept this donor if he was DCD because long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar.
If yes, what is the prognosis?
-Kidneys from deceased elderly ( ˃60 year )donors with good eGFR and better HLA-DR matched kidneys will produce better outcomes.
What are we dealing with?
-EDC(age ˃60 years) , DBD and AKI secondary to hepatorenal syndrome.
Reference:
BTS/Transplantation from deceased donors after circulatory death
Would you accept this DBD donor?
Yes ,after exclude malignancy ,viral hepatitis and TB. And detailed history .
Would you accept this donor if he was DCD?
The incidence of delayed graft function is increased in DCD recipients and this
should be discussed with the patient prior to transplantation
What are we dealing with?
Hepato renal syndrome with AKI ,Alcoholic liver cirrhosis
Reference
: British Transplantation Society Guidelines
considering patient age more than 65 with cerebrovascular complication (SAH) and have AKI and acute liver failure all these causes make the out come for this graft unfavourable
1-so to accept this graft if
the AKI is reverse
the recipient the benefit for this transplant is weight his risk been on dialysis.
explain to the recipient the benefit versus the risk of this transplantation.
2- iwill not iccept this donor with AKI and been DCD as out come of graft is not good (delay graft function ,cold ischemia time).
3- prognosis from the literature if AKI stage 1 is favourable but AKI stage 2 is worse as in our case .
4- we are dealing with AKI deceased donor most proper hepatorenal syndrome ,as we konw, the kidney in hepatorenal syndrome which is confirmed by exclusion can be savely transplant because there is only vasoconstriction other wise the kidney is normal
f Reference
Klein R, Galante NZ, de Sandes-Freitas TV, de Franco MF, Tedesco-Silva H, Medina-Pestana JO. Transplantation with kidneys retrieved from deceased donors with acute renal failure. Transplantation. 2013;95(4):611–6.
our patient 65-year-old male DBD (donor after brain death) donor who suffered from SAH (grade 5) complicating acute liver failure. This patient is known to have alcoholic liver cirrhosis for years. His baseline S Cr was 60 µmol/L.
depens on the history of the patient ,the most likley diagnosis is hepatorenal syndrome
we could accept this patient but first we have to roll out three things :
viral hepatitis
malignancy
acute tubelar necrosis
after rolling out these things ,I could accept this donor.
DCD has more comlication in compare with DBD especially cold ischemia and early rejection
by adding the AKI in our patient I will not accept his as DCD donor.
refference
BTS Guildlines
_Yes I will accept this DBD donor .
-Yes I can accept the DCD donor because as per BTS guidelines 2013 the long term outcomes of DCD recipients are similar to those of DBD recipients .
Meanwhile DCD kidneys appear to be more susceptible
to cold ischaemia, and the incidence of delayed graft function is increased in DCD recipients and this must be clarified to the patient before transplantation.
In transplants from DCD warm ischemia contributes to worse graft outcome and the donor haemodynamic parameters can predict delayed graft function (DGF) and graft failure.
– The long-term function of the graft and survival of patients and grafts in recipients of kidneys from ECD donors are comparable to SCD donors. Therefore ECD kidneys are used to face the constantly increasing demand versus limited offer of organs.
Phadke et al reported successful kidney transplants from a donor with acute hepatic failure due to acetaminophen overdose and AKI.
-Graft outcome is more closely related to whether a transplant is ECD vs SCD rather than whether the mode of retrieval is DCD vs DBD and more data are required to determine whether the effect of ECD is different in DCD and DBD donors.
This donor is considered an ECD because his age is above 60 years , his creatinine > or equal to 1.5mg/dl , death resulting from SAH added to that being a liver cell failure patient with AKI
So this is considered a high risk transplant and biopsy will be needed to detect the pathology upon organ retrieval and GFR assessment
dual kidney transplantation can be a suitable option as the quality of the graft seems to be below the standard requirements.
Reference
-BTS guidelines 2013
-Phadke, Gautam; Mahale, Adit; Chemiti, Gopal; Levitski, Teresa; Ahlin, Thomas; Mistry, Bhargav. Successful Kidney Transplants From a Donor With Acute Hepatic Failure due to Acetaminophen Overdose and Acute Kidney Injury. Transplantation: July 27, 2008 – Volume 86 – Issue 2 – p 368-369
Dear Dr Doaa, that is an excellent decision-making with supportive evidence.
Ajay
graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD .
GFR is initially poorer because of the high incidence of DGF in DCD, but is equivalent after 3 months. At 3 years post- transplantation, the median GFR following DCD is 45 ml/min/1.73m2 and following DBD is 46 ml/min/1.73m2 .
DCD kidneys are more prone to the detrimental effects of cold ischaemia than DBD kidneys,
In addition to the general absolute contraindications to organ donation defined by NHSBT, (i.e. invasive or haematological malignancy, untreated systemic infection, prion disease, and HIV disease), obvious absolute contraindications to the use of organs for DCD kidney transplantation are:
1-End-stage kidney disease (CKD stage 5, eGFR <15 ml/min)
2-CKD stage 4 (eGFR 15-30 ml/min)
3-Acute cortical necrosis on pre-implantation kidney biopsy
Acute kidney injury, even that requiring dialysis for the donor during the current hospital admission, is not an absolute contraindication to kidney donation. However, it is likely to increase the risk of DGF or primary non function (PNF) to a greater degree than that associated with DBD donation.
Relative contraindications:
Donor and retrieval factors that impact upon graft outcomes include donor age and cold ischaemic time .Additional factors such as donor hypertension and cardiovascular disease have also been shown to have an impact on DCD kidney survival, but to a lesser degree than these factors .
For 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 .Such kidneys are normally discarded, although good outcomes have been described using DBD kidneys with moderate disease when used as dual transplants into a single recipient .Given the comparable outcomes between DCD and DBD kidneys, a similar approach may successfully expand the DCD donor pool, but experience is limited.
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 .
Recommendation:
@Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, and the proposed national allocation scheme should take this into account. (B2)
@The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation. (A1)
@Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys. (B1)
@Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants. (A1)
Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD. (B2)
Prospective data are required to determine whether the impact of expanded criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
Reference:
Transplantation from deceased donors after circulatory death
Compiled by a Working Party of The British Transplantation Society
July 2013
Dear Dr Asmaa,
I enjoyed reading your response but I would not find any conclusive decision-making in this index case from you as a transplant clinician.
Ajay
This donor represents an ECD as ECD includes:
Age ≥ 60 years
Or Ages 50–59 years with 2 of the following::
1) cerebrovascular accident as the cause of mortality
, 2) Hypertension
3) serum creatinine > 1.5 mg
So I will accept the donor with some precautions treatment of AKI to improve baseline KFTs
assessment of the virology profile to exclude transmission of viral infections to the recipient
early introduction of monoclonal or polyclonal immunosuppression to decrease the risk of early rejection is associated with delayed graft functions (as the delayed introduction of CNI )
Counseling the recipient that there is a high risk for delayed graft functions.
Would you accept this donor if he was DCD?
This is another risk factor for delayed graft functions with more susceptibility for early rejection with poorer graft outcomes.
So I will accept the donor after comparing the risk of mortality of being on the waiting list and the expectance of poorer graft functions after counseling of the patient.
What are we dealing with?
Donor with ECD Age > 60
Liver cirrhosis with unknown etiology ( virology profile is needed )
AKI ( Pre renal (HRS) vs Intrinsic ATN )
SAH
with many risk factors for poor graft outcome
Age 65 ( however some studies study demonstrated no significant association
Regarding donor age when other donor variables such as kidney function and donor-recipient variables(delayed graft function and acute rejection episodes)are taken into consideration
But there is an increase of Kidney functions
Expectance of delayed graft functions with more risk of acute rejections especially if he was DCD
Ref :
Wu C, Shapiro R, Tan H, et al. Kidney transplantation in elderly
people: the influence of recipient comorbidity and living kidney
donors. J Am Geriatr Soc. 2008;56(2):231-238.
Ferrer F, Mota A, Alves R, et al. Renal transplantation with
expanded criteria donors: the experience of one Portuguese
center. Transplant Proc. 2009;41(3):791-793.
Superb reply, Dr Ghanem.
This potential donor is:
The decision is not easy as there is a high risk of DGF as the donor is ECD.studies showed the association between donor AKI and DGF. DGF can add days to a recipient’s hospital stay and increase the total cost of care. In addition, lower graft function is found in recipients of grafts with AKI. Most studies related the long-term graft survival to the AKI stage before transplantation; in stages 1 & 2, the overall graft survival is comparable between AKI and non-AKI donors. A higher rate of all-cause graft failure among stage 3 AKI kidneys.
In addition, infections like hepatitis B & C need to be excluded.
Given the donor’s age, we may need a preimplantation biopsy to assess the degree of GS and chronicity features.
I may accept the offer if the donor is compatible with a highly sensitized recipient who spent a long period on the waitlist after explaining the risk to the recipient.
NO, I will not.
The risk of DGF in DCD grafts with AKI is higher than that for DBD grafts.
A study showed that:
Stage 1 AKI DCD grafts have equivalent outcomes to those from AKI-matched BD donors.
Stage 2 AKI DCD donors have worse outcomes.
Though stage 3 DCD outcomes may be equivalent, significantly fewer of these grafts were studied.
All transplanted kidneys likely outperform waitlist/dialysis survival.
An ECD with acute liver injury and SAH.
References:
Well done you can add HRS which is highly probable.
thank you
Elderly donor ( 65 y )
* Acute Liver failure
* SAH grade 5 which mean possibility of coagulopathy
* Chronic alcoholic liver disease
* AKI Often in the context of hepatorenal syndrome type 1 ( reversible ) with good baseline creatinin so
● I will accept this DBD after Assessment infection espicially HBV , HCV , HIV , …
and assessment the liver carcinoma
Beside to counseled the recipiant regarding the risk of DGF and PNF
Considered that donors with AKI are more likely to undergo delayed graft function but have similar long-term outcomes as donors without AKI.
● If he was DCD the risk for DGF and PNF
Will be higher so I will prefer to reject him
● We deal with ECD ( marginal kidney donor )
Is there a long term difference in graft survival between DBD,and DCD
can councelling the recipient make a difference.
In the current scenario which is exploring the acceptance of ECDs and long term graft survival.
The ECDs are donors with age ≥ 60 years and those ≥ 50 years with at least two of the following characteristics: final creatinine > 1.5mg/dL, high blood pressure and/or cerebrovascular accident (CVA) as cause of death old and diabetic donors.
A lot of studies illustrated the need for a better decision making guidance regarding assessment of potential donors rather than only the classification into kidneys from standard or expanded criteria donors. The kidney donor profile index (KDPI) which concluded a score of ten factors which are age,hight,weight,HTN,DM,Hepatitis C ,cause of death,DBD/DCD,Last serum creatinine and Ethnicity .
KDPI is not only the tool for matching the suitable donor/Recipient (Allocation) but also to determine the risk for kidney transplant failure. For example, the graft of a donor with a KDPI of 70% has a higher predictive risk of graft failure than 70% of the grafts transplanted in the previous year.
In the current index case with potential donor with history of liver cirrhosis and presented with AKI which can be from different causes either prerenal as HRS or intrinsic renal as ATN (ischemic or toxic) which can be assessed with implantation biopsy. So we have a potential donor with ECD with old age and AKI if biopsy excluding permanent damage and work up of viral serology we can proceed for transplantation and counselling the recipient regarding risk of DGF,acute rejection episodes.
It is reported that DBD donor KT recipients who received kidneys from ECDs with AKI showed worse long-term graft survival than other KT recipients as well as DGF rate was higher with AKIN stage 2 and 3 disease. There are studies reported that induction with high dose r-ATG could reduce ischemic reperfusion injury and reduce the incidence of DGF.
Would you accept this donor if he was DCD?
Basically, DCD kidneys are subject to warm ischaemic injury that increases the risk of primary non-function (PNF) and delayed graft function (DGF) and may compromise long-term graft survival and particularly when they come from expanded criteria donors.
Transplant physicians have more open-minded attitude now towards donor acceptance criteria. Several studies of kidney transplants in elderly recipients and the use of advanced-age kidneys, adopting an old-for-old allocation policy, have shown favourable results, demonstrating improved survival compared with waitlisted patients remaining on dialysis. So based on that the offer can be accepted with consideration of recipient age.
References:
Guirado, L. Does rabbit antithymocyte globulin (Thymoglobuline(R)) have a role in avoiding delayed graft function in the modern era of kidney transplantation?. J. Transplant. 2018, 4524837
Watson CJ, Johnson RJ, Birch R, Collett D, Bradley JA. A simplified donor risk index for predicting outcome after deceased donor kidney transplantation. Transplantation. (2012) 93:314–8. doi: 10.1097/TP.0b013e31823f14d4
Perez-Saez MJ, Arcos E, Comas J et al. Survival benefit from kidney transplantation using kidneys from deceased donors aged [1]75 years: a time-dependent analysis. Am J Transplant 2016; 16: 2724–2733
Excellent answer but :
why a HIGH DOSE of rATG is used in sequential therapy in IRI which can induce rejection.
As reported ,High dose rATG give valuable time for late introduction of CNI to avoid aggravation of DGF.
This potential DBD donor is 65 years old, with SAH grade 5, acute liver failure &AKI ( HRS)
He can be accepted as AKI does not preclude donation.
If he is DCD, it will be worse due to higher incidence of DGF with increased CIT, better not accepting donation but it could be possible if accepted after patient counselling.
If accepted, DGF will happen in short term outcome ; but long term outcomes are similar in both DCD and DBD.
The potential donor we are dealing with is expanded criteria donor old age with preexisting renal with AKI. Underlying viral cause of liver cirrhosis should be investigated for.
BTS Guidelines.
Thankyou well done
we are dealing with :Expanded Criteria Donor
Our potential donor is :
-DBD
-65 years
-Liver cirrhosis
-AKI ( Hepatorenal syndrome is a possible differential diagnosis)
-SAH as a direct cause of death
An ECD is one who, at the time of death, is aged ≥60 years or aged 50–59 years with any two the following three criteria: 1) cause of death is cerebrovascular accident, 2) pre-existing history of systemic hypertension, and 3) terminal serum creatinine >1.5 mg/dl.
*Donor age has the strongest independent association with long-term kidney transplant outcomes .Some centers consider dual versus single kidney transplants using older kidneys. However, when using donors aged ≥60 years, no graft survival advantage at 5-year was observed comparing dual versus single kidney transplantation in an analysis from the United Kingdom between 2005–2017 although higher GFR is seen with dual Tx.
If he was DCD???
Increasing donor or recipient age, repeat transplantation, and CIT >12 h were associated with worse graft survival for recipients of DCD kidneys.
“Although survival was better post-transplantation compared to remaining waitlisted, it raises a level of caution in decision making when dealing with donor-recipient extremes. Therefore, use of ECD-DCD kidneys is acceptable for select waitlisted kidney transplant candidates when carefully balanced against their mortality risk without transplantation and quality of life considerations”.
Prognosis:
-ECD vs SCD
-Deceased with AKI vs non AKI
-DBD vs DCD
*The criteria for defining ECD were based on the presence of variables that historically increased the risk for graft failure by 70% compared with a standard criteria donor (SCD) kidney .
*ECD kidneys may be better prioritized for older recipients by ignoring immunology-based allocation. Using this strategy, the Eurotransplant Senior program have shown favorable 5-year outcomes using ECD kidneys in older recipients .
*Recent analyses support broadening access with careful risk stratification. Pooled 5-year patient survival probabilities were 78.4% versus 86.4% in ECD versus SCD recipients respectively.
*Optimal utilization of ECD kidneys may also be stratified by recipient age, with studies suggesting recipients aged ≥60 years or ≥65 years be prioritized.
*The absolute risk difference between SCD and ECD kidneys in the long-term may be marginal when compared to remaining on the waiting-list.
————————————————————————————
*37 studies were identified comparing transplant outcomes between kidneys with versus without donor AKI. Donor AKI was associated with DGF, with prolonged nights in hospitals and additional attributed costs.
*A meta-analysis of 14 cohort studies exploring 15,345 donors, Zheng et al. estimate the relative risk of DGF to be 1.76 for recipients of kidneys with versus without donor AKI .
*Single center outcomes using donors with both AKI (comparing advanced stages 2–3 versus 0–1) and high KDPI (≥85%) demonstrated more DGF , more primary non-function , no difference in eGFR in ml/min/1.732 and lower 1-year death-censored graft failure 14.5% versus 3.5% for AKI 2-3 versus AKI 0-1 high KDPI kidneys respectively.
————————————————————————————
*Data from the USA , examining outcomes in adult recipients receiving a deceased donor kidney transplant between 2000–2007, compared survival outcomes between 8,289 DBD kidneys and 845 DCD kidneys showed increased rates of DGF after DCD kidney transplantation however first-time recipients of DCD kidneys or DBD kidneys (showed no difference in 5-year graft survival.
*Increasing donor or recipient age, repeat transplantation, and CIT >12 h were associated with worse graft survival for recipients of DCD kidneys.
*Prolonged CIT (>24 h versus <12 h) was associated with poorer graft survival for DCD versus DBD kidneys in many cohorts .
————————————————————————————-
References
1. Jardine, AG, Gaston, RS, Fellstrom, BC, and Holdaas, H. Prevention of Cardiovascular Disease in Adult Recipients of Kidney Transplants. Lancet (2011) 378(9800):1419–27. doi:10.1016/S0140-6736(11)61334-2
PubMed Abstract | CrossRef Full Text | Google Scholar
2. Chapman, JR. The Consequences of Successful Transplantation. Lancet (2011) 378(9800):1357–9. doi:10.1016/S0140-6736(10)61111-7
PubMed Abstract | CrossRef Full Text | Google Scholar
3. Chaudhry, D, Chaudhry, A, Peracha, J, and Sharif, A. Survival for Waitlisted Kidney Failure Patients Receiving Transplantation versus Remaining on Waiting List: Systematic Review and Meta-Analysis. BMJ (2022) 376:e068769. doi:10.1136/bmj-2021-068769
4. Watson, CJ, and Dark, JH. Organ Transplantation: Historical Perspective and Current Practice. Br J Anaesth (2012) 108(1):i29–42. doi:10.1093/bja/aer384
5. Gill, JS, Abichandani, R, Kausz, AT, and Pereira, BJ. Mortality after Kidney Transplant Failure: the Impact of Non-immunologic Factors. Kidney Int (2002) 62(5):1875–83. doi:10.1046/j.1523-1755.2002.00640.x
PubMed Abstract | CrossRef Full Text | Google Scholar
6. Rao, PS, Schaubel, DE, Jia, X, Li, S, Port, FK, and Saran, R. Survival on Dialysis post-kidney Transplant Failure: Results from the Scientific Registry of Transplant Recipients. Am J Kidney Dis (2007) 49(2):294–300. doi:10.1053/j.ajkd.2006.11.022
7. Foley, DP, and Sawinski, D. Personalizing Donor Kidney Selection: Choosing the Right Donor for the Right Recipient. Clin J Am Soc Nephrol (2020) 15(3):418–20. doi:10.2215/CJN.09180819
PubMed Abstract | CrossRef Full Text | Google Scholar
8. Mohan, S, Chiles, MC, Patzer, RE, Pastan, SO, Husain, SA, Carpenter, DJ, et al. Factors Leading to the Discard of Deceased Donor Kidneys in the United States. Kidney Int (2018) 94(1):187–98. doi:10.1016/j.kint.2018.02.016
9. Stewart, DE, Garcia, VC, Rosendale, JD, Klassen, DK, and Carrico, BJ. Diagnosing the Decades-Long Rise in the Deceased Donor Kidney Discard Rate in the United States. Transplantation (2017) 101(3):575–87. doi:10.1097/TP.0000000000001539
10. Council of Europe, . Newsletter Transplant: International Figures on Donation and Transplantation (2018). EQDM 2019. ISSN: 2171-4118.
11. Maghen, A, Mone, TD, and Veale, J. The Kidney-Transplant Waiting List and the Opioid Crisis. N Engl J Med (2019) 380(23):2273–4. doi:10.1056/NEJMc1817188
*Donor age has the strongest independent association with long-term kidney transplant outcomes.
**Increasing donor or recipient age, repeat transplantation, and CIT >12 h were associated with worse graft survival for recipients of DCD kidneys.
*Prolonged CIT (>24 h versus <12 h) was associated with poorer graft survival for DCD versus DBD kidneys in many cohorts .
Hi Dr Essmat,
That is a very good diagram depicting graphic representation of a range of risk factors that pose risk of long term allograft function with strength of evidence.
Although survival was better post-transplantation compared to remaining waitlisted, it raises a level of caution in decision making when dealing with donor-recipient extremes. Therefore, use of ECD-DCD kidneys is acceptable for select waitlisted kidney transplant candidates when carefully balanced against their mortality risk without transplantation and quality of life considerations
Thank you.
Thank you for this comprehensive answer Mohamed
Thank you dear Professor
Would you accept this DBD donor?
Acceptance of this donor must be studied well as there is high risk for DGF
This donor has:
-AKI mostly HRS but other causes must be excluded as ATN , cortical necrosis may need kidney biopsy
-old age
We should discuss with the recipient and to be included in all problems and the high risk for DGF and decreased graft survival
So I will accept if it is needed urgently and no other option also it is still better than waiting on dialysis
Would you accept this donor if he was DCD?
Yes I will accept in spite DCD is more susceptible to ischemia which increase possibility of DGF
and low graft survival
Prognosis :
Poor prognosis with high risk of DGF especially donor has AKI and old age
Dealing with marginal kidney
Thankyou for your cautious acceptance but don’t forget a virology profile although he is a documented alcoholic cirrhosis.
Hi Dr Essmat,
that is an excellent review.
I would re-emphasis that age matching is a good idea. However, we need to be aware that ECD kidneys for marginal recipients may not be a sensible decision. In case of primary non-function of significant DGF, marginal recipients are at a risk of dying.
I would accept him as a donor but I would discuss with the potential recipient about the possibility to have DGF.
I need also to exclude:
– Active infection
– Missed active malignancy
–
I would prefer to give this graft to a dialysis patient who was in the tx waiting list for a long time.
Although it will be more risk to develop DGF due more added ischemia to kidney tissue in view of his AKI secondary to HRS, I would accept him as a donor with DCD
We are dealing with DBD with acute liver failure complicated by HRS and high grade SAH leading to death.
Thank you, Mike
I noticed you developed the habit of NOT writing the references.
65-year-old male DBD (donor after cardiac death) donor who suffered from SAH (grade 5) complicating acute liver failure. This patient is known to have alcoholic liver cirrhosis for years. His baseline S Cr was 60 µmol/L. On admission S Cr was reported to be 300 µmol/L (3.4 mg/dl). Urine output was 20mls/h during the last hour and 1.1 L over the last 24 hours.
Would you accept this DBD donor?
No, I would not accept this donor.
First; The patient had chronic alcoholic liver cirrhosis, with grade 5 SAH complicating acute liver failure cause not determined.
I will dig in the cause of this acute liver failure by doing full viral serology ( hepatitis A, hepatitis B, hepatitis E , CMV, EBV, HSV, HIV …etc), from history to exclude any medications or drug use-example paracetamol toxicity that might also be the cause of his AKI [1].
Second; He is old age >60 year old and experienced acute kidney injury with worsening kidney function and decreasing urine output to 20ml/hr at the last hour, which increase the risk of graft dysfunction (delayed graft function), and deleterious graft and patient survival [2].
Would you accept this donor if he was DCD?
Yes, I would accept him if he is DCD as the acute liver failure is due to ischemic injury from cadiogenic shock, after exclusion of all viral illnesses.
If yes, what is the prognosis?
Donor eGFR are predictors of overall graft and patient survival, Donor age and serum creatinine affects graft survival, Recipient age and comorbidities predict the prognosis also[2].
Acute kidney injury at the time of procurement of the organ, carries a worse prognosis[3].
What are we dealing with?
Expanded-criteria deceased donor of 65 years, with SAH , unknown etiology of acute hepatic failure, and acute kidney injury at the time of offering the kidneys.
References:
[1] Bernal W, Wendon J. Acute liver failure. N Engl J Med. 2013 Dec 26;369(26):2525-34. doi: 10.1056/NEJMra1208937. PMID: 24369077.
[2] Adekoya AO, Halawa A. Kidneys From Deceased Elderly Donors: Factors Associated With Adverse Outcomes. Exp Clin Transplant. 2016 Feb;14(1):32-7. PMID: 26862822.
[3] Kolonko A, Chudek J, Pawlik A, Wilk J, Jałowiecki P, Więcek A. Acute kidney injury before organ procurement is associated with worse long-term kidney graft outcome. Transplant Proc. 2011 Oct;43(8):2871-4. doi: 10.1016/j.transproceed.2011.07.017. PMID: 21996176.
Thank you.
Would you accept this DBD donor?
I would accept this donor
a) A case of hepato-renal syndrome in which the kidney function deterioration is related to liver failure, and once the liver transplant being carried out, the normal kidney function will be reversed.
b) The age of 65 is a concern, but provided normal baseline function of the kidney, nothing precludes to accept donation.
Would you accept this donor if he was DCD?
I would also accept this donor if he was DCD.
a) Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
b) DCD kidneys are more prone to the detrimental effects of cold ischaemia than DBD kidneys, as confirmed by a recent UK cohort study.
If yes, what is the prognosis?
No significant association regarding donor age when other donor variables such as kidney function and donor-recipient variables (delayed graft function and acute rejection episodes) are taken into consideration1.
What are we dealing with?
We are dealing with:
a) ECD/DBD; Kidney’s offer from an old age>60.
b) Potential donor with high SCr before retrieval, and the cause of renal impairment is HRS.
Reference
1. Kidneys From Deceased Elderly Donors: Factors Associated With Adverse Outcomes Adebowale O. Adekoya, Ahmed Halawa
Thank you, Safi
Would you accept this DBD donor?
This 65-year-old male DBD who suffered from SAH secondary to acute liver disease also has AKI which is probably due to hepatorenal syndrome as he is known to have alcoholic liver cirrhosis.
The use of kidneys from DBD donors with AKI is a strategy to expand the donor pool.
In a retrospective cohort study reviewed all patients who underwent KT from DBD donors between June 2003 & April 2016.
The cohort included 376 donors (no AKI group, n= 117 [31.1%]; AKI group n= 259 [68.9%]). Death censored graft survival was similar according to the presence of AKI, AKI severity, & the AKI trend.
The use of low dose r-ATG (1.5 mg/kg for 3 days) was associated with significantly superior death-censored graft survival compared with patients who received basiliximab.
So, AKI in DBD donors did not affect long-term death-censored graft survival.
Low dose r-ATG may be considered as an induction IS in recipients receiving kidneys with AKI because it showed better graft survival than basiliximab.
In view of these results, I would accept this donor; the use of low dose ATG could also be considered.
=========================
Would you accept this donor if he was DCD?
Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia, andthe proposed national allocation scheme should take this into account. (B2) (The British Transplantation Society Guidelines, July 2013)
Donation after DCD & AKI donors have been considered an independent risk factors for DGF, allograft failure, & inferior outcomes.
In a retrospective cohort study, Caroline C. Jadlowiec et al. reviewed outcomes for 76 DCD AKIN stage 2‐3 recipients & compared them to 548 DBD AKIN stage 2‐3 recipients. Kidneys were preselected for use based on the center’s practice of reviewing pre-implantation frozen-section renal biopsies.
Using the following selection criteria, they observed good outcomes that are comparable between DCD & DBD AKI groups:
1. For solitary DKD transplants, they do not utilize kidneys with biopsies showing moderate or severe chronic changes or if tubular cortical necrosis exceeds 10%.
2. Kidneys with cortical necrosis >10% or moderate‐to‐severe chronic changes were discarded.
They did not observe any differences in DGF or ACR when comparing DCD & DBD AKI kidneys.
So, in view of these encouraging results, I would accept this donor if he was DCD, but only if my transplant center has similar logistics & settings mentioned in this study.
=========================
If yes, what is the prognosis?
According to the above retrospective studies, the death censored graft survival was similar according to the presence of AKI, AKI severity, & the AKI trend. The prognosis was ven better when small dose used for induction versus basliximab.
=========================
What are we dealing with?
We are dealing with a case of DBD kidney donor with a background of liver cirrhosis secondary to alcoholic liver disease. The case is also complicated by acute kidney injury possibly a type 1 hepatorenal syndrome.
References
1. Kyeong Deok Kim et al. Safety and effectiveness of kidney transplantation using a donation after brain death donor with acute kidney injury:a retrospective
cohort study. Scientific Reports | (2021) 11:5572 | https://doi.org/10.1038/s41598-021-84977-1
2. Caroline C. Jadlowiec. Transplanting kidneys from donation after cardiac death donors with acute kidney injury. Am J Transplant. 2020;20:864–869.. DOI: 10.1111/ajt.15653
Thank you, Mohamed
I like your reflection
Having DBD old age with :
SAH (grade 5)
acute liver failure with hx of alcoholic liver cirrhosis
Normal base line creatinine now with AKI
Would you accept this DBD donor?
First we should know the real cause of acute liver failure and screening about viral infection ,systemic diseases ,etc …. even if there is hx of alcoholic cirrhosis
The cause of AKI may be due t HRS or pre renal cause even so
I would like to accept this donor as
AKI in DBD donors did not affect long-term death-censored graft survival. Low-dose r-ATG may be considered as an induction immunosuppression in recipients receiving kidneys with AKI because it showed better graft survival than basiliximab.
Would you accept this donor if he was DCD? If yes, what is the prognosis?
I would accept this donor even if he was DCD ,
There is no evidence that DCD ECD donor kidneys suffer from more long term graft dysfunction than equivalent DBD ECD donor kidneys .
NHSBT data show that increasing donor and recipient age and a cold ischaemic time of >12 hours are associated with worse outcome .
UNOS data show that the incidence of DGF is increased in DCD recipients, ranging from 41-51% compared with 24% in DBD recipients .
It is important to note that the most recent evidence suggests that ECD DCD donor kidneys are no more likely to fail early than ECD DBD donor kidneys .
obvious absolute contraindications to the use of organs for DCD kidney transplantation are:
It is likely to increase the risk of DGF or primary non function (PNF) to a greater degree than that associated with DBD donation.
Early function is dependent upon the underlying health of the donor as well as the ischaemic time and any damage sustained during the process of the death and organ retrieval.
There are currently no histological markers that predict PNF as a result of excess warm ischaemia or irreversible ischaemia-reperfusion.
What are we dealing with?
ECD with AKI
Reference
Thank you, Huda for the comprehensive answer
A 65 yrs old DBD donor with SAH, Acute on chronic alcoholic liver failure, AKI / hepatorenal syndrome,it is a marginal graft, extended donor criteria, this donor had baseline normal S Cr , which indicates most likely ATN. So I will accept this donor with informed consent & pre-transplant renal biopsy.
If he was DCD donor still accepted this marginal graft with pre-transplant biopsy, with a high risk of DGF & decrease graft survival .
We are dealing with extended donor criteria with reversible AKI due to mostly ATN.
Dear Dr Akram,
I can appreciate why a decision is not very easy. You should have supported your argument by uploading evidence
You mention that ATN is likely and it needs to be ruled out by performing renal histopathology.
I would emphasize that histopathology of renal biopsy may not be available at odd hours, moreover, it would not show functional changes that happen in hepatorenal syndrome manifesting as reduced perfusion in the medulla due to severe renal vasoconstriction. Autopsy studies have demonstrated that histopathology of the kidney does not show any significant findings (1).
Ajay
(1) Epstein, M. (Apr 1994). “Hepatorenal syndrome: emerging perspectives of pathophysiology and therapy.”. J Am Soc Nephrol 4 (10): 1735-53.
This patient has many negative points
The age of donor itself makes the donation classified as expanded criteria donor (ECD)
So when an other risk factor as AKI exists we should be aware of balance between the risk of mortality and morbidity on waiting list and the acceptance of this donor
Therefore the gold standard concept is the benefit to the recipient .
we’ d rather not accept this donor unless there is an urgent need to kidney transplant
This donor is considered as DBD but also he can be classified as category 3 DCD due to (SAH5)
The difference between them is the higher incidence of DGF in DCD
If we accept this donor we should rule out viral infection HCV – HBV- HAV – EBV – CMV……
renal biopsy if available to exclude the chronicity (sclerosis) and cortical necrosis ….
This donor may need dialysis
The prognosis is related to perioperative complications and graft survival
The incidence of DGF increases with the presence of AKI
Such kidneys are normally discarded, although good outcomes have been described using DBD kidneys with moderate disease when used as dual transplants into a single recipient
Dear Dr Ghalia,
I like that you are considering dual renal transplant.
I appreciate why you would accept this donor as DBD rather than DCD. Many such extended criteria donors would serve better purpose if offered as DBD.
Noenetheless, The decision is not very easy.
This donor’s baseline creatinine was excellent. If these kidneys are good in size, then I would use these kidneys in 2 small-size female recipients or as a dual renal transplant in one big-size male recipient.
I quote:
Neel Koyawala and Chirag R. Parikh. A Review of Donor Acute Kidney Injury and Posttransplant Outcomes. Transplantation ■ August 2020 ■ Volume 104 ■ Number 8
“Existing literature suggests transplanting more donor kidneys with stage 1 and 2 AKI, and cautious utilization of stage 3 AKI donors, may increase the pool of viable kidneys. Doing so can reduce the number of people who die on the waitlist by over 500 every year.”
Thank you for your comment and explanation
1. I will accept this DBD donor, but with the following precautions:
_ as basal creatinine was 0.6, so the current rise to 3 mg/dl is AKI that may be due to nephrotoxic medications, prerenal injury as HRS or ATN from ischemia and hypo-perfusion after significant SAH, so mostly it is acute and reversible condition, and the kidney will recover after transplantation.
_ however, higher risk of DGF is expected , so proper counseling of the recipient and obtaining a consent from him is essential.
_ biopsy to exclude cortical necrosis and aging glomerulosclerosis more than 20% is essential to exclude age related changes.
_ in addition, proper selection and matching of a recipient with the concept (old for old) as this is a marginal graft due to (age of donor, AKI prior to death).
_ induction therpay with mono or polyclonal antibodies to allow for CNI delay to minimize the risk of nephrotocicty and DGF, together with avoidance of AR episodes.
2. What about if the donor is DCD:
I think acceptance of such marginal kidney (AKI, craetinine 3, old age ) after cardiac death carries a very high risk of DGF and I will not accept the offer, as circulatory failure will agrevate the AKI and ischemic insult on the kidney with poor graft and patient outcome.
Although the long term graft outcome of DBD and DVD may be comparable, but in the current case with elevated creatinine , the condition will be aggrevated.
3_ long term prognosis:
sure, expected high risk of DGF and AR carries a risk of poor graft outcome. However, it is proved that EDC has better outcome than being on wait-list on HD
4. What we are dealing with:
We are dealing with marginal kidney or extended criteria donor (age , AKI), so weighing benefit and risk and taking into consideration that EDC is better than dialysis.
_ Matching between donor and recipient, appropriate care of the cadveric donor to maintain adequate organ perfusion, all can improve the outcome.
Hi Dr Shawky,
You should have supported your argument by uploading evidence. I like your decision and arguments, however.
I will neither accept this donor as DBD nor as DCD because this potential donor has multiple issues which can cause delayed graft function (DGF) or primary non function(PNF).
I think pre implantation biopsy will give most answers. It no cortical necrosis, no glomerulopathy, no senile changes like atherosclerosis or hypertensive changes and it’s just ATN we can consider donation.
REF:
Hi Dr Saini,
I can appreciate why you are concerned about PNF and DGF. The decision is not very easy. You should have supported your argument by uploading evidence rather then just writing ‘BTS Guidelines’.