3. You were offered kidneys from a 61-year-old DCD female donor who suffered from SAH (grade 4/5). No history of hypertension or DM. Her GP records showed that she was running eGFR between 50 and 60 mls/min over the last few years. She had excellent urine output (110mls/h during the last hour and 2.8 L over the last 24 hours).
- Would you accept this donor?
- If yes, how do you select the recipient(s) suitable for this case?
1. Do you think that DKT could be a better option compared to transplanting these kidneys separately?
2. What are the selection criteria for the 2 potential recipients of these kidneys?
You mentioned you would transplant them separately.
3. Do we need to perform a biopsy to inform our decision? please justify.
yes, biopsy is highly needed to know the original pathology of CKD and to evaluate the prognosis and the expected graft survival.
I note your viewpoint, Dr Omar. Ajay
DKT is better than transplanting these suboptimal kidneys separately; such an offer can be considered for low immunological risk patients, small-size or female patients, had exhausted vascular access, long waiting time till transplantation.
Biopsy may be misleading and will increase the discard rate.
I note your viewpoint, Dr Taee.
As long as biopsy, if available at odd hours, will help indecision-making as long as it is helping us to discard kidneys that do not have enough reserves.
Ajay
Of course prof.
References:
[1] Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
[2] Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
note your viewpoint, Dr Alshaikh,
As long as biopsy, if available at odd hours, will help indecision-making as long as it is helping us to discard kidneys that do not have enough reserves.
Ajay
The current patient is an ECD / marginal kidney due to age> 60 years, death from cerebrovascular accident; border line GFR 50-60 ml/min, moreover she is a DCD which is associated with higher incidence of DGF
We have to choose between one of 3 decisions either SKT, DKT or discarding the kidneys according to the following:
A- First of all we have to exclude significant proteinuria > 3gm which will preclude donation, we have to know creatinine before retrieval and us abdomen should be done also for assessment of kidney size
B- Second I will recommend biopsy since the GFR of the current patient is 50-60 ml/min (borderline), biopsy will help our decision
C- Third, Viability assessment including flow and RI during machine perfusion
So I will accept either SKT for 2 recipients or DKT to the following recipient
Provided that life expectancy is > 1 year and no available living or SCD kidney
1-regarding DKT if we choosed this donor as ECD criteria donor ,her eGFR if till same as base line we50 to 60 ,can benefit from DKT but if updated eGFR 30 or less or serum creatinine more than 2-5 mg/dl the organ should be discarded,regarding kidney biopsy it will not added more as pateint diagnosis CKD before.
2- selection criteria of these recipents
age mor than 40 year old.
low immunological risk patient.
DM.
waiting time more than3.5 years.
has vascular access failure
3- biopsy indicated if eGFR remain 50 to 60 if scoring system
0 to 3 offer SKD.
0 to 6 offer DKD.
7 to 12 discard
but if latest eGFR bleow 30 no need to go for biopsy
references
prof.Ahmed Halwa lecture
Would you accept this case:
Yes I will accept
this donor is marginal donor ( old age )
Biopsy can be done to decide single or dual kidney transplant
Machine perfusion can be used
Modification of immunosuppressive medications ( ATG induction , CNI free protocol )
Suitable recipient would be:
Low immunological risk
Multiple access failure
Female or small muscle mass
Diabetics
Elderly
Age more than 40
On waiting list more than 4 years
refersnce:
dr Ahmed Halawa lecture
if I am going to do a dual kidney transplant there is no need to do the biopsy. if a separate kidney transplant will be done so kidney biopsy in my opinion will be mandatory. performed in many centers but it was of no obvious benefit, but increasing organ discard rate[2]
References:
[1] Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
[2] Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
Yes, I will accept this donor to increase donor pool by using ECD ( associated with bitter graft & patient survival when compared to patients on dialysis) when use the recipients carefully & reduce the number of discarded ECD with DCD kidneys ( associated with reducing mortality by 56% compared to patients on waiting list).
DKT used to increase number of functional nephrons needed to keep the patient dialysis independent. SKT had less functional nephron, in addition to ischemia perfusion injury & effect of CNI can deteriorate renal parenchymal injury, so for this patient DKT is better.
CIT<30 hrs inaddition to age of donor & presence of co-morbidities with finding of renal biopsy ( Remuzzi score) can help in deciding to use SKT or DKT with 100% survival at 6 months & 93% at 3 years.
Recipient benefit from DKT are age & wight matched persons, low immunological risk & patient with ideal BMI.
References:
Do you think that DKT could be a better option compared to transplanting these kidneys separately?
Yes DKT is better with this GFR less than 60.
2_selection criteria for 2 PTR.
Female recipient.
Old recipient.
Recipient waiting more than 4 years in
transplant list.
Recipient with end vascular access. .
3_Do we need biopsy?
Ithink it won’t add any further information
if we choose DKT.
Being over 60 years old with no recent eGFR just before organ retrieval will put the recipient at risk of high immune suppression because of highly probable DGF.. I will prefer and plan to transplant the two kidneys into age matched donor. I will take a biopsy but would prefer a needle biopsy if possible. Wedge biopsy will give me bad results anyhow. If the current eGFR is consistent with previous records, I may change the plan into:
either transplanting each kidney into two separate old donors or DKT for the young recipient to increase the nephron mass
Dear Dr Ahmed,
I will accept this donor for DKT only. Stable GFR over the past few years between 50-60 ml/min means that we need to transplant both kidneys to a single donor to keep adequate nephron mass comparable to a single SCD.
I think there is no need for a kidney biopsy in this case as the GFR was stable over the past few years, indicating the absence of any active disease to be detected by biopsy.
1.DKT is a good option in marginal kidneys to increase nephron number.
2. Suitable recipient would be: age more than 40, diabetic, low immunological risk, small size female, more than 4 years being on waiting list, vascular access failure
3. Biopsy is not available any time we need and may be misleading. But biopsy would help us to discard useless kidneys.
Thank you All
Do you think that there is enough information about kidney function was provided?
What else is missing?
I think the missing data , would be the current creatinine level prior to procurement of the kidney. Any way , I would accept this kidney as an extended criteria donor with borderline allograft function( its Maastricht category 4) . According to the urine output ,no evidence of AKI could be suspected, however. recent creatinine is missing and non provided.
For the patient selection for this allgraft with reduced nephrone mass , I would consider the elder patients , as it would be expected to have sub optimal long term survival.Similarly non diabetic and non hypertensive patients would be preferred.
DKT is another option to rekon with as the donor is ECD with eGFR is borderline,DKT is supportive with increasing the dose of nephrones and mitigating the inherent hyper filtration that would be developed, owing to reduced nephrone number otherwise.
Yes Dr Jebur
How can a event eGFR affect your decision?
yes i think we have to roll out ADPKD
cause history of bleeding without hypertension may suggest aneurysm in case of polycystic kidney disease
in this indexed case we are missing the current serum creatinine at the time of organ retrieval this is offered from ECD with age > 60, death from CVA, and donation of cardiac death in addition she is CKD with baseline GFR 50-60ml/min, I need to know her current serum creatinine if increased > 2.5mg from baseline of GFR lower than 30ml/min this organ can be discarded according to some centers clinical criteria for accepting such allograft for DKD if still GFR between 30-60ml/min with organ preservation by using hypothermic machine perfusion to reduce the CIT and DGF risk in addition to the good selection of recipients with age match female and size, low mass < 30BMI, running out of her vascular access, the low immunological risk to offer her CNI free or minimization protocol,
I don’t think the biopsy and histological scoring will add to our decision-making as we know we have a low nephron mass from ECD and better to go by clinical criteria for DKT to increase the total nephron mass that would improve the graft survival and impact the outcome of such transplantation in carefully selected and matched recipient after full explanation to the recipient .
References:
1. Transplantation from deceased donors after circulatory death. British Transplantation Society Guidelines July 2013.
2.Dual Kidney Transplant Ahmed Hassan, Ahmed Halawa
Excellent
Excellent for not overrating the biopsy for decision taking to choose DKT
serum creatinine (the current one and the baseline one prior to her admission)
The information regarding the terminal serum creatinine is missing in the scenario.
The history of prior eGFR between 50-60 for last few years implies CKD in the index case. If the terminal eGFR is less than 30, then the kidney should not be taken up for donation.
According to UK Kidney Advisory Group, donor with serum creatinine more than 1.97 mg/dl to be used for dual kidney transplantation (DKT).
Reference:
Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
I think that there was some information missing like the creatinine levels and also urinalysis or a urine test to see if there was any protein in the urine. Also, possible kidney ultrasound to see the kidney sizes and renal duplex or doppler ultrasound.
Thank you, All
Missing urine test for proteinuria and haematuria if we are talking about bilateral small kidneys
Do you think that DKT could be a better option compared to transplanting these kidneys separately?
2. What are the selection criteria for the 2 potential recipients of these kidneys?
You mentioned you would transplant them separately.
3. Do we need to perform a biopsy to inform our decision? please justify.
J. ZHENG ET AL stated that the donor score, Remuzzi score and ATI were independent risk factors for DGF occurrence post-transplantation.
This study also declared that donor score, donation kidney Remuzzi score and HMP parameters combined together can not only evaluate the quality of donor kidney, but also more accurately predict the occurrence of DGF.
Reference
J. ZHENG ET AL.Comprehensive assessment of deceased donor kidneys with clinical characteristics, pre-implant biopsy histopathology and hypothermic mechanical perfusion parameters is highly predictive of delayed graft function.RENAL FAILURE 2020, VOL. 42, NO. 1, 369–376
I think serum creatinine level before retrieval is missing.
Missing information:
The missing is the cause of decreased GFR
No base creatinine level
I will accept this ECD with considering DKT
The above donor has CKD with low eGFR and is currently DCD..There is no hypertension or diabetes..currently there is good urine output…Accepting the donor will be possible with a suitable recipient only…
The recipient should be of age>55 years atleast, with poor vascular access, low immunological risk, low BMI….Dual kidney transplant should be offered as there is overall decreased GFR and DKT will restore the nephron mass
This potential donor is an extended criteria donor with CKD GFR less than 60 but more than 30 ml/minute . With excellent urine output so I will accept this potential donor . The better option is dual kidney Transplant.
ECD has lower graft outcome in comparison to standard criteria donors and all criteria of ECD regarding chosing recipient are applied in this case .
Especially DKT approach and using this ECD in recipients with short life expectancy than that in waiting list .
Yes. However, renal biopsy will guide on the primary etiology of CKD before transplant.
Selection of recipient
1) middle age.
2)long waiting list for kidney transplant with exhausted vascular access for HD and UF failure for CAPD.
3)low immunological risk
Pt has good UOP but low GFR ,NO creat level ,no proteinuria or hematuria were mentioned
Biopsy can be used and Rumizzi score to decide for kidney donation
Would you accept this donor?
This is an ECD DCD donor who is currently having good urine output with previous records of acceptable eGFR. If the current serum creatinine is less than 2 with no evidence of proteinuria in urinalysis, i will accept this donor. A preimplantation biopsy may help determine the cause of CKD and aid in the prognosis and management of such kidneys after implant.(1)
DKT is a better option as previous eGFR records are between 50 to 60 ml/min.(2)
Employing optimal techniques of organ retrieval, minimal cold ischemia time and hypothermic machine perfusion will improve graft outcomes
Recipient Selection:
References:
Would you accept this donor?
This is a 61-y old female donor, DCD, SAH, not DM, not HTN, CKD for last few years.
This is an ECD/ marginal kidney with higher risk of DGF.
This donor can be accepted or rejected; it can be accepted with single kidney donation to 2 recipients or dual kidney donation to one recipient. It would be rejected if pre-donation biopsy scores above 6.
Pre-donation clinical assessment including serum creatinine, e-GFR, USS-kidneys and presence of proteinuria>3g/day will help guide decision of donation.
Pre-donation histological assessment: kidney biopsy is important in this clinical scenario because it will guide our decision.
If yes, how do you select the recipient(s) suitable for this case?
Recipients who can be offered this kidney include: elderly, low muscle mass like female, low immunological risk, long waiting time on transplant list and those with multiple access failure.
DKT can be offered to recipients with high BMI with minimal co-morbidities, good vascular tree and younger age.
I will accept him as a marginal donor for proper recipient after explaining the conditions. It’s better to perform dual kidney transplantation and delay CNI with proper induction.
Suitable recipient would be: age more than 40, diabetic, low immunological risk, small size female, more than 4 years being on waiting list, vascular access failure
The donor has marginal kidneys, her age is 61 years, the cause of death was cerebrovascular event and eGFR was <60
This donor can be accepted but with considering dual kidney transplantation to increase available functional nephrons.
The suitable recipient is preferred to be elderly with limited metabolic demands and not requiring graft survival for >20 years according to expected life span.
Small size or female recipient
Low immunological risk to avoid the increased rate of acute rejection to avoid injury of limited renal mass and to allow CNI minimization protocols to avoid associated nephrotoxicity.
Hassan A, Halawa A. Dual kidney transplant. Exp Clin Transplant. 2015 Dec 1;13:500-9.
Yes, I would accept it for evaluation. A donor with extended criteria, without circulatory failure and biopsy evaluation is a guide for decision, as we would assess the degree of glomerulosclerosis. Good preservation of the organ would guarantee that the recipient who received the organ would not have new injuries to recover from.
I would try to choose a recipient with similar clinical characteristics to the donor, as it could increase the chances of adaptation with the degree of existing injuries.
The scenario offered here discusses ECD for 61 year old female, DCD previously known to have renal impairment, no medical comorbidities suggested as HTN or DM, history of smoking, analgesic abuse need to be ruled out.
The above data is indicative of marginal kidneys, to improve the outcome dual renal transplantation can be valuable after approval of the surgical team members (urology, anaesthesia and vascular consultants).
Proper selection of the candidate after detailed counselling for the expected delayed graft function, the candidate recipient is advised to be of 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, with favourable delay for the use of CNI after stabilization of renal functions under covered by the use of ATG or basiliximab.
Reference:
According to the British Transplant Society guidelines.
Aubert et al; BMJ; 101h; 1157 (2015)
Merion et al JAMA; 294; 2726 (2009)
I will accept after optimization, despite the disadvantages its better option to proceed for DKT rather to waiting in waiting list.
Biobsy is mandtory in this case because shed had marginal low urinecompared with peevios.
For the recipent i will follow the score post biobsy then decide
_I will accept the current donor as ECD, (age more than 60, death due to cerebrovascular accident).
_ The decision to proceed to either dual kidney transplantation for single recipient or single kidney transplantation can be based on preimplantation biopsy and using Remuzzi score (of the degree of glomerulosclerosis, tubular atrophy and interstitial fibrosis):
_ score less than 3… Proceed to SKT
_ score between 4_6 …proceed to DKT.
_ score More than 7 …discard the kidneys.
_ clinical based decision based on GFR:
_ GFR more than 60 …proceed to SKT.
_ betwern 30-60 …proceed to DKT.
_ less than 30 ..discard them
_appropriate selection of the recipient:
_ patient older than 40 years, of low immunological risk, and of low muscle mass (thin and female), long waiting time and devoid of vascular access)
_ shorten the ischemia time and use of HMP to minimize the ischemia reperfusion injury.
_ use of ATG induction to delay CNI introduction to decrease the risk of DGF
*This DCD 61 years DCD donor had SAH Grade 4/5 , no past medical history eGFR 50-60 ml/min but had excellent UOP So; she considered to be ECD.
I will accept this marginal donor but consider DKT to increase nephron size, will increase eGFR. Pre-transplant renal biopsy will help to know the pathological changes of the graft , and the original disease and help decision either to make SKT or DKT.
*The recipient(s) suitable for this case:
-older patients > 40 years, recipient should be age match with donor ,DM, small muscle mass , long time hemodialysis with multiple
failed vascular access and having low immunological risk, patient should counselled about risk of DGF , acute rejection episodes, and delayed graft function.
*Machine perfusion, is better option to decrease DGF rate and improve renal graft survival.
Yes, but biopsy is important to know the cause of CKD prior the event.
– Patients older than 40 years
– Long median waiting time (> 4 years)
– Patients of low immunological risk
– Diabetics
– Dialysis patients with vascular access problems
Dual Kidney Transplantation is a better option
This offer from 61years old patient with e GFR 50-60ml/min and died because of SAH. She has good urine out put.
So she can be accepted as marginal kidney, as her age above 60 and cause of death was SAH. So, recipient need to be counselled that this is not standard kidney, but its survival is good for age matched recipient. We can consider dual kidney transplantation if we followed some of the recommendation that put age above 60 with CVA as cause of death as acceptable reason for dual kidney transplantation. But the United Kingdom Kidney Advisory Group suggested that kidneys from donors who are age 70 years or older could be used for DKTs if 1 or more of the following clinical risk factors were present: history of hypertension, myocardial infarction, type 2 diabetes mellitus, cerebrovascular event as cause of death, serum creatinine level of > 1.97 mg/dL at retrieval, or presence of any
anatomic anomaly (renal artery stenosis, polycystic, small kidneys). So for this case can be either single kidney or dual kidneys.
Recipient should be age match with the donor. Better to be on dialysis for some times and low immunological risk.
References::
Ahmed Hassan, Ahmed Halawa/Experimental and Clinical Transplantation (2015) 6: 500-509 Exp Clin Transplant.
BTS guidelines
The available donor is 61 years old female DCD and SAH grade 4/5 ,no past medical history GFR decreased (40-50) ml/min and good UOP 2.8 L/day
I will accept this donor with considering DKT to increase nephron mass and consider biopsy if possible to give brief on her primary kidney disease.
The recipient INSHALLAH must
40 years.
Decreased imnemological condition.
Can a long waiting list.
on dialysis with vascular access problem.
Little comorbidities.
Female.
This female donor 61 years old with no past
medical history
Her eGFR over lasr few years was below expected for her age, she is ckd patient stage 3
which wasn’t explained by any medical conditions .
She had good urine out put till last hour.
i will accept her as a donor and i will think about DKT to increase nephron mass delivered to recipient by transplantation of marginal kidneys.
Pre transplante Biopsy will help to evaluate chronic pathological changes of the graft and help more the decision of SKT or DKT.
But if not avilable or results will be delayed i will go for DKT from the start
Selection criteria of the recipient
-older patient more than 40 year preferred to be age matched.
-diabetic patients .
-female patients with smaller muscle mass .
– patients with failed vascular access.
-long waiting time on dialysis.
– low immunological risk patients.
*oxygenated machine perfusion, if available ,is better to decrease incidence of DGF and improve graft survival.
*recipient must be counselled carefully about potential risk of DGF ,acute rejection episodes, and graft dysfunction.
*induction with ATG and CNI free protocol to decrease incidence of CNI toxicity in marginal kidneys, especially with older recipients
Would you accept this donor?
61 year old DCD female
No medical condition
eGFR 50-60 ml/min
She is an ECD
She is a borderline case
A biopsy if available will help in decision making and we can know the cause of her decline of GFR.
Biopsy score up to 3- Single kidney transplant
4-6- Dual kidney transplant
> 6 – discard
If out of hours biopsy is not available then a DKT will better option.
Suitable recipients will be-
Low immunological risk patients
> 60 years old
Issues with access and long waiters
Small females
Diabetics.
● DCD elderly donor with CKD so she is ECD
biopsy is needed in this case to evaluating the cause for her borderline GFR and to make decision for SKT or DKT or discarded the kidney
As she has bordeline GFR I will prefered DKT
The suitable recipient will be
* Older > 60 year
* Lower immunologic risk
* long waitting list
* urgent recipiant and have no vascular access
* Small female recipiant
* DM
Our donor
She considered as ECD and the ESP included the option of transplanting the both kidneys to single recipient in case the donor creatinine clearance is < 70 ml/min
So I will proceed for donation with DKT
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
>>> DKT to increase nephrons mass
>>> using suitable perfusion techniques improve graft survival
This is a DCD ECD. She is a female(lower nephron mass) CKD3 with good urine output. However, in this scenario some data are missing including the terminal eGFR prior to harvesting, the presence of proteinuria or hematuria, the original kidney disease as some disease have high incidence of recurrence post transplantation.
Donor eGFR prior to harvesting is an easily applicable criteria to allocate ECD kidneys and yields satisfactory results in terms of short-term graft survival and renal function(eGFR > 60 use SKT, eGFR between 30 and 60 use DKT, eGFR < 30 discard the donor kidney). Histological results from the pre-implantation biopsies if feasible can provide valuable information provided waiting for results does not significantly increase cold ischemic time(we should not over rate the importance of pre-implant biopsy as this would result in discarding the graft if cold ischemia time is prolonged).
Would you accept this donor?
Yes, I will accept this offer under ECD criteria. Despite the fact that ECD carries a higher risk for PNF, DGF rates(more with DCD), more acute rejection episodes and reduced long-term graft function when compared to SCD grafts, it still provides a survival benefit when compared to waiting on dialyses.
If yes, how do you select the recipient(s) suitable for this case?
A. Age greater than 40 years
B. On the Waiting list for a long time.
C. Low immunogenicity
D. Those with diabetes
E. Those with problematic Vascular access
F. Preferably Small sized recipients ( Females)
Reference
1. Transplantation from deceased donors after circulatory death. British Transplantation Society Guidelines July 2013
2. R. Snanoudj et al. Donor-Estimated GFR as an Appropriate Criterion for Allocation of ECD Kidneys into Single or Dual Kidney Transplantation. American Journal of transplantation. November 2009. Pages 2542-2551
Would you accept this donor?
Yes.
This ECD in cause of death CVA and age .
ECD is better option than waiting in translant list or hemodialysis (pro.Halawa).
Old for old recipients.
Female.
More than 4 years in transplant list.
Low immunological risk
Patient with no vasculat access. ( FROM LECTURE OF PROF.Halwa.)
Kidney transplantation is the best modality of RRT which is associated with lower morbidity and mortality in comparison to dialysis. This donor is an extended criterion donor (age >60 years), after cardiac death (DCD) with eGFR around 60ml/min, urine output 100 ml/hour).
Assessment of a deceased kidney depends on main 6 parameters which include
1. Clinical data
2. Laboratory and radiological assessment
3. Pre-implantation biopsy (Remuzzi score)
4. KDPI
5. KDRI.
6. Viability assessed by perfusion machine
I will accept this donor as dual kidney transplantation as the outcomes of an ECD transplant are better than remaining on the wait list but some data still needs to be fulfilled such as urine PCR, kidneys ultrasound, blood group, and HLA to compare with possible recipients on the waiting list.
Such a donor has an increased risk of DGF, rejection, and poor-term graft survival.
Hanse that ECD kidneys have an increased risk of DGF, rejection, and poor term graft survival as compared to standard criteria donor kidneys. it is important to select the recipient appropriately based on immunological risk, age, body surface area matching, and same demographic area to decrease CIT.
but some optimization of this kidney is needed by
References:
1) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 17, 2022.
2) Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transpl Int. 2008 Jan;21(1):11-7. doi: 10.1111/j.1432-2277.2007.00543.x. Epub 2007 Sep 10. PMID: 17850235.
3) Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3 Suppl 4:114-25. doi: 10.1034/j.1600-6143.3.s4.11.x. PMID: 12694055.
4) Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
In this scenario ,I think kidney biopsy is mandatory not to decide we will accept it or no but because of the history of DM and HTN and CKD , so in such case it is important to have kidney biopsy to know how much kidney is affected my the patient comorbidity and for future follow up .
This is elderly donor with ckd and DM,htn and post cardiac arrest so we need to go for DKT is better as his eGFR is between 50 to 60 ml/mint .need to select recipient with old age and small mass in the same time to select the recipient who is in waiting list for 4 years or have vascular access problems
Would you accept this donor?
I would accept this donor
a) ECD; her age above 60, eGFR between 50 -60 and DCD.
b) Good UOP.
c) No comorbidities; no DM and no HTN.
If yes, how do you select the recipient(s) suitable for this case?
a) This kidney offer is suitable for DKT as eGFR <60.
b) I would select a recipient with an old age to match this offer. Age for age and size
for size.
c) BMI< 30.
d) Low immunological risk.
e) No or less comorbidities.
sorry, Imean recipent selection with DM ,vscular acess….. not donor
The donor is ECD as (age > 60 with baseline eGFR 50-60 ml/min with good UOP, No hx of DM or HTN )
Yes I will accept the donor as Transplantation from ECD have survival advantages over dialysis patients remaining on the transplant waiting list.
the recipient(s) suitable for this case?
older patients
low body mass (Females )
low immunological risk ( to decrease the risk of rejection )
prolonged waiting for an SCD kidney
multiple running-out vascular access
Diabetics
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
Late introduction of CNI
decrease cold ischemia times
use of machine perfusion
DKT ( to increase nephron mass with a good outcome )
according to Remuzzi classifications that assessed their biopsies. the grade was classified as mild if the score was 0–3 SKT
moderate 4–6 >> DKT
and severe 7–12 >> will be discarded.
On the other hand, others refuse to depend on renal biopsy for decisions for DKT .
Reasons for refusal were multiple including the history of hypertension, donor instability, donor age, or marked elevation in donor creatinine level after hospital admission, suboptimal pretransplantation biopsy findings, or a combination of these factors
Snanoudj and his colleagues prospectively compared DKT and SKT receiving grafts from ECD donors aged > 65 years and allocated kidneys according to the donor’s estimated glomerular filtration rate. DKT was done if the estimated glomerular filtration rate was between 30 and 60 mL/min and SKT if the estimated glomerular filtration rate was greater than 60 mL/min with the same outcome in both groups.
and not advice for renal Biopsy as may increase CIT
Ref :
Shapiro R., Halloran P. F., Delmonico F. L., Bromberg J. S. The “two, one, zero” decision: what to do with suboptimal deceased donor kidneys. American Journal of Transplantation. 2010;10(9):1959–1960. doi: 10.1111/j.1600-6143.2010.03204.x
Frutos M. A., Mansilla J. J., Cabello M., et al. Optimising expanded donor organs through dual kidney transplantation: a case-control study. Nefrologia. 2012;32(3):306–312. doi: 10.3265/Nefrologia.pre2011.Dec.11173.
.
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.
– Donor kidney biopsy
– Dual kidney transplant if Remuzzi score 4-6
Based on these data ,I can accept that donation with DKT according to giver eGFR value. Potential recipients could be low body mass , with dialysis access problems ,with low immunological risk…If split kidney function given ,it will help in decision making.
ECD, DCD, no history of DM or HTN, low eGFR, good UOP, no recent s.cr level
I still can accept the offer after assessing serum creatinine level and donor KDPI, and consideration for DKT for a recipient with a small size or female gender with low immunological risk and long listing time with exhausted accesses.
Reference:
Lee APK, and Abramowicz D. Is the Kidney Donor Risk Index a step forward in the assessment of deceased donor kidney quality? Nephrol Dial Transplant (2015) 30: 1285–1290.
Would you accept this donor?
61 year old, no DM, no HTN, but reduced kidney function eGFR between 50-60 ml/min, good urine output.- ECD criteria is met-.
Sure; I would accept this donor kidneys, for Dual kidney transplants, after knowing her past medical history, and her base line urinalysis if there is any proteinuria or hematuria to age matched recipients 60 years or older, with low immunological risk, or recipient < 60 years old, with minimal comorbidities and body mass index < 30 kg/m2.
The kidneys to be perfused by hypothermic machine perfusion inorder to decrease the risk for DGF, and try to minimize the cold ischemia time.
Needle kidney biopsy where available for better scoring of glomerular sclerosis, interstitial fibrosis or atrophy, to decide for SKTs (score <3), or DKTs score (3-6), and to discard kidneys of those scoring 7 or more.
Kidney Donor Risk Index (KDRI)- estimation of the relative risk of post transplant graft loss based on donor medical, demographic variables.
Patients with KDPI > 85% has higher graft survival, and lower recipient mortality.
If yes, how do you select the recipient(s) suitable for this case?
Suitable recipient would be :
– Age > 40 years of age.
– No history of DM, HTN.
– Long time on waiting list for transplantation.
– Access loss for dialysis.
– Small, female recipient.
– Low immunological risk.
– Immunosuppression with ATG/Alemtuzumab induction, CIN free protocol.
– Low risk for infections- prophylactic antibiotics.
References:
[1] Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
[2] Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
Would you accept this donor?
If yes, how do you select the recipient(s) suitable for this case?
1- very elderly.
2- well-matched for HLA and having no DSA.
2- having poor vascular access for hemodialysis and not suitable for peritoneal dialysis
3- HIV +ve patients.
4- patients with sickle cell anemia as their expected survival is about 3 years.
5- other less healthy patients.
Would you accept this donor?
Recipient for this case:
Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. American Journal of Transplantation. 2003 Apr;3:114-25.
Hassan A, Halawa A. Dual kidney transplant. Exp Clin Transplant. 2015 Dec 1;13:500-9.
The case in the current scenario of old age potential deceased donor,female with relatively small kidneys (as per gender),DCD,SAH with history of GFR of 50-60 ml/min without information regarding current GFR.
So, the question here Would you accept this donor?
Generally speaking, the Donor characteristics have included KDPI which is [low (<20%), medium (20-80%), high (>80%)], age, graft types [extended criteria (ECD), cardiac death (DCD), standard criteria (SCD)], CDC , HCV status and cold ischemic time (CIT).
The kidneys from older donors had poorer graft survival than the kidneys from younger donors when transplanted into recipients. These data suggest that kidneys from donors over the age of 55 overall have reduced functional reserve, which has an adverse effect on long-term graft function. In view of that, attempts should be made to better estimate functional reserve among the older age group, but age alone should not be the only factor for exclusion of a potential donor.
In settings of global shortage of organ and the efforts to expand the donor pool justified the significant increased use of kidneys from older donors. In addition, an increasing number of donors with significant comorbidities (hypertension and diabetes) or deceased due to stroke leading to the concept of “marginal” donors.
So, the challenge is now to improve the graft outcome gap between patients receiving grafts from “marginal” and “optimal” donors. This can be done with implementing transplantation strategies during all transplant phases, including reduction of cold ischemia time, recipient selection, adaptation of immunosuppressive drug regimens, increase in nephron mass by dual kidney transplantation and improvement in the graft selection process using histological criteria.
It is proposed to find an effective balance between maintaining graft survival, reducing the impact of immunosuppressive toxicity and maximizing patient quality of life through the reduced incidence of cardiovascular disease and malignancies.
From the previous review,I will accept the offer for special population of recipients of old age who will accept the offer.
Practically we have a potential deceased donor (50 years old, history of cardiac arrest presented with brain death,non oliguric AKI with pretransplant creatinine of 1.5 who is considered as ECD-6/6 MM,no DSA and negative FCXM) transplanted today to old age female donor 75 years old on dialysis for 5 years with background of stable SLE and history of treated cancer colon for more than 5 years .So I think it will be a better option for her in comparison of staying on dialysis with it is long term complications.
This potential donor lies in the group of ECD because:
Age: 61 and eGFR < 60
However; still we need to collect some important data about the kidneys of this potential donor ; so we need KUB u/s
I would go for DKT
With the following selection criteria of the recipient :
– Diabetic patient
– In long time waiting list (> 4 years)
– Female patient or small size recipient
– Age match if possible
The kidneys are ECD with egfr less than 60 but more tha 30. these kidneys will be better to do DKT. The reason being those kidneys are less than 60 which is required for single kidney transplant according to nephron mass for longevity and survival benefit.
her urine output is 2.8L per day, is it post ATN diuresis? not sure the patient had AKI or not. i would like to know about latest creatinine level and proteinuria indices. i would like to recalculate egfr to decide on discard or transplantation.
Recipients with age match female and size, low mass < 30BMI, running out of her vascular access, longer dialysis vintage and the low immunological risk will be better option.
Biopsy not going to help in decision for transplantation as the egfr less than 60 and no history DM/HTN , it’s clearly for DKT without biopsy. so i would choose DKT.
A 61-year-old DCD female donor, SAH(grade 4/5), No history of hypertension or DM. Her eGFR between 50 and 60 mls/min over the last few years, has good UOP.
Would you accept this donor?
YES, I shall accept her for donation but should be evaluated more .
KUB/USG, Urine routine, urine PCR.
New e GFR according to result we can proceed for DKT if still e GFR between 30- 60 ml/min or to discard it if e GFR less than 30 ml/min
If yes, how do you select the recipient(s) suitable for this case?
1-recipient >40 years .
2-waiting time (>4 years).
3-Diabetics/ HTN.
4-vascular access exhaustion .
5-female recipient or a small patient.
6-Low immunological risk.
7-Better to transplant DKT.
References:
1- Metzger RA, Delmonico FL, Feng S, et al. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3(s4):114–125.
2- Zheng J, Hu X, Ding X, et al. Comprehensive assessment of deceased donor kidneys with clinical characteristics, pre-implant biopsy histopathology and hypothermic mechanical perfusion parameters is highly predictive of delayed graft function. Ren Fail. 2020;42(1):369-376. doi:10.1080/0886022X.2020.1752716.
3-British Transplantation Society Guidelines.
Transplantation from deceased donors after circulatory death
I will accept this Donor after proper assessment through :
-Ultrasound
-Urine analysis and proteinuria screening
-pretransplant biopsy
Aim for optimization through :
-Machine perfusion -hypothermic -02 based
-Dual kidney Tx for fit patients -Remuzzi score 4-6
-CNI minimization or free based regimens
-recipient more than 40 years old
-low immunological risk recipient
-Diabetic
-Recipient on waiting list more than 4 years
-low built recipient -females
References :
1-S.K. Singh, S.J. Kim Does expanded criteria donor status modify the outcomes of kidney transplantation from donors after cardiac death?
Am J Transplant, 13 (2013).
2-P. Nagaraja, G.W. Roberts, M. Stephens, S. Horvath, Z. Kaposztas, R. Chavez, et al.
Impact of expanded criteria variables on outcomes of kidney transplantation from donors after cardiac death
Transplantation, 99 (2015).
3-L.W. van Heurn, D. Talbot, M.L. Nicholson, M.Z. Akhtar, A.I. Sanchez-Fructuoso, L. Weekers, et al. Recommendations for donation after circulatory death kidney transplantation in Europe
– This donor is an ECD due to her age 61 y , and can be considered controlled DCD (Maastricht Category 4) with eGFR 50-60 ml/min representing CKD stage 3 a with acceptable urinary output.
Yes she can be accepted after assessing the quality of the organs by KDRI score , biopsy using Remuzzi score and viability testing using machine perfusion.
– Such donor must be matched with a suitable recipient could be old better a female with nearly same size,or those remaining on long waiting lists ,those having failed vascular access as well as those with low immunological risk
Mean while DKT can be a better option to increase the nephron mass and overall renal function.
Also cold ischemia time need to be minimised to preserve the functioning nephron mass and immunosuppression tailored with induction therapy with mono- or polyclonal antibodies and CNI minimised maintenance regimen to decrease DGF incidence
Reference
-BTS guidelines 2013
Summary:
1) Age 61-year-old
2) DCD who suffered from SAH grade 4/5
3) No history of DM and HTN
4) Recorded GFR 50-60 m[s/min
5) Excellent urine output 110 mls/h and 2.8L in 24 hours
The patient is 60 years of age and died from SAH with DCD. There is a history of kidney disease likely stage 3 due to GFR 50-60 MLS/MIN. She maintains adequate urine output. With the above, I will accept the patient as a donor but as ECD with the intention to use both kidneys since there is a GFR of around 50-60 mls/min. There is the possibility of DGF. So, yes the donor’s kidney can be used.
The recipient I would choose that can be suitable may have the following characteristics:
1) A recipient around the same age or around 40 years of age. The patient can be diabetic or hypertensive but control, with possible low immunological risk, small muscle mass individual, has been on the waiting list for a while, and has difficult vascular access. A kidney biopsy can be performed.
2) The procedure should be one where hot and cold ischemic time should be reduced as much as possible and the immunosuppressive drugs must be one that should not have delayed the initial GFR function.
3) The recipient must be advised about all the possible complications and graft delays and also failure.
BTS/Transplantation from deceased donors after circulatory death
Individuals with advanced or end-stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential kidney donors.
obvious absolute contraindications to the use of organs for DCD kidney transplantation are:
End-stage kidney disease (CKD stage 5, eGFR <15 ml/min)
CKD stage 4 (eGFR 15-30 ml/min)
Acute cortical necrosis on pre-implantation kidney biopsy
this Donor with GFR between 50 and 60 mls/min,No history of hypertension or diabetes.good UOP
we can accept this donor
But we should do the following assessment
1-urine analysis for proteinurea
2-Ultrasound to assess kidney size
3-Pretransplant biopsy (Remuzzi Score)
According to the final grading of this score
0-3 single kidney donation
4-6 dual kidney donation
7-12 discarded the donation
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
4- Kidney Donor Risk Index (KDRI)
For estimation the relative risk of post-transplant graft failure (in an average, adult recipient) from a particular deceased donor compared to a reference donor
Lower KDRI values are associated with increased donor quality and expected longevity.
5- The Kidney Donor Profile Index (KDPI)
is a Percentile Score ranging from 0 to 100%, referring to the median donor of all transplants of the previous year.
Transplantation of recipients >60 years of age using kidneys with a KDPI >85% is associated with lower mortality risk after the first year compared with remaining in the waitlist.
Management for an ECD kidney is based on potential nephron-protecting strategies and match the appropriate kidney to the appropriate recipient
1-CIT minimization
2- use Oxygenated Hypothermic Machine Perfusion
3-immunosuppression focused on nephrotoxicity minimization, and adequate infection prophylaxis
4-the successful use of ECD kidneys can be enhanced by restricting the use of these kidneys to unsensitized patients receiving a first graft(low immunological risk)
5-transplanting two ECD kidneys (dual kidney)rather than one, in one recipient might help improve outcomes
6-recipient >40 years
7-waiting time (>4 years)
8-Diabetics
9-vascular access exhaustion
10-female recipient or a small patient
Reference
1- Expanded Criteria Donor
By Ahmed Halawa Consultant Transplant Surgeon Associate Professor, University of Liverpool – UK
2- British Transplantation Society Guidelines.
Transplantation from deceased donors after circulatory death
Thank you, well done.
Would you accept this donor?
DCD with ECD (age > 60 years)
The donor is known to have CKD stage 3, but no DM or HTN. It could be idiopathic but other causes like APKD leading to SAH is possible
No mention of s. creatinine or eGFR in this admission as this may be enough to discard this donor
eGFR calculation (Cockcroft and Gault formula):
*eGFR < 30 mL/min, discard kidneys
*eGFR between 30-60, for DKT
*eGFR > 60 mL/min, for SKT (not in the index case)
So, to accept this donor or not accept this depends on the current eGFR and possible pretransplant biopsy. If accepted it will be DKT (high risk marginal donor) after discussion with the recipient
For Remuzzi biobsy score (GS, tubular Atrophy, interstitial fibrosis, and arterial and arteriolar narrowing):
1. Score 0-3, for SKT (not in the index case)
2. Score 4-6, for DKT
3. Score 7-12, discard (absolute contraindication)
Rapid organ retrieval, minimization of CIT, use of HMP/NMP and viability test
The long term outcome is related to donor factors (age and comorbidities), CIT and Remuzzi biopsy score
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%)
Induction immunosuppressant and omit or reduce the dose of CNIs
References
1. BTS guidelines. Transplantation from deceased donors after circulatory death. July 2013.
2. Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
Thank you, well done.
The index donor is an extended criteria donor (age > 60 year) with donation after cardiac death (DCD). In addition, she is having history of CKD. Her urine output is excellent, but the terminal serum creatinine is missing. Such a donor has increased risk of DGF (1).
I will accept this donor, subject to availability of terminal creatinine report (if GFR is more than 30) as the outcomes of ECD transplant are better than remaining on wait-list (2). The only option available for such a donor is a dual kidney transplant (DKT) as the donor has history of CKD (3).
If the GFR is less than 30, I would not accept this donor.
The ECD kidneys have lower graft survival as compared to standard criteria donor kidneys (4). Hence it is important to select the recipient appropriately.
The recipient selection in this scenario would be based on age and body surface area matching (2). A small sized recipient (like females) would be better. The recipient should be more than 60 years old or diabetic patient with age more than 40 years, with low immunological risk, with failing vascular access and with expected waiting time on wait-list exceeding life expectancy on the waiting list without transplant (4).
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 (1).
Peri- and post-transplantation management will include use of machine perfusion, induction therapy in form of either ATG or Alemtuzumab. Maintenance immunosuppression in form of Tacrolimus – with delayed introduction of Tacrolimus (to reduce the incidence of DGF), MMF and steroids (1).
References:
1) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 17, 2022.
2) Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transpl Int. 2008 Jan;21(1):11-7. doi: 10.1111/j.1432-2277.2007.00543.x. Epub 2007 Sep 10. PMID: 17850235.
3) Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
4) 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.
Thank you, well done.
Would you accept this donor?
Yes I would accept her as a donor
If yes, how do you select the recipient(s) suitable for this case?
This is an expanded criteria DCD donor (being 61 years) with eGFR has between 50-60 ml/min prior to this event.
The potential recipients could be:
The use of this type of organ should be accompanied by the optimization of surgical times and the shortest possible cold ischemia.
The potential recipient should be informed about the risk of delayed graft function and reduced graft survival
Reference:
· MONTEOLIVA, Paloma Barreda, et al. Kidney transplant outcome of expanded criteria donors after circulatory death. Nefrología (English Edition), 2022.
· Filiopoulos V, Boletis JN. Renal transplantation with expanded criteria donors: Which is the optimal immunosuppression? World J Transplant. 2016 Mar 24;6(1):103-14. doi: 10.5500/wjt.v6.i1.103. PMID: 27011908; PMCID: PMC4801786.
Thank you, well done.
Can it be DKT?
yes, he is a marginal donor, we can perform DKT
Would you accept this donor?
-Yes ,I would accept this DCD ECD donor kidneys .
-S.creatinine before cardiac arrest is missed.
-The increased risk of DGF and its consequences should be discussed with the recipient
– The most recent evidence suggests that ECD DCD donor kidneys are no more likely to fail early than ECD DBD donor kidneys
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:
-BTS/Transplantation from deceased donors after circulatory death
-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
Well done but is your decision if the pre harvest eGFR is <30 ml/min?
This is an expanded criteria DCD donor (age of 61 years) who had SAH and no history of DM/HTN. Her eGFR has been between 50-60 mld/min and she has good urine output.
I would ask for the current serum creatinine and imaging to rule out ADPKD or any structural anomalies
I would accept her as a donor
The potential recipient should be older, have low immunological risk, have a longer median waiting time.
The potential recipient should be informed about the risk risk of delayed graft function and reduced graft survival
The potential recipient should be given antibody induction therapy to delay the initiation of CNIs
Perfusion of the organ should be done using hypothermic perfusion
Auber O et al. BMJ 2015;315:h3557
British Transplant Society Guidelines 2013
Well done but is the value of the recent eGFR for your decision as how to use this kidney
Thank you Professor Dawlat
The recent eGFR can help us decide if we will do a dual kidney transplant or a single kidney transplant. If the eGFR is less than 60 mls/min a DKT is recommended to increase graft survival
I will accept this marginal aging kidney
We should chose the recipients carefully like old age , female or small size , waiting more than 4 years , diabetic and running out of access . And counseling him about the small nephron mass and risk of DGF and decrease survival rate which is still better than staying on dialysis .
For this marginal kidney it’s preferable to use DKT .
What is the role of the recent eGFR in your decision as how to use this kidney?
If the recent GFR below 30 , this kidney discarded.
if 30-60 ,go for DKT