4. You were offered kidneys from a 59-year-old female DCD donor who suffered from SAH (grade 4/5). According to the GP notes, this donor’s weight was 55 kg, but there was no significant medical history apart from mild controlled hypertension. S Cr was 89 µmol/L before retrieval. She had excellent urine output (110 mls/h during the last hour and 2.8 L over the last 24 hours). During retrieval, the surgeon reported bilateral small kidneys (62 and 71 grams respectively).
- Would you accept this donor?
- If yes, how do you select the recipient(s) suitable for this case?
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.
Dear Professor ,
we have a 59 years old , DCD , HTN with small sized kidneys .
I prefer DKT rather than SKT
The selection criteria for 2 potential recipients would be :
-Of low body built
-Low immunological risk
-HDx access problems
-More than 40 years
-Been on the waiting list for 4 years or more
I won’t perform a biopsy from these kidneys , i will depend on the GFR and perfusion parameters for asessment.
1-Many centers used histological tool along with various clinical parameter for allocation. 2-Others relied on hypothermic perfusion parameters or estimation of GFR or kidney donor profile index (KDPI)-KDPI, without doing a biopsy.
Hypothermic perfusion parameters
*Navarro et al. used hypothermic machine perfusion to preserves the organs. They assessed pressure flow index (defined as flow per 100 grams renal mass divided by systolic blood pressure) and concentration of glutathione transferase, an enzyme marker of ischemic injury.
1-SKT was done when pressure flow index was 0.4 mL/min per 100 g/mm Hg and glutathione transferase was less than 100 IU/L/100 grams renal mass.
2-Kidneys were discarded if pressure flow index was less than 0.4.
3-DKT was done when if pressure flow index was satisfactory but glutathione transferase was higher than the cut-off value. Patients having comorbidities and prolonged cold also underwent DKT.
*The group concluded that viability testing in nonheart beating donors can help in distinguishing kidneys that may be unsuitable for SKT but when used as double transplant have the potential to produce sufficient renal function.
*The preimplantation biopsy can have pitfalls.
A-They may sample a zonal scar and may not be a true representation of the kidney.
B-Superficial biopsies may not sample adequate arteries and arterioles; therefore the vasculature may not get evaluated.
C-Shallow wedge biopsies can overestimate glomerulosclerosis, owing to the increased incidence of this in the subcapsular region
We should remember that the kidneys here are small
*DKT is considered better for age and weight matched recipient. Greater number of nephrons in DKT is suitable for elderly patients with low basal metabolism and reduced body mass. The results of DKT in elderly were comparable with the younger SKT population .
References :
1.Navarro A. P., Sohrabi S., Reddy M., Carter N., Ahmed A., Talbot D. Dual transplantation of marginal kidneys from nonheart beating donors selected using machine perfusion viability criteria. Journal of Urology. 2008;179(6)
2. Snanoudj R., Rabant M., Timsit M. O., et al. Donor-estimated gfr as an appropriate criterion for allocation of ecd kidneys into single or dual kidney transplantation. American Journal of Transplantation. 2009;9(11):2542–2551.
3. 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.
4. Rao P. S., Schaubel D. E., Guidinger M. K., et al. A comprehensive risk quantification score for deceased donor kidneys: the kidney donor risk index. Transplantation. 2009;88(2):231–236. doi: 10.1097/tp.0b013e3181ac620b.
5. Tanriover B., Mohan S., Cohen D. J., et al. Kidneys at higher risk of discard. Expanding the role of dual kidney transplantation. American Journal of Transplantation. 2014;14(2):404–415. doi: 10.1111/ajt.12553.
6. Klair T., Gregg A., Phair J., Kayler L. K. Outcomes of adult dual kidney transplants by KDRI in the United States. American Journal of Transplantation. 2013;13(9):2433–2440. doi: 10.1111/ajt.12383.
7. Muruve N. A., Steinbecker K. M., Luger A. M. Are wedge biopsies of cadaveric kidneys obtained at procurement reliable? Transplantation. 2000;69(11):2384–2388. doi: 10.1097/00007890-200006150-00029.
8. Randhawa P. Role of donor kidney biopsies in renal transplantation. Transplantation. 2001;71(10):1361–1365. doi: 10.1097/00007890-200105270-00001.
Well done your final comment for small kidney size and weight sums it all.
Performing two biopsies here for the two small kidneys will prolong the WITin these marginal ones.
I agree with my colleague. want to add this patient is probably of low BMI, but if not, I need to know the cortical thickness. Because This is a deceased and ECD, considering DKT will be better
Sir,
The donor is 59 years old, HTN, DCD with small sized kidneys.
I would consider Dual Kidney Transplant in this patient fits the following criteria:
BTS guidelines say:
Suitable recipient for the above case would be:
Andrews PA, Burnapp L, Manas D. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70
Hassan A, Halawa A. Dual kidney transplant. Exp Clin Transplant. 2015 Dec 1;13:500-9.
note your viewpoint, Dr Patil.
Ajay
DKT is a better option
Primplantaion biopsy has a controversial role in assessing the viability of the renal graft .
The usefulness of preimplantation biopsy as a predictive tool for graft survival has not been validated and its value for the assessment of the quality of organs from ECD is discussed by studies.
Previous studies did not find survival differences when comparing KT with mild and moderated lesions in preimplantation biopsy, so the discard of an allograft should not be done exclusively according to the histological analysis
In the current case attributed to the kidney small size measures other than biopsy can be used as e GFR split evaluation.
Reference
Villanego F, Vigara LA, Cazorla JM, Naranjo J, Atienza L, Garcia AM, Montero ME, Minguez MC, Garcia T, Mazuecos A. Evaluation of Expanded Criteria Donors Using the Kidney Donor Profile Index and the Preimplantation Renal Biopsy. Transpl Int. 2022 Jun 6;35:10056.
note your viewpoint, Dr Doaa.
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
Thank you Prof. Ahmad Halawa;
In this case the best option is to discard this potential donor with small kidneys by gross appearance the surgeon noticed, but if to proceed i think the kidney biopsy here would be of no benefit, and time wasting., and the better option would be ipsilateral DKTs.
The selection criteria for the 2 potential donors, depend on donor factors, history of HTN, DM, Proteinuria, and eGFR > 60 ml/min/1.73m2, serum creatinine, and KDPI/KDRI calculation to estimate the risk for graft loss, and recipient criteria > 40 years of age , low immunological risk, long time on waiting list, having access problem to dialysis, small female, with no comorbidities, ie DM, HTN…etc.
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)Zheng J, Hu X, Ding X, Li Y, Ding C, Tian P, Xiang H, Feng X, Pan X, Yan H, Hou J, Tian X, Liu Z, Wang X, Xue W. 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 Nov;42(1):369-376. doi: 10.1080/0886022X.2020.1752716. PMID: 32338125; PMCID: PMC7241463.
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
Would you accept this case:
Yes I will accept
Marginal donor as age 59 with hypertension besides small kidneys
Dual kidney can be used
Machine perfusion can be used
Modification of immunosuppressive medications ( ATG induction , CNI free protocol )
Suitable recipient would be:
long period on waiting list
immunological risk is low
low body mass index
exhausted vascular access
diabetics
reference:
dr Ahmed halwa lecture
DKT is a good option in the case of marginal kidney.
The potential recipient should be ( in case of single kidney Tx):
Preimplantation biopsy is of little benefit and may be misleading and will increase the discarding rate.
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
thanks
The current patient is an ECD / marginal kidney due to hypertension and death from cerebrovascular accident; border line GFR 60 ml/min, small sized kidneys, 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
B- Second I will recommend biopsy for the larger kidney since the GFR of the current patient is 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 (larger kidney) or DKT to the following recipient
Provided that life expectancy is > 1 year and no available living or SCD kidney
note your viewpoint, Dr Yusuf
Ajay
criteria used to select recipeints fort this donor
age more than 40
Female or BMI less than 30
DM
low immunological risk.
wating time more than 3.5 years
running vascular access.
no need for kidney biopsy as increased risk of discard and rejection we can used other non invasive tool such as HPM to ass pressure flow index and concentration of glutathione to this marginal donor with high risk of poor graft function but DKT will increase nephron mass and with proper recipent selection and immunosuppression therapy management
Sir
In this case, I will not comment much on WIT and standard recipient selection criteria which applies to all recipients. I will consider following I this case.
Low donor wight ( low nephron mass) associated with reduced graft function when compared to recipient wight. Low dkw/rbw ratio was found to be associated increase risk of proteinuria, more anti-hypertensive drugs, GS & increase risk of graft loss. Also nephron dosing to recipient metabolic demand mismatch combining to donor age associated with great impact on early post-transplant function & size mismatch between donor & recipient considered as a major risk factor for late graft loss.
So best option is DKT rather than SKT. & the recipient better to be age & size matched to donor.
Renal biopsy will not provide sufficient information due to sample errors or inadequate sample & also it depend on pathologist who read the slide( on call vs specialist pathologist) & it will increase WIT.
References:
YES DKT transplant is better option in this DKT and ECD low small size.
if yes, how do you select the recipient(s) suitable for this case?
Recipient with low immunological risk.
or recipient more than 4years on dialysis.
Female recipient (less mass index).
More than 40years.
Kidney biopsy wont add information specially in these small kidneys.
Dear Dr Ahmed,
I will accept this donor for DKT only. I will not recommend SKT from this donor due to her age and small kidney mass.
The donor had an excellent kidney function and Adequate urine output despite the small kidney size, as the available nephron mass was adequate for her age and body size. Therefore, I will proceed with DKT for a single donor with the following criteria:
– Age-matched recipient.
– Small body surface area (i.e. less muscle mass)
– Preferably females (again due to the lower muscle mass)
– Low immunological risk.
Kidney biopsy in this scenario is not indicated as there is no suspected active kidney disease or history of recent insult affecting the kidney to justify the biopsy.
. I will prefer DKT than proceed to do transplant separately
The recipient INSHALLAH should older age, low inmenological risk with long waiting list ongoing haemodialys is with recurrent vascular access problem with little associated comorbiditis
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. The other option is decision-making using information from perfusion machine.
The current donor is 59 years old after DCD, hypertension…But there was normal creatinine with good urine output at the time of organ retrievel….
The issue of bilateral small kidneys could be due to long standing hypertension or small kidneys by birth itself….As the kidney is a marginal kidney with DCD also, there is a high chance of DGF or primary non function of the kidney…The potential recipient should be counselled for the same before transplant…
The most suitable recipient would be elderly with low immunological risk profile with less BMI (not obese), with poor vascular access where continuing hemodialysis would be difficult…the recipients should recieve induction with ATG and select a CNI sparing regimen initially…Hypothermic machine perfusion and normothermic machine perfusion maybe useful before transplantation to improve the outcomes….Dual Kidney transplant should be thought of in this patient due to increase in nephron mass provided by both the kidneys…Surgical expertise is needed before performing DKT
Preimplantation biopsy is controversial as many studies did not corelate the biopsy findings with the long term outcome of patient survival and graft survival….If the services are available in the night, a biopsy may help in decision making with the Remuzzi score about single or dual transplant …. <3 – single kidney transplant…4-6 – Dual kidney transplant and >7 – discard the kidneys
Would you accept this donor?
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.
If yes, how do you select the recipient(s) suitable for this case?
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 .
Biopsy from both kidneys is essential
Yes. Renal biopsy not necessary.
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
DKT may be the best option although it is technically difficult but for these 2 small kidneys this is the best option
I will accept this donor and consider it for DKT. (1)
Recipient selection should be age (>40 years) and BMI matched with low immunological risk,on a long waiting list with exhausted dialysis access. (2)
Reference:
Would you accept this donor?
I would accept this donor.
This is an ECD: a 59 Y old DCD female, SAH, low BW 55kg, mild HTN, bilateral small kidneys, Cr 89 umol/L, good UOP.
If yes, how do you select the recipient(s) suitable for this case?
Dual Kidney donation is better than single kidney donation in ECD with marginal kidneys to increase the nephron mass.
Potential selected recipients include: older age group, low body mass, low immunological risk, multiple access problems, long duration on waiting list for more than 4 years.
Yes, I’ll accept this kidney. It is better to perform a dual kidney transplantation, because of small size kidneys of a small size patient.
Proper recipient: age more than 40, diabetic, low immunological risk, small size female, more than 4 years being on waiting list, vascular access failure
The donor is considered with marginal kidneys as her age is > 50 with history of HTN, the cause of death was due to cerebrovascular event and the both kidneys were small sized.
Small sized kidneys may be suboptimal regarding the number of functioning nephrons, Dual kidney transplantation increase the available functioning nephrons, bilateral pre-transplant renal biopsy if feasible to decide determine the Remuzzi score, dual kidney transplant is considered if the score is between 4&6
Elderly recipient is preferred for dual kidney transplant due to their limited metabolic demands and may not require graft survival >20 years according to their expected lifespan
Matched recipient with donor age and size
Recipients with low immunological risk as they are at lower risk of acute rejection and can receive immunosuppression with CNI minimization protocols
Hassan A, Halawa A. Dual kidney transplant. Exp Clin Transplant. 2015 Dec 1;13:500-9.
A patient for donation who deserves a very detailed evaluation, especially with a biopsy to evaluate the lesion, as the kidneys are already small. If the histopathological evaluation rules out important lesions, it could be accepted, with care to support the risk of high DGF.
As the criteria for donation would be quite borderline, perhaps choosing a recipient for a dual transplant would be indicated. Or a recipient who would benefit a lot from this kidney, for example, one with a long queue due to awareness or who, even with a shorter queue, had greater urgency due to lack of venous access.
The provided scenario is representative of ECD of marginal kidneys ,DCD female donor ,low body mass ,low nephron mass ,mild HTN , relatively old age kidneys.
The proposed risk for maintenance on dialytic support or remaining on lengthy duration of waiting list is worse in outcome compared to accepting these marginal kidneys.
After further explanation to candidate recipient about the predicted outcome and the predicted delayed graft function, the need of induction of immunosuppression along with proper counselling ,special selection of the recipient is required by choosing those candidates of small lean mass, long duration for waiting list exceeding 4 years, failed vascular access, old aged recipient, and of low immunological risk.
Optimizing immunosuppression is also recommended with favourable delay for the use of CNI after stabilization of renal functions under covered by the use of ATG or basiliximab.
Reference:
Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9.
British Transplant Society guidelines.
Aubert et al; BMJ; 101h; 1157 (2015)
Merion et al JAMA; 294; 2726 (2009)
He has a good out put with normal with good renal function, I would proceed for DKT.
DKT for many reson, age of donor ,HTN associated with small kidneys.
biosy is better to at least know abou the dignosis , then after that to select the case .
frommy site the case is older age more than 40 with he or she in the list for more than 4 or 5 years and no chance for living kidney TX
_ the current kidneys are extremely ECD, (old age , Hyoertension, atrophied or small ones )
_ their acceptance should be after counseling if the recipient if the potential risk of primary non function and DGF.
_ choice of appropriate recipient : matched for age (old for old), being on waiting list more than 4 years, low immunological risk, devoid of vascular access, strong induction with ATG, CNI minimzation or avoidance protocols، low muscle mass.
_Dual kidney tranplantation to increase nephron mass, although technically difficult but it can have better graft outcome.
_ preimplantation biopsy and Remuzzi score can help in decision making about SKT (score less than 3) or DKT (score 4_6) or discard them (if score More than 7).
*This potential DCD donor 59 years old , HTN with small sized kidneys .Weighing 133gm. Although; normal creatinine, but her eGFR 61ml/min. So, I will accept this marginal donor but will make DKT to increase the nephron mass and the recipient longer graft survival.
*The recipient(s) suitable for this case:
Age matching with the donor, DM ,on long time hemodialysis, having low immunological risk with multiple vascular access failure. Counselling recipient clearly about the risks of primary non-functioning PNF and DGF, acute rejection episodes and surgical complications and an informed consent must be taken.
References:
Ahmed Hassan & Ahmed Halawa : Experimental and Clinical Transplant.(2015) 6: 500-509 Exp.Clin.Transplant.
This is a marginal kidney, donor between 50-60years, died of SAH and has hypertension. In addition, she has small kidneys, both weighing 133gm. Despite being normal creatinine, this is upper limit of normal for female in many laboratories giving her e GFR CKD EPI of 61ml/min, presuming that her kidney function is stable over 2-3 weeks. Putting all these in mind, I will accept this offer but will take them as dual kidney to one recipient to increase the nephron mass and give the recipient longer graft survival.
Sine this is marginal kidney, we have to choose the recipient to be age/weight matching with the donor, being on dialysis for 4years at least, with low immunological risk and with vascular access.
References:
· BTS guidelines
· Ahmed Hassan, Ahmed Halawa/Experimental and Clinical Transplantation (2015) 6: 500-509 Exp Clin Transplant.
age is marginal,controled HTH, good urine out put with bilateral small kidneys.
I need to know the cause of small kidneys
Biopsy might help
Yes, but it is better to do Dual Kidney Transplantation
Again, who eill benefit are:
• Patients older than 40 years
• Long median waiting time (> 4 years)
• Patients of low immunological risk
• Diabetics
• Dialysis patients with vascular access problems
This is an ECD DCD donor(age > 50 years, hypertensive and had SAH)
She has a good urine output and acceptable renal functions (CKD with eGFR between 30-60 ml/min)before retrieval. However, She is a female with low BMI and bilateral small sized kidneys denoting a low nephron Mass.
I will accept this kidney based on ECD criteria. However transplanting a single marginal kidney with low nephron mass me be suboptimal for the recipient to become dialysis independent and may affect the graft survival and function. Dual kidney transplant in a single recipient is justifiable to increase nephron mass for a better graft survival and function.
We will depend on the eGFR or kidney donor profile index (KDPI) in this donor rather than carrying a renal biopsy in view of its limitation.
A full explanation about the risks of PNF and DGF in addition to surgical complications should be provided to the recipient and an informed consent should be taken.
When selecting the suitable recipient consider the following:
1)Matching the donor and recipient age( old donor to old recipient).
2) Allocating a recipient with low muscle mass like females and low metabolic demand
3) Low immunogenicity (PRA <50%)
4) going for recipients with vascular access problems and waiting for a long time on the waiting list
5) Diabetics
To improve graft viability , every effort should be done to reduce cold ischemia time together with the routine use of pulsatile machine perfusion and tailoring immunosuppression( CNI delayed introduction or avoidance regimens)
References:
1. Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9.
2. . Kyo Won Lee et al. Dual kidney transplantation offers a safe and effective way to use kidneys from deceased donors older than 70 years. BMC Nephrology (2020) 21:3
The available donor is 59 years old female DCD history of SAH grade 4/5 s hypertension good UOP but small kidney size
I will accept this ECD with DKT
The recipient INSHALLAH must
Female
Adage> 60 years old
On a long waiting list.
On going dialysis with a vascular access problem.
Little comorbiditis.
Decreased immunological condition.
This femal donor had mild controlled hypertension( it wasn’t mentioned if she was on one or more antihy-pertensive agent but being mild i would assume it was single agent )
Her weight was 55 kg mostly small size donor with a small muscle mass.
She had good urine out put ,s creatinine was 89 µmol/L before retrieval.
her kidneys size was small,most probably due to small body mass of the donor.
No history of diabetes or other medical conditions.
I will accept this donor but due to small nephron mass i prefer DKT ,to increase nephron mass delivered to the recipient to allow recipient to become dialysis independent.
DKT provides comparable graft survival and graft function to single ECD KT despite older donors with higher sCr levels, more diabetes, and higher KDPI and KDRI scores.
DKT is a safe and feasible way to use kidney grafts from extremely marginal donors, thereby reducing the organ discard rate.
* biopsy if available with rapid results will help to determine chronic pathological changes of kidney degree of glomerulosclerosis, interstitial fibrosis.
Although results sometimes may be misleading as surgons may perform elliptical biopsy which over estimate glomerulosclerosis.
But with current scenario with good kidney function ,and eGFR 56 ml/min / 1.73m2, i will go for DKT not waiting for biopsy
-Older donors is prefared ” old for old “strategy showed good resullts in many studies.
-Female recipients with low body mass index.
-diabtic patients.
– Low immunological risks panel reactive antibody titer < 50% to avoid burden of heavy immunosuppression and allow use of CNI free protocol
-failed vascular access .
-long waiting time on dialysis.
would you accept this donor?
yes.
This ECD BY the cause of death.
Could be used for both SDT or DKT depend on EGFR and perfusion parameters. The
low kidney mass is associated with increase risk of DGF AND have a statistically higher rate of graft loss
that is more pronounced in ECD kidney.
If yes, how do you select the recipient(s) suitable for this case?
Recipient with low immunological risk.
or recipient more than 4years on dialysis.
Female recipient (less mass index).
More than 40years.
Kidney transplantation is the best modality of RRT which is associated with lower morbidity and mortality in comparison to dialysis.
Evaluation of GFR done by 2 main methods estimated GFR and measured GFR
The patient although her creatinine is 86 mg/mmol her GFR is expected to be low because creatinine is a late marker and her kidneys size is small and her weight is low
As long as we have no measured GFR the patient should be considered as having normal GFR and mostly her GFR will be below 60ml/min
She is 59y, hypertensive, with low GFR and DCD so, she is ECD with a high risk of DGF and poor long-term graft survival. Low donor weight is associated with low nephron mass and some studies showed size mismatch between donor & recipient is considered as a major risk factor for late graft associated with increased risk of proteinuria, more anti-hypertensive drugs, lower graft survival & an increased risk of graft loss.
Assessment of a deceased kidney depends on the 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 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, 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 (1).
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
5)Qiu Y., Liu J., Jiang Y., Song T., Huang Z., et al. Effect of donor kidney morphology parameters on the prognosis in living kidney transplantation recipients. Trans Androl Urol,2020;9(5):1957-1966.
6)Kasiske B., Snyder J. and Gilbertson D. Inadequate Donor Size in Cadaveric Kidney Transplantation. J Am Soc Néphron, 2002;13: 2152-2159.
7)Lepeytre F., Delmas-Frenette C., Zhang X., Lariviere-Beaudoin S., Sapir-Pichhadze R., et al. Donor Age, Donor-Recipient Size Mismatch, and Kidney Graft Survival. CJASN,2020;15:1455-1463.
● DCD 59 year old donor with HTN and small kidneys and small muscle mass
so she is ECD
biopsy is needed in this case to help in making decision for SKT , DKT or discard the kidney
DKT is good option in this case which will provide better nephron mass
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
59 year old DCD weight55 kg with HTN ,small kidneys ,and normal kidney function
She is considered as ECD
And So I will proceed for donation with DKT as kidneys with moderate disease when used as dual transplants into a single recipient in order to increase donor pool.
Dual kidney transplantation (DKT) is also more frequently done and experience with this technique is slowly building up. DKT not only helps to reduce the number of patients on waiting list but also limits unnecessary discard of viable organs. Surgical complications of DKT are comparable to single kidney transplantation (SKT).
Various criteria are considered: age, presence of comorbidity (diabetes or hypertension), cold ischemia time, creatinine clearance, and preimplantation biopsy finding for allocation. Preimplantation biopsy finding predicts long term outcome of the graft.
Generally, the recipients of DKT were older when compared to SKT. Results of most studies showed that elderly patients who had DKT tend to have lower metabolic rate and low body mass index than the average SKT patients .DKT is considered better for age and weight matched recipient. Greater number of nephrons in DKT is suitable for elderly patients with low basal metabolism and reduced body mass.
Bearing this evidence in mind, DKT should be offered to elderly patients with lower immunological risk and a normal body mass index.
DKT is helpful in expanding donor pool and preventing discard. Various histological and clinical parameters are used to select a donor. There is a need to integrate histological score into multifactor score and to develop a consensus in selection of the donor for 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
Reference
Dual Kidney Transplantation: A Review of Past and Prospect for Future
Muhammad Abdul Mabood Khalil, Jackson Tan, […], and Rabeea Azmat
Dr.Ahmed Halawa lecture.
Small size donor with bilateral small kidney and good functioning both kidney, In this situation i will accept as dull kidney transplant
how do you select the recipient(s) suitable for this
Small size patient
older patient
low immunological risk
poor vascular access
lont time waiting list
I can accept for DKT considering small sized kidneys; for which biopsy is of less help .Potential recipients could be selected of matching age ,low immunological risk ,on HD for 4 years ,with issues related to access…
Would you accept this donor?
I will accept this donor
This is a ECD due to CVA and hypertension. She is also a DCD. DCD can be associated with higher risk of DGF. few considerations should be given before making a decision.
It is important to assess proteinuria- If> 3gm/day the donation is not possible.
Biopsy can be considered to assess Remuzzi score. Score up to 3 – single kidney transplant, 4-6- Dual kidney transplant, Score > 6- Discard
Assess RI during machine perfusion to assess health of kidneys.
.Recipient has to be counselled in detail about risk of DGF as its a donation from ECD.
If yes, how do you select the recipient(s) suitable for this case?
DKT or single kidney transplant can be done for elderly recipients , females, low immunological risk recipients.
It will be suitable for those potential recipients who are on waiting list for long time and have access issues
Those with low BMI.
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.
Would you accept this donor?
I would accept this offer
a) SCD without comorbidity apart from mild and controlled HTN.
b) Normal serum creatinine before retrieval.
c) The retrieved kidney size and weight are attributable to her overall body weight(55 Kg).
If yes, how do you select the recipient(s) suitable for this case?
Provided the retrieved kidneys are small in size despite the good kidney function:
a) I will consider SKT for a recipient with matching age, low body weight and no comorbidity.
b) I will consider DKT for young recipient without comorbidity provided the BMI < 30 and the immunological risk is low.
summary this case 59 years old female DCD with body weight 55kg,seum creatinine89 unmol/l with good U.O.P. and bilateral small kidneys.
iwill accept this marginal donor with small size kidneys as ECD donor after kidneys assessment.
renal biopsy is not preferred as is invasive and lead to tissue damage and increase risk of acute rejection and the degree of glomerrulosclosis on biopsy were significantly associtted with increaes the oragan discard . .
hypothermic machine perfusion viability assessment:
usually used in marginal donor as in our case and their higher risk of poor graft function
biomarker measured in the urine and perfuse have advandge over biopsy data of being non invasive but fewer routinely used in clincal practize and no single or parameter has yet proves to be defintive,
this HPM ass pressure flow index and concentration of glutathione transferse is enzymatic marker of ischemic injury and if 0.4ml/min offer SKT can be done if less 0.4ml/min organ discard.
more over kidney donor profile index (KDPI).
dual kidney transplantation preferable in kidney with small size ,eGFR less than 70ml/minsand older recipients
selection suitable recipient :
female or low body mass index recipients.
DM recipient
vascular access failure
wating time more than3.5 years
low immunological risk
age mor than 40 years old
managment of immunosuppression therapy should be balanced between decrease incidence of rejection and minimize CNI exposure
rferences
Clinical Data
Donor is ECD as (age > 50 years + HTN )
S Cr was 89 µmol/L + excellent urine output (110 mls/h during the last hour and 2.8 L over the last 24 hours
But bilateral small kidneys (62 and 71 grams respectively)
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?
It preferred to be
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
The question is SKT vs DKT
Higher nephron mass through DKT should reduce the deterioration in long term graft function especially if small sized kidneys
There are concerns that the small nephron mass provided by small kidneys may not provide adequate renal function in adult recipients with a potential risk of hyperfiltration-associated renal injury and graft loss.
Remuzzi histological scores.
SKT for >>score 0–3.
Kidneys with scores 4–6 were >> for DKT
score 7–12 were discarded
On the other hand others refuse to depend on renal biopsy for a decision 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
The assessment of pressure flow index and concentration of glutathione transferase, an enzyme marker of ischemic injury during use of hypothermic machine perfusion .
SKT was done when pressure flow index was 0.4 mL/min per 100 g/mm Hg and glutathione transferase was < 100 IU/L/100 grams renal mass.
Kidneys were discarded if pressure flow index was less than 0.4.
DKT was done when if pressure flow index was satisfactory but glutathione transferase was higher than the cut-off value.
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
ReferencesNavarro A. P., Sohrabi S., Reddy M., Carter N., Ahmed A., Talbot D. Dual transplantation of marginal kidneys from nonheart beating donors selected using machine perfusion viability criteria. Journal of Urology. 2008;179(6):2305–2309
Gill J., Cho Y. W., Danovitch G. M., et al. Outcomes of dual adult kidney transplants in the United States: ananalysisoftheOPTN/UNOSdatabase. Transplantation. 2008;85(1):62–68. doi: 10.1097/01.tp.0000296855.44445.af
Islam A. K., Knight R. J., Mayer W. A., Hollander A. B., Patel S., Teeter L. D. Intermediate-term outcomes of dual adult versus single-kidney transplantation: evolution of a surgical technique. Journal of Transplantation. 2016;2016:
This ECD and marginal donor can be accepted with dual kidney transplant 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.
note your viewpoint, Dr Ansary
Ajay
This is kidney from DCD from SAH Maastricht Category 4. the donor is small 55 kg and creatinine is 89 and excellent urine output. The kidneys are small.
Depending on which recipient I would like to choose SKT or DKT
SKT
1- children who awaits potential donor
2- female recipients who are small build
3- when the number of donors are scarce and desperate for donors
DKT-is considered better for age and weight matched recipient.
Decision whether SKT vs DKT can also be taken as per the pressure flow index and glutathione transferase concentration. SKT was done when pressure flow index was 0.4 mL/min per 100 g/mm Hg and glutathione transferase was less than 100 IU/L/100 grams renal mass. Kidneys were discarded if pressure flow index was less than 0.4. DKT was done when if pressure flow index was satisfactory but glutathione transferase was higher than the cut-off value. Patients having comorbidities and prolonged cold also underwent DKT.
I would not do renal biopsy for this patient, but will opt for KDRI/KDPI for choosing suitable for transplanataion. Klair T et al showed >2.2 is a useful discriminatory cut-off for the determination of graft survival benefit with the use of DKT; however, the benefit of increased graft years was less than half of single kidneys from donors in the same KDRI range.
DKT of kidneys with KDRI >2.2 was associated with significantly better overall graft survival [adjusted hazard ratio (aHR) 0.83, 95% confidence interval (CI) 0.72-0.96] compared to single kidneys with KDRI >2.2. DKT was associated with significantly decreased odds of delayed graft function (top 2 KDRI categories) and significantly decreased odds of 1-year serum creatinine level >2 mg/dL (top 3 KDRI categories).
Another option will be Donor-estimated GFR as an appropriate criterion for allocation of ECD kidneys into single or dual kidney transplantation.DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min.
stimulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to allocation based on donor eGFR/
so, more reason not to do renal biopsy
references
Andrews PA, Burnapp L, Manas D. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70
Hassan A, Halawa A. Dual kidney transplant. Exp Clin Transplant. 2015 Dec 1;13:500-9.
Klair T., Gregg A., Phair J., Kayler L. K. Outcomes of adult dual kidney transplants by KDRI in the United States. American Journal of Transplantation. 2013;13(9):2433–2440.
Snanoudj R, Rabant M, Timsit MO, Karras A, Savoye E, Tricot L, Loupy A, Hiesse C, Zuber J, Kreis H, Martinez F, Thervet E, Méjean A, Lebret T, Legendre C, Delahousse M. Donor-estimated GFR as an appropriate criterion for allocation of ECD kidneys into single or dual kidney transplantation. Am J Transplant. 2009 Nov;9(11):2542-51. doi: 10.1111/j.1600-6143.2009.02797.x. PMID: 19843032.
note your viewpoint, Dr Theepa
Ajay
59-year-old female
DCD donor
weight 55 kg
no significant medical history apart from mild HTN
normal serum creatinine level
good UOP
bilateral small size kidneys
For me, I will accept after assessing the quality using KDPI
May consider DKT to increase nephron mass
Reference:
Villanego F, L. Vigara LA, Cazorla JM, Naranjo J , Atienza L , Garcia AM, et al. Evaluation of Expanded Criteria Donors Using the Kidney Donor Profile Index and the Preimplantation Renal Biopsy. Transplant International. June 2022 | Volume 35 | Article 10056.
Many thanks Dr Taee.
Would you accept this donor?
Our potential donor is a 59 yr old female maastricht category 4 DCD, normal creatinine and good urine output, had mild controlled HTN, and low BMI? (wt 55 kgs).
No, i would not accept this donor kidneys.
she had bilateral small kidneys the surgeon reports, indicates a chronic kidney disease, in spite of normal creatinine, this may be due low muscle mass(wt 55 kgs) or poor feeding (metabolic) status.
BTS -deceased donor after circulatory death stated individuals with advanced or end stage chronic kidney disease, or with cortical necrosis demonstrable on biopsy should not be considered as potential donors(B1).
If yes, how do you select the recipient(s) suitable for this case?
If yes then the suitable recipient would be
· Age > 40 years.
· Low immunological risk (no pervious transplant, PRA< 50%).
· No history of DM, HTN.
· Long time on waiting list for transplantation (> 4 years).
· Access problem to dialysis.
· Small, female recipient.
· Immunosuppression with ATG/Alemtuzumab induction, CIN free protocol.
· Low risk for infections- prophylactic antibiotics.
· Reduce the cold ischemia time.
and will consider DKTs as an option here with this marginal small kidneys.
Reference:
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.
I like your approach, Dr Alshaikh. Ajay
– This donor is an ECD and can be considered controlled DCD (Maastricht Category 4) with serum creatinine 1 mg/dlwith acceptable urinary output, mild controlled hypertension
Yes she can be accepted after assessing the quality of the organs by KDRI score , checking urine analysis ,urinary proteinuria, renal US , renal biopsy and Remuzzi score grading as elderly, hypertensive donors could have chronic lesions such as glomerulosclerosis, tubular atrophy, interstitial fibrosis and arterial sclerosis.
In the preimplantation biopsy, glomerular sclerosis >20% is associated with a worse graft evolution
But for our case due to the small kidney sizes( but it could be matching with the donors weight) biopsy may not be a first option if other assessment methods were conclusive.
also viability testing and repairing using machine perfusion can be needed.
– Such donor must be matched with a suitable recipient regarding the age whom need to be old ,weight ,size ,or those remaining on long waiting lists ,those having failed vascular access as well as those with low immunological risk
Mean while in order to improve the quality of this graft DKT can be a better option to increase the nephron mass and overall renal function,and 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
– Zheng Jin etal . Comprehensive assessment of deceased donor kidneys with clinical characteristics, pre-implant biopsy histopathology and hypothermicmechanical perfusion parameters is highly predictive of delayedgraft function.RENAL FAILURE 2020, VOL. 42, NO. 1, 369–376
-Villanego F, Vigara LA, Cazorla JM, Naranjo J, Atienza L, Garcia AM, Montero ME, Minguez MC, Garcia T, Mazuecos A. Evaluation of Expanded Criteria Donors Using the Kidney Donor Profile Index and the Preimplantation Renal Biopsy. Transpl Int. 2022 Jun 6;35:10056.
Well done ,also for mentioning other non invasive ,non time consuming methods as KDRI .
Well done
Would you accept this donor?
If yes, how do you select the recipient(s) suitable for this case?
Thankyou but short ,needs more analytical information
do you need a biopsy here to help you decide for DKT or go ahead without one.
it is already CKD. biopsy will not change the decision. DKT should be done
This potential donor lies in the group of ECD because:
Age: 59 with hypertension and DCD Moreover; the small sized kidneys
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
Thankyou but short with no references
Donor with 55 kg
no significant medical history apart from mild controlled hypertension
Good RFT and UOP
*body size, expressed as weight and length, is an important factor to consider when analyzing sex differences in kidney size. In this context, relative kidney size (corrected for body weight or body surface area (BSA)) may offer more accurate information than absolute kidney size, and tell us if kidney size remains larger in men once corrected for body size.
absolute and relative renal weight (corrected for body weight and/or body surface area) are both greater in men than in women.
Absolute and relative renal weights were both smaller in women. This is in line with recent studies stating that nephron numbers are also lower in women. Relative renal length was longer in women, suggesting that female kidneys have a more elongated shape.
*So I will accept this donor and do dual kidney transplantation
*Dual kidney transplantation
the transplantation of 2 expanded criteria donor (ECD) adult kidneys into a single recipient, was developed to increase the use of kidneys from older donors.
Selection criteria that have placed kidneys into the ECD category include ((donor age, donor instability, and a biopsy specimen from the donor
kidney that demonstrates adverse histology))
the total nephron mass is important in the outcome of the transplantation. Therefore, older donors or donors with longstanding hypertension presumably would not have sufficient functioning nephron mass and this would portend transplantation failure when single cadaveric renal transplantation (CRT) is performed previously, these kidneys were discarded.
Reports of dual kidney transplants have described similar outcomes in the recipients of dual transplants vs recipients of single transplants from younger donors.
Recipients of dual kidney transplants from ECDs have excellent outcomes similar to recipients of single control kidneys.
Higher nephron mass in humans through DKT should theoretically reduce the deterioration in long term graft function
Logically, single kidney from ECD has less number of functional nephrons when compared with two ECD kidneys which should translate to better overall kidney function.
Organ preservation, ischemia reperfusion injury, exposure to calcineurin inhibitors, rejections, and hypertension in posttransplantation period have deleterious effects on renal parenchyma. Single kidney from ECD by virtue of having less functional renal parenchyma will be more vulnerable to damage by these factors.
graft and patient survival in DKT is encouraging and comparable with SKT. Keeping in view similar surgical complications risk and similar incidence of delayed graft function and rejection with reasonable survival benefit of DKT
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
References
1-Reference values and sex differences in absolute and relative kidney size. A Swiss autopsy study. Open Access
Sabrina Addidou Kalucki1, Christelle Lardi2, Jonas Garessus1, Alain Kfoury1, Silke Grabherr2,3, Michel Burnier1 and Menno Pruijm1* Kalucki et al. BMC Nephrology (2020) 21:289 https://doi.org/10.1186/s12882-020-01946-y
2-Dual Kidney Transplantation: A Review of Past and Prospect for Future
Muhammad Abdul Mabood Khalil,1 Jackson Tan,2 Taqi F. Toufeeq Khan,3 Muhammad Ashhad Ullah Khalil,4 and Rabeea Azmat5
Hindawi.International Scholarly Research Notices Volume 2017, Article ID 2693681, 14 pages https://doi.org/10.1155/2017/2693681
3- Excellent Outcome in Recipients of Dual Kidney Transplants.A Report of the First 50 Dual Kidney Transplants at Stanford UniversityAmy D. Lu, MD, MPH; Jonathan T. Carter; Rebecca J. Weinstein; et al
Arch Surg. 1999;134(9):971-976. doi:10.1001/archsurg.134.9.971
4- Expanded Criteria Donor
By Ahmed Halawa Consultant Transplant Surgeon Associate Professor, University of Liverpool – UK
Thankyou ,Exellent model answer with conclusive reasoning.
Summary:
1) Female donor DCD with SAH stage 4/5
2) Low weight 55kg
3) History of mild HTN
4) Kidney functions creatinine 89
5) Excellent urine output of 2.8 L in 24 hours with 110 mls/h
6) During retrieval both kidneys were small
I believe that the patient can be a donor as she has good kidney functions but the kidneys are small could be due to her weight or low birth weight.
Accepting this patient’s kidney there is a risk of DGF.
The recipient must be one that has the following characteristics:
1) Small body mass
2) Around the same age or older like around 40 plus
3) Probably DM and HTN well controlled
4) Low immunological risk
5) Has been on the waiting list for a while
6) May have vascular difficulties
7) Maybe elderly patients older than 60 years
The recipient must be made aware of the possible complications and possible graft delay. Immunosuppressive must be one that doesn’t affect graft function delay or reduce the risk of such. Close follow-ups must be done to ensure graft function or detection of early rejection to act aggressively to detain the same.
BTS guidelines. Transplantation from deceased donors after circulatory death. July 2013.
Thanks, Marius
Please see the question posted above
This is an ECD (59 years – Hypertension)
She has others weak points
Low weight
Small kidneys
We don’t know the cause
If it is a result of her weight
Or she was pretem or she had low birth weight
So , she has decreased nephrons numbers
May be biopsy also, has no big role because she has a good renal function unless she had DM or Proteinuria
We can select recipient who is matching
To improve the transplantation result we can use
Normothermic machines perfusion
or we can perform dual kidney transplant for a fit recipient
REFERENCE
Professor Ahmad Halawa lecture
Thanks, Ghalia
Please see the question posted above
Yes, I will accept her as an ECD donor.
Dual kidney transplantation is best option here. I will select recipient as follows:
More than 40 years
Small size preferably female
Low immunological risk
Diabetic
Poor vascular access
I will arrange short possible CIT to improve outcome
I like your logical approach, but you have not uploaded any evidence to support your arguments.
A 59-year female DCD who is 55 kg and have mild well controlled hypertension ,suffered from SAH but having normal creatinine and good urine output before retrieval and bilateral small sized kidneys per-operatively can be considered for donation as it falls into marginal kidney donor and to improve nephro mass ,dual kidney transplant should be done
how do you select the recipient(s) suitable for this case?
The recipient should be counselled about the short term and long term patient and graft survival , the recipient selected should be of the same age or elderly and female preferably that is more than 40 yrs ,of low immunological risk,diabetic ,with lower life expectancy on dialysis ,had difficult vascular access.Hypothermic machine perfusion to decrease CIT and optimisation of immunosuppression to prevent DGF and improve graft survival .
REFERENCE:
1-Prof Ahmed Halawa lecture on Expanded Criterial Donation.
2-Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015;13(6):500-509.
I like your logical approach
The index donor is an extended criteria donor (age 50-60 year with death resulting from a cerebrovascular accident and hypertension) with donation after cardiac death (DCD).
Her urine output is excellent, and the terminal serum creatinine is 89 µmol/L. Her body weight is low and bilateral kidneys are small in size.
DCD donors have increased risk of DGF (1).
I will accept this donor as the outcomes of ECD transplant are better than remaining on wait-list (2).
The question for such a donor is whether performing a single kidney transplant (SKT) or a dual kidney transplant (DKT) as the donor has small sized kidneys, hence lower nephron mass (3). According to the UK kidney advisory group criteria, ECD with small kidneys should be taken up for DKT (3,4).
The selection for SKT versus DKT can also be done on the basis of pressure flow index and glutathione transferase concentration in kidneys undergoing HMP (hypothermic machine perfusion).
Discard DCD kidneys if pressure flow index is less than 0.4ml/min per 100 g/mmHg. SKT can be performed with DCD kidneys having pressure flow index >0.4ml/min per 100 g/mmHg and concentration of glutathione transferase in perfusate of less than 100 U/L/100 grams renal mass. DKT should be performed if concentration of glutathione transferase in perfusate is more than 100 U/L/100 grams renal mass (3).
The ECD kidneys have lower graft survival as compared to standard criteria donor kidneys (5). 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 (5).
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).
DKT would be preferred in this scenario due to small sized kidneys. Decision of SKT versus DKT can also be taken as per the pressure flow index and glutathione transferase concentration.
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 18, 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) Allen J, Hudson A. Dual kidney transplantation. Kidney Advisory Group. 2011;16(11):1-9.
5) 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.
I like your logical approach. That is an impressive short write-up.
Would you accept this donor?
Yes I would accept her as a donor. She has excellent chemistry with good urine output, however, I might use DKT to maximize nephron mass.
If yes, how do you select the recipient(s) suitable for this case?
This is an expanded criteria DCD donor.
The potential recipients could be:
· Patients older than 40 yr
· Long median waiting time (> 4 yr)
· Patients with diabetes or hypertension
· Patients of low immunological risk
· Dialysis patients with vascular access problems
· Dialysis patients whose life expectancy in dialysis is lower than the estimated waiting time for kidney transplantation
· Elderly: Patients who receive a cDCD/≥60 graft have better survival than those who continue on the waiting list
The use of this type of organ should be accompanied by the optimization of surgical times and the shortest possible cold ischemia.
Reference:
· 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.
yes Dr Alalawi. Not only dual renal transplant, but also ‘optimization of surgical times and the shortest possible cold ischemia’.
You were offered kidneys from a 59-year-old female DCD donor who suffered from SAH (grade 4/5). According to the GP notes, this donor’s weight was 55 kg, but there was no significant medical history apart from mild controlled hypertension. S Cr was 89 µmol/L before retrieval. She had excellent urine output (110 mls/h during the last hour and 2.8 L over the last 24 hours). During retrieval, the surgeon reported bilateral small kidneys (62 and 71 grams respectively).
====================================================================
HISTORY
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how do you select the recipient(s) suitable for this case?
A- Recipent >40 years living in an organ procurement network catchment area .
B- With a long median wating time >3,5 years .
C- Recipent with low immunological risk .
D- Recipent with diabetics.
E- Dialysis pateint with poor or problem with vascular access
F- Female recipent–smal.
====================================================================
Eligibilty for DKT transpant according to standarized scoe system
====================================================================
Reference
1- Mathur AK, Heimbach J, Steffick DE, Sonnenday CJ, Goodrich NP, Merion RM, et al. Donation after cardiac death liver transplantation: predictors of outcome. Am J Transplant 2010;10:2512‐2519..
2- Tanriover B., Mohan S., Cohen D. J., et al. Kidneys at higher risk of discard: expanding the role of dual kidney transplantation. American Journal of Transplantation. 2
3-Vinkers M. T., Smits J. M., Tieken I. C., De Boer J., Ysebaert D., Rahmel A. O. Kidney donation and transplantation in Eurotransplant 2006-2007: minimizing discard rates by using a rescue allocation policy. Progress in Transplantation. 2009;19(4):365–370. doi: 10.1177/152692480901900414
That is an excellent reply, Dr Wadi.
Yes I will accept this ECD kidney with DCD , old age ,CVA , Ht. and small size .
After maximizing the kidney by decreasing the CIT and use the normothermic or hypothermic machine perfusion and manipulate the immunosuppressant drugs. The small size kidney mean low nephron mass , so this mean that DKT is the best option to maximize nephron mass.
In edition, recipient choice is very important:
Must be small size or female
with low immunological risk
Diabetic
Old age
Waiting for long time
Running out vascular access.
With counseling the recipients about the risk of DGF of such grafts.
I appreciate your logical approach, Dr Khudhur.
Would you accept this donor?
-Yes ,I would accept this DCD ECD donor kidneys.
-ECD because age ˃50 with hypertension and CVA.This donor’s weight was 55 kg and maybe short so her kidney small.There is a significant positive correlation between absolute renal length and subject’s height .
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 References:
-Lipika Paul et al .Renal Length and Its Relationship with the Height of an Individual: A Review .IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 15, Issue 4 Ver. III (Apr. 2016), PP 19-23
-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 Don
Well done .
This is an expanded criteria donor (age more than 50 years, history of HTN, CVA)
The serum creatinine is 89 mls/min (eGFR using CKD EPI is 64 mls/min) with a good urine output. The patient has a weight of 55 kg suggesting possible short stature which could explain the small size of the kidneys
I would accept this donor as the renal function is good.
The potential recipient should be more than 40 years of age, have low immunological risk, have a longer median waiting time (more than 4 years)
These are small kidneys with a reduced nephron mass in an ECD donor
The question that needs to be asked is should we do a single kidney transplant or a dual kidney transplant.
Several criteria have been used including histological (pre-implantation biopsy) and clinical parameters like the NewCastle scoring system ( the perfusion flow index and intracellular enzymes like glutathione transferase which is an enzyme of ischemic injury in the effluent)
One of the simpler criteria used is looking at the eGFR or KDRI. If the eGFR is more than 60 mls/min or KDRI is less than 2.2, then kidneys should go for SKT
For our patient, the eGFR is more than 60 mld/min, so the kidneys should go for SKT
Auber O et al. BMJ 2015;315:h3557
Khalil M. Dual Kidney Transplantation: A Review of Past and Prospect for Future. Int Sch Res Notices 2017; 2017: 2693681
With this e GFR of 64 (borderline) it would be SKT
but consider the other risk factor,age DCD, SAH4 small size kidneys
test the viability of the kidney also put into consideration: pressure flow index, glutathione transferase.
Pressure <0.4. discard
peasure 0.4 ,GT high go for DKT
Yes Prof
Thank you
Size was not a significant factor for patient or graft survival in recipients of kidney transplants from donors over age 50. The only donor factor that showed a decreased chance of a serum creatinine ≥ 2 mg/dl one year after transplant was a BMI of less than 25. Recipient male gender, and diabetes are significant risk factors for a serum creatinine of more than 2 mg/dl. An elevated creatinine at one year following transplant in recipients of ECD kidneys is a significant risk factor for patient and graft survival.
our patient should have BMI calculation .
after rolling out protienurea and maybe kidney biopsy if needed (also help desiding to transplant one or tow kidneys through rimuzzie score)
I will accept this donor with DkT
1-Patients older than 40 yr
2-Long median waiting time (> 4 yr)Patients with diabetes or hypertension
3-Patients of low immunological risk
4-Dialysis patients with vascular access problemsDialysis patients whose life expectancy in dialysis is lower than the estimated waiting time for kidney transplantation.
refference :
Does Size Matter in Extended Criteria Donor (ECD) Kidney Transplantation?
BTS guildlines
You can spare her a biopsy by using the UK Kidney advisory group which gives consideration to the kidney size among other risk factors.