5. You were offered the kidneys from 72-year-old male DBD (donor after brain stem death) donor who suffered from hypoxic brain damage secondary to unwitnessed cardiac arrest. The estimated down time (the cardiac arrest period elapsed before resuscitation) is 30 to 40 mins. After resuscitation S Cr was 130 µmol/L. Urine output was 20mls/h during the last hour and 1.1 L over the last 24 hours.
- Would you accept this donor?
- If yes, how do you manage this case?
Dear All
We learned from the journal club that the biopsy could be misleading, especially the frozen section. It also may not provide useful information or add something we do not already know.
Will you still biopsy these kidneys?
How would you transplant these kidneys, single or dual, if you have a desperate patient who is 23-year-old and running out of access?
no biopsy should be done because of its variable results which may be confusing leading to discard the kidney
yes we can do dual kidney transplant in a single recipient
Hi Dr Riham,
I would have a different take on you comment, as I quote, “no biopsy should be done because of its variable results which may be confusing leading to discard the kidney.”
If histopathology by an expert renal histopathologist is available, it is good to get that precious information though not absolutely essential. We need to be aware of limitation of frozen section report that can be mis-leading.
A histopathology of renal biopsy is not always available at odd hours, we have to decide based on the information given to us, because such referrals are often made at 3-4 o’clock in morning !
Many transplant surgeons would ask for Remuzzi score on histopathology of renal allograft biopsy. We go by functional studies such as pre-morbid renal function of proposed donor when deciding about feasibility of dual renal transplant.
In such a setting with young patient, who is running out of access; then dual kidneys can be transplanted without biopsy.
Dear Dr Ansary,
I like your decision. You should have supported your argument by uploading evidence
Sudden cardiac arrest is common & it represent large sample of potential donors(30%) & in last decade DCD increased 10 folds. But the risk of ischemia reperfusion injury, post arrest organ dysfunction in addition to presence of medical co-morbidities in those potential donors can be a problem limit the use go these donors.
The most important factors determine the acceptance of unwitnessed cardiac arrest ( category I Maastricht) are warm ischemia time <45 minutes & terminal renal function. DCD associated with high risk of DGF & ischemia reperfusion injury compared to DBD but the long term survival at 10 years was comparable in both categoryI&II DCD & DBD. So accepting less ideal kidney is challenging.
Renal biopsy finding will not affect the acceptance of this donor in addition it will increase cold ischemia time & more tissue damage during waiting the result of biopsy.
This donor can be accepted if the recipient was desperate without patent vascular access especially young patients & to improve the outcome dual transplant can be done to overcome sub-idial kidney.
References:
That is a superb reply, dear Dr Ben
Thank you sir
I agree with Dr Ban Mezher regarding accepting this donor for a dual kidney transplant. I just wanted to add that avoiding the CNI in the induction phase and until the kidney functions stabilize may be beneficial (1).
CNI is known to cause vasoconstriction of the allograft vessels, which may aggravate the ischemic injury already present in this case scenario, especially considering the donor’s age.
References:
1) Steddon S, Ashman N, Chesser A, et al. Oxford Handbook of Nephrology and Hypertension. Second edition, Oxford University Press, ISBN 978–0–19–965161–0, 2014.
Yes, I still proceed with the biopsy. according to the eGFR of the donor < 60ml/min/1.73.
It will depend on the biopsy score assessment to proceed with single or dual or discard the kidneys.
It is very important to consider the recipient status:
DKT should be offered to elderly patients with lower immunological risk and a normal body mass index.
Younger patients may invariably have better outcomes but should be made aware that the long-term survivability of grafts may not match their life expectancy and may complicate their sensitization for future transplants.
Yes Dr Waem,
Many transplant surgeons would ask for Remuzzi score on histopathology of renal allograft biopsy. We go by functional studies such as pre-morbid renal function of proposed donor when deciding about feasibility of dual renal transplant.
A histopathology of renal biopsy is not always available at odd hours, we have to decide based on the information given to us, because such referrals are often made at 3-4 o’clock in morning !
I will not do the biopsy, and go for dual kidney transplantation rather than single kidney.
yes, Dr Ben
*Although this candidate donor 72 years old considered as marginal donor, and also unwitnessed cardiac arrest ( category 1 ), with down time 30-40 min supposed to be not suitable for organ donation, just tissues . But I would accept him in this setting for sake of desperate young patient with no vascular access.
*But can make dual kidney transplant.
*I wouldnot go for kidney biopsy
I will not biopsy the kidneys in this case because age and cardiac arrest can reveal a lot about the kidneys.
I would transplant the recipient with both kidneys.
Yes, Dr Badal
Dear professor ,
While deceased donor kidney biopsies are routinely performed in the United States to facilitate the decision of organ allocation, the evidence is poor that they are associated with important clinical outcomes.
There is large variability in conclusions from existing studies, which is at least partially related to the quality of the studies themselves.
Further, there is a discrepancy in biopsy technique, sample process and pathologist expertise between study setting and daily practice, which undermines the applicability of study findings .
Most importantly, reliance on donor kidney biopsies may be associated with an inappropriately high discard rate of transplantable kidneys.
While it is clear that donor kidneys with advanced pathology are not suitable for transplantation, existing data does not allow rigorous identification of clear cut-offs .
So The interpretation of deceased donor biopsy findings is best performed in conjunction with clinical parameters.
yes i will still do biopsy , and accept this donor for the 23 years old recipient , Some centers consider dual versus single kidney transplants using older kidneys. However, when using donors aged ≥60 years, no graft survival advantage at 5-year was observed comparing dual versus single kidney transplantation in an analysis from the United Kingdom between 2005–2017 .
So i will go for this transplant , single kidney and save 2 recipients rather than 1.
References :
1. Dare AJ, Pettigrew GJ, Saeb-Parsy K. Preoperative assessment of the deceased-donor kidney: From macroscopic appearance to molecular biomarkers. Transplantation 2014; 97: 797–807.
2. Sung RS, Christensen LL, Leichtman AB, et al. Determinants of discard of expanded criteria donor kidneys: Impact of biopsy and machine perfusion. Am J Transplant 2008;8: 783–792.
3. Scientific Registry of Transplant Recipients Annual Data Report 2012. Available from: http://srtr.transplant.hrsa.gov/annual_ reports/2012/flash/01_kidney_13/index.html#/13/.
4. Kasiske BL, Stewart DE, Bista BR, et al. The role of procurement biopsies in acceptance decisions for kidneys retrieved for transplant. Clin J Am Soc Nephrol 2014;9: 562–571.
5. Edwards EB, Posner MP, Maluf DG, Kauffman HM. Reasons for non-use of recovered kidneys: The effect of donor glomerulosclerosis and creatinine clearance on graft survival. Transplantation 2004; 77: 1411–1415.
6. Bajwa M, Cho YW, Pham PT, et al. Donor biopsy and kidney transplant outcomes: An analysis using the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) database. Transplantation 2007; 84: 1399–1405.
7. Cicciarelli J, Cho Y, Mateo R, El-Shahawy M, Iwaki Y, Selby R. Renal biopsy donor group: The influence of glomerulosclerosis on transplant outcomes. Transplant Proc 2005; 37: 712–713.
8. Lin NC, Yang AH, King KL, Wu TH, Yang WC, Loong CC. Results of kidney transplantation from high-terminal creatinine donors and the role of time-zero biopsy. Transplant Proc 2010; 42: 3382–3386.
Waiting for the frozen section biopsy can further prolong the WIT the down time is 30/40 min.
AGE >70
comorbidities of the D not known
why not give hom the benefit of the doubt?!
Dear Professor ,
I will give him the chance and may use perfusion machine for the time elapsed
In this scenario, our concerns about this particular donor who fits the ECD sustaining prolonged cardiac arrest means he had to prolong Ischemia-reperfusion injury at the time of initial cardiac arrest, and after arrest organ dysfunction as the predicted warm ischemia time (for DCD) influence the OPCs’ evaluation In addition to the preexisting medical comorbidities that lead to cardiac arrest likely at his age due to underlying CAD with ACS, also he had AKI with oliguria I think in his case the need for biopsy is justifiable if done by an expert pathologist we know from the JC the limitations and variation in interpretation of the frozen section and might increase the chance of this kidney to be discarded but still we do it is selected cases to assess the suitable organ for donation and probably will go for dual kidney donation for single recipient that has special circumstances like high risk of mortality with limited vascular access or on the long waiting list after full explanation and get consent from the recipient then go ahead with dual transplantation.
References:
1.Elmer J, Molyneaux BJ, Shutterly K, Stuart SA, Callaway CW, Darby JM, Weisgerber AR. Organ donation after resuscitation from cardiac arrest. Resuscitation. 2019 Dec; 145:63-69.
2. Procurement Biopsies in Kidney Transplantation: More information may Not Lead to Better DecisionsKrista L. Lentine,1 Bertram Kasiske,2 and David A. Axelrod,3
Exellent
Would you accept this donor?
This donor is considered ECD as he is old also with hypoxia and AKI due to prolonged cardiac arrest , so his kidney at great risk of DGF and low survival
No I will not accept this donor unless the recipient has exhausted vascular access and on waiting list for long time
If yes, how do you manage this case?
Full explanation to the recipient that the graft at high risk of DGF and poor outcome
• kidney biopsy
• Minimizing ischemia time
• Transplanting both kidneys
How would you transplant these kidneys, single or dual, if you have a desperate patient who is 23-year-old and running out of access?
In this scenario, no biopsy is needed and single kidney to be transplanted
No scoring system, either alone or in combination with pump parameters or histological scoring, has yet been shown to accurately define which organs should be discarded due to an excessive risk of PNF or seriously impaired long-term graft function. So, it is not necessary to do a preimplantation biopsy as the result may be misleading.
Being a marginal kidney, dual renal transplantation may be considered.
Thankyou
In such case dual kidney transplantation can be done without biopsy as there are no histological markers available to predict the primary non function as a result of excess warm ischaemia or irreversible ischaemia-reperfusion.
Meanwhile Scores combining donor hypertension and creatinine with histological scoring can offer better predictive value.
Reference
BTS guidelines2013
You mean KDPI!
I will not biopsy as it misleading and lead to organ discard.
been patient young23 years old and running of access iwill accept this donor but ineed to explain to the patient the high risk of delay graft function.
in this recipeint used dual kidney from this donor
I think that the creatinine level of 130, which is relevant to 50 ml/min/1.73 m²Estimated GFR by 2021 CKD-EPI Creatinine equation is probably chronic. The creatinine level is expected to increase, and the GFR is downing. The urine is more than 40-50 ml/hour, which is now toward oliguria. If we wait, ATN is inevitable.
Yesterday we had a patient who ran from access abut the peritoneum is also off (no UF), has peritonitis now and had transhepatic access for dialysis, which infected .. we were obliged to return to HD yesterday. For such a patient (As Prof. Ahmed asks), I will accept this donor if no other contraindicatşon exists).
In the centre I moved to recently, they have a 0-time biopsy for re-evaluation post-op to differentiate the causes later on; in case of DGF or persistent high creatinine).
Currently there are no histological markers that predict PNF as a result of excess warm ischaemia or irreversible ischaemia-reperfusion so biopsy will add nothing
Therefore I will not do biopsy for this kidney
And as recipiant is young and urgent so dual kidney transplant is preferred to single kidney in case of this elderly DCD donor with long WIT
no need for biobsy
i will procced l with dual transplantation.
referrence :
Hwang JK, Park SC, Kwon KH, Choi BS, Kim JI, Yang CW, Kim YS, Moon IS. Long-term outcomes of kidney transplantation from expanded criteria deceased donors at a single center: comparison with standard criteria deceased donors. Transplant Proc. 2014;46(2):431–6.
Lionaki S, Kapsia H, Makropoulos I, Metsini A, Skalioti C, Gakiopoulou H, Zavos G, Boletis JN. Kidney transplantation outcomes from expanded criteria donors, standard criteria donors or living donors older than 60 years. Ren Fail. 2014;36(4):526–33.
Tanrisev M, Hoscoskun C, Asci G, Sozbilen M, Firat O, Ertilav M, Ozkahya M, Toz H. Long-term outcome of kidney transplantation from elderly living and expanded criteria deceased donors. Ren Fail. 2015;37(2):249–53.
Sir,
Biopsies may be misleading.
BTS guidelines say “No scoring system either alone or in combination of pump parameters or biopsy histology have shown to accurately define the organs that should be discarded dure to excessive risk of primary non function of graft or impaired long-term outcome.”
If there is a 23-year old patient running out of access, then dual kidney transplant can be considered.
Some parameters, that may help in decision making are
flow on machine perfusion > 0.4ml/min/mmHg/100gm of tissue –> consider for single kidney transplant.
But, if this index is <0.4ml/min/mmHg/100gm of tissue, High GST, elderly, low eGFR, diabetic donor, with prolonged ischemia time –> consider for Dual kidney transplant.
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.
The role of biopsy would be to see acute cortical necrosis or severe glomerulosclerosis.
A dual kidney transplant of this donor can be offered to such a patient (23 year old, without vascular access)
Kidney biopsy is not helpful in this situation. Dual kidney transplantation would be a good option.
Since kidney biopsy could be misleading and increases cold ischemic time, we could precede dual kidney transplantation in an emergent situation.
I think in case of donor shortage, dual transplantation without biopsymwhich may be time consuming is the best option
The proposed donor is an ECD with 40 mins arrest time.. Poor graft outcome but better than Hdx..
Shall accept this donor after consenting the receipt and explaining the outcome probabilities.
We shall do dual kidney transplant in a single recipient
This donor is an ECD with history of unwitnessed cardiac arrest 30-40 minutes prior to resuscitation. Post arrest Brain death in the index case developed AK and reduction in urine output which make the kidney higher risk for DGF
AKI perse, I would accept the donor kidney
If yes, how do you manage this case?
kidney should be transplanted as dual kidney transplant. The recipient should be someone who 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, however presence of acute cortical necrosis or severe glomerulosclerosis would preclude the transplantation . AKI-.ATN would lead to increased DGF, but would recover with time with long-term outcome similar to those without AKI.
Usage of machine perfusion, induction therapy in form of ATG and Maintenance immunosuppression in form of Tacrolimus – with delayed introduction of CNI (to reduce the incidence of DGF), MMF and steroids
This is a “marginal” and “expanded criteria” donors .
Expanded-Criteria Donor is one who, at the time of death, is aged >60 or aged 50 to 59 yr and has any two the following three criteria: (1) Cause of death is cerebrovascular accident; (2) preexisting history of systemic hypertension; and (3) terminal serum creatinine >1.5 mg/dl. The criteria for the definition of ECD were based on the presence of variables that increased the risk for graft failure by 70% (relative hazard ratio 1.70) compared with an SCD kidney.
Donation after Brain Death describe a donor who had primary brain death in whom cardiac circulation and respiration remain intact or are maintained by medical measures, including mechanical ventilation, drugs, intra-aortic balloon pump, or extracorporeal machine oxygenation device. A DBD could be an ECD or SCD depending on whether the ECD/SCD criteria are separately fulfilled.
There is no universal definition of marginal or expanded criteria donors (ECDs). However, the presence of some conditions associated with shortened survival, reduced graft function or the risk of disease transmission has been used to characterize organs as of “marginal” quality .The characteristics of marginal donors relative to graft function: higher short-term morbidity (delayed graft function or primary graft nonfunction) and shorter graft survival. These events might be associated with the donor’s age, past pathological history, anthropometric measurements, cause of death, previous function of the organ to be donated, anatomical abnormalities, intoxications and poisonings, hemodynamic instability, prolonged ischemia time and donation after circulatory death .
The use of marginal donors is only justified when the life expectancy after transplantation is higher compared with conventional clinical treatment. Under borderline circumstances, the decision to transplant organs is made by the transplantation team with the informed consent of the recipient. The organs must be removed, and if they are not used in the same Brazilian state, then they should be offered to the National Transplant Center for allocation to other states.
Kidney graft function and survival are impaired when donors are greater than 60 years old . Expanded criteria kidneys are those that are harvested from donors greater than 70 years old with no additional risk factors and from donors aged 60 to 70 years old with a history of diabetes, systemic arterial hypertension, significant proteinuria (over 1 g/24 hours) and signs of hypertension- or diabetes-related target organ injury. Kidneys from such donors are associated with a higher risk of death and graft loss, especially when transplanted into recipients under 60 years of age .(2)
Different immunosuppressive strategies in ECD recipients may be discussed. The goal in ECD is to reduce not only the incidence of infections and cancers but also acute rejection in this at-risk population. In induction therapy, rabbit antithymocyte globulin (rATG) has shown lower risk of acute rejection as compared to IL-2 receptor antagonists without an increased risk of death in older recipients and high-risk kidney such as ECD. Steroids maintenance or withdrawal has to be weighed between the higher risk of acute rejection and the risk of side effects in older patients. It was shown that an early steroid withdrawal at the time of first discharge post transplantation was associated with a better adjusted overall graft survival [HR = 1.32 (1.1–1.56), P = 0.002) and patient survival [HR = 1.46 (1.16–1.83), P = 0.001] but not death-censored graft survival. In a subgroup analysis, these results were confirmed only in the T-cell-depleting induction treatment (thymoglobulin) group but not in the IL-2 receptor blocker (Basiliximab) group .
In 2009, Rao et al. published the kidney donor risk index based on the Scientific Registry of Transplant recipients in the North American population. The kidney donor risk index appears to be an interesting tool to stratify the risk and estimate outcomes posttransplantation based on 14 donor and transplant factors associated with death and graft failure. This score is currently used in the United States to allocate kidney graft for single kidney transplantation or dual kidney transplantation. KDPI score was assessed also in European cohorts of high-risk donor–recipient pairs and was efficient to improve the graft outcome prediction.
In Europe, the Eurotransplant senior program (ESP) was created to improve transplant allocation and shorten the time on waiting list. It was designed to allocate kidney from ≥65 years old donors to ≥65 years old recipients regardless of HLA matching but with a focus on reducing the cold ischemia time. Frei et al. published the 5-year results of the ESP and showed that death-censored graft survival of ESP patients was similar when compared to old donor giving to other any recipients (67% survival) but was lower as compared to any aged donor giving to old recipients (81%). These results were obtained at the price of higher incidence of acute rejection. Results from the Dutch Organ Transplant Registry, which is part of Eurotransplant and ESP, showed a 5-year death censored graft survival of 83.8% in DBD and 75.3% in DCD. In this old recipient population, delayed graft function was a strong risk factor of death (+40% risk) and of rejection (+57%) and DSA development.(3)
1-Panduranga S. Rao, Akinlolu Ojo, The Alphabet Soup of Kidney Transplantation: SCD, DCD, ECD—Fundamentals for the Practicing Nephrologist, CJASN Nov 2009, 4 (11) 1827-1831; DOI: 10.2215/CJN.02270409
2-Westphal GA, Garcia VD, Souza RL, Franke CA, Vieira KD, Birckholz VR, Machado MC, Almeida ER, Machado FO, Sardinha LA, Wanzuita R, Silvado CE, Costa G, Braatz V, Caldeira Filho M, Furtado R, Tannous LA, Albuquerque AG, Abdala E; Associação de Medicina Intensiva Brasileira; Associação Brasileira de Transplante de Órgãos. Guidelines for the assessment and acceptance of potential brain-dead organ donors. Rev Bras Ter Intensiva. 2016 Sep;28(3):220-255. doi: 10.5935/0103-507X.20160049. PMID: 27737418;
3-Noble J, Jouve T, Malvezzi P, Süsal C, Rostaing L. Transplantation of Marginal Organs: Immunological Aspects and Therapeutic Perspectives in Kidney Transplantation. Front Immunol. 2020 Jan 31;10:3142. doi: 10.3389/fimmu.2019.03142. PMID: 32082306; PMCID: PMC7005052.
I will accept him
Sudden cardiac arrest is common, and many patients hospitalized after resuscitation from cardiac arrest will die after progression to brain death or withdrawal of life-sustaining therapy. Thus, post-arrest patients represent an important population of potential organ donors. Concerns about ischemiareperfusion injury at the time of initial cardiac arrest, post-arrest organ dysfunction and preexisting medical comorbidities in this patient population may temper enthusiasm for pursuing organ procurement from post-arrest patients. Despite these concerns, growing evidence suggests long-term graft function of organs procured from post-arrest patients is comparable to organs procured from other deceased donors.
Elmer J, Molyneaux BJ, Shutterly K, Stuart SA, Callaway CW, Darby JM, Weisgerber AR. Organ donation after resuscitation from cardiac arrest. Resuscitation. 2019 Dec;145:63-69.
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.
accordingly, dual transplants to a single recipient
no biopsy
counsel the recipient about delayed graft function
I will reject this donor as accepting 72 years DBD male donor with prolonged ischemia time of 30 -40 min –developing AKI later ,has high chances of DGF and rejection..
If Yes, how do you manage ?
Such type of donors can only be accepted only after detailed counseling of the recipient about the short term and long term benefits and risks and if the patient has difficult vascular access and having problems or complications of dialysis or has been on waiting list for long for deceased donation.This has also been stated in BTS guidelines
Single or dual transplant are the options in such cases, but it depends on the renal biopsy report and REMUZZI scoring system that is to be interpreted by a pathologist and if this facility not available then smaller muscle mass, the elderly female recipient should be considered. Acute cortical necrosis or glomerulosclerosis should not be present in the biopsy. Induction therapy should be given with ATG and CNI should be commenced later.
REFERENCES:
1-Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 17, 2022
2-Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671
Would you accept this donor?
I would not accept this donor.
Unwitnessed cardiac arrest with AKI secondary to ATN, these organs from donors with anoxic brain damage are associated with higher degree of injury with higher incidence of DGF or non-functioning graft.
If yes, how do you manage this case?
1- These 2 kidneys from this donor are prone to long warm ischaemia time, so they will need procedures to recondition the organs via oxygenated normothermic perfusion.
2- Measures to minimize cold ischaemia time.
3- Pre-transplant biopsy to assess degree of injury and decide about single or dual kidney transplantation.
4- Dual kidney transplantation to increase nephron mass if moderate injury in pre-donation biopsy.
5- Induction IS: according to immunological risk, try to use lower doses of CNI.
6- Protocol biopsy as per local center guidance.
Q1: This is a case of ECD, DCD donor with AKI and high risk for DGF.
This donor would be accepted for recipients of the same age, recipients older than 40 years with diabetes with vascular access problems and therefore at the risk of mortality without transplantation.
Q2: After choosing a proper recipient, dual kidney transplantation has a better outcome in this donor. Informed consent should be taken from the recipient. Machine perfusion is necessary. Introduction with ATG and Alemtuzumab is done to delay CNI introduction. Triple maintenance therapy is recommended with enough levels.
This donor is better to be declined as his age is 72 years with estimated down time 30-40 minutes, It may result in poor long term outcome.
Dual kidney transplantation will increase available renal mass and can be considered in recipients with vascular access exhaustion, elderly and in small size recipients, ands it is better to use immunosuppression regimen with minimization of CNI to avoid its nephrotoxicity.
Transplantation from deceased donors after circulatory death, British Transplantation Society Guidelines, 2013.
Based on the following data; DBD donor with old age (marginal kidneys), hypoxic brain insult preceded by long time elapsed by cardiac arrest (long ischemia time; poorly perfused organs), the cause of cardiac death carries the probability of severe atherosclerosis indicative of poor renal flow as well, renal impairment also is present in the form of oliguria which is of poor outcome.
so,proper detailed recipient counselling should be offered prior to renal transplantation.
Thus; accepting such offer is non favourable at all, only limited options for those recipient who has been on long waiting time for deceased donation list ,lacking suitable vascular access ,elderly with decreased life expectancy to improve quality of life rather than dialytic support and complications occurring from dialysis procedures.
Acceptance to improve the outcome preferably to be dual organ donation according to the urology team, anaesthesia and vascular team decision as it would be lengthy operation, more complications are to be expected, in addition to the immunosuppressive induction by suitable agents as ATG or basiliximab as the renal functions initially would be poor and delayed graft function is expected resulting in further delay for CNI administration.
Dealing with marginal aging kidneys will require minimal optimum drug level later on.
Reference:
Transplantation from deceased donors after circulatory death. British Transplant Society. 2013
Would you accept this donor?
The given donor is a 72 year old with DBD with unwitnessed cardiac arrest and was revived by CPR…So he is not Donor after cardiac death but still Donor after Brain death….The approximate time of CPR was 30-40min and after which ROSC was obtained as per the history….Post arrest he has developed AKI with decreased urine output and elevated creatinine…Such a donor has elevated risk of DGF…But the overall long term outcomes in terms of patient survival for 5 years in ECD as compared to SCD are the same, hence I will proceed with organ donation….The recipients have a better mortality rate and overall survival rate that is better after transplant as compared to be waiting on the HD list….The recipient should be counselled about the presence of DGF before transplant and also it is better if we select an elderly recipient for this donor given the risk of DGF which may reduce the graft expectancy which could be same as the life expectancy of the elderly recipient….
How to manage this case?
Recipient selection as outlined above will improve the outcomes in the transplant…elderly age recipent, diabetic recipient >50 years, with low body surface area, those recipients whose life expectancy on dialysis is less than a year due to failing vascular access are the candidates for the transplant….
A pre implantation biopsy will show ATN as expected…It will also show glomerulosclerosis and IFTA…Acute cortical necrosis on biopsy is a contraindication for renal transplant….Remuzzi score can be calculated in the biopsy…A score of 0-3 is OK for single transplant..A score of 4-6 means more chronicity and should be suggested for dual kidney transplant…A score of 7-12 means transplant is not possible…We could decide on dual kidney transplant based on remuzzi score…
I would give low dose ATG (1-1.5mg/kg) for 1 – 4 days depending on the WBC and the differential count…I would avoid CNI in the initial stages and maintain high dose of MMF with standard dose of steroids
This is a case of controlled DCD (Maastricht classification – category 4) after successful resuscitation (was Maastricht classification – category 1).
ECD is based on age more than DCD,60y, and eGFR below 60ml/min so, there is a high risk of PNK, DGF, and graft failure.
So, I will not accept this kidney.
If I will accept the potential donor. I have 3 main plans:
1. wait and observe the trend of serum creatinine and urine output, if creatinine improves and stabilizes, GFR increases to > 60 ml/min and UOP increases to > 0.5 ml /kg/h
2. kidney biopsy to be interpreted by an expert pathologist then according to the REMUZZI scoring system I will decide to do single or Dual kidney transplantation after discussion with the surgeon as it is technically difficult, time-consuming, associated with a higher incidence of wound dehiscence, and associated with more postoperative complications especially vascular thrombosis and ureteric complications when compared to single kidney transplantation.
3. if a biopsy is not available the potential recipient should be old age, female or with a small muscle mass.
Induction therapy using ATG and delay CNI after recipient counseling.
References :
1. Dare AJ, Pettigrew GJ, Saeb-Parsy K. Preoperative assessment of the deceased-donor kidney: From macroscopic appearance to molecular biomarkers. Transplantation 2014; 97: 797–807.
2. Sung RS, Christensen LL, Leichtman AB, et al. Determinants of discard of expanded criteria donor kidneys: Impact of biopsy and machine perfusion. Am J Transplant 2008;8: 783–792.
3. Scientific Registry of Transplant Recipients Annual Data Report 2012. Available from: http://srtr.transplant.hrsa.gov/annual_ reports/2012/flash/01_kidney_13/index.html#/13/.
4. Kasiske BL, Stewart DE, Bista BR, et al. The role of procurement biopsies in acceptance decisions for kidneys retrieved for transplant. Clin J Am Soc Nephrol 2014;9: 562–571.
5. Edwards EB, Posner MP, Maluf DG, Kauffman HM. Reasons for non-use of recovered kidneys: The effect of donor glomerulosclerosis and creatinine clearance on graft survival. Transplantation 2004; 77: 1411–1415.
6. Bajwa M, Cho YW, Pham PT, et al. Donor biopsy and kidney transplant outcomes: An analysis using the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) database. Transplantation 2007; 84: 1399–1405.
7. Cicciarelli J, Cho Y, Mateo R, El-Shahawy M, Iwaki Y, Selby R. Renal biopsy donor group: The influence of glomerulosclerosis on transplant outcomes. Transplant Proc 2005; 37: 712–713.
8. Lin NC, Yang AH, King KL, Wu TH, Yang WC, Loong CC. Results of kidney transplantation from high-terminal creatinine donors and the role of time-zero biopsy. Transplant Proc 2010; 42: 3382–3386.
I think this is marginal donor with high probability of AKI secondary to CV shutdown. I will avoid single kidney rather will choose dual.
1) Would you accept this donor?
Yes if potential recipient has exhausted vascular access for RRT on long waiting list.
2) If yes, how do you manage this case?
Counsel recipient the possibility of delay graft function.
No need for renal biopsy.
Dual kidney transplantation
Transplantation from deceased donors after circulatory death. British Transplant Society. 2013.
1) The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
2 ) The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
3)Graft outcome is more closely related to whether a transplant is ECD vs SCD than whether the mode of retrieval is DCD vs DBD.
Kidney transplantation from donors with AKI, although associated with a higher rate of delayed graft function,
ECD is associated with less graft survival compared to SCD but is superior to dialysis.
Using a suitable perfusion technique improves graft survival.
Dual Kidney Transplant IS a good option
# Would you accept this donor?
* I wouldn’t accept this donor(72-year-old male DBD who suffered from hypoxic brain damage secondary to unwitnessed cardiac arrest. The estimated down time the cardiac arrest period elapsed before resuscitation is 30 to 40 mins. After resuscitation S Cr was 130 µmol/L. Urine output was 20mls/h during the last hour and 1.1 L over the last 24 hours.
# If yes, how do you manage this case?
*Adequate nephron mass is a predictor of long term graft outcome.
*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.
*ECD is defined as all deceased donors ≥ 60 years of age or donors who were 50–59 years of age and had two of the following: donor history of hypertension; donor death due to cerebrovascular accident/stroke; or terminal serum creatinine value greater than 1.5 mg/dl. ECD needs meticulous evaluation before deciding to do SKT or DKT.
*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.
*Criteria used for high risk ECD included elderly donor with age ≥ 70 or 60–69 with one of the following risk factors:
Serum creatinine > 1.5 mg/dl.
Calculated creatinine clearance ≤ 60 ml/minute.
History of hypertension and/or diabetes.
Proteinuria > than 1 gram.
Cause of death cerebrovascular accident.
*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. Recent advances and experience have accorded the use of various surgical techniques without compromising the rates of surgical complications. Long term graft and patient survival are promising and comparable to SKT.
Dual Kidney Transplantation: A Review of Past and Prospect for Future
Muhammad Abdul Mabood Khalil, Jackson Tan, Taqi F. Toufeeq Khan, Muhammad Ashhad Ullah Khalil, Rabeea Azmat 2017; 2017: 2693681.
Published online 2017 Jul 2.
This donor is an extended criteria donor (age > 60 years) with history of unwitnessed cardiac arrest 30-40 minutes prior to resuscitation. Post arrest Brain death in the index case is associated with increased serum creatinine (AKI) and decreased urine output. Such a donor has increased risk of DGF (1).
But I will accept this donor as the outcomes of ECD transplant are better than remaining on wait-list (2).
The ECD kidneys have lower graft survival as compared to standard criteria donor kidneys (3). Hence it is important to select the recipient appropriately.
The recipient selection in this scenario would be based on age and body surface area matching (2). A small sized recipient (like females) would be better. The recipient should be more than 60 years old or diabetic patient with age more than 40 years, with low immunological risk, with failing vascular access and with expected waiting time on wait-list exceeding life expectancy on the waiting list without transplant (3).
Another aspect which needs to be dealt with is regarding using a single kidney or dual kidney transplant (DKT). A pre-implantation kidney biopsy will help in taking a decision in this regard (4). Kidney biopsy with a Remuzzi score of 4-6 (or glomerulosclerosis between 15-50%) should be used for DKT.
In this scenario, the only criteria for not transplanting this kidney would be presence of acute cortical necrosis or severe glomerulosclerosis. ATN is expected in this, which would lead to increased DGF, but would recover with time with long-term outcome similar to those without AKI (5).
In this scenario the kidney should be transplanted as dual kidney transplant (DKT). The ideal DKT recipient has not been defined, but age-matched with the donor, having lower immunologic risk (first transplant, PRA less than 50%), and minimal co-morbidities (BMI < 30 or body weight less than 80 kilograms) are some of the characteristics commonly looked into (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.
Peri- and post-transplantation management will include use of machine perfusion, induction therapy in form of either ATG or Alemtuzumab. Maintenance immunosuppression in form of Tacrolimus – with delayed introduction of Tacrolimus (to reduce the incidence of DGF), MMF and steroids (1).
References:
1) Donation after Circulatory Death. British Transplant Society. Available at: http://www.bts.org.uk/Documents/Guidelines. Accessed October 17, 2022.
2) Audard V, Matignon M, Dahan K, Lang P, Grimbert P. Renal transplantation from extended criteria cadaveric donors: problems and perspectives overview. Transpl Int. 2008 Jan;21(1):11-7. doi: 10.1111/j.1432-2277.2007.00543.x. Epub 2007 Sep 10. PMID: 17850235.
3) Metzger RA, Delmonico FL, Feng S, Port FK, Wynn JJ, Merion RM. Expanded criteria donors for kidney transplantation. Am J Transplant. 2003;3 Suppl 4:114-25. doi: 10.1034/j.1600-6143.3.s4.11.x. PMID: 12694055.
4) Hassan A, Halawa A. Dual Kidney Transplant. Exp Clin Transplant. 2015 Dec;13(6):500-9. PMID: 26643671.
5) Boffa C, van de Leemkolk F, Curnow E, Homan van der Heide J, Gilbert J, Sharples E, Ploeg RJ. Transplantation of Kidneys From Donors With Acute Kidney Injury: Friend or Foe? Am J Transplant. 2017 Feb;17(2):411-419. doi: 10.1111/ajt.13966. Epub 2016 Aug 25. PMID: 27428556.
The available donor is 72 years old male DBD ( death after brain death)
Hypoxic brain damage due to unwitnessed cardiac arrest elapsed before resuscitation 30-40 min after resuscitation seem creatinine 130 ummol/l UOP 1.1 L / 24H
I will not accept this donor
-Paired kidney transplantation
-Biopsy can be considered
There’s relative contraindication. I wouldn’t accept this donor for a patient who can wait longer in the list. However, a patient with little sensitization and no longer tolerating on the list I would consider accepting, since the donor does not have previous kidney disease, nor predisposing factors, not even hypertension.
I work to minimize cold ischemia time of >12 hours because this is associated with worse outcome.
Bibliography:
1 – Transplantation from deceased donors after circulatory death 2013. British Transplantation Society Guidelines
This is a potential donor with ECD kidney (age 72 years) and DBD after unwitnessed cardiac arrest. His down time is estimated to be 30-40min which relatively high ( above 20min), Another point he is oliguric which may reflect the degree of damage that happened to the kidneys, ,
So, with these available data I will not accept this offer. May be if in next 2-3 days his urine output improved .
Yea i will accept this donor but there’s risk of delay graft function unwittness post cardiac arrest and renal biopsy help in acceptance of donor but may increase ischemia perfusion time. So dul kidney transplant in this situation better than single kidney transplant
– No absolute contraindication here to accept this case for donation but there are many risks of delayed graft function & early graft rejection like age72 ys , hypoxic state , prolonged ischemia warm time & AKI .
– I will accept only if for potential recipient who has been on waiting list for long time & suffering on dialysis with no available living donors & with counselling regarding the high risk of delayed graft function & early graft rejection.
– Biopsy here may be of value showing degree of Glomerulosclerosis but we should not depend on it alone due to limitations as the long outcome here will be depend on the donor’s criteria as EDC & remuzzi score can help us deciding if dual kidney transplant will be better (indicated if score 4-6, in high risk marginal donor with age >70 ys).
– AB induction should be considered.
the case of 72 years old male DBD due to unwitnessed cardiac a rest with serum creatinine 130 umol/l all these mention factor in addition to this donor may had medical condition lead to cardiac a rest and this graft will have ischemic reperfusion ischemic injury risk so I wll not except this donor unless the patient has multiaccess failure or in long time of wating list and this should explain to the patient the risk of delay graft function and .dual kidney transplant it can help to increase nephron mass ,
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes .
· Long term outcomes of DCD recipients are similar to those of DBD recipients and the allocation system for DCD and DBD organs should be similar. Nevertheless, it is recognised that DCD kidneys appear to be more susceptible to cold ischaemia. The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidneys. Long-term outcomes for standard criteria donors are equivalent for DCD and DBD kidney transplants.
references
BTS guidelines 2013
I will not accept this donor
72-year-old male DBD (donor after brain stem death) donor
With hypoxic brain damage , unwitnessed cardiac arrest.
The estimated down time more than 30 min
prolonged warm ischaemia is a contraindication to kidney donation.
when the systolic blood pressure falls below 50 mmHg the recommendation is a maximum of 2 hours for the FWIT
In the event of no blood pressure, 30 minutes appears to be an absolute upper limit of acceptable warm ischaemia, although registry analysis suggests outcomes are less good beyond 20 minutes
The use of kidneys with >30 minutes of total WIT should be restricted to programmes which are undertaking measures to ‘recondition’ organs via ex situ oxygenated normothermic perfusion
The ‘ideal’ kidney comes from a young, controlled DCD donor without significant comorbidity prior to the terminal illness ,with a rapid death on withdrawal of support, a quick laparotomy, aortic cannulation, perfusion and venous exsanguination, and good appearance on removal.
Such kidneys will be expected to work promptly if cold ischaemia is minimised. In such patients, no viability testing is required, although the role of machine perfusion to ‘improve’ the kidney is debated.
Kidneys retrieved from DCD donors will inevitably have suffered warm ischaemic damage and will be at increased risk of both PNF and DGF.
Widely favoured strategies to reduce the incidence of DGF and the risk of clinically silent rejection occurring during periods of DGF include
1-Minimized cold ischemic time
2-Paired kidney transplantation
3-The use of induction therapies to reduce the risk of rejection and the avoidance or delay in introduction of calcineurin inhibitors (CNIs).
In high-risk recipients, such as the recipients of DCD organs, the preferred regimen is to use lymphocyte depleting induction with polyclonal anti- T cell agents such as thymoglobulin, or the monoclonal Alemtuzumab
4-Systemic heparinisation is sometimes used
5-prophylactic antibiotic cover, including anaerobic prophylaxis, is often administered for three days after transplantation
Reference
British Transplantation Society Guidelines.
Transplantation from deceased donors after circulatory death
What I learnt by reading all the answers and hints given by our worthy teachers is that this donor should be accepted but not for single kidney donation rather dual.
Reasons for this decision are
Old donor age 70
un witnessed cardiac arrest
Down time 30-40 min
post resuscitation AKI
Biopsy can help but at cost of further worsening ischemic time
-Yes ,I would accept this donor and dual transplants.
– For older DCD donors (>60 years), particularly those with hypertension and/or cardiovascular death, pre-implantation biopsy may identify kidneys with substantial arterial disease or glomerulosclerosis that are likely to have poor long term outcome . Such kidneys are normally discarded, although good outcomes have been described using DBD kidneys with moderate disease when used as dual transplants into a single recipient .
Reference:
– BTS/Transplantation from deceased donors after circulatory death
A complicated scenario with a DBD ECD who suffered a prolonged cardiac arrest > 30 min that resulted in anoxic brain injury with an AKI and oliguria.
The duration of cardiac arrest and absent blood pressure was more than the acceptable upper limit for warm ischemia as stated by the BTS guidelines . It is well known that the longer the WIT the poorer the outcome in terms of primary non function, DGF or even graft failure.
The graft outcome in this index case will be more closely related to the donor character being an ECD rather than the mode of donation (DCD or DBD). ECD has higher risk of graft failure but many of these kidneys are potentially utilizable organs with acceptable outcomes for carefully selected patients.
Both BBD and DCD showed similar outcomes with 5-year graft survival approaching 90% with an increase in DGF in DCD compared to DBD attributed to longer cold ischemia time.
Definitely a good history to check for other co-morbidities like hypertension, Diabetes, dyslipidemia and other cardiovascular risks that resulted in cardiac arrestwould be valuable
In view of the above, there is no absolute contraindication and I will accept this DBD ECD donor with careful selection of a suitable recipient (waiting for a long time on the waiting list) as the outcome will be better than waiting on dialysis.
· If yes, how do you manage this case?
– Careful selection of the recipient (avoid young adults as the quality and the life span of this graft is short and they will be sensitized reducing their further transplantation chances, on the other hand older recipients will have poor outcomes. We will concentrate on other factors like the duration on the cadaveric waiting list, recipient blood group, a patient with consumed vascular access etc).
– Renal biopsy with an expert pathology opinion can still provide valuable information and may help to determine if one or both kidney to be used for one recipient (Remuzzi score)or discard them if there is acute cortical necrosis). However, it may not be feasible and waiting for a frozen section result can prolong more the WIT besides limitations in its interpretation increasing the chances of discarding this graft.
– Using 2 kidneys in 1 recipient might be considered as in young recipients to increase the nephron mass.(The graft survival reported by Remuzzi et al. was 100% at six months and 93% at three years). Unilateral placement of both kidneys has the advantages of single surgical access and shorter operation time and availability of the contralateral iliac fossa for future re-transplantation surgeries.
– Immunosuppression: Antibody induction therapy should be used as part of the initial immunosuppressive regimen for recipients of DCD kidneys, and the avoidance or delay in the introduction of CNIs.
– Optimize hemodynamics(rule of 100) and minimize cold ischemia time
– It is important is these exceptional proceedings to have an in-depth patient counseling and consent.
– References:
– BTS guidelines for DCD.
– Remuzzi G, Grinyò J, Ruggenenti P, Beatini M, Cole EH, Milford EL, Brenner BM. Early experience with dual kidney transplantation in adults using expanded donor criteria. Double Kidney Transplant Group (DKG). J Am Soc Nephrol. 1999 Dec;10(12):2591-8.
– Wang Z, Durai P, Tiong HY. Expanded criteria donors in deceased donor kidney transplantation – An Asian perspective. Indian J Urol. 2020 Apr-Jun;36(2):89-94.
Would you accept this donor?
This 72 year old DBD will be a marginal donor.
He is above 60 year
There is unwitnessed cardiac arrest
Low urine output
Hypoxic brain damage
The cardiac arrest period before resuscitation was 30-40 minutes . In such scenarios the outcome may be poor. This potential donor can be accepted with higher risk of poor graft outcomes as there is relative contraindication. All these facts should be explained to potential recipients.
If yes, how do you manage this case?
Pre implantation biopsy may help. The Remuzi score may guide us whether to implant one kidney or do a dual kidney implant.
Score varies from 0-12
Those with score 4,5 or 6 may be considered for dual renal transplant.
It is mandatory to strictly manage fluid and electrolyte balance. SBP>100 mmHg, Urine output > 100 ml/hr, Hb 100 g/L, PaO2> 100 mm Hg. 100 % control of sugar.
As regards immunosuppression, Induction therapy and delay in starting CNI may improve outcomes.
Reference
1- Remuzzi G, Grinyò J, Ruggenenti P, Beatini M, Cole EH, Milford EL, Brenner BM. Early experience with dual kidney transplantation in adults using expanded donor criteria. Double Kidney Transplant Group (DKG). J Am Soc Nephrol. 1999 Dec;10(12):2591-8.
2- BTS Guidelines 2012
Our Potential donor is
72 years old ( > 60 years ) >> so ECD with more risk of poor graft outcome (Graft outcome is more closely related to whether a transplant is ECD vs SCD )
Unfortunately unwitnessed cardiac arrest:
cardiac arrest period was 30 -40 minutes (use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted )
AKI after Cardiac resuscitation ( Acute kidney injury, even that requiring dialysis for the donor during the current hospital admission, is not an absolute contraindication to kidney donation. However, it is likely to increase the risk of DGF or primary non function )
So this graft is more susceptible to delayed graft function with more risk of acute rejection So I will not accept this donor.
If yes
* So I will consider kidney donation for the older recipient with multiple vascular access failure
with some precautions
*Induction with polyclonal Immunosuppression due to delayed introduction of CNI to avoid the risk of Acute rejection
*Trial to decrease cold Ischemia time
*Maintain BP with target MAP > 60, avoid Hypoxia target Oxygen saturation >95 %
*Maintain the donor euvolemic with good UOP
* Dual kidney transplantation :
( due to expected more nephron loss )
References :
Reid AW, Harper S, Jackson CH, et al. Expansion of the kidney donor pool by using
cardiac death donors with prolonged time to cardiorespiratory arrest. Am J Transplant 2011; 11: 995-1005.
Summers DM, Johnson RI, Fuggle SV, Collett D, Watson CJ, Bradley JA. Analysis of
factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study. Lancet 2010; 376: 1303-11
the graft survival of DBCD ( donation after brain death followed by circulatory death) transplants may be better than DCD transplants. The main risk factors for allograft loss included an increasing donor age, recipient age, warm ischemia time > 15 min, prolonged dialysis duration, acute rejection, delayed graft function, and HLA mismatch ≥4 HLA loci.
Kidney donation through DBCD achieves equally successful outcomes as DBD, and could provide a feasible path to graft availability for billions of people who face barriers to organ donation from DBD.
Cardiopulmonary resuscitation (CPR) usually is not one of the extended criteria currently used in the evaluation of deceased donor organs
Still, there is reluctance among clinicians to accept these organs for transplantation due to concerns of ischemia-reperfusion injury at CPR and potential post-CPR organ dysfunction
the CPR donors with documented total CPR time into two groups according to CPR duration (≤20 min vs >20 min), CPR donors with documented no-flow time (n = 120) into three groups according to no-flow duration: zero (immediate start of CPR, zero minutes of no-flow), short (1–9 min of no-flow) and long no-flow (≥10 min of no-flow). Donor characteristics were not significantly different between these three no-flow categories. More short and long no-flow donors were resuscitated ex-hospital as compared with those donors without any no-flow time
MY DECISION
============
I will accept him as a donor if the recipient
1) highly sensitized /on the long time waiting list with exhausted vascular access
2) acceptable crossmatch
3) if we can transplant 2 kidneys to compensate for the deficient viable kidney mass (as dual kidney transplant needs special considerations from a surgical point of view
References
Fang X, Chen S, Fu J, Liu R, Dai T, Wang D, Wu W, Yang S. Risk factors for renal allograft survival with China novel donation category: Donation after brain death followed by cardiac arrest. Transpl Immunol. 2022 Jun;72:101591. doi: 10.1016/j.trim.2022.101591. Epub 2022 Mar 30. PMID: 35364244.
Impact of cardiopulmonary resuscitation on organ donation in Switzerland
DOI: https://doi.org/10.4414/smw.2021.20413
Publication Date: 05.02.2021
Swiss Med Wkly. 2021;151:w20413
Thankyou Micheal l understand the recipient reasons to accept the graft but can you explain the situation with this donor more clearly !
I will not accept this old age with hypoxic brain death with prolonged WIT due to unwitnessed cardiac arrest.
Following DCD kidney transplantation, there is increased risk of delayed graft
function due to DCD injury.
The incidence of delayed graft function is increased in DCD recipients and this should be discussed with the patient prior to transplantation.
But if it’s the only available offer I will use dual kidney transplantation and try to decrease the cold ischemia time and proper use of immunosuppressant agent .
Induction therapy with mono- or polyclonal antibodies may be used to reduce the risk of clinically unrecognised acute rejection prior to recovery from DCD injury.
Induction therapy is often combined with delayed introduction or reduced intensity of calcineurin inhibition to limit the incidence and duration of delayed graft function.
Antibody induction therapy should be considered as part of the initial immunosuppressive regimen for recipients of DCD kidney
Graft outcome is more closely related to whether a transplant is ECD or SCD than whether the mode of donation is DCD or DBD.
Prospective data are required to determine whether the impact of extended criteria donation (ECD) is different in DCD and DBD donors and whether different thresholds for organ use may be required.
Reference:
BTS guidelines
Well done but when you agree to give him this compromised graft would you agree to give him two kidneys?
-This donor is considered ECD due to being elderly with estimated FWIT >30 min and he is ,considered uncontrolled DCD with Maastricht Category 1
Prolonged WIT is associated with poor outcome concerning primary non function and subsequent graft failure.
The absolute Functional WIT that affects outcome is unknown but the current recommendation is a maximum of 2 hours. Undetectable blood pressure for more than 30 minutes seems to be an absolute upper limit of acceptable warm ischaemia, meanwhile it is suggested that outcomes are less good beyond 20 minutes.
Therefore the acceptance of this kidney will be conditioned as kidneys with >30 minutes of total WIT should be restricted to programmes which are undertaking measures to ‘recondition’ organs via ex situ oxygenated normothermic perfusion, with further assessment of organ quality .
For uncontrolled DCD or kidneys with poor perfusion on retrieval, additional viability testing is needed . Using the New Castle criteria for viability testing in DCD kidney transplantation if the donor was elderly having high GST, low GFR, diabetes, prolonged cold ischaemia ;dual renal transplant can be considered.
There is a large ethical dilemma regarding avoidance of exposing young patients to sensitisation from a poorly matched, poor quality organ which may fail shortly. On the other hand , the potential for serious morbidity or death resulting from complications associated with DGF in older, more highly co-morbid recipients raises the query about utilisation of combined ECD DCD organs, with worse outcomes associated with donor age and co-morbidity and increased risk of DGF due to DCD retrieval.
-In high-risk recipients as in this case to reduce the incidence of DGF and clinically silent rejection the induction therapies include lymphocyte depleting induction with polyclonal anti-T cell agents such as thymoglobulin, or the monoclonal Alemtuzumab, and CNI can be delayed
Reference
BTS guidelines 2013
I will not accept him as a donor
Categorization of DCD Donors
·should be categorized as Deceased circulatory death donors according to the Maastricht
classification to aid research, communication, and audit. (A1)
· The functional (or accurate) warm ischaemic period starts when the systolic blood
pressure has a sustained (i.e., at least 2 minutes) fall below 50 mmHg and extends up
to the onset of cold in situ perfusion.
Although donor low oxygen saturation (<70%) is a concern and may well be a
the measure of inadequate organ perfusion and poor outcome, prospective evidence is
awaited. The current recommendation is that oxygen saturation below 70% is not
used as an indicator of shoddy work or as a reason for nonusage, but that retrieval
teams should keep a record of when oxygen saturation falls below 70% to
allow correlation with graft outcome.
Maastricht Category 1: Dead on arrival
Maastricht Category 2: Unsuccessful resuscitation
Maastricht Category 5: Unexpected cardiac arrest in a critically ill patient
The use of donors with functional warm ischaemic time >2 hr or absent blood
should restrict pressure for 30 minutes to (currently experimental) protocols
which attempts to resuscitate organ viability
Antibody induction therapy should be considered part of the initial immunosuppressive regimen for recipients of DCD kidneys.
This is an ECD with unwitnessed cardiac arrest and hypoxic brain injury.
I will not accept the offer.
The unwitnessed cardiac arrest will cause ischemic damage to the organs, such as ATN. Hence, the risk of DGF is high in this case; in addition, prolonged warm ischemic time of more than 20 minutes is associated with poor outcomes.
Reference:
BTS guidelines 2013 Transplantation from deceased donors after circulatory death.
yes accept this donor .
as dawn time is less than 120minutes ,which accepted for DCD renal donation.
as Recommended by BTS Kidney: 120 minutes – then reassess with regard to logistics;
can extend to a further 120 minutes in selected donors.(1)
Also his serum creatinine improved which denotes early dysfunction during resuscitation
,which improved.
References:
1- BTS -Organ Donation after Circulatory Death. JUNE 2010.
72-year-old male category 1 DCD. The estimated down time is 30 to 40 mins.After resuscitation S Cr was 130 µmol/L. Urine output was 20mls/h during the last hour and 1.1 L over the last 24 hours.
Would you accept this donor?
I will not accept this donor category 1 DCD, and age of 75
years, with acute kidney injury and history of prolonged hypo perfusion time
30-40 minutes.
The cons in this donor are:
1. Age 72 years and DCD he is categorized to be in the extended- criteria donor, with cardiovascular cause of death, and terminal creatinine of 130 µmol/L these type of donor’s associate with increased risk of delayed graft function, acute rejection.
2. Primary warm ischemia time > 30 – 40 minutes, uncontrolled DCD or when perfusion of the kidneys on retrieval is poor, using parameters such as high resistance during machine perfusion or high enzyme levels within the perfusate may indicate increased cellular damage and an increased risk of primary non function but this is not universally accepted, In the event of no blood pressure, 30 minutes appears to be an absolute upper limit of acceptable warm ischemia, although registry analysis suggests outcomes are less good beyond 20 minutes.
3. Acute kidney injury is not an absolute contraindication to kidney donation. but increase the risk of DGF or primary non function [1].
If yes, how do you manage this case?
= Low flow rates on machine perfusion or high enzyme levels within the perfusate indicate an increased level of cellular damage which may indicate an increased risk of PNF
= Systemic heparinisation.
= prophylactic antibiotic cover, including anaerobic prophylaxis, is often administered for three days after transplantation.
= The induction and maintenance immunosupreesion should be addressed.
= Histopathologic biopsy scoring by an expert pathologist if available, those with 3 or less single kidney to be transplanted, from 4-6 dual kidneys to be transplanted, and more than 7 to be discarded [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] Remuzzi G, Cravedi P, Perna A, Dimitrov BD, Turturro M, Locatelli G, Rigotti P, Baldan N, Beatini M, Valente U, Scalamogna M, Ruggenenti P; Dual Kidney Transplant Group. Long-term outcome of renal transplantation from older donors. N Engl J Med. 2006 Jan 26;354(4):343-52. doi: 10.1056/NEJMoa052891. PMID: 16436766.
Would you accept this donor?
a) I would accept this donor as ECD(age > 60) with marginal kidney function that may reflect peri-arrest patho-physiological changes.
b) I will allocate this kidney to a potential recipient with similar age and life expectancy to be short.
If yes, how do you manage this case?
Protocols for donor management
“Rule of 100”:
a) targets of SBP ≥100 mmHg.
b) urine output ≥100 ml/h.
c) hemoglobin of ≥100 g/L.
d) PaO2 ≥100 mmHg.
e) blood sugar targeted at 100% normal.
Elements of donor management are:
1. Temperature: The aim is to keep the core temperature >35°C prior to organ donation.
2. Fluid management: Crystalloids are the first choice and balanced salt solutions (Ringer’s lactate, Plasmalyte-A, Ringer’s acetate, half normal saline with sodium bicarbonate) may be superior to normal saline as theydonotproducehyperchloremicacidosis. Hydroxyethylstarches are contraindicated in organ donors because they can damage renal epithelial cells and cause early graft dysfunction in the transplanted kidneys.
3. Replacement of blood and blood products could follow guidelines for the care of the critically ill and a hemoglobin of 10 g/L could improve tissue oxygenation indices.
4. Inotropes and cardiovascular system: Dopamine is the first choice of inotrope in hypotension unresponsive to volume and has beneficial effects on the renal graft. Nor-adrenaline in doses >0.05 mcg/kg/min resulted in impaired cardiac contractility in transplanted hearts and in particular impairment of right ventricular performance.
5. Ventilatory management: The principles are along the lines of management of ALI (low tidal volume 6-8 ml/ kg, minimum plateau pressure, lung recruitment).
6. Replacement of hormones after brain death:
7. Standardization of hormone therapy after brain death in combination with a central venous pressure <10 mmHg significantly improved utilization of the heart and lungs for transplant without affecting other organ systems.[49] The recommended replacements are:
a) Vasopressin 1 U bolus followed by an infusion of 0.5-4.0 U/h.
b) Methylprednisolone 15 mg/kg immediately after diagnosis of brain death and 24th hourly thereafter.
c) Insulin 10 U in 50% dextrose followed by an infusion to maintain blood glucose between 80 and 150 mg.
d) Thyroxine (T4) 20 mcg bolus followed by infusions of10mcg/h.Tri-iodothyronine(T3)given as a 4-mcg bolus followed by an infusion of 3 mcg/h. T4 improves hemodynamics and prevents cardiovascular collapse in hemodynamically unstable organ donors.
I would not like to accept such old age donor , with hypoxia brain damage unwitnessed cardiac arrest and resuscitation more than 30 min withAKI
The kidney is the organ for which most experience and published data are available in relation to DCD transplantation, there are complex interactions between different degrees of warm ischaemic DCD injury, cold ischaemic injury, and pre-existing damage due to hypertension, diabetes, atheromatous disease, and to other co-morbidities in kidneys from extended criteria donors (ECD).
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.
The use of donors with functional warm ischaemic time >2 hr or absent blood pressure for 30 minutes should be restricted to (currently experimental) protocols which attempt to resuscitate organ viability.
Although registry analysis suggests outcomes are less good beyond 20 minutes.
Given the clear association between WIT and poor outcome, both in terms of PNF and subsequent graft failure, the presence or clear anticipation of prolonged warm ischemia is a contraindication to kidney donation.
.
Reference
British Transplantation Society Guidelines 2013
Thank you
Thank you prof Ahmed
· Would you accept this donor?
Generally kidneys from ECD have worse survival rates compared to SCD. However, the rate of ECD has greatly increased in the last decade, especially in Europe (almost 50% of all deceased donors in recent years). In 2018, 25% of all DKD transplanted within the Euro-transplant region came from donors aged ≥65 years.
Some centers reported good results for kidneys from ≥70-year-old donors with graft survival comparable to kidneys from younger donors by using pre-implantation biopsies & proceeding with either single or dual-kidney transplantation or discarding the organs, depending on the biopsy results.
A German study assessed a total of 116,870 patients, 59,158 in the transplant period 1997–2006 & 57,712 patients in the transplant period 2007–2016.
Within only one decade, namely from 1997–2006 to 2007–2016, the 5-year death censored graft survival of kidneys from ≥70-year-old donors improved to a level of kidneys from 60 to 69-year-old donors in the previous decade.
So, in the presence of universal organ shortage & in view of some encouraging results, I would rather consider accepting this elderly donor.
However, I should exercise caution as kidneys from younger donors fare better than those from senior donors.
======================
If yes, how do you manage this case?
According to Maastricht classification for donors after circulatory death, the index case is considered category II (donors suffer sudden & unexpected cardiac arrest, typically outside the hospital; they have significant potential to expand the donor pool).Management to improve graft survival rates includes:
Post-transplant surveillance including frequent kidney biopsies plus more standardized histological evaluation.
Close surveillance of immunosuppressive drug levels
Regular screening for DSA.
Effective antiviral prophylaxis.
Diagnosis & treatment of concomitant CV & renal risk factors.
To tailor the choice of IS agents to the immunological risk profile of each patient.
Using 2 kidneys in 1 recipient might be considered if one would not be enough, e.g. young recipients.
References
1. Fabian Echterdiek, Vedat Schwenger, Bernd Döhler, Joerg Latus, Daniel Kitterer, Uwe Heemann and Caner Süsal. Kidneys From Elderly Deceased Donors—Is 70 the New 60? Frontiers in Immunology November 2019/Volume 10/Article 2701
2. María José Pérez-Sáez, Núria Montero , Dolores Redondo-Pachón, Marta Crespo, and Julio Pascual. Transplantation. 2017 Apr;101 (4):727-745. doi: 10.1097/TP.000000000000 1635.
Dear All
1.By history : This potential 72 years old DBD donor : unwitnessed cardiac arrest( category 1 Maastricht , with hypoxic brain damage considered ( marginal or extended criteria donors (ECD). Also; he is oliguric ( UOP 20mls/h ). his down time 30-40 minutes which is considered having poor long term graft outcome, although good outcomes have been described using DBD kidneys with moderate disease when used as dual transplants into a single recipient in comparison to DCD donors.
2. Renal biopsy is a bit important to augment a dual kidney transplantation decision in a single recipient although the incidence of increase long ischemia time while waiting biopsy results.
References:
1– BTS Guidelines,2013 :Transplantation from deceased donors after circulatory death.
2– Remuzzi G, Cravedi P, et al.: Long-term outcome of renal transplantation from older donors. N Engl J Med 2006; 354: 343-52.
Thank you, Dina
Will you still insist on the biopsy?
This patient developed unwitnessed cardiac arrest and time period before resuscitation is 30 to 40 minutes. There is a high chance of non functioning graft or graft failure. Moreover, patients creatinine was 130 micromole/l and urine output is 20 ml/hour in last hour. This also suggests probability og graft failure.
So, I will not accept him as a donor.
Thank you, see my question above
Summary: a 72-year-old male with DBD that suffered hypoxic brain damage 2nd to cardiac arrest. Post-arrest resuscitation started about 30-40 minutes. The cardiac arrest was unknown and unwitnessed so the length of hypoxia is unknown with potential donor urine output being 20ml/hr at the last hour.
The potential donor has risk factors that are against donating and are:
1) Age
2) Duration of arrest
3) Time for organ reperfusion
These details are essential because they will influence the donation of the kidney. The details will give information on possible ischemic time if prolonged may have a negative effect on the donor’s kidney. So the patient had a prolonged warm ischemic time of more than 30 minutes before CPR started and this can be more due to the fact it is unknown when he started cardiac arrest.
The next issue is the donor’s age. He is greater than 60 years older and will be classified as an Extended criteria donor. In this case, physiological changes, arteriosclerosis, etc. can influence graft survival and make a decision to use a single or both kidneys.
With all the problems mentioned, I may refuse the kidney donation for this patient especially if it was a young recipient. If the recipient was in the same age group, then I would consider using the donor.
To accept the donor one must ensure that:
1) Vitals are stable that is blood pressures are at an acceptable level for exemplar SBP greater than 90mmHg with a MAP of 60-90
2) Maintain good renal perfusion that is a urine output of greater than 1-4 ml/min
3) Blood levels are fine or the Hts is 25%
4) Blood oxygenation is greater than 93%
5) Avoid metabolic acidosis
6) Ensure the cold and warn ischaemic time is reduced or close to standard.
1) Oxford specialist handbooks of kidney transplantation
2) Dual Kidney Transplant: Clinical Experience and Overview of Surgical Techniques
HI Dr Badal,
IN a way you have already suggested as above would you consider dual renal transplant? You should have supported your argument by uploading evidence rather than just mentioning 2 incompletely typed references.
Yes, I accept this DBD donor, with unwitnessed cardiac arrest, as long as his renal function is still not bad & patient produces urine, that indicates cardiac arrest was not prolonged . we need a biopsy to differentiate between reperfusion injury & ATN .& to look for the viability of the graft,glomreuloscolosis ,& the condition of the small vessels
It is a marginal graft with extended criteria, so a dual kidney transplant is better than a single one .
Dear Dr Akram,
I like your decision of dual renal transplant.
You should have supported your argument by uploading evidence rather than just mentioning BTS guidelines.
_ the current donor with unwitnessed cardiac arrest , with cardiac arrest time more than 30 min is category 1 and not suitable for organ donation, just tissues as cornea.
_ if he is used as organ donor, not for this young recipient with long life expectancy.
_ dual kidney transplantation can be considered for donation in elderly patient (old for old concept).
Dear Dr Shawky,
I like your decision of dual renal transplant.
You should have supported your argument by uploading evidence rather than just mentioning BTS guidelines.
I will not accept this donor primarily because of 2 reasons of which first one is major:
REF; BTS guidelines
I think because of reason of refusal due to WIT of more than equal to 3pm in with no BP, I will not give second thought for donation and hence will not consider biopsy
HI Dr Saini,
Would you consider dual renal transplant? You should have supported your argument by uploading evidence rather than just mentioning BTS guidelines.
I’ll accept this as ECD.
Dual kidneys can be transplanted in a single recipient.
Proper counselling regarding graft failure or DGF is mandatory.
Hi Dr Ansary,
I like your decision. However, you should have supported your argument by uploading evidence
Hi Dr Gafar,
I understand your reason for age-matching. However, marginal kidney in a marginal recipient is not a good idea.
no, i will not accept the donor because of unwitnessed cardiac arrest and estimated time before resuscitation was 30-40 min, so the risk of primary non function graft and delayed graft function are high
if accept donor, dual kidney transplant in a single recipient is better option to increase nephron mass as this donor was also old age beside the problem of unwitnessed cardiac arrest
British Transplantation Society Guidelines 2013
I like your arguments, dear Dr Riham,
I can appreciate that the lack of experience in dual transplant can be a reason for this hesitation in using these kidneys. Simpler option would be to consider one transplant in each side in an older but relatively fit recipient. Only in 1 out of out 46 dual renal transplants, both sides have been used for renal transplant from one donor.
This is an elderly male who had a prolonged cardiac arrest – more than 30 minutes and suffered hypoxic brain injury. His serum creatinine is 130 mmoles/L
This is a Maastricht 1 category as this was an unwitnessed cardiac arrest
I would not accept him as an organ donor
We may use the tissues like cornea for corneal transplantation but the organs would not be used in this case.
He is also more than 65 years and this puts him in the category of an ECD meaning that the kidney function os already sub-optimal
Thankyou