Expanded criteria donor and donation after circulatory death renal allografts in the West of Scotland: Their place in the kidney allocation process
Introduction
Renal transplantation has experienced an exponential growth.1 Shortage in organ supply has replaced inadequacies in immunosuppression therapy as the limiting factor for this treatment. Donor pool expansion has formed a central part of the UK strategy aimed at reversing this trend and the ambitious target of the organ donor task force, a 50% increase in donor numbers, has been reached.1 Achieving this has involved acceptance of older donors with significant co-morbidity. This naturally leads to increased numbers of organs from expanded criteria donors (ECD) and donations after circulatory death (DCD). Although outcomes following DCD and ECD transplants are better than those on dialysis, concern remains about the risks associated with these non-traditional sources of deceased donor organs.1, 2, 3
By definition, ECD kidneys have a 70% higher relative risk of graft failure compared to standard criteria donor (SCD) kidneys because they are characterized by worse prognostic factors (relative hazard ratio = 1.70). 4, 5, 6, 7DCD kidney allografts have been associated with a greater risk of delayed graft function (DGF, usually defined as a need for the use of dialysis in the first postoperative week).4 There are those who have argued that the absence of the neuroendocrine crisis associated with brain stem dead donors (DBD), that itself is associated with a major up regulation of systemic inflammation and stress, may favour the DCD kidney.4 Until recently, DCD organs have been only allocated locally as it was believed that reducing the cold ischaemic time would be the only way to abrogate the effects of the warm ischaemia associated with circulatory arrest. However, based on published outcomes and statistical modelling of transport and cold ischaemic times, the prevailing opinion has changed.
There is therefore a need for more data on the implications of DCD and ECD kidney transplantation. This information is central to recipient counselling and optimal allocation. The purpose of this study was to compare the outcomes of SCD versus ECD and DCD versus DBD kidney transplants. By robustly defining the factors that dictate outcomes, patients, healthcare teams and policy makers will be able to make more informed decisions and allocation policies may be appropriately tailored. This will improve the overall utility and equity of kidney transplantation.
Section snippets
Study population
The study population included all patients that received a deceased-donor renal transplant in a single centre in the West of Scotland from 2001. The scope of the investigation was limited to transplants that occurred between 2001 and 2010 inclusive, as follow-up data for transplants post 2010 were incomplete. Every transplant in the study time window was evaluated and categorised as either a standard or expanded criteria donor organ. ECDs were defined as donors aged >60 years or aged between 50
Results
Data from a total of 729 renal transplants performed between 2001 and 2010 inclusive were available for analysis. After exclusions, data from 510 procedures were analysed (see Fig. 1).
Discussion
Kidney transplantation is the treatment of choice for ESRD, yet to match the 260% increase in the deceased donor waiting list, the transplantation community cannot rely on a declining pool of optimal DBD donors and so must instead look to other sources. This includes expanded criteria donations (ECD) and donations after circulatory death (DCD). 4, 5, 6, 7Studies have shown that ECD kidneys have historically increased the donor pool modestly at the expense of a worse outcome. By contrast, DCD
Conclusion
Our results support the use of ECD kidney allografts. Although worse than the outcomes of SCD kidneys, the results of ECD kidney transplantations are acceptable. By placing more value on recipient age and duration on dialysis when offering ECD kidneys, these outcomes could still improve. Furthermore, as our data suggests that DCD allografts are comparable to DBD kidneys, the recent proposal to allocate DCD kidneys from younger donors nationally appears a reasonable approach provided a
References (15)
- et al.
A systematic review of kidney transplantation from expanded criteria donors
Am J Kidney Dis
(2008 Sep) - et al.
Expanded criteria donors for kidney transplantation
Am J Transpl
(2003) - et al.
Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation
Am J Transpl
(2007 Jul) - et al.
Expanding the donor kidney pool: utility of renal allografts procured in a setting of uncontrolled cardiac death
Am J Transpl
(2006 Jul) - et al.
Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study
Lancet
(2010 Oct 16) - et al.
Non-heart beating donor kidneys with delayed graft function have superior graft survival compared with conventional heart-beating donor kidneys that develop delayed graft function
Am J Transpl
(2003 May) - et al.
Short- and long-term outcomes with the use of kidneys and livers donated after cardiac death
Am J Transpl
(2007 Jan)
Cited by (5)
Rapid Access in Donation After Circulatory Death (DCD): The Single-Center Experience With a Classic Pathway in Uncontrolled DCD Algorithm
2022, Transplantation ProceedingsCitation Excerpt :Recommendations from Spanish and French centers suggest the use of extracorporeal circulation, which undoubtedly improves the effectiveness of the surgical team and the coordination of organ procurement. Nevertheless, technical problems during extracorporeal circulation often result in procedures without retrieval or post-recovery organ disqualification [43,44]. After 1 year of follow-up, the analysis of endpoints in the presented DCD group did not reveal any cases of graft loss or recipient death.
Efficacy and Safety Outcomes of Extended Criteria Donor Kidneys by Subtype: Subgroup Analysis of BENEFIT-EXT at 7 Years After Transplant
2017, American Journal of TransplantationEthical Thoughts on the Quality Evaluation of the Kidneys from Expanded Criteria Donors
2022, Chinese Medical EthicsExploration on the experience of long ⁃ term external normothermic machine perfusion of discarded human kidney for the first time in China
2022, Chinese Journal of Nephrology