Elsevier

The Surgeon

Volume 14, Issue 3, June 2016, Pages 136-141
The Surgeon

Expanded criteria donor and donation after circulatory death renal allografts in the West of Scotland: Their place in the kidney allocation process

https://doi.org/10.1016/j.surge.2014.06.007Get rights and content

Abstract

Introduction

Due to the rising disparity between demand and availability, organs from expanded criteria donors (ECD) and donors after determination of circulatory death (DCD) are increasingly used. The purpose of this study was to report outcomes in recipients of ECD and DCD renal allografts from a single centre.

Methods

A retrospective analysis from a single centre for all renal transplants performed between 2001 and 2010 inclusive was undertaken. SCD (standard criteria donor) and ECD organs were compared, as were DCD and DBD (donation after determination of brain stem death) organs. Baseline data and predefined standard transplant outcomes were collected and compared using appropriate statistical tests. P < 0.05 was defined as significant.

Results

729 renal transplants were performed. Comparing ECD to SCD organs, there was a significant difference in graft survival between groups (logrank for trend, p = 0.032) with ECD organs doing worse than SCD organs. Short-term outcomes showed a similar disparity with a higher 1-year post-transplant creatinine and delayed graft function (DGF) rate in ECD grafts. Nevertheless, outcomes were still clinically acceptable. When comparing DCD to DBD organs, no such differences were apparent, with DCD organs appearing to perform at least as well as DBD organs. In our cohort, unlike some previous studies, DGF rates were similar in both DCD and DBD groups.

Conclusions

Although ECD organs perform less well than SCD organs, outcomes are still acceptable and our results support their continuing use. When considering DCD organs, our data support the view that they should no longer be necessarily regarded as marginal grafts. Our low DGF rates are perhaps explained by local factors contributing to a short CIT.

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

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 Proceedings
    Citation 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.

View full text