IntroductionEx vivo normothermic perfusion (EVNP) is a novel technique that reconditions the kidney and restores renal function prior to transplantation. Phase I data from a series of EVNP in extended criteria donor kidneys have established the safety and feasibility of the technique in clinical practice.Methods and analysisThis is a UK-based phase II multicentre randomised controlled trial to assess the efficacy of EVNP compared with the conventional static cold storage technique in donation after circulatory death (DCD) kidney transplantation. 400 patients receiving a kidney from a DCD donor (categories III and IV, controlled) will be recruited into the study. On arrival at the transplant centre, kidneys will be randomised to receive either EVNP (n=200) or remain in static cold storage (n=200). Kidneys undergoing EVNP will be perfused with an oxygenated packed red cell solution at near body temperature for 60 min prior to transplantation. The primary outcome measure will be determined by rates of delayed graft function (DGF) defined as the need for dialysis in the first week post-transplant. Secondary outcome measures include incidences of primary non-function, the duration of DGF, functional DGF defined as <10% fall in serum creatinine for 3 consecutive days in the first week post-transplant, creatinine reduction ratio days 2 and 5, length of hospital stay, rates of biopsy-proven acute rejection, serum creatinine and estimated glomerular filtration rate at 1, 3, 6 and 12 months post-transplant and patient and allograft survival. The EVNP assessment score will be recorded and the level of fibrosis and inflammation will also be measured using tissue, blood and urine samples. Ethics and dissemination. The study has been approved by the National Health Service (NHS) Health Research Authority Research Ethics Committee. The results are expected to be published in 2020.Trial registration numberISRCTN15821205; Pre-results.

et al. Circulation 2007;116(suppl I):I-98-105. Conclusion: Remote ischemic preconditioning (RIPC) reduces postoperative myocardial injury, myocardial infarction, and renal impairment in patients undergoing elective open abdominal aortic aneurysm (AAA) repair.Summary: Remote ischemic preconditioning is a phenomenon where brief periods of ischemia, followed by reperfusion, can provide systemic protection from prolonged ischemia. The authors sought to investigate whether RIPC could reduce the incidence of myocardial and renal injury in patients undergoing elective AAA repair. This was a randomized trial, and 82 patients were randomized to undergo AAA repair with RIPC or AAA repair without RIPC. Remote ischemic preconditioning was performed using two cycles of intermittent cross-clamping of the common iliac arteries with 10 minutes of ischemia, followed by 10 minutes of reperfusion. Cardiac troponin levels were used to assess postoperative myocardial injury and myocardial infarction. Renal injury was assessed by serum creatinine level. Baseline characteristics were well matched in both groups.The incidence of myocardial injury was reduced 27% by RIPC (39% vs 12%; 95% confidence interval [CI], 8.8%-45%; P ϭ .005). Also reduced in the RIPC patients were myocardial infarction (27% vs 5%; 95% CI, 7.3%-38%; P ϭ .006) and renal impairment (30% vs 7%; 95% CI, 6.4%-39%; P ϭ .009. The effect of covariables was assessed with multivariable analysis. The protective effect of RIPC on myocardial injury (odds ratio, 0.22; 95% CI, 0.07-0.67; P ϭ .008), myocardial infarction (odds ratio, 0.18; 95% CI, 0.04-0.75; P ϭ .006) was independent of the covariables.Comment: Studies suggest that ischemia at a site distal from the heart can confer ischemic protection at remote sites. This must occur through some sort of neural mechanism or a circulating humoral mechanism. It is intriguing to think that a simple maneuver that is feasible in most AAA open repairs could reduce cardiac and renal impairment after open AAA repair.

ObjectivesOutcomes of liver transplantations from donation after circulatory death (DCD) donors may be inferior to those achieved with donation after brain death (DBD) donors. The impact of using DCD donors is likely to depend on specific national practices. We compared risk-adjusted graft loss and recipient mortality after transplantation of DCD and DBD livers in the UK.DesignProspective cohort study. Multivariable Cox regression and propensity score matching were used to estimate risk-adjusted HR.Setting7 liver transplant centres in the National Health Service (NHS) hospitals in England and Scotland.ParticipantsAdults who received a first elective liver transplant between January 2005 and December 2010 who were identified in the UK Liver Transplant Audit.InterventionsTransplantation of DCD and DBD livers.OutcomesGraft loss and recipient mortality.ResultsIn total, 2572 liver transplants were identified with 352 (14%) from DCD donors. 3-year graft loss (95% CI) was higher with DCD livers (27.3%, 21.8% to 33.9%) than with DBD livers (18.2%, 16.4% to 20.2%). After adjustment with regression, HR for graft loss was 2.3 (1.7 to 3.0). Similarly, 3-year mortality was higher with DCD livers (19.4%, 14.5% to 25.6%) than with DBD livers (14.1%, 12.5% to 16.0%) with an adjusted HR of 2.0 (1.4 to 2.8). Propensity score matching gave similar results. Centre-specific adjusted HRs for graft loss and recipient mortality seemed to differ among transplant centres, although statistical evidence is weak (p value for interaction 0.08 and 0.24, respectively).ConclusionsGraft loss and recipient mortality were about twice as high with DCD livers as with DBD livers in the UK. Outcomes after DCD liver transplantation may vary between centres. These results should inform policies for the use of DCD livers.

It is essential to minimize the unnecessary discard of procured deceased donor kidneys, but information on discard rates and the extent to which discard can be avoided are limited. Analysis of the UK Transplant Registry revealed that the discard rate of procured deceased donor kidneys has increased from 5% in 2002-3 to 12% in 2011-12. A national offering system for hard-to-place kidneys was introduced in the UK in 2006 (the Declined Kidney Scheme), but just 13% of kidneys that were subsequently discarded until 2012 were offered through the scheme. In order to examine the appropriateness of discard, 20 consecutive discarded kidneys from 13 deceased donors were assessed to determine if surgeons agreed with the decision that they were not implantable. Donors had a median (range) age of 67 (31-80) yr. Kidneys had been offered to a median of 3 (1-12) centers before discard. Four (20%) of the discarded kidneys were thought to be usable, and nine (45%) were possibly usable. As a result of these findings, major changes to the UK deceased donor kidney offering system have been implemented, including simultaneous offering and broader entry criteria for hard-to-place kidneys. Organizational changes are necessary to improve utilization of deceased donor kidneys.

Background: Organ scarcity has prompted increased use of organs from donation after circulatory death (DCD) donors. An early single-centre experience of simultaneous pancreas-kidney (SPK) transplantation from controlled DCD donors is described here. Conclusion: DCD SPK grafts had comparable short-term outcomes to DBD grafts, even when procured from selected donors with a prolonged agonal phase.