Effect of donor nephrectomy time during circulatory-dead donor kidney retrieval on transplant graft failure

Abstract

Background: When the blood supply ceases in a deceased organ donor, ischaemic injury starts. Kidneys are cooled to reduce cellular metabolism and minimize ischaemic injury. This cooling is slow and kidneys are lukewarm during nephrectomy. Smaller single-centre studies have shown that prolonged donor nephrectomy time decreases early kidney transplant function, but the effect on long-term outcome has never been investigated in large multicentre cohort studies. Methods: The relationship between donor nephrectomy time and death-censored graft survival was evaluated in recipients of single adult-to-adult, first-time deceased-donor kidneys transplanted in the Eurotransplant region between 2004 and 2013.Results: A total of 13 914 recipients were included. Median donor nephrectomy time was 51 (i.q.r. 39-65) min. Kidneys donated after circulatory death had longer nephrectomy times than those from brain-dead donors: median 57 (43-78) versus 50 (39-64) min respectively (P < 0⋅001). Donor nephrectomy time was independently associated with graft loss when kidneys were donated after circulatory death: adjusted hazard ratio (HR) 1⋅05 (95 per cent c.i. 1⋅01 to 1⋅09) per 10-min increase (P = 0⋅026). The magnitude of this effect was comparable to the effect of each hour of additional cold ischaemia: HR 1⋅04 (1⋅01 to 1⋅07) per h (P = 0⋅004). For kidneys donated after brain death, there was no effect of nephrectomy time on graft survival: adjusted HR 1⋅01 (0⋅98 to 1⋅04) per 10 min (P = 0⋅464). Conclusion: Prolonged donor nephrectomy time impairs graft outcome in kidneys donated after circulatory death. Keeping this short, together with efficient cooling during nephrectomy, might improve outcome.

Comparing outcomes in right versus left kidney transplantation: A systematic review and meta‐analysis

“…58 During this period ('nephrectomy time') organs are subject to additional ischemic damage. None of the DD studies reported on nephrectomy time; differences in which kidney is retrieved last may contribute to inferior outcomes as found by Heylen et al 59 Whilst this is the first meta-analysis comparing right and left DD kidneys, there are three other meta-analyses to our knowledge which attempt to compare right versus left LD kidneys. [21][22][23] All three focus primarily on donor outcomes rather than the recipient outcomes described in this study.…”

“Time is tissue”—A minireview on the importance of donor nephrectomy, donor hepatectomy, and implantation times in kidney and liver transplantation

“…In our recent Eurotransplant registry study, donor nephrectomy time independently predicted death‐censored graft failure in DCD but not DBD kidneys. For each 10‐min increase in donor nephrectomy time, the odds of graft failure increased by 5% 9 . The magnitude of this effect was comparable to the effect of each additional hour of cold ischemia.…”

“…Graft susceptibility to ischemia during donor nephrectomy and implantation depends on donor type with more pronounced detrimental effects in DCD compared to DBD kidneys. In the Eurotransplant registry, increasing donor nephrectomy time increased the risk of graft failure only in DCD and not DBD 9 . The same registry showed a more pronounced effect of implantation time on graft failure in DCD versus DBD 17 .…”

“…En bloc procurement will likely increase donor back‐table time as a consequence, but whether this affects outcome still needs to be investigated. In Eurotransplant, donor hepatectomy and nephrectomy times are longer in DCD than DBD 9,24 . This is likely explained by the DCD‐procurement technique where all dissection happens after cold flush.…”

Author response to: Comment on: Effect of donor nephrectomy time during circulatory-dead donor kidney retrieval on transplant graft failure

“…We thank van Straalen and Minnee for their thoughts regarding surgical time intervals impacting on post‐transplant kidney outcomes.…”