Machine Perfusion or Cold Storage in Deceased-Donor Kidney Transplantation

Abstract

BACKGROUNDStatic cold storage is generally used to preserve kidney allografts from deceased donors. Hypothermic machine perfusion may improve outcomes after transplantation, but few sufficiently powered prospective studies have addressed this possibility. METHODSIn this international randomized, controlled trial, we randomly assigned one kidney from 336 consecutive deceased donors to machine perfusion and the other to cold storage. All 672 recipients were followed for 1 year. The primary end point was delayed graft function (requiring dialysis in the first week after transplantation). Secondary end points were the duration of delayed graft function, delayed graft function defined by the rate of the decrease in the serum creatinine level, primary nonfunction, the serum creatinine level and clearance, acute rejection, toxicity of the calcineurin inhibitor, the length of hospital stay, and allograft and patient survival. RESULTSMachine perfusion significantly reduced the risk of delayed graft function. Delayed graft function developed in 70 patients in the machine-perfusion group versus 89 in the cold-storage group (adjusted odds ratio, 0.57; P = 0.01). Machine perfusion also significantly improved the rate of the decrease in the serum creatinine level and reduced the duration of delayed graft function. Machine perfusion was associated with lower serum creatinine levels during the first 2 weeks after transplantation and a reduced risk of graft failure (hazard ratio, 0.52; P = 0.03). One-year allograft survival was superior in the machine-perfusion group (94% vs. 90%, P = 0.04). No significant differences were observed for the other secondary end points. No serious adverse events were directly attributable to machine perfusion. CONCLUSIONSHypothermic machine perfusion was associated with a reduced risk of delayed graft function and improved graft survival in the first year after transplantation. (Current Controlled Trials number, ISRCTN83876362.)

Hypothermic Machine Perfusion of Kidney Grafts: Which Pressure is Preferred?

“…Following recent studies showing the beneficial effect of MP over CS preservation of deceased kidney grafts, MP holds the potential for a true comeback. 6,8,10,17 In the first large multi-center, prospective, randomized clinical trial performed by Moers et al, 17 it was demonstrated that kidney grafts from standard as well as extended criteria donors benefit from MP as the risk of delayed graft function was significantly reduced.…”

“…The rationale of lowering the PP originates from the common regard that pressure induced endothelial damage is one of the main drawbacks associated with MP. 3,9,17 Also, the feasibility of the new perfusion solution POLYSOL was evaluated. By using a similar experimental model as Maathuis et al, parameters of microcirculatory integrity, renal function and morphology were assessed.…”

“…17 The benefit of MP is probably that it ensures a uniform distribution of preservation fluid throughout the organ, which is better than a single flush. 22 Although MP provides favorable preservation quality over CS, it remains a more complex and expensive procedure.…”

Advancing Transplantation

“…42 A meta-analysis demonstrated similar results, 44 whereas in a separate study, graft survival remained significantly higher in the machine perfusion group at year 3. 45 Kwiatkowski et al 46 reported a significant improvement in both graft survival and renal function at 5 years. In a separate study, DGF and cold ischemia time more than 24 hours were associated with a reduction in graft survival; however, patients with DGF but without AR did not experience an inferior graft survival rate.…”

New Strategies and Concepts in Organ Preservation

“…This report, however, places a primary focus on graft mortality, which, putatively for statistical reasons, has not been the primary endpoint in most of the controlled studies and, hence, might not come up directly with significant results. Nonetheless, in the latest randomized controlled study on kidneys donated after brain death, the 3-year study graft survival after machine perfusion was superior to that after cold storage, with differences being most pronounced for kidneys recovered from expanded criteria donors [39]. As far as delayed graft function and organ quality might be taken as clinically relevant outcome characteristics, the advantages of HMP over cold storage seem to be widely accepted, and renal preservation by machine perfusion has become an established alternative in many countries.…”