Non‐heart‐beating Donors: Renewed Source of Organs for Renal Transplantation during the Twenty‐first Century

Abstract

The growing demand of organs for renal transplantation makes it necessary to explore alternative routes for kidney donation. Non-heart-beating donors (NHBDs) are a valuable source of cadaveric organs and have been the subject of renewed interest in recent years. In addition to difficulties with legal and ethical acceptability, there are concerns regarding medical safety. The current NHBD program at St. George's Hospital in London was started in March 1995. A total of 41 kidneys from category I to III donors (according to the Maastricht classification) were retrieved from the Accident and Emergency Department and several intensive care units and were subsequently transplanted. Cold in situ perfusion was commenced via femoral access or rapid aortic cannulation in most donors. Of these transplanted kidneys, 35 started functioning within 4 weeks. The permanent nonfunction (PNF) rate was 14.6% (6/41) and the estimated 1-year graft survival 82.9% (34/41). The delayed graft function (DGF) rate (defined as recipients requiring posttransplant dialysis for 3 days or longer) was 80.0% (28/35). The median serum creatinine concentration in patients with a functioning graft at 1 year was 165 micromol/L. NHBD kidneys have contributed about 15% to the regional transplant activity over the last 6 years, even though not all potential NHBDs were used. It was possible to lower the PNF rate with strict donor selection criteria and more recently with pulsatile machine perfusion. NHBDs represent a valuable source for kidneys and can extend the donor pool. More experience is currently needed to continue to lower PNF rates reliably before promoting more widespread use of NHBDs for renal transplantation.

Outcome of Nonheart‐Beating Donor Kidneys with Prolonged Delayed Graft Function after Transplantation

“…As a result of the shortage of organs, there is an increasing use of marginal organs (1) such as nonheart-beating donor (NHBD) kidneys (2,3). These kidneys show a relatively high percentage of delayed graft function (DGF) (2,4,5), which complicates post-transplant management and increases both the duration of initial hospitalization admission and the cost of transplantation (6,7).…”

Outcome of renal allografts from non-heart-beating donors with delayed graft function

“…The proximal tubules, which are most sensitive to ischaemia, cannot survive without damage in this setting. If no additional detrimental effect is added, such as impaired donor-organ quality, advanced donor age or immunological damage due to rejection, this form of ATN in NHBDs has been shown to be completely reversible with no long-term side effects [7,101. In some HBD programmes this and other donor-and recipient-related problems (increasing donor age, incomplete perfusion, prolonged cooling, co-morbidities such as atherosclerosis, diabetes and hypertension, etc.)…”

“…DGF in uncontrolled NHBDs is usually unavoidable even with improved preservation techniques [7,91. In this study, it lasted on average, for 22 days.…”

Kidney donation after cardiac death

“…When compared with kidneys recovered from DBD, DCD kidneys have increased rates of DGF and primary non function (PNF) [15,27,30] -mainly due to increased warm ischaemia time during recovery but also due to cold ischaemia. Based on a porcine model of DCD, Jani et al [54] hypothesised that DCD kidneys have increased caspase-1 due to warm ischemia and increased caspase-3 and apoptosis due to cold ischaemia.…”

“…Since its implementation four and a half years ago, DCD has accounted for 10.9% of deceased donor activity in Ontario, Canada [18] . The majority of DCD kidneys are from controlled donors meaning that the number of organs can be further increased by utilising uncontrolled donors [3,4,12,[19][20][21][22][23][24][25][26][27][28][29][30] although the associated workload is considerably more and the yield rate poorer. Reports from some centres show that DCD from deaths outside the hospital may be a good source of donor kidneys and may provide a way to successfully increase the donor pool for organ transplantation [31] .…”