Optimal donation of kidney transplants after controlled circulatory death

Abstract

Controlled donation after circulatory death (cDCD) is used for “extended criteria” donors with poorer kidney transplant outcomes. The French cDCD program started in 2015 and is characterized by normothermic regional perfusion, hypothermic machine perfusion, and short cold ischemia time. We compared the outcomes of kidney transplantation from cDCD and brain‐dead (DBD) donors, matching cDCD and DBD kidney transplants by propensity scoring for donor and recipient characteristics. The matching process retained 442 of 499 cDCD and 809 of 6185 DBD transplantations. The DGF rate was 20% in cDCD recipients compared with 28% in DBD recipients (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI] 1.12–1.82). When DBD transplants were ranked by cold ischemia time and machine perfusion use and compared with cDCD transplants, the aRR of DGF was higher for DBD transplants without machine perfusion, regardless of the cold ischemia time (aRR with cold ischemia time <18 h, 1.57; 95% CI 1.20–2.03, vs aRR with cold ischemia time ≥18 h, 1.79; 95% CI 1.31–2.44). The 1‐year graft survival rate was similar in both groups. Early outcome was better for kidney transplants from cDCD than from matched DBD transplants with this French protocol.

Improved Organ Utilization and Better Transplant Outcomes With In Situ Normothermic Regional Perfusion in Controlled Donation After Circulatory Death

“…This may translate into 5 additional years of graft life for the recipients. 21,22 Recent French data 13 suggest that recipients of NRP kidneys have comparable 1-y outcomes with recipients of DBD kidneys, albeit the French mandate ex situ hypothermic machine perfusion of kidneys following NRP, something that is not routine in the United Kingdom and was not done in any NRP donor kidney at the point of donation in this series. In our study, we have noted a slight reduction in the rate of primary nonfunction plus a notable decrease in DGF rate from 31% for non-NRP cDCD transplants to 23% when NRP was used.…”

“…9,10,14 Data on the impact of NRP on organ utilization and the outcomes of renal and pancreas transplantation are scarce. [13][14][15] This study compared the utilization rates and clinical outcomes of organs offered for transplantation and recovered using NRP with a contemporaneous UK cohort of cDCD donors undergoing standard organ recovery over a 9-y period, where at least 1 abdominal organ was accepted for transplant. We have shown that NRP is an independent factor in increasing organ utilization for all abdominal organs.…”

“…[8][9][10][11] Excellent outcomes for NRP cDCD liver transplantation have been reported, with better graft survival and a reduced incidence of ischemic cholangiopathy. [8][9][10]12 To date, there has been no in-depth analysis of how NRP impacts the utilization of abdominal organs from cDCD donors, with a single registry report 13 and isolated small series suggesting a potentially improved function following kidney transplantation. 14,15 This article describes the impact of NRP on the utilization of abdominal organs offered from cDCD donors and reports the outcomes of these transplants in the United Kingdom.…”

“A Delicate balance”—Perceptions and Experiences of ICU Physicians and Nurses Regarding Controlled Donation After Circulatory Death. A Qualitative Study

“…Controlled donation after circulatory death (cDCD) refers to organ donation from patients whose death is defined using circulatory criteria after the planned withdrawal of lifesustaining treatments (WLST) (1). The scarcity of donor organs and the good transplantation outcomes (2)(3)(4) legitimately support the development of this type of donation (5)(6)(7) in a context where WLST decisions occur more and more frequently in intensive care units (ICU) worldwide (8)(9)(10).…”

Transferring an ICU Patient at the End of His Life for the Purpose of Organ Donation: Could It Be Considered?

“…Today, the scarcity of donor organs and the good transplantation outcomes [ 5 , 6 ] legitimately support the development of cDCD in a context where WLST decisions occurs more and more frequently in ICUs worldwide [ 7 ]. This development is limited by technical and organizational aspects, in particular related to the systematic use of normothermic regional perfusion (NRP), which requires technology (NRP device) and expertise (NRP settings and vessels cannulation) not available in all hospitals.…”