The duration of asystolic ischemia determines the risk of graft failure after circulatory-dead donor kidney transplantation: A Eurotransplant cohort study

Abstract

Circulatory death donor (DCD) kidney transplantations are steadily increasing. Consensus reports recommend limiting donor warm ischemia time (DWIT) in DCD donation, although an independent effect on graft outcome has not been demonstrated. We investigated death-censored graft survival in 18 065 recipients of deceased-donor kidney transplants in the Eurotransplant region: 1059 DCD and 17 006 brain-dead donor (DBD) kidney recipients. DWIT was defined as time from circulatory arrest until cold flush. DCD donation was an independent risk factor for graft failure (adjusted hazard ratio [HR] 1.28, 95% CI 1.10-1.46), due to an increased risk of primary nonfunction (62/1059 vs 560/17 006; P < .0001). With DWIT in the model, DCD donation was no longer a risk factor, demonstrating that DWIT explains the inferior graft survival of DCD kidneys. Indeed, DCD transplants with short DWIT have graft survival comparable to that of standard-criteria DBD transplants (P = .59). DWIT also associated with graft failure in DCDs (adjusted HR 1.20 per 10-minute increase, 95% CI 1.03-1.42). At 5 years after transplantation, graft failure occurred in 14 of 133 recipients (10.5%) with DWIT <10 minutes, 139 of 555 recipients (25.0%) with DWIT between 10 and 19 minutes, and 117 of 371 recipients (31.5%) with DWIT ≥20 minutes. These findings support the expert opinion-based guidelines to limit DWIT.

Warm ischemic time as a critical risk factor of graft failure from donors after cardiac death: A single‐center experience over three decades in the Kidney Donor Profile Index/Kidney Donor Risk Index era in Japan

“…also suggested the influence of the WIT on the survival of DCD grafts . A recent Eurotransplant cohort study also supported the present findings that the duration of asystolic ischemia (donor WIT) determines the risk of graft loss from DCD …”

“…14 A recent Eurotransplant cohort study also supported the present findings that the duration of asystolic ischemia (donor WIT) determines the risk of graft loss from DCD. 19 Suntharalingam et al reported that in DCD donors, warm ischemia started at the moment of withdrawal of life support, as the cardiopulmonary function slowly deteriorated, and was evident at the time of circulatory arrest. The median agonal phase was reported to be approximately 36 min, ranging from 5 min to 3 days, although most centers abandon donation if circulatory arrest has not occurred within 1-2 h. 20 Below 4 h, the agonal phase duration does not seem to influence the transplant outcome.…”

Preliminary experience of sequential use of normothermic and hypothermic oxygenated perfusion for donation after circulatory death kidney with warm ischemia time over the conventional criteria - a retrospective and observational study

“…According to the Eurotransplant cohort study, in the 5 years of post‐transplant follow‐up, the longer the WIT is prolonged and the more the graft failure increases. Nevertheless, these results were obtained without reporting the use of organ preservation techniques for DCD .…”

A metabolic approach during normothermic regional perfusion in uncontrolled donors after circulatory death—A pilot study

“…In controlled donors after circulatory death (cDCD), the effects of warm ischemia during the hypotensive phase, exacerbated during cold ischemia, may result in a higher incidence of primary nonfunction and delayed graft function in kidney transplantation. 1 Notably, while cDCDs have WIT that can be estimated, the WIT is often inexact and extended in uncontrolled donors after circulatory death (uDCD), making assessment of organ injury difficult. Abdominal normothermic regional perfusion (nRP) with extracorporeal membrane oxygenation (ECMO) device has been proposed to restore blood after the determination of death.…”

“…bolic profiling during nRP in uncontrolled DCD in relation to WIT flow (median, IQR) (min) 8(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) Low flow (median, IQR) (min) 100 Low flow post-ECG (median, IQR) (min) 20(5-67) Warm ischemic time (median, IQR) (min) 132 (127-145) F, females; IQR, interquartile range; M, males; SD, standard deviation. F I G U R E 2 Creatinine values (top), lactate (middle) and ph (bottom) values throughout the study period.…”