The effect of inadequate in situ perfusion in the non heart-beating donor

Abstract

Summary In situ aortic perfusion in the nonheart‐beating donors (NHBD) is an important procedure to reduce primary warm ischaemic injury prior to formal donor organ retrieval. It allows an interim period to obtain donor family consent and theatre preparation. This study describes our experience of inadequate aortic perfusions resulting from difficult aortic cannulations and associated adverse outcome despite reasonable viability tests. Since 1998, all NHBD in our institution are perfused in situ using a double balloon triple lumen (DBTL) catheter inserted through a femoral artery cut‐down procedure. The DBTL catheter is positioned with distal occlusive balloon at the aortic bifurcation using the ‘pull‐back’ technique, the proximal occlusive balloon lies above the renal arteries. This provides selective aortic perfusion in particular the kidneys. Venous decompression using a femoral vein catheter enables a ‘two‐way infusion system’. Pre‐transplant viability status of retrieved kidneys is determined by measuring pressure/resistance characteristics to the flow and biochemical markers for ischaemic injury. There were 90 NHBD renal transplants performed from 72 donors. Three renal transplants were carried out from three donors of ineffective in situ perfusion secondary to cannulation difficulties. Femoral cannulation was difficult as a result of extensive atherosclerosis of donor vessels. The comparison of allograft outcome from effective and ineffective in situ perfusion of donors showed high rate of primary nonfunction (PNF) from ineffective perfusion (chi‐squared, P < 0.0001). The cases demonstrated poor outcome from ineffective perfusion related to the cannulation difficulties. Therefore a strict policy should be taken in cases where aortic cannulation and perfusion is inadequate, despite pretransplant assessment. In these circumstances, the primary warm ischaemia time should be extended to include this period of ineffective perfusion.

Preservation of kidneys from controlled donors after cardiac death

“…The main reason for discard was poor kidney quality after preservation. In 12 of the kidneys from the DBTL group, the flush-out was poor, resulting in a blue congested kidney, as also described by others 17 . This may have been due to insufficient flushing during perfusion through the catheter.…”

Ex Vivo Normothermic Perfusion of Declined Human Kidneys After Inadequate In Situ Perfusion

“…In this present report, both kidneys appeared pink and healthy throughout EVNP. Furthermore, the level of renal blood flow and urine output were within range of EVNP parameters in kidneys from our clinical series, suggesting their suitability for transplantation (3).…”

Successful Transplantation of Human Kidneys Deemed Untransplantable but Resuscitated by Ex Vivo Normothermic Machine Perfusion

“…Platelets adhering to the vascular endothelium can induce endothelial apoptosis and aggravate reperfusion injury after transplantation 4. Gok et al reported an exceptionally high rate of primary nonfunction from inadequately perfused kidneys: 66.7% compared with 4.8% in those with adequate perfusion 9. Therefore, there is much reluctance to use these organs.…”