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Kidney transplantation from marginal donors
Kidney Transplantation From Marginal Donors P. Veroux, C. Puliatti, M. Veroux, D. Cappello, M. Macarone, D. Puliatti, and D. Vizcarra ABSTRACT Aim. The increasing demand for transplantation and the shortage of available organs limit the success of organ transplant programs. The use of marginal donors to expand the donor pool is receiving increased attention. We reviewed a 28-month experience of kidney transplants from marginal donors to assess the impact on patient and graft survival. Patients and Methods. From January 2001 to May 2003, 78 kidney transplants were performed, including 50 grafts from cadaver donors and 28 from living donors with 3 patients receiving a double kidney transplant. The patients were divided into 4 groups: 31 patients received a kidney from an ideal cadaver donor (group 1a); 19 patients received a graft from a marginal cadaver donor (group 1b); 19 patients received an ideal living related kidney (group 2a); and 9 patients received a marginal living kidney graft (group 2b). Results. Twenty-eight grafts from marginal donors were transplanted with an average follow-up of 16 months (range, 1–28 months). The graft survival rates for groups 1a, 1b, 2a, and 2b were 93%, 79%, 100%, and 100% and patient survival rates were 96%, 89%, 100%, and 100%, respectively. Conclusion. Despite the observation that use of marginal donors has been associated with a worse outcome compared with ideal donors, we of such grafts resulted in improved quality of life and survival expectancy compared with maintenance dialysis. The marginal kidney donors represent a feasible way to improve the donor pool.
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HE INCREASING demand for transplantation and the shortage of available organs limit the success of organ transplant programs. Although procurement and distribution systems have improved, we have attempted to supply our long waiting list by using organs from marginal donors, both from cadaver or living sources. The aim of this article was to assess the impact on patient and graft survival of using marginal kidney donors. PATIENTS AND METHODS From January 2001 to May 2003, 78 kidney transplants included 50 grafts from cadaver donors, 28 from living donors, and 3 patients received double kidney transplants. We defined as “marginal” a donor with 1 or more of the following characteristics: donor age ⬎60 years, clinical history of hypertension or diabetes, plasma creatinine level ⬎2.5 mg/dL, and cold ischemia ⬎30 hours. All recipients were warned about the risks versus benefits and written consent was obtained. The transplant surgeon responsible for the donor operation had to decide in every case whether the donor should be regarded as marginal. Special attention was given to matching age, body mass index, and arterial pressure to select the recipients for these kidneys. Dual transplantation with both kidneys to 1 recipient was © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 497⫺498 (2004)
performed from donors in whom the serum creatinine level was ⬎2.5 mg/dL, or had a long-term history of diabetes or hypertension. All patients underwent a standardized posttransplantation immunosuppressive protocol: induction with basiliximab, and maintenance mycophenolate mofetil, steroids, and calcineurin inhibitors when renal function was demonstrable. All patients were administrated intravenous iloprost for 12 days posttransplantation. We analyzed patient and graft survival at a median follow-up of 16 months, comparing the results obtained with grafts from marginal donors with those retrieved from ideal donors. The patients were divided into 4 groups: 31 patients received a kidney from an ideal cadaver donor (group 1a); 19 from a marginal cadaver donor (group 1b); 19 from an ideal living related kidney (group 2a); and 9 from a marginal living donor kidney graft (group 2b). From the Department of Surgery, Transplantation and Advanced Technologies, Organ Transplant Unit, University Hospital of Catania, Catania, Italy. Address reprint requests to Prof. Dr. Pierfrancesco Veroux, Department of Surgery, Transplantation and Advanced Technologies, Organ Transplant Unit, University Hospital of Catania, Via S. Sofia, 78, 95123 Catania, Italy. E-mail: [email protected] 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.012 497
498
RESULTS
Twenty-eight grafts from marginal donors were transplanted at our institution, including 38% of cadaver kidney transplants and 32.1% of living donors in the 28-month period. The average cold ischemia time was 16.4 hours, being lower in the marginal cadaver donor group (12.5 hours) than in the ideal cadaver donor group (19.4 hours). All recipients of a living related graft received their graft within 2 hours from the procurement. Marginal cadaver organ recipients were older than those who received transplants from ideal donors (mean age, 50 years vs 38 years, respectively). Acute tubular necrosis occurred in 65.4% of marginal recipients versus 20.3% of ideal recipients. At an average time of 16 months (range, 1–28 months), graft survival rates were 93%, 79%, 100%, and 100% and patient survival rates were 96%, 89%, 100%, and 100% for groups 1a, 1b, 2a, and 2b, respectively. Mean serum creatinine level in group 1a was 1.5 mg/dL (range, 0.5–1.8 mg/dL); group 1b, 2.4 mg/dL (range, 1.1–3.2 mg/dL); group 2a, 1.3 mg/dL (range, 0.6 –1.6 mg/dL); and group 2b, 2.2 mg/dL (range, 1.8 –3.2 mg/dL). DISCUSSION
There are about 7000 patients on the waiting list for kidney transplantation in Italy; only 20% of patients receive a graft each year. In the South of Italy, the rate of cadaver donors is 8/pmp, indicating a shortage of donors and mandating new criteria to expand the donor pool. The use of marginal donors to expand the pool has received increased attention. Marginal kidney donors consisted of 38% of cadaver donors and 32.1% of living donors in our experience. Despite the observation that the use of marginal donors
VEROUX, PULIATTI, VEROUX ET AL
has been associated with a worse outcome when compared with ideal donors,1–3 even the use of grafts from marginal donors improves the quality of life for patients.4,5 Moreover, transplantation of a marginal kidney is associated with a significant benefit in life expectancy when compared with maintenance dialysis.2 With informed consent, patients must have the opportunity to choose whether they prefer to receive a marginal kidney or to continue waiting for an ideal graft. We believe that a marginal kidney transplanted with an appropriate strategy, such as reduction of cold ischemia time, delay in beginning calcineurin inhibitors until renal function is demonstrable, administration of prostanoid in the postoperative period as an organ protector, and, finally, use of the organ in a population of healthy patients of older than 60 years of age (old-to-old program), yields the best results. This combination of strategies may be considered a feasible way to expand the donor pool, offering an increased number of potential grafts to wait-listed patients on maintenance dialysis. REFERENCES 1. Michelon T, Piovesan F, Castilho C, et al: Marginal cadaveric kidney donors: an attractive way to expand the donor pool. Transplant Proc 34:2515, 2002 2. Ojo AO, Hanson JA, Maier-Kriesche HU, et al: Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant recipients. J Am Soc Nephrol 12:589, 2001 3. Belardinelli L: Living donor transplantations with marginal kidneys. Transplant Proc 35:941, 2003 4. Laupacis A, Keown P, Pus N, et al: A study of the quality of life and cost-utility of renal transplantation. Kidney Int 50:235, 1996 5. Jofre R, Lopez-Gomez JM, Moreno F, et al: Changes in quality of life after renal transplantation. Am J Kidney Dis 32:93, 1998
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HE INCREASING demand for transplantation and the shortage of available organs limit the success of organ transplant programs. Although procurement and distribution systems have improved, we have attempted to supply our long waiting list by using organs from marginal donors, both from cadaver or living sources. The aim of this article was to assess the impact on patient and graft survival of using marginal kidney donors. PATIENTS AND METHODS From January 2001 to May 2003, 78 kidney transplants included 50 grafts from cadaver donors, 28 from living donors, and 3 patients received double kidney transplants. We defined as “marginal” a donor with 1 or more of the following characteristics: donor age ⬎60 years, clinical history of hypertension or diabetes, plasma creatinine level ⬎2.5 mg/dL, and cold ischemia ⬎30 hours. All recipients were warned about the risks versus benefits and written consent was obtained. The transplant surgeon responsible for the donor operation had to decide in every case whether the donor should be regarded as marginal. Special attention was given to matching age, body mass index, and arterial pressure to select the recipients for these kidneys. Dual transplantation with both kidneys to 1 recipient was © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 497⫺498 (2004)
performed from donors in whom the serum creatinine level was ⬎2.5 mg/dL, or had a long-term history of diabetes or hypertension. All patients underwent a standardized posttransplantation immunosuppressive protocol: induction with basiliximab, and maintenance mycophenolate mofetil, steroids, and calcineurin inhibitors when renal function was demonstrable. All patients were administrated intravenous iloprost for 12 days posttransplantation. We analyzed patient and graft survival at a median follow-up of 16 months, comparing the results obtained with grafts from marginal donors with those retrieved from ideal donors. The patients were divided into 4 groups: 31 patients received a kidney from an ideal cadaver donor (group 1a); 19 from a marginal cadaver donor (group 1b); 19 from an ideal living related kidney (group 2a); and 9 from a marginal living donor kidney graft (group 2b). From the Department of Surgery, Transplantation and Advanced Technologies, Organ Transplant Unit, University Hospital of Catania, Catania, Italy. Address reprint requests to Prof. Dr. Pierfrancesco Veroux, Department of Surgery, Transplantation and Advanced Technologies, Organ Transplant Unit, University Hospital of Catania, Via S. Sofia, 78, 95123 Catania, Italy. E-mail: [email protected] 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.012 497
498
RESULTS
Twenty-eight grafts from marginal donors were transplanted at our institution, including 38% of cadaver kidney transplants and 32.1% of living donors in the 28-month period. The average cold ischemia time was 16.4 hours, being lower in the marginal cadaver donor group (12.5 hours) than in the ideal cadaver donor group (19.4 hours). All recipients of a living related graft received their graft within 2 hours from the procurement. Marginal cadaver organ recipients were older than those who received transplants from ideal donors (mean age, 50 years vs 38 years, respectively). Acute tubular necrosis occurred in 65.4% of marginal recipients versus 20.3% of ideal recipients. At an average time of 16 months (range, 1–28 months), graft survival rates were 93%, 79%, 100%, and 100% and patient survival rates were 96%, 89%, 100%, and 100% for groups 1a, 1b, 2a, and 2b, respectively. Mean serum creatinine level in group 1a was 1.5 mg/dL (range, 0.5–1.8 mg/dL); group 1b, 2.4 mg/dL (range, 1.1–3.2 mg/dL); group 2a, 1.3 mg/dL (range, 0.6 –1.6 mg/dL); and group 2b, 2.2 mg/dL (range, 1.8 –3.2 mg/dL). DISCUSSION
There are about 7000 patients on the waiting list for kidney transplantation in Italy; only 20% of patients receive a graft each year. In the South of Italy, the rate of cadaver donors is 8/pmp, indicating a shortage of donors and mandating new criteria to expand the donor pool. The use of marginal donors to expand the pool has received increased attention. Marginal kidney donors consisted of 38% of cadaver donors and 32.1% of living donors in our experience. Despite the observation that the use of marginal donors
VEROUX, PULIATTI, VEROUX ET AL
has been associated with a worse outcome when compared with ideal donors,1–3 even the use of grafts from marginal donors improves the quality of life for patients.4,5 Moreover, transplantation of a marginal kidney is associated with a significant benefit in life expectancy when compared with maintenance dialysis.2 With informed consent, patients must have the opportunity to choose whether they prefer to receive a marginal kidney or to continue waiting for an ideal graft. We believe that a marginal kidney transplanted with an appropriate strategy, such as reduction of cold ischemia time, delay in beginning calcineurin inhibitors until renal function is demonstrable, administration of prostanoid in the postoperative period as an organ protector, and, finally, use of the organ in a population of healthy patients of older than 60 years of age (old-to-old program), yields the best results. This combination of strategies may be considered a feasible way to expand the donor pool, offering an increased number of potential grafts to wait-listed patients on maintenance dialysis. REFERENCES 1. Michelon T, Piovesan F, Castilho C, et al: Marginal cadaveric kidney donors: an attractive way to expand the donor pool. Transplant Proc 34:2515, 2002 2. Ojo AO, Hanson JA, Maier-Kriesche HU, et al: Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant recipients. J Am Soc Nephrol 12:589, 2001 3. Belardinelli L: Living donor transplantations with marginal kidneys. Transplant Proc 35:941, 2003 4. Laupacis A, Keown P, Pus N, et al: A study of the quality of life and cost-utility of renal transplantation. Kidney Int 50:235, 1996 5. Jofre R, Lopez-Gomez JM, Moreno F, et al: Changes in quality of life after renal transplantation. Am J Kidney Dis 32:93, 1998