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Results From A Single Kidney Procurement Center
0022"S347 /83/ i2SG-l l l 1$02,00/0 _;29, June
T::.:::E JDURNAL O::? UROLCGY
Copy-Tight© 1983 by The '.)Vill:ia:n:1s
"vVilld:'1S Co.
RESULTS FROIVI:
Printed in U.S.A.
SINGLE KIDNEY PROCUREIViENT CENTER
J. T. ROSENTHAL, D. DENNY
AND
T. R HAKALA
From the Department of Surgery, Division of Urological Surgery, University o/ Pittsburgh School o/ Medicine, Pittsburgh, Pennsylvania
ABSTRACT
During a 16-month interval 235 kidneys were recovered from 120 consecutive donors, 15 of which were not transplanted for a variety of reasons. The factors believed to be important in producing a low wastage rate of procured kidneys included careful management of the donor during the brain death period, en bloc resection to avoid damage to vascular structures and the ureter, and avoidance of cold ischemia. Because of reduced cost of treatment and increased rehabilitation of patients with functioning grafts kidney transplantation is the preferred treatment for suitable patients with end stage renal disease. A minority of patients with end stage renal disease have suitable living related donors. The need for cadaver kidneys exceeds the supply currently available. To increase the number of kidneys available for transplantation continuing efforts must be made to increase the pool of identified donors and decrease the wastage of recovered organs. Development of criteria for death has facilitated donor identification. Methods of organ procurement that minin1ize organ loss and maximize functioning kidneys are desirable. Techniques and advantages of en bloc resection i.n heartbeating cadaver donors 1 and important perioperative considerations in obtaining kidneys have been described. 2 However, the results of these techniques in terms of kidney viability and wastage are difficult to determine. We herein present our approach to organ recovery, which has resulted in decreased kidney wastage and increased function rates compared to those reported generally, TECHNIQUE
Between 1, 1980 and April 1, 1982, 235 kidneys were recovered from 120 donors (table 1). All procedures were performed by a member of the procurement team or under their direct supervision. All donors had suffered brain death as determined by accepted operational criteria. Donors were between 6 months and 57 years old. No antecedent of cardiac or renal disease was present. Potential donors excluded for any ,~~n,<--m~ blood cultures or other infection. all brain death had Foley catheters and tubes nosltitve cultures of these sites were not criteria for exclusion, mens were culturnd routinely ferentiate intrarenal infection bladder bacteriuria. Ten donors had W-''~'"F;VS,,~ """""in,,rn ·Nhich was not a criterion exclusion, =c-uvus;u fluid was cultused during the nephrectomy. were excluded if there vvas gross contamination with bowel contents. Management was coordinated a member of the organ retrieval team in an effort to maintain and support urine output and blood pressureo Blood pressure was maintained at a mean arterial pressure >88 mm. Hg, using crystalloid, colloid and dopamine at doses of 2 to 10 µ,g./k. per minute if necessary. The brain dead cadaver often had a massive water diuresis. ·We used a modification of the en bloc dissection described by Ackermann and Snell. 3 Either a cruciate abdominal incision or sternal splitting plus a midline abdominal incision was used. Kidneys were mobilized including Gerota's fascia. The aorta was isolated above the celiac artery after division of both Accepted for publication November 5, 1982.
superior mesenteric and celiac arteries when kidneys alone were being removed. The crura of the diaphragm were freed from the aorta< High cephalad dissection was used because polar renal arteries often were found to arise at the level of the superior mesenteric artery. The vena cava was isolated just below the liver. No dissection was performed in the area of the renal hili. Lumbar vessels were divided and ligatedo Dissection was carried wide of the ureters, including periureteral fat to avoid ureteral devascularization. The aorta and vena cava were cannulated above their bifurcations. No dissection was performed lateral to the aorta or vena cava since the location of the renal arteries was unknown. In atherosclerotic aortas cannulation was done through 1 iliac artery, so that when cross aortic occlusion above the renal arteries was performed any debris that was broken off could be flushed down the opposite iliac artery and not into one of the renal arterieso Mannitol 25 per cent (l to 2 gm./kg< body weight) was given either as a continuous infusion or in 3 to 4 boluses during nephrectomy. A continuous intravenous adrninistration of chlorpromazine hydrochloride (250 mg. in 500 cc) was begun at the incision if the systolic blood pressure was maintained at > 100 mm. Hgo Otherwise, 100 mg. chlorpromazine hydrochloride and 20,000 units heparin were immediately before cross clamping the proxLmal aorta. Immediately after the aorta was cross clamped in situ was done with cold Collins' solution (4C) to produce hypothermia. The ,nrmcmQ en bloc ,.vith the aorta and vena cava then were removed and placed in an ice slush bath A of Warm ischemia time with this technique was for nrP::s,•n,,:-it1011 and was done in the An aortic conduit was un;iuueu with each so that cannulation the renal arteries was avoided B and C of of vena cava was left on the for late:c 1e1e1g1"rncn.mg were placed on a at about 50 to 54 and was set at 55 ,11m, Hg. The to decrease and stabilize as vasculature dilated. pressure of 20 to 25 mm. Hg &nd individual perfusate flow through each of 1 cc/gm. were considered acceptable. RESULTS
Using this technique 235 kidneys were recovered from 120 consecutive donors. One kidney from each of 3 donors was not recovered owing to premortem lesions (2 lacerations and 1 congenital abnormality). Two kidneys were not recovered when unsuspected malignancy was discovered in the donor. Of the recovered kidneys 15 (6.7 per cent) were not transplanted (table 2), 7 because of inability to find a suitable recipient. Of the 7 kidneys 3 were sent to other institutions where potential recipients failed crossmatches before transplantation, 1 was discarded because transportation could not be obtained owing to
1111
1112
ROSENTHAL, DENNY AND HAKALA
a blizzard, 1 was sent to another institution but was lost because of technical errors before transplantation and 2 were unusable because of inadequate material for tissue typing. Eight kidneys from 5 donors had poor perfusion characteristics. Of these kidneys 5 were from 3 women, ages 57, 54 and 43 years, who had severe, diffuse atherosclerotic disease at the time of nephrectomy (table 2). No kidney was lost because of technical problems at operation, such as damage to renal arteries or ureters. Multiple renal arteries were encountered in 48 kidneys (20 per cent), 6 of which had 3 arteries and l had 4 arteries. All kidneys were transplanted successfully with a variety of well described techniques. 4 Crude discard rates are a measure of efficiency. Another equally important criterion is the rate of function of the transplanted kidneys. Although recipient management varies considerably and there are many factors governing renal function, immediate and early graft function is at least in part a reflection of donor management, and organ recovery and preservation. Of the 220 kidneys 161 were transplanted at our hospital and 59 were transplanted elsewhere. Followup is available on all 161 of our kidneys and 54 of the exported kidneys. Urine output of 750 cc more than the pre-transplant output occurred in the first 24 hours in 145 local recipients (89 per cent) and in 45 recipients (82 per cent) who underwent transplantation elsewhere. Firstweek dialysis was required in 35 local recipients (21 per cent) and 7 outside recipients (12 per cent). There were no vascular complications, while ureteral leakage occurred in 3 of our recipients (1.8 per cent). DISCUSSION
An effective means of organ recovery is essential because kidney transplantation is now an important primary treatment for end stage renal disease. Wastage of potentially transplantable kidneys is inefficient and expensive. Transplanting kidneys that may have sustained damage to blood vessels, ureters or parenchyma from trauma or ischemia gives recipients less than optimal chances of good graft function. Technical problems resulting in poorly functioning kidneys and graft failure should TABLE
be avoidable. Scrupulous pre-recovery management of the brain dead donor is important to support blood pressure and urine output, and to prevent infection. In situ cold perfusion,5 use of vasodilators 6 and en bloc resection minimize warm ischemia and possible damage to vessels and ureters. Finally, preservation methods are important. The issue of cold storage versus pulsatile perfusion is unresolved. 7 ' 8 We opted to use pulsatile perfusion initially but avoided direct cannulation of the renal arteries, since this may damage the arterial intima. Others have reported the use of simple cold storage for >24 hours. 9 Whether perfusion characteristics are true determinants of ultimate graft function is unresolved. Poor perfusion has occurred only in 8 kidneys and the decision to discard these organs was made by including other factors, such as age of the donor, condition of the large vessels or pre-recovery hypotension. The efficacy of the current approach is demonstrated by the low wastage and high early graft function rates. Data on rates of kidney nonuse following procurement are available from few sources. The pooled data from 38 centers of the South Eastern Organ Procurement Foundation showed 25 per cent kidney nonuse, with some individual groups reporting wastage rates as high as 50 per cent. Other groups have reported rates of 179 and 20.2 per cent. 10 The wastage rate in this series is 6.4 per cent and only 4 of the last 147 recovered kidneys were not transplanted (2.6 per cent). Urologic and vascular complication rates, and first-week dialysis rates are comparable to other large series. 11 ' 12 Most of the steps used herein have been described previously. We believe it is the familiarity with all aspects of donation and the organ recovery operation, as well as meticulous attention to details, that allows a low percentage of kidney wastage and a high percentage of good functioning kidneys. Some have advocated large scale community involvement in organ retrieval. The time commitment on the part of the transplant center staff is increased by having 1) a coordinator assist the pre-recovery management and 2) a center surgeon present at or performing all procedures. However, this center-oriented experience suggests that familiarity with unusual donor management and
1. Fate of kidneys procured by our university
TABLE
2. Reasons for nonuse of procured kidneys
No. Kidneys(%) Transplanted at our hospital Transplanted at other centers Shipped to other centers but not used Not transplanted Total
161 59 4
___1_1__(4.6)
235
No. Kidneys Inadequate lymph nodes for tissue typing No transportation available Shipped but not used Poor perfusion Total
2 1 4 8
15
® A, kidneys en bloc with vena cava and aorta in situ, with cannulas in place for perfusion. B and C, right and left kidneys after separation with segments of aorta and vena cava attached.
1113 renal anatornic variatior.Ls 1T1ay result in dec:rea.sed o:rgan_ loss and increased function. REFERENCES l. Linke, C. A., Linke, C. L, Davis, R. S. donor neph:rectomy. 6: 2. Salvatierra, 0., Jr., Olcott, K. C., Amend, W. J., Jr. and Feduska, N. J.: Procurement of cadaver kidneys. Urol. Clin. N. Amer., 3: 457, 1976. 3. Ackermann, J. R. and Snell, M. E.: Cadaveric renal transplantation: a technique for donor kidney removal. Brit. J. Urol., 40: 515, 1968. 4. Novick, A. C., Magnusson, M. and Braun, W. E.: Multiple-artery renal transplantation: emphasis on extracorporeal methods of donor arterial reconstruction. J. Urol., 122: 731, 1979. 5. Das, S., Maggio, A. J., Jr., Sacks, S. A., Smith, R. B. and Kaufman, J. J .: In situ flushing of donor kidneys: its technique and rationale. J. Urol., 121: 262, 1979. 6. Belzer, F. 0., Reed, T. W., Pryor, J.P., Kountz, S. L. and Dunphy, J. E.: Cause of renal injury in kidneys obtained from cadaver donors. Surg., Gynec. & Obst., 130: 467, 1970. 7. Belzer, F. 0. and Southard, J. H.: The future of kidney preservation. Transplantation, 30: 161, 1980. 8. Marshall, V. C.: Renal preservation prior to transplantation. Transplantation, 30: 165, 1980. 9. Barry, J.M., Fischer, S., Lieberman, C. and Fuchs, E. F.: Successful human kidney preservation by intracellular electrolyte flush followed by cold storage for more than 24 hours. J. Urol., 129: 473, 1983. 10. Cerny, J. C. and Hammock, R.: An analysis of renal wastage in cadaveric donor nephrectomy. Read at annual meeting of American Urological Association, abstract 260, Boston, Massachusetts, May 10-14, 1981. 11. Najarian, J. S., Sutherland, D. E., Simmons, R. L., Kjellstrand, C. M., Ramsay, R. C., Goetz, F. C., Fryd, D. and Sommer, B. G.: Ten year experience with renal transplantation in juvenile onset diabetics. Ann. Surg., l!Hl: 487, 1979. 12. Salvatierra, 0., Jr., Feduska, N. J., Cochrum, K. C., Najarian, J. S., Kountz, S. L. and Belzer, F. 0.: The impact of 1,000 renal transplants at one center. Ann. Surg., 186: 424, 1977.
EDITORIAL COMMENTS These authors report the outcome of cadaver kidney procurement fron, 120 consecutive donors. There were 235 kidneys removed and only 15 of the recovered kidneys were not transplanted. With kidney wastage rates varying from 20 to 50 per cent at other transplant centers the 6.4 per cent wastage rate described is an outstanding achievement. These results should serve as a standard against which other transplant centers can compare their results. Presently, charges for cadaver kidneys that are billed to recipient hospitals vary from $8,000 to more than $9,500 kidney. If the average procurement cost is $8,500 per kidney and average wastage rate is 25 per cent, then the saving realized by the authors of this report from a single procurement center is $374,000. The authors have detailed carefully those factors that they believe have resulted in a low kidney wastage rate. The high cost of kidney procurement can be reduced substantially by following the guidelines set forth in this report. Russell K. Lawson Department of Urology Froedtert Memorial Lutheran Hospital Milwaukee, Wisconsin The authors have achieved excellent results in their organ procurement program by strict adherence to established principles regarding donor preparation and cadaver kidney removal. This is reflected in the low reported rates of organ wastage (6.4 per cent) first-week recipient dialysis (19.5 per cent), post-transplant ureteral fistulas (1.8 per cent) and post-transplant vascular complications (O per cent). In this study all procurement operations were either performed or supervised by a member of the transplant center staff. Recruitment and training of community surgeons to perform organ retrieval are an alternate approach that has been implemented successfully in some programs.' Andrew C. Novick Department Cleveland Cleveland, Ohio 1. Barry, J. M., Fischer, S. M., Craig, D. H., Fuchs, E. F. and Farnsworth, M. A.: Effect of donor surgeon on first cadaver kidney transplant function. J. Urol., 127: 227, 1982.
II
T::.:::E JDURNAL O::? UROLCGY
Copy-Tight© 1983 by The '.)Vill:ia:n:1s
"vVilld:'1S Co.
RESULTS FROIVI:
Printed in U.S.A.
SINGLE KIDNEY PROCUREIViENT CENTER
J. T. ROSENTHAL, D. DENNY
AND
T. R HAKALA
From the Department of Surgery, Division of Urological Surgery, University o/ Pittsburgh School o/ Medicine, Pittsburgh, Pennsylvania
ABSTRACT
During a 16-month interval 235 kidneys were recovered from 120 consecutive donors, 15 of which were not transplanted for a variety of reasons. The factors believed to be important in producing a low wastage rate of procured kidneys included careful management of the donor during the brain death period, en bloc resection to avoid damage to vascular structures and the ureter, and avoidance of cold ischemia. Because of reduced cost of treatment and increased rehabilitation of patients with functioning grafts kidney transplantation is the preferred treatment for suitable patients with end stage renal disease. A minority of patients with end stage renal disease have suitable living related donors. The need for cadaver kidneys exceeds the supply currently available. To increase the number of kidneys available for transplantation continuing efforts must be made to increase the pool of identified donors and decrease the wastage of recovered organs. Development of criteria for death has facilitated donor identification. Methods of organ procurement that minin1ize organ loss and maximize functioning kidneys are desirable. Techniques and advantages of en bloc resection i.n heartbeating cadaver donors 1 and important perioperative considerations in obtaining kidneys have been described. 2 However, the results of these techniques in terms of kidney viability and wastage are difficult to determine. We herein present our approach to organ recovery, which has resulted in decreased kidney wastage and increased function rates compared to those reported generally, TECHNIQUE
Between 1, 1980 and April 1, 1982, 235 kidneys were recovered from 120 donors (table 1). All procedures were performed by a member of the procurement team or under their direct supervision. All donors had suffered brain death as determined by accepted operational criteria. Donors were between 6 months and 57 years old. No antecedent of cardiac or renal disease was present. Potential donors excluded for any ,~~n,<--m~ blood cultures or other infection. all brain death had Foley catheters and tubes nosltitve cultures of these sites were not criteria for exclusion, mens were culturnd routinely ferentiate intrarenal infection bladder bacteriuria. Ten donors had W-''~'"F;VS,,~ """""in,,rn ·Nhich was not a criterion exclusion, =c-uvus;u fluid was cultused during the nephrectomy. were excluded if there vvas gross contamination with bowel contents. Management was coordinated a member of the organ retrieval team in an effort to maintain and support urine output and blood pressureo Blood pressure was maintained at a mean arterial pressure >88 mm. Hg, using crystalloid, colloid and dopamine at doses of 2 to 10 µ,g./k. per minute if necessary. The brain dead cadaver often had a massive water diuresis. ·We used a modification of the en bloc dissection described by Ackermann and Snell. 3 Either a cruciate abdominal incision or sternal splitting plus a midline abdominal incision was used. Kidneys were mobilized including Gerota's fascia. The aorta was isolated above the celiac artery after division of both Accepted for publication November 5, 1982.
superior mesenteric and celiac arteries when kidneys alone were being removed. The crura of the diaphragm were freed from the aorta< High cephalad dissection was used because polar renal arteries often were found to arise at the level of the superior mesenteric artery. The vena cava was isolated just below the liver. No dissection was performed in the area of the renal hili. Lumbar vessels were divided and ligatedo Dissection was carried wide of the ureters, including periureteral fat to avoid ureteral devascularization. The aorta and vena cava were cannulated above their bifurcations. No dissection was performed lateral to the aorta or vena cava since the location of the renal arteries was unknown. In atherosclerotic aortas cannulation was done through 1 iliac artery, so that when cross aortic occlusion above the renal arteries was performed any debris that was broken off could be flushed down the opposite iliac artery and not into one of the renal arterieso Mannitol 25 per cent (l to 2 gm./kg< body weight) was given either as a continuous infusion or in 3 to 4 boluses during nephrectomy. A continuous intravenous adrninistration of chlorpromazine hydrochloride (250 mg. in 500 cc) was begun at the incision if the systolic blood pressure was maintained at > 100 mm. Hgo Otherwise, 100 mg. chlorpromazine hydrochloride and 20,000 units heparin were immediately before cross clamping the proxLmal aorta. Immediately after the aorta was cross clamped in situ was done with cold Collins' solution (4C) to produce hypothermia. The ,nrmcmQ en bloc ,.vith the aorta and vena cava then were removed and placed in an ice slush bath A of Warm ischemia time with this technique was for nrP::s,•n,,:-it1011 and was done in the An aortic conduit was un;iuueu with each so that cannulation the renal arteries was avoided B and C of of vena cava was left on the for late:c 1e1e1g1"rncn.mg were placed on a at about 50 to 54 and was set at 55 ,11m, Hg. The to decrease and stabilize as vasculature dilated. pressure of 20 to 25 mm. Hg &nd individual perfusate flow through each of 1 cc/gm. were considered acceptable. RESULTS
Using this technique 235 kidneys were recovered from 120 consecutive donors. One kidney from each of 3 donors was not recovered owing to premortem lesions (2 lacerations and 1 congenital abnormality). Two kidneys were not recovered when unsuspected malignancy was discovered in the donor. Of the recovered kidneys 15 (6.7 per cent) were not transplanted (table 2), 7 because of inability to find a suitable recipient. Of the 7 kidneys 3 were sent to other institutions where potential recipients failed crossmatches before transplantation, 1 was discarded because transportation could not be obtained owing to
1111
1112
ROSENTHAL, DENNY AND HAKALA
a blizzard, 1 was sent to another institution but was lost because of technical errors before transplantation and 2 were unusable because of inadequate material for tissue typing. Eight kidneys from 5 donors had poor perfusion characteristics. Of these kidneys 5 were from 3 women, ages 57, 54 and 43 years, who had severe, diffuse atherosclerotic disease at the time of nephrectomy (table 2). No kidney was lost because of technical problems at operation, such as damage to renal arteries or ureters. Multiple renal arteries were encountered in 48 kidneys (20 per cent), 6 of which had 3 arteries and l had 4 arteries. All kidneys were transplanted successfully with a variety of well described techniques. 4 Crude discard rates are a measure of efficiency. Another equally important criterion is the rate of function of the transplanted kidneys. Although recipient management varies considerably and there are many factors governing renal function, immediate and early graft function is at least in part a reflection of donor management, and organ recovery and preservation. Of the 220 kidneys 161 were transplanted at our hospital and 59 were transplanted elsewhere. Followup is available on all 161 of our kidneys and 54 of the exported kidneys. Urine output of 750 cc more than the pre-transplant output occurred in the first 24 hours in 145 local recipients (89 per cent) and in 45 recipients (82 per cent) who underwent transplantation elsewhere. Firstweek dialysis was required in 35 local recipients (21 per cent) and 7 outside recipients (12 per cent). There were no vascular complications, while ureteral leakage occurred in 3 of our recipients (1.8 per cent). DISCUSSION
An effective means of organ recovery is essential because kidney transplantation is now an important primary treatment for end stage renal disease. Wastage of potentially transplantable kidneys is inefficient and expensive. Transplanting kidneys that may have sustained damage to blood vessels, ureters or parenchyma from trauma or ischemia gives recipients less than optimal chances of good graft function. Technical problems resulting in poorly functioning kidneys and graft failure should TABLE
be avoidable. Scrupulous pre-recovery management of the brain dead donor is important to support blood pressure and urine output, and to prevent infection. In situ cold perfusion,5 use of vasodilators 6 and en bloc resection minimize warm ischemia and possible damage to vessels and ureters. Finally, preservation methods are important. The issue of cold storage versus pulsatile perfusion is unresolved. 7 ' 8 We opted to use pulsatile perfusion initially but avoided direct cannulation of the renal arteries, since this may damage the arterial intima. Others have reported the use of simple cold storage for >24 hours. 9 Whether perfusion characteristics are true determinants of ultimate graft function is unresolved. Poor perfusion has occurred only in 8 kidneys and the decision to discard these organs was made by including other factors, such as age of the donor, condition of the large vessels or pre-recovery hypotension. The efficacy of the current approach is demonstrated by the low wastage and high early graft function rates. Data on rates of kidney nonuse following procurement are available from few sources. The pooled data from 38 centers of the South Eastern Organ Procurement Foundation showed 25 per cent kidney nonuse, with some individual groups reporting wastage rates as high as 50 per cent. Other groups have reported rates of 179 and 20.2 per cent. 10 The wastage rate in this series is 6.4 per cent and only 4 of the last 147 recovered kidneys were not transplanted (2.6 per cent). Urologic and vascular complication rates, and first-week dialysis rates are comparable to other large series. 11 ' 12 Most of the steps used herein have been described previously. We believe it is the familiarity with all aspects of donation and the organ recovery operation, as well as meticulous attention to details, that allows a low percentage of kidney wastage and a high percentage of good functioning kidneys. Some have advocated large scale community involvement in organ retrieval. The time commitment on the part of the transplant center staff is increased by having 1) a coordinator assist the pre-recovery management and 2) a center surgeon present at or performing all procedures. However, this center-oriented experience suggests that familiarity with unusual donor management and
1. Fate of kidneys procured by our university
TABLE
2. Reasons for nonuse of procured kidneys
No. Kidneys(%) Transplanted at our hospital Transplanted at other centers Shipped to other centers but not used Not transplanted Total
161 59 4
___1_1__(4.6)
235
No. Kidneys Inadequate lymph nodes for tissue typing No transportation available Shipped but not used Poor perfusion Total
2 1 4 8
15
® A, kidneys en bloc with vena cava and aorta in situ, with cannulas in place for perfusion. B and C, right and left kidneys after separation with segments of aorta and vena cava attached.
1113 renal anatornic variatior.Ls 1T1ay result in dec:rea.sed o:rgan_ loss and increased function. REFERENCES l. Linke, C. A., Linke, C. L, Davis, R. S. donor neph:rectomy. 6: 2. Salvatierra, 0., Jr., Olcott, K. C., Amend, W. J., Jr. and Feduska, N. J.: Procurement of cadaver kidneys. Urol. Clin. N. Amer., 3: 457, 1976. 3. Ackermann, J. R. and Snell, M. E.: Cadaveric renal transplantation: a technique for donor kidney removal. Brit. J. Urol., 40: 515, 1968. 4. Novick, A. C., Magnusson, M. and Braun, W. E.: Multiple-artery renal transplantation: emphasis on extracorporeal methods of donor arterial reconstruction. J. Urol., 122: 731, 1979. 5. Das, S., Maggio, A. J., Jr., Sacks, S. A., Smith, R. B. and Kaufman, J. J .: In situ flushing of donor kidneys: its technique and rationale. J. Urol., 121: 262, 1979. 6. Belzer, F. 0., Reed, T. W., Pryor, J.P., Kountz, S. L. and Dunphy, J. E.: Cause of renal injury in kidneys obtained from cadaver donors. Surg., Gynec. & Obst., 130: 467, 1970. 7. Belzer, F. 0. and Southard, J. H.: The future of kidney preservation. Transplantation, 30: 161, 1980. 8. Marshall, V. C.: Renal preservation prior to transplantation. Transplantation, 30: 165, 1980. 9. Barry, J.M., Fischer, S., Lieberman, C. and Fuchs, E. F.: Successful human kidney preservation by intracellular electrolyte flush followed by cold storage for more than 24 hours. J. Urol., 129: 473, 1983. 10. Cerny, J. C. and Hammock, R.: An analysis of renal wastage in cadaveric donor nephrectomy. Read at annual meeting of American Urological Association, abstract 260, Boston, Massachusetts, May 10-14, 1981. 11. Najarian, J. S., Sutherland, D. E., Simmons, R. L., Kjellstrand, C. M., Ramsay, R. C., Goetz, F. C., Fryd, D. and Sommer, B. G.: Ten year experience with renal transplantation in juvenile onset diabetics. Ann. Surg., l!Hl: 487, 1979. 12. Salvatierra, 0., Jr., Feduska, N. J., Cochrum, K. C., Najarian, J. S., Kountz, S. L. and Belzer, F. 0.: The impact of 1,000 renal transplants at one center. Ann. Surg., 186: 424, 1977.
EDITORIAL COMMENTS These authors report the outcome of cadaver kidney procurement fron, 120 consecutive donors. There were 235 kidneys removed and only 15 of the recovered kidneys were not transplanted. With kidney wastage rates varying from 20 to 50 per cent at other transplant centers the 6.4 per cent wastage rate described is an outstanding achievement. These results should serve as a standard against which other transplant centers can compare their results. Presently, charges for cadaver kidneys that are billed to recipient hospitals vary from $8,000 to more than $9,500 kidney. If the average procurement cost is $8,500 per kidney and average wastage rate is 25 per cent, then the saving realized by the authors of this report from a single procurement center is $374,000. The authors have detailed carefully those factors that they believe have resulted in a low kidney wastage rate. The high cost of kidney procurement can be reduced substantially by following the guidelines set forth in this report. Russell K. Lawson Department of Urology Froedtert Memorial Lutheran Hospital Milwaukee, Wisconsin The authors have achieved excellent results in their organ procurement program by strict adherence to established principles regarding donor preparation and cadaver kidney removal. This is reflected in the low reported rates of organ wastage (6.4 per cent) first-week recipient dialysis (19.5 per cent), post-transplant ureteral fistulas (1.8 per cent) and post-transplant vascular complications (O per cent). In this study all procurement operations were either performed or supervised by a member of the transplant center staff. Recruitment and training of community surgeons to perform organ retrieval are an alternate approach that has been implemented successfully in some programs.' Andrew C. Novick Department Cleveland Cleveland, Ohio 1. Barry, J. M., Fischer, S. M., Craig, D. H., Fuchs, E. F. and Farnsworth, M. A.: Effect of donor surgeon on first cadaver kidney transplant function. J. Urol., 127: 227, 1982.
II