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Role of Pulsatile Perfusion With Tissue Plasminogen Activator in Deceased Donor Kidneys With Extensive Glomerular Thrombosis
CLINICAL
Role of Pulsatile Perfusion With Tissue Plasminogen Activator in Deceased Donor Kidneys With Extensive Glomerular Thrombosis D.D. Nghiem, P.R. Olson, and K.K. Sureshkumar ABSTRACT Background. Pulsatile perfusion (PP) improves delayed graft function, whereas tissue plasminogen activator (tPA) lyses thrombi. We studied the role of PP with tPA containing perfusate in deceased donor kidneys (DDK) with 50% thrombosed glomeruli. Methods. Fourteen DDK with extensive glomerular thrombi on biopsies were preserved using PP with histidine-tryptophan-ketoglutarate solution containing tPA. Wedge biopsies were repeated after PP. Results. Causes of donor death included closed head trauma in 8, anoxia in 2, and stroke in 4. Donors who averaged 33.3 years old displayed a final 24-hour urine volume of 1933 mL, a terminal serum creatinine level of 1.8 mg/dL, a blood urea nitrogen of 20 mg/dL, and a platelet count of 128,000/L. The initial flow of 47 mL improved to 111 mL/min after 16.17 hours of perfusion. Resistive indices (RI) decreased from 0.69 to 0.26 at 4.2°C. Biopsy specimens after PP showed a reduction in glomerular thrombi from 50% to 23%. Recipients averaged 54.9 years old. Cold ischemia time averaged 35.5 hours. One patient displayed primary allograft nonfunction, 3 required transient dialysis, and 10 showed prompt allograft function. Recipient follow-up averaged 12 months, with serum creatinine levels of 4.3 mg/dL at 1 week, 2.0 mg/dL at 1 month, and 1.6 mg/dL at last follow-up. Conclusions. Renal allografts with extensive glomerular thrombosis improved their biopsy appearance following PP with tPA. Improvement in PP parameters allowed successful transplantation of such kidneys that otherwise would have been discarded. PP with tPA appears to be beneficial for kidneys with extensive glomerular thrombosis.
D
ECEASED donor kidneys (DDK) with microvascular and glomerular thromboses have not been widely accepted for transplantation.1,2 We have reported on the successful transplantation of kidneys with severe glomerular thrombosis using tissue plasminogen activator (tPA) flush.3 We now report on the use of pulsatile perfusion (PP) with histidine-tryptophane-ketoglutarate solution (HTK; Custodiol, Odyssey Pharmaceutical Inc., East Hanover, NJ, United States) containing Alteplase, a DNA recombinant
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 41, 29 –31 (2009)
tissue plasminogen activator (Activase, Genentech Inc, South San Francisco, Calif, United States). This approach
From the Division of Transplantation (D.D.N.), Department of Laboratory Medicine (P.R.O.), and Division of Nephrology and Hypertension (K.K.S.), Allegheny General Hospital, Pittsburgh, Pennsylvania, USA. Address reprint requests to Dai D. Nghiem, MD, 340 Huelva Court, Oceanside, CA 92057, USA. E-mail: [email protected] 0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2008.08.150 29
30
NGHIEM, OLSON, AND SURESHKUMAR
might permit one to combine the property of PP to reduce delayed graft function (DGF) and the thrombolytic effects of Activase.
reactive antibody levels ⬎20% were also kept on low-dose prednisone maintenance.
RESULTS MATERIALS AND METHODS This is a retrospective study of the function of 14 DDK with massive glomerular thromboses (50% thrombosed glomeruli detected on wedge biopsies) that were treated with PP using Custodiol containing 200 mg Alteplase. This new protocol was implemented in July 2006, by the Medical Board of Directors, Center for Organ Recovery and Education (CORE, Pittsburgh, Penn, United States). All kidneys were flushed in situ with 10 L Custodiol during organ procurement. Wedge biopsies yielded frozen sections stained with hematoxylin-eosin to be read by pathologists and a surgeon knowledgeable in renal biopsies. Glomerular thrombosis was expressed as the ratio number of thrombosed/total glomeruli per slide on low magnification. Results were reported to 6 transplantation centers served by CORE (University of Pittsburgh Medical Center, Pittsburgh Children’s Hospital, West Virginia Charleston Area Medical Center, Pittsburgh Veterans Administration Health Services, University of West Virginia at Morgantown, and Allegheny General Hospital). All kidneys with thrombosed glomeruli underwent PP with a Waters RM 3 apparatus (Waters Inc., Rochester Minn, United States). All kidneys turned down by the other 5 transplantation centers had at least 50% thrombosed glomeruli. Only kidneys with minimal arteriosclerosis and interstitial fibrosis, absence of tissue necrosis, improvement of biopsy results after PP, and normalization of perfusion parameters were used at our center. Kidneys that maintained low perfusion flows and resistive indices (RI) ⬎0.40 were discarded. Biopsies were repeated prior to transplantation. One half of wedge biopsy specimens were frozen sectioned for immediate interpretation and the decision to use the organs. The remaining halves fixed in formalin were processed for permanent sections with special staining. All recipients were informed of the nature of the kidneys, the results of biopsies, and the perfusion parameters. Nine recipients with 1 of the following parameters (age ⬎ 55 years, diabetes mellitus, or coronary artery disease) received induction therapy with basiliximab (Simulect, Novartis, East Hanover, NJ, United States). The remaining 5 patients received either rabbit antithymocyte globulin (Thymoglobulin, Sangstat, Fremont, Calif, United States) or, more recently, alemtuzumab (Campath 1H, Genzyme Corporation and Bayer Schering Pharma AG, Germany). We used therapy with a calcineurin inhibitor, mycophenolate mofetil, and 4 days of intravenous methylprednisolone. Patients with panelTable 1. Deceased Donor and Kidney Demographic Characteristics Age (y) Final 24-h urine output (mL) Terminal BUN (mg/dL) Terminal serum creatinine (mg/dL) Blood sugar (mg/dL) Serum sodium (meg/L) WBC count (L) Platelet count (L) HLA AB-DR match Thrombosed glomeruli (%)
33.3 (17–55) 1933 (1300–2500) 20 (11–29) 1.8 (0.3–3.3) 150 (130–400) 145 (135–174) 10,000 (14,000–20,000) 128,000 (52,000–474,000) 1.3 (1.0–6.0) 48 (35–60)
Abbreviations: BUN, blood urea nitrogen; WBC, white blood cell.
Donor and kidney demographic data are shown in Table 1. Causes of donor death included close head trauma (n ⫽ 8), stroke (n ⫽ 4), and anoxia (n ⫽ 2). The kidneys on PP with tPA showed an average initial flow of 47 mL/min (19 –105 mL) under low perfusion pressure. This improved to 111 mL/min (55–196 mL) after 16.17 hours (7–24 hours) of perfusion at 4.2°C (3.2°–5.1°). Their RI improved from 0.69 (0.4 –1.57) to 0.26 (0.12– 0.45) when kidneys were removed from PP for transplantation. A reduction in thrombosed glomeruli from 50% to 23% was observed among pretransplantation biopsy specimens. Cold ischemia time (CIT) averaged 35.5 hours (22.4 –51.1 hours). One patient showed primary nonfunction, 3 required transient dialysis, and 10 displayed prompt allograft function. Recipient follow-up averaged 12 months (range, 6 –23 months). Serum creatinine levels were 4.3 mg/dL (1.9 –9.7 mg/dL) at 1 week posttransplantation, 2.0 mg/dL (1.4 – 3.2 mg/dL) at 1 month, and 1.6 mg/dL (1.2–2.6 mg/dL) at last follow-up. No biopsies were performed after transplantation to follow the progression/regression of glomerular thrombosis. DISCUSSION
The systematic renal allograft biopsy protocol in donors with brain injury or massive blood transfusion has identified a special category of extended criteria donors (ECD), namely, those with microvascular and glomerular thrombosis. There is a paucity of literature pertinent to the use of these high-risk donor kidneys. We have relied on current therapeutic manipulations to transplant those kidneys that showed improvement of PP parameters and lysis of glomerular thrombosis with tPA, leading to recovery of a greater number of ECD and donation after cardiac death (DCD) kidneys. Thus PP has gained renewed interest and acceptance since its first use in the 1970s. In the May 2007 Scientific Registry of Transplant Recipients (SRTR) analysis, 91.1% of DCD and ECD kidneys were pumped to improve spasm and reduce DGF.4 A systematic review and meta-analysis by Wright et al described a 20% reduction in the incidence of DGF when kidneys were preserved using PP compared with cold storage (CS), especially those with longer CIT.5 However, this did not translate into improved 1-year graft survival. Analysis of the SRTR data base from 1994 –2003 revealed a greater than 6-fold odds of incurring DGF among transplants with more than 30 hours of CIT that were not pumped relative to those with 0 –12 hours of CIT that underwent PP.6 The DGF rate among DCD transplants was 54% with CS and 46.0% with PP (P ⬍ .001). Among the ECD kidneys, the DGF rate was 52.1% when CS was used compared with 37.2% with PP (P ⬍ .001). Thus there is a strong interest among organ procurement organizations to send high-risk kidneys with diffuse glomerular thrombosis
EXTENSIVE GLOMERULAR THROMBOSIS
to centers using them to shorten the CIT as soon as the results of primary biopsies are available. Perfusion parameters, such as flow and RI, have recently gained acceptance among centers as a means to evaluate the “quality” of the kidneys and help make decisions whether to transplant or to discard. Analysis of a single donor service area data-base by Cho et al reported an adjusted odds ratio for discard of 8.86 for RI ⬎0.40 versus a lower RI (P ⫽ .006).7 The discard rate was 73.3% when final RI was ⬎0.40 versus 7.2% for final RI of ⱕ0.30. In one study8 there was a correlation between predictable kidney quality and the reduction rate of RI. Among the group with immediate graft function, RI improved from 0.50 to 0.30 within 3 hours of PP, whereas in the DGF group it took up to 12 hours to improve RI from 0.80 to 0.30. In the current study, it took up to 16 hours to dissolve the glomerular thrombi with the low tPA levels in the perfusate; whereas it took only 1 hour to completely lyse the glomerular thrombi with the 30% concentration of tPA that was reported previously.3 Recovery of the allograft function seems likely after 12–16 hours of PP when RI was brought down to 0.30 levels. In summary, it is concluded that the presence of massive glomerular thrombosis does not preclude transplantation provided that there is excellent terminal function and lack of cortical necrosis. Thrombi can be successfully lysed with
31
12–16 hours of PP using perfusate containing tPA, Improvement in PP parameters such as increased perfusion flows and reduced RI ⬍0.30 signals a transplantable organs. Ex vivo thrombolysis using tPA perfusion may expand the donor pool. REFERENCES 1. Mc Call SJ, Tutle-Newhall JE, Howell DN, et al: Prognostic significance of microvascular thrombosis in donor kidney allograft biopsies. Transplantation 75:1847, 2003 2. Hefty TR, Cotterell LW, Fraser CS, et al: Disseminated intravascular coagulation in cadaveric organ donors. Transplantation 55:442, 1992 3. Nghiem DD, Olson PR, Sureshkumar KK: Significance of microvascular thrombosis in renal allografts: role of ex-vivo thrombolytic therapy. Clin Transplant 21:172, 2007 4. Sung RS, Galloway J, Tutle-Newhall JE, et al: Organ donation and utilization in the United States, 1997–2006. Am J Transplant 8:922, 2008 5. Wright JP, Chilcott JB, Holmes MW, et al: Pulsatile machine perfusion vs. cold storage of kidneys for transplantation: a rapid and systematic review. Clin Transplant 17:293, 2003 6. Schold JD, Kaplan B, Howard RJ, et al: Are we frozen in time? Analysis of the utilization and efficacy of pulsatile perfusion in renal transplantation. Transplantation 5:1681, 2005 7. Cho YW, Shah T, Stadtler M, et al: Factors associated with discard of recovered kidneys. Transplant Proc 40:1032, 2008 8. Retznik ON, Bagnenko SF, Loginov VA, et al: Machine perfusion as a tool to select kidneys recovered from uncontrolled donors after cardiac death. Transplant Proc 40:1023, 2008
Role of Pulsatile Perfusion With Tissue Plasminogen Activator in Deceased Donor Kidneys With Extensive Glomerular Thrombosis D.D. Nghiem, P.R. Olson, and K.K. Sureshkumar ABSTRACT Background. Pulsatile perfusion (PP) improves delayed graft function, whereas tissue plasminogen activator (tPA) lyses thrombi. We studied the role of PP with tPA containing perfusate in deceased donor kidneys (DDK) with 50% thrombosed glomeruli. Methods. Fourteen DDK with extensive glomerular thrombi on biopsies were preserved using PP with histidine-tryptophan-ketoglutarate solution containing tPA. Wedge biopsies were repeated after PP. Results. Causes of donor death included closed head trauma in 8, anoxia in 2, and stroke in 4. Donors who averaged 33.3 years old displayed a final 24-hour urine volume of 1933 mL, a terminal serum creatinine level of 1.8 mg/dL, a blood urea nitrogen of 20 mg/dL, and a platelet count of 128,000/L. The initial flow of 47 mL improved to 111 mL/min after 16.17 hours of perfusion. Resistive indices (RI) decreased from 0.69 to 0.26 at 4.2°C. Biopsy specimens after PP showed a reduction in glomerular thrombi from 50% to 23%. Recipients averaged 54.9 years old. Cold ischemia time averaged 35.5 hours. One patient displayed primary allograft nonfunction, 3 required transient dialysis, and 10 showed prompt allograft function. Recipient follow-up averaged 12 months, with serum creatinine levels of 4.3 mg/dL at 1 week, 2.0 mg/dL at 1 month, and 1.6 mg/dL at last follow-up. Conclusions. Renal allografts with extensive glomerular thrombosis improved their biopsy appearance following PP with tPA. Improvement in PP parameters allowed successful transplantation of such kidneys that otherwise would have been discarded. PP with tPA appears to be beneficial for kidneys with extensive glomerular thrombosis.
D
ECEASED donor kidneys (DDK) with microvascular and glomerular thromboses have not been widely accepted for transplantation.1,2 We have reported on the successful transplantation of kidneys with severe glomerular thrombosis using tissue plasminogen activator (tPA) flush.3 We now report on the use of pulsatile perfusion (PP) with histidine-tryptophane-ketoglutarate solution (HTK; Custodiol, Odyssey Pharmaceutical Inc., East Hanover, NJ, United States) containing Alteplase, a DNA recombinant
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 41, 29 –31 (2009)
tissue plasminogen activator (Activase, Genentech Inc, South San Francisco, Calif, United States). This approach
From the Division of Transplantation (D.D.N.), Department of Laboratory Medicine (P.R.O.), and Division of Nephrology and Hypertension (K.K.S.), Allegheny General Hospital, Pittsburgh, Pennsylvania, USA. Address reprint requests to Dai D. Nghiem, MD, 340 Huelva Court, Oceanside, CA 92057, USA. E-mail: [email protected] 0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2008.08.150 29
30
NGHIEM, OLSON, AND SURESHKUMAR
might permit one to combine the property of PP to reduce delayed graft function (DGF) and the thrombolytic effects of Activase.
reactive antibody levels ⬎20% were also kept on low-dose prednisone maintenance.
RESULTS MATERIALS AND METHODS This is a retrospective study of the function of 14 DDK with massive glomerular thromboses (50% thrombosed glomeruli detected on wedge biopsies) that were treated with PP using Custodiol containing 200 mg Alteplase. This new protocol was implemented in July 2006, by the Medical Board of Directors, Center for Organ Recovery and Education (CORE, Pittsburgh, Penn, United States). All kidneys were flushed in situ with 10 L Custodiol during organ procurement. Wedge biopsies yielded frozen sections stained with hematoxylin-eosin to be read by pathologists and a surgeon knowledgeable in renal biopsies. Glomerular thrombosis was expressed as the ratio number of thrombosed/total glomeruli per slide on low magnification. Results were reported to 6 transplantation centers served by CORE (University of Pittsburgh Medical Center, Pittsburgh Children’s Hospital, West Virginia Charleston Area Medical Center, Pittsburgh Veterans Administration Health Services, University of West Virginia at Morgantown, and Allegheny General Hospital). All kidneys with thrombosed glomeruli underwent PP with a Waters RM 3 apparatus (Waters Inc., Rochester Minn, United States). All kidneys turned down by the other 5 transplantation centers had at least 50% thrombosed glomeruli. Only kidneys with minimal arteriosclerosis and interstitial fibrosis, absence of tissue necrosis, improvement of biopsy results after PP, and normalization of perfusion parameters were used at our center. Kidneys that maintained low perfusion flows and resistive indices (RI) ⬎0.40 were discarded. Biopsies were repeated prior to transplantation. One half of wedge biopsy specimens were frozen sectioned for immediate interpretation and the decision to use the organs. The remaining halves fixed in formalin were processed for permanent sections with special staining. All recipients were informed of the nature of the kidneys, the results of biopsies, and the perfusion parameters. Nine recipients with 1 of the following parameters (age ⬎ 55 years, diabetes mellitus, or coronary artery disease) received induction therapy with basiliximab (Simulect, Novartis, East Hanover, NJ, United States). The remaining 5 patients received either rabbit antithymocyte globulin (Thymoglobulin, Sangstat, Fremont, Calif, United States) or, more recently, alemtuzumab (Campath 1H, Genzyme Corporation and Bayer Schering Pharma AG, Germany). We used therapy with a calcineurin inhibitor, mycophenolate mofetil, and 4 days of intravenous methylprednisolone. Patients with panelTable 1. Deceased Donor and Kidney Demographic Characteristics Age (y) Final 24-h urine output (mL) Terminal BUN (mg/dL) Terminal serum creatinine (mg/dL) Blood sugar (mg/dL) Serum sodium (meg/L) WBC count (L) Platelet count (L) HLA AB-DR match Thrombosed glomeruli (%)
33.3 (17–55) 1933 (1300–2500) 20 (11–29) 1.8 (0.3–3.3) 150 (130–400) 145 (135–174) 10,000 (14,000–20,000) 128,000 (52,000–474,000) 1.3 (1.0–6.0) 48 (35–60)
Abbreviations: BUN, blood urea nitrogen; WBC, white blood cell.
Donor and kidney demographic data are shown in Table 1. Causes of donor death included close head trauma (n ⫽ 8), stroke (n ⫽ 4), and anoxia (n ⫽ 2). The kidneys on PP with tPA showed an average initial flow of 47 mL/min (19 –105 mL) under low perfusion pressure. This improved to 111 mL/min (55–196 mL) after 16.17 hours (7–24 hours) of perfusion at 4.2°C (3.2°–5.1°). Their RI improved from 0.69 (0.4 –1.57) to 0.26 (0.12– 0.45) when kidneys were removed from PP for transplantation. A reduction in thrombosed glomeruli from 50% to 23% was observed among pretransplantation biopsy specimens. Cold ischemia time (CIT) averaged 35.5 hours (22.4 –51.1 hours). One patient showed primary nonfunction, 3 required transient dialysis, and 10 displayed prompt allograft function. Recipient follow-up averaged 12 months (range, 6 –23 months). Serum creatinine levels were 4.3 mg/dL (1.9 –9.7 mg/dL) at 1 week posttransplantation, 2.0 mg/dL (1.4 – 3.2 mg/dL) at 1 month, and 1.6 mg/dL (1.2–2.6 mg/dL) at last follow-up. No biopsies were performed after transplantation to follow the progression/regression of glomerular thrombosis. DISCUSSION
The systematic renal allograft biopsy protocol in donors with brain injury or massive blood transfusion has identified a special category of extended criteria donors (ECD), namely, those with microvascular and glomerular thrombosis. There is a paucity of literature pertinent to the use of these high-risk donor kidneys. We have relied on current therapeutic manipulations to transplant those kidneys that showed improvement of PP parameters and lysis of glomerular thrombosis with tPA, leading to recovery of a greater number of ECD and donation after cardiac death (DCD) kidneys. Thus PP has gained renewed interest and acceptance since its first use in the 1970s. In the May 2007 Scientific Registry of Transplant Recipients (SRTR) analysis, 91.1% of DCD and ECD kidneys were pumped to improve spasm and reduce DGF.4 A systematic review and meta-analysis by Wright et al described a 20% reduction in the incidence of DGF when kidneys were preserved using PP compared with cold storage (CS), especially those with longer CIT.5 However, this did not translate into improved 1-year graft survival. Analysis of the SRTR data base from 1994 –2003 revealed a greater than 6-fold odds of incurring DGF among transplants with more than 30 hours of CIT that were not pumped relative to those with 0 –12 hours of CIT that underwent PP.6 The DGF rate among DCD transplants was 54% with CS and 46.0% with PP (P ⬍ .001). Among the ECD kidneys, the DGF rate was 52.1% when CS was used compared with 37.2% with PP (P ⬍ .001). Thus there is a strong interest among organ procurement organizations to send high-risk kidneys with diffuse glomerular thrombosis
EXTENSIVE GLOMERULAR THROMBOSIS
to centers using them to shorten the CIT as soon as the results of primary biopsies are available. Perfusion parameters, such as flow and RI, have recently gained acceptance among centers as a means to evaluate the “quality” of the kidneys and help make decisions whether to transplant or to discard. Analysis of a single donor service area data-base by Cho et al reported an adjusted odds ratio for discard of 8.86 for RI ⬎0.40 versus a lower RI (P ⫽ .006).7 The discard rate was 73.3% when final RI was ⬎0.40 versus 7.2% for final RI of ⱕ0.30. In one study8 there was a correlation between predictable kidney quality and the reduction rate of RI. Among the group with immediate graft function, RI improved from 0.50 to 0.30 within 3 hours of PP, whereas in the DGF group it took up to 12 hours to improve RI from 0.80 to 0.30. In the current study, it took up to 16 hours to dissolve the glomerular thrombi with the low tPA levels in the perfusate; whereas it took only 1 hour to completely lyse the glomerular thrombi with the 30% concentration of tPA that was reported previously.3 Recovery of the allograft function seems likely after 12–16 hours of PP when RI was brought down to 0.30 levels. In summary, it is concluded that the presence of massive glomerular thrombosis does not preclude transplantation provided that there is excellent terminal function and lack of cortical necrosis. Thrombi can be successfully lysed with
31
12–16 hours of PP using perfusate containing tPA, Improvement in PP parameters such as increased perfusion flows and reduced RI ⬍0.30 signals a transplantable organs. Ex vivo thrombolysis using tPA perfusion may expand the donor pool. REFERENCES 1. Mc Call SJ, Tutle-Newhall JE, Howell DN, et al: Prognostic significance of microvascular thrombosis in donor kidney allograft biopsies. Transplantation 75:1847, 2003 2. Hefty TR, Cotterell LW, Fraser CS, et al: Disseminated intravascular coagulation in cadaveric organ donors. Transplantation 55:442, 1992 3. Nghiem DD, Olson PR, Sureshkumar KK: Significance of microvascular thrombosis in renal allografts: role of ex-vivo thrombolytic therapy. Clin Transplant 21:172, 2007 4. Sung RS, Galloway J, Tutle-Newhall JE, et al: Organ donation and utilization in the United States, 1997–2006. Am J Transplant 8:922, 2008 5. Wright JP, Chilcott JB, Holmes MW, et al: Pulsatile machine perfusion vs. cold storage of kidneys for transplantation: a rapid and systematic review. Clin Transplant 17:293, 2003 6. Schold JD, Kaplan B, Howard RJ, et al: Are we frozen in time? Analysis of the utilization and efficacy of pulsatile perfusion in renal transplantation. Transplantation 5:1681, 2005 7. Cho YW, Shah T, Stadtler M, et al: Factors associated with discard of recovered kidneys. Transplant Proc 40:1032, 2008 8. Retznik ON, Bagnenko SF, Loginov VA, et al: Machine perfusion as a tool to select kidneys recovered from uncontrolled donors after cardiac death. Transplant Proc 40:1023, 2008