Renal transplantation from

non-heart beating donors

M L Nicholson

P N Furness*Departments of Transplant Surgery and

*Pathology

Leicester General Hospital

UKThe University of Leicester

The problem - 1

The problem - 2

Sources of asystolic donors in Leicester

Irreversible cardiorespiratory arrest Accident & Emergency department –

failed resuscitation after MI Medical wards –

catastrophic intracerebral haemorrhage with ‘coning’

Leicester selection criteria for NHBDs

Age<60 Warm ischaemic time <40 minutes No history of renal impairment No uncontrolled hypertension No complicated insulin dependent diabetes No systemic sepsis or malignancy

Mechanical cardiopulmonary resuscitation device (a.k.a. ‘The Thumper’)

Correct positioning of aortic catheter

Cyclosporin protocol

Acute rejection rates

HBD

N=224

NHBD

N=77

LD

N=49Acute rejection 32.6% 28.6% 46.9%

Requiring ATG 12.1% 5.2% 14.3%

Early graft function rates

HBD

N=224

NHBD

N=77

LD

N=49Primary non-function

2.7% 9.1% 2%

Delayed graft function

21.0% 84.4% 4.1%

Initial function 76.3% 6.5% 93.9%

Graft function

Graft survival

NEWCASTLE DATA: KM - Survival curves Kidney survival - KM curve

0 1 2 30

20

40

60

80

100NHBD

Control

Time (year)

% s

urv

ival

Logrank p = ns

Patient Survival - KM curve

0 1 2 30

20

40

60

80

100 NHBD

Control

Time (year)

% s

urv

ival

Logrank p = ns

With thanks to:

Gok MA

Buckley PE

Mohamed MAS

Balupuri S

Shenton BK

Robertson H

Soomro N

Manas D

Talbot D

Liver / Renal Transplant Unit, The Freeman Hospital, Newcastle Upon Tyne,

UK

NEWCASTLE DATA: Creatinine Clearance (Cockroft & Gault)

Creatinine Clearance

0 3 6 9 12 15 18 21 24 27 30 33

0

20

40

60

80

100NHBD

Control

p < 0.0001 Mann Whitney U

Time (months from discharge)

Cre

at. C

l (m

l/min

)

Biopsy results: a ‘typical’ case, 1 week

Same case, 3 months

Hypertrophyof tubules

Littlefibrosis

Biopsy results: a ‘good’ case

1 week 1 month

Biopsy results: a ‘bad’ case. Pre-perfusion:

1 week:

3 weeks:

2 months:

Sirius Red analysis - fibrotic kidney

0

2.5

5

7.5

10

12.5

Conventional NHBD

Interstitial collagen volume fraction (Sirius Red, polarized light)Conventional and NHBD kidneys, 6 month protocol biopsies

P<0.05%

Conclusions: Non-heart beating donor kidneys

Increased PNF rate (decreases with experience) High DGF rate; dialysis usually needed Slightly higher serum creatinine, may compensate Slightly more interstitial fibrosis at 6 months Indistinguishable graft survival rate at 5 years Biopsy does not help with donor selection (?) Protocol biopsies detect acute rejection at unchanged rate Biopsy helps to distinguish PNF and DGF, but care

needed