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
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