Safety of dual kidney transplantation compared to single kidney transplantation from expanded criteria donors: a single center cohort study of 39 recipients

Our objective was to compare the outcomes of dual kidney transplanataion (DKT) to single kidney transplantation (SKT) performed with grafts from expanded criteria donors (ECD) in recipients ≥65 years, focusing on surgical complications. All kidney transplantations (KT) performed between 2006 and 2014 in our institution were analysed. DKT was indicated according to the criteria of the French national Agence de la Biomedecine. Thirty‐nine DKT and 155 SKT were included, with a median follow‐up of 36 and 26.5 months, respectively. The rate of early surgical revisions was not significantly higher after DKT (23.1% vs 15.5% (P = 0.2593)) but more venous graft thromboses (12.8% vs 3.2% (P = 0.02)) were reported. The glomerular filtration rate (GFR) 24 months after KT was significantly higher after DKT (45.0 ± 16.3 vs 39.8 ± 13.8 ml/min/1.73m²; P = 0.04) and allowed shorter waiting time without a significant increased risk of surgical revision, excepted for venous graft thrombosis, more frequent after DKT. Graft survivals were not significantly different and GFR was higher after DKT. DKT seems to remain an appropriate strategy to address the growing graft shortage in elderly patients.     

Kidney transplantation from donation after cardiac death donors: lack of impact of delayed graft function on post‐transplant outcomes

Singh RP, Farney AC, Rogers J, Zuckerman J, Reeves‐Daniel A, Hartmann E, Iskandar S, Adams P, Stratta RJ. Kidney transplantation from donation after cardiac death donors: lack of impact of delayed graft function on post‐transplant outcomes.
Clin Transplant 2011: 25: 255–264. © 2010 John Wiley & Sons A/S. Abstract: Introduction: Delayed graft function (DGF) is more common in recipients of kidney transplants from donation after cardiac death (DCD) donors compared to donation after brain death (DBD) donors. Methods: Single‐center retrospective study to evaluate the impact of DGF on controlled (Maastricht category III) DCD donor kidney transplant outcomes. Results: From 10/01 to 6/08, 578 adult deceased donor kidney transplants were performed including 70 (12%) from DCD and 508 (88%) from DBD donors. Mean follow‐up was 36 months. DCD donor kidney transplants had significantly greater rates of DGF (57% DCD vs. 21% DBD, p < 0.0001)) and acute rejection (29% DCD vs. 16% DBD, p = 0.018) compared to DBD donor kidney transplants, but patient and graft survival rates were similar. DBD donor kidney transplants with DGF (n = 109) had significantly greater rates of death‐censored graft loss (12.5% DCD vs. 31% DBD), primary non‐function (0 DCD vs. 10% DBD) and higher 2 year mean serum creatinine levels (1.4 DCD vs. 2.7 mg/dL DBD) compared to DCD donor kidney transplants with DGF (n = 40, all p < 0.04). On univariate analysis, the presence of acute rejection and older donor age were the only significant risk factors for death‐censored graft loss in DCD donor kidney transplants, whereas DGF was not a risk factor. Conclusion: Despite higher rates of DGF and acute rejection in DCD donor kidney transplants, subsequent outcomes in DCD donor kidney transplants with DGF are better than in DBD donor kidney transplants experiencing DGF, and similar to outcomes in DCD donor kidney transplants without DGF.     

Kidney transplantation in valvular heart disease and pulmonary hypertension: Consensus in waiting

Kidney transplantation induces a lesser anesthetic, surgical, and physiological alterations than other solid organ transplantation. Concomitant valvular pathologies expose these patients to poor postoperative outcome. There is a critical gap in knowledge and lack of coherence in the guidelines related to the management in patients with end‐stage renal disease with valvular heart disease. The individualized diagnostic and management plan should be based on the assessment of perioperative outcomes. Similarly, pulmonary hypertension in end‐stage renal disease poses a unique challenge, it can manifest in isolation or may be associated with other cardiac lesions, namely left‐sided valvular heart disease and left ventricular systolic and diastolic dysfunction. Quantification and stratification according to etiology are needed in pulmonary hypertension to ensure an adequate management plan to minimize the adverse perioperative outcomes. Lack of randomized controlled trials has imposed hindrance in proposing a unified approach to clinical decision‐making in these scenarios. In this review, we have described the magnitude of the problems, pathophysiologic interactions, impact on clinical outcomes and have also proposed a management algorithm for both the scenarios.     

Mechanical ventricular assist device as a bridge to recovery post‐ABO‐incompatible heart transplantation for failed Fontan circulation

A girl received an ABO‐incompatible heart transplantation (ABOiHTx) at the age of 3.5 years for failed univentricular palliation with protein‐losing enteropathy (PLE). She was born with a hypoplastic left heart syndrome and underwent multistage palliation to a Fontan circulation at 2½ years of age. After the Fontan surgery, she developed PLE, necessitating a Fontan revision, followed by a Fontan takedown and eventually HTx, which was performed with a blood group B heart into an O recipient. Right ventricular (RV) failure secondary to increased pulmonary vascular resistance (PVR) evolved immediately after HTx. A temporary right ventricular assist device (RVAD) was implanted and later switched to a pneumatic pulsatile RVAD. With the adaption of PVR on the RVAD, the PLE resolved and the RVAD was explanted. In the following 12 months, she developed multiple relapses of PLE which eventually resolved after exchange of the calcineurin inhibitor.     

The Impact of Deceased Donor Kidney Risk Significantly Varies by Recipient Characteristics

As of May 2012, over 92 000 patients were awaiting a solitary kidney transplant in the United States and new waitlist registrations have been rising for over a decade. The decreasing availability of donor organs makes it imperative that organ allocation be as efficient and effective as possible. We performed a retrospective cohort study of adult recipients in the United States (n = 109 392) using Scientific Registry of Transplant Recipients data. The primary aim was to evaluate the interaction of donor risk with recipient characteristics on posttransplant outcomes. Donor quality (based on kidney donor risk index [KDRI]) had significant interactions by race, primary diagnosis and age. The hazard of KDRI on overall graft loss in non‐African Americans was 2.16 (95%CI 2.08‐2.25) versus 1.85 (95%CI 1.75‐1.95) in African Americans (p < 0.0001), 2.16 (95%CI 2.08‐2.24) in nondiabetics versus 1.84 (95%CI 1.74‐1.94) in diabetics (p < 0.0001), and 2.22 (95%CI 2.13‐2.32) in recipients <60 years versus 1.83 (95%CI 1.74‐1.92) in recipients ≥60 (p < 0.0001). The relative hazard for diabetics at KDRI = 0.5 was 1.49 but at KDRI = 2.0 the hazard was significantly attenuated to 1.17; among African Americans the respective risks were 1.50 and 1.17 and among recipients 60 and over, it was between 1.64 and 1.22. These findings are critical considerations for informed decision‐making for transplant candidates.     

Dual kidney transplantation after liver transplantation: a good option to rescue a patient from dialysis

Abstract:  Chronic renal failure (CRF) due to calcineurin inhibitor (CNI) nephrotoxicity is one of the most serious side effects influencing mortality and morbidity after liver transplantation (LTx). One way to offer a longer survival and better quality of life to LTx recipients who develop CRF is kidney transplantation, though this is not feasible for all candidates due to the shortage of organs. With changes in the characteristics of the global donor pool, which includes increasing number of elderly donors, both kidneys from one older donor are transplanted into the same adult recipient (dual kidney transplantation, DKT) to offset the lower nephron mass. DKT might be an option after LTx to rescue a patient from dialysis, with consequent survival benefits. We report on two cases of DKT after LTx in patients with CRF who were on dialysis due to CNI nephrotoxicity.     

Mechanical bridge with extracorporeal membrane oxygenation and ventricular assist device to heart transplantation

The aim of this study was to evaluate the effect of double bridges with extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) in clinical heart transplantation. Between May 1994 and October 2000, 134 patients underwent heart transplantation at the National Taiwan University Hospital. Ten patients received ECMO or VAD support as bridges to transplantation. The ages ranged from 3 to 63 years. The indications included cardiac arrest under cardiopulmonary resuscitation in 2 and profound cardiogenic shock refractory to conventional therapy in 8 patients. Usually ECMO was first set up as rescue therapy. If ECMO could not be weaned off after short-term (usually 1 week) support, suitable VADs (HeartMate or Thoratec VAD) were implanted for medium-term or long-term support. Five patients received ECMO support as emergency rescue for 2 to 9 days, and then moved to Thoratec VAD for 8, 49, and 55 days, respectively, or centrifugal VAD for 31 days, or HeartMate VAD for 224 days. They all survived. The survival rate of double bridges with ECMO and VAD was 100%. In postcardiotomy cardiogenic shock, circulatory collapse from acute myocardial infarction or myocarditis, ECMO is the device of choice for short-term support. If heart transplantation is indicated, VADs should replace ECMO for their superiority as a bridge to heart transplantation. Our preliminary data of double bridges with ECMO and VAD revealed good results and were reliable and effective bridges to transplantation.     

Percutaneous venoarterial extracorporeal membrane oxygenation as a bridge to double valve implantation in acute biventricular heart failure with profound cardiogenic shock

A 71‐year‐old woman was admitted with acute hypoxic and hypercapnic respiratory failure and cardiogenic shock, secondary to acute on chronic biventricular systolic and diastolic congestive heart failure and severe aortic and mitral valve stenosis. She further presented with pulmonary hypertension and moderate‐to‐severe tricuspid regurgitation requiring high and increasing doses of vasopressors. The patient was percutaneously cannulated for venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and stabilized on ECMO, with a urine output of 17.3 L within the following 8 days. Balloon valvuloplasty and/or transcatheter aortic valve replacement were discussed but ruled out by the multidisciplinary team considering the mitral valve could not be fully addressed. Though lung function was not fully optimized, a window of opportunity was identified and used for double valve replacement on day 8 of VA‐ECMO support. After a 24‐hour vasoplegic period, the patient was extubated to continuous positive airway pressure and further transitioned to nasal cannula, following which she recovered well.     

Single lung transplantation from a brain-dead donor for a patient with idiopathic pulmonary fibrosis

Two single lung transplants from a single cadaveric donor were successfully conducted at 2 institutions on March 29, 2000, the first such procedure in Japan under newly introduced legislation. Our patient was a 48-year-old woman with idiopathic pulmonary fibrosis who underwent left single-lung transplantation under cardiopulmonary support. The donor lung was preserved in 4 degrees C modified Euro-Collins solution. Total ischemic time was 5 hours and 37 minutes. The postoperative course was uneventful. The patient was discharged on postoperative day 62 with satisfactory respiratory function.     

Successful Transplantation of Kidneys from a Donor with Myoglobinuric Acute Renal Failure

The shortage of donor organs is reflected in the growing number of patients on the waiting list for kidney transplantation worldwide. It seems to be sensible to expand the scarce donor pool by the cautious use of extended donor criteria. Kidneys from a 21-year-old deceased donor road traffic accident victim who suffered acute renal failure (ARF) due to myolysis were transplanted. Both transplantations were successful after an initial period of delayed graft function. Therefore, kidneys from deceased donors with ARF should not be excluded for transplantation in general.     

Impact of cold ischemia time on graft survival among ECD transplant recipients: a paired kidney analysis

Delays in expanded criteria donor (ECD) kidney placement increases cold ischemia times (CIT) potentially leading to discard. The effect of increased CIT on ECD kidney transplant outcomes is unknown. We evaluated paired ECD kidneys (derived from the same donor transplanted to different recipients) from the SRTR registry transplanted between 1995 and 2009 (n = 17,514). To test the effect of CIT, we excluded paired transplants with the same CIT (n = 3286). Of 14,230 recipients (7115 donors) the median difference in CIT was 5 h (Q1 = 3 h, Q3 = 9 h). Delayed graft function (DGF) was significantly more likely between pairs with greater CIT (35% vs. 31%, p < 0.001) including substantially higher rates for CIT differences ≥ 15 h (42%). Overall graft loss was not significantly different between recipients with higher CIT relative to paired donor recipients with lower CIT (p = 0.47) or for pairs with differences of 1-3 h (p = 0.90), 4-9 h (p = 0.41), 10-14 h (p = 0.36) or ≥ 15 h (p = 0.10). Results were consistent in multivariable models adjusted for recipient factors. Although increasing cold ischemia time is a risk factor for DGF among ECD kidney transplants, there is no effect on graft survival which may suggest an important utility for donor kidneys that may not currently be considered viable.     

Impact of mechanical circulatory support on pediatric heart transplant candidates with elevated pulmonary vascular resistance

With the new era of increasing use of mechanical circulatory support (MCS) in children, seemingly more patients with elevated pulmonary vascular resistance (PVR) are having positive outcomes. The purpose of this study was to define the effect of MCS on pediatric patients listed for heart transplant with an elevated PVR. The United Network for Organ Sharing (UNOS) database was used to identify patients aged 0‐18 at the time of listing for heart transplant between 2010 and 2019 who had PVR documented (n = 2081). Patients were divided into MCS (LVAD, RVAD, BiVAD, and TAH) and No MCS groups, then divided by PVR (PVR) at the time of listing: <3, 3‐6, and >6 Wood units (WU). MCS was used in 20% overall (n = 426); 57% of those with PVR <3, 27% with PVR 3‐6, and 16% with PVR >6. MCS, PVR <3 patients had a higher chance of positive waitlist outcome than all No MCS groups (vs. PVR <3, P = .049; vs. PVR 3‐6, P = .004; vs. PVR >6, P < .001). MCS, PVR 3‐6 patients had a higher chance of positive waitlist outcome than all No MCS groups (vs. PVR <3, P = .048; vs. PVR 3‐6, P = .009; vs. PVR >6, P < .001). MCS, PVR >6 patients had a higher chance of positive waitlist outcome than No MCS, PVR >6 patients (P = .012). Within the No MCS group, patients with a PVR >6 had a higher incidence of negative waitlist outcome compared to PVR <3 (17% vs. 10%, P = .002); this was not the case in the MCS group (5% vs. 6%, P = .693). More patients in the MCS group were ventilator dependent (15% vs. 9%, P < .001) at the time of listing and less likely to have a functional status >50% (43% vs. 73%, P < .001). No significant differences in post‐transplant survival were found in pairwise comparisons of MCS and No MCS PVR subgroups. Patients supported with MCS had a significantly higher chance of a positive waitlist outcome than those without such support regardless of PVR status. This was most pronounced with a PVR greater than 6 WU. MCS compared to No MCS patients had better waitlist survival and equivalent post‐transplant survival. MCS patients, despite being more ill, had better overall survival regardless of PVR.     

Duration of delayed graft function and outcomes after kidney transplantation from controlled donation after circulatory death donors: a retrospective study

The impact of the duration of delayed graft function (DGF) on graft survival is poorly characterized in controlled donation after circulatory death (DCD) donor kidney transplantation. A retrospective analysis was performed on 225 DCD donor kidney transplants between 2011 and 2016. When patients with primary nonfunction were excluded (n = 9), 141 recipients (65%) had DGF, with median (IQR) duration of dialysis dependency of 6 (2–11.75) days. Longer duration of dialysis dependency was associated with lower estimated glomerular filtration rate at 1 year, and a higher rate of acute rejection. On Kaplan–Meier analysis, the presence of DGF was associated with lower graft survival (log‐rank test P = 0.034), though duration of DGF was not (P = 0.723). However, multivariable Cox regression analysis found that only acute rejection was independently associated with lower graft survival [HR (95% CI) 4.302 (1.617–11.450); P = 0.003], whereas the presence of DGF and DGF duration were not. In controlled DCD kidney transplantation, DGF duration itself may not be independently associated with graft survival; rather, it may be that acute rejection associated with prolonged DGF is the poor prognostic factor.