Reasons Why Organs From Deceased Donors Were Not Accepted for Transplantation

IntroductionThe rate of organ donations from deceased donors in Turkey is among the lowest in the world. We analyzed the reasons why some potential donors whose families had given consent did not become actual solid organ donors.MethodsWe retrospectively reviewed the organ donation, retrieval, and transplantation registries of 102 potential donors from the Ministry of Health Organ and Tissue Transplant Coordination Centre of Istanbul Region from the year 2015.ResultsCardiac arrest occurred in 8 of the potential donors while waiting for organ procurement or during surgery. The organ specific suitability ratio was 83% for kidneys, 82% for livers, 72% for hearts, and 75% for lungs. Of these suitable organs, the transplantation rates were as follows: kidneys 88%, livers 70%, hearts 30%, and lungs 13%. Medical reasons (donor unsuitable) (14%–24%) and poor organ function (2%–24%) were the reasons most organs were not accepted for transplant. These reasons included diabetes insipidus, electrolyte imbalance caused by neuro-humoral changes, inotrope/vasopressor requirement for hemodynamic instability, hypoperfusion, and myocardial dysfunction after brain death.ConclusionThe mismatch between organ donation and demand is a major problem worldwide. In addition to low organ donation rates, late diagnosis of potential donors or inappropriate management of the pathophysiological consequences of brain death reduce the number of transplantable organs even more in our country. In order to overcome these setbacks, we need education programs to improve quality and decrease donor losses in an intensive care unit goal-directed protocol for the management of potential donors.     

Correlation of the Renal Cortex Volume With the Glomerular Filtration Rate in Live Donors for Renal Transplantation

Introduction

As a pretransplantation evaluation, renal function is determined by the glomerular filtration rate (GFR) with the use of renal scintigraphy (RS) and the estimated glomerular filtration rate (eGFR). To date, there are few studies that correlate renal cortex volume with eGFR determined with renal gammagram (GR) and eGFR by equations (Cockroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration equation) in Latin American living donors.

Proposal of Categorization of Expanded Criteria Donors in Renal Transplantation

IntroductionTransplantation of renal allografts that have been procured from expanded criteria donors (ECD) have prevailed in an attempt to expand the donor pool. Even though ECD is an acceptable source of donors, the wide range of age along with the presence or not of risk factors necessitates further categorization. The aim of this study was to analyze the allograft and recipient survival of the ECD renal grafts and to propose an ECD categorization model.Patients and MethodsWe reviewed the medical records of renal transplant recipients from January 2002 to July 2012, who received renal allografts from expanded and standard criteria donors (SCD) without risk factors such as hypertension, cerebrovascular disease or impaired renal function.ResultsDuring the study period, 310 renal transplantations were performed in our Transplant Unit, of which 86 and 114 renal grafts were procured from ECD and SCD respectively. ECD renal graft survival the first, third and fifth year was 92%, 82% and 70% while respective recipient survival was 95%, 87% and 82%. Comparison with the control group of SCD showed that ECD renal graft survival after the third post-transplant year was significantly inferior (P < .0001). Donor age was a considerable prognostic factor of long-term renal graft function. Serum creatinine of ECD grafts was the first and third year 1.86 ± 0.6 mg/dL and 1.91 ± 0.8 mg/dL, respectively, showing significant difference to that of SCD grafts (P < .0001). Further categorization of ECD showed that renal allografts procured from donors above 60 years old without risk factors had better renal graft survival and function compared to grafts procured from donors aged 50–59 with 2 or 3 risk factors.ConclusionsRenal transplantation from ECD offers acceptable graft survival rates, however they are inferior compared to renal grafts from optimal kidney donors. ECD kidney grafts have to be categorized, taking into consideration the independent risk factors.     

Living Kidney Transplantation: Evaluation of Renal Function and Morphology of Potential Donors

The evaluation of potential living kidney donors requires an accurate study of renal function and morphology. The gold standard to assess renal function is the measurement of glomerular filtration rate (GFR). However, GFR is often estimated from serum creatinine (SCr), cystatin C (SCys), or creatinine clearance (CCr). Otherwise, GFR is predicted using formulas based on SCr or SCys. Ultrasound scanning evaluates morphology and dimensions, while scintigraphy provides information on morphofunctional symmetry of kidneys. The aim of this study in 79 potential donors was to assess the accuracy of the tests employed to estimate GFR and the utility of renal ultrasound and scintigraphy for morphofunctional evaluation of potential donors. GFR (clearance of ^99mTc-DTPA) was compared with estimates obtained with Cockcroft and Gault (CG-CCr) and Modification of Diet in Renal Disease (MDRD-GFR) formulas, and from SCys (Cys-GFR). The correlation with GFR was statistically significant for SCys and for all estimates, but not for SCr. CCr showed a poor agreement with GFR, with a large range of agreement and a marked and significant overestimation of GFR (33.8 mL/min). The accuracy of CG-CCr and MDRD-GFR as indicators of a GFR < 80 mL/min was better than that of Cys-GFR and CCr. However, their mean prediction errors versus GFR were relevant. Renal dimensions, particularly renal volume, showed a good correlation with GFR. The correlation was higher than that of all prediction equations. The direct measurement of GFR remains the reference method to assess renal function in potential kidney donors. The measurement of renal dimensions can provide useful information also on renal function.     

Renal Transplantation With Expanded Criteria Donors: The Experience of One Portuguese Center

Background

The shortage of kidneys available for transplantation has led to enlarged criteria donors (ECD): namely, donors older than 60 years or aged between 50 and 59 years with 2 of the following characteristics-hypertension, predonation serum creatinine level higher than 1.5 mg/dL or cerebrovascular disease as the cause of death. The aim of this study was to analyze renal transplants using ECD compared with standard criteria donors (SCD) concerning the incidences of delayed graft function (DGF), acute rejection episodes (ARE), and patient and graft survivals.

Materials and Methods

This retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD.

Results

Of the transplants, 24.4% used ECD. The baseline characteristics of recipients of ECD versus SCD kidneys were similar, except for age and cold ischemia time. Comparing ECD and SCD, we observed an higher incidence of DGF (35% vs 18%), occurrence of ARE (34.4% vs 16.6%), average serum creatinine levels at 6 (1.87 vs 1.4 mg/dL), and 12 months (1.88 vs 1.43 mg/dL) as well as lower graft survival at 1 (82% vs 91%) and 3 years (75% vs 84%) after transplantation. Recipient survival at 1 year was not different. Multivariate analysis identified recipient age, cold ischemia time, ARE, and DGF as risk factors for graft failure.

Conclusions

Renal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.     

Renal Allografts From Donors Older Than 70 Years Are Useful for Single Transplantation

Kidney transplantation has been related in elderly recipients to a greater longevity compared with dialysis. Due to the scarcity of donors, transplantation of older patients depends on the acceptance of older donors. We compared the characteristics and evolution of transplants from donors ≥70 years (n = 53) with those from donors >55–<70 years (n = 201). Group D≥70 included older recipients (65.37 ± 4.9 vs 55.92 ± 9.66 years; P = .000) and more women (62.3% vs 45.3%; P = .02), with more peripheral arterial disease (10.9% vs 2.4%; P = .011). No differences in donor characteristics were observed. Induction treatment with thymoglobulin or basiliximab was more common in D≥70 (81.1% vs 57.3%; P = .006), with no differences in other immunosuppressive drugs. The incidence of delayed graft function (DGF) was similar (P = .82), with a trend to a lower incidence of acute rejection episodes among D≥70 (11.8% vs 22.5%; P = 0.09). Serum creatinine and proteinuria levels did not differ during follow-up (P > .05). Patients in D≥70 displayed more episodes of urinary sepsis (19.1% vs 6.4%; P = .008), but no differences were observed in cytomegalovirus (CMV) infection (P = .629), neoplasia (P = .118), ischemic cardiopathy (P = .642), or hospital readmission due to infections (P = .567). Graft survivals at 5 years were 70% and 75% (P = .279) among groups D≥70 and D>55–<70, respectively, and patient survivals at 5 years were 88% and 88% (P = .63), respectively. In conclusion, our study showed that selected kidneys from donors older than 70 years were followed with excellent graft and patient survivals, permitting older patients on renal replacement therapy to benefit from renal transplantation.     

Urology in the Twenty-first Century: Noninvasive Targeted Treatments for Urologic Malignancies

Abstract Notwithstanding the major advances that have been made in the treatment of bladder cancer, prostate cancer, and kidney cancer, much remains to be done if we are to translate the gains that have been made in "disease-free survival" into actual survival in terms of quantity as well as quality of life. Indeed, we are still at an embryonic stage in understanding how cancers originate, whether defense mechanisms exist that can recognize these cancers and recognize them when they first develop, when cancers metastasize during their development, whether we have methods that are sufficiently accurate to distinguish between organ-confined and regional extension or spread of disease, and the means by which we can identify cancers that are likely to remain organ-confined and distinguish them from those that are predestined to metastasize. If we are to be successful in the assessment and treatment of various urologic cancers, these questions must be answered. Many new methods of assessment and treatment are being explored that in themselves may provide some answers. The present discussion focuses on these issues, on how they may lead to further understanding of the unique biology of many of these tumors, and what we may expect in terms of increased longevity and improved quality of life as we attempt to cure patients of their disease. E-pub: 14 August 2000     

International Society of Urology in the Twenty-first Century

Abstract The International Society of Urology (SIU) has revised its by-laws and reformed its system to adjust to the changes of the new millennium. The most important role the SIU can play at present is to fill the gap between developing and developed countries, which can be accomplished through the sister center program. After having achieved this primary aim, international cooperative work at a higher level can be considered through establishment of various institutes to bolster the high standard of world urology. E-pub: 17 July 2000     

Improved Outcomes of Renal Transplantation from Cardiac Death Donors: A 30-Year Single Center Experience

Outcomes of renal transplantation from donation after cardiac death (DCD) donors over 30 years were analyzed. Between 1975 and 2004, 256 renal transplantations from DCD donors were performed. The recipients were divided into four groups according to a time period as follows: 1975-1979 (Group 1; n = 18), 1980-1989 (Group 2; n = 81), 1990-1999 (Group 3; n = 84) and 2000-2004 (Group 4; n = 73). Of the 256 transplanted kidneys from DCD donors, 38 (15%) functioned immediately after transplantation. The incidence of delayed graft function (DGF) was 72%. Warm ischemic time and total ischemic time were 7.4 +/- 9.4 min and 11.9 +/- 5.6 h, respectively. The overall graft survival rates at 1, 5 and 10 years were 80%, 72% and 53%, respectively. Graft survival rates in each group have continually improved over time (5-year graft survival; 23% vs. 64% vs. 74% vs. 91%, respectively). However, there was no significant difference in graft survival rates between the groups of patients who survived with a functioning graft for more than 1 year. A multivariate Cox regression analysis showed acute rejection and donor age to be independently associated with graft outcome. DCD donors are a valuable source of kidneys for transplantation with promising long-term outcomes.     

Experiences of Living Donors for Small Bowel Transplantation

Introduction

Along with developments in surgical and immunosuppression techniques, the success rate of small bowel transplantation has increased. In Korea, the incidence of small bowel transplantations has increased, and the longest surviving living donor recipient has now survived for over 12 years postsurgery. The purpose of this study was to assess the experiences of living donors for small bowel transplantation before, during, and after the transplantation.

Association of Lower Costs of Pulsatile Machine Perfusion in Renal Transplantation from Expanded Criteria Donors

Pulsatile machine perfusion (PMP) has been shown to reduce delayed graft function (DGF) in expanded criteria donor (ECD) kidneys. Here, we investigate whether there is a cost benefit associated with PMP utilization in ECD kidney transplants. We analyzed United States Renal Data System (USRDS) data describing Medicare‐insured ECD kidney transplant recipients in 1995–2004 (N = 5840). We examined total Medicare payments for transplant hospitalization and annually for 3 years posttransplant according to PMP utilization. After adjusting for other recipient, donor and transplant factors, PMP utilization was associated with a $2130 reduction (p = 0.007) in hospitalization costs. PMP utilization was also associated with lower DGF risk (p < 0.0001). PMP utilization did not predict differences in rejection, graft survival, patient survival, or costs at 1, 2 and 3 years posttransplant. PMP utilization is correlated with lower costs for the transplant hospitalization, which is likely due to the associated reduction in DGF among recipients of PMP kidneys. However, there is no difference in long‐term Medicare costs for ECD recipients by PMP utilization. A prospective trial is necessary as it will help determine if the associations seen here are due to PMP utilization and not differences in the population studied.     

Clinical Analysis of Living Related Renal Transplantation With Donors Older Than 50 Years in China

Objective

The objective of this study was to investigate whether kidney grafts from living related donors older than 50 years were safe for the donors and recipients in the long term.

Methods

One hundred seven living related donor kidney transplantations were performed in our center from April 1994 to December 2007. No prisoners or organs from prisoners were used in the collection of these data. Donors were divided into 2 groups: >50 years of age (range, 51-78 years), designated as the study group, and ≤50 years of age (range, 21-50 years), designated as the control groups. The mean time of follow-up was 49 months (range, 12-180 months). Clinical data were compared, including donor serum creatinine (Scr) levels, glomerular filtration rates (GFR) before and after the procedures operative complications, and postoperative short-term and long-term recovery of renal function in recipients as well as their complications and recipient and kidney survivals.

Results

All operations were successfully performed. Before the operation, the mean Scr and GFR were 82.16 ± 10.86 umol/L and 85.82 ± 6.26 mL/min, respectively, in the study group versus 78.66 ± 10.41 umol/L and 88.74 ± 9.44 mL/min, respectively, in the control group. There were no significant differences in mean Scr or GFR values between the groups at various preoperative or postoperative times (P > .05). No severe perioperative complications occurred, and no subsequent renal function failure was observed upon long-term follow-up of donors in the 2 groups. Comparisons of recipient age, gender ratio, duration on dialysis, HLA matches, cold/warm ischemia times, and immunosuppression therapy showed a correlations between the 2 groups. Mean Scr levels of recipients, which were compared from 1 week to 3 years following surgery, were slightly higher among the control than the study group, but the difference was not significant (P > .05). There were no significant differences between the study and control groups in 1-,3-,5-, and 8-year recipient/graft survival rates (P > .05).

Conclusions

Long-term follow-up showed that transplantations using grafts from donors older than 50 years of age yielded similar results to those with younger donors.     

Outcome of Renal Transplantation From Deceased Donors After Cardiac Death: A Single-Center Experience From a Developing Country

Background

Limited information is available in the literature about the use of organs from donation after cardiac death (DCD) renal transplantation (RTx) from a developing country.

Material and Methods

We report RTx outcome between DCD donors ≥70 years (Group 1; n = 14; mean age, 75.7 ± 5.81) and DCD donors <70 years (Group 2; n = l9; mean age, 51.7 ± 10.1) between January 1999 and January 2012. The mean age of recipients was 39.5 ± 14.7 years, 24 of whom were males. The mean donor age was 61.9 ± 14.6 years, 21 of whom were males. All recipients received single-dose thymoglobulin induction followed by immunosuppression with a steroid, a calcineurin inhibitor, and mycophenolate mofetil or azathioprine. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis.

Results

Over a mean follow-up of 3.21 ± 3.46 years, one-, five-, and ten-year, patient survival rates were 77%, 67.4%, and 67.4%, respectively, and death-censored graft survival rates were 85.7% for one, five, and ten years. Delayed graft function (DGF) was observed in 36.4% (n = 12) with 12.1% (n = 4) biopsy-proven acute rejection (BPAR). Patient survival (P = .27), graft survival (P = .20), DGF (P = .51), and BPAR (P = .74) were similar in 2 groups. A total of 27.2% (n = 9) of patients died, mainly due to infections (n = 5).

Conclusion

Given the widespread organ shortage, outcomes of controlled DCD renal transplantation has a potential to expand the donor pool and shorten the waiting list for RTx, encouraging the use of this approach even in low-income countries.     

History and Evolution of Surgical Ethics: John Gregory to the Twenty-first Century

As surgery grew to become a respected medical profession in the eighteenth century, medical ethics emerged as a response to the growing need to protect patients and maintain the public’s trust in physicians. The early influences of John Gregory and Thomas Percival were instrumental in the formulation of patient-centered medical ethics. In the late nineteenth century, the modern surgical advances of anesthesia and antisepsis created the need for a discipline of ethics specific to surgery in order to confront new and evolving ethical issues. One of the founding initiatives of the American College of Surgeons in 1913 was to eliminate unethical practices such as fee-splitting and itinerant surgery. As surgery continued to advance in the era of solid organ transplantation and minimally invasive surgery in the latter half of the twentieth century, surgical innovation and conflict of interest have emerged as important ethical issues moving forward into the twenty-first century. Surgical ethics has evolved into a distinct branch of medical ethics, and the core of surgical ethics is the surgeon–patient relationship and the surgeon’s responsibility to advance and protect the well-being of the patient.     

Renal Graft Outcome in Simultaneous Kidney Transplantation Combined With Other Organs: Experience of a Single Center

Aim

We report the renal graft outcomes among a series of patients who underwent simultaneous combined liver-kidney transplantations (CLKT) or heart-kidney transplantations (CHKT) at a single center.

Methods

From 1975 to December 31, 2007, we performed 1524 kidney transplantations, 427 liver transplantations, and 483 heart transplantations, including 7 simultaneous CLKT and 2 CHKT. We analysed the main patient characteristics, renal graft outcomes, and patient survivals.

Results

CLKT indications were as follows: alcoholic cirrhosis (n = 5) and hepatitis C virus (n = 2) with chronic glomerulonephritis (n = 5), hypertensive nephropathy (n = 1), and polycystic disease (n = 1). Cold renal ischemia time was 6.9 hours (range, 6-9). In 5 patients there were no kidney rejection episodes; 3 of these patients are alive with creatinine levels between 1.4 and 1.7 mg/dL with an average follow-up of 6.9 years (range, 10 months-8 years). One patient died of esophageal cancer at 13 years after transplantation with a serum creatinine level of 1.16 mg/dL and another died of breast cancer at 7 years after transplantation with a creatinine level of 1.1 mg/dL. One patient lost his renal graft just after the kidney transplantation due to renal vein thrombosis. The last patient suffered 1 episode of acute rejection and lost his kidney 5 years later due to chronic rejection. CHKT indications were as follow: dilated myocardiopathy (n = 2) and chronic glomerulonephritis (n = 1) or interstitial nephropathy (n = 1). The cold renal ischemia time was 4 hours. There were no acute rejection episodes. One patient is alive with a creatinine level of 2.05 mg/dL at 6 years after the transplantation; the other patient lost his kidney due to chronic rejection at 270 days after simultaneous CHKT, and 2 years later received a second kidney that is functioning normally.

Conclusions

Simultaneous CLKT and CHKT in selected cases provided satisfactory long-term outcomes in both graft function and patient survival with lesser number of acute rejection episodes than nonsimultaneous transplantations. They are worthy options for patients with liver or heart failure associated with renal failure.     

Early Molecular Diagnosis of Acute Chagas Disease After Transplantation With Organs From Trypanosoma cruzi–Infected Donors

Organ transplantation (TX) is a novel transmission modality of Chagas disease. The results of molecular diagnosis and characterization of Trypanosoma cruzi acute infection in naïve TX recipients transplanted with organs from infected deceased donors are reported. Peripheral blood and cerebrospinal fluid samples from the TX recipients of organs from infected donors were prospectively and sequentially studied for detection of T. cruzi by means of kinetoplastid DNA polymerase chain reaction (kDNA‐PCR). In positive blood samples, a PCR algorithm for identification of T. cruzi Discrete Typing Units (DTUs) and quantitative real‐time PCR (qPCR) to quantify parasitic loads were performed. Minicircle signatures of T. cruzi infecting populations were also analyzed using restriction fragment length polymorphism (RFLP)‐PCR. Eight seronegative TX recipients from four infected donors were studied. In five, the infection was detected at 68.4 days post‐TX (36–98 days). In one case, it was transmitted to two of three TX recipients. The comparison of the minicircle signatures revealed nearly identical RFLP‐PCR profiles, confirming a common source of infection. The five cases were infected by DTU TcV. This report reveals the relevance of systematic monitoring of TX recipients using PCR strategies in order to provide an early diagnosis allowing timely anti‐trypanosomal treatment.     

Dual Kidney Transplantation Involving Organs From Expanded Criteria Donors: A Review of Our Series and an Update on Current Indications

BackgroundOur purpose was to review our kidney transplantation program based on the use of expanded criteria donors, and to determine current indications for dual kidney transplantation (DKT). In 1996, a program was initiated to transplant kidneys from donors of over 60 years performing single or dual transplantation.MethodsIn 1996, a program was initiated to transplant kidneys from donors of over 60 years performing single or dual transplantation. DKT were performed with donors >75 and donors between 60 and 74 years of age and glomerulosclerosis of >15%. The kidneys of donors between 60 and 74 years of age and with glomerulosclerosis of <15% were used for single kidney transplantation (SKT). In 2005, we started to perform SKT despite glomerulosclerosis being >15%, taking into account donor and recipient characteristics.ResultsFrom 1996 to 2004, 222 SKTs and 88 DKTs were performed. Graft survival after 1 and 4 years was, respectively, 91% and 78% for SKT and 95% and 79% for DKT. In 2005, we started to perform SKT despite glomerulosclerosis being >15%, taking into account donor and recipient characteristics. From 2005 to 2011, 328 SKT and 32 DKT were performed. During this period most kidneys used for DKT were from female donors >75 years old, weighing <65 kg, with a creatinine of >1 mg/dL and glomerulosclerosis of >15%. The recipients for DKT were mostly male, <70 years old and whose weight was >75 kg.ConclusionDKT from expanded criteria donors shows good outcomes. However, in many cases SKT may fulfill the need of the recipient. The archetype for DKT is an older female weighing <65 kg and the most common recipient is an overweight male who is <70 years old.