DCD Kidneys Can Yield Good Outcomes
QUEBEC CITY, QUEBEC—Transplantation of kidneys donated after cardiac death (DCD) can result in good outcomes, a Canadian team has confirmed.
DCD kidney donation was common until the 1960s but has just regained popularity across North America recently. Surgeons at the London Health Sciences Centre, London, Ontario, have transplanted 63 DCD kidneys since July 2006. The one-year graft and patient survival were 96.4% and 98.2%, respectively. The rate of delayed graft function (DGF) was 65.1%.
In a multivariate analysis, the surgeons found that machine perfusion of the kidneys prior to transplantation and reduced time from asystole to flushing have contributed to their gradually improved outcomes over time. They presented the findings at the Canadian Society of Transplantation's 2012 Annual Meeting.
Mike Moser, MD, and his colleagues examined their DCD kidney transplant learning curve. They compared the outcomes of the 31 procedures they performed between July 2006 and January 2009, and those of 32 they performed between March 2009 and October 2011.
Donor and recipient characteristics from the two time periods have not changed significantly. The time from asystole to flushing has also decreased significantly, from 16 to 12 minutes on average. Furthermore, a perfusion pump was used in 81.3% of the more recent cases compared with 25.8% of the earlier cases. The average time with mean arterial pressure (MAP) below 55 mm Hg decreased from 25 to 18 minutes, and cold ischemic time increased from 464 to 725 minutes on average. The average length of stay also dropped, from 16 to 13 days.
The recipients' average creatinine clearance at three days post-op has also improved, from 7.8 to 11.9 µmol/L. Multivariate analysis showed that the two factors that contributed significantly to this increase was use of machine perfusion and reduced asystole to flush time. The average creatinine clearance rate at one month was 42.8 µmol/L and at one year is 67 µmol/L.
Factors associated with DGF include longer time with MAP below 55 mm Hg lower and recipient pre-transplant urine output, a novel finding, the study showed. In addition, creatinine clearance from DGF kidneys catches up to that of early-function kidneys within a year.
“Patients on the waiting list got 63 kidneys that they wouldn't otherwise have gotten, and they did work well,” concluded Dr. Moser, now a transplant surgeon at the University of Saskatchewan, in Saskatoon. “The lessons learned over time have been invaluable -- in London they now use the pump on every single DCD kidney they retrieve.”
According to an American transplant surgeon, the findings of Dr. Moser's paper mirrors the experience in the United States, where the proportion of transplants involving DCD kidneys has increased from approximately 2% in 2002 to 13% in 2012.
“While the rate of delayed graft function is higher in DCD kidneys, we and others have shown that long-term these kidneys work as well as kidneys from brain-dead donors,” said Anthony D'Alessandro, MD, Professor of Surgery at the University of Wisconsin Medical School in Madison. “Machine perfusion with DCD kidneys does seem to have a beneficial effect on DCD kidneys compared to those that are preserved by cold storage. The University of Wisconsin on average does 25%-30% of our kidney transplants as DCD donors, resulting in 75 organ transplants that would otherwise not have occurred.”