Donor ARF Need Not Stop Renal Transplants

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PARIS—Kidneys transplanted from deceased donors with terminal acute renal failure (ARF) are associated with excellent short-term outcomes, researchers reported here at the 14th Congress of the European Society for Organ Transplantation.

In fact, investigators said kidneys retrieved from deceased donors with terminal ARF may represent an additional means of safely expanding the organ pool.

Robert J. Stratta, MD, Professor of Surgery and Director of Transplantation at Wake Forest University in Winston-Salem, N.C., and colleagues reviewed data from all renal transplant recipients who received a kidney from a deceased donor with ARF from January 1, 2007 through October 10, 2008. The recipients were followed up for at least 11 months.

The researchers defined ARF as a doubling in the admission serum creatinine (SCr) level and a terminal SCr level greater than 2.0 mg/dL in a donor without a prior diagnosis of CKD.

“A variety of renal insults immediately before or during hospitalization, including hypoxic-ischemic injury, exposure to nephrotoxic medications, infection, or rhabdomyolysis may cause significant renal damage and frequently lead to acute tubular necrosis and acute renal failure, which may be completely reversible once the underlying cause is treated or removed,” Dr. Stratta said.

Therefore, he added, it is reasonable to speculate that kidneys retrieved from organ donors with acute tubular necrosis may also experience near complete recovery of function after removal from the hostile donor environment and transplantation into the recipient.

During the study period, Dr. Stratta's group transplanted 25 kidneys from 17 deceased donors with ARF, including 22 from standard criteria deceased donors. All kidneys had been refused by multiple centers. Kidney recipients had a mean age of 49 years and a mean waiting time to transplantation of 36 months.

The mean admission and terminal SCr levels were 1.3 mg/dL, and 3.2 mg/dL, respectively. The mean calculated terminal creatinine clearance was 43 mL/min. All but two kidneys were placed on pump perfusion, with a mean cold ischemia time of 27.4 hours.

At a mean follow-up of 20 months, patient and graft survival rates were 100% and 92%, respectively. Eight patients (32%) had delayed graft function (defined as the need for dialysis in the first week post-transplant) and the mean duration of post-transplant dialysis was two weeks.

Three patients (12%) had biopsy-proven acute rejection episodes that occurred within the first month post-transplant; all cases resolved with treatment. Infections developed in eight patients (32%), and three patients (12%) required reoperations. The mean SCr levels and glomerular filtration rates were 1.9 mg/dL and 45 mL/min/1.73 m2, respectively, at one month post-transplant, 1.6 mg/dL and 50 mL/min/1.73 m2 at six months, and 1.5 mg/dL and 52 mL/min/1.73 m2 at 12 months.

“These results demonstrate excellent short-term outcomes in selected kidneys transplanted from standard criteria deceased donors with terminal ARF in the absence of preexisting or chronic kidney damage,” Dr. Stratta said.

He also noted that the results are comparable to those typically occurring with non-ARF standard criteria deceased donor kidney recipients.  

Finally, he stressed that more patients and longer follow-up are needed to determine the safety of this approach.

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