Renal transplantation from non-heart beating donors
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Transcript of Renal transplantation from non-heart beating donors
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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
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The problem - 1
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The problem - 2
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Sources of asystolic donors in Leicester
Irreversible cardiorespiratory arrest Accident & Emergency department –
failed resuscitation after MI Medical wards –
catastrophic intracerebral haemorrhage with ‘coning’
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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
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Mechanical cardiopulmonary resuscitation device (a.k.a. ‘The Thumper’)
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Correct positioning of aortic catheter
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Cyclosporin protocol
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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%
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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%
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Graft function
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Graft survival
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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
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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
)
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Biopsy results: a ‘typical’ case, 1 week
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Same case, 3 months
Hypertrophyof tubules
Littlefibrosis
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Biopsy results: a ‘good’ case
1 week 1 month
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Biopsy results: a ‘bad’ case. Pre-perfusion:
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1 week:
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3 weeks:
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2 months:
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Sirius Red analysis - fibrotic kidney
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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%
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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