Clinical and histopathological characteristics of acute kidney injury in a cohort of brain death donors with procurement biopsies.

BACKGROUND: Kidney biopsies are routinely used for diagnostic and prognostic purposes but their utility in the intensive care unit (ICU) setting is limited. We investigated the associations of clinical and histopathological risk factors with ICU-acute kidney injury (AKI) in donors with brain death (DBD) with kidneys of lower quality and procurement biopsies. METHODS: Overall, 221 donors with brain death, 239 biopsies and 197 recipients were included. The biopsies were reread and scored according to the Banff recommendations. Clinical and histopathological data were compared between donors with and without AKI defined by serum creatinine and by urine output. Logistic regression analysis was applied to identify independent clinical and histopathological risk factors for both phenotypes. Lastly, the impact of each AKI phenotype on outcome was explored. AKI was diagnosed based on the RIFLE (Risk, Injury, Failure, Loss of function, End-stage kidney disease) AKIN (Acute Kidney Injury Network) or KDIGO (Kidney Disease Improving Global Outcomes) criteria. RESULTS: Acute kidney injury occurred in 65% of donors based both upon serum creatinine and by urine output. Serum creatinine was able to better discriminate AKI. Multiorgan failure and severe AKI were captured by serum creatinine, and hemodynamic instability by urine output. Donors with serum creatinine-AKI showed lower chronic macrovascular scores, while donors with urine output-AKI had higher chronic microvascular and tubulointerstitial scores. Tubular injury was similar between the subgroups. Except for delayed graft function and one-year death-censored graft survival, the other short-term recipient outcomes were similar for both AKI phenotypes. CONCLUSION: Serum creatinine is more suitable than urine output for defining AKI in donors with brain death. There are distinct clinical risk factors for each AKI-ICU phenotype. Donor AKI phenotype does not predict the recipient´s prognosis. Kidney biopsies do not seem to confer any tangible benefit in defining AKI in donors with brain death.

Histological and clinical evaluation of discarded kidneys in a European cohort of deceased brain death donor kidneys of marginal quality.

BACKGROUND: Despite organ shortages, the discard rate of deceased donor kidneys is high. Risk factors for this trend warrant further study. METHODS: We investigated reasons for discard in a cohort of brain death donors with marginal kidneys and procurement biopsies. Paraffin embedded procurement biopsies were systematically reevaluated and graded for the purpose of the study. Assessment included percentage of global glomerulosclerosis, Banff Lesion scores and tubular epithelial damage. Donor-, transplant process-, perfusion quality-, histopathology-, and recipient-related parameters were compared between discarded and transplanted organs. RESULTS: Although most clinical characteristics were similar between donors whose kidneys were transplanted and those whose kidneys were procured but discarded, discarded kidneys were more likely to be from donors with hepatitis C, to have undergone wedge biopsies, to show changes of acute and chronic injury and to be deemed poor quality. Except for obvious anatomic abnormalities, kidneys were often discarded due to the findings of procurement biopsies. Donors of kidneys discarded for histologic reasons more often had hypertension, coronary artery disease, stroke, and increased serum creatinine. The reason for discard was unknown in 20% of cases. Discarded kidneys came from donors who appeared to be clinically similar to donors whose kidneys were utilized for transplant. CONCLUSION: A considerable proportion of discarded kidneys were of acceptable quality. The analysis of the outcome of every recovered organ could help to overcome this problem. Procurement biopsies more often lead to discard than to transplantation of recovered organs. Proper handling during allocation has to be determined.

Liver Procurement from Poisoned Donors: A Survival Study.

OBJECTIVES: Although transplant teams understand the effects of donor characteristics on liver transplant outcomes, few studies have investigated the quality of livers obtained from poisoned donors. The aim of this study was to compare livers procured from poisoned donors with a matched control group. MATERIALS AND METHODS: Liver transplant outcomes from poisoned donors and from donors with trauma-induced death (as the control group) were compared using data of an Organ Procurement Unit from 2000 to 2013. Procured livers were evaluated via histology findings before transplant. Recipient characteristics were assessed in both groups, and immediate and medium-term (up to 5 years after transplant) survival rates were compared with the use of Kaplan-Meier analyses and log-rank tests. RESULTS: Over a 13-year organ donation program, 1485 livers from brain dead patients were donated. Among them, 115 poisoned donors were evaluated for liver grafts; of these, 74 successful liver transplants were performed. In the poisoned donors, the incidence of reversed cardiac arrest was 54.1%. Likewise, acute kidney injury was detected in 14.9% of the patients, and 16.2% needed urgent dialysis either for clearance of the toxic agents or for treatment of acute kidney injury. No significant differences were observed in 1- to 5-year survival rates, and log-rank test also showed a significance level of 0.83. CONCLUSIONS: Proper case selection strategies can be implemented to expand the donor pool, including use of poisoned donors. Hence, poisoning is not a contra-indication for a referral, which could lead to decreased mortality for patients requiring a liver transplant.

Impact of Recruitment Maneuvers to Cover Adverse Effects of Donor Transfer.

OBJECTIVES: Our aim was to investigate the negative effects of transferring brain-dead donors to the intensive care unit on the ratio of PaO2 to inspired oxygen fraction and the benefits of recruitment maneuvers on its reversal. MATERIALS AND METHODS: In this randomized trial, we assigned 30 brain-dead donors to an intervention group and a control group. After transfer to the intensive care unit, donors in the intervention group received a lung recruitment maneuver according to protocol for 1 hour, whereas the control group did not receive this intervention. Arterial blood gas was drawn before transfer, immediately aftertransfer, and 3 hours after transfer. RESULTS: Before transfer to immediately after transfer, the PaO2-to-inspired oxygen fraction ratio decreased from 281.30 ± 100.33 to 225.03 ± 95.72 mm Hg (P < .01). At 3 hours aftertransfer,the PaO2-to-inspired oxygen fraction ratio in the intervention and control groups was 280.4 ± 120.4 and 213.4 ± 75.5 mm Hg (P = .017), respectively. The absolute difference in PaO2-to-inspired oxygen fraction ratio from before to 3 hours after transfer was -16.9 ± 44.1 and 51.8 ± 61.4 mm Hg (P < .001), in the intervention and control groups,respectively. Increasing central venous pressure and/or transfer time further potentiated the decrease ofthe PaO2-to-inspired oxygen fraction ratio. CONCLUSIONS: The PaO2-to-inspired oxygen fraction ratio decreased after transfer of brain-dead donors to the intensive care unit. This was partially reversible by standardized recruitment maneuvers.

Influence of Deceased Donor and Pretransplant Recipient Parameters on Early Overall Kidney Graft-Survival in Germany.

Background. Scarcity of grafts for kidney transplantation (KTX) caused an increased consideration of deceased donors with substantial risk factors. There is no agreement on which ones are detrimental for overall graft-survival. Therefore, we investigated in a nationwide multicentre study the impact of donor and recipient related risks known before KTX on graft-survival based on the original data used for allocation and graft acceptance. Methods. A nationwide deidentified multicenter study-database was created of data concerning kidneys donated and transplanted in Germany between 2006 and 2008 as provided by the national organ procurement organization (Deutsche Stiftung Organtransplantation) and BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 4411, isolated KTX). Results. Risk factors associated with graft-survival were donor age (1.020 [1.013-1.027] per year), donor size (0.985 [0.977-0.993] per cm), donor's creatinine at admission (1.002 [1.001-1.004] per µmol/L), donor treatment with catecholamine (0.757 [0.635-0.901]), and reduced graft-quality at procurement (1.549 [1.217-1.973]), as well as recipient age (1.012 [1.003-1.021] per year), actual panel reactive antibodies (1.007 [1.002-1.011] per percent), retransplantation (1.850 [1.484-2.306]), recipient's cardiovascular comorbidity (1.436 [1.212-1.701]), and use of IL2-receptor antibodies for induction (0.741 [0.619-0.887]). Conclusion. Some donor characteristics persist to impact graft-survival (e.g., age) while the effect of others could be mitigated by elaborate donor-recipient match and care.

The joint impact of donor and recipient parameters on the outcome of heart transplantation in Germany after graft allocation.

Organ shortage in heart transplantation (HTx) results in increased use of grafts from donors with substantial risk factors. It is discussed controversially which donor characteristics may be detrimental. Therefore, we evaluated the joint impact of donor- and patient-related risk factors in HTx on patient survival by multiple analysis in a nationwide multicentre study after donor selection was carried out. The research database consists of data concerning hearts donated and transplanted in Germany between 2006 and 2008 as provided by Deutsche Stiftung Organtransplantation and the BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 774, recipient age ≥ 18 years). Survival was significantly decreased by donor age (1.021 [1.008-1.035] per year), nontraumatic cause of death (1.481 [1.079-2.034]), troponin >0.1 ng/ml (2.075 [1.473-2.921]), ischaemia time (1.197 [1.041-1.373] per hour), recipient age (1.017 [1.002-1.031] per year) and in recipients with pulmonary vascular resistance ≥ 320 dyn*s*cm(-5) (1.761 [1.115-2.781]), with ventilator dependency (3.174 [2.211-6.340]) or complex previous heart surgery (1.763 [1.270-2.449]). After donor selection had been conducted, multiple Cox regression revealed donor age, nontraumatic cause of death, troponin and ischaemia time as well as recipient age, pulmonary hypertension, ventilator dependency and previous complex heart surgery as limiting risk factors concerning patient survival.

Factors limiting organ donation in Baden-Württemberg.

UNLABELLED: In the German state of Baden-Wurttemberg, the number of deceased donors from whom organs have been recovered has been decreasing over the past several years. We questioned whether changing donor age and/or cause of death (COD) were contributing to this trend. METHODS: All potential donors who reported to our regional Baden-Württemberg organ procurement organization were reviewed (2006-2010, n = 1771). Changes in age distribution and COD were analyzed, factors we thought might have affected the conversion from potential to successful organ donation. RESULTS: Between 2006 and 2010, the annual number of reported cases with subarachnoid hemorrhage (SAH) as the COD decreased from 117 to 65, while the number of deaths from other reasons increased from 264 to 294. Conversion rates were higher in the SAH group (56%) compared with the other reasons group (37%). DISCUSSION: Mortality rates are changing in certain devastating brain injuries. This, and other factors, may contribute adversely to organ donation rates.

Organ donation: when should we consider intestinal donation.

UNLABELLED: Although more than 2300 intestinal transplantations (IT) have been performed worldwide, a description of intestinal donor criteria is still missing. This causes confusion among transplant coordinators, OPOs, physicians at intensive care unit and transplant surgeons. A Med-line search looking for publications about donor criteria or donor selection in human IT was performed in December 2011. Retrospective analysis of 39 deceased donors from whom, in the period January 2006-December 2011, 20 isolated intestinal grafts and 19 multivisceral grafts were recovered and successfully transplanted. REVIEW OF THE LITERATURE: Among 3504 publications about IT, no study reported specifically about intestinal donor profile. The most commonly cited donor criterion was age, while all other criteria were inconsistently discussed. Based on the collected data, we suggest following inclusion criteria for donation of IT grafts: age 0-50 years, ICU-stay <1 week, no blunt abdominal trauma, most recent Sodium <155 mmol/l, no severe ongoing transfusion requirements, standard donor therapy including early enteral nutrition and a compatible donor-recipient size match. By providing simple criteria for intestinal donation from deceased donor, we may help to properly utilize the limited donor pool.

Joint impact of donor and recipient parameters on the outcome of liver transplantation in Germany.

BACKGROUND: The shortage of donor organs in Germany has led to the use of organs from donors with extended donor criteria (EDC). EDC have been defined on the basis of expert opinions, but their clinical relevance is controversial. This may cause loss of organs otherwise available for transplantation. We evaluated the impact of donor and recipient factors in liver transplants on patient and graft survival in a nationwide multicenter analysis, with special focus on EDC and donor risk index. METHODS: A database was created from data on livers donated and transplanted in Germany between 2006 and 2008 as provided by Deutsche Stiftung Organ transplantation and BQS Institute. Cox regression (significance level 5%, risk ratio [95% confidence interval]) was used for calculating the impact on patient survival (n=2095) and on graft survival (n=2175). RESULTS: Patient and graft survival were significantly affected only by donor age (1.012 and 1.011/year), recipient age (1.019 and 1.014/year), creatinine (1.248 and 1.205/mg/dL), bilirubin (1.022 and 1.023/mg/dL), and high urgency status (1.783 and 1.809). Inferior organ quality resulted in lower graft survival (1.243) and donor history of smoking in lower patient survival (1.249). CONCLUSION: Multiple Cox regression revealed no significant impact of EDC or donor risk index on patient and graft survival except for donor age after donor selection at recovery. Among recipient variables, only age, creatinine and bilirubin, and high urgency status were associated with poorer outcome.

Late reuse of liver allografts from brain-dead graft recipients: the Munich experience and a review of the literature.

The increasing donor organ shortage requires the consideration of any possible organ donor in order to meet the current demand. However, the growing number of long-term survivors of liver transplantation may create a situation in which former organ recipients may experience brain death with a functioning graft and therefore become organ donors themselves. Previous reports concerning this rare situation predominantly refer to the reuse of donor organs within the first 8 days after primary liver transplantation. So far, only a single case of late reuse of a donor liver has been published, with 2 additional cases mentioned in a summary of the United Network for Organ Sharing database. Here we report the case of a 43-year-old female donor who had received a liver graft for complications of Budd-Chiari syndrome 5 years before becoming an organ donor herself after cerebral infarction with consecutive brain death.