Editor's Choice - Interventions to Achieve Functionality in Newly Created Arteriovenous Fistulas in the Shunt Simulation Study Cohort.

OBJECTIVE: Although observational cohort studies report that interventions to achieve functionality are clinically successful in 85% of patients, the proportion of newly created autologous arteriovenous fistulas that result in functional vascular access typically is only 70 - 80%. To address this discrepancy, the selection and outcomes of interventions to achieve functionality in a multicentre prospective cohort study were analysed. METHODS: The Shunt Simulation Study enrolled 222 patients who needed a first arteriovenous fistula in nine dialysis units in The Netherlands from 2015 to 2018 and followed these patients until one year after access creation. In this observational study, the technical and clinical success rates of interventions to achieve functionality based on lesion and intervention characteristics were analysed and the clinical outcomes of arteriovenous fistulas with assisted and unassisted functionality were compared. RESULTS: For patients who were on dialysis treatment at the end of the study, unassisted fistula functionality was 54% and overall fistula functionality was 78%. Thirty-four per cent of arteriovenous fistulas required an intervention to achieve functionality, 68% of which eventually became functional. Seventy-five per cent of these interventions were percutaneous balloon angioplasties of vascular access stenoses. Patients with clinically successful interventions to achieve functionality had larger pre-operative vein diameters (2.8 ± 1.0 mm vs. 2.3 ± 0.6 mm, p = .036) and less often presented with thrombosed fistulas than patients with unsuccessful interventions (7% vs. 43%, p = .006). Arteriovenous fistulas with assisted functionality had similar secondary patency as fistulas with unassisted functionality (100% and 98% at six months, p = .44), although they required more interventions to maintain function (2.6 vs. 1.7 per year; rate ratio 1.52, 95% CI 1.04 - 2.18, p = .032). CONCLUSION: Interventions to achieve functionality were needed in about a third of newly created arteriovenous fistulas. Most thrombosed fistulas were abandoned, and when selected for thrombectomy rarely reached clinical success. On the other hand, interventions to achieve functionality of patent fistulas had high clinical success rates and therefore can be done repeatedly until the fistula has become functional.

Access flow volume (Qa) and survival in a haemodialysis population: an analysis of 5208 Qa measurements over a 9-year period.

BACKGROUND: The aim of this study was to determine associations between characteristics of arteriovenous access (AVA) flow volume (Qa; mL/min) and 4-year freedom from cardiovascular mortality (CVM) in haemodialysis (HD) patients. METHODS: HD patients who received a primary AVA between January 2010 and December 2017 in one centre were analysed. Initial Qa was defined as the first Qa value obtained in a well-functioning AVA by a two-needle dilution technique. Actual Qa was defined as access flow at a random point in time. Changes in actual Qa were expressed per 3-month period. CVM was assessed according to the European Renal Association-European Dialysis and Transplant Association classification. The optimal cut-off point for initial Qa was identified by a receiver operating characteristics curve. A joint modelling statistical technique determined longitudinal associations between Qa characteristics and 4-year CVM. RESULTS: A total of 5208 Qa measurements (165 patients; 103 male, age 70 ± 12 years, autologous AVA n = 146, graft n = 19) were analysed. During follow-up (December 2010-January 2018, median 36 months), 79 patients (48%) died. An initial Qa <900 mL/min was associated with an increased 4-y CVM risk {hazard ratio [HR] 4.05 [95% confidence interval (CI) 1.94-8.43], P < 0.001}. After 4 years, freedom from CVM was 34% lower in patients with a Qa <900 mL/min (53 ± 7%) versus a Qa ≥900 mL/min (87 ± 4%; P < 0.001). An association between increases in actual Qa per 3-month period and mortality was found [HR 4.48/100 mL/min (95% CI 1.44-13.97), P = 0.010], indicating that patients demonstrating increasing Qa were more likely to die. In contrast, actual Qa per se was not related to survival. CONCLUSIONS: Studying novel AVA Qa characteristics may contribute to understanding excess CVM in HD patients.

Study protocol for Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID) : A multi-center, multinational validation study to assess the accuracy and feasibility of measuring vascular access function in clinical practice.

BACKGROUND: A functioning vascular access (VA) is crucial to providing adequate hemodialysis (HD) and considered a critically important outcome by patients and healthcare professionals. A validated, patient-important outcome measure for VA function that can be easily measured in research and practice to harvest reliable and relevant evidence for informing patient-centered HD care is lacking. Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID) aims to assess the accuracy and feasibility of measuring a core outcome for VA function established by the international Standardized Outcomes in Nephrology (SONG) initiative. METHODS: VALID is a prospective, multi-center, multinational validation study that will assess the accuracy and feasibility of measuring VA function, defined as the need for interventions to enable and maintain the use of a VA for HD. The primary objective is to determine whether VA function can be measured accurately by clinical staff as part of routine clinical practice (Assessor 1) compared to the reference standard of documented VA procedures collected by a VA expert (Assessor 2) during a 6-month follow-up period. Secondary outcomes include feasibility and acceptability of measuring VA function and the time to, rate of, and type of VA interventions. An estimated 612 participants will be recruited from approximately 10 dialysis units of different size, type (home-, in-center and satellite), governance (private versus public), and location (rural versus urban) across Australia, Canada, Europe, and Malaysia. Validity will be measured by the sensitivity and specificity of the data acquisition process. The sensitivity corresponds to the proportion of correctly identified interventions by Assessor 1, among the interventions identified by Assessor 2 (reference standard). The feasibility of measuring VA function will be assessed by the average data collection time, data completeness, feasibility questionnaires and semi-structured interviews on key feasibility aspects with the assessors. DISCUSSION: Accuracy, acceptability, and feasibility of measuring VA function as part of routine clinical practice are required to facilitate global implementation of this core outcome across all HD trials. Global use of a standardized, patient-centered outcome measure for VA function in HD research will enhance the consistency and relevance of trial evidence to guide patient-centered care. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03969225. Registered on 31st May 2019.

Revision using distal inflow for high flow hemodialysis access alters arterial flow characteristics in the dialysis arm.

OBJECTIVE: Revision using distal inflow (RUDI) is currently proposed in patients on hemodialysis having a high flow access (HFA; >2 L/min) or hemodialysis access-induced distal ischemia (HAIDI). However, a recurrence of high flow or hand ischemia is not unusual in the years after RUDI. The aim of the present study was to describe changes in flow characteristics and arterial diameters in the dialysis arm after RUDI for HFA. METHODS: Volume flow, diameter, peak systolic velocity and end diastolic velocity of the brachial artery (BA) were studied 2 and 12 months after RUDI using duplex imaging. In a portion of patients, these characteristics were also assessed at proximal and distal portions of radial and ulnar arteries (proximal forearm radial artery, distal radial artery, ulnar artery, and distal ulnar artery), and in the greater saphenous venous interponate. HFA patients were grouped according to presence of concomitant hand ischemia (HFA-HAIDI) or absence (HFA). RESULTS: Fifteen patients (54 ± 16 year old; 10 males; HFA-HAIDI, n = 6; HFA, n = 9) with a BA HFA (flow volume, 2740 ± 322 mL/min) undergoing RUDI were studied between March 2011 and October 2016 in two Dutch hospitals. After 2 months, flow volume had decreased (1180 ± 189 mL/min), but again increased at 12 months (1520 ± 217 mL/min; P < .001). BA diameters did not change (7.4 ± 0.5 mm), but proximal forearm radial diameters doubled (overall 2.6 ± 0.2 mm to 5.4 ±1.0 mm; P < .001), albeit less prominent in HFA-HAIDI (+80%) than in HFA (+130%; P = .019). During follow-up, the distal ulnar artery peak systolic velocity in HFA-HAIDI (83 ± 10 cm/s) was higher compared with the HFA group (54 ± 5 cm/s; P < .01). Dilatation was not present in the greater saphenous venous interponate. CONCLUSIONS: RUDI for HFA reduction does not reverse BA dilatation, suggesting irreversible structural arterial wall damage possibly contributing to recurrent high flow. Radial artery remodeling is attenuated in HFA patients previously reporting concurrent hand ischemia diminishing the likelihood of high flow recurrence in this subgroup.

The Effect of Geometric Graft Modification on Arteriovenous Graft Patency in Haemodialysis Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: Arteriovenous grafts (AVGs) are the second best option for haemodialysis access when native arteriovenous fistulae placement is not possible, because they have a lower patency owing to neointimal hyperplasia at the venous anastomosis. This review aimed to evaluate the effect of geometric graft modification to the graft-vein interface on AVG patency. DATA SOURCES: The MEDLINE and Embase (OvidSP) databases were systematically searched for relevant studies analysing the effect of geometrically modified AVGs on graft patency and stenosis formation (last search July 2019). REVIEW METHODS: Data regarding AVG type, patency, and graft outlet stenosis was extracted for further evaluation. Data were pooled in a random effects model to estimate the relative risk of graft occlusion within one year. Follow up, number of patients, and relevant patient characteristics were extracted for the quality assessment of the included studies using Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The quality of the evidence was determined according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. RESULTS: Search strategies produced 2772 hits, of which eight articles met predetermined inclusion criteria. Overall, the included articles had low to moderate risk of bias. In total, 414 expanded polytetrafluoroethylene AVGs (232 geometrically modified and 182 standard) were analysed, comprising two modified AVG types: a prosthetic cuff design (Venaflo®) and grafts with a Tyrell vein patch. Overall, modified grafts did not show a statistically significantly higher one year primary (relative risk [RR] 0.86, 95% confidence interval [CI] 95% 0.64-1.16; GRADE: "low to very low") or secondary patency (RR 0.57, 95% CI 0.32-1.02; GRADE: "low to very low") when compared with standard AVGs. Analysis of prosthetic cuffed grafts (112 patients) separately demonstrated a statistically significantly higher one year primary (RR 0.75, 95% CI 0.61-0.91) and one year secondary patency (RR 0.47, 95% CI 0.30-0.75) compared with standard grafts (92 patients). The results on stenosis formation were inconclusive and inadmissible to quantitative analyses. CONCLUSION: The meta-analysis showed that a prosthetic cuff design significantly improves AVG patency, while a venous cuff does not. Although the heterogeneity and low number of available studies limit the strength of the results, this review shows the potential of grafts with geometric modification to the graft-vein anastomosis and should stimulate further clinical and fundamental research on improving graft geometry to improve graft patency.

Loss of Kidney Function after Endovascular Treatment of Peripheral Arterial Disease.

BACKGROUND: Administration of radiocontrast during endovascular procedures for peripheral arterial disease (PAD) may cause acute kidney injury, which generally recovers with supportive treatment. Long-term effects of endovascular procedures on renal function remain to be investigated. METHOD: This retrospective observational cohort study includes all patients who newly presented to the vascular surgery outpatient clinic with Rutherford class II or III PAD and who were treated with either supervised exercise therapy or endovascular interventions. Changes in estimated glomerular filtration rates (eGFR) after 1 year were compared between the 2 treatment groups. Multivariate regression analysis and propensity score-matched paired analysis were done to correct for potential confounders. RESULTS: One year after treatment, eGFR was reduced by 8.6 mL/min (95% confidence interval [CI], 7.3-9.9, P < 0.001) after endovascular intervention (n = 284) and by 1.7 mL/min (95% CI, 0.9-25, P < 0.001) after supervised exercise therapy (n = 299). After correction for potential confounders, endovascular interventions were associated with 9.2 mL/min (95% CI, 5.9-12.4, P < 0.001) more renal decline compared to exercise therapy. Similar results were found in the propensity score-matched paired analysis. CONCLUSIONS: Endovascular procedures for PAD are associated with clinically relevant and long-term loss of kidney function.

Loss of kidney function in patients with critical limb ischemia treated endovascularly or surgically.

BACKGROUND: Acute kidney injury after the administration of contrast material during endovascular procedures for peripheral arterial disease generally recovers with supportive treatment. However, long-term effects of endovascular procedures for critical limb ischemia on renal function remain to be investigated. METHODS: This retrospective observational cohort study included all patients who newly presented to the vascular surgery outpatient clinic with Rutherford class 4 to class 6 peripheral arterial disease and who were treated with either endovascular or surgical interventions. Changes in estimated glomerular filtration rate (eGFR) after 1 year were compared between the two types of intervention. Multivariate linear regression analysis was done to correct for potential confounders. RESULTS: One year after treatment, eGFR was reduced by 15.0 mL/min (95% confidence interval [CI], 13.1-17.0; P < .001) after endovascular interventions (n = 209) and by 7.6 mL/min (95% CI, 5.1-10.0; P < .001) after surgical therapy (n = 81). Although eGFR rates decreased in both groups, loss of renal function was significantly greater in patients after endovascular interventions (P < .001). Furthermore, 77% of patients receiving endovascular interventions experienced fast renal decline (defined as >4 mL/min loss of eGFR within 1 year) compared with 54% of patients treated surgically (P < .001). After correction for potential confounders, endovascular intervention was associated with 7.4 mL/min (95% CI, 5.4-9.3; P < .001) greater loss of renal function compared with patients treated surgically. CONCLUSIONS: Endovascular procedures for critical limb ischemia are associated with clinically relevant permanent long-term loss of kidney function. This loss of renal function is greater than in comparable patients who were treated with open surgery.

Radiation Exposure during Percutaneous Transluminal Angioplasty for Symptomatic Peripheral Arterial Disease.

BACKGROUND: Endovascular interventions often are the preferred treatment in peripheral arterial disease for both intermittent claudication and chronic critical limb ischemia. Ever more advanced and anatomically complex procedures are being performed, which may increase the radiation exposure of patients and medical staff. We sought to determine the radiation exposure sustained in contemporary interventional radiology practice. METHODS: A single-center observational cohort study of patients undergoing endovascular interventions for symptomatic peripheral arterial disease between January 1st, 2011 and July 31st, 2013 was performed. Radiation dose area product (DAP), peak skin dose (PSD), fluoroscopy time, and volume of contrast media were either measured or calculated and stratified according to patient demographics and anatomic location. RESULTS: In 951 patients, who were treated with endovascular interventions, mean DAP was 108 ± 88 Gy × cm(2) and mean fluoroscopy time was 13 ± 12 min. DAP was significantly higher for aortoiliac procedures (142 ± 103 Gy × cm(2)) compared with femoral (58 ± 73 Gy × cm(2)), below-knee (45 ± 51 Gy × cm(2)) and multilevel (83 ± 90 Gy × cm(2)) procedures (P < 0.001 for all comparisons). PSD was significantly higher for aortoiliac procedures (0.99 ± 0.54 Gy) compared with femoral (0.55 ± 0.55 Gy), below-knee (0.48 ± 0.27 Gy), and multilevel (0.68 ± 0.47 Gy) procedures (P < 0.001 for all comparisons). In contrast, mean fluoroscopy time in aortoiliac interventions was significantly shorter (10 ± 15 min) compared with femoral (15 ± 12 min), below-knee (19 ± 10 min), and multilevel (23 ± 14 min) procedures (P < 0.001 for all comparisons). CONCLUSIONS: Endovascular interventions in patients with symptomatic peripheral arterial disease involve a substantial radiation dose. Although fluoroscopy time is shorter, aortoiliac interventions result in greater radiation exposure than femoropopliteal or infrapopliteal interventions.

Flap fixation reduces seroma in patients undergoing mastectomy: a significant implication for clinical practice.

BACKGROUND: Seroma formation is a common complication following mastectomy for invasive breast cancer. Mastectomy flap fixation is achieved by reducing dead space volume using interrupted subcutaneous sutures. METHODS: All patients undergoing mastectomy due to invasive breast cancer or ductal carcinoma in situ (DCIS) were eligible for inclusion. From May 2012 to March 2013, all patients undergoing mastectomy in two hospitals were treated using flap fixation. The skin flaps were sutured on to the pectoral muscle using polyfilament absorbable sutures. The data was retrospectively analysed and compared to a historical control group that was not treated using flap fixation (May 2011 to March 2012). RESULTS: One hundred and eighty patients were included: 92 in the flap fixation group (FF) and 88 in the historical control group (HC). A total of 33/92 (35.9%) patients developed seroma in the group that underwent flap fixation; 52/88 (59.1%) patients developed seroma in the HC group (p = 0.002). Seroma aspiration was performed in 14/92 (15.2%) patients in the FF group as opposed to 38/88 (43.2%) patients in the HC group (p < 0.001). CONCLUSIONS: Flap fixation is an effective surgical technique in reducing dead space and therefore seroma formation and seroma aspirations in patients undergoing mastectomy for invasive breast cancer or DCIS.

Prospective study of a single treatment strategy for local tumescent anesthesia in Muller phlebectomy.

BACKGROUND: Ambulatory Muller phlebectomy for varicose veins can be performed under local anesthesia. However, subcutaneous injection of local tumescent anesthetics may cause discomfort because of acidity of the solution. Addition of sodium bicarbonate lowers the acidity of anesthetic solutions, which might cause less pain. The objective of this study was to study whether alkalinization of the local anesthetic solution with sodium bicarbonate 1.4% decreases perioperative pain during Muller phlebectomies. METHODS: It is a double-blind single-center randomized controlled trial. In all, 101 patients scheduled for ambulatory Muller phlebectomy were randomized to receive either local anesthesia with alkalinized solution (lidocaine 1% and epinephrine in sodium bicarbonate 1.4%) or standard solution (lidocaine 1% and epinephrine in saline 0.9%). Primary outcome was pain during injection of local anesthetics with the use of the Visual Analogue Scale (VAS). Secondary outcomes were peroperative and postoperative pain, use of analgesics, patient satisfaction, return to function, and complications. RESULTS: Patients receiving subcutaneous injection of local anesthetics diluted in sodium bicarbonate 1.4% experienced significantly less pain during injection compared with patients treated with standard anesthetic solution (VAS, 1.75 ± 1.8 vs. 3.55 ± 2.2, P < 0.00). Peroperative and postoperative pain, complication rates, use of analgesics, patient satisfaction, return to function, and complications did not differ between the 2 groups (P > 0.10). CONCLUSIONS: Alkalinization of local anesthetic solution with sodium bicarbonate 1.4% significantly improves patient comfort during injection of local tumescent anesthesia.

Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) Erasmus+ project: The Renal Expert in Vascular Access (REVAC) module.

The Renal Expert in Vascular Access (REVAC) is one of the four modules of the Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) project, the first European-wide advanced training course in diagnostics and interventional nephrology, funded by Erasmus+ Knowledge Alliance, a European Commission program. The N-PATH primary goal was to train 40 young European nephrologists in both theoretical knowledge and practical skills related to interventional nephrology. The REVAC module focused on the crucial aspects of vascular access (VA) care in nephrology practice, as a complementary training path to the actual residency program. The aim was to provide nephrology fellows with comprehensive knowledge and skills related to VA management. The methodology was based on face-to-face meetings and online learning, modern facilities, experienced tutors, cutting edge simulators, augmented reality tools by means of a multidisciplinary international faculty and hands-on-courses. A feedback survey reported the experience of fellows who attended the REVAC module, confirming the positive impact on their ongoing nephrology training. We are confident that this project will revitalize their nephrology careers and will help training the next generation of nephrologists; they will be able to manage VA needs with the help of multi-disciplinary teams to safely optimize the care of hemodialysis patients.

Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) program: the teachers' perspective.

The N-PATH (Nephrology Partnership for Advancing Technology in Healthcare) program concluded with the 60th European Renal Association 2023 Congress in Milan, Italy. This collaborative initiative aimed to provide advanced training in interventional nephrology to young European nephrologists. Funded by Erasmus+ Knowledge Alliance, N-PATH addressed the global burden of chronic kidney disease (CKD) and the shortage of nephrologists. CKD affects >850 million people worldwide, yet nephrology struggles to attract medical talent, leading to unfilled positions in residency programs. To address this, N-PATH focused on enhancing nephrology education through four specialized modules: renal expert in renal pathology (ReMAP), renal expert in vascular access (ReVAC), renal expert in medical ultrasound (ReMUS) and renal expert in peritoneal dialysis (RePED). ReMAP emphasized the importance of kidney biopsy in nephrology diagnosis and treatment, providing theoretical knowledge and hands-on training. ReVAC centred on vascular access in haemodialysis, teaching trainees about different access types, placement techniques and managing complications. ReMUS recognized the significance of ultrasound in nephrology, promoting interdisciplinary collaboration and preparing nephrologists for comprehensive patient care. RePED addressed chronic peritoneal dialysis, offering comprehensive training in patient selection, prescription, monitoring, complications and surgical techniques for catheter insertion. Overall, N-PATH's strategy involved collaborative networks, hands-on training, mentorship, an interdisciplinary approach and the integration of emerging technologies. By bridging the gap between theoretical knowledge and practical skills, N-PATH aimed to revitalize interest in nephrology and prepare proficient nephrologists to tackle the challenges of kidney diseases. In conclusion, the N-PATH program aimed to address the shortage of nephrologists and improve the quality of nephrology care in Europe. By providing specialized training, fostering collaboration and promoting patient-centred care, N-PATH aimed to inspire future nephrology professionals to meet the growing healthcare demands related to kidney diseases and elevate the specialty's status within the medical community.

FLOW: Flow dysfunction of hemodialysis vascular access: A randomized controlled trial on the effectiveness of surveillance of arteriovenous fistulas and grafts.

INTRODUCTION: It is assumed that identification and correction of asymptomatic stenoses in the vascular access circuit will prevent thrombosis that would require urgent intervention to continue hemodialysis treatment. However, the evidence base for this assumption is limited. Recent international clinical practice guidelines reach different conclusions on the use of surveillance for vascular access flow dysfunction and recommend further research to inform clinical practice. METHODS: The FLOW trial is a double-blind, multicenter, randomized controlled trial with a 1:1 individual participant treatment allocation ratio over two study arms. In the intervention group, only symptomatic vascular access stenoses detected by clinical monitoring are treated, whereas in the comparison group asymptomatic stenoses detected by surveillance using monthly dilution flow measurements are treated as well. Hemodialysis patients with a functional arteriovenous vascular access are enrolled. The primary outcome is the access-related intervention rate that will be analyzed using a general linear model with Poisson distribution. Secondary outcomes include patient satisfaction, access-related serious adverse events, and quality of the surveillance process. A cost effectiveness analysis and budget impact analysis will also be conducted. The study requires 828 patient-years of follow-up in 417 participants to detect a difference of 0.25 access-related interventions per year between study groups. DISCUSSION: As one of the largest randomized controlled trials assessing the clinical impact of vascular access surveillance using a strong double-blinded study design, we believe the FLOW trial will provide much-needed evidence to improve vascular access care for hemodialysis patients.

Transplantation of kidneys from paediatric DCD donors: a comparison with DBD donors.

BACKGROUND: Although acceptable outcomes have been reported in kidney transplantation from donation after cardiac death (DCD), little is known about kidney transplantation from paediatric DCD. The objective of this study was to compare the outcome of kidney transplantation using paediatric DCD with the outcome of paediatric donation after brain death (DBD). METHODS: Recipients from DCD and DBD donors <18 years of age transplanted in the Netherlands between January 1981 and July 2006 were included in this study. Ninety-one patients were transplanted with kidneys from paediatric DCD donors and 405 patients received grafts from paediatric DBD donors. RESULTS: Grafts from DCD donors were associated with higher percentage of primary non-function (9 versus 2%, P < 0.01) and delayed graft function (48 versus 8%, P < 0.001) compared with DBD donor grafts. Estimated glomerular filtration rate did not differ between groups (57 ± 17 versus 58 ± 21 mL/min at 1 year and 62 ± 14 versus 57 ± 22 mL/min at 5 years, respectively). After correction for confounding variables, the risk of graft failure was higher in the DCD group [hazard ratio 2.440 (95% confidence interval (CI) 1.280-4.650; P = 0.007]. Patient survival, however, was similar between groups [hazard ratio 1.559 (95% CI 0.848-2.867; P = 0.153)]. CONCLUSIONS: Paediatric DCD kidneys represent a valuable source of donor kidneys that has not been fully utilized. Although transplantation of paediatric DCD kidneys is associated with a higher risk of graft failure than transplantation of paediatric DBD kidneys, results are comparable with adult donors. We therefore conclude that paediatric DCD kidneys can be safely added to the donor pool.

Improvements in kidney transplantation from donors after cardiac death.

To reduce the growing waiting list for kidney transplantation, we explored the limits of kidney transplantation from donors after cardiac death by liberally accepting marginal donor kidneys for transplantation. As the percentage of primary non-function (PNF) increased, we evaluated our transplantation program and implemented changes to reduce the high percentage of PNF in 2005, followed by a second evaluation over the period 2006-2009. Recipients of a kidney from a donor after cardiac death between 1998 and 2005 were analyzed, with PNF as outcome measure. During the period 2002-2005, the percentage of PNF increased and crossed the upper control limits of 12% which was considered as unacceptably high. After implementation of changes, this percentage was reduced to 5%, without changing the number of kidney transplantations from donors after cardiac death. Continuous monitoring of the quality of care is essential as the boundaries of organ donation and transplantation are sought. Meticulous donor, preservation, and recipient management make extension of the donor potential possible, with good results for the individual recipient. Liberal use of kidneys from donors after cardiac death may contribute to a reduction in the waiting list for kidney transplantation and dialysis associated mortality.