Optimization of expanded donors using dual kidney transplantation: case-control study.

BACKGROUND: Cadaveric donation is now experiencing a trend toward the use of expanded criteria donors (ECD) who may not yield a suitable kidney for single organ transplantation which has occasionally led to their use as dual renal transplantations. MATERIAL AND METHODS: We undertook a case-control study to analyze our experiences between May 2007 and March 2011 with 80 kidneys from ECD who were older than 65 years. Of these, 40 were used as single transplants (STX) and the other 40 as dual cases (DTX). Criteria to determine STX versus DTX were established by biopsy results and other donor factors. RESULTS: The mean age of the ECD for STX was 68.7 ± 3.0 years and for DTX, 74.2 ± 4.3 years (P < .001), with more women among DTX (75%) versus STX (40%; P < .001). The DTX kidneys showed higher biopsy scores than the STX organs. DTX were older than STX recipients, but there were no differences in cold ischemia time, delayed graft function, hemorrhagic complications or reinterventions. DTX recipients achieved better CrCl at 1, 3, 6, and 12 months, although only significantly so at 6 months (53.4 ± 19.5 Ml/min versus 44.5 ± 15.6 mL/min; P < .05). Death-censored graft survival was 90% at 3 years for both groups. CONCLUSIONS: DTX offered good results for graft survival and renal function, despite the more complicated surgery and worse quality of the allografts. DTX allowed the use of ECD kidneys that showed less satisfactory histologic and donor characteristics.

Increased organ donations from people born outside Spain.

Organs donated from persons born outside Spain are becoming increasingly numerous. These persons now account for 26.1% of all donors in the "Malaga sector," an area of tourism with a high percentage of immigrants. Acceptance to donation among persons from Europe and South America is similar to that of Spanish persons but lower among those born in Africa. We must recognize the great help that cultural mediators provided not only by assistance with the language barrier but also by generating confidence among families and understanding their emotions, feelings, and traditions, mainly during interviews with families from different social and cultural miliere. To be efficient, the interpreters or cultural mediators need to have received specific training in the organ donation process and to be involved and convinced that organ donation and transplantation is the best solution for severe health problems.

Organ donors with exceptional medical conditions also count!

All organ donors, even those who have died under exceptional conditions, can provide at least one valid organ for transplantation. It is thus necessary to evaluate the outcomes of donors with unusual diseases. We reviewed 909 organ donors at six hospitals over the last 15 years. Of these, 29 (3.19%) were considered to be exceptional either because of prior disease, the circumstance of death, or complications arising during admission. Among the 53 organs transplanted from all these donors (except two), the mean number of valid organs per donor was 1.88 rather than 2.36 for standard donors. One patient who received a liver transplant died due to the same infection as that diagnosed in the donor. The remaining recipients experienced no primary graft failure or transmission of problems present in the donor.

Profile of organ donors not authorized for judicial reasons.

Loss of donors as a consequence of a coroner's refusal to authorize is an unusual problem that prevents organs becoming available for transplantation. Of 1123 effective donors, 433 (38.5%) died of accidental death. In these latter, it was therefore necessary to request judicial authorization for donation during the coroner's examination. Organ extraction was not performed because of judicial refusal in 15 of these donors (3.46% of the total number of judicial extractions requested and 1.33% of the total number of donors). Despite the lack of differences in the cause of death profile in the four provinces, large differences were noted between the provinces, with most judicial refusals in Malaga (10 refusals; 6.6% of the total judicial refusals), followed by Granada with five refusals (2.9%), Seville with two refusals (1.7%), and zero in Almería. To minimize these judicial refusals, we propose joint action protocols between transplant coordinators, judges, and coroners for these donors to be examined in the hospital prior to extraction and in the operating room during extraction. Any external lesion of judicial interest can then be examined, photographed, and evaluated.

Expanded criteria donors for kidney transplantation: quality control and results.

Although the number of kidneys from expanded criteria deceased donors (ECDs) is growing in most transplant centers, the limits for acceptance of these kidneys and the safety standards have still not been fully established. We evaluated 342 kidney transplants performed between January 1999 and December 2004. In 77 (22.5%) of these, the kidneys were from ECDs, that is, donors age >60 years and with one of the following characteristics: hypertension, death due to cerebrovascular accident (CVA) or glomerular filtration rate (GFR) <70 mL/min. The results of the ECD transplants were compared with 265 transplants during the same period from standard donors (SDs), that is, donors age <60 years and GFR > 70 mL/min. All the ECD kidneys underwent biopsy and were accepted for transplantation only if the score was <7. The ECDs (66.5 +/- 4.3 years) in comparison with the SDs (48.0 +/- 16.0 years) had a greater frequency of death due to CVA (94.8% vs 49.8%) and a lower GFR (80.4 +/- 25.0 vs 111 +/- 41.6 mL/min; P < .05). Of the ECDs, 97.4% had a history of hypertension versus 24.3% of the SDs. Kidney biopsies were performed in 116 SD kidneys because the donor age was >55 years or there was a history of hypertension. The median score for the kidney biopsies of the ECD kidneys was 3 versus 2 for the SD kidneys. Graft survival was not significantly different until the fifth year. The GFR at 12 months was significantly different (SDs, 58.0 +/- 22.7 vs ECDs, 48.9 +/- 16.5 mL/min; P < .05). Although the GFR in the ECD kidneys was lower than that of the SD kidneys, it could still be adequate for recipients older than 50 years of age. Accordingly, the acceptance criteria for ECD kidneys based mainly on the kidney biopsy score and donor GFR benefit the recipients.

Expanded donor criteria due to age: an effort rewarded.

The life expectancy of the current Spanish population is 78 years, with some 20% of the population aged over 65 years. The continuing increase in the demand for transplants has led to widening of the criteria for acceptance of donors without worsening the results, but without reducing transplant waiting lists or mortality. This has resulted in the need to include the concept of the expanded criteria donor (ECD). We undertook a retrospective study of 77 donors from a hospital with no neurosurgery service from January 2000 to December 2005. Four of the donors younger than 60 years of age (n = 38) were not appropriate (10.5%), whereas five of the donors older than 60 years of age (n = 39) were not appropriate (12.8%; P = NS). The older donors provided 47 used kidneys (60.2%) and 22 livers (56.4%), slightly fewer than those obtained from the younger donors, though the difference was not significant. Thus, ECDs, those older than 60 years of age, did not result in a significant loss of kidneys or livers available for transplantation. Other factors associated with systemic vascular disease and accompanying disorders could be determinant when predicting the usefulness of organs for transplantation.

Organ donation: a comparison of donating and nondonating families.

The family interview to determine the wishes of the deceased during life about organ donation is not only a legal requirement, it is also the stage at which most potential donors are lost. Minimizing these losses necessitates awareness of all the variables involved in the family interview so that, before starting the interview, one understands the important key points affecting the outcome. We showed that some variables among 268 interviews are susceptible to intervention: the information and treatment perceived by the family members during the hospital stay and the preparation of the interview, such that a suitable number of the closest members of the family with a decision capacity is always present. Other noncontrollable factors that are important in the final decision included the social and demographic level, the prosocial attitude of the deceased, and prior knowledge and opinions about organ donation. Informative events within the hospital to improve the predisposition and collaboration of health care professionals were key to improving the public's perception of organ donation and achieving greater confidence in health care centers and their staff. Furthermore, the family interview must be planned by the transplant coordinators to limit improvisation.

Pancreas donation for islet transplantation.

Islet transplantation, though still in the experimental phase, is a therapeutic option that has opened new expectations for the control of diabetes mellitus. Initial results are encouraging for the significant advantages compared with whole pancreas transplantation for selected patients with type 1 diabetes mellitus, with or without kidney failure. However, the success of transplantation, both at centers with more experience and others with less, is limited by the difficulty in obtaining a suitable number of donors and by laboratory isolation techniques. Significant advances require changes in donor selection, perfusion, oxygenation, and transfer of the pancreas, and in the process of isolation, purification, and culture in the laboratory. Of the 32 pancreases sent to the islet isolation laboratory from different hospitals in Andalusia, a viable percentage of islets was finally available in 19. However, in only 4 (18%) procedures were the preparations considered optimal for implantation in 2 recipients.

Multifactorial snowball effect in the reduction of refusals for organ procurement.

Interviewing the family of a possible organ donor is a legal requirement in Spain, but it is the stage at which most potential donors are lost. Multiple factors influence the family's acceptance or rejection of this option, including awareness of the wishes of the deceased, personal preconceived attitudes of family members, as well as issues related to the hospital and its health care personnel, whose attitudes are a key factor in obtaining permission. We examined all 651 donation situations in a single hospital that included a family interview over the last 15 years. Among these 651 cases, 191 families refused donation (29.3%). The rate of donation refusal has fallen from 46.3% to 12.5% over these 15 years. To better understand the evolution of donor characteristics, interviewees, and the setting, we divided the sample into three 5-year periods to analyze key variables collected from the family interviews. The results showed that at the same time as the donor profile has changed, namely, fewer brain trauma cases and more victims of stroke as well as older mean age and more coexistent diseases, these has been an improvement in the factors related to the information and opinion of both the families and the donor about this process. The main reasons for refusal of donation have changed from negation of brain death, religious factors, and the desire to maintain the body intact during the 1990s, to sociocultural reasons in minority ethnic groups, to presumed refusal during life, and to family disagreements during the more recent years.