Kidney transplantation from donation after circulatory death using abdominal normothermic oxygenated circulation: are the outcomes equivalent?

PURPOSE: To increase the pool of kidneys available for transplantation, a renewed interest in donation after circulatory death (DCD) has emerged. This study aims to determine the outcomes of kidney transplantation from DCD after abdominal normothermic oxygenated circulation (ANOR) support. METHODS: From January 2016 to December 2018, 58 kidneys were implanted from uncontrolled DCD after ANOR support. We performed an observational prospective study, assessing graft function and cumulative incidence of surgical complications. A descriptive analysis was conducted. Potential determinants of the outcomes were evaluated, including donor and receptor gender and age, and warm and cold ischemia times. Regression coefficients (ß) and odds ratio (OR) were calculated with 95% confidence intervals. A p-value < 0.05 was considered statistically significant. Statistical analysis was accomplished using Stata 11.0 software. RESULTS: The median follow-up time was 31.2 months. Delayed graft function (DGF) was evident in 80%, with a mean Cr one month after transplantation of 1.81 mg/dL and 1.33 mg/dL after one year. Primary non-function (PNF) occurred in 5.2% of cases. Male donors were associated with a lower DGF (OR = 0.21, p < 0.05), and a higher donor age was a predictor of poorer graft function at one year (ß = - 0.88, p < 0.05). Surgical complications occurred in 31% patients, predominantly vascular. Warm ischemia time superior to 60 min correlated with a higher risk of surgical complications (OR = 11.33, p < 0.05). CONCLUSION: Kidney transplantation from DCD is a valuable option, allowing an improvement in the balance between patients waiting for a transplant and the available kidneys.

An integrated program of extracorporeal membrane oxygenation (ECMO) assisted cardiopulmonary resuscitation and uncontrolled donation after circulatory determination of death in refractory cardiac arrest.

AIM: To assess the feasibility of an integrated program of extracorporeal cardiopulmonary resuscitation (ECPR) and uncontrolled donation after circulatory determination of death (uDCDD) in refractory cardiac arrest (rCA). METHODS: Single center, prospective, observational study of selected patients with in-hospital (IHCA) and out-of-hospital (OHCA) rCA occurring in an urban area of ∼1.5 million inhabitants, between October-2016 and May-2018. 65 year old or younger patients without significant bleeding or comorbidities with witnessed nonasystolic cardiac arrests were triaged to ECPR if they had a reversible cause and high quality CPR lasting < 60 min. Otherwise they were considered for uDCDD after a ten minute no touch period using normothermic regional perfusion. RESULTS: 58 patients were included, of which 41 (71%) were OHCA and 18 (31%) had ECPR initiated. Median age was 52 (IQR 45-56) years. Cannulation was successful in 49/58 (84%) cases. Compared to ECPR, patients referred for uDCDD were more frequently OHCA (90 vs. 28%), had bystander CPR (28 vs. 83%) and prolonged low-flow period (40 (35-50) vs. 60 (49-78) min). Survival to hospital discharge with full neurological recovery (cerebral performance category 1) occurred in 6/18 (33%) ECPR patients. uDCDD resulted in transplantation of 44 kidneys. CONCLUSIONS: An integrated program for rCA consisting of a formal pathway to uDCDD referral in ECPR ineligible patients is feasible. ECPR-referred patients had a reasonable survival with full neurologic recovery. Successful kidney transplantation was achieved with uDCDD.

Organs transplantation - how to improve the process?

The transplant of cadaveric organs must be performed in a short period of time in order to achieve satisfactory results. In Hospital S. João (HSJ), a large Portuguese hospital, during 2008 and 2009, 65 and 61 respectively potential donors were identified, but 12 and 19 of them were not validated as such in time. The number of validated donors could increase if the information workflow between donor hospitals and coordinator offices became more efficient. The goal of this work is to design and implement a multi-agent software platform to assist the information workflow between donor hospitals and coordinator offices. Through several meetings with HSJ coordinator office it was characterized a set of basic data that would allow coordinator offices to early identify possible organs donors. This preliminary characterization provided the necessary grounds for the development of an agent based software application allowing the storage and management of potential donors' information and optimizing the information workflow. The information workflow and the current communication processes characterization allowed the development of a multi-agent web platform, providing a way to assist the information workflow, between coordinator hospitals and their attached hospitals network. The platform also improves direct communication between coordinator offices about most relevant facts. By using this tool or a similar one the information workflow between donor hospitals and coordinator offices can become more efficient, optimizing the pre-transplantation tasks and consequently the number of successful transplants in our country.

Conversion from sirolimus to everolimus in kidney transplant recipients receiving a calcineurin-free regimen.

BACKGROUND: Everolimus (EVL) and sirolimus (SRL) were introduced into immunosuppressive regimens, in an attempt to replace or reduce the dose of the nephrotoxic calcineurin inhibitors (CNI). In our institution, due to an administrative decision, conversion from SRL to EVL, was carried out, providing us the opportunity to investigate the effectiveness and safety profile of both drugs and to review the practical conversion dose between them. METHODS: We retrospectively analyzed the medical records of 51 maintenance kidney transplant recipients receiving an SRL-based CNI-free regimen, who were switched to EVL. SRL dose was concentration controlled to a through level of 4-8 ng/mL. Patients were converted to a variable dose of EVL that was adjusted to achieve a trough concentration of 3-8 ng/mL. RESULTS: SRL mean dose at time of conversion was 2.0 ± 0.9 mg/d. Initial EVL mean dose was 1.3 ± 0.5 mg/d. Six months after conversion, mean EVL trough level was 6.2 ± 2.8 ng/mL. EVL dose at this point was 2.0 ± 0.9 mg/d, which was not statistically different from SRL dose at the time of conversion (p = 0.575), suggesting a conversion factor of 1:1. During this six month period post conversion, no significant changes were observed in serum creatinine, hematocrit level, platelet count, proteinuria or lipid levels. No patient experienced an acute rejection episode. CONCLUSIONS: Conversion from SRL to EVL in renal transplant recipients receiving a CNI-free immunosuppressive regimen can be performed safely with a low trough level range of EVL. We report for the first time a conversion factor between SRL and EVL.

[Metastatic calcification detected on bone scintigraphy]. / Calcificação metastática detectada em cintigrafia óssea.

PURPOSE: To show the value of bone scintigraphy in the diagnosis of metastatic calcification in end-stage renal insufficiency. MATERIAL AND METHODS: The authors present a fifty-one-year-old male with terminal renal insufficiency of hypertensive renovascular etiology, on hemodialysis for the last 10 years, referred for a bone scan because of osteoarticular complaints, and no other associated symptoms or findings on physical examination. RESULTS: Whole body bone scintigraphy images (HMDP-99mTc, 925MBq), showed increased uptake in the lower half of both lungs, the stomach and renal parenchyma, compatible with metastatic calcification. CONCLUSIONS: Bone scintigraphy, due to its high sensitivity, even in the detection of early changes, might be a useful instrument in the initial evaluation and follow-up of patients with high risk of developing metastatic calcification.

[Antiviral drug-induced nephrotoxicity]. / Nefrotoxicidade dos antivíricos.

Antiviral drug-induced kidney injury, frequently leading to acute renal failure, is increasing in incidence. We review the pathogenesis and clinical manifestations of antiviral drug-induced nephrotoxicity, as well as strategies for prevention and treatment.