[Renal harvest. State of the art.] / Extracción renal. Situación actual.

Kidney transplantation (KT) is the best treatment for end-stage renal disease. Despite Spain isone of the leading countries in donation, the need for transplantable organs exceeds the available supply. Graft survival depends on the quality of the organ, the damage it suffers during the donation and transplantation process, as well as the risk of rejection. Among the factors that must be controlled and minimized are the ischemia-reperfusion injuries that occurs in the moments surrounding the death of the donor, the procurement and the preservation of the organ until kidney transplantation. Static cold storage is the traditional method of preservation of the organ until the moment of implantation, since it is a technique with wide availability and low cost. The use of perfusion machines in DCD and expanded criteria has shown better short-term results (primary failur delayed on set of function) without affecting recipient orgraft survival. The objective of our article is to review the current situationand the resources available to increase the pool of transplantable organs and their quality. We conducted a systematic review on kidney extraction, donor management, preservation methods and techniques to optimize cadaveric donor kidney donation.

El trasplante renal (TR) es el mejor tratamiento para la enfermedad renal crónica terminal. En España no se dispone de suficientes órganos para suplirla demanda de pacientes en lista de espera a pesar deser uno de los países líderes en donación. La supervivencia del injerto depende de la calidad delórgano, el daño que sufre durante el proceso de donacióny trasplante, así como de la posibilidad de que seproduzca rechazo. Entre los factores que debemos minimizar y optimizar se encuentran las lesiones inducidas por los mecanismos de isquemia-reperfusión, en los momentos que rodean la muerte del donante, la extracción y la preservación del órgano hasta su trasplante.Tradicionalmente la preservación del órgano hasta elmomento del implante se ha llevado a cabo mediante la conservación en frío, ya que es una técnica con amplia disponibilidad y bajo coste. El uso de máquinas de perfusiónen donaciones en asistolia y criterio expandido,ha demostrado mejores resultados a corto plazo (fallo primario, inicio retrasado de función) sin afectar a la supervivencia del receptor o del injerto. El objetivo de este trabajo es revisar la situación actual,así como los recursos disponibles para aumentar el poolde órganos trasplantables y la calidad de estos. Hemos realizado una revisión sobre la extracción renal, manejo del donante, métodos y técnicas de preservación para optimizar la donación renal de donante cadáver.

Extracción renal. Situación actual / Kidney extraction. Current situation

El trasplante renal (TR) es el mejor tratamiento para la enfermedad renal crónica terminal. EnEspaña no se dispone de suficientes órganos para suplirla demanda de pacientes en lista de espera a pesar deser uno de los países líderes en donación. La supervivencia del injerto depende de la calidad delórgano, el daño que sufre durante el proceso de donación y trasplante, así como de la posibilidad de que seproduzca rechazo. Entre los factores que debemos minimizar y optimizar se encuentran las lesiones inducidaspor los mecanismos de isquemia-reperfusión, en los momentos que rodean la muerte del donante, la extraccióny la preservación del órgano hasta su trasplante.Tradicionalmente la preservación del órgano hasta elmomento del implante se ha llevado a cabo mediante laconservación en frío, ya que es una técnica con amplia disponibilidad y bajo coste. El uso de máquinas de perfusión en donaciones en asistolia y criterio expandido,ha demostrado mejores resultados a corto plazo (falloprimario, inicio retrasado de función) sin afectar a lasupervivencia del receptor o del injerto. El objetivo de este trabajo es revisar la situación actual,así como los recursos disponibles para aumentar el poolde órganos trasplantables y la calidad de estos. Hemosrealizado una revisión sobre la extracción renal, manejodel donante, métodos y técnicas de preservación paraoptimizar la donación renal de donante cadáver.(AU)

Kidney transplantation (KT) is the besttreatment for end-stage renal disease. Despite Spain isone of the leading countries in donation, the need fortransplantable organs exceeds the available supply. Graft survival depends on the quality of the organ, thedamage it suffers during the donation and transplantation process, as well as the risk of rejection. Among the factors that must be controlled and minimized are the ischemia-reperfusion injuries that occursin the moments surrounding the death of the donor, theprocurement and the preservation of the organ until kidney transplantation.Static cold storage is the traditional method of preservation of the organ until the moment of implantation, sinceit is a technique with wide availability and low cost. Theuse of perfusion machines in DCD and expanded criteria has shown better short-term results (primary failure, delayed onset of function) without affecting recipient orgraft survival.The objective of our article is to review the current situation and the resources available to increase the pool oftransplantable organs and their quality. We conducted a systematic review on kidney extraction,donor management, preservation methods and techniques to optimize cadaveric donor kidney donation:(AU)

Post-kidney donation glomerular filtration rate measurement and estimation. / Medición y estimación del filtrado glomerular posdonación renal.

BACKGROUND: Long-term consequences associated with kidney donation are controversial. Pre- and post-donation glomerular filtration rates (GFRs) are determinants of renal and cardiovascular risk weighting. In Latin America, there is limited experience in evaluating kidney function using GFR measurement techniques in kidney donors. The MDRD 4-variable and CKD-EPI equations are considered reasonable options. The objective of this study was to evaluate the performance of the MDRD and CKD-EPI equations in post-nephrectomy GFR dynamics in kidney donors. MATERIALS AND METHODS: A prospective cohort study with GFR measurement and estimation in 189 kidney donors who underwent nephrectomy between 2007 and 2016 at the Hospital Privado Universitario de Córdoba [Private University Hospital of Córdoba] in Córdoba, Argentina. GFRs were evaluated before and after nephrectomy by iothalamate clearance determined by HPLC and by the MDRD and CKD-EPI equations for estimating GFR. Two groups were formed for this study: Group 1 (n=107), with an evaluation time subsequent to GFR stabilization (3 months) of up to 5 years, and Group 2 (n=82), with an evaluation time of 5-10 years following donation. Measured GFR (mGFR) was assessed by iothalamate clearance determined by HPLC. RESULTS: Renal compensation values were 61.9% (52.0%-71.1%) and 75.6% (64.9%-84.4%) for Group 1 (n=107) and Group 2 (n=82), respectively. MDRD underestimated the GFR in 3.2% (90ml/min/1.73m2) and 38.6% (60ml/min/1.73m2) compared to the mGFR, and CKD-EPI underestimated the GFR in 2.6% (90ml/min/1.73 m2) and 13.8% (60ml/min/1.73 m2). Diagnostic performance was evaluated with a ROC curve (mGFR<60ml/min/1.73 m2) for MDRD (ABC=0.66; CI: 0.59-0.73; sensitivity: 98.7%; specificity: 63.3%) and for CKD-EPI (ABC=0.79 CI: 0.73-0.85; sensitivity: 96.9%; specificity: 76.4%. Estimated GFR (eGFR) showed poor performance for estimating the glomerular filtration rate in the post-nephrectomy follow-up of donors over 50 years of age. CONCLUSIONS: Equations for estimating GFRs showed poor performance for long-term follow-up of post-nephrectomy GFRs. Measuring GFRs to determine kidney function is recommended in the screening and follow-up of some donors under the current selection criteria.

The experience of donating and receiving a kidney: A systematic review of qualitative studies.

BACKGROUND: The experiences described by people who have undergone kidney transplant are complex. Understanding how donors and recipients experience kidney transplantation can help us to design strategies that provide a more person-centred health care. OBJECTIVES: To review articles that report the experiences of donors and recipients in the living-donor kidney transplantation process. METHOD: A systematic review of qualitative studies was carried out. PubMed, Scopus, Web of Science, CINAHL and PsycINFO databases were used to search for articles published in English, French and Spanish between 2005 and 2018. RESULTS: Twenty-nine articles were included in this review. For recipients, receiving a kidney is a positive experience (positive feelings and significant experience) that also involves certain difficulties and stressors (making a difficult decision, fears and worries). The experience of the donors is positive as they are motivated to improve the life of the recipient. They are committed to donating and use coping strategies as well as experiencing personal growth. On the contrary, being a donor involves certain difficulties and stressors (personal investment, mental, physical and economic impact and overcoming opposition) and a perception of deficiency in the health system (lack of information and attentiveness). CONCLUSION: Donating and receiving a kidney is a positive experience that involves certain difficulties and a variety of stressors for both the donors and recipients. Moreover, the donors note deficiencies in the health system.

ANTECEDENTES: Las experiencias que explican las personas sometidas a un trasplante renal son complejas. Entender como experimentan el trasplante renal los donantes y los receptores nos puede ayudar a diseñar estrategias para proporcionar una atención sanitaria más centrada en la persona. OBJETIVOS: Revisar artículos que hablen sobre las experiencias de los donantes y los receptores en el proceso de trasplante renal de donante vivo. MÉTODO: Se realizó una revisión sistemática de estudios cualitativos. Se utilizaron las bases de datos Pubmed, Scopus, Web of Science, Cinahl y Psycinfo para buscar artículos desde el año 2005 hasta 2018 publicados en inglés, francés o español. RESULTADOS: Se incluyeron 29 artículos en esta revisión. Para los donantes la experiencia de donar es positiva ya que están motivados para mejorar la vida del receptor, donan de forma convencida, utilizan estrategias de afrontamiento y experimentan crecimiento personal. Por otro lado, donar supone dificultades y estresores (inversión personal, impacto económico, físico, mental y superar la oposición) y percepción de carencia en el sistema sanitario (falta de información y desatención). Para los receptores el recibir un riñón es una experiencia positiva (sentimientos positivos y experiencia significativa) ligada también a dificultades y estresores (toma de decisión difícil, temores y preocupaciones). CONCLUSIONES: Dar y recibir un riñón es una experiencia positiva que comporta dificultades y factores estresantes diferentes para los donantes y para los receptores. Además, los donantes constatan una carencia en el sistema sanitario. This article is protected by copyright. All rights reserved.

Factors associated with renal function compensation after donor nephrectomy. / Factores asociados a la compensación de la función renal tras la nefrectomía para donación.

INTRODUCTION: Kidney transplant donors lose 50% of their renal mass after nephrectomy. The remaining kidney compensates for this loss and it is estimated that 70% of the baseline renal function prior to donation is recovered. Factors associated with post-donation renal compensation are not well understood. METHODS: Retrospective study of 66 consecutive kidney donors (mean age 48.8 years, 74.2% women). We analysed the potential factors associated with the compensatory mechanisms of the remaining kidney by comparing donors according to their renal compensation rate (RCR) (Group A, infra-compensation [<70%]; Group B, normal compensation [>70%]). RESULTS: We compared Group A (n=38) and group B (n=28). Predictors for RCR>70% were higher baseline creatinine (A vs B: 0.73±0.14 vs 0.82±0.11; P=.03) and a lower baseline glomerular filtration rate (GFR), estimated both by MDRD-4 (A vs B: 97.7±18.8 vs 78.6±9.6ml/min; P<.001) and CKD-EPI (A vs B: 101.7±15 vs. 88.3±11.7ml/min; P≤.001). Age, gender, smoking, hypertension and GFR measured by Tc-DTPA did not show any correlation with the RCR. The multivariate analysis confirmed baseline estimated glomerular filtration rate (eGFR) to be a predictor of compensation: the higher the baseline eGFR, the lower the likelihood of >70% compensation (MDRD-4, OR=0.94 [95% CI 0.8-0.9], P=.01). The compensation rate decreased by 0.4% (P<.001) and 0.3% (P=.006) for every ml/min increase in baseline eGFR estimated by MDRD-4 and CKD-EPI, respectively. CONCLUSIONS: One year after living donor nephrectomy, the remaining kidney partially compensates baseline renal function. In our experience, baseline eGFR is inversely proportional to the one-year renal compensation rate.

MDRD or CKD-EPI for glomerular filtration rate estimation in living kidney donors. / MDRD o CKD-EPI en la estimación del filtrado glomerular del donante renal vivo.

INTRODUCTION: The evaluation of the measured Glomerular Filtration Rate (mGFR) or estimated Glomerular Filtration Rate (eGFR) is key in the proper assessment of the renal function of potential kidney donors. We aim to study the correlation between glomerular filtration rate estimation equations and the measured methods for determining renal function. MATERIAL AND METHODS: We analysed the relationship between baseline GFR values measured by Tc-99m-DTPA (diethylene-triamine-pentaacetate) and those estimated by the four-variable Modification of Diet in Renal Disease (MDRD4) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in a series of living donors at our institution. RESULTS: We included 64 donors (70.6% females; mean age 48.3±11 years). Baseline creatinine was 0.8±0.1 mg/dl and it was 1.1±0.2 mg/dl one year after donation. The equations underestimated GFR when measured by Tc99m-DTPA (MDRD4-9.4 ± 25ml/min, P<.05, and CKD-EPI-4.4 ± 21ml/min). The correlation between estimation equations and the measured method was superior for CKD-EPI (r=.41; P<.004) than for MDRD4 (r=.27; P<.05). eGFR decreased to 59.6±11 (MDRD4) and 66.2±14ml/min (CKD-EPI) one year after donation. This means a mean eGFR reduction of 28.2±16.7 ml/min (MDRD4) and 27.31±14.4 ml/min (CKD-EPI) at one year. CONCLUSIONS: In our experience, CKD-EPI is the equation that better correlates with mGFR-Tc99m-DTPA when assessing renal function for donor screening purposes.

Long-term safety in living kidney donors for paediatric transplantation. Single-centre prospective study. / Seguridad a largo plazo en el donante vivo para trasplante renal pediátrico. Estudio prospectivo, unicéntrico.

INTRODUCTION: There is enough evidence concerning the short-term safety of living donors after kidney transplantation. However, long-term complications continue to be studied, with a particular interest in young donors. Previous studies have been conducted in older donors for adult renal patients. We present a study of long-term complications in kidney donors for our paediatric population. METHODS: We carried out a long-term donor study for the 54 living kidney-donor transplantations performed at our department from 1979 to June 2014. We monitored the glomerular filtration rate (GFR) on the basis of 24-hour urine creatinine clearance, 24-hour proteinuria and the development of arterial hypertension in the 48 donors who were followed up for more than one year. Only the 39 patients who were exclusively followed up by our department have been included in the results analysis. RESULTS: GFR through creatinine clearance was stable after an initial decrease. No proteinuria was observed in any of the cases. One patient developed chronic kidney disease (CKD), which resulted in a cumulative incidence of 2%. GFR below 60mL/min/1.73 m2 was not reported in any other patients. Arterial hypertension was diagnosed in 25% of donors, 90% of which were treated with antihypertensives. CONCLUSIONS: Risk of CKD and hypertension in living kidney donors for paediatric recipients, who are carefully monitored throughout their evolution, is similar to that of the general population. Therefore, this technique appears to be safe in both the short and long term.

Valoración en un solo paso del potencial donante renal: Angiografía y urografía por RM con correlación quirúrgica / One-step MR angiography and urography in the evaluation of potential renal living donors.

Objetivos. Evaluar el rendimiento diagnóstico de la angiografía renal (ARM) y urografía (URM) por Resonancia Magnética (RM) en potenciales donantes de riñón mediante la correlación con hallazgos quirúrgicos. Materiales y Métodos. Se evaluaron 55 potenciales donantes mediante protocolo angiográfico y urográfico en múltiples fases en un resonador de 1,5 T. La ARM valoró la existencia de variantes anatómicas o alteraciones estructurales arteriales o venosas y la URM valoró el parénquima renal y el sistema colector en fases nefrográfica y excretora. Los resultados fueron comparados con hallazgos quirúrgicos. Resultados. La correlación se realizó en 42 donantes efectivos. En ellos, se observó una especificidad de la ARM del 94% y una exactitud diagnóstica del 93%. Se identificaron variantes anatómicas y alteración estructural arterial en el 29% de los pacientes. La valoración venosa y urográfica de la RM resultó concordante quirúrgicamente en todos los casos. Conclusión. Las imágenes de RM proveen un método seguro y eficaz para la valoración prequirúrgica renal de forma integral en potenciales donantes de riñón.

Objectives. To evaluate diagnostic accuracy of renal MRangiography(MRA) and MR- urography (MRU) in the assessment of normal anatomy and renal vascular pathology in potential renal living donors compared with surgical findings. Materials and Methods. Evaluation of 55 potential living donors performing one-step MR angiography and MR urography in a 1.5 T magnet. MRA evaluated the presence of anatomic variants or arterial or venous pathologic conditions. MRU depicted renal parenchyma anatomy and collector system. These results were compared with surgical findings. Results. MRA and MRU findings were actually compared with surgical findings in 42 effective donors. MRA specificity was 94 % and diagnostic accuracy was 93 %. Anatomic variants and arterial structural abnormalities were detected in 29 % of patients. Venous and excretory surgical findings were consistent in 100 % of cases. Conclusion. One-step MRA and MRU constitutes an accurate method for pre-operative assessment of renovascular and excretory anatomy in potential living donors.

Protocolos de selección y estudio del donante y receptor, aplicables a la práctica chilena, en trasplante renal / Screening and selection protocol of donor and recipient in kidney trasplantation, applied to chilean practice

En el trasplante de órganos siempre hay un donante y receptor cuyas voluntades deben ser respetadas y que deben ser estrictamente evaluados desde el punto de vista médico, social, psicológico y moral para determinar la idoneidad de cada uno para recibir la acción médica. En el presente artículo se describen las pautas para estudiar a un potencial donante renal vivo o cadavérico y a los potenciales receptores de un trasplante renal para evitar yerros que compliquen el trasplante o atenten contra normas éticas y científicas básicas universalmente aceptadas que se aplican al trasplante de órganos sólidos en general y de riñón en particular.

Organ transplantation is a medical procedure that should be accomplished by the concurrence of a deceased or living donor and a recipient. Both participants should be submitted to a rigorous screening that includes medical, social, psychological and moral evaluation, before being accepted as donor and recipient. In the present article we describe the worldwide established protocols that must be performed in order to assure the optimal quality of either participant in the donation/acceptation process, in order to avoid mistakes that shade solid organ transplantation in general and kidney transplantation among them.