CHAPTER 32: Deceased Donor Considerations

PROLONGED COLD ISCHEMIA TIME

• Prolonged cold ischemia time has been reported to be associated with impaired graft survival

• In our experience, satisfactory outcomes have been observed in the setting of ischemic times of 20 hours or greater with:

  • Grafts from donors under 60 years of age

  • In first-time recipients

• Induction therapy with an interleukin-2 antagonist is preferred

ELDERLY DONORS

• Transplantation of kidneys from donors of 75 years of age or older is controversial

• In our experience, satisfactory outcomes can be potentially achieved with such kidneys in elderly recipients when:

  • Dual kidney grafting is used

  • In the absence of:

    • Retransplantation

    • Surgical complications

HYPOTHERMIC MACHINE PERFUSION

Continuous pulsatile hypothermic machine perfusion has been found to be associated with:

• Reduced risk of delayed graft function and improved graft survival in the first year after transplantation

• Reduced rate of primary transplant renal non-function and improved 1-year graft survival rate of kidneys with delayed graft function (DGF) for kidneys from donors aged 65 years or older

• Improved quality-adjusted life-years while reducing costs

• Reduced risk of DGF and improved 1-year graft survival and function of expanded criteria donors (ECD) kidneys

• Reduced risk of DGF and better early graft function up to 1 month after transplantation of donor after cardiac death (DCD) kidneys

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) HIGH RISK DONORS

Extended Criteria Donors

• The acceptance of high-risk centers for disease control and prevention (CDC) donors extended criteria donors (ECD) is based on each individual transplant center guidelines

• Recipients should always be made aware of this fact and provided with the necessary information

• Counseling specific to each circumstance should always be provided if requested by the candidate

• Thorough documentation is required as per UNOS guidelines

DONORS UNDER 5 YEARS OF AGE

• Donors in this category can be transplanted en bloc or independently

• Outcomes of single grafts seem to be satisfactory in pediatric recipients

TRANSPLANTATION SIMULTANEOUS WITH IMPLANTATION OF VASCULAR GRAFTS

• Atherosclerotic disease is almost universally encountered in kidney transplant recipients

• Occasionally, simultaneous reconstruction with vascular prosthetic grafts (such as aortofemoral bypass grafting) may be required to achieve improved arterial flow to both graft and lower extremity of the recipient

• These procedures were found to be safe and to optimize outcomes

• It is recommended that an experienced vascular surgeon be involved in the procedure

FURTHER READING