Kidney Transplants From Donors on Extracorporeal Membrane Oxygenation Prior to Death Are Associated With Better Long-Term Renal Function Compared to Donors After Circulatory Death

Abstract

Donation after circulatory death (DCD) allows expansion of the donor pool. We report on 11 years of Italian experience by comparing the outcome of grafts from DCD and extracorporeal membrane oxygenation (ECMO) prior to death donation (EPD), a new donor category. We studied 58 kidney recipients from DCD or EPD and collected donor/recipient clinical characteristics. Primary non function (PNF) and delayed graft function (DGF) rates, dialysis need, hospitalization duration, and patient and graft survival rates were compared. The estimated glomerular filtration rate (eGFR) was measured throughout the follow-up. Better clinical outcomes were achieved with EPD than with DCD despite similar graft and patient survival rates The total warm ischemia time (WIT) was longer in the DCD group than in the EPD group. Pure WIT was the highest in the class II group. The DGF rate was higher in the DCD group than in the EPD group. PNF rate was similar in the groups. Dialysis need was the greatest and hospitalization the longest in the class II DCD group. eGFR was lower in the class II DCD group than in the EPD group. Our results indicate good clinical outcomes of kidney transplants from DCD despite the long "no-touch period" and show that ECMO in the procurement phase improves graft outcome, suggesting EPD as a source for pool expansion.

Keywords: donation after circulatory death; eGFR; extracorporeal membrane oxygenation; hypothermic perfusion; renal transplantation.

FIGURE 1

Timeline from the cardiac arrest to the organ transplant in DCD and EPD. ACLS, Advanced Cardiovascular Life Support; DCD, Donation after Circulatory Death; DCDII, Maastricht class II DCD; DCDIII, Maastricht class III DCD; ECLS, Extracorporeal Life Support; EEG, Electroencephalography; EKG, Electrocardiogram; EPD, Extracorporeal Membrane Oxygenation (ECMO) Prior to Death Donation/Donor; EPDc, Patient’s death certified by cardiac criteria; EPDn, Patient’s death certified by neurological criteria; MP, Machine Perfusion; WIT, Warm Ischemia Time; WLST, Withdrawal Life Sustaining Treatment.

FIGURE 2

Clinical outcome, graft function, and graft and patient survival in the DCD and EPD groups. (A) DGF rate in the Maastricht class II DCD, Maastricht class III DCD, and EPD groups (DCDII vs. DCDIII, *p < 0.0001; DCDII vs. EPD, °p < 0.0001; DCDIII vs. EPD, #p < 0.0001). (B) Dialysis requirement in Maastricht class II DCD, Maastricht class III DCD, and EPD recipients (EPD vs. DCDII, *p < 0.001; DCDIII vs. DCDII, °p < 0.05). (C) Hospital length of stay in the studied groups (DCDII vs. EPD, *p < 0.05). (D) eGFR in Maastricht class II DCD, Maastricht class III DCD, and EPD recipients (DCDII vs DCDIII, °p < 0.005; EPD vs. DCDII, *p < 0.001). (E) Kaplan-Meier curve of graft survival, by group (log rank test p = 0.408). (F) Kaplan-Meyer curve of patient survival, by group (log rank test p = 0.245).