Kidney donation after circulatory death (DCD): state of the art
2015; Elsevier BV; Volume: 88; Issue: 2 Linguagem: Inglês
10.1038/ki.2015.88
ISSN1523-1755
AutoresDominic M. Summers, Christopher J.E. Watson, Gavin J. Pettigrew, Rachel Johnson, D. Collett, James Neuberger, J. Andrew Bradley,
Tópico(s)Liver Disease and Transplantation
ResumoThe use of kidneys from controlled donation after circulatory death (DCD) donors has the potential to markedly increase kidney transplants performed. However, this potential is not being realized because of concerns that DCD kidneys are inferior to those from donation after brain-death (DBD) donors. The United Kingdom has developed a large and successful controlled DCD kidney transplant program that has allowed for a substantial increase in kidney transplant numbers. Here we describe recent trends in DCD kidney donor activity in the United Kingdom, outline aspects of the donation process, and describe donor selection and allocation of DCD kidneys. Previous UK Transplant Registry analyses have shown that while DCD kidneys are more susceptible to cold ischemic injury and have a higher incidence of delayed graft function, short- and medium-term transplant outcomes are similar in recipients of kidneys from DCD and DBD donors. We present an updated, extended UK registry analysis showing that longer-term transplant outcomes in DCD donor kidneys are also similar to those for DBD donor kidneys, and that transplant outcomes for kidneys from expanded-criteria DCD donors are no less favorable than for expanded-criteria DBD donors. Accordingly, the selection criteria for use of kidneys from DCD donors should be the same as those used for DBD donors. The UK experience suggests that wider international development of DCD kidney transplantation programs will help address the global shortage of deceased donor kidneys for transplantation. The use of kidneys from controlled donation after circulatory death (DCD) donors has the potential to markedly increase kidney transplants performed. However, this potential is not being realized because of concerns that DCD kidneys are inferior to those from donation after brain-death (DBD) donors. The United Kingdom has developed a large and successful controlled DCD kidney transplant program that has allowed for a substantial increase in kidney transplant numbers. Here we describe recent trends in DCD kidney donor activity in the United Kingdom, outline aspects of the donation process, and describe donor selection and allocation of DCD kidneys. Previous UK Transplant Registry analyses have shown that while DCD kidneys are more susceptible to cold ischemic injury and have a higher incidence of delayed graft function, short- and medium-term transplant outcomes are similar in recipients of kidneys from DCD and DBD donors. We present an updated, extended UK registry analysis showing that longer-term transplant outcomes in DCD donor kidneys are also similar to those for DBD donor kidneys, and that transplant outcomes for kidneys from expanded-criteria DCD donors are no less favorable than for expanded-criteria DBD donors. Accordingly, the selection criteria for use of kidneys from DCD donors should be the same as those used for DBD donors. The UK experience suggests that wider international development of DCD kidney transplantation programs will help address the global shortage of deceased donor kidneys for transplantation. Kidney transplantation is the optimal treatment for selected patients with end-stage kidney failure, but the severe shortage of deceased donor kidneys for transplantation means that patients often have a long and uncertain wait for transplantation.1.Wolfe R.A. Ashby V.B. Milford E.L. et al.Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.N Engl J Med. 1999; 341: 1725-1730Crossref PubMed Scopus (3953) Google Scholar,2.Tonelli M. Wiebe N. Knoll G. et al.Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes.Am J Transplant. 2011; 11: 2093-2109Crossref PubMed Scopus (757) Google Scholar In the United Kingdom, the average waiting time for a deceased donor kidney transplant is over 3 years, and 12% of listed patients die or are removed from the waiting list owing to ill health within 3 years of listing.3.NHS Blood and Transplant Organ Donation and Transplantation—Activity Report 2013–2014. Available from https://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/activity_report_2013_14.pdfGoogle Scholar The majority of recipients of a deceased donor kidney receive their kidney from brain-dead heart-beating (donation after brain-stem death or DBD) donors, but in recent years there has, in several countries, been a marked increase in the number of transplants using kidneys from donation after circulatory death (DCD) donors. The United Kingdom, the Netherlands, and Belgium now have very successful DCD donor programs with 7.0–9.5 DCD donors per million population (pmp) in 2013 (Figure 1).4.Matesanz R. International figures on donation and transplantation—2013.Newsletter Transplant. Available from. 2014: 19http://www.ont.es/publicaciones/Documents/NEWSLETTER%202014.pdfGoogle Scholar The USA, Australia, Spain, and Croatia also have well-developed DCD programs with 2.1–3.8 DCD donors per million population. Many countries, however, have no or only very few DCD donors and would benefit from this important source of deceased donor kidneys. DCD kidney transplantation is not without controversy. In countries that have DCD donor kidney transplant programs, there is sometimes reluctance to accept DCD kidneys for transplantation because of continuing concern that transplant outcomes are poorer than for DBD donor kidneys.5.Callaghan C.J. Harper S.J.F. Saeb-Parsy K. et al.The discard of deceased donor kidneys in the UK.Clin Transplant. 2014; 28: 345-353Crossref PubMed Scopus (47) Google Scholar Moreover, many clinicians are uncertain about the selection criteria for kidneys from DCD donors, particularly when the donors are old or have multiple comorbidities and when kidney ischemia times are prolonged.6.Rao P.S. Ojo A. The alphabet soup of kidney transplantation: SCD, DCD, ECD—fundamentals for the practicing nephrologist.Clin J Am Soc Nephrol. 2009; 4: 1827-1831Crossref PubMed Scopus (133) Google Scholar,7.McDonald S. Clayton P. DCD ECD kidneys-can you make a silk purse from a sow's ear?.Am J Transplant. 2013; 13: 249-250Crossref PubMed Scopus (5) Google Scholar Here we review the UK experience of DCD donor kidney transplantation. Nearly all DCD donors in the United Kingdom are controlled DCD donors in whom organs are recovered following circulatory arrest after the planned withdrawal of life-supporting treatment in hospital.8.Kootstra G. Daemen J. Oomen A. Categories of non-heart-beating donors.Transplant Proc. 1995; 27: 2893-2894PubMed Google Scholar In some countries, notably the Netherlands and Spain, there are significant numbers of uncontrolled DCD donors, who arrive in the hospital after cardiorespiratory arrest or have a cardiorespiratory arrest in hospital with unsuccessful resuscitation.8.Kootstra G. Daemen J. Oomen A. Categories of non-heart-beating donors.Transplant Proc. 1995; 27: 2893-2894PubMed Google Scholar This review focuses exclusively on the use of kidneys from controlled DCD donors. Recent trends in the number and demographics of deceased donors are described, along with the organ donation process and offering system in the United Kingdom. In addition to previously published data, we provide an extended and updated UK Transplant Registry analysis that allows more definitive conclusions to be drawn about long-term transplant outcomes and represents the largest published series of expanded-criteria DCD donors. The UK experience may inform the development of policies for accepting DCD kidneys for transplantation and support the wider adoption of DCD donation to help address the international shortage of deceased donor kidneys. Historically, the number of deceased donors in the United Kingdom was low compared with the US and many European countries. Over the past decade, there has been a marked increase in the number of deceased kidney donors in the United Kingdom, and this is largely attributable to an increase in DCD kidney donor numbers (Figure 2a). DCD donor numbers increased sixfold from 84 in 2004 to 527 in 2013.3.NHS Blood and Transplant Organ Donation and Transplantation—Activity Report 2013–2014. Available from https://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/activity_report_2013_14.pdfGoogle Scholar The increase in deceased donor numbers corresponds with the implementation of recommendations made in 2008 by the UK Organ Donation Taskforce.9.Organ Donation Taskforce Organs for transplants: a report from the Organ Donation Taskforce—Department of Health. Available from. 2008http://www.nhsbt.nhs.uk/to2020/resources/OrgansfortransplantsTheOrganDonorTaskForce1streport.pdfGoogle Scholar The Taskforce was established in 2006 to identify obstacles to organ donation and find solutions to overcome them. The recommendations of the Taskforce were implemented by NHS Blood and Transplant (the health authority responsible for organ donation and transplantation in the United Kingdom) and included a centrally coordinated UK-wide network of specialist nurses in organ donation embedded in all intensive care units and a national organ retrieval service. The Taskforce also highlighted the need for a robust professional, ethical, and legal framework for controlled DCD donation that has been fulfilled by a number of authoritative UK reports that provide clear guidance for the clinical practice of DCD donation.10.Simpson P. A Code of Practice for the Diagnosis and Confirmation of Death. Available from. Academy of Royal Medical Colleges, London2008http://www.aomrc.org.uk/doc_view/42-a-code-of-practice-for-the-diagnosis-and-confirmation-of-deathGoogle Scholar, 11.British Transplantation Society British Transplantation Society and Intensive Care Society Donation after circulatory death: report of a consensus meeting.2010http://www.bts.org.uk/Documents/Guidelines/Active/DCD%20for%20BTS%20and%20ICS%20FINAL.pdfGoogle Scholar, 12.UK Donation Ethics Committee An Ethical Framework for Controlled Donation after Circulatory Death. Academy of Royal Medical Colleges, London2011http://www.aomrc.org.uk/doc_view/9425-an-ethical-framework-for-controlled-donation-after-circulatory-deathGoogle Scholar, 13.NHS Blood and Transplant NHS Blood and Transplant National Standards for Organ Retrieval from Deceased Donors.2012https://www.bts.org.uk/Documents/9.1.13%20Retrieval%20Standards%20Document%20v2%206%20effective%20010113.pdfGoogle Scholar In addition to the increased use of kidneys from DCD donors, the other important factor that led to a rise in donor numbers in the United Kingdom has been the greater use of kidneys from older DBD and DCD donors. In 2004, only 14% of DCD donors were aged >60 years, but this increased to 43% in 2013 (Figure 2b). The increase in the use of kidneys from older donors has been much greater for DCD than for DBD donors, and this likely reflects initial caution in the use of kidneys from DCD donors. The classification of deceased donors as either standard criteria donors or expanded-criteria donors (ECD) helps inform clinicians and potential recipients about potential outcomes and aids organ allocation.14.Port F. Bragg-Gresham J. Metzger R. et al.Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors.Transplantation. 2002; 74: 1281-1286Crossref PubMed Scopus (629) Google Scholar On the basis of factors shown to be associated with graft loss, ECD donors are defined as those aged >60 years or aged≥50 years with two of the following: (i) a terminal serum creatinine level of >1.5 mg/dl, (ii) a cerebrovascular accident as the cause of death, and (iii) a donor history of hypertension.14.Port F. Bragg-Gresham J. Metzger R. et al.Donor characteristics associated with reduced graft survival: an approach to expanding the pool of kidney donors.Transplantation. 2002; 74: 1281-1286Crossref PubMed Scopus (629) Google Scholar The percentage of DBD and DCD donors who fulfill the expanded criteria has increased markedly over time in the United Kingdom (Figure 2c). The increase is attributable, in large part, to the use of older donors, but other criteria that define ECD, notably hypertension and a cerebrovascular accident as the cause of death, are also increasingly common in DCD donors.15.Summers D.M. Counter C. Johnson R.J. et al.Is the increase in DCD organ donors in the United Kingdom contributing to a decline in DBD donors?.Transplantation. 2010; 90: 1506-1510Crossref PubMed Scopus (40) Google Scholar The majority (>90%) of controlled DCD donors in the United Kingdom are patients in critical care units who have suffered catastrophic irreversible brain injury but who do not fulfill the criteria for brain-stem death (Maastricht category III).8.Kootstra G. Daemen J. Oomen A. Categories of non-heart-beating donors.Transplant Proc. 1995; 27: 2893-2894PubMed Google Scholar,16.Summers D.M. Johnson R.J. Hudson A. et al.Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: a cohort study.Lancet. 2013; 381: 727-734Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar Instead, death is certified following cessation of cardiopulmonary function after further treatment is deemed futile and life-supporting treatment is withdrawn. Withdrawal of life-supporting treatment typically involves discontinuation of inotropes and ventilatory support.17.Suntharalingam C. Sharples L. Dudley C. et al.Time to cardiac death after withdrawal of life-sustaining treatment in potential organ donors.Am J Transplant. 2009; 9: 2157-2165Crossref PubMed Scopus (79) Google Scholar In the United Kingdom, a period of 5 min of observation is required after circulatory arrest before death can be confirmed and organ retrieval can be begun.10.Simpson P. A Code of Practice for the Diagnosis and Confirmation of Death. Available from. Academy of Royal Medical Colleges, London2008http://www.aomrc.org.uk/doc_view/42-a-code-of-practice-for-the-diagnosis-and-confirmation-of-deathGoogle Scholar The time period deemed necessary from cessation of circulation to the start of organ procurement varies internationally from 2 to 20 min.18.Domínguez-Gil B. Haase-Kromwijk B. Van Leiden H. et al.Current situation of donation after circulatory death in European countries.Transpl Int. 2011; 24: 676-686Crossref PubMed Scopus (228) Google Scholar,19.Reich D.J. Mulligan D.C. Abt P.L. et al.ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation.Am J Transplant. 2009; 9: 2004-2011Crossref PubMed Scopus (278) Google Scholar In contrast to the USA, it is not permissible in the United Kingdom to heparinize the potential donor or to cannulate the femoral vessels before death.11.British Transplantation Society British Transplantation Society and Intensive Care Society Donation after circulatory death: report of a consensus meeting.2010http://www.bts.org.uk/Documents/Guidelines/Active/DCD%20for%20BTS%20and%20ICS%20FINAL.pdfGoogle Scholar,19.Reich D.J. Mulligan D.C. Abt P.L. et al.ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation.Am J Transplant. 2009; 9: 2004-2011Crossref PubMed Scopus (278) Google Scholar Only a small minority of controlled DCD donors in the United Kingdom ( 60% die within 3 hours.21.Bradley J.A. Pettigrew G.J. Watson C.J. Time to death after withdrawal of treatment in donation after circulatory death (DCD) donors.Curr Opin Organ Transplant. 2013; 18: 133-139Crossref PubMed Scopus (34) Google Scholar Organ recovery in the United Kingdom has, since 2010, been undertaken by a national organ retrieval service. The seven abdominal organ retrieval teams use a standardized protocol that currently requires them to be immediately available, in the donation hospital operating room, for a minimum of 3 hours from withdrawal of life-supporting treatment for cardiac arrest to occur.13.NHS Blood and Transplant NHS Blood and Transplant National Standards for Organ Retrieval from Deceased Donors.2012https://www.bts.org.uk/Documents/9.1.13%20Retrieval%20Standards%20Document%20v2%206%20effective%20010113.pdfGoogle Scholar,21.Bradley J.A. Pettigrew G.J. Watson C.J. Time to death after withdrawal of treatment in donation after circulatory death (DCD) donors.Curr Opin Organ Transplant. 2013; 18: 133-139Crossref PubMed Scopus (34) Google Scholar The time period of 3 hours is based largely on the practical challenges of maintaining a surgical team at the ready away from their base hospital with immediate access to the operating room. The UK retrieval protocol states that, following the onset of ‘functional warm ischemia’ (arbitrarily defined as a systolic blood pressure <50 mm Hg), the retrieval team will wait for 2 hours before finally abandoning procurement, because the kidneys are deemed nontransplantable owing to excessive warm ischemic damage.13.NHS Blood and Transplant NHS Blood and Transplant National Standards for Organ Retrieval from Deceased Donors.2012https://www.bts.org.uk/Documents/9.1.13%20Retrieval%20Standards%20Document%20v2%206%20effective%20010113.pdfGoogle Scholar The degree of hemodynamic instability during the withdrawal period is extremely variable, and few studies have examined the impact of this instability on kidney transplant outcome. Recent evidence from one large UK center shows that, within the boundaries of current clinical practice, neither the presence of prolonged hemodynamic instability during the withdrawal phase nor the duration of the withdrawal phase is associated with reduced renal transplant function and survival.22.Sohrabi S. Navarro A. Asher J. et al.Agonal period in potential non-heart-beating donors.Transplant Proc. 2006; 38: 2629-2630Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,23.Reid A.W.N. Harper S. Jackson C.H. et al.Expansion of the kidney donor pool by using cardiac death donors with prolonged time to cardiorespiratory arrest.Am J Transplant. 2011; 11: 995-1005Crossref PubMed Scopus (68) Google Scholar Surgery to procure the kidneys from DCD donors in the United Kingdom is undertaken according to a national protocol similar to that used in most other countries.24.Oniscu G. Forsythe J. Fung J. Abdominal Organ Retrieval and Transplantation Bench Surgery. John Wiley & Sons, 2013Crossref Scopus (3) Google Scholar Rapid laparotomy and arterial cannulation is performed, the abdominal organs are perfused with cold organ preservation solution, and ice slush is placed intraperitoneally to aid topical cooling of the organs. Despite the mandatory 5-min observation period following cardiopulmonary arrest, the median asystolic warm ischemic period in the United Kingdom is very short at 14 min (interquartile range (IQR) 11–17 min).16.Summers D.M. Johnson R.J. Hudson A. et al.Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: a cohort study.Lancet. 2013; 381: 727-734Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar After in situ cooling, the kidneys are excised and may, at the discretion of the organ retrieval team, be subjected to further cold perfusion on the back-table before cold storage. After procurement, the majority (around 75%) of DCD kidneys in the United Kingdom are subjected to simple static cold storage, and the remainder undergo cold pulsatile machine perfusion, according to the preference of the retrieving and implanting surgeons.16.Summers D.M. Johnson R.J. Hudson A. et al.Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: a cohort study.Lancet. 2013; 381: 727-734Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar The UK pathway for the use of DCD kidneys by recipient centers has evolved to maximize the appropriate use of kidneys from potential DCD donors (Figure 3). Kidneys are only retrieved from a potential DCD donor when an implanting kidney transplant center has indicated that they are provisionally prepared to transplant them, on the basis of the available donor information, including age, comorbidity, and risk of disease transmission. There is marked variation between transplant centers in their willingness to use kidneys from DCD donors in the United Kingdom, especially kidneys from ECD donors.3.NHS Blood and Transplant Organ Donation and Transplantation—Activity Report 2013–2014. Available from https://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/activity_report_2013_14.pdfGoogle Scholar, 5.Callaghan C.J. Harper S.J.F. Saeb-Parsy K. et al.The discard of deceased donor kidneys in the UK.Clin Transplant. 2014; 28: 345-353Crossref PubMed Scopus (47) Google Scholar, 23.Reid A.W.N. Harper S. Jackson C.H. et al.Expansion of the kidney donor pool by using cardiac death donors with prolonged time to cardiorespiratory arrest.Am J Transplant. 2011; 11: 995-1005Crossref PubMed Scopus (68) Google Scholar, 25.Summers D.M. Johnson R.J. Hudson A.J. et al.Standardized deceased donor kidney donation rates in the UK reveal marked regional variation and highlight the potential for increasing kidney donation: a prospective cohort study†.Br J Anaesth. 2014; 113: 83-90Crossref PubMed Scopus (10) Google Scholar If the transplant center local to the potential donor declines the kidneys, the organs have, since 2008, been offered nationally. When organ retrieval has been completed, additional information arising from the retrieval, including the withdrawal phase characteristics and quality of organ perfusion, is transmitted to the recipient center to confirm that they still wish to accept the kidneys. If the organs are declined at this stage, they are then offered simultaneously to other UK centers through a recently introduced fast-track scheme for ‘hard-to-place kidneys’.5.Callaghan C.J. Harper S.J.F. Saeb-Parsy K. et al.The discard of deceased donor kidneys in the UK.Clin Transplant. 2014; 28: 345-353Crossref PubMed Scopus (47) Google Scholar Around 13% of DCD donor kidneys are currently discarded after retrieval, because they have been declined by all centers.3.NHS Blood and Transplant Organ Donation and Transplantation—Activity Report 2013–2014. Available from https://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/activity_report_2013_14.pdfGoogle Scholar Another recent development in the United Kingdom was the introduction of a national allocation scheme for selected DCD kidneys.26.NHS Blood and Transplant Organ donation and transplantation. Available from. Kidney Transplantation, Deceased Donor Organ Allocation2014http://www.odt.nhs.uk/pdf/kidney_allocation_policy.pdfGoogle Scholar Although this was only introduced in September 2014, the evidence-base for the allocation scheme was derived from data obtained during the period included within the present analysis (2001–2012). Before this scheme started, most kidneys from DCD donors were allocated to patients living within the region associated with the donor hospital. The new allocation scheme for DCD kidneys is very similar to the well-established UK allocation scheme for kidneys from DBD donors, except that one donor kidney is retained for local use and the paired kidney is shared within one of four UK regions. Shared kidneys are allocated according to an algorithm that takes into account recipient waiting time, sensitization, human leukocyte antigen (HLA) match, and donor–recipient age match.27.Johnson R. Fuggle S. Mumford L. et al.A New UK 2006 national kidney allocation scheme for deceased heart-beating donor kidneys.Transplantation. 2010; 89: 387-394Crossref PubMed Scopus (81) Google Scholar To avoid major changes in transplant center activity, the DCD sharing scheme is being phased in: currently only kidneys from DCD donors under the age of 50 years are shared and one kidney from all DCD donors is retained for local allocation. The most striking difference in outcome between DCD and DBD donor kidneys is in the incidence of delayed graft function (DGF)—most commonly defined as the need for dialysis in the first 7 days post transplant.28.Mallon D.H. Summers D.M. Bradley J.A. et al.Defining delayed graft function after renal transplantation: simplest is best.Transplantation. 2013; 96: 885-889Crossref PubMed Scopus (176) Google Scholar Because of the warm ischemic injury associated with controlled DCD donation, recipients of such kidneys have twice the risk of developing DGF compared with recipients of kidneys from DBD donors.16.Summers D.M. Johnson R.J. Hudson A. et al.Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: a cohort study.Lancet. 2013; 381: 727-734Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar, 20.Summers D.M. Johnson R.J. Allen J. et al.Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study.Lancet. 2010; 376: 1303-1311Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar, 29.Locke J. Segev D. Warren D. et al.Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation.Am J Transplant. 2007; 7: 1797-1807Crossref PubMed Scopus (204) Google Scholar The currently reported incidence of DGF after DCD kidney transplantation in the United Kingdom is 49%, which is comparable to that reported in other countries.30.Hoogland E.R.P. Snoeijs M.G.J. Winkens B. et al.Kidney transplantation from donors after cardiac death: uncontrolled versus controlled donation.Am J Transplant. 2011; 11: 1427-1434Crossref PubMed Scopus (66) Google Scholar,31.Singh S.K. Kim S.J. Does expanded criteria donor status modify the outcomes of kidney transplantation from donors after cardiac death?.Am J Transplant. 2013; 13: 329-336Crossref PubMed Scopus (41) Google Scholar Importantly, although DGF increases the duration of hospital stay and may mask early rejection, it has no impact on DCD kidney graft survival.20.Summers D.M. Johnson R.J. Allen J. et al.Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study.Lancet. 2010; 376: 1303-1311Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar, 29.Locke J. Segev D. Warren D. et al.Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation.Am J Transplant. 2007; 7: 1797-1807Crossref PubMed Scopus (204) Google Scholar, 32.Brook N. White S. Waller J. et al.Non-heart beating donor kidneys with delayed graft function have superior graft survival compared with conventional heart-beating donor kidneys that develop delayed graft function.Am J Transplant. 2003; 3: 614-618Crossref PubMed Scopus (111) Google Scholar The use of cold pulsatile machine perfusion is increasing in popularity worldwide, and while, as noted previously, most kidneys in the United Kingdom are stored by simple cold storage our UK Transplant Registry analysis suggested an association between the use of machine perfusion and reduced DGF.16.Summers D.M. Johnson R.J. Hudson A. et al.Effect of donor age and cold storage time on outcome in recipients of kidneys donated after circulatory death in the UK: a cohort study.Lancet. 2013; 381: 727-734Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar This finding is consistent with other cohort studies showing a beneficial effect of machine perfusion on DGF, although the potential for selection bias in this type of study precludes definitive conclusions to be drawn.33.Gill J. Dong J. Eng M. et al.Pulsatile perfusion reduces the risk of delayed graft function in deceased donor kidney transplants, irrespective of donor type and cold ischemic time.Transplantation. 2014; 97: 668-674PubMed Google Scholar,34.O'Callaghan J.M. Morgan R.D. Knight S.R. et al.Systematic review and meta-analysis of hypothermic machine perfusion versus static cold storage of kidney allografts on transplant outcomes.Br J Surg. 2013; 100: 991-1001Crossref PubMed Scopus (120) Google Scholar Moreover, randomized controlled trials of machine perfusion for DCD kidneys have produced conflicting results with respect to DGF, and none have shown a beneficial effect on graft survival: further studies are required before machine perfusion is recommended over static cold storage as a way of reducing DGF.35.Jochmans I. Moers C. Smits J.M. et al.Machine perfusion versus cold storage for the preservation of kidneys donated after cardiac death: a multicenter, randomized, controlled trial.Ann Surg. 2010; 252: 756-764Crossref PubMed Scopus (213) Google Scholar,36.Watson C.J. Wells A.C. Roberts R.J. et al.Cold machine perfusion versus static cold storage of kidneys donated after cardiac death: a UK multicenter randomized controlled trial.Am J Tr
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