Anil Kumar MS, Khan SM, Jaglan S, et al.Transplantation. 2006;82:1640-1645
Over a 2.5-year period, 55 kidneys from 38 deceased donors with acute renal failure (ARF) were transplanted and compared retrospectively with case-matched concurrent control groups of 55 kidneys transplanted from 48 standard criteria donors (SCD) and 55 kidneys transplanted from 36 expanded criteria deceased donors (ECD). ARF was defined as a donor serum creatinine (SCr) ≥ 2.5 mg/dL (mean 4.6 mg/dL) at the time of organ recovery with persistent oliguria and no trend toward improvement. ARF donors were selected if they met the following criteria: age ≤ 50 years, the presence of normal renal function at the time of admission, negative medical history, brain death, and a baseline kidney biopsy showing < 15% glomerulosclerosis or other significant structural changes. All but 5 of the ARF donor kidneys were pumped. Patients in all 3 groups received basiliximab induction plus a calcineurin inhibitor, mycophenolate mofetil or sirolimus, and early corticosteroid withdrawal. Despite a higher incidence (88%) and prolonged duration (mean 11.6 days) of delayed graft function resulting in a longer initial hospital stay (mean 10.5 days) in recipients of ARF donor kidneys, survival and functional outcomes were intermediate compared with SCD and ECD kidney recipients at 3-year follow-up. Surveillance biopsy monitoring did not reveal an increased incidence of either (sub)clinical acute rejection or chronic allograft nephropathy. The use of kidneys from ARF donors increased overall transplant activity at this center by 8% to 10%.
This bold and provocative study provides a number of important lessons to the transplant community. First and foremost, it underscores the importance of initial (or admission) renal function as opposed to terminal renal function when deliberating on organ offers. As a proof of concept, this study suggests that in the absence of significant preexisting renal parenchymal disease, acute tubular necrosis in the donor kidney is a reversible phenomenon in the recipient environment. It is safe to say that most centers would not even consider using kidneys from the donors defined as having ARF in this study. It is important to note, however, that the authors excluded older donors, ECDs, and donation-after-cardiac-death donors from their ARF donor acceptance algorithm. In addition, all of the ARF and ECD kidneys were biopsied and most were preserved by machine perfusion to assist in the global assessment of viability. Moreover, recipients selected for these kidneys, similar to ECD kidney recipients in their experience, had a lower body mass index and were older than their SCD kidney counterparts. The overall results in recipients of ARF kidneys are truly remarkable (90% graft survival, mean SCr 1.9 mg/dL, mean estimated creatinine clearance 66 mL/min at 3-year follow-up). It would be interesting to know whether any ARF kidneys meeting the above criteria were discarded (ie, on the basis of pump numbers) or whether criteria for identifying an acceptable ARF donor have evolved over time and with experience.