M.A. Gok

How to improve the quality of kidneys from non-heart-beating donors: a randomised controlled trial of thrombolysis in non-heart-beating donors.

Background. The growth in the prevalence of end-stage renal failure has been accompanied with a rise in the waiting list for renal transplantation, which has not been matched by an increase in the kidney donor pool. Non–heart-beating donors (NHBD) offer a potential source of kidneys that are not currently being significantly used. Cardiac arrest for a protracted period of time leads to in situ thrombosis, and, as a consequence, the discard rates for harvested kidneys is higher than brain–stem-dead donors. Methods. A double-blinded, randomised, controlled trial of streptokinase preflush or placebo for NHBD was performed. An initial 30 donors were entered into the study. After routine nephrectomy, NHBD kidneys were machine perfused as part of viability screening before transplantation. Kidneys were then transplanted within 24 hours of cardiac arrest. The primary objectives were the improvements of viability parameters (perfusion, enzyme levels, and histopathology) of the kidneys. The secondary objective was to increase the number of kidneys passing the viability tests and thus transplanted. Results. The two groups of NHBD donors and their kidneys were similar in their descriptive epidemiologic characteristics. The NHBD kidneys from the streptokinase-treated donors had a better appearance at procurement (P <0.001) and performed better during machine preservation (P <0.001). Enzyme biomarkers present in the kidney perfusate were all significantly reduced by the use of streptokinase. These included glutathione S-transferase (P <0.001), fatty acid binding protein (P <0.001), and alanine aminopeptidase (P <0.001). However, although there was a higher proportion of kidneys transplanted through the use of streptokinase (63.6% with streptokinase vs. 42.6% with placebo), this did not achieve significance. There was no difference with respect to postoperative bleeding and transfusion requirements in the recipient whether streptokinase preflush or placebo was used. Conclusion. This study using streptokinase preflush in the NHBD was found to improve the condition of the kidneys retrieved. The improvement in the quality of the donor kidneys was not associated with an increased morbidity in the recipient.

Randomized clinical trial of daclizumab induction and delayed introduction of tacrolimus for recipients of non‐heart‐beating kidney transplants

Kidneys from non‐heart‐beating donors (NHBDs) have high rates of delayed graft function (DGF). Use of calcineurin inhibitors is associated with a reduction in renal blood flow, which may delay graft recovery from ischaemic acute tubular necrosis.

Ischemia-Reperfusion Injury in Cadaveric Nonheart Beating, Cadaveric Heart Beating and Live Donor Renal Transplants

PURPOSE Ischemia-reperfusion injury is gaining importance in transplantation as being responsible for allograft dysfunction. Ischemia occurs during kidney procurement, which is shortest in LDs, and prolonged in cadaveric HBDs and NHBDs. MATERIALS AND METHODS Renal transplants from 17 LDs, 15 HBDs and 19 NHBDs were assessed during reperfusion for biochemical markers of ischemia-reperfusion injury and assessed clinically. Central venous blood sampling was assayed for free radicals using electron spin resonance and tissue injury biomarkers, namely lactate dehydrogenase, fatty acid binding protein, alanine aminopeptidase, lactate and total antioxidants. RESULTS The return to stable renal function was more rapid in LD renal transplants, while recovery continued from 3 months after hospital discharge in NHBD renal transplants. Injury markers, such as lactate dehydrogenase, fatty acid binding protein, alanine aminopeptidase and lactate, were raised at the time of reperfusion, especially in NHBD renal transplants. Free radical release measured by electron spin resonance showed 2 phase release, that is early (0 to 10-minute) and late (20 to 40-minute) release. In NHBD, HBD and LD renal transplants the index of free radical release in the early phase was 1.43, 1.36 and 1.20, and in the late phase it was 1.43, 1.38 and 0.97, respectively (each ANOVA p <0.05). CONCLUSIONS NHBD renal transplants were accompanied by a greater release of free radicals at reperfusion (NHBD > HBD > LD), which was associated with an increase in tissue injury markers at reperfusion. This was reflected in a slower return to stable renal function in NHBD compared to HBD and LD renal transplants.

CURRENT LONG TERM OUTCOMES OF BOTH CONTROLLED AND UNCONTROLLED NON HEART BEATING DONOR (NHBD) KIDNEYS - A FIVE YEAR FOLLOW UP STUDY.: 2740

A. Kanwar1, M.A. Khurram2, S. Stamp3, L. El-Asir1, M. Reddy4, H. Wyrley-Birch1, J. Asher4, M. Gok4, A. Cunningham5, N. Carter5, B. Jacques1, N. Soomro4, D. Rix4, D. Manas4, D. Talbot4 1Liver / Renal Transplantation, Freeman Hospital, Newcastle upon Tyne hospitals, NHS trust, Newcastle upon Tyne/UNITED KINGDOM, 2Liver/renal Transplant Unit, Freeman hospital , Newcastle upon Tyne/Tyne and wear/UNITED KINGDOM, 3, Newcastle University, Newcastle upon Tyne/UNITED KINGDOM, 4Liver/renal Transplant Unit, Freeman hospital, Newcastle upon Tyne/UNITED KINGDOM, 5, University of Sunderland, Sunderland/UNITED KINGDOM