Elsevier

The Lancet

Volume 376, Issue 9749, 16–22 October 2010, Pages 1303-1311
The Lancet

Articles
Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study

https://doi.org/10.1016/S0140-6736(10)60827-6Get rights and content

Summary

Background

A third of all kidneys from deceased donors in the UK are donated after cardiac death, but concerns have been raised about the long-term outcome of such transplants. We aimed to establish these outcomes for kidneys donated after controlled cardiac death versus brain death, and to identify the factors that affect graft survival and function.

Methods

We used data from the UK transplant registry to select a cohort of deceased kidney donors and the corresponding transplant recipients (aged ≥18 years) for transplantations done between Jan 1, 2000, and Dec 31, 2007. Kaplan-Meier estimates were used to assess graft survival, and multivariate analyses were used to identify factors associated with graft survival and with long-term renal function, which was measured from estimated glomerular filtration rate (eGFR).

Findings

9134 kidney transplants were done in 23 centres; 8289 kidneys were donated after brain death and 845 after controlled cardiac death. First-time recipients of kidneys from cardiac-death donors (n=739) or brain-death donors (n=6759) showed no difference in graft survival up to 5 years (hazard ratio 1·01, 95% CI 0·83 to 1·19, p=0·97), or in eGFR at 1–5 years after transplantation (at 12 months −0·36 mL/min per 1·73 m2, 95% CI −2·00 to 1·27, p=0·66). For recipients of kidneys from cardiac-death donors, increasing age of donor and recipient, repeat transplantation, and cold ischaemic time of more than 12 h were associated with worse graft survival; grafts from cardiac-death donors that were poorly matched for HLA had an association with inferior outcome that was not significant, and delayed graft function and warm ischaemic time had no effect on outcome.

Interpretation

Kidneys from controlled cardiac-death donors provide good graft survival and function up to 5 years in first-time recipients, and are equivalent to kidneys from brain-death donors. Allocation policy for kidneys from cardiac-death donors should reduce cold ischaemic time, avoid large age mismatches between donors and recipients, and restrict use of kidneys poorly matched for HLA in young recipients.

Funding

UK National Health Service Blood and Transplant, and Cambridge National Institute for Health Research Biomedical Research Centre.

Introduction

The demand for kidney transplantation far exceeds the supply of donor organs and the shortfall is becoming more severe as donor numbers fail to keep pace with increasing numbers of patients listed for transplantation.1, 2 Most deceased-donor kidneys are from donors with brain-stem death whose hearts were beating (brain-death donors).1, 2 During the past decade, the number of brain-death donors has declined in the UK for reasons that include a reduction in deaths from trauma and changes in neurosurgical practice.3, 4, 5 By contrast, use of kidneys from non-heart-beating donors (cardiac-death donors) has risen steeply from 3% of all deceased donors in 2000 to 32% in 2009,6 and if the present pattern continues, they will become the dominant type of deceased donor by 2015. In the UK, most cardiac-death donors are controlled donors (Maastricht category 3)7 who have suffered massive irreversible brain injury but do not fulfil the criteria for brain-stem death; death is instead certified by cessation of cardiopulmonary function after a decision to withdraw life-supporting treatment.

Kidneys donated after brain death or cardiac death inevitably acquire a variable degree of injury during donation, but the nature of injury differs according to donor type. Kidneys from brain-death donors are exposed to substantial metabolic and hormonal disturbances that accompany brain-stem death,8, 9, 10 whereas kidneys from cardiac-death donors incur a variable period of warm ischaemia between cessation of cardiopulmonary function and perfusion with cold preservation solution. Warm ischaemic injury increases the incidence of delayed graft function, suggesting that kidneys from cardiac-death donors are inferior to those from brain-death donors. Little information is available about long-term renal function in recipients of kidneys from controlled cardiac-death donors,11, 12, 13 but the outcome in terms of graft survival seems to be broadly similar to that recorded in recipients of kidneys from brain-death donors.14, 15

To make best use of kidneys from deceased donors, the factors that affect outcome after transplantation need to be understood so that resources within transplant centres are used effectively, and decisions about organ allocation are evidence-based. For kidneys from brain-death donors these factors are well established.16, 17, 18, 19 In the UK, all kidneys from brain-death donors are allocated according to an evidence-based national organ sharing scheme that aims to keep inequity of access to a minimum, and to allocate kidneys to the most suitable recipients. Kidneys are allocated according to a points-based scoring system that prioritises long waiting time, HLA match, and age match.20 By contrast, the factors that affect outcome after transplantation with kidneys from cardiac-death donors are largely unknown. In view of the nature of renal injury acquired during donation, the types and relative effects of risk factors in recipients of these kidneys might differ from the factors identified in recipients of kidneys from brain-death donors. In the UK, because of this absence of adequate information, kidneys from cardiac-death donors are not allocated through the national organ sharing scheme, but are instead allocated locally according to the policy in individual transplant centres.

To inform future transplant policy, particularly with respect to kidney allocation, we undertook a comprehensive UK-wide cohort analysis of the outcome of kidney transplants from controlled cardiac-death donors to identify the factors that affect survival of graft and patient and transplant function up to 5 years after transplantation.

Section snippets

Study population

The UK transplant registry is held by National Health Service (NHS) Blood and Transplant, and 23 UK adult renal transplant centres provide mandatory data to this registry. We used the registry to identify all renal transplantations from deceased donors between Jan 1, 2000, and Dec 31, 2007. We selected for analysis all transplants of kidneys from controlled cardiac-death donors of Maastricht category 3, defined as donors awaiting cardiac arrest after withdrawal of life-supporting treatment in

Results

9134 recipients of renal transplants from deceased donors were recorded during the 8-year study period, of whom 845 (9%) received kidneys from controlled (Maastricht category 3) cardiac-death donors, and 8289 (91%) received kidneys from heart-beating brain-death donors. Table 1 shows the characteristics of donors and recipients. Cardiac-death donors were younger, more predominantly male and white, and less likely to have smoked than were brain-death donors. The most common cause of death in

Discussion

This study is a comprehensive analysis of outcome in recipients of kidneys from controlled cardiac-death donors, providing two important findings. First, for recipients of their first grafts, kidneys from controlled cardiac-death donors had excellent results that were equivalent to results for kidneys from heart-beating brain-death donors. Second, important variables were associated with transplant outcome in recipients of kidneys from cardiac-death donors, and these variables could be used to

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