Favorable outcomes of kidneys from non-heart-beating donors whose cardiac arrest occurred out of hospital

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Abstract

BACKGROUND

Studies of kidney transplantations from non-heart-beating donors (NHBDs) have generally involved individuals who have died from cardiac arrest in hospital ('controlled' donors).

OBJECTIVE

To determine whether kidneys from NHBDs whose cardiac arrest occurred outside hospital ('uncontrolled' donors) survive as long as kidneys from heart-beating donors (HBDs).

DESIGN AND INTERVENTION

Investigators at the Hospital Clínico San Carlos, Madrid, Spain performed a retrospective review of uncontrolled NHBD kidney transplantations performed at their center between January 1989 and December 2004. When a cardiac arrest occurring outside the hospital in an individual aged <60 years is deemed irreversible, heart massage, mechanical ventilation and intravenous fluid administration are continued until arrival at the hospital. The donor is then connected to a cardiopulmonary bypass machine for cold perfusion (maximum duration 4 h) while the next of kin's consent for organ retrieval is obtained. The maximum interval between cardiac arrest and initiation of bypass is 2 h. Outcomes were compared with those of adult cadaveric HBD kidneys transplanted during the same period. From July 1996, immunosuppression comprised triple therapy, with the addition of muromonab-CD3 or antithymocyte globulin for patients with panel-reactive antibody ≥50%. Daclizumab was added after March 2001 for recipients of kidneys from NHBDs, or from HBDs ≥60 years old. Follow-up continued until 1 September 2005, and was censored in the event of death with a functioning graft.

OUTCOME MEASURE

Graft loss (surgical removal, retransplantation or permanent reinitiation of dialysis) was the main endpoint.

RESULTS

Outcome data from 320 patients who received kidneys from NHBDs (273 from donors who were brought in dead; 47 from donors who died in the emergency department) and 584 patients who received kidneys from adult cadaveric HBDs were analyzed. Median follow-up was 68 months (range 9-198 months). Nonviable transplantations among the NHBD kidneys were considerably more common than among the 458 kidneys from HBDs aged <60 years (4.4% vs 1.1%) but only slightly more common than among the 126 kidneys from HBDs aged ≥60 years (4.4% vs 4.0%). The incidence of delayed graft function was higher in NHBD kidneys (60.9%) than in kidneys from HBDs aged <60 years (20.4%) and ≥60 years (27.4%). The NHBD kidneys had similar 1-year and 5-year graft survival to that of the kidneys from HBDs aged <60 years (87.4% vs 90.7% and 82.1% vs 85.5%; P = 0.22), and higher graft survival than that of the kidneys from HBDs aged ≥60 years (87.4% vs 79.8% and 82.1% vs 73.3%; P = 0.014). Patient survival rates at 1 year and 5 years were similar between groups (95% and 90% for the recipients of NHBD kidneys; 97% and 91% for the recipients of kidneys from HBDs aged <60 years and 93% and 84% for the recipients of kidneys from HBDs aged ≥60 years).

CONCLUSION

NHBDs who suffer cardiac arrest outside hospital are a suitable source of kidneys for transplantation.

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