Donor Death Category Is an Effect Modifier Between Cold Ischemia Time and Post-transplant Graft Function in Deceased-Donor Kidney Transplant Recipients

Objectives: We aimed to analyze the effect of cold ischemia time (CIT) on post-transplant graft function through mixed-effect model analysis to reduce the bias caused by paired mate kidneys.Methods: We reviewed all kidney transplantation records from 2015 to 2019 at our center. After applying the exclusion criteria, 561 cases were included for analysis. All donor characteristics, preservation and matching information, and recipient characteristics were collected. Transplant outcomes included delayed graft function (DGF) and estimated glomerular filtration rate (eGFR). Generalized linear mixed models were applied for analysis. We also explored potential effect modifiers, namely, donor death category, expanded criteria donors, and donor death causes.Results: Among the 561 cases, 79 DGF recipients developed DGF, and 15 recipients who died after surgery were excluded from the eGFR estimation. The median stable eGFR of the 546 recipients was 60.39 (47.63, 76.97) ml/min/1.73 m2. After adjusting for confounding covariates, CIT had a negative impact on DGF incidence [odds ratio = 1.149 (1.006, 1.313), P = 0.041]. In the evaluation of the impact on eGFR, the regression showed that CIT had no significant correlation with eGFR [β = −0.287 (−0.625, 0.051), P = 0.096]. When exploring potential effect modifiers, only the death category showed a significant interaction with CIT in the effect on eGFR (Pinteraction = 0.027). In the donation after brain death (DBD) group, CIT had no significant effect on eGFR [β = 0.135 (−0.433, 0.702), P = 0.642]. In the donation after circulatory death/donation after brain death followed by circulatory death (DCD/DBCD) group, CIT had a significantly negative effect on eGFR [β= −0.700 (−1.196, −0.204), P = 0.006]. Compared to a CIT of 0–6 h, a CIT of 6–8 or 8–12 h did not decrease the post-transplant eGFR. CIT over 12 h (12–16 h or over 16 h) significantly decreased eGFR. With the increase in CIT, the regenerated eGFR worsened (Ptrend = 0.011).Conclusion: Considering the effect of paired mate kidneys, the risk of DGF increased with prolonged CIT. The donor death category was an effect modifier between CIT and eGFR. Prolonged CIT did not reduce the eGFR level in recipients from DBDs but significantly decreased the eGFR in recipients from DCDs/DBCDs. This result indicates the potential biological interaction between CIT and donor death category.

Comparison of intraoperative hemodynamic parameters of recipients in adult living donor and deceased donor kidney transplantations

Objective: There are many studies on kidney transplant anesthesia, there is not enough data in the literature in terms of intraoperative parameters according to the donor type. In this study, we aimed to compare the intraoperative hemodynamic parameters in adult patients who underwent living-donor and deceased-donor kidney transplantation (KT). Material and Methods: The patients who underwent KT were divided into 2 groups according to the donor kidney type. Recipients who underwent deceased donor transplantation were included in the study as Group 1. Among the living donor kidney transplant recipients, the same number of patients with similar demographic data as Group 1 were designated as Group 2. Both groups were compared in terms of recorded data and intraoperative hemodynamic parameters. Results: Twenty-four patients were included in the study. The mean durations of dialysis were 81.6 ± 64.8 and 16.8 ± 17.4 months for Group 1 and Group 2, respectively (p = 0.001). The mean cold ischemia time was significantly longer in Group 1 than Group 2 (p = 0.001). The mean operative urine output for Group 1 and Group 2 were 87.3 ± 149.6 and 634.2 ± 534.5, respectively (p = 0.002). Mean arterial pressure, heart rate, peripheral oxygen saturation and CVP values were all comparable between the two groups. Conclusion: Cold ischemia time is longer and operative urine volume is lower in deceased donor transplants compared to living donor transplants. With good preoperative preparation, close intraoperative follow-up, and proper fluid management, similar intraoperative hemodynamic parameters are achieved in both types of donor recipients. Keywords: Anesthesia, cadaver, hemodynamic monitoring, kidney transplantation, living donors

Early morning kidney transplantation: Perioperative complications

Introduction: To reduce cold ischemia time (CIT), many kidney transplants are performed in the early morning. Conducting complex surgeries in the early morning may influence the surgeon's technical capacity and rate of surgical complications (SC). Aim: Evaluate the influence of surgery start hour (SSH) regarding duration of surgery (DS), immediate diuresis (ID), SC and acute rejection (AR); evaluate the influence of CIT regarding SC, ID, and AR.Methods: 2855 cadaveric transplants performed between June 1980 and March 2018 were retrospectively evaluated. Regarding SSH, two groups were created: Group M (00: 00h-05.59h, n = 253) and Group D (06: 00h - 23: 59h, n = 2602). Analyzing the impact of SSH on DS, ID, SC and AR. Evaluate the relationship between CIT (< 18h, 18-30h and > 30h) on ID, SC and AR utilizing univariate and multivariate statistical analysis with SPSS. Results and Conclusion: Groups M and D were comparable in all evaluated demographic variables (p > 0.05), except cold ischemia time (Group M with higher CIT, p < 0.001). Regarding univariate analysis, Surgery start hour did not influence DS (p = 0.344), and SC (p = 0.264), but related with higher ID (p = 0.028) and AR (p = 0.018). CIT related with immediate diuresis (p = 0.020) and acute rejection (p < 0.001) but did not relate with complications (p = 0.734). Regarding multivariate analysis, SSH only influenced immediate diuresis (p = 0.026) and did not influenced acute rejection (p = 0.055). CIT influenced immediate diuresis (p = 0.019) and acute rejection (p < 0.001). Surgery start hour influences Immediate diuresis. With this study, we conclude that the priority must be a short cold ischemia time.

MO942PREDICTORS OF DELAYED GRAFT FUNCTION IN KIDNEY TRANSPLANT RECIPIENTS THROUGHOUT 3 DECADES: A SINGLE-CENTER EXPERIENCE

Background and Aims Delayed graft function (DGF), defined as the need for dialysis within one week post-transplantation, is associated with poorer kidney graft survival. We aimed to identify risk factors for DGF throughout 3 decades and evaluate their effect on graft survival. Method Retrospective study including 3081 kidney transplants performed at our transplantation unit between January 1st, 1989 and December 31st, 2018, split in 3 decades (1: 1989-1998; 2: 1999-2008; 3: 2009-2018). Data regarding donor and recipient demographics, time on dialysis, immunization, cold ischemia time, hemodynamic parameters and immunosuppression were collected from our prospectively maintained data base. Results Main donor, recipient and perioperative characteristics are summarized in table 1. There were clear differences in these characteristics between the decades, standing out more adverse features from both recipients and donors. Overall incidence rate of DGF was 16% (n=493): 14% in decade 1; 19.3% in decade 2 and 15% in decade 3. On univariate analysis, most studied variables included in table 1 were statistically significant as predictors of DGF. However, on multivariate analysis, we found that in the first decade the predominant risk factors for DGF were pre-transplant dialysis time and cold-ischemia time, whilst in the following decades donor characteristics, as well as recipient’s weight became more relevant (table 2). Conclusion The observed shift from donor-unrelated variables in the first decade into donor-related variables in the second and third decades as the main determinants of DGF highlights the impact of expanding donor’s acceptance criteria. Nevertheless, the increase in expanded criteria donors did not translate into poorer overall results, probable contributors being shorter cold-ischemia times and stronger immunosuppression.

Impact of long-distance (up to 3.500 km) deceased donor liver transportation on cold ischemia time, initial graft function and transplant outcomes

Rationale. Currently, a long-distance transportation of the deceased donor livers is not a routine practice for Russian transplantation centers; therefore, a research-based analysis of even relatively small single-center experience seems to be a topical task.The study purpose was to evaluate the impact of long-distance donor liver transportation on the cold ischemia time, the initial graft function as well as on immediate and long-term transplant outcomes.Material and methods. The retrospective single-center study included the data on specific features and results of 72 consecutive deceased donor liver transplantations. The cases were allocated into two groups depending on cold ischemia time: for less than 9 hours (group 1; n = 41) and for 9 hours or longer (group 2; n = 31). The parameters of donor organ transportation, characteristics of donors and recipients, specific features of surgery and the early postoperative period, immediate and long-term outcomes were compared between the groups. For the entire sample size, the relationship between the distance from the donor hospital to the transplant center, the transportation type and time, and the cold ischemia time were assessed.Results. Donor livers were delivered from hospitals 40-3500 km away from the transplant center, including by using regular air flights in 67% of cases. Transportation time varied from 1 to 8 h (median 3.5 h), which made 41% (interquartile range: 35-54%) of cold ischemia time.No statistically significant differences between the groups were seen in the donor, recipient and surgery characteristics. The median distance was 509 km in group 1 (interquartile range 130-1321 km), and 1321 in group 2 (interquartile range 897-3441 km), p<0.001; transportation time was 3.5 h (interquartile range : 2.5–4.7 h) and 3.5 h (interquartile range: 3.3–7.0 h), p = 0.022, the cold ischemia time was 8 h (interquartile range: 7–9.5 h) and 10 hours (interquartile range: 9-10.5 h), p <0.001, in group 1 and group 2, respectively, the difference being statistically significant for all parameters. Despite the tendency to increases in the incidence of the early allograft dysfunction (6/41 in group 1, 9/31 in group 2; p = 0.155), primary graft non-function (1/41 in group 1, 3/31 in group 2; p = 0.308), and the graft loss incidence during the first 6 weeks (4/41 in group 1; 7/31 in group 2; p = 0.189), these differences did not reach the statistical significance.Conclusion. The results of this retrospective study have confirmed the feasibility and clinical efficacy of donor liver transplantation after long-distance transportation. However, cold ischemia time exceeding 9 hours is the risk factor for poor initial graft function.