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The Ultimate Gift
A
newsletter from the transplant team
at Rhode Island Hospital
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Transplants from Older Donors:
What are the outcomes?
The Organ Procurement Transplant Network (OPTN) defines an expanded
criteria donor (ECD) as one with a RR of failure greater than or
equal to 1.7 when compared to a reference group of non-hypertensive
donors between the ages of 10-39 [UNOS Renal Allocation Policy 3.5].
ECD kidneys meet the following criteria:
- Age greater than 60, or
- Age greater than 50 with at least two of the following:
- Serum creatinine at procurement >1.5
- CVA as cause of death
- History of hypertension.
Since February of 2005, all transplant centers in New England are
participating in a study to evaluate the outcomes of ECD kidneys.
By design kidneys from ECD donors are biopsied after procurement
and placed on a pump for pulsatile perfusion. Based on these data
the kidneys are offered preferentially to patients on the "ECD
list." Wait-listed patients are informed of this special list
(they still remain on the standard waiting list) and agree to participate
in the ECD program. Waiting times are shorter for patients willing
to accept ECD kidneys. Ideal candidates for the list include:
- Older recipients, particularly newly listed patients facing
long waiting times
- Patients with ESRD due to IDDM with limited life expectancy
- Patients running out of dialysis access.
ECD kidneys that are refused for solitary organ transplantation
(based on donor age, renal function, or biopsy data) may be considered
for 2-for-l transplants. We have done six such transplants;
one from a pediatric donor, one from a 49 year old donor with 20-25%
glomerulosclerosis and four from donors >73 year old. All of
these transplants functioned and 4 out of 6 recipients enjoy normal
renal function 6 months to 4 years later.
What are the long-term consequences of using ECD kidneys?
Recall that prior to the ECD distinction these kidneys were placed
through the standard allocation algorithm. We reviewed the outcomes
of our transplants from donors greater than or equal to age 55 (range
55 - 77). There were 58 such transplants.
Outcomes
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Category
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N |
Explanation
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Presently functioning
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48 |
Creatinine < 2.0 in 43/48 pt.
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Primary allograft nonfunction
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1 |
Technical failure
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Death with allograft function
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7 |
Died post-op day 3-1251
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| Returned to dialysis |
2 |
Dialysis 210 and 736 days after transplant |
Notes
- Recipient age (mean)
- Donor age (mean)
- Recipient creatinine (mean)
- Delayed graft function
- Acute rejection
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54 years
62 years
1.67 mg/dl (2-year follow-up)
11/58(19%)
10/58 (17%)
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- The recipients who died after renal transplant were medically
high-risk patients. Two died during the transplant admission
and the others died 3-41 months after transplantation. Three
succumbed to AMI or CVA and four to infectious complications.
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Summary
The majority of patients receiving allografts from older donors
do well. The transplant success rate, censored for death-with-function,
is 94% with nearly two years of follow-up. In addition, 45/48 kidneys
have good to excellent function. Only two kidneys were lost to chronic
allograft nephropathy, both in patients with previous severe acute
rejection.
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