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The Ultimate Gift
A
newsletter from the transplant team
at Rhode Island Hospital
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Expanded Criteria Donors
in Real Time
Recently an excellent kidney (normal creatinine and normal biopsy)
from a Rhode Island donor was transplanted in Boston because two
patients at Rhode Island Hospital were listed for expanded criteria
donor (BCD) kidneys. The transplant team reviewed our list of 138
patients waiting for a kidney transplant and recommended to many
patients that they consider placement on the BCD list. These patients
fell into three categories: (1) older than age 60, (2) older than
age 50 with a long expected wait time or (3) over age 40 with high
PRA, failing HD access or advanced medical problems (IDDM with complications,
e.g.).
As a reminder, BCD kidneys arise from deceased organ donors who
are older than 59 or 50-59 years old with a history of high blood
pressure or death due to stroke. UNOS maintains two separate lists
for patients waiting for kidney transplants. One list consists of
all patients awaiting renal transplantation. The second list is
for patients who would benefit from an BCD kidney. This list is
much shorter and waiting times are reduced. This listing is voluntary.
In addition, any offered kidney may be refused without penalty.
An account of some recent kidney offers suggests the value of
placement of on the BCD list:
- BCD List: A 60-year-old female, 5'4", weight 130
lbs., in good health died from a ruptured cerebral aneurysm (subarachnoid
hemorrhage). She was on no medications. She was stable in the
ICU, on no pressors with a serum creatinine of 0.8 on admission
and 0.9 at the time of organ recovery. The Rhode Island Hospital
BCD list consisted of two patients who due to limited waiting
time were patients 6 and 7 on the "match run." The kidneys
were recovered at Rhode Island Hospital and transplanted in Boston—both
with immediate function.
- Standard List: A 49-year-old male with bipolar disorder
and long-term Li+ use died from trauma. The donor creatinine was
1.1 mg/dl. Amazingly the donor was a match for two highly sensitized
young patients: (1) a young woman with a failed prior transplant
four years previous and (2) a teenage boy who rejected his first
renal transplant due to noncompliance. A renal biopsy was obtained
because of the Li+ use, which revealed extensive interstitial
fibrosis in both kidneys. The kidneys were discarded.
The criteria for BCD kidneys were derived from a retrospective
review of Registry data. This review asked the question—which
donor criteria "significantly" decrease kidney allograft
survival. Significant was defined as a relative risk of graft failure
(over time, not immediate failure) greater than 1.7. The criteria
identified are noted above in the second paragraph. The two cases
demonstrate that donor age and serum creatinine alone are insufficient
to predict outcomes for a particular allograft. The decision to
use a kidney for transplantation is based on the aggregate of donor
characteristics (medical history, stability, urine output, need
for pressors, urine analysis, cultures), intraoperative findings
(renal size, flush, degree of arteriosclerosis, anatomy) and recipient
factors (age, medical condition, sensitization).
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