The Long-term Outcomes of Kidney Transplantation from Donation after Circulatory Death during Brain Death Donor Evaluation in a Single Center in Korea

Nayoon Hur; Hyojun Park; Kyowon Lee; Gyuseong Choi; Jong Man Kim; Jae Berm Park; Choon Hyuck Kwon; Sung Joo Kim; Jae-Won Joh; Suk-Koo Lee

doi:10.4285/jkstn.2015.29.4.216

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Hur, Park, Lee, Choi, Kim, Park, Kwon, Kim, Joh, and Lee: The Long-term Outcomes of Kidney Transplantation from Donation after Circulatory Death during Brain Death Donor Evaluation in a Single Center in Korea

Original Article

J Korean Soc Transplant 2015;29(4):216-226.

Published online: 10 December 2015

DOI: https://doi.org/10.4285/jkstn.2015.29.4.216

The Long-term Outcomes of Kidney Transplantation from Donation after Circulatory Death during Brain Death Donor Evaluation in a Single Center in Korea

Nayoon Hur, M.D., Hyojun Park, M.D., Kyowon Lee, M.D., Gyuseong Choi, M.D., Jong Man Kim, M.D., Jae Berm Park, M.D., Choon Hyuck Kwon, M.D., Sung Joo Kim, M.D., Jae-Won Joh, M.D., Suk-Koo Lee, M.D.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Corresponding author: Jae Berm Park, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: 82-2-3410-3647, Fax: 82-2-3410-0040 E-mail: jbparkmd@gmail.com

Received 3 August 2015 Revised 30 October 2015 Accepted 13 November 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

While the number of deceased donor donations has increased in Korea, the organ shortage remains a major limitation for kidney transplantation. Donation after circulatory death (DCD) can be an option to expand the donor pool. In this study we evaluated the short and long term survival of grafts and patients and assessed the risk factors for graft failure.

Methods

In a single center, from August 1997 to December 2013, 28 cases of recipients who received kidney transplantation from DCD were enrolled. Information about donor and recipient factors, graft conditions, and transplant outcomes was collected through review of medical records. We calculated overall graft and patient survival rates and the risk factors for graft failure according to donor criteria and whether or not delayed graft function (DGF) occurred.

Results

There was no primary non-function, but DGF developed in 67.9% (19/28). Graft losses occurred in five patients during a median follow-up period of 68.2 months (4∼204). There was no significant difference in graft survival rates depending on the donor criteria and the occurrence of DGF. In addition, there were no noteworthy risk factors for graft failure among donor age, donor creatinine, extended criteria donor, recipient age, warm ischemic time, cold ischemic time, and DGF.

Conclusions

In this study, despite the high incidence of DGF, the long-term graft and patient survival in kidney transplantation from DCD were acceptable. Therefore, DCD can be an alternative to expand the donor pool and to shorten the waiting time.

Keywords: Kidney transplantation, Donation after circulatory death, Graft survival

References

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Fig. 1.

Overall survival. (A) Donation after circulatory death (DCD): overall graft survival. (B) DCD: overall patient survival.

Fig. 2.

Survival according to donor criteria (standard criteria donor [SCD] vs. extended criteria donor [ECD]). (A) Donation after circulatory death (DCD): graft survival according to donor criteria (SCD vs. ECD). (B) DCD: patient survival according to donor criteria (SCD vs. ECD).

Fig. 3.

Survival according to delayed graft function (DGF) occurrence. (A) Graft survival according to DGF occurrence. (B) Patient survival according to DGF occurrence.

Fig. 4.

Overall survival (donation after circulatory death [DCD] vs. donation after brain death [DBD]). (A) Overall graft survival. (B) Overall patient survival. (C) Graft survival according to donor criteria (DCD-standard criteria donor [SCD] vs. DCD-extended criteria donor [ECD] vs. DBD-SCD vs. DBD-ECD). (D) Patient survival according to donor criteria (DCD-SCD vs. DCD-ECD vs. DBD-SCD vs. DBD-ECD).

Table 1.

Basal characteristics of the patients

Characteristic	DCD (total) (n=28)	DCD-SCD (n=20)	DCD-ECD (n=8)	P-value
Recipient
Age (yr)	44.8±9.3	43.0±9.4	49.4±7.9	0.102
Sex (male:female)	17:11	11:9	6:2	0.419
Underlying disease
Hypertension	24 (85.7)	18 (90)	6 (75)	0.555
Diabetes mellitus	4 (14.3)	3 (15)	1 (12.5)	1.000
Duration of dialysis (mo)	59.3±43.8	65.7±47.6	43.4±20.1	0.530
HLA-mismatching ＞3	24 (85.7)	16 (80)	8 (100)	0.295
PRA (%)				1.000
0∼50	27 (96.4)	19 (95)	8 (100)
＞50	1 (3.6)	1 (5)	0
Donor/graft factor
Age (yr)	40.9±16.5	33.9±13.9	58.5±5.3	＜0.001
Sex (male:female)	18:10	14:6	4:4	0.400
Underlying disease
Hypertension	10 (35.7)	4 (20)	6 (75)	0.011
Diabetes mellitus	0	0	0
Cause of death				0.576
Cerebrovascular accident	15 (53.6)	11 (55)	4 (50)
Trauma	9 (32.1)	7 (35)	2 (25)
Suicide or hypoxic brain damage	4 (14.3)	2 (10)	2 (25)
Cardiopulmonary resuscitation	6 (21.4)	4 (20)	2 (25)	1.000
Intensive care unit stay (day)	9.0±4.9	9.4±5.0	8.1±5.1	0.562
Donation other than kidney	4	3	1	1.000
Serum creatinine (mg/dL)	2.21±1.67	2.35±1.97	1.88±0.05	0.277
Warm ischemic time (min)	9.04±6.55	8.83±7.11	9.50±5.48	0.816
Cold ischemic time (min)	472.3±175.9	403.4±135.2	627.3±162.6	0.352
Follow-up duration	67.0 (4∼206)	78.5 (47∼206)	62.0 (4∼70)	0.021

Data are presented as mean±SD, number (%), or median (range).

Abbreviations: DCD, donation after circulatory death; SCD, standard criteria donor; ECD, extended criteria donor; HLA, human leukocyte antigen; PRA, panel-reactive antibody.

Table 2.

Subgroup analysis according to donor criteria

Variable	DCD-SCD (n=20)	DCD-ECD (n=8)	P-value
PNF	0	0
DGF	13 (65)	6 (75)	1.000
Time of HD during DGF			0.545
1∼4	3 (23.08)	3 (50)
5∼9	6 (45.15)	3 (50)
10∼	3 (23.08)	0
Sequential creatinine
level change (mo)	1.74±0.75	1.88±0.63	0.381
SCR 1∼3	1.44±0.30	1.83±0.51	0.133
SCR 4∼6	1.37±0.27	1.73±0.59	0.245
SCR 7∼9	1.36±0.31	1.73±0.68	0.17
SCR 10∼12	1.37±0.44	2.77±2.77	0.381
Last SCR
Graft survival (yr)			0.013
1	100	100
5	100	71.4
10	71.4	–
Patient survival (yr)			0.434
1	100	87.5
5	95.0	87.5
10	95.0	–

Data are presented as number (%), mean±SD, or percentage.

Abbreviations: DCD, donation after circulatory death; SCD, standard criteria donor; ECD, extended criteria donor; PNF, primary non-function; DGF, delayed graft function; HD, hemodialysis; SCR, serum creatinine.

Table 3.

Subgroup analysis according to presence of delayed graft function

Variable	DGF (+)(n=19)	DGF (−)(n=9)	P-value
Warm ischemic time (min) ^a	7.8±4.3	11.4±9.3	0.560
Cold ischemic time (min)	515.7±185.4	390.3±128.0	0 0.084
Sequential creatinine level
change (mo)	2.00±0.74	1.31±0.33	0.006
SCR 1∼3	1.67±0.40	1.27±0.21	0.009
SCR 4∼6	1.56±0.43	1.27±0.23	0.101
SCR 7∼9	1.55±0.50	1.28±0.30	0.247
SCR 10∼12	2.03±1.88	1.22±0.35	0.145
Last SCR
Graft survival (yr)			0.638
1	100	100
5	88.9	100
10	59.3	75.0
Patient survival (yr)			0.317
1	94.7	100
5	89.2	100
10	89.2	100

Data are presented as mean±SD or percentage.

Abbreviations: DGF, delayed graft function; SCR, serum creatinine.

^a Warm ischemic time, time between cardiac arrest and cold perfusion.

Table 4.

Risk factor analysis for graft failure (univariate analysis)

Faxtor	HR	95% CI	P-value
Donor age	1.084	0.972∼1.208	0.146
Donor serum creatinine	0.984	0.432∼2.242	0.970
SCD vs. ECD	0.002	0.000∼63,968.685	0.484
Recipient age	0.942	0.839∼1.056	0.305
Warm ischemic time	1.010	0.899∼1.136	0.862
Cold ischemic time	1.004	0.997∼1.011	0.315
DGF (reference=0)	2.415	0.242∼24.094	0.453

Abbreviations: HR, hazard ratio; CI, confidence interval; SCD, standard criteria donor; ECD, extended criteria donor; DGF, delayed graft function.

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