Expanded criteria donors for kidney transplantation

Abstract

The ideal deceased organ donor is a younger person who dies from traumatic head injury that is isolated to the brain and leaves the thoracic and abdominal organ function intact. Such a deceased donor provides excellent transplantable organs with an opportunity to achieve immediate allograft function and long-term patient survival. As the size of the recipient waiting list and the number of waiting list deaths increase, older donors and donors with characteristics once thought to preclude organ donation are being used more and more frequently (1Kauffman MH Bennett LE McBride MA Ellison MD The expanded donor.Transplant Rev. 1997; 11: 165-190Crossref Scopus (54) Google Scholar). The clinical characteristics that differentiate ‘marginal’ renal allografts are derived from the social and medical history of the donor (age, history of hypertension or diabetes, the risk of transmitting infectious disease and/or malignancy), the cause of donor death (trauma vs. cerebrovascular accident), the mechanism of donor death (brain death vs. cardiac death), the anatomy of the allograft (vessel abnormalities), the morphology on biopsy (glomerulosclerosis, interstitial nephritis and/or fibrosis), and the functional profile (serum creatinine or calculated glomerular filtration rate) prior to transplantation (2Becker TY Use of marginal donors in kidney transplantation.Graft. 2000; 3: 216-220Google Scholar, 3Randhawa P Role of donor kidney biopsies in renal transplantation.Transplantation. 2001; 71: 1361-1365Crossref PubMed Scopus (82) Google Scholar). Kauffman suggests that the term ‘expanded’ be used to refer to the donor whose organs may be associated with poorer outcome because the term ‘marginal’ may be considered pejorative by the patients who receive them, as well as by the programs that transplant them (1Kauffman MH Bennett LE McBride MA Ellison MD The expanded donor.Transplant Rev. 1997; 11: 165-190Crossref Scopus (54) Google Scholar). Kidneys transplanted from older donors are considered to be from the expanded pool because these allografts have a higher rate of delayed graft function, more acute rejection episodes, and decreased long-term graft function. Several factors, including prolonged cold ischemia time (CIT), increased immunogenicity, impaired ability to repair tissue, and impaired function with decreased nephron mass may contribute to this (4De Fijter JW Mallat MJK Doxiadis IIN et al.Increased immunogenicity and cause of graft loss of old donor kidneys..J Am Soc Nephrol. 2001; 12: 1538-1546Crossref PubMed Google Scholar). But recently, Ojo et al. have demonstrated that the recipients of expanded kidneys receive the benefit of extra life-years when compared to wait-listed dialysis patients (5Ojo AO Hanson JA Meier-Kriesche H et al.Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates.J Am Soc Nephrol. 2001; 12: 589-597Crossref PubMed Google Scholar). Still, placement of these organs is often difficult and delayed, and some centers continue to prefer not to utilize them (6Lee CM Scandling JD Pavlakis M Markezich AJ Dafoe DC Alfrey EJ A review of kidneys that nobody wanted: determinants of optimal outcome.Transplantation. 1998; 65: 213-219Crossref PubMed Scopus (34) Google Scholar). The crisis in organ supply presents a compelling responsibility for the transplant community to maximize the use of organs procured from all deceased donors. In March, 2001, representatives of the transplant community convened in Crystal City, VA, in order to develop guidelines that would improve the recovery and transplantation of organs from the deceased donor. This meeting, sponsored by The American Society of Transplantation and The American Society of Transplant Surgeons, produced the ‘Report of the Crystal City Meeting to Maximize the Use of Organs Recovered from the Cadaver Donor’, published in the American Journal of Transplantation (7Rosengard BR Feng S Alfrey EJ et al.Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor.Am J Transplant. 2002; 2: 1-10Crossref PubMed Scopus (275) Google Scholar). At the meeting, five work groups were assembled that focussed upon increasing the use of hearts, lungs, livers, and kidneys, from deceased donors with a history of malignancy or serology testing positive for hepatitis B or C. The Kidney Work Group (7Rosengard BR Feng S Alfrey EJ et al.Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor.Am J Transplant. 2002; 2: 1-10Crossref PubMed Scopus (275) Google Scholar) noted that in recent years the discard rate of kidneys from deceased donors has increased substantially and approaches 50% for kidneys recovered from donors over age 60. They estimated a potential increase of 38% in the rate of donors per million population if the United States could match Spain's rate of recovery of kidneys from donors over age 45. The work group recommended, and the conference participants endorsed, expedited placement of kidneys from all donors over age 60, based upon waiting time only, to a list of preselected and preinformed recipients who would accept these kidneys. Expanded criteria kidneys are expected to increase overall kidney utilization by stimulating higher procurement rates and lower discard rates. Under the work group's proposed plan, the Organ Procurement and Transplantation Network (OPTN), through its contract with the United Network for Organ Sharing (UNOS) would be asked to develop a standard policy whereby a local organ procurement organization (OPO) could adopt the policy upon notification to OPTN/UNOS of local OPO approval. Finally, allocation would occur primarily at the level of the OPO or the region, except for the identification of zero antigen mismatched recipients, which would be allocated nationally. Another objective of the work group was to evaluate the use of biopsies in the decision to transplant a kidney from an older donor. Currently, biopsies at the time of recovery assume a high importance in kidney distribution; however, available evidence remains controversial (see below). The work group recommended assessing the glomerular filtration rate (GFR) using the Cockcroft–Gault formula or creatinine clearance and to compare the GFR value to biopsy findings to determine the utility of either or both in predicting immediate and long-term function of the older donor's kidney. At the same time, the OPTN/UNOS Organ Availability and Kidney/Pancreas Committees were each seeking to better define the expanded criteria donor (ECD) in order to provide the transplant community with a more objective basis for decision-making for utilization of these organs for transplantation. The Crystal City kidney proposal was subsequently modified by a collaboration of the OPTN/UNOS Organ Availability Committee, OPTN/UNOS Kidney/Pancreas Committee, and the Scientific Registry of Transplant Recipients (SRTR) contracted to University Renal Research and Education Association (URREA). The result of their interaction with the Crystal City Kidney Group was to define the ECD based upon not only age but also using other statistically significant risk factors determined by the SRTR analyses. Three additional significant donor medical risk factors were identified: history of hypertension, cerebrovascular accident as a cause of death, and final preprocurement creatinine >1.5 mg/dL. Donor kidneys were characterized according to combinations of these four parameters, and a relative risk of graft loss was determined for each donor profile. The ECD kidney was then precisely defined as any kidney whose relative risk of graft failure exceeded 1.7 when compared to a reference group of ideal donor kidneys: those from donors of age 10–39 years, who were without hypertension, who did not die of a cerebrovascular accident, and whose terminal predonation creatinine level was <1.5 mg/dL (Table 1). this based on the relative risk of graft all donors over age and donors with at of the medical criteria are as (Table et characteristics associated with graft survival. an to the pool of kidney 2002; PubMed Scopus Google Scholar). the number of donors age was were not in the ECD in order to the defined of graft loss by four donor of death was not cerebrovascular of death was cerebrovascular SRTR as of donor in in a expanded criteria for kidney donors. The decision using relative risk of graft failure 1.7 (see for donors older years of are the expanded criteria by which kidney donors are defined as expanded and the expedited age of the accident was cause of history of >1.5 creatinine in a SRTR as of donor in accident was cause of history of >1.5 creatinine This of an ECD was by the OPTN/UNOS of in 2001, and allocation of ECD the allocation policy of in The policy procured from the ECD be allocated to patients determined to be for zero antigen mismatched patients this group of patients with time and for all other patients and based upon time waiting and not The Organ to expanded criteria donor organs for the zero antigen mismatched according to the list of patients waiting for expanded criteria kidneys for a of which time the Organ the OPO that may the expanded criteria kidneys by the standard of and are to potential recipients a match and the for the transplant the organ for kidneys from expanded criteria donors or the organs for patients and then (7Rosengard BR Feng S Alfrey EJ et al.Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor.Am J Transplant. 2002; 2: 1-10Crossref PubMed Scopus (275) Google Scholar). standard donors as all other and that potential recipients to the waiting list for the ECD kidneys would also be to receive standard kidneys. the of an are that be the use of organs recovered from donors. The is to transplant kidneys from the ECD by not them, them to be The discard of kidneys recovery from the deceased donor has increasing at an rate in the United the years, the discard rate has increased from to because of the increase in the number of donors older who over of the donor In the SRTR of kidneys defined as ECD with relative risk of graft failure were in In only of standard kidneys were the same (Table The for the high rate of kidney discard is often to organ function and of ECD kidneys were because of biopsy findings in (see of kidneys from criteria not not transplant transplant transplanted as of are based on including and in in a of kidneys from expanded criteria not not transplant transplant transplanted as of are based on including and in organs recovered for transplant but not as well as organs in a for of recovered expanded criteria donor kidneys, for recovered ischemia time organ or organ history findings recipient recipient recipient not or list for not prior to organs recovered for transplant but not as well as organs prior to as of are based on including and in Organ organ or recipient recipient not or list for not prior to organs recovered for transplant but not as well as organs in a as of are based on including and in as of are based on including and in organs recovered for transplant but not as well as organs as of are based on including and in The of kidney biopsy findings with immediate and long-term function remains both controversial and The MH AO as a of function of older donor renal PubMed Scopus Google Scholar) in the by et has for not to its that a biopsy a donor kidney for transplantation P Role of donor kidney biopsies in renal transplantation.Transplantation. 2001; 71: 1361-1365Crossref PubMed Scopus (82) Google Scholar). This only a number of allografts with function transplantation and a of at the time of a creatinine mg/dL and four of these kidneys the of has a for a transplant not to accept a kidney for transplantation. et al. by the use of biopsies of kidneys from older donors and those donors with cerebrovascular those with preprocurement creatinine MH AO as a of function of older donor renal PubMed Scopus Google Scholar). and a of biopsies of deceased donor kidneys, and that kidneys whose biopsies demonstrated or more an graft rate of S M H of in procurement biopsy for of marginal 2000; PubMed Scopus Google Scholar). only of these donors were older et al. that procurement biopsies provide only for the decision or not to accept a donor kidney for transplantation. A of kidneys recovered from the ECD that donor kidney function and with kidney function and outcome remains to be Such a could the transplantation rate of kidneys from older donors. 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