Renal transplantation from non-heart beating donors M L Nicholson P N Furness* Departments of Transplant Surgery and *Pathology Leicester General Hospital UK The University of Leicester

The problem - 1

The problem - 2

Sources of asystolic donors in Leicester Irreversible cardiorespiratory arrest Accident & Emergency department – failed resuscitation after MI Medical wards – catastrophic intracerebral haemorrhage with ‘coning’

Leicester selection criteria for NHBDs Age<60 Warm ischaemic time <40 minutes No history of renal impairment No uncontrolled hypertension No complicated insulin dependent diabetes No systemic sepsis or malignancy

A & E suture room

Mechanical cardiopulmonary resuscitation device (a.k.a. ‘The Thumper’)

Correct positioning of aortic catheter

Cyclosporin protocol

Acute rejection rates 32.6% 28.6% 46.9% 12.1% 5.2% 14.3% HBD N=224 NHBD N=77 LD N=49 Acute rejection 32.6% 28.6% 46.9% Requiring ATG 12.1% 5.2% 14.3%

Early graft function rates HBD N=224 NHBD N=77 LD N=49 Primary non-function 2.7% 9.1% 2% Delayed graft function 21.0% 84.4% 4.1% Initial function 76.3% 6.5% 93.9%

Graft function

Graft survival

NEWCASTLE DATA: KM - Survival curves With thanks to: Gok MA Buckley PE Mohamed MAS Balupuri S Shenton BK Robertson H Soomro N Manas D Talbot D Liver / Renal Transplant Unit, The Freeman Hospital, Newcastle Upon Tyne, UK NEWCASTLE DATA: KM - Survival curves

NEWCASTLE DATA: Creatinine Clearance (Cockroft & Gault)

Biopsy results: a ‘typical’ case, 1 week

Same case, 3 months Hypertrophy of tubules Little fibrosis

Biopsy results: a ‘good’ case 1 week 1 month

Biopsy results: a ‘bad’ case. Pre-perfusion:

1 week:

3 weeks:

2 months:

Sirius Red analysis - normal kidney

Sirius Red analysis - fibrotic kidney

Interstitial collagen volume fraction (Sirius Red, polarized light) Conventional and NHBD kidneys, 6 month protocol biopsies % P<0.05

Conclusions: Non-heart beating donor kidneys Increased PNF rate (decreases with experience) High DGF rate; dialysis usually needed Slightly higher serum creatinine, may compensate Slightly more interstitial fibrosis at 6 months Indistinguishable graft survival rate at 5 years Biopsy does not help with donor selection (?) Protocol biopsies detect acute rejection at unchanged rate Biopsy helps to distinguish PNF and DGF, but care needed