Survival Benefits of Kidneys from Donors after Cardiac Death

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					   Survival Benefits of Kidneys
from Donors after Cardiac Death
   Reference: Snoeijs MG, Schaubel DE, Hene
   R, et al. Kidneys from donors after cardiac
    death provide survival benefi t. J Am Soc
          Nephrol. 2010;21:1015–1021.
• Due to the increasing incidences of end-stage renal failure in
  general, the list of patients waiting for kidney transplantation has
  been increasing.
• While the number of recipients have been increasing, the number
  of donors have been on the decline.
• This is largely due to the fact of waiting for a kidney from a brain-
  dead donor which has been the ideal solution for decades.
• Kidney transplantation has been proven to increase survival
  benefits in many developed countries.
• Due to this factor alone, efforts have been ongoing to increase the
  number of donor kidneys available for transplantation.
• One way of overcoming the problem of waiting for a kidney from a
  brain-dead donor, has been the option of using kidneys from donors
  after cardiac death.
• Kidneys from brain-dead donors have been used successfully in
• The graft rejection episodes have been managed with the use of
  novel pharmacological agents.
• Kidneys in such cases have been well-preserved and the
  transplantation has been carried out after good planning.
• But in case of kidneys from donors after cardiac death, preservation
  of the perfusion of the organs has been a challenge.
• This results in acute ischemic injury leading to incidences of delayed
  graft rejection or dysfunction of the transplanted kidneys.
• However, transplantation of functioning kidneys has shown
  promising results in this category.
• However, there was no data on the benefits of
  receiving a kidney from a donor after cardiac death in
  comparison with waiting for a kidney from a brain-
  dead donor while continuing with routine dialysis.
• A study was conducted by Snoeijs et al. on the survival
  benefits of transplanted kidneys received from
  different types of donors in the patients on dialysis.
• The patients were registered on the waiting list for
  their fi rst kidney transplantation between the years
  1999 and 2004.
• At the start of the study, 2708 subjects were recruited and among
  them, 133 were excluded because they were not on dialysis or
  receiving kidney transplantation from non- Eurotransplant region or
  due to being on a multiorgan transplant waiting list.
• The endpoint of the study was considered to be death or end-of-
  study on 31/12/2005.
• About 2575 patients completed the study. Among them, 680
  received kidneys from brain-dead donors and 459 received kidneys
  form donors after cardiac death.
• The authors compared the mortality rates of the patients with
  donation after brain death and donation after cardiac death with
  that of alternative therapeutic option of dialysis treatment or
  waiting on dialysis.
Effects of Kidney Transplantation on Survival
   of Dialysis Patients on the Waiting List
  • Mortality rate after standard-criteria brain-dead donor
    kidney transplantation was 49% lower when compared
    with dialysis treatment (hazard ratio (HR) 0.51; 95% confi
    dence interval (CI) 0.32–0.81; p=0.004).
  • Mortality rate after standard-criteria cardiac-dead donor
    kidney transplantation was 56% lower when compared
    with continuing dialysis and waiting for a standardcriteria
    brain-dead donor kidney (HR 0.44; 95% CI 0.24–0.80;
  • Mortality rates after expanded-criteria donors, either from
    brain dead donors or cardiac dead donors kidney
    transplantation were not signifi cantly different from
    conventional therapy (p=0.62 and p=0.15, respectively).
   Posttransplant Survival Benefits of
         Kidney Transplantation
• In transplantation studies, there is a need to study the
  mortality rates to assess the success of the transplantation
• The mortality rates change with time after transplantation.
   – In the early posttransplantation period, the mortality rate of
     transplanted patients was higher than those on conventional
     therapy (dialysis).
   – The mortality rate decreased with the passage of time and led
     to a survival benefi t for the transplanted patients in comparison
     to the patients on conventional therapy.
• The mortality rate of patients receiving a standardcriteria
  kidney from a cardiac-dead donor was equal to patients
  receiving conventional therapy at 7 months while the
  survival benefi t of the two groups equaled at 13 months.
• After this period, there was an increase in the survival
  benefi t for patients receiving the cardiac-dead donor
  transplantation in comparison to patients on conventional
  therapy on dialysis waiting for a standardcriteria kidney
  from a brain-dead donor (see Fig. 1).
• At about 4 years posttransplantation, patients receiving the
  cardiac-dead donor transplantation were expected to live
  on an average 2.4 months longer than patients on dialysis.
• The same details when assessed in patients after
  standardcriteria brain-dead donor kidney transplantation,
  mortality rates and survival probabilities were equal to
  those of dialysis treatment at 5 and 9 month after
  transplantation, respectively, whereupon transplant
  recipients had the advantage (see Fig. 2).
• The results are promising towards transplantation of
  kidneys from cardiac-dead donors.
• This will help in overcoming the shortage of kidneys for
  transplantation in patients with end-stage renal disease.
• Patients who receive standard-criteria cardiac dead donor
  kidney transplantation live longer than patients who
  continue dialysis treatment with the option of later
  receiving conventional brain dead donor kidney
• Longer follow-up will yield more credible data to make the
  decision of using kidneys from cardiac-dead patients more
  relevant by reducing the waiting times for transplantation.

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