Waiting for a Kidney Department of Urologic Sciences Grand Rounds William Gourlay Christopher Nguan April 25, 2007 Objectives 1. review the waiting times for deceased-donor kidney transplants in BC and Canada 2. review the strategies to shorten waiting times including; a. live donor transplants b. living donor exchange c. living anonymous donation d. expanded criteria donor kidneys (ECD) e. donation after cardiocirculatory death (DCD)
Deceased Donation Since 2001, deceased donation has been surpassed by living donation as the most common type of renal transplantation in Canada CORR 2006
Deceased Donation in Canada BC has the second lowest deceased donation rate in Canada Comparison to the World Organ Donor Rate per Million Population World Wide, 2004 40 35 30 25 20 15 10 5 0 Canada US Eurotra nsplant France Italy Spain Scandin avia RPMP 13.5 24.3 15.4 20.9 21.1 34.6 16 13.8 10.8 UK Australi a
Deceased Donation in Canada Ongoing discrepancy between waitlist and available donors Cost of a Prolonged Wait List As of December 31, 2005, there were 3,974 patients waiting for an organ transplant in Canada appears to be fairly constant since 2001 Patients waiting for a kidney transplant comprise 69% of the waiting list (n=2,730). During 2005, 275 people died while waiting for an organ( 140 while waiting for liver and 67 waiting for kidney) compared with 225 in 2004.
Increasing Deceased Donor Rates Extended criteria donation Donation after Cardiac death Extended Criteria Donation (ECD) Definition by UNOS derived from the SRTR database This definition based on a 70% greater death censored graft failure rate than non ECD Tx (RR 1.7) The United Network of Organ Sharing, Policies, Section 3.5.1. Organ distribution: Allocation of cadaveric kidneys. Definition of expanded criteria donor and standard donor. Available at: http://www.unos.org/policiesandbylaws/policies.asp?resources=true.
Utility of ECD Kidneys Should a patient on the CAD list accept an ECD kidney? Retrospective review of the SRTR database of 122,175 patients Adjusted 5YS: IDK 72%, ECD 59% Ojo et al, JASN 2001 Utility of ECD Kidneys ECD is superior to dialysis beyond 185d for RR of death 5.1 years improvement in life expectancy over WLD Long term relative mortality risk reduction of 25% in ECD (p<0.001) 48% for IDK (p<0.001)
ECD in BC Transplantation BCTS 2007 data An option for increasing deceased donor organ pool Ongoing contribution by ECD donor group ECD Summary ECD transplants have a lower graft survival than IDK transplants, but are useful for patients at risk on the waiting list In BC, ECD kidneys comprise up to 35% of total numbers of deceased donor renal transplants
Donation after Brain Death Currently, deceased donors are eligible for donation if they are deemed neurologically brain dead GCS 3 Absent brain stem reflexes Positive apnea test Absence of blood flow to brain EEG Nuclear scan Angiography UNOS criteria for identifying DCD candidates
Donation after Cardiac Death - Principles A strategy to preserve human life, not hasten the conversion of an organ donor Care of the living is never compromised in favor of potential organ recipients The interest of procuring organs does not interfere with optimal patient management Consideration of organ donation is done only after after a decision to withdraw/withhold life support and the family is interested in donation Organ procurement procedure is aborted in the event patient death does not occur following removal of life support or if organ ischemia is prolonged Any protocol, however well scripted, explicitly prohibits any intervention whose primary intervention is to shorten the patient s life Policy must promote and enhance public trust Donation after Cardiac Death Technical Details Patient must meet the following criteria: Spontaneous unassisted ventilation is associated with prompt and severe oxygen desaturation and is so ineffective as to be incompatible with life for more than 1 hour Unresponsive and unreceptive coma with no response to noxious painful stimuli Reversible consitions mimicking irreversible coma (seizure, hypothermia, hypotension,effects of drug ingestion, etc) shall have been eliminated Patient is brought into the OR for withdrawal of life support An accurate and prompt diagnosis of cardiac death must be made (i.e. irreversible cessation of circulatory and respiratory functions) Greater than 5 minutes of asystole, and absence of ventiliatory efforts If diagnosis of cardiac death is confirmed, the procurement team will immediately begin the procedure Peripheral perfusion cannulae vs Open great vessel cannulation
Donation after Cardiac Death - Outcomes Donation after Cardiac Death Improving Outcomes
DCD in BC Transplantation Protocols and procedures are being drafted for implementation in BC 2 Lifeport pulsatile perfusion machines have been purchased for this purpose Estimated impact on donation rate: 5-10 extra donors / year Some programs have increased deceased donor rates up to 30% Conclusion The concept of ECD kidneys is well established in renal transplantation, and BC will continue to use them and are developing an old to old policy to attempt more appropriate matching of ECD kidneys to ECR (recipients) BC is developing the DCD program as a parallel strategy to increase the deceased donor pool