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      Posttransplant Outcomes of Kidneys Donated After Brain Death Followed by Circulatory Death: A Cohort Study of 128 Chinese Patients

      research-article
      , PhD, MD 1 , , PhD, MD 2 , , PhD, MD 3 , , MD 4 , , MD 5 , , MD 6 , , PhD, MD 7 , , PhD, MD 8
      Transplantation Direct
      Lippincott Williams & Wilkins

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          Abstract

          Background

          Donation after brain death followed by circulatory death (DBCD) is a new class in the unique Chinese donor classification system. Currently, in China, the organ transplantation of DBCD is rising. However, there is a dearth of research on the characteristics and outcomes of DBCD kidney transplantation.

          Method

          We collected 128 DBCD renal transplant patients who underwent surgery between June 2013 and May 2016 at our center to analyze clinical outcomes and to share our experience to enhance perioperative management in DBCD kidney transplantation.

          Results

          At the end of follow-up, no patients experienced primary nonfunction, but delayed graft function occurred in 25.8%. One- and 3-year graft survivals were 97.7% and 94.5%, respectively. The average length of stay was 20.88 ± 14.6 days, the incidence of posttransplant complications was 46.1% (59 patients), and 31 patients suffered more than 1 complication. In addition, the average length of stay of patients without complications and with at least 1 complication was 13.07 ± 2.01 days and 30.02 ± 17.4 days, respectively. There was a significantly higher incidence of complications associated with the postoperative hospital stay in DBCD patients.

          Conclusions

          Patients who received a DBCD kidney demonstrated a good outcome in terms of both graft survival and graft function. Hence, DBCD is suitable for national reality and conditions and offers a feasible option for deceased-donor kidney transplantation in China. To prevent complications and reduce the duration of hospital stay, we should strengthen preoperative and postoperative management.

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          Most cited references20

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          Deceased-donor characteristics and the survival benefit of kidney transplantation.

          Transplantation using kidneys from deceased donors who meet the expanded criteria donor (ECD) definition (age > or =60 years or 50 to 59 years with at least 2 of the following: history of hypertension, serum creatinine level >1.5 mg/dL [132.6 micromol/L], and cerebrovascular cause of death) is associated with 70% higher risk of graft failure compared with non-ECD transplants. However, if ECD transplants offer improved overall patient survival, inferior graft outcome may represent an acceptable trade-off. To compare mortality after ECD kidney transplantation vs that in a combined standard-therapy group of non-ECD recipients and those still receiving dialysis. Retrospective cohort study using data from a US national registry of mortality and graft outcomes among kidney transplant candidates and recipients. The cohort included 109,127 patients receiving dialysis and added to the kidney waiting list between January 1, 1995, and December 31, 2002, and followed up through July 31, 2004. Long-term (3-year) relative risk of mortality for ECD kidney recipients vs those receiving standard therapy, estimated using time-dependent Cox regression models. By end of follow-up, 7790 ECD kidney transplants were performed. Because of excess ECD recipient mortality in the perioperative period, cumulative survival did not equal that of standard-therapy patients until 3.5 years posttransplantation. Long-term relative mortality risk was 17% lower for ECD recipients (relative risk, 0.83; 95% confidence interval, 0.77-0.90; P 1350 days), ECD recipients had a 27% lower risk of death (relative risk, 0.73; 95% confidence interval, 0.64-0.83; P<.001). In areas with shorter waiting times, only recipients with diabetes demonstrated an ECD survival benefit. ECD kidney transplants should be offered principally to candidates older than 40 years in OPOs with long waiting times. In OPOs with shorter waiting times, in which non-ECD kidney transplant availability is higher, candidates should be counseled that ECD survival benefit is observed only for patients with diabetes.
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            Differences in quality of life across renal replacement therapies: a meta-analytic comparison.

            A meta-analysis compared emotional distress and psychological well-being across renal replacement therapies (RRTs) and examined whether differences could be explained by: (1) treatment modalities, (2) case mix, or (3) methodologic rigor. Standard meta-analytic procedures were used to evaluate published comparative studies. Successful renal transplantation was associated with: (1) lower distress (effect size, d = -0.43 SD) and greater well-being (d = 0. 62 SD) than in-center hemodialysis (CHD) and (2) lower distress (d = -0.29 SD) and greater well-being (d = 0.53 SD) than continuous ambulatory peritoneal dialysis (CAPD). CAPD was characterized by greater well-being (d = 0.18 SD) than CHD and CHD was associated with greater distress (d = 0.16 SD) than home hemodialysis. Although methodologic rigor and case-mix differences did not correlate with the magnitude of psychosocial differences across RRTs, 10 of the 12 comparisons (83%) were threatened by publication bias (ie, that nonsignificant comparisons may have been underrepresented in the published literature). Thus, although significant quality-of-life differences were evident across treatment groups, the types of patients representative of the various RRTs also differed significantly in terms of case-mix variables relevant to psychosocial well-being and emotional distress. Published findings indicating differential quality of life across RRTs may thus be attributable to: (1) valid differences in effective renal replacement, reduced medical complications, and lifestyles afforded by these treatment modalities; (2) case-mix differences in the patient samples selected to represent them in research comparisons; or (3) both of these alternative explanations.
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              Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation.

              Although donation after cardiac death (DCD) kidneys have a high incidence of delayed graft function (DGF) and have been considered marginal, no tool for stratifying risk of graft loss nor a specific policy governing their allocation exist. We compared outcomes of 2562 DCD, 62,800 standard criteria donor (SCD) and 12,812 expanded criteria donor (ECD) transplants reported between 1993 and 2005, and evaluated factors associated with risk of graft loss and DGF in DCD kidneys. Donor age was the only criterion used in the definition of ECD kidneys that independently predicted graft loss among DCD kidneys. Kidneys from DCD donors <50 had similar long-term graft survival to those from SCD (RR 1.1, p = NS). While DGF was higher among DCD compared to SCD and ECD, limiting cold ischemia (CIT) to <12 h decreased the rate of DGF 15% among DCD <50 kidneys. These findings suggest that DCD <50 kidneys function like SCD kidneys and should not be viewed as marginal or ECD, and further, limiting CIT <12 h markedly reduces DGF.
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                Author and article information

                Journal
                Transplant Direct
                Transplant Direct
                TXD
                Transplantation Direct
                Lippincott Williams & Wilkins
                2373-8731
                August 2017
                05 July 2017
                : 3
                : 8
                Affiliations
                [1] 1 Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-Sen University.
                [2] 2 Department of Urology, The Third Affiliated Hospital of Sun Yat-Sen University.
                [3] 3 Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-Sen University.
                [4] 4 Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-Sen University.
                [5] 5 Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University.
                [6] 6 Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-Sen University.
                [7] 7 Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University.
                [8] 8 Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University.
                Author notes
                Correspondence: Jianguang Qiu, PhD, MD, Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University. Tianhe Road 600, Guangzhou, Guangdong Province, 510630, China. ( qjg_zssy@ 123456126.com ); Dejuan Wang, PhD, MD, Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University. Tianhe Road 600, Guangzhou, Guangdong Province, 510630, China. ( wdj_sysu@ 123456126.com ).
                Article
                TXD50182 00004
                10.1097/TXD.0000000000000704
                5540627
                2db6129e-d705-442d-9521-08fcff72c339
                Copyright © 2017 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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                Kidney Transplantation
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