Horizon Scanning on organ perfusion

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Horizon Scanning on organ perfusion

• Kidneys
• David Talbot

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• Maastricht II and Maastricht III
• Cold machine perfusion its future
• Non used kidneys

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Summary of NHBD Kidney Programme 1998- 13th
November 2006
NHBD 105 Donors ( 210 kidneys) 138 Renal Transplants 72 Non used Kidneys II III IV 100 96 14 43 77 14 57 15 0 II III IV 100 96 14 43 77 14 57 15 0
NHBD Dual donors Recipients of dual kidneys 13 4 0 13 4 0 13 4 0 13 4 0
Primary WIT ( minutes) 22.2 1.0 22.2 1.0
Secondary WIT (minutes) 37.7 1.0 37.7 1.0
CIT (minutes) 1486 34.8 1486 34.8
Survival rates () First Year Third Year
KIDNEY PATIENT 88.4 91.4 84.7 88.7
Transplant Rate ----- Cat II 45.1 Cat
III 82.1 Cat IV -100 Overall
Transplants of NHBD 62.8
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Maastricht II/III distribution in Newcastle
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Active MII programmes

• France
• Netherlands
• Spain 2 centres

All centres that utilise uncontrolled DCD use
cold machine perfusion as a viability test.
Poor flow indicates non use. St Petersburg did
use cold machine perfusion for this but now uses
in situ normothermia
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French DCD programme

• Change in legislation 2007 allowing cannulation
  after pronouncement of death without consent
• MIII not being allowed
• Commenced multiple sites cold perfusion
• One Paris site with an ECMO programme for cardiac
  arrest continued with a normothermic approach.
• Successful liver transplants from this source
  also- 11 (3 centres)
• Data from Benoit Barrou

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French experience abbreviated from Benoit Barrou

• 670 potential donors
• 321 donors realised
• 390 kidneys transplanted
• 245 kidneys not used
• Commenced 2007 virtually all cold perfusion
• 2012 only 20 cold perfusion the rest warm
• 43 transplants 2007 81 in 2012, improvement
  mainly due to more donors rather than warm
  perfusion
• Best graft outcome seen in 2009 when lt10 warm
  perfusion

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Summary from France

• 48 conversion rate from potential MII donors
• 61 of these kidneys utilised (29 of total)
• Steady increase in proportion of donors managed
  by normothermia
• Best outcome of grafts in 2007-9 when lt8
  normothermia
• Utilisation rate hasnt changed enormously for
  kidneys with addition of normothermia (11 Livers
  so far from 3 units, 2 PNF)

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Cold machine perfusion for MIII DCD
Improved DGF with machine perfusion Improved
graft outcome
DCD and DBD pairs Perfusate different for static
storage
Cyril Moers, Jacqueline M Smits, Mark-Hugo J
Maathuis, Jurgen Treckmann, et al. The New
England Journal of Medicine. Boston Jan 1, 2009.
Vol. 360, Iss. 1 pg. 7
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Cold Machine Perfusion Versus Static Cold Storage
of Kidneys Donated After Cardiac Death A UK
Multicenter Randomized Controlled Trial. Watson
CJ et al. Am J Transplant 2010 Sep Vol. 10
(9), pp. 1991-9.
DCD paired kidneys Solutions matched Duration of
machine perfusion sometimes short No difference
in outcome
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Son of PPART

• Close to 100 kidneys recruited
• Machine perfused from donor hospital
• Therefore close to first analysis
• But intention to treat doesnt necessarily
  indicate machine perfused

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Long term outcome of Newcastle data (MIII)
according to perfusion characteristics at 3 hours
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Age and perfusion flow index of MIII kidneys-
Newcastle data
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Donor hypertension and machine perfusion
characteristics
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Postulation

• Hypertensive donors and elderly donors have a
  higher resistance to flow of cold perfusate
  through the kidney- (expanded criteria)
• Therefore quality of perfusion if perfused
  statically is likely to be poorer for expanded
  criteria donors than standard
• Cold machine perfusion improves the quality of
  perfusion over static for expanded criteria
  donors

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Machine perfusion attenuates the impact of DGF on
GS
The Machine Preservation Trial

MP no DGF (94)
CS no DGF (92)
MP DGF (77)
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CS DGF (62)

• Moers C et al. N Eng J Med 20123667701.

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Overall graft survival in ECD kidneys at 3 years
The Machine Preservation Trial
HR for graft failure 0.38, p0.01
MP (86)
CS (76)
Moers C et al. N Engl J Med 20123667701.
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As a consequence Machine perfusion in Europe in
2012
DCD SCD ECD
BeNeLux 79 0 9
France 90 0 276
Germany 0 0 30
Italy 0 0 112
Poland 0 136 112
Scandinavia 0 0 138
Spain 40 0 123

• Data from Organ Recovery

• France, Spain and Eire recommend machine
  perfusing of all ECD kidneys.

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Future for cold machine perfusion?

• MII all kidneys should be machine perfused
• MIII SCD with rapid demise and prompt cannulation
  probably no difference between machine or static
• DBD/DCD ECD all should have machine perfusion
• MIII SCD protracted demise, difficult
  cannulation, blue kidneys should be handled as
  ECD ie machine perfusion

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Kidneys that no one wants
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1st April 2012 - 31st March 2013 Kidneys
DBD Organs offered for donation 1403 Organs not
retrieved 112 Organs retrieved but not
transplanted 95 (donor unsuitable 36, organ
unsuitable, clinical 20, poor function 2, other
37)
DCD Organs offered for donation 1012 Organs not
retrieved 38 Organs retrieved but not
transplanted 177 (donor unsuitable medical 63,
donor age 1, organ unsuitable- clinical 56, poor
function 4, other 53)
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(No Transcript)
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Proposal

• Kidneys from donors with previously normal
  function- (can be currently abnormal)
• Declined for transplant
• Accepted for testing by may be 3 or 4 national
  units

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Testing the declined kidney
Kidney arrives
NHS BT runs a veteran matching run for
suitable recipients
Biopsy for Rumuzzi score
Kidney prepared and placed on cold machine
perfusion
Poor score- discard
Good score
Good flows
Poor flows- discard
Recipient identified, nephrologist contacted
Accept
Decline
2 hours warm perfusion to re-charge or O2
persufflation or O2 into machine perfusion
Returned to cold machine perfusion for transfer
to recipient centre
Transplant
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Summary- 1

• MII donor programmes difficult due to declining
  sudden death of young people
• Expanding MII programmes would have to accept
  older donors
• Normothermia has some potential here as allows
  more time and possibly kinder to kidneys from
  older donors but expensive and return for funding
  has to be considered- legislation change for
  England
• Cold machine perfusion mandatory for all kidneys
  from MII

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Summary- 2

• Cold machine perfusion is almost certainly better
  than static storage for expanded criteria donors
  whether DBD or DCD
• Kidneys from standard criteria MIII DCDs are
  likely to have similar outcome whether or not MPS
  is used
• If the primary warm ischaemic time is protracted
  for standard criteria MIII (blue kidneys) MPS is
  likely to be superior

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Summary- 3

• 207 kidneys from DBD and 215 kidneys from DCD
  were not used in 2012/13 in the UK
• This potentially could be addressed by a
  restricted number of test stations offering
  biopsy/ cold flow characteristics/ some sort of
  re- animation which could be cold as well as warm
  with kidneys offered to veterans