Snoeijs Maarten G J, Dekkers Angela J E, Buurman Wim A, van den Akker Luc, Welten Rob J T J, Schurink Geert Willem H, van Heurn L W Ernest
Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
Ann Surg. 2007 Nov;246(5):844-52. doi: 10.1097/SLA.0b013e318142cb1b.
To describe the results and complications of in situ preservation (ISP) of kidneys from donors after cardiac death (DCD).
DCD donors are increasingly being used to expand the pool of donor kidneys. ISP reduces warm ischemic injury which is associated with DCD donation.
Insertion of a double-balloon triple-lumen catheter allows selective perfusion of the abdominal aorta to preserve the kidneys in situ. From January 2001 until August 2005, 133 ISP procedures were initiated in our procurement area.
Fifty-six (42%) ISP procedures led to transplantation; in the remaining 77 cases (58%), the donation procedure was abandoned or both kidneys were discarded because of ISP complications (n = 31), poor graft quality (n = 23), no consent for donation (n = 13), medical contraindications (n = 8), or unknown cause (n = 2). Increasing donor age (odds ratio (OR) 1.06 per year, P < 0.001) and uncontrolled DCD donation (OR 5.4, P < 0.001) were independently correlated with ISP complications. After transplantation, prolonged double-balloon triple-lumen catheter insertion time was an independent predictor of graft failure (OR 2.0, P = 0.05). Selected controlled DCD donors were managed by rapid laparotomy and direct aortic cannulation; graft survival of these kidneys was superior to kidneys from controlled DCD donors managed by ISP.
A minority of initiated ISP procedures led to transplantation, resulting in a high workload compared with donation after brain death. The association between increasing catheter insertion time and inferior graft outcome emphasizes the need for fast and effective surgery. Therefore, rapid laparotomy with direct aortic cannulation is preferred over ISP in controlled DCD donation. Despite these limitations, we have expanded our donor pool 3- to 4-fold by procuring DCD kidneys that were preserved in situ.
描述心脏死亡后供体肾脏原位保存(ISP)的结果及并发症。
心脏死亡后供体越来越多地被用于扩大供肾来源。原位保存可减少与心脏死亡后供肾相关的热缺血损伤。
插入双球囊三腔导管可选择性灌注腹主动脉以原位保存肾脏。2001年1月至2005年8月,在我们的获取区域启动了133例原位保存程序。
56例(42%)原位保存程序成功进行了移植;其余77例(58%)中,捐赠程序因原位保存并发症(n = 31)、移植物质量差(n = 23)、未获得捐赠同意(n = 13)、医学禁忌证(n = 8)或原因不明(n = 2)而被放弃或双肾被丢弃。供体年龄增加(优势比(OR)每年1.06,P < 0.001)和非受控心脏死亡后供肾(OR 5.4,P < 0.001)与原位保存并发症独立相关。移植后,双球囊三腔导管插入时间延长是移植物失败的独立预测因素(OR 2.0,P = 0.05)。选定的受控心脏死亡后供体通过快速剖腹术和直接主动脉插管进行处理;这些肾脏的移植物存活率优于通过原位保存处理的受控心脏死亡后供体的肾脏。
少数启动的原位保存程序成功进行了移植,与脑死亡后捐赠相比工作量较大。导管插入时间增加与移植物结果较差之间的关联强调了快速有效手术的必要性。因此,在受控心脏死亡后供肾中,快速剖腹术和直接主动脉插管优于原位保存。尽管有这些局限性,但通过获取原位保存的心脏死亡后供肾,我们已将供体库扩大了3至4倍。