Kidney Transplantation ExpandedCriteria Donor 2010 KONOS annual report

Kidney Transplantation : Expanded-Criteria Donor 신장내과 이지연

2010 KONOS annual report

2012. 6 기준 2010 KONOS annual report

2012. 6 현재 2010 KONOS annual report

c. JASN 4; ; 1827 -1831, 2009 AJKD, 49(6) 744 -752, 2007

Classification of Deceased Donors Standard-Criteria Donor • 35 -yr-old man who has no history of hypertension or diabetes and for whom the cause of death is a motor vehicle accident • who do not meet any of the criteria for an ECD c. JASN 4; 1827 -1831, 2009

Classification of Deceased Donors Donation after Brain Death • whom cardiac circulation and respiration remain intact • maintained by medical measures, including mechanical ventilation, drugs, intra-aortic balloon pump, or extracorporeal machine oxygenation device c. JASN 4; 1827 -1831, 2009

Donation after Cardiac death • donor who does not meet the criteria for brain death but in whom cardiac standstill or cessation of cardiac function occurred before the organs were procured • non–heart-beating donor Controlled DCD • a donor whose life support will be withdrawn and whose family has given written consent for organ donation in the controlled environment of the operating room Uncontrolled DCD • a candidate who expires in the emergency room or elsewhere in the hospital before consent for organ donation is obtained and catheters are placed in the femoral vessels and peritoneum to cool organs until consent can be obtained c. JASN 4; 1827 -1831, 2009

Classification of Deceased Donors c. JASN 4; ; 1827 -1831, 2009 AJKD, 49(6) 744 -752, 2007

Graft survival ?

• • renal TAE 시행 후 4개월 뒤 이식 • • • Rt. renal a. 77 Cadeveric kidney transplants January 2003 to December 2009 ECD (N=28), SCD(N=49) Donor GFR< 60 m. L/min , HTN(Donor), Cause of brain death- CVA 공여자의 나이가 60세 이상 심정지 공여자 36 month GFR 저혈압이 3회 이상 혈청 크레아티닌 3 mg/d. L 이상 또는 크레아티닌 청소율이 60 m. L/min 이하 2회 이상의 소변검사에서 단백뇨가 (++) 이상 Korean J Med 2011; 80: 408 -418

• Rt. renal a. Korean J Med 2011; 80: 408 -418

• 77 Cadeveric kidney transplants • January 2003 to December 2009 • Transplant patients (n=52) with a kidney procured with ARF • Donor – Age (years) : 45. 7 ± 12. 7 e. GFR at harvest (ml/min) : 30. 4 ± 8. 3 Occurrence of heart arrest (%) : 50 • Time for diuresis to recover(days) : 2. 4 ± 2. 9 • Time for renal function to recover (days) : 7. 6 ± 7. 1

Renal function comparisons at Month 3 * * There were no significant differences between the two groups regarding age of recipient, gender of the donor or recipient, cold ischemia time, occurrence of cardiac arrest, collapse, acute rejection * P < 0. 05 NDT 25: 1980 -1986, 2010

• 77 Cadeveric kidney transplants • Primary deceased-donor KT • Group 1 : recipients age ≥ 60 yrs (n=189) ECD (n=96), SCD (n=93) • Group 2 : recipients age 40 -59 yrs (n=370) ECD (n=105), SCD (n=265) * ECD : UNOS (Cr>1. 5, HTN, CVA event) c. JASN 7; 2012

Five-year graft survival Group 1 (≥ 60 yrs) 92% 72% 69% 72% 59% 54% Group 2 SCD ECD ECD Group 2 88% 73% 56% 72% 59% 54% Group 1 (40 -59 yrs) 91% 83% 70% 88% 73% 56% ECD (death censored%)

Patient survival with ECD kidneys with DGF 5 -year patient survival Group 2 ECD (40 -59 yrs) SCD 1 -year patient survival ECD Group 1 (≥ 60 yrs) Group 2 Group 1 Group 2 ECD (death Group 1 censored%)

ECD- graft survival • • • Donor age Cause of death – CVA, CH HTN (Donor) GFR (Donor) Recipient age

Delayed graft function using ECDs > < > >

AKJD 52: 553 -586, 2008

ECD-Patient Manageament Nephron-protecting strategies • Minimization of cold ischemia time • Pulsatile perfusion preservation • Tailored immunosuppression with early CNI minimization or delayed moderate dose CNI addition after induction • Adequate infection prophylaxis AKJD 52: 553 -586, 2008

Pulsatile perfusion preservation NEJM 2009; 360: 7 -19

Patient Manageament : Immunosuppressive therapy Delayed introduction of CNI • Basiliximab(2 d) or daclizumab(2 d) or ATG + MMF, steroid + Cs. A or Tacrolimus (s. Cr <3 -4 mg) CNI free with MMF-based therapy • ATG(5 -6 d)+ MMF + steroid CNI-free with SRL-MMF-based therapy • ATG or basiliximab+ SRL+ MMF + steroids AKJD 52: 553 -586, 2008

Patient Manageament : Immunosuppressive therapy Delayed introduction of CNI • Basiliximab(2 d) or daclizumab(2 d) or ATG + MMF, steroid + Cs. A or Tacrolimus (s. Cr <3 -4 mg) CNI free with MMF-based therapy • ATG(5 -6 d)+ MMF + steroid CNI-free with SRL-MMF-based therapy • ATG or basiliximab+ SRL+ MMF + steroids AKJD 52: 553 -586, 2008

SCH-CASE DONOR RECIPIENT • 38/F • Cardiac arrest d/t suicide (hanging neck) • HTN, DM Hx (-) • CPR : 10 min • Brain death - #HAD 5 • Hypotension –ECMO, vasopressor • B/Cr – 44/2. 89 (e. GFR 19. 8) • RUA – protein trace • 52/M • 1 st transplantation • HTN(+), DM(-) DBD UNOS : ECD(-) KONOS: ECD(+)

SCH-CASE Treatment • Cold ischemia time : 720 min • Delayed graft function (+) : POD #1 dialysis • Delayed introduction of CNI ATG(3 d) + MMF, steroid + Tacrolimus (s. Cr: 7. 49)