H- 09 : clinic
H- 09 : Immunology
Kidney donation after circulatory death (DCD): state of the art
Dominic M Summers1,2, Christopher J E Watson1, Gavin J Pettigrew1, Rachel J Johnson2, David
Collett2, James M Neuberger2 and J Andrew Bradley1,3
1Department of Surgery, School of Clinical Medicine, University of Cambridge, Cambridge, UK
2Organ Donation and Transplantation, NHS Blood and Transplant, Bristol, UK
3NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
Correspondence: J. Andrew Bradley, Department of Surgery, University of Cambridge, Box 202,
Addenbrooke's Hospital, Hill's Road, Cambridge CB2 0QQ, UK. E-mail: JAB52@cam.ac.uk
Journal : Kidney International
Year : 2015 / Month : August
Volume : 88
Pages : 241–249
doi:10.1038/ki.2015.88
ABSTRACT
The use of kidneys from controlled donation after circulatory death (DCD) donors has the potential
to markedly increase kidney transplants performed. However, this potential is not being realized
because of concerns that DCD kidneys are inferior to those from donation after brain-death (DBD)
donors. The United Kingdom has developed a large and successful controlled DCD kidney
transplant program that has allowed for a substantial increase in kidney transplant numbers. Here
we describe recent trends in DCD kidney donor activity in the United Kingdom, outline aspects of the
donation process, and describe donor selection and allocation of DCD kidneys. Previous UK
Transplant Registry analyses have shown that while DCD kidneys are more susceptible to cold
ischemic injury and have a higher incidence of delayed graft function, short- and medium-term
transplant outcomes are similar in recipients of kidneys from DCD and DBD donors. We present an
updated, extended UK registry analysis showing that longer-term transplant outcomes in DCD donor
kidneys are also similar to those for DBD donor kidneys, and that transplant outcomes for kidneys
from expanded-criteria DCD donors are no less favorable than for expanded-criteria DBD donors.
Accordingly, the selection criteria for use of kidneys from DCD donors should be the same as those
used for DBD donors. The UK experience suggests that wider international development of DCD
kidney transplantation programs will help address the global shortage of deceased donor kidneys for
transplantation.
Keywords : DCD; donation after circulatory death; kidney transplantation; organ donation
COMMENTS
Kidney transplantation is the optimal treatment for selected patients with end-stage kidney failure,
but the severe shortage of deceased donor kidneys for transplantation means that patients often
have a long and uncertain wait for transplantation.
Here the authors analyze the present status of deceased donors transplantation in the United
Kingdom. Many countries, however, have no or only very few DCD donors and would benefit from
this important source of deceased donor kidneys.
DCD kidney transplantation is not without controversy. In countries that have DCD donor kidney
transplant programs, there is sometimes reluctance to accept DCD kidneys for transplantation
because of continuing concern that transplant outcomes are poorer than for DBD donor kidneys.
Moreover, many clinicians are uncertain about the selection criteria for kidneys from DCD donors,
particularly when the donors are old or have multiple comorbidities and when kidney ischemia times
are prolonged.
The most striking difference in outcome between DCD and DBD donor kidneys is in the incidence of
delayed graft function (DGF)—most commonly defined as the need for dialysis in the first 7 days
post transplant. Because of the warm ischemic injury associated with controlled DCD donation,
recipients of such kidneys have twice the risk of developing DGF compared with recipients of
kidneys from DBD donors.
The authors provide an extended and updated UK Transplant Registry analysis that allows more
definitive conclusions to be drawn about long-term transplant outcomes and represents the largest
published series of expanded-criteria DCD donors.
DCD kidneys have a high incidence of DGF, and long CIT is more detrimental than for DBD kidneys.
However, there is now good medium- and longer-term outcome data from the United Kingdom
showing that transplant outcomes are similar to those seen in recipients of kidneys from DBD
donors. Importantly, renal function at 5 years and graft survival at 10 years following transplantation
are similar for recipients of DCD and DBD kidneys. Contrary to the expectation of many clinicians,
the transplant outcome for kidneys from older and Expanded Criteria Donor (ECD), DCD donors is
no less favorable than for older or ECD DBD donors.
The decision regarding selection of kidneys from old donors and donors with major cardiovascular
disease and other comorbidities for transplantation remains challenging for both DCD and DBD
kidneys, but may be aided by the routine use of preimplantation biopsy to grade chronic kidney
injury. The available evidence suggests that the criteria on which to base selection of kidneys from
deceased donors should be similar for DCD and DBD kidneys.
Pr. Jacques CHANARD
Professor of Nephrology