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AN ANALYSIS OF CADAVER DONOR AND KIDNEY BIOPSY PARAMETERS WITH CORRELATION TO TRANSPLANT OUTCOMES PowerPoint Presentation
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ARE WE DISCARDING KIDNEYS APPROPRIATELY ?. AN ANALYSIS OF CADAVER DONOR AND KIDNEY BIOPSY PARAMETERS WITH CORRELATION TO TRANSPLANT OUTCOMES Martin Mozes MD, Mel Schwartz MD, Janis Orlowski MD Michael Harmon BSN, Ronald Skolek BSN Regional Organ Bank of Illinois and Rush Presbyterian

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slide1

ARE WE DISCARDING KIDNEYS APPROPRIATELY ?

AN ANALYSIS OF CADAVER DONOR AND KIDNEY BIOPSY PARAMETERS WITH CORRELATION TO TRANSPLANT OUTCOMES

Martin Mozes MD, Mel Schwartz MD, Janis Orlowski MD

Michael Harmon BSN, Ronald Skolek BSN

Regional Organ Bank of Illinois and Rush Presbyterian

-St. Lukes Medical center, Chicago IL.

background
Background
  • Proportion of kidneys from cadaveric donors over age 50 (“marginal donors”) has >doubled over 10 years to 30% of total.
  • The kidney discard rate from “marginal” donors is >32%, double that of overall discard rates.
  • Transplant outcomes with these kidneys is acceptable.
  • There is a need to define factors leading to discard
  • There is a need to validate the correctness of the decision to discard “marginal” kidneys.
slide4

CADAVER DONOR AGE

Age

1990-1991

1998-1999

% Increase

Age

1990-1991

1998-1999

Increase

(%)

(%)

(%)

(%)

> 65

210 (2.4)

1,019 (8.8)

385%

> 65

210 (2.4)

1,019 (8.8)

X 4.8

50-64

1,294 (14.3)

2,468 (21.2)

91%

50-64

1,294 (14.3)

2,468 (21.2)

X 1.9

11-49

6,535 (72.3)

7,234 (62.1)

10.7%

11-49

6,535 (72.3)

7,234 (62.1)

X 1.1

< 10

996 (11.0)

924 (7.9)

7.2%

< 10

996 (11.0)

924 (7.9)

X 0.9

Total

9,035 (100%)

11,645 (100%)

29%

Total

9,035 (100%)

11,645 (100%)

29%

UNOS 2000 Annual Report

UNOS 2000 Annual Report

discard rates after recovery of cadaveric kidneys
Discard Rates after Recovery of Cadaveric Kidneys

* Data through November 30,2000

SRTR

donor traits associated with kidney graft failure
Donor Traits Associated with Kidney Graft Failure*

Hazard Ratio

Hypertensive, Normal Creatinine

Non-Hypertensive, High Creatinine

Hypertensive, High Creatinine

Non-Hypertensive, Normal Creatinine

Donor Age (years)

SRTR

* Deaths not due to graft failure were censored

survival benefit from marginal kidneys
Survival Benefit from Marginal Kidneys

Relative Risk (RR) of Death

Days since transplantation (Equal time from wait-listing)

SRTR

slide8

PURPOSE of THE STUDY

*To determine the ROBI kidney discard rates in Marginal Donors.

*To determine donor and kidney biopsy factors associated with discard

*To design a predictive score for kidney discard.

*To validate the decision to discard.

slide9

Methods

  • Data reviewed of all ROBI cadaver donors with kidney biopsy at ROBI during 1996-1999.
  • Kidney biopsy findings (Wedge-frozen and permanent) reviewed, graded and coded.
  • Kidney recipients identified-with F/U 6M-5 years.
  • Uni and multivariate analyses performed.
slide11

DISCARD RATES OF BIOPSIED KIDNEYS

539 DONORS (D) – 957 KIDNEYS (K)

DISCARDS - 332 K (34%)

BILATERAL BIOPSIES

418 D– 836 K

DISCARDS – 305 K (36%)

UNILATERAL BIOPSIES

121 D – 121K

DISCARDS – 27 K (22%)

DONORS WITH BIOPSY RELATED DISCARDS

361 D – 772 K

DISCARDS: BILAT - 91 D

UNILAT- 43 D

NONE - 227 D

ALL DISCARDS: 225 K (31%)

donor parameters bilateral biopsies n 361
Donor Parameters-Bilateral Biopsies (N=361)*

AGE: 51.0 + 15.6 ( Range 3-82)

GENDER: Male- 177(49%) Female- 184 (51%)

RACE: C- 233(64.5%), AA- 96(26.6%), H-24(6.6%)

O- 8 (2.2%)

HTN: 175(48%) TREAT. HTN:136(38%)

>5 yrs. 85(49%) < 5 yrs.- 68 (39%) dur. unknown - 22(12%)

DM: 31(8.8%) (IDDM -12, NIDDM -19)

P.V.D.: 14 (4%)

C.V.D: 24 (6.6%) *Biopsy related discards

slide13

DONOR PARAMETERS II (BILATERAL BIOPSIES*)

S. CREAT.: ADMIT 1.1 + .4 FINAL: 1.4+ 0.7

GFR** : ADMIT 89.6 + 46.9 FINAL 76.2 + 53.3

PROTEINURIA: 0 -TRACE:60%; 1+:16%; 2+:14%; 3+:8%; 4+:0.6%

DIC: 19 (5.3%)

INTRA-OP FINDINGS:

AORTIC PLAQUE: None-17%; Mild-40%; Mod.-19%;Severe-16%

RENAL A. PLAQUE:None-44%; Mild-27%; Mod.-12%; Sev-11%

CYSTS: None 80%; 1-2: 16%; >2: 17%

** Cockroft-Gault estimation *Biopsy related discards

grading of biopsy findings
Grading of Biopsy Findings

1. Glomerulosclerosis = % sclerotic glomeruli

2. *Atrophic cortical tubules

3. *Cortical Interstitial Fibrosis

4. *Arterial Lumen occluded by sub-intimal fibrosis

5. *Arterial Lumen occluded by sub-intimal hyalinosis

*Semi-quantitated in quartiles and graded 1+ to 4+

slide15

FROZEN VS. PERMANENT SECTION READINGS

COMPARISON USING @804 BIOPSIES

Median (25th, 75th percentiles )

Frozen Permanent

# GLOMERULI 35 (24, 51) 43 (27, 63)

# SCLEROTIC GLOMERULI 1 (0, 5) 3 (0,8)

% ATROPHIC CORT.TUBULES 1 (0, 1) 1 (0,1)

% INTERSTITIAL FIBROSIS 1 (0,1) 1 (0,1)

% ARTERIAL LUMEN OCCLUSION

SUBINTIMAL FIBROSIS 0 (0,1) 0 (0,1)

HYALINOSIS 0 (0,1) 0 (0,1)

coding key :

0 = none, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, 4=76=100%

slide16

Donor Factors as Predictors of Kidney Discard

Univariate Analysis for “all or some” kidneys transplanted

Significant p<.05 Not Significant

Age Height Race Weight

Hx. HTN Donor Date Hx.Rx.HTN Lupus

Hx HTN> 5 years SCD

Hx DM Proteinuria

Duration DM DIC

CVD GFR (admit to final)

Creat. Final

GFR Admit

GFR Final

slide17

Predictive Model For 2/2 KIDNEY USE (227/361)

Age Points

Under 40 1.5

40-49 1.5

50-59 1.3

60 + 0.0

Race

Caucasian 0.0

AA -1.1

Hispanic 0.2

Other -1.8

GFR final < 50 0.0

GFR final > 50 1.4

Hx. DM 0.0

No Hx HTN 1.6

O-Tr Prot 0.6

O-Mild A.Plaque. 0.7

AUC = 0.831

4.2 pts=80% use and 5.6 pts>90% use

slide18

Predictive Model For 2/2 KIDNEY DISCARD (91/361)

VariablePoints

Age

Under 40 0.0

40-49 1.6

50-59 1.6

60 + 2.4

Race

Caucasian 0.0

AA 1.1

Hispanic -0.8

Other 1.0

GFR final < 50 1.6

GFR final > 50 0.0 Hx DM 1.1

Hx Rx HTN 1.2

>4.2 Points.=>80% bilateral discard

slide19

Prediction models with Donor and Biopsy Parameters

ODDS RATIOS.

HxRxHTN .39

Creat.Final .53

Age .96

% GlomScl 3+ .12

Art. Hyalinosis 4+ .07

.35

.51

.96

.08

.05

graft survival for paired to discard kidneys
Graft Survival for ”Paired to Discard” Kidneys

Recipient Characteristics

(N=25*)

Gender: M-18 F-7

Age: 53+ 9.8 (34-67)

DM: Yes-10 No-14

Race: C-13 AA-7

H-4 O-1

CIT: 27+8 hrs. MP- 9

S. Creat at 6 M - 1.7+.4

*25/43 with complete data

slide23

summary

  • The KidneyDiscard rates in Marginal Donors is>30%
  • Donor factors predictive of discard are age, race, GFR (admit and final),HTN and DM.
  • Predictive Biopsy factors are: % Glomerulosclerosis and degree of Arteriolar hyalinosis.
  • A highly accurate predictive score for kidney discard can be developed based on above factors.
  • Kidneys paired to discarded kidneys result in acceptable outcomes when transplanted.
slide24

CONCLUSIONS

  • Current transplant practices result in a high discard rate of “marginal donor” kidneys.
  • Transplantation of kidneys similar to those currently being discarded results in acceptable outcomes.
  • More wide spread application of innovative approaches will result in successful transplantation of many more patient:
    • Two-for-one transplants.
    • Alternate recipient lists for marginal kidneys.
    • Accelerated placement protocols for marginal donors.