Correspondence
Machine Perfusion or Cold Storage in Deceased-Donor Kidney Transplantation
N Engl J Med 2009; 360:1460-1461April 2, 2009
- Article
To the Editor:
Moers et al. (Jan. 1 issue)1 report on their trial of machine perfusion versus static storage of kidneys from deceased donors. The benefit of machine perfusion2 is probably that it ensures a uniform distribution of preservation fluid throughout the organ, which is better than a single flush.
Perhaps this benefit can be illustrated best by our experience with a series of 38 poorly preserved kidneys obtained at our center from 19 donors after cardiac death, all of whom had undergone femoral cannulation and were Maastricht category II or III donors.3 (Patients in Maastricht category III generally had a misplaced cannula.) In these donors, the kidneys were blue and poorly perfused at laparotomy, and these indicators did not improve with a single flush after recovery. On the basis of standard criteria, these organs were not suitable for transplantation; however, after machine perfusion, only four kidneys were not transplanted. The appearance and flow were improved by means of machine perfusion, and this method of preservation resulted in 10 dual and 14 single kidney transplantations.
Machine perfusion may improve the appearance and usability of kidneys that otherwise would not be transplanted.4
4 ReferencesChristopher Ray, M.B., Ch.B.
Soroush Sohrabi, M.D.
David Talbot, M.D., Ph.D.
Freeman Hospital, Newcastle upon Tyne NE7 7DN, United Kingdom
dr.chris. ray@gmail. com 1
Moers C ,Smits JM ,Maathuis M-HJ , et al. Machine perfusion or cold storage in deceased-donor kidney transplantation. N Engl J Med 2009;360:7-19
Full Text | Web of Science | Medline2
St Peter SD ,Imber CJ ,Friend PJ . Liver and kidney preservation by perfusion. Lancet 2002;359:604-613
CrossRef | Web of Science | Medline3
Balupuri S ,Buckley P ,Mohamad M , et al. Early results of a non-heartbeating-donor (NHBD) programme with machine perfusion. Transpl Int 2000;13:Suppl 1:S255-S258
CrossRef | Medline4
Matsuoka L ,Shah T ,Aswad S , et al. Pulsatile perfusion reduces the incidence of delayed graft function in expanded criteria donor kidney transplantation. Am J Transplant 2006;6:1473-1478
CrossRef | Web of Science | Medline
To the Editor:
In their editorial, Tullius and García-Cardeña1 describe solid-organ transplantation as beginning with renal isografts in the 1950s. However, corneal transplantation has a much longer history. Eduard Zirm successfully transplanted a full-thickness corneal allograft in 1905,2 and lamellar keratoplasty has an even longer history.3 Corneas are the most frequently transplanted tissues in the United Kingdom.4
4 ReferencesNathaniel Knox Cartwright, M.A.
Royal United Hospital, Bath BA1 2SS, United Kingdom
n.knoxcartwright@gmail. com 1
Tullius SG ,Garcia-Cardena G . Organ procurement and perfusion before transplantation. N Engl J Med 2009;360:78-80
Full Text | Web of Science | Medline2
Zirm E . Eine erfolgreiche totale Keratoplastik. Graefes Arch Clin Exp Ophthalmol 1906;64:580-5933
von Hippel A . Eine neue Methode der Hornhauttransplantation. Graefes Arch Ophthalmol 1888;34:108-130
CrossRef4
NHS Blood and Transplant. Transplant activity in the UK, 2007-2008. (Accessed March 13, 2009, at http://www.uktransplant.org.uk/ukt/statistics/transplant_activity_report/current_activity_reports/ukt/transplant_activity_uk_2007-2008.pdf.)
Author/Editor Response
Our international clinical study compared machine perfusion with cold storage of kidneys obtained from donors after brain death or from donors after cardiocirculatory death (in Maastricht category III). The organs studied in our trial are the most common deceased-donor kidneys. We very much agree with Ray and colleagues that machine perfusion is also likely to be useful for renal allografts obtained from donors after cardiocirculatory death who are in Maastricht categories I, II, or IV, because their organs have sustained more severe ischemic injury. The study by Ray et al. presents promising results. Our group has found that perfusion settings are critical for maintaining the viability of the vascular endothelium.1
Currently, in our prospective data set, we are investigating whether vascular resistance and various perfusate biomarkers during machine perfusion have independent predictive value for determining which kidneys have a high risk of complications or failure after transplantation. We speculate that with the use of such data, machine perfusion might become an additional diagnostic tool for selecting kidneys that are sufficiently viable for transplantation but that might otherwise have been discarded.2 In addition, normothermic machine perfusion and normothermic recirculation are interesting new techniques that may improve the viability of marginal donor kidneys.3-5
5 ReferencesCyril Moers, M.D.
Mark-Hugo J. Maathuis, M.D., Ph.D.
Rutger J. Ploeg, M.D., Ph.D.
University Medical Center Groningen, 9713 GZ Groningen, the Netherlands
c.moers@chir. umcg. nl 1
Maathuis MHJ ,Manekeller S ,van der Plaats A , et al. Improved kidney graft function after preservation using a novel hypothermic machine perfusion device. Ann Surg 2007;246:982-988
CrossRef | Web of Science | Medline2
Gok MA ,Pelzers M ,Glatz JF , et al. Do tissue damage biomarkers used to assess machine-perfused NHBD kidneys predict long-term renal function post-transplant? Clin Chim Acta 2003;338:33-43
CrossRef | Web of Science | Medline3
Moers C ,Leuvenink HGD ,Ploeg RJ . Non-heart beating organ donation: overview and future perspectives. Transpl Int 2007;20:567-575
CrossRef | Web of Science | Medline4
Maathuis MHJ ,Leuvenink HGD ,Ploeg RJ . Perspectives in organ preservation. Transplantation 2007;83:1289-1298
CrossRef | Web of Science | Medline5
Fondevila C ,Hessheimer AJ ,Ruiz A , et al. Liver transplant using donors after unexpected cardiac death: novel preservation protocol and acceptance criteria. Am J Transplant 2007;7:1849-1855
CrossRef | Web of Science | Medline
Author/Editor Response
We thank Cartwright for highlighting the importance of corneal transplants, both in the history of transplantation and in regard to the clinical significance of this procedure.
Since our editorial focuses on perfusion techniques in vascularized organ transplants, we do not address corneal transplantation. Nevertheless, it is important to mention that, as compared with other organs, corneas are less sensitive to prolonged ischemia. Indeed, an average preservation time of 11 days for corneas, as compared with preservation times of hours for other organs, has been reported.1 Corneas are usually preserved in medium under tissue-culture conditions at 37°C before transplantation. In contrast, cold preservation at 4°C is in general the preferred method for preserving organ transplants.
1 ReferencesStefan G. Tullius, M.D., Ph.D.
Guillermo García-Cardeña, Ph.D.
Harvard Medical School, Boston, MA 021151
Patel HY ,Brookes NH ,Moffatt L , et al. The New Zealand National Eye Bank study 1991-2003: a review of source and management of corneal tissue. Cornea 2005;24:576-582
CrossRef | Web of Science | Medline
