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• W2011799424 abstract "The decreasing rate of early acute cellular rejection has shifted transplant research priorities towards understanding and improving ways to decrease early “alloantigen independent” allograft dysfunction, antibody-mediated rejection, and chronic allograft nephropathy. The improved outcomes of live donor compared to well-matched deceased donor transplants (1) demonstrate the marked impact of brain death, preservation, and ischemia reperfusion injury. The Collaborative Transplant Group's work, reported by Opelz and Döhler in this issue of Transplantation, has focused on this important problem. Their report reflects a remarkable collaboration between 195 transplant centers on three continents, analyzing the outcome of 91,673 deceased donor transplants performed from 1990 to 2005. This study confirmed worse outcomes in deceased donor transplants, even with very short ischemia times, compared to live donors. Graft survival in deceased donor transplants remained stable for up to 18 hours of cold ischemia and worsened further with time, particularly after 36 hours. The authors concluded that short ischemia times did not eliminate the effect of human leukocyte antigen matching; donor kidneys of all ages were adversely affected by increasing ischemia times at the same rate; University of Wisconsin solution, but not pulsatile perfusion, improved graft survival. Despite the large number of patients and important questions, the study was limited by comparing outcomes over a broad period during rapid evolution of immunosuppression and other therapies. The absence of data on the rate of delayed graft function or need for dialysis early after transplant was a missed opportunity to factor in this important clinical variable (2). Delayed graft function increases length of hospital stay, complexity of early immunosuppression, risk of rejection, and worsens long-term outcomes (3, 4). The authors stated that ischemia up to 18 hours was not detrimental to graft outcome. This conclusion could be misleading, particularly given the evidence of the superior graft survival of live donor kidneys as well as other reports of worse outcomes with short increments in ischemia time (3, 5). Even 30 minutes of ischemia time injures the kidney and the delayed fibrotic changes can be missed by measuring creatinine alone (6). Because younger kidneys generally do better than older ones, ischemic times in an older kidney still need to be factored in when selecting the proper kidney for the individual recipient, preferably with guidance from histology (7). Some centers only use machine preservation for higher-risk kidneys; thus, comparing outcomes from this technique with simple cold preservation may not reflect preexisting risk. With increasing individualization of transplant care, it is noteworthy that less than 5% of studied recipients were of African descent, and genetic differences could alter response to kidney ischemia and fibrosis (8, 9). This study also demonstrates that kidney ischemia, particularly longer times, increases immunogenicity and predisposes to fibrosis, important links that are not completely understood. Wide-scale international research collaborations, like the one reported in this issue, can generate high-impact original data that will improve the lives of our patients." @default.
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• W2011799424 date "2007-02-01" @default.
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• W2011799424 title "Impact of Ischemia Times on Kidney Transplant Outcomes" @default.
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• W2011799424 doi "https://doi.org/10.1097/01.tp.0000251782.07786.3f" @default.
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