A pair analysis of the delayed graft function in kidney recipient: The critical role of the donor

Abstract

Purpose

The aim of this study was to analyze the importance of donor factors and especially the potential role of hemodynamic management in regard to delayed graft function in paired kidney recipient patients after renal transplantation and to analyze the urine of organ donors by proton-nuclear magnetic resonance spectroscopy to identify urine markers potentially correlated with delayed graft function in recipient patients.

Methods

A prospective multicenter epidemiologic study was conducted. A logistic regression model taking into account paired data was used.

Results

Data from 72 donors and the 144 corresponding paired recipients were analyzed. Univariate analysis showed that age of donor, previous history of tobacco, ischemic cause of brain death, norepinephrine infusion, and recipient age were the risk factors for delayed graft function. After adjusting for correlated outcome data and controlling for other potential prognostic factors, 3 variables remained significantly associated with outcome: donor age (odds ratio [OR], 10.7), hemodynamic status (OR, 0.167), and hydroxyl-ethyl starch infusion (OR, 0.135). Proton-nuclear magnetic resonance analysis evidenced 3 metabolites of interest in donors (trimethylamine-N-oxide, citrate, and lactate). However, these peaks were not correlated the clinical parameters in donors.

Conclusions

Paired analysis of kidney transplantation emphasizes the important role of factor donor associated with delayed graft function in recipient. Thus, a particular attention should be paid to the hemodynamic management of donor.

Introduction

Delayed graft function (DGF) after renal transplantation has been shown to have a significant influence on the clinical outcome after 5 years [1]. Factors associated with DGF are related to the donor, the preservation of organs, and the recipient [2]. The importance of risk factors linked to donors has been emphasized by studies reporting similar performances of paired kidneys issued from the same donor, both on short- and long-term graft function [3], [4] However, in these studies, only few donor-related factors could be identified as risk factor for DGF in recipient patients [4]. Conversely, a recent study showed that the 2 kidneys from a same donor should be considered independently regarding the DGF risk factor [5]. The evaluation of the quality of the kidneys in organ donor is based on the analysis of hemodynamic condition, plasma creatinine levels, and diuresis. The management goals regarding the hemodynamic status of the donor are to achieve normovolemia, maintain blood pressure, and optimize cardiac output with the use of the least amount of vasoactive-drug support [6]. In intensive care unit (ICU) patients, experimental and clinical data strongly suggest that vasopressor therapy is safe and probably beneficial from a renal point of view [7]. The importance of catecholamine therapy of the organ donor for the occurrence of DGF is controversial. Some authors came to the conclusion that catecholamine therapy of the donor increased the risk of DGF [8], [9]. Others showed opposite results emphasizing the importance of maintaining an efficient renal perfusion pressure with norepinephrine [10].

During acute renal failure, plasma creatinine level underestimates the level of alteration of glomerular filtration due to a potential dramatic increase of tubular creatinine secretion [11]. Inulin clearance determination, considered as the reference method, cannot be used routinely. Thus, the determination of new markers allowing a more precise assessment of the renal quality in organ donors would be of interest. Proton-nuclear magnetic resonance (1H-NMR) spectroscopy enables biologic screening with a minimal sample preparation and determines the presence of osmolites such as trimethylamine-N-oxide (TMAO) and other methylamine derivatives that have been detected in the urine after medullar ischemia [12]. However, 1H-NMR spectroscopy has not been used to assess the potential quality of organs in organ donor patients.

Thus, in this study, we sought to analyze the importance of donor factors and especially the potential role of hemodynamic management in regard to DGF amelioration in paired kidney recipient patients. Furthermore, we analyzed the urine 1H-NMR spectroscopy of organ donors to identify potential urine markers, which could be correlated to the poor quality of renal graft and predict DGF in recipient.