In Brief | Critical Care, Anaesthetics & Emergeny Medicine | Transplant Surgery
Expanding kidney donor pools: 'Africa First' study highlights the promise of controlled donation after circulatory death
Time to read: 03:22
Time to listen: 05:29
Published on MedED: 18 November 2024
Originally Published: 24 March 2024
Sourced: The South African Medical Journal
Type of article: In Brief
MedED Catalogue Reference: MOIB0014
Category: Critical Care, Anaesthetics & Emergency Medicine
Cross Reference: Transplant Surgery
Keywords: Chronic Kidney Disease, organ donation, living organ donor, circulatory organ donor
Originally Published: 24 March 2024
Sourced: The South African Medical Journal
Type of article: In Brief
MedED Catalogue Reference: MOIB0014
Category: Critical Care, Anaesthetics & Emergency Medicine
Cross Reference: Transplant Surgery
Keywords: Chronic Kidney Disease, organ donation, living organ donor, circulatory organ donor
Key Takeaway
Top
Controlled donation after circulatory death (DCD) offers a promising solution to address the growing kidney transplant demand in South Africa, with long-term outcomes comparable to international standards, despite the challenges involved.
Originally published in The South African Medical Journal, 24 March 2024. This summary does not represent the original research, nor is it intended to replace the original research. Access the full Disclaimer Information
In South Africa, approximately 3,500 patients with end-stage kidney disease (ESKD) are on the waiting list, but the country has one of the lowest deceased organ donor rates in the world (1.6 donors per million population). Despite the implementation of living-donor kidney transplant programs, the demand for organs continues to outpace the supply. Expanding the deceased donor pool and improving organ utilisation are essential strategies to address this gap.
One approach which is utilised with success internationally is the use of controlled donation after circulatory death (DCD), as compared to donors obtained after brain death (DBDs).
While early data from countries like the UK and USA indicated higher rates of primary non-function (PNF) and delayed graft function (DGF) for DCD kidney transplants compared to brain-dead donors (DBDs), long-term outcomes have been found to be comparable. Indeed, DCD transplants have been shown to offer significant survival benefits over continued dialysis.
Editors Note
The expanded criteria donor (ECD) is any donor over the age of 60, or a donor over the age of 50 who meets two of the following criteria: a history of high blood pressure, a creatinine (blood test that shows kidney function) greater than or equal to 1.5, or death resulting from a stroke.
Despite the success shown internationally, South Africa has not widely adopted DCD kidney transplant programs.
This observational cohort study - the first from the African continent - aimed to assess the feasibility and outcomes of DCD in a low- to middle-income setting with declining deceased organ donation rates.
The data reviewed was obtained from prospectively maintained donor referral and kidney transplant registries of controlled DCD kidney transplants performed at Groote Schuur Hospital and Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, over a 17-year period from 2007 to mid-202.
Primary endpoints were 1-, 2- and 5-year graft and transplant survival.
Secondary endpoints included the incidence of delayed graft function (DGF), 30-day morbidity, length of stay, and donor and recipient clinical characteristics
The following findings were recorded:
Donors
Of the 229 patients referred to as potential organ donors, 155 were from trauma-related incidents.
A total of 80 patients were deemed suitable for DCD, and 21 families consented to donation
These donors were predominantly young, with a median age of 22 years, and none met the extended criteria donor (ECD) classification.
Ultimately, 15 donors (14 adults and one child) underwent kidney procurement.
There was no organ discard
Recipients
Thirty patients received DCD kidney transplants, with a median cold ischemic time (CIT) of 11.5 hours.
Recipient allocation was based on a negative complement-dependent cytotoxicity T- and B-cell crossmatch test.
The cohort included 28 adult and 2 child recipients, many of whom had multiple human leukocyte antigen (HLA) mismatches or prior transplants.
Of the 30 recipients
12 experienced immediate graft function,
18 recipients experienced DGF, requiring at least one session of haemodialysis
15 allograft biopsies were done within 30 days post-transplant
Acute tubular necrosis was found in 10 patients, with four of the remaining patients each experiencing acute cellular rejection, borderline rejection, ascending pyelonephritis, CNI toxicity.
There was one normal allograft kidney on biopsy.
There was one normal allograft kidney on biopsy.
The median length of hospital stay was 16 days, and 19 days for those with DGF
Thirty-day morbidity was 20%, which included complications such as surgical site infections, sepsis, and graft pyelonephritis. (n=1 in each case)
In the first year post-transplant, three patients experienced acute cellular rejection, all of which responded well to steroid therapy.
Long-term graft survival rates were 100% at 1 year, 96% at 2 years, and 73.7% at 5 years.
Patient survival rates were 93.3%, 93.3%, and 88.4%, respectively.
Three patients succumbed to sepsis, 1 patient died in a motor vehicle accident, and 3 patients were not reaccepted for haemodialysis after allograft failure.
The study highlights several challenges in DCD practice, including identifying suitable candidates, maintaining the trust of bereaved families, integrating transplant nurses into end-of-life care teams, and managing the ethical, professional, and legal implications of warm ischemia.
Despite these challenges, DCD may be culturally more acceptable in African countries, where circulatory death is often viewed more favourably than brain death.
The study reinforces the potential of DCD to help address organ donor shortages in South Africa, particularly in settings where religious or cultural objections to brain death are prevalent.
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