Unlike donation of organs after cardiac death (DCD), cardiovascular circulation is intact during the donation of organs after brain death (DBD). DCD kidneys due to warm ischemia are likely to suffer delayed graft function (DGF) and early graft loss. However, due to organ scarcity, increasingly DCDs are being used. Any prolonged cold storage of these kidneys is likely to add to the injury, although this has not been specifically addressed. Therefore, the objective here was to examine the relationship between cold ischemia time (CIT) and DCD kidney function and survival. A total of 5,879 kidneys were identified as DCD in the UNOS Registry between 1993-2004, which forms a 2.6% of total diseased donor kidneys procured during this period. An increase in DCD kidneys has been, however, noted for the last few years with a doubling in 2003 (n = 409) vs. 2000. In 2003, core cooling was employed in 98% and cardiac death was achieved in controlled settings in 92%. Although the age and HLA mismatches were slightly higher for DCD, the DCD recipients were not different for other demographics. CIT was slightly higher for DCD vs. DBD kidneys in 2000 (mean ± SD, 20.2 ± 9.4 hr vs.19.2 ± 8.5 hr) but similar in 2004 (18.4 ± 8.6 hr vs.18.0 ± 8.0 hr) suggesting prompt utilization of DCD kidneys. The first-week-dialysis requirement after transplantation was 2-fold higher in DBD with a significantly higher serum creatinine upon discharge. In Cox analysis, DCD kidneys with CIT more than 20 hr were associated with the higher risk of graft loss over an 8-yr period (Figure). However, unlike DBD kidneys, CIT as a continuous variable had no significant association with DCD kidneys' discharge S Cr or survival probably due to the overriding influence of periprocurement injury. Despite the early injury, however, the 8-yr graft survival of the DCD kidneys was not different from the DBD kidneys. In aggregate, despite early injury, DCD kidneys appear to have long-term survival comparable to DBD kidneys. However, with the finding that CIT over 20 hr may be associated with lower survival of DCD kidneys, the current measures of avoiding prolonged cold ischemia should be continued.
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