Response to organ shortage: kidney retrieval programme using non-heart beating donors

Patients, methods, and results

Two sources of potential donors were identified. In the accident and emergency department patients aged under 65 in whom resuscitation after cardiorespiratory arrest or trauma had failed were referred to the transplant team providing not longer than 30 minutes without cardiac massage had elapsed. On the medical wards elective ventilation4 of donors is not always possible if there are no intensive care beds. In these circumstances arrangements were made for in situ perfusion, on the ward, after death. Requests for donation were made only by a senior member of the accident and emergency, medical, or transplant team. When relatives were not available in the accident and emergency department in situ perfusion was started as a temporising measure and withdrawn if permission was subsequently not obtained. This aspect of the protocol was discussed with the local ethics committee and soundings taken in the local press to assess public response. No significant adverse correspondence was received.

In situ perfusion was performed as described by Booster et al5 using a 16 French gauge double balloon triple lumen kidney transplant catheter (TXF Medical, High Wycombe, UK). A rapid 8 litre infusion of chilled (4°C) kidney perfusion solution (Soltran, Baxter Health Care, Thetford, UK) followed by a slower infusion at 75-100 ml/min was used to achieve renal cooling. Recipients were chosen using our normal criteria with age matching between donor and recipient wherever possible. The source of the kidney was not revealed to recipients, but centres to whom organs were exported were informed.

In the first year there were 27 referrals, 19 from the accident and emergency department and eight from the medical wards. The outcome of these referrals is summarised in the table. Technical errors were common due to misplaced catheters in diseased aortoiliac vessels. A policy of x ray screening has been adopted to reduce the incidence of this problem. A request for consent was made in 22 cases with four refusals (18%). In situ perfusion was performed in 16 potential donors (median age 49, 14 men) with a median insertion time of 25 minutes (range 15-48). In six cases the perfusion was started before relatives arrived in the accident and emergency department.

Eighteen kidneys were successfully retrieved and 16 of these were transplanted (no suitable recipient for two). During the same 12 month period 26 renal transplants from conventional heart beating donors were performed. The non -heart beating donor programme therefore contributed 38% of all transplanted kidneys. Fourteen grafts (88%) functioned after an initial delay of 21 days (range 8-49) due to reversible acute tubular necrosis. The median serum creatinine concentration at two months after transplantation was 166 μmol/l (range 124-436). Two grafts failed, one due to a renal vein thrombosis and one due to ischaemic damage after a prolonged cathether insertion time of 48 minutes.

Comment

These results show that the retrieval of kidneys for transplantation from patients dying in the accident and emergency department and on medical wards using in situ perfusion can provide a valuable additional source of functioning grafts. A team with organisational, technical, and counselling skills is required. Careful selection of donors, sensitive handling of relatives, and rapid in situ cooling enables such a programme to be successful.

We thank the following for their help in setting up the retrieval programme: transplant coordinators Mrs A Simpson and Mrs R Ellwell; consultants Messrs G G Bodiwala, M R Allen, and D I Quinton; registrars Mr P Bradley, Mr F Hickey, and Dr T Hussein; nurse managers Miss B Doyle, Mrs S Broome, and Mrs L J Bass.