CHAPTER 9
Kidney Preservation
John O'Callaghan  •  Henri G.D. Leuvenink  •  Peter J. Friend  •  Rutger J. Ploeg
CHAPTER OUTLINE
TOWARDS “TAILORED” PRESERVATION
STRATEGIES
PRINCIPLES OF COLD STORAGE PRESERVATION
Energy and Acidosis
Cell Swelling
Reactive Oxygen Species
Calcium
Enzymes
COMPOSITION OF CLINICALLY USED
SOLUTIONS
Eurocollins Solution
University of Wisconsin Solution
Histidine-Tryptophan-Ketoglutarate Solution
TOWARDS “TAILORED” PRESERVATION
STRATEGIES
To date, donor kidneys are very different from those re-
trieved two decades ago. To maintain quality and increase
viability different donor types and kidneys procured for
transplantation require different preservation strategies
using more adjusted methods and solutions.
Transplant waiting lists have universally lengthened
since their creation, and at a greater rate than the avail-
ability of donors. The classical donor type was that of the
deceased, heart-beating donor, or donation after brain
death (DBD). These were typically younger people suf-
fering irreversible brain damage during motor vehicle
accidents, referred to as standard criteria donors (SCD).
Declining numbers of this donor type are available due to
a combination of improved neurosurgery and road safety.
Transplant programs are therefore increasingly turning
to expanded criteria donation (ECD) and donation after
circulatory death (DCD) to meet the shortfall. Each do-
nor type is associated with risk factors that could affect
the outcome of the transplant and therefore the methods
of preservation are crucial. Many organ donors are now
complex, with comorbidities and an associated cascade of
injury to the donor organs such that the applied preserva-
tion strategies become even more important.
ECD was established as a defined donor group based
upon the association of certain factors with reduced graft
survival. Historically ECD were known as “marginal”
or “expanded” donors but are now more appropriately
referred to as “higher risk.” They are defined as donors
130
Hyperosmolar Citrate Solution
Celsior Solution
Institut Georges Lopez-1 Solution
HYPOTHERMIC MACHINE PERFUSION REVISITED
NORMOTHERMIC PERFUSION
Normothermic Regional Perfusion
Normothermic Machine Perfusion
Normothermic Reconditioning
Mechanism of Action
Perfusion Fluid and Oxygen Carrier
Viability Assessment
FUTURE OUTLOOK
over 60 years old, or aged 50–59 years, with at least two
of the following conditions: cerebrovascular cause of
death, serum creatinine over 1.5 mg/dL, hypertension.102
Transplantation of an ECD kidney gives a substantial
survival advantage over maintenance on dialysis from
18 months posttransplant, despite the negative compari-
son with kidneys from SCD.96 Graft survival for ECD
kidneys is, by definition, inferior to that for SCD. The
relative risk of graft loss for ECD kidneys is greater than
1.7 times that of SCD kidneys.102 Absolute differences in
graft survival show a 15% and 16% reduction at 1 and
3 years.83
The use of ECD kidneys has risen in many coun-
tries.65,98 In the United States the number of ECD kid-
neys rose by 36% between the years 1999 and 2005, while
SCD rose by approximately 13%.98 ECD contributed
22% of the kidneys transplanted in the United States in
2009.32
DCD has also been explored in order to meet the de-
mands of transplant waiting lists. The different types of
DCD may be categorized using the Maastricht criteria70
(Table 9-1). Typically, DCD donors are those who have
suffered massive brain injury but do not meet the criteria
for brain death. A decision to withdraw supportive treat-
ment is made independently of donor status (so-called
“controlled DCD” or Maastricht category III) and o ­ rgans
from these patients undergo a period of warm ischemia
as well as the inflammatory processes of brain death.
Patients who have circulatory arrest in relatively uncon-
trolled situations may also become cardiac death donors.
These so-called “uncontrolled DCD,” or Maastricht