Renal preservation

Effective and successful kidney

transplantation
depends
on
a
sequence of events. These events
can
be
described
as
the
transplantation cascade

The transplantation cascade

 At the time of retrieval of the organ

from the donor, blood supply is
interrupted, which results in
ischemia.
To ensure function after
transplantation, this period of
ischemia needs to be as short as
possible because warm ischemic
damage is extremely detrimental to
the kidney.

 During the warm ischemic period, the kidney

is devoid of blood, oxygen, and nutrients,
while metabolism continues at full strength.
Reducing metabolic activity is crucial to
prevent organ damage beyond repair.
Most commonly used nowadays is the static
cold storage technique, which includes an
initial flush and washout of the kidney with
subsequent storage in a preservation solution
at 0C to 4C.

 The use of cold storage preservation

provides time for tissue typing and
crossmatching, allocation and
transportation of the organ to the
recipient center, and preparation of
the recipient.

 The implantation phase - is another

critical period. Apart from technical
surgical issues, a second period of
warm or semiwarm ischemia occurs.
During this phase, vascular
anastomoses need to be prepared
before blood flow can be
reconstituted.

 Intuitively, one may think that the

most dangerous period for the graft
should have passed after restoration
of blood flow into the transplanted
kidney
because the supply of
warm well-oxygenated blood should
lead to an increase of metabolism
resulting in a proper functioning graft
BUT .

 The reperfusion phase is not

devoid of side effects, however.
During the reperfusion phase, the
preexisting damage occurring in the
donor kidney as a result of brain
death, cold preservation, and warm
ischemia at the time of implantation
becomes apparent.
All these complex damage influences
the viability of the implanted kidney.

 The reintroduction of oxygen leads to

enhanced formation of free radical
oxygen species.
Misbalances in intracellular and
extracellular ion concentrations and
edema need to be counteracted
quickly to limit further damage.

 Preservation
solutions
are
designed
to
counteract
cold
ischemiainduced changes in the
graft.

PRINCIPLES OF COLD STORAGE

PRESERVATION

Removal of the kidney from the

circulatory system leads to disruption
of the blood supply.
The absence of oxygen delivery to
the cells rapidly leads to major
metabolic problems.
Suppression of metabolism is
essential to prolong the time of
ischemia the kidney can sustain

 Reducing the core temperature of the

kidney to less than 4 degrees C
results in a reduction of
metabolism to 5% to 8% in most
cells and diminishes enzyme
activity.

 In 1963, Calne showed that simple

cooling of kidneys in ice water
preserved function of kidneys for 12
hoursthe temperature effect
With a preservation solution, cold
ischemia times can be significantly
prolonged, and preservation quality
can be improvedthe solution
effect

 Despite the beneficial concept and

effect of hypothermia, it causes
several unwanted side effects in the
preserved organ:
- cell swelling
- acidosis
- production of radical oxygen
species on reperfusion

 Cell Swelling
Histological alterations in cellular
structures observed during
preservation are cell swelling and
formation of protruding pockets.

 The mechanism that induces structural changes

is due to impaired activity of Na+,K+ATP-ase.
As a result, sodium is no longer excreted and
passively enters the cell attracted by the negative
charge of cytoplasmic proteins;
This creates a hyperosmolar intracellular
environment and subsequently an influx of
water resulting cellular swelling

 To re-establish the disturbed equilibrium of the

membrane and to prevent cell swelling,
impermeants and colloids are added to
preservation solutions.
Effective impermeants are saccharides and
nonsaccharide anions.
Larger saccharides are the most effective

Energy and Acidosis

The absence of oxygen results in a rapid
decrease
in
intracellular
adenosine
triphosphate (ATP) levels.
Even at a dramatically reduced metabolic
rate, at 0C to 4C (8-9%), cellular ATP
content is
rapidly depleted.
Within 4 hours, nearly 95% of ATP has
disappeared with a shift to adenosine
monophosphate
as
the
predominant
nucleotide.

 During cold storage, anaerobic

metabolism of 1 mol of glucose
yields only 2 mol of ATP versus a
maximum of 38 mol in aerobic
glycolysis. Two lactic acid molecules
are formed leading to acidosis

 The contribution of acidosis to ischemic

injury is pH dependent:
- Severe acidosis activates phospholipases
and proteases causing lysosomal damage
and eventually cell death
- Mild acidosis (pH 6.9 to 7.0) has been
suggested to have a protective effect,
however,
by
inhibiting
phosphofructokinase
Adequate
important
solutions.

control of
function of

pH is an
preservation

Reactive Oxygen Species

Reactive oxygen species (ROS) are
generated by several processes in
ischemic
and
postischemic
reperfused organs.
An extensively studied generator of
ROS is xanthine oxidase, which
simultaneously produces hydrogen
peroxide
(H2O2)
and
the
superoxide anion (O2)

 The subsequent reduction of H2O2, catalyzed

by iron, leads to hydroxyl radical formation
(OH).
ROS reacts rapidly with other molecules,
which results in severe damage to lipids,
nucleic acids, and proteins during reperfusion.
Infiltration of leukocytes into the graft after
reperfusion results in production of mainly
superoxides

Other sources of ROS

- infiltration of leukocytes into the graft after
reperfusion results in production of mainly
superoxides
- mitochondrial malfunctioning resulting
from partial reduction of the respiratory chain
is an important contributor to ROS formation
after reperfusion
Preservation solutions should aim to
counteract ROS mediated injury.

Calcium
During normal circumstances, a large
difference in free calcium concentration
exists between the intracellular and
extracellular space fluid.
This difference is maintained by active
transport of Ca2+ by several ATPdemanding processes, including Ca2+ATPase and Na+-Ca2+ exchanger

 During cold preservation, cellular ATP

concentrations are low leading to
increased intracellular Ca2+.
Accumulation of Ca2+ in the cold leads to
activation of calcium-dependent
processes, such as calpain activation.
Calpain activation leads to loss of cell
structure by breakdown of the
cytoskeleton spectrin.

Enzymes
Intracellular proteases are involved
in the breakdown of proteins during
preservation most likely because of
the absence of oxygen leading to
detachment of endothelial cells from
the underlying matrix.

COMPOSITION OF CLINICALLY USED

SOLUTIONS

EC, EuroCollins;
HES, hydroxyethyl starch;
HTK, histidinetryptophanketoglutarate;
ROS, reactive oxygen species;
UW,University of Wisconsin cold
storage solution.

Prof. Belzer with his hypothermic perfusion

machine
1963

CONCLUSION
Despite the fact that static cold
storage preservation methods have
facilitated many transplant programs
throughout the world, it seems that
the increasing challenge to maintain
viability in marginal or extended
criteria donor organs has now
touched the limits of cold storage
preservation.

CONCLUSION
Even with beneficial additives and
enriched compositions, static cold
storage, at best, slows down
ischemic damage

CONCLUSION
To improve organ viability further, a more
dynamic preservation method is needed to
better fulfill metabolic demands of damaged
organs.
Many groups are switching gears and are
revisiting
the
possibilities
of
HMP
(hypothermic
machine
perfusion)
or
investigating the possibilities of normothermic
(or near-normothermic) perfusion of donor
organs