The agonal phase of DCD donors: parameters of success?

H. Peters-Sengers, R.W. Klaasen, J.A.M. Hagenaars, M.M. Idu, J.J. Homan van der Heide, J.I. Roodnat, F.J. Bemelman

Chair(s): dr. D.E. Braat & dr. N.C. van der Weerd

Thursday 9 march 2017

9:24 - 9:36h at Johan de Meesterzaal

Categories: Parallel - Klinisch

Parallel session: Parallelsessie XII – Klinisch 4 - Pretransplantatie en donatie

Background:
Donation after circulatory death (DCD) is an important source for kidney transplantation in the Netherlands. Data from experimental animal studies showed that prolonged warm ischemia time and hypoxemia can have deleterious consequences for the quality of the DCD donor kidney. Hemodynamic profiles during the agonal phase—i.e. the period between withdrawal of life-sustaining treatment to cardiac arrest—vary widely among DCD donors, raising the possibility that agonal phase characteristics are associated with recipient transplant outcome.

Methods:
We investigated the association between the parameters of saturation (SpO2, measured with finger pulse) and systolic blood pressure (SBP) during agonal phase and primary non-function (PNF), delayed graft function (DGF), and 3-year graft survival rate. Graft survival was defined as graft loss or patient death or a permanent eGFR < 15 ml/min/m2. Parameters during agonal phase were dichotomized into minutes of SpO2 > 60% or SpO2 < 60%, and minutes of SBP > 80 mmHg or SBP < 80 mmHg. We included 409 recipients (≥18y) from two Dutch transplant centers, transplanted from January 2006 to January 2014 with a circulatory-death donor (≥18y) kidney, and followed them till May 2015.

Results:
Median duration of agonal phase was 16 min (IQR 11-23). After the switch-off, median SBP > 80 mmHg lasted longer than SpO2 > 60% (4 min, IQR 2-9 vs. 7 min IQR 7-13). Median SpO2 < 60% was 10 min (6-16) and median SBP < 80 was 7 min (IQR 4-13) till the heart stops beating. Median 1st warm ischemic time (WIT) from cardiac arrest to cold perfusion was 16 min (IQR 13 – 20). Median cold ischemic time (CIT) was 17.4 hours (IQR 13.9 – 21.0). Primary non-function rate was 6%, delayed graft function rate was 64%, and graft survival at 3 years was 77%. Longer periods of agonal phase were (borderline) significantly associated with primary non-function (p=.065), delayed graft function (p=.012), and graft survival (p=.098). Multiple regression analysis—adjusted for donor age, donor cause of death, donor creatinine, 1st WIT, and cold ischemic time—showed that 1 min increase of SBP < 80 mmHg was independently associated with DGF (OR 1.06, p=.004), and graft failure (HR 1.02, p=.002), whereas 1 min increase of SBP > 80 was independently associated with PNF (OR 1.02, p=.025). Associations were not found for SpO2.  

Conclusions:
We conclude that duration of agonal phase is associated with early transplant outcome. SBP during agonal phase shows better discrimination for transplant outcome of DCD donor kidneys than SpO2. Relevant cut-offs for SPB and other methods to measure SpO2 needs further investigation.

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