Publications

Background: The number of donors from donation after circulatory determination of death (DCDD) has increased by at least 4-fold over the past decade. This study evaluated the association between the antecedent cardiac arrest status of controlled DCDD donors and the risk of delayed graft function (DGF).Methods: Using data from the Australia and New Zealand Dialysis and Transplant, the associations between antecedent cardiac arrest status of DCDD donors before withdrawal of cardiorespiratory support, DGF, posttransplant estimated glomerular filtration rate (eGFR), and allograft loss were examined using adjusted logistic, linear mixed modeling, and cox regression, respectively. Among donors who experienced cardiac arrest, we evaluated the association between duration and unwitnessed status of arrest and DGF.Results: A total of 1173 kidney transplant recipients received DCDD kidneys from 646 donors in Australia between 2014 and 2019. Of these, 335 DCDD had antecedent cardiac arrest. Compared with recipients of kidneys from donors without antecedent cardiac arrest, the adjusted odds ratio (95% confidence interval) for DGF was 0.85 (0.65-1.11) among those with kidneys from donors with cardiac arrest. There was no association between antecedent cardiac arrest and posttransplant eGFR or allograft loss. The duration of cardiac arrest and unwitnessed status were not associated with DGF.Conclusions:This focused analysis in an Australian population showed that the allograft outcomes were similar whether DCDD donors had experienced a prior cardiac arrest, with no associations between duration or unwitnessed status of arrest and risk of DGF. This study thus provides important reassurance to transplant programs and the patients they counsel, to accept kidneys from donors through the DCDD pathway irrespective of a prior cardiac arrest.

Background: While intra-operative duplex ultrasound scanning can be readily performed in renal transplantation, the value of this intervention in routine practice is not established.Methods: Three hundred thirty-one consecutive single renal transplants in adult recipients underwent intraoperative scanning at implantation. Early graft losses were compared with those recorded in the ANZDATA Registry.Results: Nine overt vascular abnormalities were corrected prior to scanning. Four further suspected venous outflow restrictions were confirmed by ultrasound and revised. Another 11 major vascular revisions were performed following intraoperative ultrasound consisting of 7 otherwise unsuspected inflow abnormalities, all corrected, and 4 anastomoses redone to reposition the graft. Thirty-two (9.7%) grafts were repositioned under ultrasound guidance to improve cortical perfusion but without vascular revision. One graft with hyperacute rejection was explanted 4 days postimplantation and one graft with primary nonfunction remained well perfused. Two patients died within 90 days, both with functioning grafts. Twenty-three grafts were re-explored within 7 days, including 9 solely for graft hypoperfusion. There were no postoperative arterial thromboses and, at re-exploration, no arterial anastomoses required revision. There were no postoperative venous thromboses, although one venous anastomosis was revised. No grafts were lost within 90 days for surgical or technical reasons compared with 76 (1.0%) of 7603 contemporaneous grafts in the ANZDATA Registry (P = .077 Fisher's exact test, P = .069 χ2 test).Conclusions: The routine use of intraoperative ultrasound appears to be of benefit by identifying otherwise unrecognized vascular abnormalities, leading to a reduction in early graft losses because of surgical factors.

Background: Parental donor kidney transplantation is the most common treatment option for children and adolescents with kidney failure. Emerging data from observational studies have reported improved short- and medium-term allograft outcomes in recipients of paternal compared to maternal donors. The INCEPTION study aims to identify potential differences in immunological compatibility between maternal and paternal donor kidneys and ascertain how this affects kidney allograft outcomes in children and adolescents with kidney failure.Methods: This longitudinal observational study will recruit kidney transplant recipients aged ≤18 years who have received a parental donor kidney transplant across 4 countries (Australia, New Zealand, United Kingdom and the Netherlands) between 1990 and 2020. High resolution human leukocyte antigen (HLA) typing of both recipients and corresponding parental donors will be undertaken, to provide an in-depth assessment of immunological compatibility. The primary outcome is a composite of de novo donor-specific anti-HLA antibody (DSA), biopsy-proven acute rejection or allograft loss up to 60-months post-transplantation. Secondary outcomes are de novo DSA, biopsy-proven acute rejection, acute or chronic antibody mediated rejection or Chronic Allograft Damage Index (CADI) score of > 1 on allograft biopsy post-transplant, allograft function, proteinuria and allograft loss. Using principal component analysis and Cox proportional hazards regression modelling, we will determine the associations between defined sets of immunological and clinical parameters that may identify risk stratification for the primary and secondary outcome measures among young people accepting a parental donor kidney for transplantation. This study design will allow us to specifically investigate the relative importance of accepting a maternal compared to paternal donor, for families deciding on the best option for donation.Discussion: The INCEPTION study findings will explore potentially differential immunological risks of maternal and paternal donor kidneys for transplantation among children and adolescents. Our study will provide the evidence base underpinning the selection of parental donor in order to achieve the best projected long-term kidney transplant and overall health outcomes for children and adolescents, a recognized vulnerable population.Trial registration: The INCEPTION study has been registered with the Australian New Zealand Clinical Trials Registry, with the trial registration number of ACTRN12620000911998 (14th September 2020).

Background and objective The annual incidence of suicide by hanging in Australia and New Zealand has increased in the past decade, and a significant number of these individuals are becoming organ donors. The rates of organ donation following deaths from hanging is unknown and the characteristics of this cohort of donors have not been described in the literature. In light of this, we aimed to examine the trends in organ donation from individuals who had died from hanging, based on the solid organ donor data from the Australia and New Zealand Organ Donation (ANZOD) Registry. Methods We conducted a retrospective study that analyzed the ANZOD Registry donor data (2006-2015) to describe the characteristics of solid organ donors who had died by hanging (post-hanging group); these characteristics were compared to those of individuals who died by all other causes (non-hanging group). Results During the study period, the number and proportion of donors who died by suicide from hanging increased. Of the 4,024 consented organ donors, 226 had died by hanging and 3,798 had died from other causes. The probability that an individual who died by hanging would become an organ donor increased from 0.5 to 3%. Compared to donors who died by all other causes, post-hanging donors were younger (median age of 30 vs. 50 years), with fewer comorbidities, and a higher incidence of smoking. There was no significant difference in the proportion of those who indicated a prior intent to donate organs between post-hanging (34%) and non-hanging donors (38%). A higher proportion of post-hanging donors donated via the donation after the circulatory death pathway (36.3%) than non-hanging donors (24.2%). Individuals in the post-hanging cohort donated an average of 4.19 organs compared to 3.62 in the non-hanging cohort. Conclusion We believe the findings of this retrospective analysis will help inform clinical decision-making regarding organ donation, including the best approaches to obtaining donation consent. Our findings will help physicians provide care to patients and to families of individuals in this challenging group, where organ donation potential is high. Further investigations are required to determine which aspects of healthcare influence the donation rates in individuals who have died by hanging and the outcomes related to transplanted organs.