The Effect Of Pre-transplantation Biopsy On The Quality Evaluation Of Deceased Donor Kidneys

BackgroundWith the improvement of renal transplantation technology and the clinical application of new immunosuppressive,renal transplantation has become the first choice for the treatment of end-stage renal disease?ESRD?.The shortage of donor kidneys has forced transplant centers to implement different strategies to increase the pools of donor kidneys.The expansion of the use of extended criteria donor?ECD?is controversial,with a large number of donor kidneys from ECD discarded,even if some of them can be transplanted.In recent decades,in order to make full use of these "marginal" donor kidneys,different scoring systems have been developed to help analyze their effectiveness and the recovery of renal function after transplantation.Remuzzi created and promoted a pathological scoring system to facilitate the use of renal biopsy before transplantation in order to more fully optimize and distribute organs from ECD based on the histological evaluation of single and/or bilateral kidneys.In order to improve the prediction ability of organ survival in ECDs,RAO re-established and improved the old classification method according to the dichotomy of ECD/SCD,who created the kidney donor profile index?KDPI?scoring system based on mathematical algorithms related to donor characteristics in the United States the previous year.In theory,the higher the KDPI score,the lower the long-term survival rate of the graft.Despite many attempts,the criteria used by different renal transplant centers to accept or reject kidneys still vary widely.With the expanded use of pre-transplantation pathological biopsies,although the number of ECD kidneys was increased,3159 kidneys were discarded in the United States in 2015,and the kidney discarded rate?KDR?was 19.2 percent.In the same period,the rate of KDR in Europe and Australia was 4%¹0% and 6.7%,respectively.On the one hand,pathological biopsy before transplantation increased the use of marginal donor kidney,on the other hand,it also increased the abandonment of "marginal" donor kidney that could have been used.In this study,the 411 donors?821 donor kidneys?completed by our center from January 2016 to November 2018,56 donor kidneys were abandoned in total,and the KDR was 6.82%,which was lower than that of the United States and similar to that of Europe and Australia.In 2015 and 2016,SRTR / UNOS reported that the pathological KDR in the United States was about 1/3.Among the many causes of kidney abandonment,pathological factor was the main.In the study,the pathological KDR?44.64%?in our center was higher than that in the United States,and pathological factor was also the main reason for kidney abandonment in our center.For ECDs confirmed by pre-transplantation pathological assessment,renal function at the early stage after transplantation can still be similar to that of standard donors.In the study,according to the Remuzzi scoring system,kidneys in the middle-risk group?4⁶ points?who originally needed a double kidney transplantation were strictly selected for suitable recipients.After minimizing or avoiding other risk factors that are detrimental to the recovery of renal function,recipients in the middle risk group will eventually undergo single kidney transplantation as well as recipients in the low risk group.After two years of follow-up,the serum creatinine and the eGFR level at each time point after renal transplantation,the eGFR in middle risk group was lower than that in the low risk group at each time point,but there was no significant difference between the two groups.Section 1 Analysis of the reasons for the 56 cases discard of deceased donor kidneysObjectiveTo summarize the reasons for the abandonment of kidney from deceased donor?DD?,and to explore the influence of pathological evaluation to the discarded kidney before transplantation.MethodsThe clinical data and pathological data of kidney donors abandoned after organ acquisition and evaluation by the first affiliated Hospital of Zhengzhou University from January 2016 to November 2018 were analyzed retrospectively.According to the definition of ECD in the United Network for Organ Sharing,it is divided into ECD group and SCD group.And the causes of discarded kidneys in ECD group and SCD group were summarized and analyzed.Results821 kidneys were obtained?from 411 DD donors,of which 1 donor was congenital solitary kidney?.56 kidneys?from 33 donors?were discarded after pathological and clinical evaluation,and the KDR was 6.82%.The discarded kidney came from 33 donors?male: female 22:11?,the age was?45.79±17.71?yr?1⁶4yr?.The causes of abandonment were chronic lesions?high proportion of glomerulosclerosis,severe interstitial fibrosis?23/56,severe acute tubular necrosis 2/56,infection 12/56,and other causes?space occupying,injury,thrombosis,dysplasia?19/56.Among them,26 donor kidneys?from 15 donors?were discarded in SCD group,the reasons for abandonment were chronic lesions?high proportion of glomerulosclerosis,severe interstitial fibrosis?5/26,severe acute tubular necrosis 2/26,infection 10/26,and the causes of abandonment were chronic lesions?high proportion of glomerulosclerosis,severe interstitial fibrosis?5/26,severe acute tubular necrosis 2/26,infection 10/26,other causes?space occupying,damage,thrombosis,dysplasia?8/26.In ECD group,30 kidneys?from 18 donors?were discarded because of chronic lesions?high proportion of glomerulosclerosis,severe interstitial fibrosis?18/30,infection 2/30,and other causes?space occupying,injury,blood,thrombus formation,dysplasia?10/30.ConclusionDonor pre-existing chronic lesions are the main causes of donor kidney abandonment.SCD kidney abandonment is mainly caused by infection factors and other factors,and ECD kidney abandonment is mainly caused by donor kidney pre-existing chronic lesions and other factors.Pathological biopsy before transplantation plays an important role in the evaluation of ECD kidney.Section 2 Effect of Remuzzi score on the recovery of renal function after renal transplantation for two yearsObjectiveTo investigate the effect of pathological biopsy before kidney transplantation on the recovery of renal function after transplantation for two years.Method The pathological biopsy data and clinical data of DD kidney transplantation in our center from August 2016 to August 2017 were analyzed retrospectively.The kidney was scored by Remuzzi score.To evaluate the effect of Remuzzi score on the recovery of renal function at third month?6s month?first and second year after transplantation.Result 240 kidneys were evaluated by routine pathological biopsy before transplantation.165 recipients with BSA>1 were selected and divided into two groups according to Remuzzi score: A groups?0³,144?and B groups?4⁶,21?.At the third month after operation,the serum creatinine and e GFR of A group were?111.83±35.47??mol/L and?68.72±24.84?ml×min^-1×1.73m²,respectively.There were significant difference between B group?127.90±25.83??mol/L??56.85±11.08?ml×min^-1×1.73m².At the 6s month after operation,the serum creatinine of A group was?108.28±37.31??mol/L,which is bot too different to that of B group ?122.52±28.41??mol/L.But the e GFR of A group(72.51±22.16ml×min^-1×1.73m²)was significantly different from B group(61.92±17.96ml×min^-1×1.73m²).At the first year after operation,the serum creatinine and e GFR of recipients in A group were?105.03±27.64??mol/L and?74.96±19.63?ml×min^-1×1.73m²,respectively,which were not significantly different from those of recipients with B group?113.29±11.63??mol/L??68.68±15.60?ml×min^-1×1.73m².At the second years after operation,the serum creatinine and e GFR were?106.00±23.27??mol/L and?78.57±16.56?ml×min^-1×1.73m² in A group,which were not significantly different from those in B group?116.22±16.86??mol/L??71.63±16.87?ml×min^-1×1.73m².Conclusion After routine pathological evaluation before transplantation,the kidney with Remuzzi score of 4⁶ was strictly selected,and the graft function recovered well at t second year after operation.SummaryThis study showed that: 1.Pathological biopsy before transplantation plays an important role in the evaluation of ECD kidneys.The pre-existed chronic lesions of kidney are the main causes of ECD kidney abandonment,and the infection of kidney is the main cause of SCD kidney abandonment.2.After the Remuzzi score before transplantation and strict selection of recipients,the kidney in the medium risk group had a good effect on the recovery of renal function in two years after single kidney transplantation.