This document summarizes key information about deceased donor kidney transplantation (DDKT). It discusses outcomes of DDKT, surgical considerations, post-transplant care, immunosuppression protocols, and delayed graft function (DGF). DGF occurs in 21-29% of DDKT and is associated with worse long-term outcomes and higher rejection rates. The document reviews strategies to prevent DGF and approaches to managing patients experiencing it.

2. Topic overview
 Outcomes of deceased donor kidney
transplantation (DDKT).
 Surgical issues.
 General post-transplant care.

3. Outcomes
2008 OPTN/SRTR Annual Report

4. Am J of Transplant 2007; 7: 1797–1807

5. Recipient issues in Surgery
 DDKT are generally conducted at a short
notice.
 Immediate pretransplant dialysis should be
avoided to minimize DGF.
 If HD is necessary, UF should be minimal.
 Some differences in surgical techniques
(Carrel aortic patch, IVC extensions, dual
kidney transplantation).

6. Induction Immunosuppression.
Options for induction immunosuppression are:
 Antithymocyte globulin.
 IL2R Antibodies (Basiliximab/Daclizumab)
 CD-52 Antibody (Alemtuzumab).

7. Induction Immunosuppression.
 ATG is traditionally used in patients at high risk
for acute rejection.
 ATG also theoretically benefits recovery from
DGF due to delayed start of CNIs.

8. Induction Immunosuppression.
Anti CD52 antibody (Alemtuzumab):
 Off label use.
 “prope” (almost) tolerance enabling lowering
the CNI dose or early steroid withdrawal.
 The INTAC study showed lesser AR
compared to IL2Ra in low risk(n=335) and
similar results to ATG in high-risk (n=139)
patients at the end of 3 yrs in an early steroid
withdrawal protocol (but ECD, DCD, prolonged
CIT and cross match positive were excluded).
Hanaway et al. N Engl J Med 2011;364:1909-19.

9. High Risk factors for acute rejection (KDIGO):
 Number of HLA mismatches.
 Younger recipient age.
 Older donor age.
 Blacks.
 PRA>0%
 Presence of DSA.
 ABO incompatibility.
 Cold ischemia time >24 hours
In these settings the KDIGO guidelines favor the
use of lymphocyte depleting agents rather
than an IL2Ra

10. Other immunosuppresive
protocols in DDKT
 Steroid withdrawal protocols has been found
to be successful in DDKT even in those with
ECD.
Data from Cornell Medical center, NY
Transplantation 2012;94

11. Data from Cornell Medical center, NY
Transplantation 2012;94

12.  Data from the OPTN/UNOS showed that rATG
based induction perform better than IL2Ra and
Alemtuzumab induction in a Tac/MMF/Early
CSWD regimen.
 This could be due to the favorable effects of
rATG induction in high-immune risk patients.
Sureshkumar et al. Transplantation2012;93: 799–805

13. Immunosuppressive protocold
in DDKT
Nephrol Dial Transplant (2011) 26: 317–324

14. Delayed Graft Function
Defined as: “failure of the kidney allograft to
function immediately post transplant with
the need of more than dialysis session
within one week.”
Incidence of DGF is variable:
 Living Donors Tx--------------3%
 Standard Criteria DDKT-----21%
 Expanded criteria DDKT----29%
USRDS Data

15.  It can be compounded by acute rejection and
CAN. DGF translates to a 40% reduction in
long term graft survival.
 Patients with both DGF and acute rejection
had a 5-year survival rate of 34%.
Transplantation 1997; 63: 968–974.
 Patients with DGF had a 49% pooled
incidence of acute rejection compared to 35%
incidence in non-DGF patients.
Nephrol Dial Transplant 2009; 24: 1039–1047.

16. Causes of ischemia in the
deceased donor kidneys.
1. Preharvest donor state 4. Transplantation of
recipient
 Prolonged second warm
2. Organ procurement
ischemia time
surgery
 Trauma to renal vessels
 Hypovolemia/hypotension
3. Organ transport and
storage 5. Postoperative period
 Cyclosporine/tacrolimus
 Acute heart failure (MI)
 Hemodialysis

18. Strategies to prevent DGF
 Ischemic preconditioning.
 Vasodilatory agents (endothelin receptor
antagonists, CCB and adenosine A1 receptor
antagonists.
 Anti-inflammatory agents.
 Induction immunosuppression (suppression of
leucocyte-rich vascular congestion &
endothelial injury).

19. Post-transplant dialytic therapy
 Best is to avoid dialysis.
 Minimal anticoagulation.
 Avoidance of hemodynamic instability.
 Peritoneal dialysis is best avoided in the 1st
week due to risks of peritonitis and spillage
over the wound site.
 PD can be safely started in extraperitoneal
transplants with small volumes and gradually
increased.

20. Approach to a DGF
Brenner, The Kidney

21. Quality of Life
Nephrol Dial Transplant (2002) 17: 2204–2211

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