1. Enterprise | Interest
Nothing to disclose

2. The impact of acute kidney injury of
donor kidneys transplanted with a low remuzzi score on incidence of delayed graft function and long term outcome
L. Cima1 , A. Eccher1 , A. Caliò1 , A. Scarpa1 , S.Gobbo2 , D. Neill3 ,
C. Mescoli4 , F. Vanzo5 , A. D’Errico6 , M. Rugge4 , M. Brunelli1
Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
Pathology Unit, Pederzoli Hospital, Peschiera Del Garda, Verona, Italy
Pathology Unit, Department of Histopathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
Department of Medicine (DIMED), Surgical Pathology and Cytopathology Unit, University and Hospital Trust of Padua, Padua, Italy
Arsenàl, Veneto’s Research Center for eHealth Innovation, Veneto, Italy
Pathology Unit, Department of Specialised, Experimental and Diagnostic Medicine, S.Orsola-Malpighi University Hospital of Bologna, Bologna, Italy

3. BACKGROUND – Status of Transplantation Activity
Kidney Transplant Center
47 years of uninterrupted activity
2108 transplant from 1968 to 2016
transplants performed per year
Liver Transplant Center
20 years of activity
20-30 transplants performed per year
Other Transplant Activities
lung
heart
cornea

4. BACKGROUND – Acute Kidney Injury
DEFINITION:
A clinical syndrome characterized by rapid reduction in renal excretory function underpinned by variety of causes
CAUSES:
Pre – Renal
Renal (Intrinsic)
Post – Renal
Serum creatinine and urine output are considered the best existing markers for AKI

5. BACKGROUND – AKI Network (AKIN) Criteria

6. Group 2-3 sec. AKIN Criteria
BACKGROUND – Deceased Donor Types
DONATION AFTER BRAIN DEATH
Standard criteria donors (SCD)
Under 50 years old
Expanded criteria donors (ECD)
Over 60 years old
Aged years old with at least 2 of the following:
Hypertension
Cerebrovascular cause of brain death
Pre-retrieval serum creatinine level > 1.5 mg/dl
DONATION AFTER CIRCULATORY DEATH
Group 2-3 sec. AKIN Criteria

7. BACKGROUND – Outcomes of Kidneys from donors with AKI
DELAYED GRAFT FUNCTION (DGF)
Low urine output and need for dialysis within first week after transplant
EARLY GRAFT FAILURE
Graft loss occurring within 30 days after kidney transplantation

8. BACKGROUND – Kidney Recovery
From Forni et al. Renal Recovery After Kidney Injury Intensive Care Med (2017)

9. Appropriate Renal Replacement Therapy
BACKGROUND – Kidney Recovery
Appropriate Renal Replacement Therapy
NO RECOVERY
From Forni et al. Renal Recovery After Kidney Injury Intensive Care Med (2017)

10. BACKGROUND – Evaluation of Donors Kidneys
From Irish et al. Nomogram for Predicting the Likelihood of Delayed Graft Function in Adult Cadaveric Renal Transplant Recipients JASN (2003)

11. BACKGROUND – Evaluation of Donors Kidneys
AND KIDNEY BIOPSY…?

12. AIMS
Assess the potential associations between clinically-defined donors with AKI, pre-implantation histological findings and recipient outcomes:
Delayed Graft Function
Serum Creatinine Levels
Cumulative Rejection Rate
Compare the recipient outcomes and the preimplantion biopsy report between the stage 3 AKIN group and the no AKIN, AKIN 1 and AKIN 2 groups

13. METHODS: Donors and Recipients
335 potential donors
Mean age of 53 years
AKIN Stage Groups
Each donors underwent to pre-implantation histopathological examination by an on-call rota pathologists of the Pathology Unit
248 recipients
Mean age of 48 years
Each recipients underwent to a two years follow-up by the transplant team of the Kidney Transplant Center

14. METHODS – Remuzzi Score
Glomerular Sclerosis (0-3)
Vascular Narrowing (0-3)
Interstitial Fibrosis (0-3)
Score of 0 to 12
Score from 0 to 3: Use and implant singly
4 to 6: Dual transplant
≥ 7: Discard
Tubular Atrophy (0-3)

15. METHODS – Acute Tubular Necrosis
Mild: < 25% of tubular involvement
Moderate: 25-50% of tubular involvement
Severe: > 50% of tubular involvement

16. METHODS - Transplant Outcomes
DELAYED GRAFT FUNCTION
Recipients requiring dialysis within first 7 days after transplantation
NO AKIN
AKIN 1
AKIN 2
AKIN 3
SERUM CREATININE LEVELS
Follow up of 1, 3, 12 and 24 Months
CUMULATIVE REJECTION RATE

17. RESULTS – Donors Outcome
NO AKIN
(81%)
AKIN 1
37 (11%)
AKIN 2
11 (3%)
AKIN 3
16 (5%)
Median Scr
77 umol/l
139 umol/l
186 umol/l
458 umol/l
Remuzzi 0-3
216 26 6 14
Remuzzi 4-6 40 5 2
Remuzzi 7-12 15 1
Mild ATN
221 28 12
Moderate ATN 48 8 3 4
Severe ATN

18. RESULTS – Recipients Outcome
NO AKIN
AKIN 1
AKIN 2
AKIN 3
DGF
12%
11% 6%
47%
Median Scr
(1 month)
310,91 (± 143,86) umol/l
305,09 (±
151,85) umol/l
275,80 (±
99,82) umol/l
503 (±
187,61) umol/l
(3 months)
143,60 (±
62.076) umol/l
146,31 (±
65,75) umol/l
127, 70 (±
49,405) umol/l
144,55 (± 74,181) umol/l
Median Scr (1 year)
136,45 (± 53,723) umol/l
133,03 (±
54,033) umol/l
122,70 (±
39,398) umol/l
118, 67 (± 56,169) umol/l
(2 years)
139,03 (± 76,548) umol/l
123,48 (±
39,520) umol/l
118,86 (±
133,75) umol/l
133,75 (±
65,713) umol/l
Cumulative Rejection Rate (2 years)
38,5%
23%
30%
45,5%
P =0,013
P =0,02
P =NS

19. Number of Donors with AKI
DISCUSSION
Authors
Number of Donors with AKI
AKI
Definition
DGF
(AKI vs non AKI)
Discard Rate
Donor Kidney Biopsy
Ugarte et al.
(2005) 65
Terminal Cr ≥ 2.0 mg/dL
66% vs 27%
(p < 0.001) NA NO
Kumar et al.
(2006) 55
Terminal Cr ≥ 2.5 mg/dL
88% vs 46%
(p = 0.03)
Zuckerman et al. (2009) 17
32% vs 22%
Kayler et al.
(2010)
3537 SCD
767 ECD
36% vs 21% SCD
41% vs 32% ECD
29% vs 8%
Lee et al.
(2014) 43
AKIN Stage 1-3
42% vs 12%
(p < 0.05)
Hall et al.
(2015)
443
41% vs 28%
Heilman et al.(2015)
162
Cima et al. (2017) 64
47% vs 29%
29% vs 38,5%
YES
Cr: Creatinine ; SCD: standard criteria donors ; ECD: expanded criteria donors

20. DISCUSSION

21. CONCLUSIONS
Donors with a severe acute kidney injury (stage 3 AKIN donors) could be used for kidney transplant
Histopathology is a useful tool to decide that AKI Kidneys (even in the severe form) should not be discarded and expand the donor pool

22. THE END
AND...
THANK YOU!