Deceased-Donor Offer with Acute Kidney Injury and Increased Terminal Creatinine
A 47-year-old man with polycystic kidney disease has been waitlisted for 14 months. He receives an offer of a deceased-donor kidney from a 52-year-old donor who suffered an intracranial hemorrhage and progressed to brain death. The donor had no hypertension or diabetes, but developed acute kidney injury during a 4-day ICU stay: creatinine rose from 0.9 to 2.8 mg/dL, urine output fell to 20 mL/h, and the donor required norepinephrine at 0.08 µg/kg/min. Donor urinalysis shows muddy brown casts. The donor is hepatitis B core antibody positive, surface antigen negative, and hepatitis C antibody negative. The recipient has no significant comorbidities and is highly sensitized (calculated PRA 85%). The procurement team asks whether to accept the kidney for this recipient or decline in favor of a better-matched offer.
1. Assess the donor kidney quality and the implications of donor acute kidney injury for acceptance. What donor and recipient factors push toward acceptance or decline?
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The donor has acute kidney injury, likely from ischemic and nephrotoxic insults during the ICU course: rising creatinine, oliguria, muddy brown casts, and vasopressor dependence. This is a donor with AKI, not necessarily intrinsic chronic kidney disease. Short-term donor AKI can be reversible after transplantation, and many centers accept such kidneys with acceptable outcomes, especially in the absence of chronic hypertension or diabetes. However, the combination of oliguria, high vasopressor dose, and rising creatinine signals a kidney at risk for delayed graft function and possibly primary nonfunction.
Factors favoring acceptance: donor age 52, no diabetes or hypertension, likely adequate nephron mass, and a recipient with no major comorbidity who can tolerate DGF and dialysis. Factors favoring decline: the recipient is highly sensitized (cPRA 85%), so a well-matched offer is valuable and a marginal kidney that fails would consume an opportunity and expose him to re-sensitization. The decision should weigh the probability of DGF against the scarcity of a compatible offer, the recipient's dialysis tolerance, and center-specific outcomes with AKI donors. A reasonable approach is acceptance with informed consent, planned biopsy or pump perfusion assessment if available, and expectation of DGF.
2. How should the hepatitis B core antibody-positive, surface antigen-negative donor be managed for this recipient, and what is the risk of transmission?
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An HBcAb-positive, HBsAg-negative donor indicates prior HBV infection with possible low-level latent virus in the liver and other tissues. The risk of HBV transmission to a seronegative recipient is low but not zero, and it is higher if the recipient is immunosuppressed or has no protective immunity. Management: (1) Check recipient HBV serology - if HBsAb positive with adequate titer, risk is lower; if naive, vaccinate or consider prophylaxis. (2) Antiviral prophylaxis with a nucleos(t)ide analog such as entecavir or tenofovir is often used, particularly for liver recipients or when the recipient is HBsAb negative. (3) Monitor HBV DNA periodically post-transplant. (4) The donor's HBsAg-negative status makes active infection unlikely, and the kidney is generally acceptable with prophylaxis and monitoring. The transplant team should document informed consent about the small transmission risk and the monitoring plan.