Results of kidney transplantation after rescue allocation

In 2009, Eurotransplant (ET) offered 4026 kidneys from deceased donors. Only 3587 were transplanted resulting in a discard rate of 11% [1]. During the standard allocation, 16% of all renal grafts were refused because of medical reasons. In the case of nonacceptance, ET offers these organs to other centers. If such a renal allograft is also refused for medical reasons by the five further centers consecutively according to the regular allocation system, the process of rescue allocation (RA) is initiated, i.e. the renal allograft is offered as noncompetitive center allocation in the region of explantation (first line-RA) and thus define the allograft to orginate from a donor with extended donor criteria (ECD) [1]. If the organ is declined by all the regional centers, a competitive center allocation in the greater area of explantation starts (second line-RA) until the organ is accepted. Thus, the number of transplanted allografts could be increased. In this manner, 7.5% of the RA-kidneys are discarded ultimately [1,2]. The reasons for the refusal of RA-kidneys are not clear. Attributable factors could include the medical history of the donor, or a ‘‘cascade effect,’’ meaning that the refusal itself is an extra factor for the following refusals [3,4]. There are only sparse published data on the outcome of rescue-allocated kidneys. We evaluated our center experience with kidneys allocated by RA. The records of all patients who received a RA kidney (first or second line) from January 2000 until December 2009 were analysed retrospectively. The main outcome parameters were the graft function according to 1-month and 12-month serum-creatinine and estimated glomerular filtration rate (eGFR), the graft survival and the patient survival. The estimated GFR was calculated according to MDRD-equation[5]. Secondary outcomes were a delayed graft function, acute rejection and the existence of long-time survivors. Data concerning the main outcome parameters were complete. From January 2000 until December 2009, 16 patients received a rescue-allocated kidney. In the same period, 330 regularly allocated kidneys from deceased donors were transplanted (ratio 4.8%). The kidneys originated from 13 donors. In three cases, we accepted both organs from the same donor. All donors were heart-beating (i.e. brain-dead on artificial life-support and artificial life-support about to be withdrawn as per advanced directives or per the power of attorney’s instructions). The demographic and medical data characterizing the donors are presented in Table 1. The 16 organs included in our study were refused 108 times by other centers. The mean number of refusal for a single kidney before acceptance was 6.8 ± 2.8 times (median 8.0). The reasons for refusal in 90.7% (n = 98) of the cases were because of medical reasons, in 5.6% (n = 6) of the cases because of logistical reasons and in the remaining 3.7% (n = 4) because the designated recipients were not transplantable. The 1-month patient survival rate was 100%. In three cases, the kidneys had a macroscopic damage that was not described in the ET-donor report. One graft was lost on the first day after transplantation because of a total venous thrombosis. Three out of the 16 recipients (18.8%) demonstrated delayed graft function. In four out of the 16 allografts, an episode of acute rejection was diagnosed during the postoperative period, which could