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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2018;18(7):e7359 doi: 10.5867/medwave.2018.07.7359
Hypothermic machine perfusion versus static cold preservation in kidney transplantation
José Ignacio Domínguez, Martin de Amesti, Alejandro Majerson
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Key Words: Hypothermic machine perfusion, static cold preservation, kidney transplantation, Epistemonikos, GRADE.

Abstract

INTRODUCTION
The adequate preservation of the allograft prior to kidney transplant is key for a good outcome after transplantation. Currently, there are two main methods: hypothermic machine perfusion and static cold preservation. The main objective of this summary is to compare both preservation systems.

METHODS
We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS
We identified 10 systematic reviews including 34 primary studies, of which 13 were randomized trials. We concluded preservation by hypothermic machine perfusion probably decreases the risk of delayed graft function and could lead to a slight increase in graft survival. However, there are no differences in patient survival between the two methods.


 
Problem

There is an imbalance between demand and availability of organs for kidney transplantation, so strategies to increase the latter are required. One of them is to address organ preservation, in order to optimize the state of the kidneys prior to transplantation and achieve better post-transplant results.

Both hypothermic machine perfusion and static cold storage are alternatives for graft preservation prior to transplantation. Hypothermic machine perfusion generates a continuous pumping of perfusion solution to the renal parenchyma, which provides nutrients and oxygen, and removes toxins, theoretically decreasing damage derived from time of ischemia. Static cold is currently the most widely used method due to its greater availability, but the use of hypothermic machine perfusion has been increasing in recent years due to the change in donors profile, advances in technology and available perfusion solutions. It is relevant to determine which method is more effective in terms of post-transplant results.

Methods

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others, to identify systematic reviews and their included primary studies. We extracted data from the identified reviews and reanalyzed data from primary studies included in those reviews. With this information, we generated a structured summary denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos) using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies when it is possible, a summary of findings table following the GRADE approach and a table of other considerations for decision-making. 

Key messages

  • Hypothermic machine perfusion probably decreases the risk of delayed graft function, might slightly improve survival of the graft at 1 year, but it makes little or no difference in the survival of the patient.
  • It is not clear whether hypothermic machine perfusion decreases primary failure of the graft because the certainty of the evidence is very low.
About the body of evidence for this question

What is the evidence.
See evidence matrix in Epistemonikos later

We found 10 systematic reviews [1],[2],[3],[4],[5],[6],
[7],[8],[9],[10], including 34 primary studies [11],[12],
[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],
[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],
[35],[36],[37],[38],[39],[40],[41],[42],[43],[44], of which 13 were randomized trials [12],[20],[21],[22],
[23],[25],[26],[29],[31],[41],[42],[43],[44].
This table and the summary in general, are based on the latter, since the observational studies did not increase the certainty of the evidence nor provide additional relevant information.
Some systematic reviews also included animal studies, which were not considered in this summary of evidence [5].

What types of patients were included*

Five trials only included donors with circulatory death [22],[25],[26],[42],[44]; four trials only included brain-dead donors [21],[23],[31],[43]; two trials included donors with both circulatory and brain death [12],[20]; one trial included brain-dead patients and expanded donor criteria [41], and one trial included patients with circulatory death, brain death, and expanded donor criteria [29].
The average age of donors was 39.9 years for donors with circulatory death and 46.3 for donors with brain death.
The average time of ischemia was 23.5 hours for kidneys receiving hypothermic machine perfusion , and 19.5 hours for static cold.

What types of interventions were included*

All trials compared hypothermic machine perfusion against static cold [12],[20],[21],[22],[23],[25],[26],[29],[31],[41] ],[42],[43],[44].

The type of perfusion machine used to perform hypothermic perfusion varied between the different trials. One trial used Waters/ Gambro [22], five trials used only Waters MOX100 [12],[21],[23],[31],[43], four trials used ORP LifePort [25],[41],[44],[29], one trial used only Gambro [42] and one trial used Nikkiso APS-02 [26]. There is no information regarding the type of machine used in one trial [20].

The different preservative fluids used in static cold also varied between trials. Four trials used the Euro-Collins solution [12],[20],[21],[31], seven trials used a solution from the University of Wisconsin [22],[26],[29],[41],[ 42],[43],[44] and one used Marshall's solution [25]. Only one trial did not specify which preservative solution for static cold was used [23].

What types of outcomes
were measured

The trials measured different outcomes, which were grouped by the systematic reviews as follows:

  • Delayed graft function
  • Primary graft failure
  • Graft survival at 1 year
  • Survival of the patient at 1 year

* The information about primary studies is extracted from the systematic reviews identified, unless otherwise specified.

Summary of findings

The information on the effects of hypothermic machine perfusion compared to static cold preservation is based on 13 randomized trials that included 2122 kidneys [12],[20],[21],[22],[23],[25],[26],[29],[31],[41],[42],[43],[44].

All trials measured delayed graft function (2122 kidneys), eight trials primary graft failure (1719 kidneys) [20],[22],[26],[29],[31],[41],[42],[44], 10 trials graft survival at one year (2002 kidneys) [20],[21],[22],[23],[25],[29],[31],[41],,[42],[44] and six survival of the patient at one-year (1622 kidneys) [20],[22],[29],[31],[41],[44].

The summary of findings is as follows: 

  • Hypothermic machine perfusion probably decreases delayed graft function. The certainty of the evidence is moderate.
  • It is not clear whether hypothermic machine perfusion decreases primary failure of the graft because the certainty of the evidence is very low.
  • Hypothermic machine perfusion might slightly improve graft survival at 1 year, but the certainty of the evidence is low.
  • Hypothermic machine perfusion results in little or no difference in survival of the patient at 1 year. The certainty of the evidence is high.

Follow the link to access the interactive version of this table (Interactive Summary of Findings – iSoF)

Other considerations for decision-making

To whom this evidence does and does not apply

  • The evidence presented in this summary applies to kidney grafts from donors with circulatory death, cerebral death or expanded criteria.
  • Most of the donors and recipients were adults, so this evidence should be extrapolated with caution to the pediatric population. There was no distinction between sexes, so the results are applicable to both groups indistinctly.
About the outcomes included in this summary
  • The outcomes included in this summary are those considered critical for clinical decision making, according to the opinion of the authors. In general, they coincide with those presented in the systematic reviews identified.
Balance between benefits and risks, and certainty of the evidence
  • Hypothermic machine perfusion probably decreases delayed graft function in comparison with the static cold storage, with a moderate level of certainty. It might also slightly improve the survival of the graft at 1 year, but the certainty of the evidence is low. Additionally, there is little or no difference in the survival of the patient at 1 year.
  • No information was found on adverse effects for both graft preservation techniques, which is an important piece of information for decision-making.
Resource considerations
  • One systematic review [2] analyzed cost-effectiveness between the two alternatives, concluding there is not enough evidence to generate an appropriate economic model, so their results should be interpreted with caution. This review indicates that hypothermic machine perfusion is associated with an increase in the costs of the transplant program in comparison to static cold preservation, mainly derived from perfusion machine and supplies. However, the costs would be offset by the subsequent reduction in hospitalization and dialysis requirements associated with a lower incidence delayed graft function and longer survival of the graft.
What would patients and their doctors think about this intervention
  • Regarding the evidence presented in this summary, many clinicians should prefer the use of hypothermic machine perfusion, since it decreases delayed graft function and could improve its survival. However, due to the lack of information on cost-effectiveness, and uncertainty about adverse effects, some variability in decision-making can be anticipated.

Differences between this summary and other sources

  • The conclusions of this summary agree with those of the identified systematic reviews.
  • The Kidney Disease Improving Global Outcomes (KDIGO) guidelines [45], the Kidney Disease Outcomes Quality Initiative (KDOQI) [46] and the Canadian Society of Transplantation [47] do not address the topic covered in this summary of evidence.
Could this evidence change in the future?
  • The probability that future research changes the conclusions of this summary is low, due to the certainty of the existing evidence, especially in relation to delayed graft function and survival of the patient.
  • We did not identify ongoing trials evaluating this question in the International Clinical Trials Registry Platform of the World Health Organization or systematic reviews in the International prospective register of systematic reviews (PROSPERO).
How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.

Follow the link to access the interactive version: Hypothermic machine perfusion versus static cold preservation in kidney transplantation

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier.

After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

This article is part of the Epistemonikos Evidence Synthesis project. It is elaborated with a pre-established methodology, following rigorous methodological standards and internal peer review process. Each of these articles corresponds to a summary, denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos), whose main objective is to synthesize the body of evidence for a specific question, with a friendly format to clinical professionals. Its main resources are based on the evidence matrix of Epistemonikos and analysis of results using GRADE methodology. Further details of the methods for developing this FRISBEE are described here (http://dx.doi.org/10.5867/medwave.2014.06.5997)

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

Potential conflicts of interest

The authors do not have relevant interests to declare.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

INTRODUCCIÓN
La adecuada preservación del aloinjerto previo al trasplante renal es crucial para mantener buenos resultados luego del trasplante. En la actualidad existen dos métodos principales, la perfusión hipotérmica asistida por una máquina y la preservación en frío estático. El objetivo principal de este resumen es comparar ambos sistemas de preservación.

MÉTODOS
Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE.

RESULTADOS Y CONCLUSIONES
Identificamos 10 revisiones sistemáticas que en conjunto incluyeron 34 estudios primarios, de los cuales 13 corresponden a ensayos aleatorizados. Concluimos que la preservación mediante perfusión hipotérmica de máquina probablemente disminuye el riesgo de retraso en el funcionamiento del injerto y podría llevar a un leve aumento en la sobrevida del injerto. Sin embargo, no existen diferencias en la sobrevida del paciente entre ambos métodos.

Authors: José Ignacio Domínguez[1,2], Martin de Amesti[1,2], Alejandro Majerson[2,3]

Affiliation:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Proyecto Epistemonikos, Santiago, Chile
[3] Departamento de Urología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile

E-mail: amajerson@med.puc.cl

Author address:
[1] Centro Evidencia UC
Pontificia Universidad Católica de Chile
Diagonal Paraguay 476
Santiago
Chile

Citation: Domínguez JI, de Amesti M, Majerson A. Hypothermic machine perfusion versus static cold preservation in kidney transplantation. Medwave 2018;18(7):e7359 doi: 10.5867/medwave.2018.07.7359

Submission date: 22/10/2018

Acceptance date: 12/11/2018

Publication date: 30/11/2018

Origin: This article is a product of the Evidence Synthesis Project of Epistemonikos Fundation, in collaboration with Medwave for its publication.

Type of review: Non-blinded peer review by members of the methodological team of Epistemonikos Evidence Synthesis Project.

PubMed record

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Bathini V, McGregor T, McAlister VC, Luke PP, Sener A. Renal perfusion pump vs cold storage for donation after cardiac death kidneys: a systematic review. J Urol. 2013 Jun;189(6):2214-20. | CrossRef | PubMed |

Bond M, Pitt M, Akoh J, Moxham T, Hoyle M, Anderson R. The effectiveness and cost-effectiveness of methods of storing donated kidneys from deceased donors: a systematic review and economic model. Health Technol Assess. 2009 Aug;13(38):iii-iv, xi-xiv, 1-156. | CrossRef | PubMed |

Deng R, Gu G, Wang D, Tai Q, Wu L, Ju W, Zhu X, Guo Z, He X. Machine perfusion versus cold storage of kidneys derived from donation after cardiac death: a meta-analysis. PLoS One. 2013;8(3):e56368. | CrossRef | PubMed | PMC |

Dikdan GS, Mora-Esteves C, Koneru B. Review of randomized clinical trials of donor management and organ preservation in deceased donors: opportunities and issues. Transplantation. 2012 Sep 15;94(5):425-41. | CrossRef | PubMed |

Hameed AM, Pleass HC, Wong G, Hawthorne WJ. Maximizing kidneys for transplantation using machine perfusion: from the past to the future: A comprehensive systematic review and meta-analysis. Medicine (Baltimore). 2016 Oct;95(40):e5083. | PubMed | PMC |

Hu X.-Y., Wang Y.-F., Ye Q.-F., Chen Z.-Q., Fan X.-L., Guo Y., Li N.. Effects of hypothermic machine perfusion versus static cold storage of kidney allografts on transplant outcomes: A Meta-analysis. Chinese Journal of Tissue Engineering Research. 2015;19(42):6882-6888.

Jiao B, Liu S, Liu H, Cheng D, Cheng Y, Liu Y. Hypothermic machine perfusion reduces delayed graft function and improves one-year graft survival of kidneys from expanded criteria donors: a meta-analysis. PLoS One. 2013 Dec 10;8(12):e81826. | CrossRef | PubMed | PMC |

Lam VW, Laurence JM, Richardson AJ, Pleass HC, Allen RD. Hypothermic machine perfusion in deceased donor kidney transplantation: a systematic review. J Surg Res. 2013 Mar;180(1):176-82. | CrossRef | PubMed |

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