To the Editor:
We read with interest the paper by Ausania et al. (1), which reviewed data from the UK national transplant database. It was a thorough examination of important recovery criteria contributing to increased rates of kidney damage from donors after circulatory death (DCD). The authors report a reduced rate of kidney procurement damage (11% vs. 19%) since the previous study by Wigmore et al. in 1999 (2). However, this timely and relevant study might be further improved if the authors could be invited to clarify several points.
The audit spanned a period of significant change in organ retrieval practices in the United Kingdom. The inception of the National Organ Retrieval Service (NORS) in April 2010 aimed to enable organ procurement to be performed by dedicated, consultant led teams. These were to provide a high quality retrieval service, close supervision and training to junior NORS team members (3). Although the paper does refer to these changes, it does not analyze the data with respect to them. It would be interesting to compare rates of organ damage, and the grade/experience of the retrieving surgeon, before and after the introduction of NORS to demonstrate the impact of changing national retrieval arrangements. It would be of great concern to find that retrieval injuries continued unabated despite a move toward a consultant delivered service.
With respect to the data collected, it relied on the reporting of damage by the retrieving surgeon. This introduces a reporting bias reliant upon honesty and recognition of injuries at the time of procurement. Although alluded to in the paper, identification of missed retrieval injuries, and potential further damage at the time of bench preparation of the graft, are more readily assessed by the implanting surgeon. It is this assessment, along with factors such as the adequacy of perfusion, that dictate if a DCD kidney is used or discarded. It would be of use to have an analysis of the concordance between the injuries and adequacy of perfusion reported by both retrieving and implanting surgeons. We agree with the authors' assertions that this data should be collected in future.
Finally, the authors rightly point out the expansion in use of DCD donor kidneys by the majority of UK centers. Even with the advent of NORS, such organs have generally been transplanted in ``local'' centers to limit transport cold ischemia times. In the future, DCD donor kidneys might be offered into the national matching scheme. Consequently, it is imperative that there is early recognition of retrieval injury and good communication between surgeons to ensure that only transplantable grafts are offered and transported nationally. This paper clearly demonstrates that there is a need to continue efforts to improve the quality of procurement surgery in this challenging group of donors.