Development of a program for kidney transplants using organs donated from donors awaiting cardiac arrest (type III Maastricht)
Desarrollo de un programa de trasplante renal con órganos procedentes de donación tras asistolia controlada, tipo III de Maastricht
REDInRen ISCIII (red06/0016), José Portolés-Pérezb, J. José Rubio-Muñozc, Juan J. Rubio-Muñozd, Omar Lafuente-Covarrubiasb, Beatriz Sánchez-Sobrinob, Joaquín Carballido-Rodrígueze, Gabriel Rodríguez-Reinae, Diego Rengifo-Abadde, Amparo Medina-Carrizob, Carmen Sanz-Morenob, José Fernández-Fernándezb
b Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Madrid,
c Unidad de Cuidados Intensivos, Hospital Universitario Puerta de Hierro, Madrid, Spain,
d Unidad de Cuidados Intensivos, Hospital Universitario Puerta de Hierro, Madrid,
e Servicio de Urología, Hospital Universitario Puerta de Hierro, Madrid,
Read
9314
Timeswas read the article
2475
Total PDF
6839
Total HTML
Share statistics
array:21 [ "pii" => "X2013251412002311" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2012.Jul.11539" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2012;32:754-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5262 "formatos" => array:3 [ "EPUB" => 293 "HTML" => 4233 "PDF" => 736 ] ] "Traduccion" => array:1 [ "es" => array:17 [ "pii" => "X0211699512002314" "issn" => "02116995" "doi" => "10.3265/Nefrologia.pre2012.Jul.11539" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia. 2012;32:754-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8789 "formatos" => array:3 [ "EPUB" => 334 "HTML" => 7785 "PDF" => 670 ] ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Desarrollo de un programa de trasplante renal con órganos procedentes de donación tras asistolia controlada, tipo III de Maastricht" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "754" "paginaFinal" => "759" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Development of a program for kidney transplants using organs donated from donors awaiting cardiac arrest (type III Maastricht)" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11539_19759_31354_es_11539_t1.jpg" "Alto" => 159 "Ancho" => 600 "Tamanyo" => 97668 ] ] "descripcion" => array:1 [ "es" => "Características básicas de los donantes" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => " REDInRen ISCIII (red06/0016), José Portolés-Pérez, J. José Rubio-Muñoz, Juan J. Rubio-Muñoz, Omar Lafuente-Covarrubias, Beatriz Sánchez-Sobrino, Joaquín Carballido-Rodríguez, Gabriel Rodríguez-Reina, Diego Rengifo-Abadd, Amparo Medina-Carrizo, Carmen Sanz-Moreno, José Fernández-Fernández" "autores" => array:12 [ 0 => array:1 [ "apellidos" => "REDInRen ISCIII (red06/0016)" ] 1 => array:2 [ "nombre" => "José" "apellidos" => "Portolés-Pérez" ] 2 => array:2 [ "nombre" => "J. José" "apellidos" => "Rubio-Muñoz" ] 3 => array:2 [ "nombre" => "Juan J." "apellidos" => "Rubio-Muñoz" ] 4 => array:2 [ "nombre" => "Omar" "apellidos" => "Lafuente-Covarrubias" ] 5 => array:2 [ "nombre" => "Beatriz" "apellidos" => "Sánchez-Sobrino" ] 6 => array:2 [ "nombre" => "Joaquín" "apellidos" => "Carballido-Rodríguez" ] 7 => array:2 [ "nombre" => "Gabriel" "apellidos" => "Rodríguez-Reina" ] 8 => array:2 [ "nombre" => "Diego" "apellidos" => "Rengifo-Abadd" ] 9 => array:2 [ "nombre" => "Amparo" "apellidos" => "Medina-Carrizo" ] 10 => array:2 [ "nombre" => "Carmen" "apellidos" => "Sanz-Moreno" ] 11 => array:2 [ "nombre" => "José" "apellidos" => "Fernández-Fernández" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "X2013251412002311" "doi" => "10.3265/Nefrologia.pre2012.Jul.11539" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251412002311?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699512002314?idApp=UINPBA000064" "url" => "/02116995/0000003200000006/v0_201502091338/X0211699512002314/v0_201502091339/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "X2013251412002303" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2012.Jul.11522" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2012;32:760-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4960 "formatos" => array:3 [ "EPUB" => 283 "HTML" => 4013 "PDF" => 664 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Kidney transplantation with grafts from type III Maastricht death cardiac donors" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "760" "paginaFinal" => "766" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trasplante renal con injertos procedentes de donantes en parada cardíaca Maastricht tipo III" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Ángel Frutos-Sanz, Miguel Á. Frutos-Sanz, Francisco Guerrero-Gómez, Domingo Daga-Ruiz, Mercedes Cabello-Díaz, Miguel Lebrón-Gallardo, Guillermo Quesada-García, Andrés Ruiz-Valverde, Víctor Baena-González, Domingo Hernández-Marrero" "autores" => array:10 [ 0 => array:2 [ "nombre" => "M. Ángel" "apellidos" => "Frutos-Sanz" ] 1 => array:2 [ "nombre" => "Miguel Á." "apellidos" => "Frutos-Sanz" ] 2 => array:2 [ "nombre" => "Francisco" "apellidos" => "Guerrero-Gómez" ] 3 => array:2 [ "nombre" => "Domingo" "apellidos" => "Daga-Ruiz" ] 4 => array:2 [ "nombre" => "Mercedes" "apellidos" => "Cabello-Díaz" ] 5 => array:2 [ "nombre" => "Miguel" "apellidos" => "Lebrón-Gallardo" ] 6 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Quesada-García" ] 7 => array:2 [ "nombre" => "Andrés" "apellidos" => "Ruiz-Valverde" ] 8 => array:2 [ "nombre" => "Víctor" "apellidos" => "Baena-González" ] 9 => array:2 [ "nombre" => "Domingo" "apellidos" => "Hernández-Marrero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699512002306" "doi" => "10.3265/Nefrologia.pre2012.Jul.11522" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699512002306?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251412002303?idApp=UINPBA000064" "url" => "/20132514/0000003200000006/v0_201502091602/X2013251412002303/v0_201502091603/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "X201325141200232X" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2012.Jul.11549" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2012;32:743-53" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6137 "formatos" => array:3 [ "EPUB" => 288 "HTML" => 5029 "PDF" => 820 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Epidemiological study of 7316 patients on haemodialysis treated in FME clinics in Spain, using data from the EuCliD® database: results from years 2009-2010" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "743" "paginaFinal" => "753" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio epidemiológico de 7316 pacientes en hemodiálisis tratados en las clínicas FME de España, con los datos obtenidos mediante la base de datos EuCliD®: resultados de los años 2009-2010" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => " Grupo ORD (Optimizando Resultados de Diálisis), Rafael Pérez-García, Inés Palomares-Sancho, José I. Merello-Godino, Pedro Aljama-García, Jesús Bustamante-Bustamante, José Luño, Francisco Maduell-Canals, Ángel L. Martín-de Francisco, Alejandro Martín-Malo, Eduard Mirapeix-i-Vicens, Manuel Molina-Núñez, Manuel Praga-Terente, Ciro Tetta, Daniele Marcelli" "autores" => array:15 [ 0 => array:1 [ "apellidos" => "Grupo ORD (Optimizando Resultados de Diálisis)" ] 1 => array:2 [ "nombre" => "Rafael" "apellidos" => "Pérez-García" ] 2 => array:2 [ "nombre" => "Inés" "apellidos" => "Palomares-Sancho" ] 3 => array:2 [ "nombre" => "José I." "apellidos" => "Merello-Godino" ] 4 => array:2 [ "nombre" => "Pedro" "apellidos" => "Aljama-García" ] 5 => array:2 [ "nombre" => "Jesús" "apellidos" => "Bustamante-Bustamante" ] 6 => array:2 [ "nombre" => "José" "apellidos" => "Luño" ] 7 => array:2 [ "nombre" => "Francisco" "apellidos" => "Maduell-Canals" ] 8 => array:2 [ "nombre" => "Ángel L." "apellidos" => "Martín-de Francisco" ] 9 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Martín-Malo" ] 10 => array:2 [ "nombre" => "Eduard" "apellidos" => "Mirapeix-i-Vicens" ] 11 => array:2 [ "nombre" => "Manuel" "apellidos" => "Molina-Núñez" ] 12 => array:2 [ "nombre" => "Manuel" "apellidos" => "Praga-Terente" ] 13 => array:2 [ "nombre" => "Ciro" "apellidos" => "Tetta" ] 14 => array:2 [ "nombre" => "Daniele" "apellidos" => "Marcelli" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699512002322" "doi" => "10.3265/Nefrologia.pre2012.Jul.11549" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699512002322?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X201325141200232X?idApp=UINPBA000064" "url" => "/20132514/0000003200000006/v0_201502091602/X201325141200232X/v0_201502091603/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Development of a program for kidney transplants using organs donated from donors awaiting cardiac arrest (type III Maastricht)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "754" "paginaFinal" => "759" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => " REDInRen ISCIII (red06/0016), José Portolés-Pérez, J. José Rubio-Muñoz, Juan J. Rubio-Muñoz, Omar Lafuente-Covarrubias, Beatriz Sánchez-Sobrino, Joaquín Carballido-Rodríguez, Gabriel Rodríguez-Reina, Diego Rengifo-Abadd, Amparo Medina-Carrizo, Carmen Sanz-Moreno, José Fernández-Fernández" "autores" => array:12 [ 0 => array:1 [ "apellidos" => "REDInRen ISCIII (red06/0016)" ] 1 => array:4 [ "nombre" => "José" "apellidos" => "Portolés-Pérez" "email" => array:1 [ 0 => "josem.portolés@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "J. José" "apellidos" => "Rubio-Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => "Juan J." "apellidos" => "Rubio-Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] 4 => array:3 [ "nombre" => "Omar" "apellidos" => "Lafuente-Covarrubias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 5 => array:3 [ "nombre" => "Beatriz" "apellidos" => "Sánchez-Sobrino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 6 => array:3 [ "nombre" => "Joaquín" "apellidos" => "Carballido-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] 7 => array:3 [ "nombre" => "Gabriel" "apellidos" => "Rodríguez-Reina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] 8 => array:3 [ "nombre" => "Diego" "apellidos" => "Rengifo-Abadd" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] 9 => array:3 [ "nombre" => "Amparo" "apellidos" => "Medina-Carrizo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 10 => array:3 [ "nombre" => "Carmen" "apellidos" => "Sanz-Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 11 => array:3 [ "nombre" => "José" "apellidos" => "Fernández-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitario Puerta de Hierro, Madrid, Spain, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 2 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitario Puerta de Hierro, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 3 => array:3 [ "entidad" => "Servicio de Urología, Hospital Universitario Puerta de Hierro, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Desarrollo de un programa de trasplante renal con órganos procedentes de donación tras asistolia controlada, tipo III de Maastricht" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11539_16025_38383_en_t111539i.jpg" "Alto" => 566 "Ancho" => 2174 "Tamanyo" => 371231 ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of organ donors" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The number of donors after brain death (DBD) has been on the decrease in recent years, with progressive changes to the characteristics of these cases. Currently, DBD are most frequently males older than 65 years of age who die of cerebrovascular problems.<span class="elsevierStyleSup">1</span> Organ transplant coordination teams have improved the rate of effective donation to the point of reaching success in 63% of all patients with brain death, but despite this progress there is a disparity between the number of available organs and the number of patients on the organ waiting list.</p><p class="elsevierStylePara">The strategy for increasing access to transplants includes three approaches: optimising live transplantation in all of its different modalities, considering the use of expanded-criteria donors, and developing programmes for non-heart beating donors. In one Spanish autonomous community, uncontrolled non-heart beating donation (Maastricht types I and II) constituted 37% of all donations.<span class="elsevierStyleSup">2</span> This group includes donors who do not recover cardiac function following cardiopulmonary arrest whether inside or outside of the hospital. However, in other countries, controlled donation is much more common, stemming from situations of cardiac arrest following limitation of life sustaining treatments (LST) within the hospital (Maastricht type III).<span class="elsevierStyleSup">3</span> This model of non-heart beating donation is respectful of the patient’s family’s wishes, has been approved by ethics committees, and was recognised in a recent expert consensus document published by the National Transplant Organisation (ONT).<span class="elsevierStyleSup">4,5</span> However, the level of experience and familiarity with this very new type of transplant option is very scarce in our country, with only two cases published in 2011.<span class="elsevierStyleSup">6,7</span></p><p class="elsevierStylePara">Here we present our experience from the establishment of a programme specifically designed for this type of organ donation, covering the short-term follow-up for the first 10 such transplants performed during a 4-month period.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">PATIENTS AND PROTOCOL</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Ours was a descriptive case series including all controlled donations from non-heart beating donors performed between January and April 2011. During the last trimester in 2011, a protocol was established for organ donation following controlled cardiac arrest, and the kidney transplantation process in general was restructured and prioritised in order to reduce cold ischaemia time. The transplant coordination, nephrology, urology, immunology, and anaesthesiology departments all participated in this process. The protocol for organ donation from patients after controlled cardiac arrest was presented to all of the departments involved in kidney transplants and the transplant committee, and was approved by the hospital health care ethics committee, the regional office for transplant coordination, and the ONT. The priority structure for the complete kidney donation and transplantation process was also backed by the hospital administration, and was presented in a general hospital conference.</p><p class="elsevierStylePara">Patients with irreversible neurological damage, terminal neuromuscular diseases, upper spinal cord injuries, and terminal respiratory diseases are all candidates for this programme for donation following limitation of LST. Once the medical team in the intensive care unit (ICU) makes the decision to remove LST based on the department’s standard protocol, the family of the patient is notified. Only after the proposal for limiting LST is accepted by the patient’s family does the transplant coordination team consider the possibility of organ donation. In this manner, the procedure for limiting a patient from LST is separated from the donation process, thus avoiding ethical conflicts of interest.</p><p class="elsevierStylePara">We used the inclusion criteria for kidney transplantation established by the British Transplantation Society: age <65 years, normal renal function or creatinine (Cr) <2mg/dl if normal renal function was evaluated prior to the event. If renal function is inconclusive, a renal biopsy is taken.<span class="elsevierStyleSup">8</span> We use the University of Wisconsin score to estimate the expected waiting time between limitation of LST and death.<span class="elsevierStyleSup">9</span> Following cardiac arrest, patient death was registered after 5 minutes of observation. If cardiac arrest did not occur within 120 minutes of limitation of LST, organ donation was suspended and the patient was returned to normal health care until death.</p><p class="elsevierStylePara">We used one of two different protocols for organ extraction. The first consisted of a rapid laparotomy with direct cannulation of the aorta and <span class="elsevierStyleItalic">in situ</span> perfusion with a storage solution together with local cooling and organ extraction. The second required <span class="elsevierStyleItalic">ante mortem</span> cannulation of the femoral vessels with double-balloon triple-lumen catheters (AJ6536 by Porgès S.A., Le Plessis-Robinson, France), leaving the balloons uninflated until patient death. After 5 minutes had passed, we perfused the patient with cold storage solution (Celsior<span class="elsevierStyleSup">®</span>), thereby minimising the time of warm ischaemia (WIT). WIT should not surpass 60 minutes in order to consider the kidneys valid for transplantation. WIT was quantified as the time period between the appearance of functional hypoperfusion (MAP<60mm Hg) and the start of cold perfusion with organ storage solution.<span class="elsevierStyleSup">9</span> We have designed a specific informed consent document for the recipient detailing the particularities of this type of donor, usage data, risks, and results published in other studies.</p><p class="elsevierStylePara">The immunosuppression protocol used takes into account the high risk of delayed graft function inherent to kidneys donated by non-heart beating donors. This entailed an induction phase with steroids and thymoglobulin (1mg/kg/day x 7 days); we added mycophenolate mofetil (1-2g/day) starting at day 1, and started tacrolimus (0.1mg/kg/day) on the seventh day. When no significant improvement was observed in renal function, the conversion from thymoglobulin to tacrolimus was performed earlier. We added prophylaxis against cytomegalovirus infection as per guideline recommendations.<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Here we present the results from 10 patients that received a kidney from one of 5 non-heart beating donors (NHBD), with a follow-up of the evolution of clinical and laboratory parameters lasting 6-24 weeks. Since this was a small sample of patients in which the numerical values did not follow a normal distribution, we expressed values as median and range. No statistical tests were performed.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">We have included the transplant results from the first 5 non-heart beating donors (4 male and 1 female) at our hospital between January and April 2012. The median donor age was 57 years (range: 45-66 years). The reasons for limiting LST were: three cases of severe encephalopathy (two following cardiopulmonary arrest due to myocardial infarction and one due to methanol intoxication), one massive cerebral haemorrhage, and one case of terminal pulmonary fibrosis. The characteristics of the donors and extraction processes used are summarised in Table 1. We used rapid organ extraction with perfusion in the surgical area in the first two cases, and the organs from the following three donors were extracted using <span class="elsevierStyleItalic">ante mortem</span> cannulation and cold perfusion after confirmation of donor death. All organs were certified as viable upon inspection and clinical evaluation, but we performed a renal biopsy of the kidneys from donor 3 due to the advanced donor age, which were also considered viable after the pathologist observed only one sclerosed glomerulus out of 35 evaluated.</p><p class="elsevierStylePara">The baseline characteristics of the transplant recipients are summarised in Table 2. The median recipient age was 58 years (range: 32-71 years), with a mean duration of time on dialysis of 31.7 months (range: 11-84 months). Two of these patients were receiving their second transplant, and none were hyper-immunised. The mean HLA compatibility score was 1.2/6, the median effective warm ischaemia time was 20 minutes (range: 8-23 minutes), and median cold ischaemia time was 7.5 hours (range: 4-14.1 hours). Six patients required dialysis or ultrafiltration following transplantation, and 4 patients developed prolonged acute tubular necrosis (ATN), with delayed graft function. The median duration of recipient hospital stay was 24.5 days (range: 8-44 days). Median Cr one month after transplantation was 2.1mg/dl (range: 0.7-3.2mg/dl) and median nadir Cr was 1.2mg/dl (range: 0.7-3.3mg/dl).</p><p class="elsevierStylePara">The only patient whose Cr did not decrease below 3.2mg/dl was biopsied, but only slight glomerular sclerosis was observed, with no signs of acute rejection, hyalinosis, or other types of vascular damage. We also found no signs of acute or chronic toxicity from calcineurin inhibitors, and polyomavirus tests were negative. The other kidney from the same donor reached a nadir Cr of 1.4mg/dl. During the entire study, the rate of surgical complications was very similar to that produced in our long-term registry of transplantations from conventional donors.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Here we present the first results from our new programme for non-heart beating donors following limitation of LST. In a very short follow-up period, our patients reached a median Cr of 1.2mg/dl, and only one patient had sustained high Cr levels despite this being the case with the longest follow-up period. Overall, the results are very similar to those achieved in other international studies<span class="elsevierStyleSup">11</span> of much larger scope, and are sufficiently promising for us to continue with the programme.</p><p class="elsevierStylePara">The experiences communicated from other transplant centres in the country have used a less systematic approach, and do not appear to be destined towards a standardised programme per se, but are rather reports of sporadic cases. We believe that this type of donor deserves a specific approach and the design of a standardised action plan, since this type of organ donation may come to constitute an important portion of transplant activity. In fact, our initial estimate led us to expect 3-4 appropriate donors of this type per year, and yet we have observed a higher incidence of patients that are appropriate cases for limitation of LST, with excellent responses by family members and optimal use of available organs. This low rate of negative responses coincides with the results traditionally observed for uncontrolled non-heart beating donors. Results compiled from the regional transplant office in Madrid from 2011 report a rate of negative results of 22% for DBD, and only 8% for NHBD.<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">The meagre use of this type of donor in Spain is due to the sufficient availability of conventional donors and a certain level of reticence to this methodology among potential donors, which was expressed in a document published by the ONT in 1999. Both of these conditions have changed, which has facilitated the progression towards a new phase of organ transplantation in Spain. The document recently published by the ONT is aligned with the stipulations in consensus documents from other countries, and is of great value for those who wish to develop this type of programme for controlled non-heart beating donors.<span class="elsevierStyleSup">4,5</span></p><p class="elsevierStylePara">Organs donated from Maastricht type III donors constitute 50% of kidney transplantations in nearby countries, such as Belgium, the United Kingdom, and Holland.<span class="elsevierStyleSup">3</span> According to data published by the United Network for Organ Sharing (UNOS), the number of transplanted kidneys provided by DBD increased by 22% between 2000 and 2005, with kidneys from non-heart beating donors increasing by 36.1% during this same time period.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">The development of programmes for controlled non-heart beating donors for more than 15 years has allowed us to apply the results from previous experiences into our own model.<span class="elsevierStyleSup">13</span> Uncontrolled non-heart beating donors imply an inferior situation for the viability of the organ, since the exact conditions of the organ are unknown and the organs generally spend a greater length of time without life support after cardiopulmonary arrest. As such, as many as 35% of these organs are rejected for transplantation, and high rates of prolonged ATN are produced, increasing the amount of time needed for nadir Cr to be reached. Despite this, mid-term functioning of these kidneys is comparable to that of organs from brain dead donors.<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara">In the case of donors with controlled cardiac arrest, the scenario of available information and organ management is very different, and could produce better results. In our study, all extracted kidneys were transplanted into recipients; the evolution of renal function in these recipients was slower than in cases of kidneys from DBD in our long-term registry, but a reasonable nadir Cr was reached, which could continue to improve in the patients who have only been monitored for a short time. Another added value of the implementation of this programme is that it has contributed to the reorientation of the health care process for kidney transplantations in our hospital, reducing cold ischaemia times to half that of the previous records for organs derived from DBD.</p><p class="elsevierStylePara">On average, the donors in our study were somewhat younger, spent a shorter period of time in the ICU, and had lower acute comorbidity rates than is usual for donors after brain death. We did not consider it necessary to systematically take biopsies from extracted organs, and we preferred to use more restrictive clinical criteria and a macroscopic evaluation of the organ.</p><p class="elsevierStylePara">Some authors believe that organ donation following removal of LST anticipates the situation of brain death, which reduces the availability of other organs that would be viable in the case of a conventional donor.<span class="elsevierStyleSup">1</span> However, the patient profiles for these two situations are quite different, requiring a precise clinical diagnosis made in the ICU. In addition, it is important to demarcate a separation between the decision to remove LST, which is a common practice in the ICU, from the donation process. In our short experience, the rate of conventional donors in the hospital has remained constant. In light of these considerations, we believe that the transplants performed under this modality would not have occurred if a specific programme for this type of donation had not been put into place.</p><p class="elsevierStylePara">The use of Maastricht type III donors implies a much less complex organisational paradigm than type I and II donors, and such a programme can be implemented in many hospitals with scarce need for additional resources. It is only necessary to develop a protocol within the hospital oriented to this type of transplant. In fact, the Canadian consensus recommends that centres that wish to work with non-heart beating donors should do so under controlled conditions.<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Obviously, ours is a preliminary short-term analysis, which presents the greatest limitation for our study. However, it is in the initial phase of implementing a new programme that the most blatant organisational issues arise, and in the first individual case that the majority of issues for the patient are brought to light, such as surgical complications and delayed graft function. Other authors have indicated that kidneys derived from this type of donor have a greater tendency for acute rejection, although mid-term graft and patient survival does not differ from that of a registry of transplants coming from donors after brain death.<span class="elsevierStyleSup">12</span> The immunosuppression therapy used was intended to avoid added tubular damage during initial phases, but was also sufficiently effective to protect against rejection. In our short follow-up period, we did not observe any cases of acute rejection. Long-term follow-up should also compare the results between kidneys derived from the different types of donors. To this end, we propose that registries of kidney patients include a specific variable that classifies patients by the type of kidney donated in order to compile results from the experience of multiple groups.</p><p class="elsevierStylePara">We believe that patients should be provided with specific information regarding the type of organ that they will receive, especially if the kidney comes from an expanded-criteria, non-heart beating donor. In these cases, the potential recipient should be informed as to the specific risks implied in order to properly evaluate this option as compared to the risks of continued dialysis treatment while waiting for a conventional donor. For this purpose we have created a specific model for organ transplants derived from controlled non-heart beating donors. In our study, only one patient refused this type of transplant in light of the information provided.</p><p class="elsevierStylePara">We can conclude that the implementation of a kidney transplant programme for Maastricht type III non-heart beating donors is an adequate alternative for increasing the number of kidney transplants, thus decreasing the waiting list time for potential recipients. Although ours was a small series of kidney transplants, it has allowed us to consider this option to be a valid and adequate alternative for overcoming the progressive decrease in the availability of DBD.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no potential conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/11539_16025_38383_en_t111539i.jpg" class="elsevierStyleCrossRefs"><img src="11539_16025_38383_en_t111539i.jpg" alt="Baseline characteristics of organ donors"></img></a></p><p class="elsevierStylePara">Table 1. Baseline characteristics of organ donors</p><p class="elsevierStylePara"><a href="grande/11539_16025_38384_en_t211539i.jpg" class="elsevierStyleCrossRefs"><img src="11539_16025_38384_en_t211539i.jpg" alt="Characteristics of the transplant recipients and the evolution of their clinical/laboratory parameters"></img></a></p><p class="elsevierStylePara">Table 2. Characteristics of the transplant recipients and the evolution of their clinical/laboratory parameters</p>" "pdfFichero" => "P1-E544-S3760-A11539-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437051" "palabras" => array:1 [ 0 => "Donante criterios expandidos" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437053" "palabras" => array:1 [ 0 => "Donante tipo III Maastricht" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437055" "palabras" => array:1 [ 0 => "Donante en asistolia" ] ] ] "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437052" "palabras" => array:1 [ 0 => "Expanded criteria donor" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437054" "palabras" => array:1 [ 0 => "Maastricht type III donor" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437056" "palabras" => array:1 [ 0 => "Non Heart-beating donor" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducción</span><span class="elsevierStyleBold">:</span> La disponibilidad de donantes es el factor limitante para el trasplante renal. El donante en asistolia (DAS) no controlado proporciona hasta un tercio de los órganos. El DAS controlado tras limitación de técnicas de soporte vital (LTSV) o tipo III de Maastricht constituye una alternativa aún por desarrollar de forma sistemática. <span class="elsevierStyleBold">Tipo de estudio</span><span class="elsevierStyleBold">:</span> Descriptivo, serie de 10 casos realizados entre enero y abril 2012. <span class="elsevierStyleBold">Métodos</span><span class="elsevierStyleBold">:</span> A lo largo de 6 meses se diseña el protocolo de extracción y manejo del trasplante e inmunosupresión entre los equipos implicados. Se evalúan los pacientes de acuerdo con los criterios consensuados por un equipo distinto al responsable de coordinación de trasplante. Se establece un tiempo máximo 120 min desde LTSV hasta fallecimiento y de 60 min de isquemia caliente. Se utilizan dos tipos de perfusión de injerto, uno <span class="elsevierStyleItalic">in situ</span> por abordaje directo en lecho quirúrgico y otro con canalización vascular <span class="elsevierStyleItalic">antemortem</span>. La pauta de inmunosupresión incluye inducción con timoglobulina, esteroides y micofenolato e introducción de tacrolimus al séptimo día. Se muestran datos como mediana y (rango). <span class="elsevierStyleBold">Resultados</span><span class="elsevierStyleBold">:</span> Se incluyen los 10 primeros casos de trasplante renal con órganos procedentes de 5 DAS tipo III de Maastricht: 4 varones, edad media 57 años (45-66), con LTSV por encefalopatía anóxica (2), intoxicación (1), accidente cerebrovascular agudo (2) e insuficiencia respiratoria terminal (1). Los tiempos registrados fueron: isquemia caliente efectiva de 20 min (8-23) e isquemia fría de 7,5 horas (4-14,1). Los receptores tenían 58 años (32-71), con distintas etiologías (2 glomerulonefritis, 1 poliquistosis, 2 nefropatía tubulointersticial, 4 vasculares y 1 no filiada), llevaban en hemodiálisis 31,7 meses (11-84) y para 2 de ellos era su segundo trasplante. Ninguno era hiperinmunizado. Seis pacientes precisaron alguna sesión de diálisis y cuatro presentaron necrosis tubular aguda prolongada, durante un ingreso de 24,5 días (8-44 d). La creatinina (Cr) al mes del trasplante fue de 2,1 mg/dl (0,7-3,2) y la Cr nadir fue de 1,2 mg/dl (0,7-3,2 mg/dl). Un paciente no mejoró su Cr por debajo de 3,2 mg/dl aunque la biopsia no mostró toxicidad ni rechazo, y su pareja de trasplante alcanzó una Cr de 1,4 mg/dl. En toda la serie se constataron complicaciones quirúrgicas similares a las de nuestra serie histórica de donantes convencionales. <span class="elsevierStyleBold">Conclusiones</span><span class="elsevierStyleBold">:</span> Con las limitaciones de un estudio preliminar, el uso de este tipo de injertos presenta una evolución favorable a corto plazo. La utilización de este tipo de donante puede ayudar a reducir el tiempo de espera para un trasplante.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span>: The availability of organ donors is a limiting factor for kidney transplants. Donations from non-heart-beating donors (NHBD) can provide as many as one-third of all organs. Controlled patients awaiting cardiac arrest following limitation of life support techniques, or type III Maastricht donors, constitute an alternative that still has yet to be systematically developed. <span class="elsevierStyleBold">Study type</span>: Descriptive series of 10 cases occurring between January and April 2012.<span class="elsevierStyleBold"> Method:</span> Over a period of 6 months, we designed a protocol for extracting and managing kidney transplants and providing immunosuppression therapy. Patients are evaluated in accordance with the criteria agreed by a different team responsible for transplant coordination. We established a maximum duration of time between limitation of life-sustaining therapy and death of 120 minutes and 60 minutes warm ischaemia. Two types of graft perfusion were used, one <span class="elsevierStyleItalic">in situ</span> through direct application to the surgical area, and another using <span class="elsevierStyleItalic">ante mortem</span> vascular canalisation. Immunosuppression therapy included induction with thymoglobulin, steroids, and mycophenolate, with introduction of tacrolimus on the seventh day. Data are expressed as median and (range). <span class="elsevierStyleBold">Results:</span> We included the first 10 cases of kidney transplants with organs from 5 NHBD (type III Maastricht): 4 males, mean age of 57 years (45-66 years), with limitation of life-sustaining therapy due to anoxic encephalopathy (2), intoxication (1), acute stroke (2) and terminal respiratory failure (1). The following mean time intervals were recorded: effective warm ischaemia: 20 minutes (8-23 minutes) and cold ischaemia: 7.5 hours (4-14.1 hours). Recipients had a mean age of 58 years (32-71 years), with various aetiologies (2 cases of glomerulonephritis, 1 polycystic kidney disease, 2 tubulo-interstitial nephropathy, 4 vascular, and 1 unknown), with a mean 31.7 months on haemodialysis (11-84 months); the kidney was a second transplant in two cases. No patients were hyper-immunised. Six patients required a dialysis session at some point, and four had prolonged acute tubular necrosis, over a mean hospitalisation period of 24.5 days (8-44 days). Mean creatinine (Cr) one month after transplantation was 2.1mg/dl (0.7-3.2mg/dl), and mean nadir creatinine was 1.2mg/dl (0.7-3.2mg/dl). One patient did not improve upon Cr values <3.2mg/dl, despite the absence of evidence of toxicity or rejection in a renal biopsy, and the transplant pair reached a Cr of 1.4mg/dl. Throughout the series, similar surgical complications were recorded to those observed in conventional donor situations. <span class="elsevierStyleBold">Conclusions</span>: Despite the limitations of this preliminary study, the use of this type of transplant produces favourable short-term evolution. Expanded use of this type of donor could reduce the waiting-list time for a kidney transplant.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11539_16025_38383_en_t111539i.jpg" "Alto" => 566 "Ancho" => 2174 "Tamanyo" => 371231 ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of organ donors" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11539_16025_38384_en_t211539i.jpg" "Alto" => 1137 "Ancho" => 2175 "Tamanyo" => 743326 ] ] "descripcion" => array:1 [ "en" => "Characteristics of the transplant recipients and the evolution of their clinical/laboratory parameters" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Domínguez-Gil B, Haase-Kromwijk B, Van Leiden H, Neuberger J, Coene L, Morel P, et al. Current situation of donation alter circulatory death in european countries. Transpl Int 2011;24(7):676-86. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21504489" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kootstra G, Daemen JH, Oomen AP. Categories of non-heart-beatingdonors. Transplant Proc 1995;27(5):2893-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7482956" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Ledicnh H, Bonvoisin C, Weekers L, de Roover A, Honoré P, Squifflet JP, et al. Results of kidney transplantation from donors after cardiac death. Transplant Proc 2010;42:2407-14. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20832517" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Shemie SD, Baker AJ, Knoll G, Wall W, Rocker G. Donation after cardiocirculatory death in Canada. CMAJ 2006;175(8):S1-S24." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Documento de consenso de la ONT sobre donación en asistolia.\u{A0}Available at:\u{A0}http://www.ont.es/infesp/DocumentosDeConsenso/DONACIÓN EN ASISTOLIA EN ESPAÑA. SITUACIÓN ACTUAL Y RECOMENDACIONES.pdf. [Accessed: May 10,\u{A0}2012]." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Corral E, Maynar J, Saralegui I, Manzano A. Donantes a corazón parado tipo III de Maastricht: una opción real. Med Intensiva 2011;35:59-60. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21146902" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S0140673609621772" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sanchez-Izquierdo A, Cisneros A, García-Guijarro R,\u{A0}Montejo JC,\u{A0}Baldrés A. Donantes tipo III de Maastricht (cartas al director). Med Intensiva 2011;35:524-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21798630" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Shemie SD, Doig C, Dickens B,\u{A0}Byrne P, Wheelock B, Rocker G, et al. Severe brain injury to neurological determination of death: Canadian forum recommendations. CMAJ 2006;174(6):S1-12." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "DeVita MA, Mori-Brooks M, Zawistowski C, Rudich S, Daly B, Chaitin E. Donors alter cardiac death: validation of identification criteria (DVIC) study for predictors of rapid death. Am J Transplant 2008;8:432-44." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Amenabar J, Arriceta G, Beneyto I, Bernis C, Calvo N, Crespo JF,\u{A0}et al. Estrategias de prevención y tratamiento de la enfermedad por citomegalovirus en pacientes con trasplante renal. Nefrologia Sup Ext\u{A0}2012;3(1):21-7." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pieter ER, Snoeijs M, van Heurn LW. DCD kidney transplantation: results and measures to improve outcome. Curr Opin Organ Transplant 2010;15:177-82. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20125021" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "ONT. Memoria de actividades 2010. Revista española de trasplantes 2011;2:1-31." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sánchez-Fructuoso A, Giorgi M, Barrientos A. Kidney transplantation from non-heartbeating donors: a Spanish view. Transplantation Reviews 2007;21:249-54." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003200000006/v0_201502091602/X2013251412002311/v0_201502091603/en/main.assets" "Apartado" => array:4 [ "identificador" => "35441" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003200000006/v0_201502091602/X2013251412002311/v0_201502091603/en/P1-E544-S3760-A11539-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251412002311?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 8 | 16 |
| 2024 October | 44 | 34 | 78 |
| 2024 September | 45 | 37 | 82 |
| 2024 August | 55 | 61 | 116 |
| 2024 July | 46 | 27 | 73 |
| 2024 June | 48 | 44 | 92 |
| 2024 May | 68 | 34 | 102 |
| 2024 April | 70 | 56 | 126 |
| 2024 March | 55 | 22 | 77 |
| 2024 February | 57 | 44 | 101 |
| 2024 January | 47 | 25 | 72 |
| 2023 December | 41 | 25 | 66 |
| 2023 November | 59 | 29 | 88 |
| 2023 October | 63 | 28 | 91 |
| 2023 September | 74 | 34 | 108 |
| 2023 August | 86 | 18 | 104 |
| 2023 July | 94 | 33 | 127 |
| 2023 June | 38 | 46 | 84 |
| 2023 May | 94 | 36 | 130 |
| 2023 April | 59 | 18 | 77 |
| 2023 March | 68 | 29 | 97 |
| 2023 February | 42 | 15 | 57 |
| 2023 January | 37 | 27 | 64 |
| 2022 December | 48 | 29 | 77 |
| 2022 November | 45 | 19 | 64 |
| 2022 October | 59 | 39 | 98 |
| 2022 September | 38 | 25 | 63 |
| 2022 August | 46 | 41 | 87 |
| 2022 July | 37 | 48 | 85 |
| 2022 June | 38 | 43 | 81 |
| 2022 May | 26 | 24 | 50 |
| 2022 April | 33 | 53 | 86 |
| 2022 March | 44 | 42 | 86 |
| 2022 February | 38 | 49 | 87 |
| 2022 January | 33 | 38 | 71 |
| 2021 December | 47 | 40 | 87 |
| 2021 November | 33 | 37 | 70 |
| 2021 October | 33 | 54 | 87 |
| 2021 September | 33 | 30 | 63 |
| 2021 August | 32 | 48 | 80 |
| 2021 July | 35 | 33 | 68 |
| 2021 June | 27 | 20 | 47 |
| 2021 May | 30 | 31 | 61 |
| 2021 April | 63 | 43 | 106 |
| 2021 March | 64 | 28 | 92 |
| 2021 February | 38 | 25 | 63 |
| 2021 January | 39 | 18 | 57 |
| 2020 December | 41 | 17 | 58 |
| 2020 November | 33 | 18 | 51 |
| 2020 October | 27 | 25 | 52 |
| 2020 September | 26 | 8 | 34 |
| 2020 August | 35 | 11 | 46 |
| 2020 July | 37 | 9 | 46 |
| 2020 June | 27 | 13 | 40 |
| 2020 May | 41 | 10 | 51 |
| 2020 April | 28 | 20 | 48 |
| 2020 March | 39 | 14 | 53 |
| 2020 February | 54 | 23 | 77 |
| 2020 January | 43 | 19 | 62 |
| 2019 December | 54 | 22 | 76 |
| 2019 November | 59 | 15 | 74 |
| 2019 October | 40 | 12 | 52 |
| 2019 September | 54 | 27 | 81 |
| 2019 August | 27 | 23 | 50 |
| 2019 July | 30 | 32 | 62 |
| 2019 June | 35 | 14 | 49 |
| 2019 May | 36 | 19 | 55 |
| 2019 April | 60 | 28 | 88 |
| 2019 March | 33 | 22 | 55 |
| 2019 February | 28 | 22 | 50 |
| 2019 January | 26 | 20 | 46 |
| 2018 December | 92 | 38 | 130 |
| 2018 November | 97 | 19 | 116 |
| 2018 October | 111 | 19 | 130 |
| 2018 September | 76 | 37 | 113 |
| 2018 August | 43 | 20 | 63 |
| 2018 July | 57 | 12 | 69 |
| 2018 June | 44 | 12 | 56 |
| 2018 May | 38 | 16 | 54 |
| 2018 April | 58 | 12 | 70 |
| 2018 March | 52 | 7 | 59 |
| 2018 February | 45 | 9 | 54 |
| 2018 January | 46 | 13 | 59 |
| 2017 December | 56 | 8 | 64 |
| 2017 November | 58 | 15 | 73 |
| 2017 October | 31 | 12 | 43 |
| 2017 September | 47 | 22 | 69 |
| 2017 August | 48 | 18 | 66 |
| 2017 July | 41 | 9 | 50 |
| 2017 June | 32 | 9 | 41 |
| 2017 May | 44 | 12 | 56 |
| 2017 April | 55 | 23 | 78 |
| 2017 March | 49 | 9 | 58 |
| 2017 February | 47 | 21 | 68 |
| 2017 January | 23 | 14 | 37 |
| 2016 December | 81 | 11 | 92 |
| 2016 November | 76 | 8 | 84 |
| 2016 October | 142 | 9 | 151 |
| 2016 September | 140 | 7 | 147 |
| 2016 August | 225 | 7 | 232 |
| 2016 July | 172 | 17 | 189 |
| 2016 June | 165 | 0 | 165 |
| 2016 May | 150 | 0 | 150 |
| 2016 April | 127 | 0 | 127 |
| 2016 March | 99 | 0 | 99 |
| 2016 February | 122 | 0 | 122 |
| 2016 January | 119 | 0 | 119 |
| 2015 December | 146 | 0 | 146 |
| 2015 November | 112 | 0 | 112 |
| 2015 October | 100 | 0 | 100 |
| 2015 September | 90 | 0 | 90 |
| 2015 August | 96 | 0 | 96 |
| 2015 July | 106 | 0 | 106 |
| 2015 June | 51 | 0 | 51 |
| 2015 May | 55 | 0 | 55 |
| 2015 April | 5 | 0 | 5 |
Show all
