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Cold Storage of Deceased Donor Kidneys: Does the Solution Matter or Is the Solution Elsewhere?

Kidneys from deceased donors inevitably incur significant ischemic injury that often leads to delayed graft function and may compromise long-term graft outcome. Ischemic renal injury often begins in the donor before organ recovery and is an unavoidable consequence of the organ recovery process, especially following donation after circulatory death (DCD). During organ recovery, the kidneys are flushed with cold preservation solution as rapidly as possible to reduce the metabolic activity and energy demands of the renal tubular cells and other cell types within the graft, after which the kidney can then be stored safely either on ice (static cold storage) or by cold pulsatile machine perfusion. However, cooling does not completely stop metabolic activity and throughout the period of cold-storage continuing anaerobic metabolism within the cells causes a progressive decline in mitochondrial energy stores. Loss of function of membrane ion-exchange pumps may result in severe ionic and osmotic disturbances and a reduction in the structural integrity of both the cell wall and intracellular organelles. The tissue damage incurred during cold storage is then further compounded when the blood supply to the graft is restored in the recipient, with the release of the reactive oxygen species and various inflammatory mediators that characterize ischemia reperfusion injury.