Hypothermic perfusion of the kidney: from research to clinical practice

Kidney transplantation is the treatment of choice for patients with end stage renal disease (ESRD). Donor availability is lower than demand, therefore suboptimal grafts retrieved from donors after brain death with expanded criteria donors (EC-DBD) and from donors after cardiac death (DCD) are increasingly used. These organs carry a higher risk of worse clinical outcomes, and subsequently need more advanced preservation systems than static cold storage (SCS). Hypothermic perfusion represents one of the aforementioned strategies. This review summarizes the main features of hypothermic perfusion: its mechanism of action through analysis of preclinical models and its clinical efficacy in kidney transplantation with a focus on marginal donors. Oxygenated hypothermic perfusion was also evaluated focusing on its potential benefits on cell metabolism and graft immungenicity. Finally, as hypothermic perfusion not only allows to recover marginal grafts, but may also recondition grafts unsuitable for transplantation, the possible methods of graft evaluation and treatment options during perfusion are described in this review.