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Living donor kidney transplantation (LDKT) is the best treatment option for end stage renal disease in terms of both patient and graft survival. However, figures on LDKT in Spain that had been continuously growing from 2005 to 2014, have experienced a continuous decrease in the last five years. One possible explanation for this decrease is that the significant increase in the number of deceased donors in Spain during the last years, both brain death and controlled circulatory death donors, might have generated the false idea that we have coped with the transplant needs. Moreover, a greater number of deceased donor kidney transplants have caused a heavy workload for the transplant teams. Furthermore, the transplant teams could have moved on to a more conservative approach to the information and assessment of patients and families considering the potential long-term risks for donors in recent papers. However, there is a significant variability in the LDKT rate among transplant centers and regions in Spain independent of their deceased donor rates. This fact and the fact that LDKT is usually a preemptive option for patients with advanced chronic renal failure, as time on dialysis is a negative independent factor for transplant outcomes, lead us to conclude that the decrease in LDKT depends on other factors. Thus, in the kidney transplant annual meeting held at ONT site in 2018, a working group was created to identify other causes for the decrease of LDKT in Spain and its relationship with the different steps of the process. The group was formed by transplant teams, a representative of the transplant group of the Spanish Society of Nephrology (SENTRA), a representative of the Spanish Society of Transplants (SET) and representatives of the Spanish National Transplant Organization (ONT). A self-evaluation survey that contains requests about the phases of the LDKT processes (information, donor work out, informed consent, surgeries, follow-up and human resources) were developed and sent to 33 LDKT teams. All the centers answered the questionnaire. The analysis of the answers has resulted in the creation of a national analysis of strengths, weaknesses, opportunities, threats (SWOT) of the LDKT program in Spain and the development of recommendations targeted to improve every step of the donation process. The work performed, the conclusions and recommendations provided, have been reflected in the following report: Spanish living donor kidney transplant program assessment: recommendations for optimization. This document has also been reviewed by a panel of experts, representatives of the scientific societies (Spanish Society of Urology (AEU), Spanish Society of Nephrology Nursery (SEDEN), Spanish Society of Immunology (SEI/GETH)) and the patient association ALCER. Finally, the report has been submitted to public consultation, reaching ample consensus. In addition, the transplant competent authorities of the different regions in Spain have adopted the report at institutional level. The work done and the recommendations to optimize LDKT are summarized in the present manuscript, organized by the different phases of the donation process. (C) 2021 Sociedad Espanola de Nefrologia. Published by Elsevier Espana, S.L.U.

Background: Spain has dramatically increased the number of controlled circulatory death donors (cDCD). The initial selection criteria for considering cDCD for kidney transplantation (KT) have been expanded progressively, with practically no limits in donor age during the last years. We aimed to analyze the early clinical outcomes using expanded (> 65 years) cDCD in comparison with standard ones. Methods: Observational multicenter study including 19 transplant centers in Spain. We performed a systematic inclusion in a central database of every KT from expanded cDCD at each participant unit from January-2012 to January-2017. Surgical procedures and immunosuppressive protocols were based on local practices. Data was analyzed in the central office using logistic and Cox regression or competitive-risk models for multivariate analysis. Median time of follow-up was 18.1 months. Results: 561 KT were performed with kidneys from cDCD, 135 from donors older than 65 years. As expected, recipients from older cDCD were also older (65.8 (SD 8.8) vs 53.7 (SD 11.4) years; p < 0.001) and with higher comorbidity. At 1 year, no differences were found amongst older and younger cDCD KT recipients in terms of serum creatinine (1.6 (SD 0.7) vs 1.5 (SD 0.8) mg/dl; p = 0.29). Non-death censored graft survival was inferior, but death-censored graft survival was not different (95.5 vs 98.2% respectively; p = 0.481). They also presented a trend towards higher delayed graft function (55.4 vs 46.7%; p = 0.09) but a similar rate of primary non-function (3.7 vs 3.1%; p = 0.71), and acute rejection (3.0 vs 6.3%; p = 0.135). In the multivariate analysis, in short follow-up, donor age was not related with worse survival or poor kidney function (eGFR < 30 ml/min). Conclusions: The use of kidneys from expanded cDCD is increasing for older and comorbid patients. Short-term graft outcomes are similar for expanded and standard cDCD, so they constitute a good-enough source of kidneys to improve the options of KT wait-listed patients, This project was co-founded by Public Research Net REDINREN ISCIII 16/009/ 009, Renal Foundation FRIAT & Research Institute Segovia Arana-HU Puerta de Hierro. OLC, PLS and JMP belong to the latter institution (HU Puerta de Hierro). Funding was used for human resources: data manager and statistician support

Introducción: 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. Tipo de estudio: Descriptivo, serie de 10 casos realizados entre enero y abril 2012. Métodos: 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 in situ por abordaje directo en lecho quirúrgico y otro con canalización vascular antemortem. 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). Resultados: 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. Conclusiones: 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. Introduction: 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. Study type: Descriptive series of 10 cases occurring between January and April 2012. Method: 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 in situ through direct application to the surgical area, and another using ante mortem 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). Results: 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