Donor organ intervention before kidney transplantation: Head‐to‐head comparison of therapeutic hypothermia, machine perfusion, and donor dopamine pretreatment. What is the evidence?

Therapeutic hypothermia, hypothermic pulsatile machine perfusion ( MP ), and renal‐dose dopamine administered to stable brain‐dead donors have shown efficacy to reduce the dialysis requirement after kidney transplantation. In a head‐to‐head comparison of the three major randomized controlled trials in this field, we estimated the number‐needed‐to‐treat for each method, evaluated costs and inquired into special features regarding long‐term outcomes. The MP and hypothermia trials used any dialysis requirement during the first postoperative week, whereas the dopamine trial assessed >1 dialysis session as primary endpoint. Compared to controls, the respective rates declined by 5.7% with MP , 10.9% with hypothermia, and 10.7% with dopamine. Costs to prevent one endpoint in one recipient amount to approximately $17 000 with MP but are negligible with the donor interventions. MP resulted in a borderline significant difference of 4% in 3‐year graft survival, but a point of interest is that the preservation method was switched in 25 donors (4.6%) for technical reasons. Graft survival was not improved with dopamine on intention‐to‐treat but suggested an exposure–response relationship with infusion time. MP was less efficacious and cost‐effective to prevent posttransplant dialysis. Whether the benefit on early graft dysfunction achieved with any method will improve long‐term graft survival remains to be established.