Living donor liver transplantation in adults: outcome in Europe

1. Eleven European centers have performed 228 living donor liver transplants (LDLT): 105 in children and 123 in adults. 2. Right lobe donation was used in 111 of 123 adult cases (90%). 3. There was 1 donor death ( approximately 0.8%), and 17.8% of donors experienced significant complications. 4. Eighty-six percent of recipients and 83% of grafts survived. Biliary complications occurred in 14.6%.

[Pediatric kidney transplantation and living donors--invaluable by virtue of necessity]

Renal transplantation is the treatment of choice for paediatric patients with end-stage renal failure. Living donor transplantation (LDT) has become an important therapeutic option due to the shortage of cadaver donors and increasingly long waiting times.

METHODS

Between 1992 and 1999, a total of 48 paediatric and adolescent patients underwent renal transplantation in Zurich. Of these, 21 patients (44%) received a kidney from a living related donor. 11 patients had been dialysed before LDT over a period of 0.2-5.7 years (median 0.6), and 10 were transplanted preemptively. Triple immunosuppression consisted of cyclosporine A, azathioprine or mycophenolate mofetil (MMF; since 1998), and prednisone. The observation period was 0.5-7.3 years (median 2).

RESULTS

Recipients were 2-18 (median 10.5) years old at transplantation. One third had either a congenital malformation, an inherited disease, or an acquired disorder. One patient died of an associated cardiac disease at 4 months with functioning graft, and one functional graft loss occurred after 2.8 years. 9 patients were switched from cyclosporine to tacrolimus, 7 for biopsy-proven rejection and 2 for cosmetic reasons (hypertrichosis). No antibody preparations were used. Median glomerular filtration rate (51Cr-EDTA), measured after one year in 11 donor/recipients, was 64 (55-95) and 54 (32-82) ml/min/1.73 m2, respectively. The most recent estimated renal function (Schwartz formula) of 19 functioning grafts was 37-79 ml/min/1.73 m2 (median 63). Median body height of 16 patients with no associated extrarenal disease was -0.9 SDS (standard deviation score); the remaining 3--with serious extra-renal disease--were considerably growth retarded. Main complications were reversible rejection episodes in 19 (90%), arterial hypertension (16), CMV disease (2) and asymptomatic CMV infection (3), pyelonephritis (3), and recurrence of the primary renal disease, seizures, diabetes mellitus and non-compliance (one each). Actuarial patient and graft survival (Kaplan-Meier) after 3 years was 95 and 83% respectively. This was not statistically different from the cadaveric donor group (n = 27) with 100 and 80% survival respectively. Overall rehabilitation was excellent. The donors were 12 mothers, 8 fathers and one grandmother aged 31 to 50 (median 39) years; none of them experienced serious postoperative problems.

CONCLUSIONS

The paediatric transplantation programme would no longer be feasible in Switzerland without LDT. The results are very encouraging; preemptive transplantation makes it possible to avoid dialysis in half of the patients. The risk for the donor is small, and careful evaluation without putting pressure on the family is essential.

Workload generated by a living donor programme for renal transplantation

BACKGROUND

The ethical and medical implications of live kidney donation result in a comprehensive work-up process. The aim of this study was to determine the magnitude of the workload and the yield of renal transplants generated by a live donor programme.

METHODS

Referrals to the Leicester live donor programme over the five-year period 1994-1998 were retrospectively assessed. These were initiated by nephrology referral and subsequently investigated in a stepwise manner. Patients were counselled and baseline tests performed prior to consultant surgeon review and assessment of donor renal function/anatomy.

RESULTS

One hundred and fifty referrals consisting of 150 recipients with 269 potential donors were originally made. This resulted in 32/120 (27%) related and 3/30 (10%) unrelated recipients (P=0.06) and 32/220 (15%) related and 3/49 (6%) unrelated donors proceeding to live donor transplantation, with a mean work-up time (+/-SD) of 9 (+/-7) months. One hundred and fifteen recipients (77%) and 234 (87%) donors failed to proceed at various stages of assessment, for a variety of immunological, medical and social reasons. A large number of expensive immunological investigations were required for potential donors, the majority of which did not proceed to transplantation. However as a result of performing these in the early stages of assessment the number of more invasive tests is kept to a minimum.

CONCLUSIONS

There is a relatively low yield of transplants from live donor referrals, particularly those between unrelated individuals. The vast majority of referrals fail to proceed for legitimate reasons, but as a result, create a significant workload with notable staffing and financial implications.

Gender disparity in living renal transplant donation

Numerous studies document that women constitute the majority of living kidney donors, but the reasons behind the disparity in donation rates between men and women remain obscure. We studied this issue by gathering data on family members of living donor allograft recipients at a single large center over a 5-year period (n = 144). By considering all potential donors (spouses and first-degree relatives) within each recipient's immediate family, we determined that men and women are excluded as donors at approximately similar rates on the basis of medical condition or known blood group type A, type B, type O incompatibility, and that a greater percentage of acceptable female donors (28.3%) compared with men (20.3%) go on to donate a kidney (P: = 0.027). However, when only first-degree relatives are considered, the difference in donation rate between men and women becomes nonsignificant (26.9% of women versus 22.2% of men; P = 0.229). Among spouses, the gender disparity in donation rate is greater (36% of wives versus 6.5% of husbands who are acceptable donors go on to donate a kidney; P = 0.003). Evidence that economic factors may contribute to the overall gender disparity is also presented. In conclusion, the gender disparity among living kidney donors observed in our population can be largely attributed to an overwhelming predominance of wives among spousal donors. Possible explanations and potential interventions to address underrepresentation of male donors are discussed.

Living unrelated donor kidney transplantation

BACKGROUND

Living unrelated donors remain an underutilized resource, despite their high graft survival rates. In this article, we updated the long-term results of more than 2500 living unrelated donor transplants performed in the United States.

METHODS

Between 1987 and 1998, 1765 spouse, 986 living unrelated, 27,535 living related, and 86,953 cadaver donor grafts were reported to the United Network for Organ Sharing Kidney Registry. Kaplan-Meier curves compared graft survival rates in stratified analyses, and a log-linear analysis adjusted donor-specific outcomes for the effects of 24 other transplant factors.

RESULTS

The long-term survival rates for both spouse and living unrelated transplants were essentially the same (5-year graft survivals of 75 and 72% and half-lives of 14 and 13 years, respectively). The results were similar to that for parent donor grafts (5-year graft survival = 74% and half-life = 12 years) and were significantly (P = 0.003) better than cadaver donor grafts (5-year graft survival = 62% and half-life = 9 years). After adjusting for the presence of transplant factors known to influence survival rates, recipients of living unrelated donor kidney transplants still had superior outcomes compared with cadaver transplants.

CONCLUSIONS

Living unrelated kidney donors represent the fastest growing donor source in the United States and provide excellent long-term results. Encouraging spouses to donate could remove nearly 15% of the patients from the UNOS waiting list, effectively increasing the number of available cadaveric organs.

Impact of a human interest video on living-donor kidney donation rates

Forty-five potential living donors participated in this study to see if a human interest video featuring living donors and recipients who had been through the transplant process would increase living-donor donation rates and knowledge about living-donor organ donation. While neither donation rates nor knowledge achieved statistical significance, the data clearly demonstrated a clinically significant (clinically relevant) increase in donation rates.

Kidney donors don't regret: follow-up of 370 donors in Stockholm since 1964

BACKGROUND

The aim of the study was to present the views of our kidney donors since 1964, at the time of donation, as well as later on--and to assess their current subjective health.

METHODS

A total of 451 living-donor nephrectomies were performed on Swedish residents in Stockholm from April 1964 until the end of 1995. A questionnaire with 11 questions about the donation and a standardized health form (SF-36) were sent to all donors alive in 1997 (n=403).

RESULTS

The mean age (+/-SD) of the donors was 61+/-14 years at follow-up and the time-since-donation was 12.5+/-7.7 years. The response rate was very good (92%). Current health, as assessed by form SF-36, was satisfactory. Donors scored somewhat better than those reported in a random sample of the Swedish population. The decision to donate had been easy: 86% made the decision themselves, without being pushed. Twenty-three percent thought that the nephrectomy had been troublesome. A higher percentage of young donors had felt that the postoperative period was difficult. Most donors (56%) stated that it had taken more than 2 months before they returned to a "normal" life, and 5% felt that they never completely recovered. Less than 1% of the donors regretted the donation. The commonest current medical prescription was antihypertensives (15%). The actual mean serum creatinine was 103+/-22 (range 48-219) micromol/L.

CONCLUSIONS

The results indicate that the degree of health is at least as high as in the general population. The decision to donate was easy for most of the donors, but surgery and the recovery period were troublesome and lasted longer than expected. Kidney function was acceptable.

Why should we implement living donation in renal transplantation?

BACKGROUND

Renal transplantation started with living donor transplants. However, after the introduction of cyclosporine, the improved results of kidney transplants from cadaveric donors have raised controversy regarding the use of living donors. There are various reasons as to why some transplant centers tend to refuse living donation: first of all, the possibility that unilateral nephrectomy can be harmful to a healthy individual.

SUBJECTS AND METHODS

By reviewing the medical literature on the various aspects of living donation, postoperative mortality in connection with living donation has been calculated to be 1:3,000.

RESULTS

Long-term follow-up investigations of donors demonstrated that the risk of progressive renal failure, hypertension, and proteinuria was not increased by nephrectomy per se, but other causes were responsible for that in occasional patients. From these studies, one can conclude that unilateral nephrectomy is not harmful to a healthy individual. In addition, there are other valid reasons to expand living donation: 1) the need for cadaveric donor kidneys for transplantation far exceeding the supply; 2) the better kidney quality from living donors due to the shorter ischemia time, the lack ofagonal phase and cytokines release that follows brain death; 3) the continuing improved results of kidney transplants from living donors in comparison with those from cadaveric donors in the cyclosporine era also. This appears to be true also for kidney transplants from unrelated living donors in spite of complete incompatibility with recipients. 4) Pre-emptive transplantation, based on living donors, not only avoids the risks, cost, and inconvenience of dialysis, but is also associated with better graft survival than transplantation after a period of dialysis, particularly within the live donor cohort.

CONCLUSIONS

In conclusion, living donor transplants should be part of any transplant center's activity. To encourage living donation, every center should have a formal recipient family education program in conjunction with national organ donation campaigns.

Simultaneous pancreas-kidney transplantation and living related donor renal transplantation in patients with diabetes: is there a difference in survival?

OBJECTIVE

To compare the outcome of simultaneous pancreas-kidney transplantation (SPK) and living related donor renal transplantation (LRD) in patients with diabetes.

SUMMARY BACKGROUND DATA

It remains unanswered whether diabetic patients with end-stage renal failure are better served by LRD or SPK.

METHODS

Using a longitudinal database, data from all diabetic patients receiving LRD or cadaveric renal transplants or SPKs from January 1986 through January 1996 were analyzed. Patient and graft survival, early graft function, and the cause of patient and graft loss were compared for 43 HLA-identical LRDs, 87 haplotype-identical LRDs, 379 SPKs, and 296 cadaveric renal transplants.

RESULTS

The demographic composition of the SPK and LRD groups were similar, but because of less strict selection criteria in the cadaveric transplant group, patients were 10 years older, more patients received dialysis, and patients had been receiving dialysis longer before transplantation. Patient survival was similar for the SPK and LRD groups but was significantly lower for the cadaveric renal transplant group. Similarly, there was no difference in graft survival between SPK and LRD recipients, but it was significantly lower for recipients in the cadaveric renal transplant group. Delayed graft function was significantly more common in the cadaveric renal transplant group. Discharge creatinine, the strongest predictor of patient and graft survival, was highest in the SPK group and lowest in the HLA-identical LRD group. The rate of rejection within the first year was greatest in SPK patients (77%), intermediate in the haplotype-identical LRD and cadaveric transplant groups (57% and 48%, respectively), and lowest (16%) in the HLA-identical LRD group. Cardiovascular disease was the primary cause of death for all groups. Acute rejection, chronic rejection, and death with a functioning graft were the predominant causes of graft loss.

CONCLUSIONS

This study demonstrates that there was no difference in patient or graft survival in diabetic patients receiving LRD or SPK transplants. However, graft and patient survival rates in diabetic recipients of cadaveric renal transplants were significantly lower than in the other groups.

The University of Toronto Liver Transplant Program: Toronto General Hospital, Hospital for Sick Children

The University of Toronto Liver Transplant Program began in 1985 at a time when the procedure had already evolved from an experimental form of surgery to an accepted treatment for many forms of liver failure. The program was established not only to provide clinical care for patients but also to address academically the barriers that impeded success. The program brought together experts in medicine, surgery, pathology, and the basic sciences of immunology, virology and molecular biology. Significant advances over the past decade and a half in immunosuppressive drugs and monitoring, patient selection, and infectious management have contributed to markedly improved patient and graft survival rates. Nevertheless, we continue to face 2 major challenges: a growing scarcity of donor organs, a problem partially addressed through development of living-related liver donation, and recurrent viral hepatitis. We expect to remain on the forefront of ongoing research to provide solutions to these and other barriers to the full deployment of liver transplantation in the year 2000.

Living non-related versus related renal transplantation--its relationship to the social status, age and gender of recipients and donors

BACKGROUND

Persistent differences between social classes and genders exist in the quality of medical care due to disparities in need and access.

METHODS

149 haemodialysis (HD) patients including 114 renal transplant candidates, and their proposed live donors were interviewed and followed for 4 years. Differences in need and access were analysed among the living non-related compared to related renal transplant according to social status, age and gender of recipients and donors. Also the motive for organ-donation as well as the recipient's survival was compared between living non-related and related renal transplantation.

RESULTS

The proportion of females among renal transplant candidates was significantly lower than among HD-patients. Females were significantly less likely to be recipients, but more likely to be donors of renal allografts, particularly if they were unemployed. Initially all of the living non-related donors claimed to have altruistic motives for organ-donation but gift rewarding, drug abuse, unemployment, and economical deadlock, urgent need of money were significantly frequent than among living related donors. The donation process lasted significantly longer in females and in living non-related donors and there was a trend for higher mortality in recipient of living non-related grafts. Almost all of the living non-related donors disappeared after organ-donation without subsequent follow-up.

CONCLUSIONS

Females are transplanted less frequently, but donate kidneys more frequently than males in living non-related transplantation programmes. There is an excess of vulnerable people among living non-related donors.

Renal retransplantation at the University of Alabama at Birmingham: incidence and outcome

Only half the patients who lost a renal allograft either returned to the waiting list (32%) or were retransplanted (17%). One fifth died soon after allograft loss. Patients did not return to the waiting list for multiple reasons including patient choice, worsened medical condition and most commonly, interest but non-referral. Diabetics had a significantly diminished chance for survival on dialysis after graft loss. African-Americans had a better chance of survival after graft loss but a much worse opportunity to be retransplanted. The use of CellCept in triple immunosuppressive therapy, along with a flow cytometry crossmatch, has improved retransplant allograft survival commensurate with primary graft outcome. The incidence of retransplantation is decreasing at our institution even though the number of potential candidates for retransplantation remains stable.

The UNOS OPTN waiting list and donor registry

1. On October 31, 1998, there were 62,994 registrants on the combined UNOS waiting list. Of these, 66% were awaiting kidney transplantation, and 18% were awaiting liver transplantation. 2. The majority of patients on the UNOS waiting list on October 31, 1998 were blood type O (52%), White (60%) and male (58%). 3. Median waiting times (MWTs) have increased steadily for nearly every organ since 1988, especially for liver, kidney, and lung registrants. 4. For patients added to the waiting list in 1996. MWTs to transplant were longest for heart-lung registrants (742 days). The shortest waiting times for this cohort were among heart registrants (223 days). No median could be calculated for kidney registrants added in 1996. 5. Death rates per patients waiting at risk declined during 1988-1997. Death rates were higher for patients awaiting life-saving organs (liver, heart, lung, heart-lung) than for non-lifesaving organs (kidney, pancreas, kidney-pancreas). 6. There were 5,478 cadaveric and 3,820 living donors recovered in 1997, a 34% and 109% increase over those recovered in 1988. 7. Large increases were seen in the number of liver (45-84%), pancreas (14-24%), and lung (3-15%) donors between 1988-1997. 8. The number of cadaveric donors aged 50 or older has increased from 12% of all donors in 1988 to 28% of all donors in 1997. 9. The typical cadaveric donor in 1997 was a white male with ABO blood type O, between the ages of 18-34. In 1997, a typical living donor was a white female with ABO blood type O between the ages of 35-49. 10. Between 1988-1997, the percentage of minority donation increased for cadaveric donors (17-24%), and for living donors (23-27%). 11. The number of living donors who were either spouses or unrelated to the recipient increased from 4% in 1988 to 15% in 1997.

Scandiatransplant: thirty years of cooperation in organ transplantation in the Nordic countries

The Nordic organ exchange organization, Scandiatransplant was established in 1969. The organization, which covers a population of 23.9 million inhabitants, includes all 11 organ transplant centers in the 5 Nordic countries Denmark, Finland, Iceland, Norway and Sweden. The economy is solely based on transplant center fees. All Nordic patients waiting for an organ transplant are registered on one common waiting list. Rules for the exchange of organs are settled by unanimous decision, and the compliance to the rules is excellent. Kidney exchange is based on HLA matching, whereas the exchange of livers and hearts is based on clinical urgency. In 1997, 43% of the liver transplantations in Scandiatransplant were performed with an exchanged organ and the exchange rate for kidneys was 20%. Currently, the Scandiatransplant waiting list includes 1,538 patients waiting for a kidney transplant, 20 patients are waiting for a liver, 37 for a heart, and 156 patients are waiting for a lung transplant. The organ donation rate in Scandiatransplant has declined in recent years, from 16.0 per million population (PMP) in 1993 to a level of 13.5 PMP in 1997. The number of kidney transplants has varied between 800-900 per year during the past 10 years, corresponding to 33-38 transplants PMP. Approximately 30% of the renal transplants were performed with kidneys from living donors. The liver transplantation activity was approximately 7 PMP per year. Heart transplantation was performed at a rate of 4-5 PMP per year, and lung transplants at 4 PMP per year.

A 25 year history of kidney transplantation at the Washington Hospital Center

The kidney and pancreas transplant programs at the Washington Hospital Center have been active participants in the evolution of transplantation over these past 25 years. Many things have come full cycle. Living donors are again becoming the dominant source of donor kidneys. The interest in non-heart beating donors has returned, which may expand the cadaver donor pool significantly. Pulsatile machine preservation of kidneys has resurfaced and is gaining popularity again. Notwithstanding these cycles, the dominant advance in the past 25 years has been the virtual elimination of early graft loss from acute rejection. We owe a great debt to all those who have perfected and made available to all of us more powerful and more specific immunosuppressive tools. For while tomorrow the algorithm for achieving graft acceptance may completely change, for today a successful transplant outcome depends entirely on the quality of immunosuppression, assuming the surgical procedure was also successful.

The national kidney transplant program in Norway still results in unchanged waiting lists

1. Of 2,670 patients starting renal replacement therapy for end-stage renal disease in Norway from 1989-1997, 76% were candidates for transplantation. The annual need for transplantations increased from 47 to 64 grafts PMP as the number of elderly patients increased. The national waiting list has remained almost stable during the period from 1989-1997 at levels of 25-30 PMP, but the dialysis population has increased from 57-105 PMP. 2. A total of 1,681 transplants was performed at an annual rate varying between 38 and 46 grafts PMP. The grafts were procured from LDs in 41% and CDs in 59% of cases. Totally 69% of all patients in need were transplanted and 54% of all patients requiring replacement therapy for end-stage renal disease received a transplant. 3. Graft survival rates in recipients of first LD grafts (n = 641) were 91% and 77% at one and 5 years, respectively. One-year graft survival was 97% in HLA-identical grafts (n = 71), 92% in haploidentical grafts (n = 419), 88% in 2 haplotype-mismatched related grafts (n = 43), and 87% in spousal donor grafts (n = 108). 4. Graft survival rates in recipients of first CD grafts (n = 801) were 84% and 65% at one and 5 years, respectively. The rates were 86% and 74% in younger (n = 557) versus 78% and 46% in older (> 65 years) (n = 244) patients. Death with a functioning graft caused approximately 45% and 75% of all graft losses in younger and older patients, respectively. Cardiovascular disease was the major cause of death. 5. A significant beneficial effect of HLA-DR matching was observed in CD grafts performed after 1989, in particular in patients older than age 65.

Kidney transplantation at the University of Maryland

1. The number of kidney transplants performed at the University of Maryland increased yearly from 51 in 1991 to 285 in 1998. Over the past 3 years, the increase in the number of kidney transplants can be ascribed almost exclusively to a marked increase in living donor transplants, from 49 cases in 1995 to 130 cases in 1998; a 160% increase. The increase in our frequency of living-donor kidney transplantation can be attributed to a formal family education program and the availability of the laparoscopic technique for kidney removal. 2. In addition to the availability of the laparoscopic technique, a number of special programs has allowed an increased number of living donor kidney transplants. This includes a special protocol for transplantation of Epstein-Barr virus negative recipients, a protocol for transplantation of patients who have a positive crossmatch with a living donor, as well as, the simultaneous living donor kidney/cadaver pancreas "SPK(LRD/PTA)" program. 3. The one-year graft and patient survival for the entire program was 87.0% and 94.5%, respectively. However, the more recent graft survival rates have markedly increased; Since August 1995, the one-year graft and patient survival was 89.8% and 95.8%, respectively. 4. Improvement in immunosuppression has lead to dramatic improvement in the success rates in living-donor kidney transplants. Despite the omission of antibody-based induction therapy, the one-year graft survival rate using a mycophenolate mofetil/tacrolimus-based immunosuppression protocol was 96.4%. The one-year rejection rate was 8% in Caucasian patients and 14% in African-American patients in this subgroup of living-donor kidney transplant recipients. 5. The data demonstrate that the use of the living-donor transplant option is grossly underutilized. Estimates are presented that more than 11,000 living-donor kidney transplants should be possible in the US yearly.

Fifteen-year experience with adult and pediatric liver transplantation at the University of California, Los Angeles

In the past 6 years, advances in surgical technique and immunosuppression regimens have improved overall survival of transplant patients. Hepatitis C and alcoholic cirrhosis are the most common indications for transplantation at this center in the adult population while biliary atresia remains the most common indication in children. Organ shortages remain the most formidable obstacle to widespread application of organ transplantation. As recipient indications and criteria for transplantation expand, the number of patients awaiting organs increases. Simultaneously, donor criteria has not expanded and overall donor numbers have not increased substantially. We have used several approaches to alleviate the shortage of organs for both adults and children. Living-related donor transplantation yields excellent results and the operation can be done in an elective setting; however, it places an otherwise healthy person at risk. It is justified on basis of good results and the present shortage of organs. In-situ split-liver transplantation presents the opportunity to transplant children with size-matched organs without reducing the adult cadaveric pool. It is limited by the technical expertise required to perform the procedure safely. It can reduce the need to resort to living donor transplantation and is routinely used as the first option for pediatric patients awaiting transplantation at UCLA. Our results show that good results can be achieved with strict donor and recipient selection. In situ splitting has had a substantial impact on decreasing the pediatric waiting list time at our institution. Small bowel transplantation results have been improving; however, the complications related to the heavy immunosuppressive regimens need to be resolved.

[Pediatric renal transplantation: Experience in Lausanne 1971 to 1998]

AIMS OF THE STUDY

Analysis of indications and results of paediatric renal transplantation in a single centre, before and after the introduction of cyclosporine A (CSA).

METHODS

Historical retrospective study.

RESULTS

19 transplantations were performed in 14 patients (5 second grafts) between 1971 and 1987 (group I). 13 patients were transplanted between 1988 and 1998 (no second transplant) (group II). In group II, all the patients had immunosuppression with CSA, but none in group I. Group II, with CSA, showed better renal survival than patients without CSA. In group I, obstructive uropathies (posterior urethral valves, pyelo-ureteral junction stenosis, vesico-ureteral reflux) represent a common cause (35%) of terminal chronic renal failure (TCRF), whereas in group II they represent only 15% of the causes and chronic glomerulonephritis is the most common cause (69%) of TCRF. Acute and chronic graft rejections were the cause of 9 and 1 graft losses in group I and II respectively. Living related donors account for 14% of all renal transplantations in group I and 46% in group II.

CONCLUSIONS

The incidence of paediatric patients referred to Lausanne for TCRF is stable. We have observed a constant and steady decrease in obstructive uropathies leading to TCRF and renal transplantations, whereas glomerulonephritis are increasingly frequent. Graft survival has much improved since the introduction of cyclosporine A, without an increase in morbidity. In carefully selected cases, intrafamilial renal transplantation provides good results and helps to shorten the time spent on dialysis.

Experience with living related liver transplantation in 63 children

The incentive to develop intrafamilial living related liver transplantation (LRLT) originated from the shortage of cadaveric organ supply. We report our experience with LRLT in 63 children during 1993-1998 in the frame of a protocol approved by the Ethics Committee of our Institution. During this period, 152 potential intrafamilial (mostly parental) donors were evaluated; 44 (28.5%) were excluded because of surgical (n = 4), medical (n = 39) or psychosocial reason (n = 1). Out of 108 who matched all medical, surgical and psychological criteria of selection, 45 did not underwent living donation because their child received a cadaveric graft (n = 22; LRLT was their second option) or because one of the parents who had both been selected was chosen [by the surgical team because of more favourable anatomy (n = 8) or by mutual agreement between the two parents (n = 5)]. Sixty-three living donors (36 mothers, 24 fathers, one grand mother, one aunt and one uncle) underwent procurement of the left lobe (n = 52), the left lobe extended to part of segment IV (n = 8) or a left hepatectomy (n = 3) without mortality or any serious morbidity. Their median hospital stay was 7 days (range: 6-12); full physical rehabilitation and normalization of liver tests were usually obtained within three weeks. Their psychological follow-up did not disclose any longstanding serious sequellae. The median age of the recipients was 13 months (range 5-189); 30 were younger than one year at the time of transplant. Their median weight was 8.1 kg (range: 4.3 to 60); 36 had an actual weight under 10 kg. Fifty-two received an ABO identical and 11 received an ABO compatible transplant. The native liver diseases were similar to common data in children, with biliary atresia being the most frequent indication (74.6%). The median weight of the graft was 260 gr (range: 138-680) with a median ratio between the graft weight and the recipient body weight of 3.17% (range: 0.75-8.08). All grafts were implanted orthotopically with semi-microvascular reconstruction of the hepatic vein, portal vein and hepatic artery [end to end anastomosis in 58 (2 arteries were reconstructed in 7 patients) and interposition of an iliac arterial allograft from the infrarenal aorta in 5]. Base line immunosuppression consisted of a triple drug regimen including steroids, Azathioprine and either Cyclosporine-Sandimmun (n = 9), Cyclosporine Microemulsion formulation-Neoral (n = 13) or Tacrolimus-Prograft (n = 41). Biopsy-proved acute rejection was treated with intravenous bolus of steroids; steroid-resistant acute rejection was treated by a switch from Cyclosporine to Tacrolimus or addition of Mycophenolate-Mofetil (Cellcept) in Tacrolimus treated patients. Actuarial patient survival was 91.8% and 89.6% after LRLT at one and five years post-transplant, respectively, and 87.5% and 82.8% at one and five years, respectively, in 90 patients who received a cadaveric graft during the same interval. Actuarial graft survival was 91.8% and 84.1% after LRLT at one and five years, respectively, and 76.4% and 73.3% at one and five years, respectively, after cadaveric transplants. Vascular thrombosis was observed in 9.5% of the patients (arterial thrombosis: 1.6%; portal thrombosis: 7.9%) without graft loss. Biliary complications were observed in 26.9% (bile leak from cut surface in 3.1%, anastomotic stricture in 22.2% and intrahepatic stricture in 1.5%); two patients died from septic shock possibly related to uncompletely relieved anastomotic stricture; all other biliary complications were successfully treated either conservatively or surgically. The incidence of acute rejection was 90.9% in 22 patients with Cyclosporine-based immunosuppression; acute rejection was corticoresistant in 50%. It was 46.3% in 41 patients with Tacrolimus-based immunosuppression (64% with Prograft in capsules and 18.7% with Prograft in granules); no acute rejection was corticoresistant. (ABSTRACT TRUNCATED)

Living donors >55 years: to use or not to use?

BACKGROUND

Kidney transplants using older donors are becoming increasingly accepted as a strategy for alleviating the growing donor organ shortage. Most studies to date have shown decreased graft survival associated with the use of older cadaver donors; however, studies on the effect of living donor age on graft survival are less clear-cut.

METHODS

We studied the effect of donor age on patient and graft survival after 1126 consecutive cyclosporine-treated primary kidney transplants performed between January 1, 1985 and December 31, 1995. Of these grafts, 598 were from living donors (74 from donors >55 years old) and 528 from cadaver donors (54 from donors >55 years). We calculated actuarial patient survival, graft survival, and death-censored graft survival for recipients of both living donor and cadaver kidneys. Living donors were then further divided by HLA mismatch (0 vs. 1 - 6) and the presence or absence of an acute rejection episode. Multivariate analysis of factors associated with decreased graft survival was performed for recipients of both living and cadaver donor kidneys. Factors included for analysis were donor age >55 years, recipient age >50 years, the presence of diabetes mellitus, HLA mismatch (0 vs. 1 - 6), and the presence of an acute rejection episode.

RESULTS

For cadaver kidneys, univariate analysis indicates that both overall (P=0.004) and death-censored (P=0.001) graft survival was significantly better with younger cadaver kidneys. This is supported by our multivariate analysis, which shows that cadaver donor age >55 years is an independent predictor of poor actuarial graft survival (P=0.0003). For living donor kidneys, univariate analysis also indicates that both overall (P=0.045) and death-censored (P=0.005) graft survival was significantly better with younger living donor kidneys. However, in the absence of acute rejection, 10-year death-censored graft survival for patients with older vs. younger living donor kidneys was 93% vs. 94%, whereas in the presence of one or more acute rejection episodes, 10-year death-censored graft survival dropped markedly to 39% with older and 54% with younger living donors. Kidneys from living donors >55 years had significantly better long-term graft survival than cadaver donors >55 years (P=0.012) and had comparable graft survival to younger cadaver donors. In contrast to our univariate analysis, multivariate analysis of our living donor data shows that decreased actuarial living donor death-censored graft survival was significantly associated only with the presence of one or more acute rejection episodes (P<0.0001). Living donor age >55 years was not independently associated with decreased graft survival.

CONCLUSIONS

Ours is the largest single-center study of outcome for recipients of kidneys from living donors >55 years. Using univariate analysis, we have shown that graft survival of kidneys from older living donors is significantly better than that of kidneys from older cadaver donors and is comparable to that of kidneys from younger cadaver donors. Using multivariate analysis, we have shown that the presence of one or more acute rejection episodes significantly shortens both cadaver and living donor long-term graft survival. Most significantly, we have shown that, although the use of kidneys from cadaver donors >55 years is associated with significantly decreased long-term graft survival, no such association exists for recipients of kidneys from living donors >55 years. We feel that our data support the continued use of kidneys from older living donors.

Variations in cardiac transplantation: comparisons between the United Kingdom and the United States

BACKGROUND

International practice variations have been documented in various health care specialties. This study compares cardiac transplantation in the UK with practice in the US.

METHODS

UK data were from an ongoing multi-center prospective study, the UK Cardiothoracic Transplant Audit. The UK population comprised 620 listings and 463 transplants. US data were obtained from UNOS and comprised 3946 listings and 4704 transplants.

RESULTS

There was a mean of 14 transplants per center per year in the US compared with 34 in the UK. Notable differences in practice include rarity of listing in the UK of patients > 65 years (0.2% vs 4.1% in US) and patients with previous transplants (UK 0.9%, US 3.2%). Patients listed in the US were more likely to be on ventricular assist devices (odds ratio 8.0, 95% CI 3.0-21.7) or inotropes (odds ratio 4.9, 95% CI 3.7-6.4). Living donor (domino) transplants, although comprising 7% of transplants in the UK, are virtually non-existent in the US (1 domino in 4704 transplants). Heterotopic transplants were more common in the UK (4.4% vs 0.5%). Indications for transplant were similar (except retransplantation). The donor age was > 35 years in 43% of UK donors vs 33% of US donors.

CONCLUSION

This study reveals substantial practice differences between the UK and US. Further studies are required to examine the reasons for these practice differences, the influence on transplant outcome, and their ethical and economic implications.

Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts

STUDY DESIGN

Between July 1993 and March 1997, 110 children were listed for primary elective liver transplantation with cadaveric (Cad: n = 68) or living-related (LR: n = 42) donors. Pregraft mortality, post-transplant survival, and surgical and immunologic complications were retrospectively compared in both groups.

RESULTS

The pregraft mortality rate was 10 (15%) of 68 versus 1 (2%) of 42 in the Cad and LR groups, respectively (P =.049). Postliver transplantation 1-year patient and graft survival rates were 87% and 75% in the Cad group (n = 49) versus 92% and 90% in the LR group (n = 41), respectively (NS). The incidence of post-transplant complications was as follows: hepatic artery thrombosis (Cad: 16%; LR: 0%, P =.020), portal vein thrombosis (Cad: 8%; LR: 2%, NS), and biliary complications (Cad: 14%; LR: 34%, P =.044). The overall incidence of acute rejection was similar in both groups; however, a lower incidence of acute rejection occurred in LR graft recipients treated with tacrolimus.

CONCLUSIONS

The introduction of an LR donor liver transplantation program allowed a significant decrease in the pretransplant mortality rate, with a consequent overall improvement in patient survival compared with the Cad series. The incidence of biliary complications was higher in the LR series, whereas better human leukocyte antigen matching in this subgroup did not result in a lower rejection incidence.

The UNOS OPTN waiting list and donor registry

1. On October 31, 1997, there were 55,789 registrations on the combined UNOS waiting list. Of these, two-thirds were awaiting kidney transplantation, and 17% were awaiting liver transplantation. 2. More than one-half of all patients on the UNOS waiting list on October 31, 1997 had blood type O, 59% were White, 58% were male, and 54% were aged 18-49. 3. Annual additions to the UNOS kidney waiting list grew from 11,916 in 1988 to 18,253 in 1996. The largest increase in waiting list size was seen in the lung waiting list, which grew 1,482% during this time. 4. Median waiting times have increased steadily for nearly every organ since 1988, especially for liver, kidney, and lung registrants. 5. For patients added to the waiting list in 1995, MWTs to transplant were longest for heart-lung registrants (887 days); however, no median could be calculated for kidney registrants added in 1995. The shortest waiting times for this cohort were experienced by heart registrants (208 days). 6. Death rates per 1,000 patient-years at risk have declined during 1988-1996. Death rates were higher for patients awaiting life-saving organs (liver, heart, lung, heart-lung) than for non-lifesaving organs (kidney, pancreas, kidney-pancreas). 7. There were 5,417 cadaveric and 3,553 living donors recovered in 1996, a 33% and 95% increase, respectively, over those recovered in 1988. 8. The number of organs recovered per cadaveric donor increased from 3.0 in 1988 to 3.8 in 1994 and dropped to 3.6 in 1996. At the same time, the number of organs transplanted per cadaveric donor recovered increased from 2.7 to 3.2. 9. Large increases in the number of donors who were liver (45-82%), pancreas (14-23%), and lung (3-14%) donors occurred between 1988 and 1996. 10. The number of cadaveric donors aged 50 or older has increased from 12% of all donors in 1988 to 27% of all donors in 1996. 11. The typical cadaveric donor in 1996 was a White male with ABO blood type O, between the ages of 18-34. In 1996, a typical living donor was a White female with ABO blood type O between the ages of 35-49. 12. Between 1988 and 1996, the percentage of minority donations increased for cadaveric donors (17-23%), and for living donors (24-27%). 13. The number of living donors who were either spouses or unrelated to the recipient increased from 4% in 1988 to 14% in 1996.

The Hamburg liver transplant program

The program of the University of Hamburg is exemplary of the problems faced by programs with rapid growth. Establishing expertise at all levels is essential to shorten the inevitable learning curve. The combination of an adult and a pediatric program was an ideal environment for the development of living donation and cadaveric in-situ split liver transplantation as complimentary solutions to eliminate pediatric mortality on the waiting list without affecting the chances of adult liver transplant candidates.

Trends in organ donation

Renal and extrarenal transplant data were collected for seven geographical regions for the period 1989-1996. In Western Europe and North America the number of kidney donors increased by 926 and 2743, respectively. The total number of transplants also increased in both regions by 3756 and 6936, respectively. Renal transplants accounted for approximately 60% of the total number of transplants and, although the number of renal transplants did not alter in Western Europe, the number rose by 3055 in North America. Outside of these regions the number of extrarenal transplants was 3-18% of the total. The number of living kidney donors in North America increased each year and was higher than the number recruited in Western Europe (3389 vs 943 in 1996). With the exception of Eastern Europe, where virtually no renal transplants were carried out using organs from living donors, the number of living kidney donors rose in other regions: for example, in Latin America, the proportion of living kidney donors rose from 29% in 1970-88 to 51% in 1995, and, in Asia, 90% of kidneys were donated by living donors. As the quality of cadaveric donor organs is often sub-optimal, the use of living donors is likely to increase in both Western Europe and North America, but is unlikely to become the most important source of organs in these regions.