Characteristics of long-term renal transplant survivors

Despite the high rates of rejection, allograft failure, and patient death in the early years of renal transplantation, some patients have done remarkably well. Forty-three (17 living related donor and 26 cadaver donor recipients) such patients with an allograft that functioned for 19 years or more (range, 19 to 29 years) were followed up at this center. The patients included 24 men and 19 women, with a mean age at transplantation of 29 years, of whom 39 were white and four were black. At most recent follow-up, the mean daily dose of azathioprine was 104 mg (range, 50 to 175 mg) and that of prednisone was 10 mg (range, 5 to 20 mg). Mean serum creatinine level was 1.6 mg/dL (range, 0.7 to 5.4 mg/dL). Acute rejection occurred in 14 (33%) patients. Nine patients had one episode and five patients had two episodes of acute rejection. Long-term risks to the recipients appeared in the form of coronary artery disease in 10 (23%) patients; malignancy in 13 (30%) patients, which included nine patients with skin malignancy; and chronic hepatitis C virus (HCV) infection in four patients, two of whom died of complications of liver failure. Other complications included avascular bone necrosis in five patients, which required total hip replacement in two patients; hyperlipidemia requiring treatment in 16 (37%) patients; posttransplantation diabetes mellitus in 10 (23%) patients after a median of 17.5 years (range, 1 to 23 years); and hypertension in 23 (53%) patients. There were seven deaths (three of coronary artery disease, two of liver failure, one each of sepsis and malignancy) and eight graft losses (five to death with function, two to chronic rejection, and one to focal and segmental glomerulosclerosis). Although long-term allograft success results in patients receiving minimal amounts of immunosuppression and having good renal function, long-term renal transplant survivors are at risk for significant morbidity even in the third decade posttransplantation.

Proposed consensus for definitions and endpoints for clinical trials of acute kidney transplant rejection

Progress in transplantation therapeutics requires validation from multicenter trials in which enrollment criteria and endpoint definitions have been standardized. A database of acute rejection was established from 19 North American, European, and Australian transplant centers and included parameters on rejection diagnosis and treatment of 50 consecutive rejection episodes from each center. Patient demographics, induction and maintenance immunosuppressive therapies, antirejection agents (drug, dose, duration), clinical signs (decrease in urine volume, presence of fever of > or =38.5 degrees C), serum creatinine concentration (nadir, at rejection, daily during antirejection therapy to 15 days, and days 30, 90, 180, and 365 after rejection date), rejection biopsy findings, morbidity, recurrence of rejection, and renal function at 1 year were recorded for 953 rejection episodes. From these data, three definitions were proposed. Acute rejection was defined as an immunologic process resulting in a serum creatinine increase of > or =0.4 mg/dL, with or without clinical signs, and should include a biopsy confirmation that has been standardized to the Banff criteria. Corticosteroid-resistant rejection was defined as a rejection episode in which a minimum of 250 to 1000 mg of methylprednisolone administered as initial therapy fails to result in stabilization or reduction of the serum creatinine after 3 days of corticosteroid treatment. Successful response to therapy was defined as a serum creatinine level < or =110% of the serum creatinine on the day of the rejection diagnosis and a return of the serum creatinine to or below the rejection creatinine level by 5 days of therapy with maintenance of this response for a minimum of 30 days. The work represented in the Efficacy Endpoints Database provides a step toward improving definitions in clinical trials. Continuity in clinical trial design should lead to improvements in evaluation of outcomes and, thereby have an effect on clinical practice.

Recurrent and de novo renal diseases after renal transplantation: a report from the renal allograft disease registry

Recurrent or de novo glomerular disease is an important cause of graft dysfunction and eventual loss. Cyclosporine A (CyA) has improved short-term renal allograft outcome but has not altered long-term graft survival. The purpose of the current study is to determine the prevalence of such disease and its impact on graft function in the CyA era. From 1984 to 1994, 1,557 renal allografts were performed at the Medical College of Wisconsin and the University of Cincinnati. Patients were followed up for an average of 7.2 years (minimum, 1 year). Recurrent disease was diagnosed by renal biopsy in 98 (6.3%) patients after an average of 36 months. Demographic characteristics of patients with and without recurrent disease were similar. Glomerulonephritis was the most common finding, occurring in 73 patients, and included focal segmental glomerulosclerosis (FSGS), 25; IgA nephropathy (IgAN), 11; membranous (MN), 11; proliferative, 11; membranoproliferative glomerulonephritis (MPGN), 10; glomerular basement membrane (anti-GBM), 3; and systemic lupus erythematosus (SLE), two. Diabetic nephropathy was present in 22, hemolytic uremic syndrome (HUS) in two, and oxalosis in one. Graft loss occurred in 60 of 98 (61%) recipients. Half-life of the allograft was diminished in patients with recurrent disease, 2,038 +/- 225 versus 3,135 +/- 385 days, P = 0.002. The actuarial allograft survival at 1, 3, 5, and 8 years posttransplantation with recurrence was 88%, 74%, 57%, and 34%, respectively; and the corresponding graft survival for patients without recurrent disease was 80%, 70%, 64%, and 53%, respectively (P = 0.003). The risk of recurrent disease increased with length of graft survival from 2.8% at 2 years to 9.8% and 18.5% at 5 and 8 years, respectively. We conclude that recurrent disease is a significant problem after renal transplantation and is associated with decreased graft survival.

Importance of allograft biopsy in renal transplant recipients: correlation between clinical and histological diagnosis

Renal allograft dysfunction after transplantation may be caused by acute rejection (AR), chronic rejection (CR), cyclosporine (CyA) or tacrolimus (FK) toxicity, and other causes such as recurrence of renal disease. Allograft biopsy is the "gold standard" to establish the correct diagnosis. However, many transplant centers routinely do not consider graft biopsy at the onset of renal dysfunction; instead, empirical steroid therapy or CyA dose reduction is the initial response to graft dysfunction. In this study, we prospectively predicted the histological findings prior to renal biopsy and correlated the clinical and histological diagnoses after the final report was issued by the pathologist. Patients with renal dysfunction after transplantation (increased serum creatinine >20% from baseline) were submitted to allograft biopsy. Three clinicians (C1, C2, and C3) involved in the care of these patients independently predicted the histological findings prior to the biopsy. A total of 100 cases (62 men, 38 women; 71 whites, 29 blacks) with a mean age of 41 years (21 to 70 years) were included in this study. Biopsy samples were taken after a mean period of 1.6 +/- 0.32 years (median, 0.25 years; range, 4 days to 17 years) after transplantation. Two patients with en bloc pediatric kidneys required postbiopsy blood transfusions for self-limiting bleeding; all other patients had no complications. All patients received azathioprine and prednisone; additionally, 74 received CyA and 19 FK. Final histopathologic diagnoses were AR (30), CyA/FK toxicity (36), AR plus CyA/FK toxicity (17), CR (11), recurrent disease (11), and other (6). In 28 cases (28%), the results of the biopsies showed more than one diagnosis. A completely correct diagnosis was predicted by C1, C2, and C3 in 47%, 42%, and 41% (mean, 43%) of the cases, incorrect diagnosis in 25%, 27%, and 25% (mean, 26%) of the cases, and partially correct diagnosis in 28%, 31%, and 34% (mean, 31%) of the cases, respectively. AR was confirmed histologically in 26 of 47 cases (55%) in the presence of therapeutic or high CyA/FK blood levels, whereas in 41 of 53 cases (77%), the histology showed CyA/FK toxicity in the presence of therapeutic or low CyA/FK blood levels. The mean serum creatinine at the time of the biopsy was 2.92 +/- 0.30 mg/dL, compared with the baseline of 1.76 +/- 0.10 mg/dL (P < 0.0001). After appropriate treatment, mean serum creatinine was 2.38 +/- 0.33 mg/dL (P < 0.0001). These data show that clinical prediction was poor, with totally correct diagnosis in only 43% of the cases. In 26%, the diagnosis was incorrect. We conclude that the renal biopsy is essential for establishing the correct diagnosis of renal allograft dysfunction and the appropriate management thereof.

Utility of standardized histological classification in the management of acute rejection. 1995 Efficacy Endpoints Conference

BACKGROUND

Standardized histological grading of transplant kidney biopsies has become a primary criterion for diagnosis of rejection in immunosuppression clinical trials.

METHODS

A consortium of 19 transplant centers from North America, Europe, and Australia convened in 1995 to examine kidney transplant rejection. Data from the 1995 Efficacy Endpoints Conference were examined for frequency of adoption of Banff schema. Biopsy grading was correlated with clinical parameters of rejection and therapy response.

RESULTS

Histological confirmation of rejection episodes occurred in 73% of 953 cases, with Banff criteria adoption increasing in frequency between 1992 and 1995. Banff grading significantly correlated with clinical rejection severity (rejection creatinine: grade I, 2.8+/-0.2 mg/dl; grade II, 3.5+/-0.2 mg/dl; grade III, 4.1+/-0.3 mg/dl; P < 0.001), although nadir creatinines were similar. Response rates of Banff grades I and II to steroid therapy were not different, but only 42% of grade III rejections responded to steroids (P < 0.003. Banff grading also correlated with postrejection creatinine, day 15: grade I, 2.2+/-0.2 mg/dl; grade II, 3.0+/-0.2 mg/dl; grade III, 3.8+/-0.4 mg/dl (P < 0.001), and day 30: grade I, 2.1+/-0.1 mg/dl; grade II, 2.2+/-0.2 mg/dl; grade III, 2.7+/-0.2 mg/dl (P < 0.06). Banff grade III correlated with reduced graft survival at 1 year: grade I, 86%; grade II, 88%; grade III, 70% (P < 0.01).

CONCLUSIONS

This multicenter review of rejection severity confirms that standardized histologic classifications such as the Banff schema provide a reliable means for stratifying patient risk of treatment success or failure. These data support the use of Banff criteria in clinical trial design.

Clinical application of immunosuppressive agents in renal transplantation

The availability of a number of new immunosuppressive drugs has resulted in significant improvements in the outcome of kidney transplantation. Currently 1-year graft survival rate for cadaver kidney transplants is approximately 85%. A number of new agents are presently in clinical studies. This article reviews the currently available agents and examines various aspects of induction and maintenance immunosuppressive therapy, and the treatment of acute rejection episodes. In addition, the agents currently in clinical trials and future directions in immunosuppressive therapy are discussed.

Economic costs of expanded criteria donors in renal transplantation

BACKGROUND

The organ shortage has increased interest in the use of "expanded criteria" donors (ECDs). Although much has been written concerning the clinical outcomes associated with the use of such donors, little has been published concerning the financial results associated with their use.

METHODS

A retrospective cost identification study of recipients of kidneys from expanded criteria cadaveric donors was used.

RESULTS

Of a total of 78 cadaveric renal transplants in fiscal year 1995, there were 38 kidneys (49%) transplanted from ECDs. Graft survival at 1 year was not statistically different between patients who received kidneys from ECDs and those who received non-ECD kidneys (84% vs. 85%, respectively). Length of stay (P < 0.05), serum creatinine at 1 year after transplantation (P < 0.01), and the percentage of patients requiring hemodialysis (P < 0.05) were all higher among patients who received kidneys from ECDs. Cold ischemic time was significantly longer in patients who received kidneys from ECDs (31.4+/-12 hr vs. 24.0+/-9 hr; P < 0.05). The total average and median costs were $12,190 and $10,911 higher in recipients of kidneys from ECDs as compared with non-ECD controls (P < 0.01). Stepwise linear regression demonstrated that length of stay was the major clinical determinant of total costs; only the use of antilymphocyte induction was otherwise significantly associated. When kidneys from ECDs were transplanted into "high-risk" recipients (age > 60 or retransplant patient), the average total costs were $15,311 more than when kidneys from ECDs were transplanted into non-high-risk patients (n=16 and 21, respectively; P < 0.05) and $20,680 more than when a non-ECD, non-high-risk pairing was undertaken (n=26; P < 0.05).

CONCLUSIONS

Kidney transplantation with organs from ECDs is significantly more expensive than with organs from non-ECDs, even in the face of similar graft survival rates. Further study is needed to determine the cost-effectiveness of renal transplantation utilizing kidneys from ECDs vis-a-vis hemodialysis.

Clinical and economic outcomes of expanded criteria donors in renal transplantation

Although graft and patient survival rates were similar between recipients of kidneys from ECDs and non-ECDs, transplantation with organs from ECDs was significantly more expensive. Multivariate analysis using stepwise linear regression demonstrated length of stay to be a strong proxy for total hospital costs. Inherent tensions between the overall good clinical outcomes associated with the use of ECDs in terms of graft survival and the markedly increased costs seen with these organs are evident.

Efficacy of OKT3 as primary therapy for histologically confirmed acute renal allograft rejection

BACKGROUND

OKT3 is often used as primary treatment for acute renal allograft rejection. In a retrospective study, we sought to determine the efficacy of OKT3 as a first-line agent in reversing histologically confirmed acute renal allograft rejection.

METHODS

Patients with mild to moderate, moderate, or severe acute cellular and acute vascular rejection who had not received any other anti-rejection treatment were included in this analysis. A total of 88 patients, who received OKT3 between 1987 and 1995, fulfilled these criteria.

RESULT

Seventy of these patients were renal transplant recipients, and 18 were combined kidney and pancreas transplant recipients. The median time to the diagnosis of rejection from transplantation was 32 days (range, 6 days to 13 years). On histology, 6 were graded as mild to moderate, 36 as moderate, 29 as moderate to severe, and 17 as severe rejection. The mean baseline serum creatinine was 1.62 mg/dl (range, 0.7-10.1 mg/dl), and the mean serum creatinine at the time of diagnosis of rejection was 2.60 mg/dl (range, 1.4-12.7 mg/dl) (P=<0.0001). The mean duration of OKT3 treatment was 11.2 days (range, 8-18 days). The mean serum creatinine at the end of OKT3 treatment was 1.73 mg/dl (range, 0.6-5.0 mg/dl; P=0.24 compared with baseline serum creatinine). Rejection was reversed in 86 (98%) patients. Graft survival at 1 year after OKT3 therapy was 87.5% (77 of 88). At a mean follow-up of 38 months, 8 patients had died and 26 grafts were lost. The mean serum creatinine level in the 64 patients with a functioning graft was 1.76 mg/dl (range, 0.8-4.0 mg/dl) at the last follow-up.

CONCLUSION

OKT3 when utilized as first-line therapy reversed 98% of the acute rejection episodes, with a 1-year post-OKT3 graft survival of 87.5%.

Combined kidney-pancreas and parathyroid transplantation: a case report

We report the first successful multiorgan kidney-pancreas and parathyroid tissue transplant in a patient with autoimmune polyglandular syndrome and medullary cystic disease. Successful transplantation included quadruple drug induction therapy consisting of antithymocyte globulin, azathioprine, cyclosporine and prednisone. All three grafts are functioning 2 yr after transplantation.

Expanding the donor pool

Advances in techniques and the development of new immunosuppressive drugs have made it possible to transplant a large number of patients throughout the world. However, the shortage of cadaveric organ donors remains the major obstacle for the full development of organ transplantation, imposing a severe limit to the number of patients who could benefit from this therapy. Although transplants save thousands of lives and transform the quality of life of thousands more, many people will die or remain on renal replacement therapy because the organ supply falls drastically short of actual demand. In the US, the number of organ donors has increased approximately 20% over the past 5 years, but this increase has been brought about largely by the use of older donors and other donors considered by some to be marginal. In the 6 years from 1988 to 1994, the waiting list for kidneys grew by 76% in the US. By the end of August 1996, there were 33,339 patients registered for kidneys on the national transplant waiting list. This report examines the issue of the elderly donor, the role of living-unrelated kidney transplantation, and proposes various strategies to enhance procurement of cadaver kidneys.

Causes of renal allograft loss in black vs. white transplant recipients in the cyclosporine era

Black renal transplant recipients have a higher rate of allograft loss than white recipients. From 1 January 1984 to 1 January 1995, 463 transplants were performed at a single center and followed for a mean duration of 71 months. The causes of graft loss for white and black recipients, their age, gender, retransplantation rate, organ source, and HLA matching were compared. In the 150 black and 313 white recipients, graft loss rates in the first year were 20% in both groups, while after 1 yr there were 42 (28%) graft losses in blacks vs. 62 (20%) in whites (log-rank test p = 0.04). All diagnoses deemed causative of allograft loss were confirmed by biopsy. Chronic rejection resulting in graft loss occurred in 15% (n = 23) of black recipients compared to only 7% (n = 22) of white recipients (p = 0.002). There were no significant differences in the rate of death with a functioning kidney or other causes of graft loss between the two groups. A significant increase in HLA mismatches was noted in black recipients of cadaveric grafts compared to whites, but there was no difference between races in the rate of graft loss due to acute rejection. While the rate of graft survival remains lower in black recipients in the cyclosporine era, this is due entirely to late graft loss after 1-yr post-transplant due to chronic rejection.

Primary care of patients with renal transplants

The number of renal transplant recipients in the community continues to rise due to improved organ and patient survival. With increasing emphasis on primary care, more organ transplant recipients are being cared for by primary care physicians. This article outlines the management of renal transplant recipients and reviews the problems unique to this group of patients.