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The combined risk of donor quality and recipient age: higher-quality kidneys may not always improve patient and graft survival. Transplantation 2015; 98:1069-76. [PMID: 24918617 DOI: 10.1097/tp.0000000000000181] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The Kidney Donor Profile Index (KDPI) is a more precise donor organ quality metric replacing age-based characterization of donor risk. Little prior attention has been paid on the outcomes of lower-quality kidneys transplanted into elderly recipients. Although we have previously shown that immunological risks associated with older organs are attenuated by advanced recipient age, it remains unknown whether risks associated with lower-quality KDPI organs are similarly reduced in older recipients. METHODS Donor organ quality as measured by the KDPI was divided into quintiles (very high, high, medium, low, and very low quality), and Cox proportional hazards was used to assess graft and recipient survival in first-time adult deceased donor transplant recipients by recipient age. RESULTS In uncensored graft survival analysis, recipients older than 69 years had demonstrated comparable outcomes if they received low-quality kidneys compared to medium-quality kidneys. Death-censored analysis demonstrated no increased relative risk when low-quality kidneys were transplanted into recipients aged 70 to 79 years (hazard ratio [HR], 1.11; P=0.19) or older than 79 years (HR, 1.08; P=0.59). In overall survival analysis, elderly recipients gained no relative benefit from medium-quality kidneys over low-quality kidneys (70-79 years: HR, 1.03, P=0.51; >79 years: HR, 1.08; P=0.32). CONCLUSION Our analysis demonstrates that transplanting medium-quality kidneys into elderly recipients does not provide significant advantage over low-quality kidneys.
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102
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Kim SC, Pearson TC, Tso PL. Revamped Rationing of Renal Resources: Kidney Allocation in Search of Utility and Justice for All. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0050-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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103
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Carmellini M, Garcia V, Wang Z, Vergara M, Russ G. Efficacy of everolimus with reduced-exposure cyclosporine in de novo kidney transplant patients at increased risk for efficacy events: analysis of a randomized trial. J Nephrol 2015; 28:633-9. [PMID: 25708913 DOI: 10.1007/s40620-015-0180-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/05/2015] [Indexed: 01/05/2023]
Abstract
The efficacy of de novo everolimus with reduced-exposure calcineurin inhibitor (CNI) was examined in kidney transplant subpopulations from the A2309 study that were identified to be at increased risk for efficacy events. A2309 was a 24-month, multicenter, open-label trial in which 833 de novo kidney transplant recipients were randomized to everolimus targeting 3-8 or 6-12 ng/ml with reduced-exposure cyclosporine (CsA), or mycophenolic acid (MPA) with standard-exposure CsA, all with basiliximab induction. The composite efficacy endpoint was treated biopsy-proven acute rejection (BPAR), graft loss, death, or loss to follow-up. Cox proportional hazard modeling showed male gender, younger recipient age, black race, delayed graft function, human leukocyte antigen (HLA) mismatch ≥3 and increasing donor age to be significantly predictive for the composite efficacy endpoint at months 12 or 24 post-transplant. CsA exposure was 53-75 % lower, and 46-75 % lower, in patients receiving everolimus 3-8 ng/ml or receiving everolimus 6-12 ng/ml, respectively, versus MPA-treated patients. The incidence of the composite endpoint was similar in all three treatment groups within each subpopulation analyzed. The incidence of treated BPAR was similar with everolimus 3-8 ng/ml or MPA in all subpopulations, but less frequent with everolimus 6-12 ng/ml versus MPA in patients with HLA mismatch ≥3 (p = 0.049). This post hoc analysis of a large, randomized trial suggests that a de novo regimen of everolimus with reduced-exposure CsA maintains immunosuppressive efficacy even in kidney transplant patients at increased risk for efficacy events despite substantial reductions in CsA exposure.
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Affiliation(s)
- Mario Carmellini
- Department of Surgery and Bioengineering, University of Siena, Siena, Italy. .,Centro Trapianti di Rene, Az. Osped Universitaria Senese Ospedale S Maria alle Scotte, U.O.C. Chirugira dei Trpianti-Dip. Chirugria Gen. e Spec, Viale Bracci 1, 53100, Siena, Italy.
| | - Valter Garcia
- Hospital Don Vicente Scherer, Santa Casa de Misericordia do Porto Alegre, Porto Alegre, Brazil
| | | | | | - Graeme Russ
- Renal Unit, The Queen Elizabeth Hospital, Woodville, Australia
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104
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Hod T, Goldfarb-Rumyantzev AS. Clinical issues in renal transplantation in the elderly. Clin Transplant 2015; 29:167-75. [DOI: 10.1111/ctr.12481] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2014] [Indexed: 12/27/2022]
Affiliation(s)
- Tammy Hod
- Center for Vascular Biology Research; Department of Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
- Division of Nephrology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - Alexander S. Goldfarb-Rumyantzev
- Division of Nephrology; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
- Transplant Institute; Beth Israel Deaconess Medical Center; Boston MA USA
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105
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Al-Shraideh Y, Farooq U, Farney AC, Palanisamy A, Rogers J, Orlando G, Buckley MR, Reeves-Daniel A, Doares W, Kaczmorski S, Gautreaux MD, Iskandar SS, Hairston G, Brim E, Mangus M, Stratta RJ. Influence of recipient age on deceased donor kidney transplant outcomes in the expanded criteria donor era. Clin Transplant 2014; 28:1372-1382. [DOI: 10.1111/ctr.12463] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Yousef Al-Shraideh
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Umar Farooq
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Alan C. Farney
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Amudha Palanisamy
- Department of Internal Medicine; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Jeffrey Rogers
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Giuseppe Orlando
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Michael R. Buckley
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Amber Reeves-Daniel
- Department of Internal Medicine; Wake Forest School of Medicine; Winston-Salem NC USA
| | - William Doares
- Department of Pharmacy; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Scott Kaczmorski
- Department of Pharmacy; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Michael D. Gautreaux
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Samy S. Iskandar
- Department of Pathology; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Gloria Hairston
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Elizabeth Brim
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Margaret Mangus
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Robert J. Stratta
- Department of General Surgery; Wake Forest School of Medicine; Winston-Salem NC USA
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106
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Chumfong I, Brown D, Keune J, Kodner I, Ray S, Zihni AM. Distributing a limited resource: ethical allocation of deceased donor kidneys. Surgery 2014; 156:198-203. [PMID: 25061657 DOI: 10.1016/j.surg.2014.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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107
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Lack of donor and recipient age interaction in cardiac transplantation. J Heart Lung Transplant 2014; 33:629-35. [DOI: 10.1016/j.healun.2014.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 02/02/2014] [Accepted: 02/07/2014] [Indexed: 11/20/2022] Open
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108
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Sayed BA, Turgeon NA. Pancreas Transplantation of Non-Traditional Recipients. CURRENT TRANSPLANTATION REPORTS 2014. [DOI: 10.1007/s40472-014-0011-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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109
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Schold JD, Reese PP. Simulating the new kidney allocation policy in the United States: modest gains and many unknowns. J Am Soc Nephrol 2014; 25:1617-9. [PMID: 24833124 DOI: 10.1681/asn.2014030235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio;
| | - Peter P Reese
- Renal, Electrolyte, and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Biostatistics and Epidemiology and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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110
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Telomere length of recipients and living kidney donors and chronic graft dysfunction in kidney transplants. Transplantation 2014; 97:325-9. [PMID: 24492422 DOI: 10.1097/01.tp.0000436705.87898.88] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A biological marker that would allow clinicians to determine the length of time an allograft will remain functional after transplantation would greatly aid the ability to stratify donors by risk and to use biologically "young" allografts in young recipients, maximizing the use of this rare resource. Telomere length (TL) has been proposed to be such a marker to determine the biological age of a tissue. METHODS We genotyped DNA from 1805 recipients and 1038 living kidney donors for TL to determine the association of TL with acute rejection (AR), chronic graft dysfunction (CGD), and graft failure of kidney allografts. DNA was isolated from peripheral blood white blood cells and TL was measured in DNA using the multiplexed monochrome quantitative polymerase chain reaction assay. RESULTS As has been previously shown, we found a significant association between log-transformed TL and donor age (P=3.8×10) and recipient age (P=5.6×10). Univariate and multivariate analysis did not show any significant associations between log-transformed TL in donor or recipient DNA with AR, CGD, or graft failure, although we did observe an association between donor chronological age and CGD (P=0.018). CONCLUSION Although older allografts have been shown to be at greater risk for AR and CGD, this does not appear to be associated with shorter TL. Different markers will need to be identified to determine how biological age impacts transplant outcome, such as age-related fibrosis or tubular atrophy and tubular loss.
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111
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Benítez C, Londoño MC, Miquel R, Manzia TM, Abraldes JG, Lozano JJ, Martínez-Llordella M, López M, Angelico R, Bohne F, Sese P, Daoud F, Larcier P, Roelen DL, Claas F, Whitehouse G, Lerut J, Pirenne J, Rimola A, Tisone G, Sánchez-Fueyo A. Prospective multicenter clinical trial of immunosuppressive drug withdrawal in stable adult liver transplant recipients. Hepatology 2013; 58:1824-35. [PMID: 23532679 DOI: 10.1002/hep.26426] [Citation(s) in RCA: 234] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 03/22/2013] [Indexed: 12/12/2022]
Abstract
UNLABELLED Lifelong immunosuppression increases morbidity and mortality in liver transplantation. Discontinuation of immunosuppressive drugs could lessen this burden, but the safety, applicability, and clinical outcomes of this strategy need to be carefully defined. We enrolled 102 stable liver recipients at least 3 years after transplantation in a single-arm multicenter immunosuppression withdrawal trial. Drugs were gradually discontinued over a 6 to 9-month period. The primary endpoint was the development of operational tolerance, defined as successful immunosuppressive drug cessation maintained for at least 12 months with stable graft function and no histopathologic evidence of rejection. Out of the 98 recipients evaluated, 57 rejected and 41 successfully discontinued all immunosuppressive drugs. In nontolerant recipients rejection episodes were mild and resolved over 5.6 months (two nontolerant patients still exhibited mild gradually improving cholestasis at the end of follow-up). In tolerant recipients no progressive clinically significant histological damage was apparent in follow-up protocol biopsies performed up to 3 years following drug withdrawal. Tolerance was independently associated with time since transplantation (odds ratio [OR] 1.353; P = 0.0001), recipient age (OR 1.073; P = 0.009), and male gender (OR 4.657; P = 0.016). A predictive model incorporating the first two clinical variables identified subgroups of recipients with very high (79%), intermediate (30%-38%), and very low (0%) likelihood of successful withdrawal. CONCLUSION When conducted at late timepoints after transplantation, immunosuppression withdrawal is successful in a high proportion of carefully selected liver recipients. A combination of clinical parameters could be useful to predict the success of this strategy. Additional prospective studies are now needed to confirm these results and to validate clinically applicable diagnostic biomarkers.
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Affiliation(s)
- Carlos Benítez
- Liver Unit, Hospital Clinic Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
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112
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Lebranchu Y, Baan C, Biancone L, Legendre C, Morales JM, Naesens M, Thomusch O, Friend P. Pretransplant identification of acute rejection risk following kidney transplantation. Transpl Int 2013; 27:129-38. [DOI: 10.1111/tri.12205] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/26/2013] [Accepted: 10/02/2013] [Indexed: 02/05/2023]
Affiliation(s)
- Yvon Lebranchu
- Department of Nephrology and Clinical Immunology EA 4245 CHRU Tours Tours France
| | - Carla Baan
- Department of Internal Medicine Erasmus MC University Medical Centre Rotterdam The Netherlands
| | - Luigi Biancone
- Division of Nephrology, Dialysis and Transplantation Department of Medical Sciences Molinette Hospital University of Turin Turin Italy
| | | | | | - Maarten Naesens
- Department of Nephrology, Dialysis and Renal Transplantation University Hospitals Leuven Leuven Belgium
| | - Oliver Thomusch
- Department of General Surgery University Clinic of Freiburg Freiburg Germany
| | - Peter Friend
- Nuffield Department of Surgical Sciences Oxford Transplant Centre Oxford UK
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113
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Martins PNA, Tullius SG, Markmann JF. Immunosenescence and immune response in organ transplantation. Int Rev Immunol 2013; 33:162-73. [PMID: 24127845 DOI: 10.3109/08830185.2013.829469] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The immune system undergoes a complex and continuous remodeling with aging. Immunosenescence results into both quantitative and qualitative changes of specific cellular subpopulations that have major impact on allorecognition and alloresponse, and consequently on graft rejection and tolerance. Here, we are going to review the immunological changes associated with the aging process relevant for transplantation. Interventions to selectively target changes associated with the senescence process seem promising therapeutic strategies to improve transplantation outcome.
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Affiliation(s)
- Paulo Ney Aguiar Martins
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
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114
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Somma C, Trillini M, Kasa M, Gentile G. Managing end-stage renal disease in the elderly: state-of-the-art, challenges and opportunities. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ahe.13.52] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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115
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Shin M, Moon H, Kim J, Park J, Kwon C, Joh JW, Kim SJ. Implication of Donor–Recipient Age Gradient in the Prognosis of Graft Outcome After Deceased-Donor Kidney Transplantation. Transplant Proc 2013; 45:2907-13. [DOI: 10.1016/j.transproceed.2013.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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116
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Heinbokel T, Elkhal A, Liu G, Edtinger K, Tullius SG. Immunosenescence and organ transplantation. Transplant Rev (Orlando) 2013; 27:65-75. [PMID: 23639337 PMCID: PMC3718545 DOI: 10.1016/j.trre.2013.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/17/2012] [Accepted: 03/19/2013] [Indexed: 12/22/2022]
Abstract
Increasing numbers of elderly transplant recipients and a growing demand for organs from older donors impose pressing challenges on transplantation medicine. Continuous and complex modifications of the immune system in parallel to aging have a major impact on transplant outcome and organ quality. Both, altered alloimmune responses and increased immunogenicity of organs present risk factors for inferior patient and graft survival. Moreover, a growing body of knowledge on age-dependent modifications of allorecognition and alloimmune responses may require age-adapted immunosuppression and organ allocation. Here, we summarize relevant aspects of immunosenescence and their possible clinical impact on organ transplantation.
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Affiliation(s)
- Timm Heinbokel
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Institute of Medical Immunology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Abdallah Elkhal
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Guangxiang Liu
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Karoline Edtinger
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Stefan G. Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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117
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Shin M, Park JB, Kwon CHD, Joh JW, Lee SK, Kim SJ. Enhanced Significance of Donor–Recipient Age Gradient as a Prognostic Factor of Graft Outcome in Living Donor Kidney Transplantation. World J Surg 2013; 37:1718-26. [DOI: 10.1007/s00268-013-2038-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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118
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Hatamizadeh P, Molnar MZ, Streja E, Lertdumrongluk P, Krishnan M, Kovesdy CP, Kalantar-Zadeh K. Recipient-related predictors of kidney transplantation outcomes in the elderly. Clin Transplant 2013; 27:436-43. [PMID: 23516994 DOI: 10.1111/ctr.12106] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND It is not clear whether in old people with end-stage renal disease kidney transplantation is superior to dialysis therapy. METHODS We compared mortality rates between kidney transplant recipients (KTRs) and the general population across different age categories. We also examined patient and allograft survival in 15 667 elderly KTRs (65-<90 yr old, 36% female) within three age subgroups (65-<70, 70-<75, and ≥75 yr). RESULTS The rise in the relative risk of death in older age groups was substantially less in KTRs than in the general population, that is, 1.8 and 2.0 vs. 21.4 and 76.6 in those aged 65-<75 and ≥75 yr, respectively, compared with 15- to <65-yr-old people (reference group). In 65- to <70-yr-old KTRs, obesity (BMI>30 kg/m(2) ) was associated with 19% higher risk of graft failure (HR: 1.19 [1.07-1.33], p = 0.002). Diabetes was a predictor of worse patient survival in all age groups but poorer allograft outcome in the youngest age group (65-<70 yr old) only. None of the examined risk factors affected allograft outcome in the oldest group (≥75 yr old) although there was a 49% lower trend of graft failure in very old Hispanic recipients (HR: 0.51 [0.26-1.01], p = 0.05). CONCLUSIONS Kidney transplantation may attenuate the age-associated increase in mortality, and its superior survival gain is most prominent in the oldest recipients (≥75 yr old). The potential protective effect of kidney transplantation on longevity in the elderly deserves further investigation.
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Affiliation(s)
- Parta Hatamizadeh
- Harold Simmons Center for Chronic Disease Research & Epidemiology, University of California Irvine Medical Center, Irvine, CA92868-3217, USA
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Abstract
INTRODUCTION Powerful immunosuppressive regimens have reduced rejection risk, leading to an expanding cohort of long-term kidney transplant recipients who are likely to encounter practitioners in other specialties. SOURCES OF DATA Key review papers and primary literature identified through searches of PubMed, Google Scholar and Medline. AREAS OF AGREEMENT Death from cardiovascular disease and malignancy remain the chief causes of transplant loss. Risk factors and phenotypes for these differ from the general population. AREAS OF CONTROVERSY Many guidelines for renal transplant recipients are based on extrapolation from studies on non-transplant cohorts and may not be appropriate. Emerging studies demonstrate that established interventions in the general population are less efficacious in transplant recipients. GROWING POINTS The influence of immunosuppression on the development of complications. AREAS TIMELY FOR DEVELOPING RESEARCH Markers to guide individualized optimal immunosuppression and predict the development of complications would allow for targeted early intervention.
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121
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Recipient age and time spent hospitalized in the year before and after kidney transplantation. Transplantation 2012; 94:750-6. [PMID: 22932116 DOI: 10.1097/tp.0b013e31826205b9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Kidney transplantation (KT) is a life-prolonging therapy in certain older end-stage renal disease patients, but concerns regarding peritransplantation morbidity remain. We estimate the relative increase in time spent hospitalized in the year post-KT for older versus younger end-stage renal disease patients. METHODS This was a retrospective analysis of 27,247 Medicare-primary KT recipients from 2000 to 2005 using United States Renal Data System and Organ Procurement and Transplantation Network data. Time spent hospitalized was enumerated in the year pre-KT and post-KT from Medicare Part A claims. Excess inpatient days were the difference in an individual's post-KT and pre-KT hospital and skilled nursing facility days, standardized by time spent alive in the year post-KT. RESULTS The median excess inpatient days were similar by age group (9 in recipients 65 years or older vs. 7 in recipients younger than 65 years); however, the distribution was skewed, such that many more older adults had large increases in inpatient time (8.6% totaled >120 excess inpatient days vs. 4.2% in younger recipients). Among older recipients, risk factors for poor outcomes included recipient age, donor age, longer dialysis vintage, diabetic nephropathy, and congestive heart failure. Reasons for posttransplantation hospitalization were similar by age with the exception of rehabilitation, which was common only in the 65+ age group. Mean inpatient costs were equivalent pretransplantation by age but significantly higher posttransplantation among older KT recipients. CONCLUSIONS Posttransplantation morbidity may not be so different in most of the older individuals selected for KT; however, a minority fares much worse.
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Shah AP, Mangus RS, Powelson JA, Samy KP, Taber TE, Goble ML, Fridell JA. Impact of recipient age on whole organ pancreas transplantation. Clin Transplant 2012; 27:E49-55. [PMID: 23228216 DOI: 10.1111/ctr.12047] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 01/10/2023]
Abstract
AIM The goal of this study was to assess the impact of recipient age on post-transplant outcome. METHODS All pancreas transplants performed at Indiana University between 2003 and 2011 were reviewed. Demographic data were compared using standard chi-square and ANOVA testing. Standard Cox regression survival analysis was performed using a direct entry method for covariates. RESULTS Patients (n = 405) were divided by decade: <30 yr (n = 37), 30-39 (n = 109), 40-49 (n = 156), 50-59 (n = 85), and ≥ 60 yr of age (n = 18). Group demographics did not differ except for median ischemia time, which was between 7.0 and 8.5 h (p = 0.02). Early graft loss and one yr graft and patient survival were similar between the groups. Long-term patient survival demonstrated a trend toward decreased five-yr survival with increasing recipient age (p = NS). Graft survival at five yr by Cox regression was the lowest for the <30 yr group (74%), while all other groups were similar around 80% (p = NS). CONCLUSION No statistically significant differences in pancreas transplant outcomes were demonstrated when recipients were stratified by recipient age. These results suggest that older recipients can successfully undergo pancreas transplantation and expect five-yr outcomes similar to those seen in younger recipients.
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Affiliation(s)
- Ashesh P Shah
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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123
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Heinbokel T, Hock K, Liu G, Edtinger K, Elkhal A, Tullius SG. Impact of immunosenescence on transplant outcome. Transpl Int 2012. [DOI: 10.1111/tri.12013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Guangxiang Liu
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
| | - Karoline Edtinger
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
| | - Abdallah Elkhal
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
| | - Stefan G. Tullius
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
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Abstract
The world population is rapidly growing and ageing at a pace that is projected to continue for at least three decades. This shift towards an older populace has invariably increased the number of individuals with diseases related to ageing, such as chronic kidney disease. The increase in chronic kidney disease is associated with a growing number of elderly patients receiving kidney transplants. Understanding how the immune system changes with increasing age will help to define the risks of rejection and infection in the elderly population and will focus attention on the need for individualized immunosuppression for patients in this age group. This Review addresses what is currently known about ageing and the immune system, highlighting age-related changes that affect the outcome of transplantation in elderly individuals. The need for new strategies to improve outcomes in this growing population of elderly renal transplant recipients is also emphasized.
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Affiliation(s)
- Dianne McKay
- Department of Medicine, Division of Nephrology-Hypertension, University of California San Diego, 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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Fernández-Lorente L, Riera L, Bestard O, Carrera M, Gomà M, Porta N, Torras J, Melilli E, Gil-Vernet S, Grinyó JM, Cruzado JM. Long-term results of biopsy-guided selection and allocation of kidneys from older donors in older recipients. Am J Transplant 2012; 12:2781-8. [PMID: 22702444 DOI: 10.1111/j.1600-6143.2012.04153.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In our old-for-old program, we discard or allocate older extended criteria donor kidneys to single (SKT) or dual kidney transplantation (DKT) depending on histological Remuzzi's score in recipients older than 60 years. Here, we analyze the long-term results of this program and try to identify independent predictors of patient and graft survival. Between December 1996 and January 2008, we performed 115 SKT and 88 DKT. Discard rate was 15%. Acute rejection incidence was higher in SKT than in DKT (22.6% vs. 11.4%, p = 0.04). Renal function was better in DKT than in SKT up to 5 years after transplantation. Surgical complications were frequent in DKT. Ten-year cumulative graft survival was significantly lower in the SKT group (31% vs. 53%, p = 0.03). In SKT, histological score 4 provided similar graft survival than 3 or less, whereas in DKT score 4, 5 or 6 displayed similar outcome. Finally, independent predictors of graft survival were history of major adverse cardiac event and 1-year serum creatinine, rather than SKT or DKT. In conclusion, this biopsy-guided old-for-old strategy resulted in acceptable long-term graft survival. Our results suggest that DKT should be considered for scores of 5 or 6 only.
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Affiliation(s)
- L Fernández-Lorente
- Nephrology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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126
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Hopper K, Mehl ML, Kass PH, Kyles A, Gregory CR. Outcome after Renal Transplantation in 26 Dogs. Vet Surg 2012; 41:316-27. [DOI: 10.1111/j.1532-950x.2011.00924.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Kate Hopper
- Department of Surgical and Radiological Sciences; School of Veterinary Medicine; University of California-Davis; Davis; CA
| | - Margo L. Mehl
- San Francisco Veterinary Specialists; San Francisco; CA
| | - Philip H. Kass
- Department of Population Health and Reproduction; School of Veterinary Medicine; University of California-Davis; Davis; CA
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127
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Abstract
Utilization rates of organs from elderly donors have shown the highest proportional increase during the last decade. Clinical reports support the concept of transplanting older organs. However, the engraftment of such organs has been linked to accelerated immune responses based on ageing changes per se and a proinflammatory environment subsequent to compromised injury and repair mechanism. We analyzed the clinical consequences of transplanting older donor organs and present mechanistic aspects correlating age, injury repair and effects on host immunoresponsiveness.
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Affiliation(s)
- R Oberhuber
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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128
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Denecke C, Ge X, Jurisch A, Kleffel S, Kim IK, Padera RF, Weiland A, Fiorina P, Pratschke J, Tullius SG. Modified CD4+ T-cell response in recipients of old cardiac allografts. Transpl Int 2011; 25:328-36. [DOI: 10.1111/j.1432-2277.2011.01417.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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129
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Veroux M, Grosso G, Corona D, Mistretta A, Giaquinta A, Giuffrida G, Sinagra N, Veroux P. Age is an important predictor of kidney transplantation outcome. Nephrol Dial Transplant 2011; 27:1663-71. [PMID: 21926404 DOI: 10.1093/ndt/gfr524] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Donor and recipient age may have an impact on the renal transplant outcome. Kidney transplantation from older donors may result in a worse outcome, and the survival benefit of kidney transplantation compared with dialysis may be reduced. The aim of this study was to evaluate the impact of donor and recipient age on kidney transplant outcome. MATERIALS AND METHODS Two hundred and twenty-three recipients of kidney transplants performed at our institution between 2002 and 2007 were analysed. The role of donor and recipient age matching on survival rate were investigated performing the Kaplan-Meier survival time analysis by decades, considering the donor's age of 60 and 70 years. The Cox proportional hazard uni- and multivariate regressions were also performed. Finally, Kaplan-Meier survival time analysis was performed to assess survival rates of patients transplanted stratified by donor age compared with wait-listed renal transplant candidates. RESULTS Elderly recipients had a significant lower graft and patient survival as well as a significantly higher risk of graft loss and patient death. Recipients younger and older than 65 years of age were at higher risk of graft loss if they received grafts from donors>65 years [hazard ratio (HR)=2.59, 95% confidence interval (CI): 1.12-6 and HR=5.65, 95% CI: 2.31-13.79, respectively]. Elderly recipients displayed a worse survival compared with transplant candidates on the waiting list. CONCLUSIONS Age is an important predictor of kidney transplantation outcome. Kidney transplantation does not offer a significant survival benefit in the intermediate term, compared to the waiting list, to elderly recipients transplanted with grafts from older donors. However, it cannot be excluded that it is still possible that there is a long-term benefit of transplantation over dialysis in this group of patients.
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Affiliation(s)
- Massimiliano Veroux
- Department of Surgery, Transplantation and Advanced Technologies, Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy.
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130
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131
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Timsit MO, Yuan X, Floerchinger B, Ge X, Tullius SG. Consequences of transplant quality on chronic allograft nephropathy. Kidney Int 2011:S54-8. [PMID: 21116319 DOI: 10.1038/ki.2010.424] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Using kidneys from expanded-criteria donors to alleviate organ shortage has raised concern on reduced transplant outcomes. In this paper, we review how critical donor-related factors such as donor age, brain death, and consequences of ischemia-reperfusion injury (IRI) determine graft quality and impact chronic allograft nephropathy. We propose that combinatorial effects of organ-intrinsic features associated with increasing age and unspecific injuries related to brain death and IRI will impact innate and adaptive immune responses. Future research will need to explore avenues to optimize donor management, organ preservation, adapted immunosuppressive strategies, as well as modifications of the allocation of suboptimal allografts.
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Affiliation(s)
- Marc-Olivier Timsit
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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132
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Naesens M, Sarwal MM, Kuypers DRJ. Organ transplantation after cardiac death. Lancet 2011; 377:203; author reply 204-5. [PMID: 21237391 DOI: 10.1016/s0140-6736(11)60037-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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