Renal Grafts From Elderly Donors: Histological Studies and Long-Term Results

Kidney Transplantation From Brain-Dead Donors: Initial Experience in China

BACKGROUND

Experience with kidney transplantation from brain-dead donors remains limited in China. Our objective was to evaluate the outcomes of kidney transplantation from brain-dead donors (group 1), compared with those from living ones of the same age (group 2).

METHODS

Clinical data of kidney transplantation from brain-dead donors and living donors in the same age range (18-45 years) performed between May 2007 and December 2011 were analyzed retrospectively. Recipients were analyzed for posttransplantation serum creatinine, creatinine clearance (calculated by the Cockcroft-Gault formula), the number of acute rejection episodes and delayed graft function, and patient/graft survival.

RESULTS

Mean donor age was comparable between the 2 groups (31.9 ± 6.5 vs 32.8 ± 7.0 years; P = .268). The terminal serum creatinine level of donors was 125.5 ± 63.5 μmol/L in group 1 (n = 30) and 65.1 ± 13.7 μmol/L in group 2 (n = 110; P = .000). Recipient creatinine clearance was comparable between the 2 groups 1 month posttransplantation and thereafter. Acute rejection episodes were seen in 7 cases in recipients of group 1 (15.9%) and in 15 cases in recipients of group 2 (13.6%; P = .716). The incidence of delayed graft function was higher in recipients of group 1 (18.2%) than that of group 2 (3.6%; P = .002). The 1-, 3-, and 5-year patient/graft survival rate was comparable between the 2 groups.

CONCLUSIONS

Our study demonstrated kidney transplantation from brain-dead donors achieved acceptable graft function and patient/graft survival in the 5-year follow-up, encouraging the use of this approach.

Progression of urinary protein excretion after kidney transplantation: A marker for poor long-term prognosis

INTRODUCTION

Post-transplantation proteinuria is a risk factor for graft failure. A progressive decline in renal graft function is a predictor for mortality in kidney transplant patients.

OBJECTIVES

To assess the development and the progression of urinary protein excretion (UPE) in the first year post-transplant in recipients of kidney transplants and its effect on patient and graft outcomes.

MATERIALS AND METHODS

We analysed 1815 patients with 24-h UPE measurements available at 3 and 12 months post-transplant. Patients were divided based on their UPE level: below 300 mg, 300-1000 mg and over 1000 mg (at 3 and 12 months), and changes over time were analysed.

RESULTS

At 3 months, 65.7% had UPE below 300 mg/24 h, 29.6% 300-1000 mg/24 h and 4.7% over 1000 mg/24h. At one year, 71.6% had UPE below 300 mg/24 h, 24.1% 300-1000 mg/24 h and 4.4% over 1000 mg/24 h. In 208 patients (12%), the UPE progressed, in 1233 (70.5%) it remained stable and in 306 (17.5%) an improvement was observed. We found that the level of UPE influenced graft survival, particularly if a progression occurred. Recipient's age and renal function at one year were found to be predictive factors for mortality, while proteinuria and renal function were predictive factors for graft survival.

CONCLUSIONS

Proteinuria after transplantation, essentially when it progresses, is a marker of a poor prognosis and a predictor for graft survival. Progression of proteinuria is associated with poorer renal function and lower graft survival rates.

A systematic review of kidney transplantation from expanded criteria donors

BACKGROUND

During the past few years, there has been renewed interest in the use of expanded criteria donors (ECD) for kidney transplantation to increase the numbers of deceased donor kidneys available. More kidney transplants would result in shorter waiting times and limit the morbidity and mortality associated with long-term dialysis therapy.

STUDY DESIGN

Systematic review of the literature.

SETTING & POPULATION

Kidney transplantation population.

SELECTION CRITERIA FOR STUDIES

Studies were identified by using a comprehensive search through MEDLINE and EMBASE databases. Inclusion criteria were case series, cohort studies, and randomized controlled trials assessing kidney transplantation in adult recipients using ECDs.

PREDICTOR

A special focus was given to studies comparing the evolution of kidney transplantation between standard criteria donors (defined as a donor who does not meet criteria for donation after cardiac death or ECD) and ECDs (defined as any brain-dead donor aged > 60 years or a donor aged > 50 years with 2 of the following conditions: history of hypertension, terminal serum creatinine level >or= 1.5 mg/dL, or death resulting from a cerebrovascular accident).

OUTCOMES

Criteria used to define and select ECDs, practice patterns, long-term outcomes, early complications, and some patient issues, such as selection criteria and immunosuppressive management.

RESULTS

ECD kidneys have worse long-term survival than standard criteria donor kidneys. The optimal ECD kidney for donation depends on adequate glomerular filtration rate and acceptable donor kidney histological characteristics, albeit the usefulness of biopsy is debated.

LIMITATIONS

This review is based mainly on data from observational studies, and varying amounts of bias could be present. We did not attempt to quantitatively analyze the effect of ECD kidneys on kidney transplantation because of the huge heterogeneity found in study designs and definitions of ECD.

CONCLUSIONS

Based on the available evidence, we conclude that patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy.