Deceased donor organ transplantation with expanded criteria donors: a single-center experience from India

Induction with rATG versus No-induction in Deceased Donor Renal Transplantation - A Retrospective Observational Study

Introduction

Deceased donor renal transplantation (DDRT) poses special immunological challenges; particularly in resource-poor scenarios. There is substantial evidence that rabbit antithymocyte globulin (rATG) is superior to interleukin-2 receptor blocker and placebo among patients at high immunological risk. However, due to the lack of randomized controlled trials, this remains controversial in DDRT maintained on tacrolimus/mycophenolic acid/steroids. Here, in this study, we compared the clinical outcomes of induction with rATG therapy to no-induction therapy.

Methods

The study was a single-center, retrospective cohort study. A total of 62 patients were divided into two groups, based on induction immunosuppression; induction with rATG (N = 25) and no-induction group (N = 37). Both groups received tacrolimus/mycophenolate mofetil sodium/prednisolone as maintenance immunosuppression. The main outcomes were incidence of acute rejection (AR) within the first year and graft survival at the end of 1 year.

Results

The AR at the end of 1-year was reported as 8% and 27% for the induction and no-induction groups (P = 0.07), respectively. A total of 15 patients died. Patient survival rates at 12 months were 83.8% (no-induction) and 64.0% (induction; P = 0.094). Death-censored graft survival rates, 12 months after transplantation, were similar in both treatment groups (83.7% vs. 83.5%, P = 0.972). The incidence of death with functioning graft was significantly high in the induction group (28% vs. 5.4%, P = 0.045).

Conclusion

The incidence of AR was less in patients who received rATG induction compared with patients who did not receive any form of induction. An added advantage of induction with ATG in terms of reduced incidence of AR must be weighed against high incidence of infection, death with functioning graft, and death.

Deceased donor renal transplantation at army hospital research and referral: Our experience

CONTEXT

In India, there are a large number of end-stage renal disease (ESRD) patients waiting for renal transplant. Deceased donor organ transplantation (DDOT) is the possible solution to bridge the disparity between organ supply and demand. The concept of expanded criteria donors (ECDs) was developed to combat the huge discrepancy between demand and organ availability. However, ECD kidneys have a higher propensity for delayed graft function (DGF), and therefore worse long-term survival. We present our experience of deceased donor renal transplantation.

AIMS

We report single centre experience on DDOT including ECDs vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), rejection episodes, and delayed graft function in 44 DDOT.

MATERIALS AND METHODS

Between August 1998 and April 2011, 44 renal transplants from 35 deceased donors were performed, of which 37.2% were expanded criteria donors. Results were analyzed in terms of age of donor, terminal SCr, graft ischemia time, graft function, post-transplant complications, and graft and patient survival. All recipients received sequential triple drug immunosuppression and induction with rabbit antithymocyte globulin (rATG). The induction is commenced by giving first dose of rATG intraoperatively (dose 1.5 mg/kg) and subsequent rATG infusions were administered daily for a minimum of 5 and maximum of 7 doses depending on initial graft function.

RESULTS

We have been able to achieve a mean cold ischemia time of 6.25 ± 2.55 h due to the coordinated team efforts. Delayed graft function occurred in 34% patients and 31.8% had prolonged drainage. There were no urinary leaks. Seven (16%) patients had biopsy-proven rejection episodes, all of which were reversed with treatment. Two patients underwent graft nephrectomy. One of these was due to hyperacute rejection and another due to anastomotic hemorrhage. One-year graft survival was 92.4% and the patient survival was 83.8%.

CONCLUSION

Deceased donor renal transplants have satisfactory graft function and patient survival despite the high incidence of delayed graft function. Retrieving kidneys from marginal donors can add to the donor pool.

Deceased donor organ transplantation: A single center experience

Renal transplantation (RTx) is the best therapeutic modality for patient suffering from end-stage renal disease (ESRD). Deceased donor organ transplantation (DDOT) accounts for <4% of RTx in India. We report 4 years single centre experience on DDOT vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), rejection episodes, and delayed graft function in 160 DDOT. Between January 2006 to December 2009, 160 RTx from 89 donors were performed, of which 25.2% were expanded criteria donors. Majority of the donors were brain dead due to road traffic/cerebrovascular accidents. The commonest recipient diseases leading to ESRD were chronic glomerulonephritis (49%), diabetes mellitus (10%), and benign nephrosclerosis (10%). Mean recipient/donor age was 35.6±14.68 and 44.03±18.19 years. Mean dialysis duration pretransplantation was 15.37±2.82 months. Mean cold ischemia time was 5.56±2.04 hours. All recipients received single dose rabbit-anti-thymocyte globulin induction and steroids, mycophenolate mofetil/calcinueurin inhibitor for maintenance of immunosuppression. Delayed graft function was observed in 30.6% patients and 14% had biopsy proven acute rejection. Over mean follow-up of 2.35±1.24 years, patient and graft survival rates were 77.5% and 89.3% with mean SCr of 1.40±0.36 mg/dl. DDOT has acceptable graft/patient survival over 4 years follow-up and should be encouraged in view of organ shortage.