Delayed Graft Function in Living-Donor Renal Transplantation: 10-Year Experience

Histopathological Features and Role of Allograft Kidney Biopsy Among Recipients With Prolonged Delayed Graft Function: A Review

Delayed graft function (DGF) is an early posttransplant complication predictive of adverse outcomes. This "acute kidney injury of transplantation" is often defined as allograft dysfunction requiring renal replacement within 7 d posttransplantation. DGF is an important area of study because it is emerging with efforts to expand the donor pool and address the supply-demand gap in kidney transplantation. DGF is often caused by severe kidney injury mechanisms because of multiple donors, recipients, and immunologic factors. The role of kidney biopsy, particularly in prolonged DGF, is an ongoing area of research and inquiry for clinicians and researchers alike to better define, manage, and predict outcomes of this early posttransplant event. This review aims to provide an in-depth, comprehensive summary of the literature to date on the histopathology of DGF and the role of kidney transplant biopsies in prolonged DGF.

Risk factors of delayed graft function following living donor kidney transplantation: A meta-analysis

INTRODUCTION

Delayed graft function (DGF) is a common condition that necessitates dialysis during the first week after transplantation. Although DGF rarely occurs following living-donor kidney transplantation (LDKT), it may eventually lead to acute or chronic graft rejection. This study aimed to assess the risk factors for DGF in patients who underwent LDKT.

METHODS

A systematic review and meta-analysis of studies published before August 2022 was conducted using the PubMed, Science Direct, Cochrane, and Directory of Open Access Journal (DOAJ) databases. The review included studies that assessed the incidence of DGF following LDKT, and examined its risk factors, while excluding studies involving deceased donors. Potential risk factors were analyzed using pooled mean differences or odds ratios with 95% confidence intervals (CIs). Review Manager 5.3 was used for the meta-analysis.

RESULTS

Among the 13 included studies, 3685 cases of DGF were identified in a total of 113,261 patients (3.25%). Potential risk factors for DGF following LDKT were examined across several aspects, including donor, recipient, donor/recipient relationship, and immunological and intraoperative factors. The identified risk factors included older donors (P = 0.07), male recipients (P < 0.0001), higher recipient body mass index (BMI) (P < 0.0001), non-white recipients (P < 0.0001), pre-existing diabetes (P < 0.0001), pre-existing hypertension (P = 0.01), history of dialysis (P < 0.0001), re-transplantation (P = 0.004), unrelated donor/recipient (P = 0.02), ABO incompatibility (P < 0.0001), higher panel reactive antibody (PRA) levels (P < 0.0001), utilization of right kidney (P < 0.0001), and longer cold ischemia time (CIT) (P = 0.004).

CONCLUSION

Several factors related to the donor, recipient, donor/recipient relationship, and immunological and intraoperative aspects were identified as potential risk factors for the development of DGF following LDKT. Addressing and optimizing these factors may improve the long-term outcomes of LDKT.

The Predictors and Risk Factors of 2-Year Rejection in Renal Transplant Patients: A Multicenter Case-Control Study

INTRODUCTION

Kidney transplantation is a definitive treatment for end-stage renal disease. It is associated with improved life expectancy and quality of life. One of the most common complications following kidney transplantation is graft rejection. To our knowledge, no previous study has identified rejection risk factors in kidney transplant recipients in Saudi Arabia. Therefore, this study aimed to determine the specific risk factors of graft rejection.

METHODS

A multicenter case-control study was conducted at four transplant centers in Saudi Arabia. All adult patients who underwent a renal transplant between January 1, 2015 and December 31, 2021 were screened for eligibility. Included patients were categorized into two groups (cases and control) based on the occurrence of biopsy-proven rejection within 2 years. The primary outcome was to determine the risk factors for rejection within the 2 years of transplant. Exact matching was utilized using a 1:4 ratio based on patients' age, gender, and transplant year.

RESULTS

Out of 1,320 screened renal transplant recipients, 816 patients were included. The overall prevalence of 2-year rejection was 13.9%. In bivariate analysis, deceased donor status, the presence of donor-specific antibody (DSA), intraoperative hypotension, Pseudomonas aeruginosa, Candida, and any infection within 2 years were linked with an increased risk of 2-year rejection. However, in the logistic regression analysis, the presence of DSA was identified as a significant risk for 2-year rejection (adjusted OR: 2.68; 95% CI: 1.10, 6.49, p = 0.03). Furthermore, blood infection, infected with Pseudomonas aeruginosa or BK virus within 2 years of transplant, were associated with higher odds of 2-year rejection (adjusted OR: 3.10; 95% CI: 1.48, 6.48, p = 0.003, adjusted OR: 3.23; 95% CI: 0.87, 11.97, p = 0.08 and adjusted OR: 2.76; 95% CI: 0.89, 8.48, p = 0.07, respectively).

CONCLUSION

Our findings emphasize the need for appropriate prevention and management of infections following kidney transplantation to avoid more serious problems, such as rejection, which could significantly raise the likelihood of allograft failure and probably death. Further studies with larger sample sizes are needed to investigate the impact of serum chloride levels prior to transplant and intraoperative hypotension on the risk of graft rejection and failure.

The effect of late-onset CMV infection on the outcome of renal allograft considering initial graft function

BACKGROUND

Delayed graft function (DGF) increases the renal allograft failure risk. Late-onset Cytomegalovirus (CMV) infection's effect on the association between DGF and allograft failure has not been determined.

METHODS

In this retrospective cohort, we included all renal allograft recipients at London Health Sciences Centre from January 1, 2014 to December 30, 2017, and continued clinical follow-up until February 28, 2020. We determined whether late-onset CMV infection affects the association between DGF and allograft failure in stratified and Cox proportional hazard analyses.

RESULTS

Of 384 patients (median age [interquartile range]: 55 [43.3-63]; 38.7% female), 57 recipients (14.8%) were diagnosed with DGF. Patients with DGF were at a greater risk of CMV infection than patients without DGF (22.8% vs. 11.3%, p = .017). Late-onset CMV infection (odds ratio [OR]: 4.7, 95% CI: 2.07-10.68) and rejection (OR: 9.59, 95% CI: 4.15-22.16) significantly increased the risk of allograft failure in recipients with DGF. Patients with DGF had a significantly greater risk of graft failure than those without DGF (17.5% vs. 6.1%, p = .007). In the adjusted Cox hazard model, CMV infection significantly increased the risk of allograft failure (aHR: 3.19, 95% CI: 1.49-6.84).

CONCLUSION

Late-onset CMV infection considerably increased the risk of graft failure in patients with DGF. A hybrid preventive model including prophylaxis followed by CMV-specific cell-mediated immunity monitoring may decrease the risk of allograft failure in recipients with DGF.

Severe delayed graft function in a living-related kidney transplant recipient due to combination of alloimmunity, autoimmunity, and heterologous immunity: A case report

BACKGROUND

Delayed graft function is a manifestation of acute kidney injury unique to transplantation usually related to donor ischemia or recipient immunological causes. Ischemia also considered the most important trigger for innate immunity activation and production of non-HLA antibodies. While ischemia is inevitable after deceased donor transplantation, this complication is rare after living transplantation. Heterologous Immunity commonly used to describe the activation of T cells recognizing specific pathogen-related antigens as well unrelated antigens is common post-viral infection. In transplant-setting induction of heterologous immunity that cross-react with HLA-antigens and subsequent reactivation of memory T cells can lead to allograft rejection.

METHODS

Here we describe a non-sensitized child with ESRD secondary to lupus nephritis and recent history of COVID-19 infection who experienced 17 days of anuria after first kidney living transplantation from her young HLA-haploidentical uncle donor. Graft histology showed acute cellular rejection, evidence of mild antibody-mediated rejection and vascular wall necrosis in some arterioles suggesting possibility of intraoperative graft ischemia. Both pre- and post-transplant sera showed very high level of several non-HLA antibodies.

RESULTS

The patient was treated for cellular and antibody-mediated rejection while maintained on hemodialysis before her graft function started to improve on day seventeen post transplantation.

CONCLUSION

The cellular rejection likely trigged by ischemia that activated T-cells-mediated immunity. The high level of non- HLA-antibodies further aggravated the damage and the rapid onset of rejection may be partly related to memory T-cell activation induced by heterologous immunity.

Nondirected Living Kidney Donation and Recipient Outcomes in the United States: A 20-Year Review

Introduction

Nondirected donation (NDD) of the kidneys is a growing practice where donors who do not have any genetic or emotional relationship are selected to donate to a wide variety of recipients with a range of selection criteria and decisions which are left up to individual transplant centers.

Methods

We review all adult living kidney donor-recipient (DR) pairs and outcomes from NDDs who were recorded in United Network for Organ Sharing (UNOS) database as code 10 (anonymous) from October 1997 to September 2017 for demographics and outcomes.

Results

A total of 2174 DR pairs were identified. The number of NDDs increased from 18 in 2000 to 256 in 2016. Survival analysis showed higher death-censored-graft survival (DC-GS) when recipient was 20 years or more older than donor followed by recipient-donor within 20 years of age and lowest when donor was 20 years or more older than recipient (P = 0.0114).

Conclusion

Overall, the number of NDDs has increased significantly in the 20-year review period. Transplants from NDDs have excellent long-term outcomes. Better matching of controllable DR factors, such as age and body mass index (BMI), could further improve GS. Further research is needed to incorporate these DR factors into paired kidney donation programs potentially enhancing the utility and beneficence of this invaluable donation.

The Impact of Obesity and Associated Comorbidities on the Outcomes after Renal Transplantation with a Living Donor vs. Deceased Donor Grafts

Background: Obesity among kidney transplant (KT) recipients can lead to metabolic comorbidity-associated deaths. This study compares post-KT survival between obese and non-obese patients and outcomes of living donor (LD) and deceased donor (DD) grafts. Methods: Between January 2005−May 2019, 1403 KT recipients from a single center were included in the study, as well as 314 patients (22.4%) with obesity (BMI > 30 kg/m2), 137 DD transplants, and 177 LD transplants. Of the 1089 (77.6%) in the control group (BMI ≤ 30 kg/m2), 384 were DD transplants and 705 LD transplants. The Kaplan−Meier method was used for survival analysis and a Cox regression was used to identify risk factors for graft loss and mortality. Propensity score matching analysis adjusting for age, IHD, and T2DM was performed. Results: The study group had higher incidence of obesity related comorbidities, delayed graft function and primary non function (p < 0.001). One-, 5-and 10-year patient and graft survival were lower in the study group (p < 0.001). Subgroup analysis of graft survival according to type of graft shows a difference in the DD (p = 0.002) but not in the LD group (p = 0.220). However, mortality was higher in both groups (LD, p = 0.045; DD, p = 0.004). Risk factors for mortality were age, T2DM, IHD, and DD, and for graft failure: IHD, BMI, donor age, re-transplant, and DD. Propensity score analysis shows an odds ratio of 0.81 for graft failure and 0.93 for death in the study group (95% CI = 0.55, 1.21, p = 0.3 and CI = 0.59, 1.46, p = 0.7, respectively). Conclusions: Recipient age and metabolic comorbidities should be emphasized when evaluating patients with obesity. We suggest considering weight loss interventions using the new GLP-1 inhibitors and bariatric procedures in selected patients to prepare overweight patients for transplant.

Crystalloid fluids and delayed graft function in kidney transplant: A cohort study

Background:

Normal saline is commonly used in the perioperative kidney transplant period; its high chloride content can cause hyperchloremic metabolic acidosis giving a possible advantage to balanced electrolyte solutions due to their lower chloride content. The evidence regarding the best practices in fluid management during kidney transplantation and its effect on the incidence of delayed graft function (DGF) is still limited.

Materials and Methods:

One hundred thirty-eight patients were included and followed up for seven days after surgery. Administered crystalloid type and volume were compared among patients with and without DGF, along with additional patient and surgical variables. To investigate whether intraoperative fluid type/amount influence DGF, patients were categorized into three groups: those who received mainly (>50%) lactated Ringer's solution, normal saline, or plasmaLyte. A logistic regression analysis was used to define variables independently correlated with DGF, and odds ratios (OR) with a 95% confidence interval (CI) were reported.

Results:

The incidence of DGF was 8.7%. Cold ischemia time independently increased the odds of DGF (OR = 1.006 (95% CI: 1.002–1.011) while fluid type (saline versus PlasmaLyte OR = 5.28, 95% CI: 0.76–36.88) or amount (OR = 1.00, 95% CI: 1.00–1.01) did not significantly modify the odds of DGF. Central venous pressure, systolic blood pressure, and mean arterial pressure were higher in the non-DGF group, but this was not statistically significant (P > 0.05). Significant intraoperative acidosis developed in patients who received normal saline compared to those in PlasmaLyte and lactated Ringer's groups; however, acid–base balance and electrolytes did not vary significantly between the DGF and non-DGF groups.

Conclusion:

DGF was primarily influenced by surgical factors such as cold ischemia time, whereas intraoperative fluid type or amount did not affect DGF incidence.

Risk factors for delayed graft function and their impact on graft outcomes in live donor kidney transplantation

BACKGROUND

Delayed graft function (DGF) is a manifestation of acute kidney injury uniquely framed within the transplant process and a predictor of poor long-term graft function1. It is less common in the setting of living donor (LD) kidney transplantation. However, the detrimental impact of DGF on graft survival is more pronounced in LD2.

PURPOSE

To study the effects of DGF in the setting of LD kidney transplantation.

METHODS

We performed a retrospective analysis of LD kidney transplantations performed between 2010 and 2018 in the UNOS/OPTN database for DGF and its effect on graft survival.

RESULTS

A total of 42,736 LD recipients were identified, of whom 1115 (2.6%) developed DGF. Recipient dialysis status, male gender, diabetes, end-stage renal disease, donor age, right donor nephrectomy, panel reactive antibodies, HLA mismatch, and cold ischemia time were independent predictors of DGF. Three-year graft survival in patients with and without DGF was 89% and 95%, respectively. DGF was the greatest predictor of graft failure at three years (hazard ratio = 1.766, 95% CI: 1.514-2.059, P = 0.001) and was associated with higher rates of rejection (9% vs. 6.28%, P = 0.0003). Among patients with DGF, the graft survival rates with and without rejection were not different.

CONCLUSION

DGF is a major determinant of poor graft functional outcomes, independent of rejection.

Injury Pathways That Lead to AKI in a Mouse Kidney Transplant Model

BACKGROUND

Prolonged cold ischemia (CI) is a risk factor for acute kidney injury after kidney transplantation. We endeavored to determine the pathways involved in the development of tubular cell injury and death before and after transplantation. We hypothesized that ex vivo cold storage before transplant would produce a different injury phenotype to that seen after engraftment in kidney transplants with or without CI.

METHODS

Four groups of mouse donor kidneys were studied: (1) nontransplanted control kidneys; (2) donor kidneys subjected to ex vivo cold ischemia (CI); (3) donor kidneys subjected to kidney transplant without CI (Txp); and (4) donor kidneys subjected to CI followed by transplantation (CI+Txp).

RESULTS

Acute kidney injury only occurred in the CI+Txp group, which had significantly increased sCr versus the Txp group and the control mice. Histologically, the CI group demonstrated significantly increased tubular cell apoptosis and caspase-9 expression, whereas the Txp group demonstrated only mild brush border injury without apoptosis or necrosis. In contrast, the CI+Txp group had tubular cell apoptosis associated with expression of caspase-8, TNFR1, and increased serum TNF-α. CI+Txp also led to significantly higher ATN scores in association with increased RIP1, RIP3, pMLKL, and TLR4 expression.

CONCLUSIONS

Our results suggest distinct therapies are needed at different times during organ preservation and transplantation. Prevention of apoptosis during cold storage is best achieved by inhibiting intrinsic pathways. In contrast, prevention of cell death and innate immunity after CI+Txp requires inhibition of both the extrinsic death receptor pathway via TNFR1 and caspase-8 and inhibition of programmed necrosis via TLR4 and TNFR1.

Delayed Graft Function and Acute Rejection in Kidney Transplant Patients with Positive Panel-Reactive Antibody and Negative Donor-Specific Antibodies

Background: Delayed graft function (DGF) and acute rejection (AR) are common complications in kidney transplant patients. Objectives: The study evaluated DGF and AR in highly sensitized patients and their effects on kidney function for six months post-transplantation. Methods: We enrolled 95 patients with kidney transplants from living donors who were divided into two groups. Group 1 included 47 highly sensitized patients with panel reactive antibody (PRA) < 20.0% and negative donor-specific antigen, and group 2 included 48 patients with negative PRA. All patients were followed for the state of DGF, AR, and kidney function for six months. Results: Group 1 showed a significantly higher proportion of DGF and AR than group 2 (27.7% versus 2.1%, P < 0.001 and 14.9% versus 2.1%, P = 0.031, respectively). The rates of positive PRA in DGF and AR patients were significantly higher than those in non-DGF and non-AR patients (92.9% versus 42.0%, P < 0.001 and 87.5% versus 46.0%, P = 0.031, respectively). Transplanted kidney function was significantly worse in patients with PRA and DGF and/or AR than in patients with negative PRA and non-DGF and non-AR only in the seventh-day post-transplantation. Conclusions: Kidney transplant in highly sensitized patients with positive PRA was related to the increased ratio of DGF and AR.

Is delayed graft function associated with ureteral stenosis in the kidney transplant recipient? A case-control study

INTRODUCTION

Ureteral stricture (US) in the kidney transplant recipient is a rare complication that can lead to morbidity and graft loss. Risk factor recognition is crucial in the prevention and management of this entity. Delayed graft function (DGF), as defined by the need for dialysis in the first week after transplantation, has been proposed as a risk factor in previous studies. Our objective is to determine the impact of DGF in US development in kidney transplant patients.

METHODS

We designed a matched case-control study. US cases in kidney transplant recipients were identified in the 2008-2017 period. We defined US as the rise in serum creatinine associated with findings suggesting obstruction in ultrasound, scintigraphy, or retrograde pyelogram; any other cause of graft dysfunction was excluded. Controls were defined as kidney transplant recipients from the same population and period without US, matched in a 1:2 fashion by age, sex, and donor type.

RESULTS

From 532 kidney transplant patients, 31 cases and 62 controls were included. Cumulative US incidence was 58 per 1000 cases. When calculating for odds ratio (OR), post-operative urinoma (OR 3.2; 95% confidence interval [CI] 2.36-4.37) and ureteral duplication (OR 3.29; 95% CI 2.40-4.51) were associated with an increased risk for US, while DGF was not found to be statistically significant as a risk factor (OR 3.3; 95% CI 0.96-11.52). No statistically significant differences were found between groups in other pre- and post-transplant-related factors CONCLUSIONS:: DGF was not associated with US in our cohort; however, ureteral duplication and postoperative urinoma were associated with an increased risk of graft ureteral stenosis development.

Association of Slow Graft Function with Long-Term Outcomes in Kidney Transplant Recipients

Background

Whether slow graft function (SGF) represents an intermediate phenotype between immediate graft function (IGF) and delayed graft function (DGF) in kidney transplant recipients is unknown.

Material/Methods

In a retrospective cohort analysis of 1,222 kidney transplant recipients, we classified patients as having IGF, SGF, and DGF using two different schemas. SGF was defined as serum creatinine (Cr) ≥3.0 mg/dL by postoperative day 5 in Schema 1, and in Schema 2, SGF was defined as Cr >1.5 mg/dL plus a creatinine reduction ratio <20% between postoperative days 1 and 3. A complementary log-log model was used to examine the association of graft function with graft survival and patient survival.

Results

Mean age of study patients was 51.5±13.3 years, 59.9% were male, and 66.7% were white. In Schema 1, SGF and DGF were associated with comparable increases in risk of graft failure compared to IGF (hazard ratio (HR) 1.46, 95% confidence intervals (CI) 1.02–2.10 for SGF and HR 1.56, CI 1.11–2.22 for IGF); estimates were similar for Schema 2 (HR 1.52, CI 1.05–2.20 for SGF and HR 1.54, CI 1.10–2.17 for IGF). However, for mortality, outcomes for SGF were similarly to IGF, both SGF and IGF were associated with lower risk relative to DGF (HR 0.54, CI 0.36–0.80 for SGF in Schema 1; HR 0.58, CI 0.39–0.85 for SGF in Schema 2).

Conclusions

These findings suggest that SGF may be a marker for graft failure but not for mortality, and SGF may therefore represent a phenotype separate from IGF and DGF.

Delayed Graft Function 5 Months After Living Donor Kidney Transplantation

BACKGROUND

Delayed graft function is a clinical term to describe the failure of the transplanted kidney to function immediately after transplantation.

CASE REPORT

A 59-year-old woman suffered from a rare case of delayed graft function lasting 148 days after unrelated living donor kidney transplantation. Until now, 15 years after transplantation, organ function is still good, with serum creatinine levels about 1.4 to 2.0 mg/dl.

CONCLUSIONS

Even after prolonged graft dysfunction, good graft function can be achieved.

Kidneys from Older Living Donors Provide Excellent Short and Intermediate Outcomes--A Single China Center's Experience

BACKGROUND

Transplantation with kidneys from older living donors is on the rise, yet controversy still exists over whether the outcomes are as satisfactory as with kidneys from younger donors.

METHODS

We retrospectively analyzed 1009 living donor kidney transplants performed at our center between 2006 and 2013. Graft and patient outcomes were compared between transplants with kidneys from old living donors (OLD, 55-65 years) (n = 264) and from young living donors (YLD, <55 years) (n = 745).

RESULTS

The age was 32.80 ± 9.71 years and 33.91 ± 5.98 years for recipient in YLD and OLD group, respectively. Death-censored graft survival at 1, 3, and 5 years was 98.8%, 97.1%, and 95.8% in patients receiving YLD kidneys, similar to the corresponding values of 97.6%, 95.5% and 95.5% in patients receiving OLD kidneys (P = 0.356). Patient survival at 1, 3, and 5 years after transplantation was also similar for patients receiving YLD kidneys (98.5%, 97.1%, and 96.7%) and for patients receiving OLD kidneys (99.6%, 99.6%, and 96.8%; P = 0.110). The OLD kidneys were not associated with increased risk of death-censored graft failure (hazard ratio, 2.5; 95% confidence interval, 0.57 to 11.11) and patient death (hazard ratio, 1.67; 95% confidence interval, 0.75 to 3.73). In addition, there is no increased graft loss or patient death for each 10-year increase in donor age. Transplantation with OLD kidneys was not associated with reduced patient or graft outcomes in the short term (≤ 12 months) or medium term (>1 year).

CONCLUSIONS

Graft and patient outcomes after living-donor kidney transplantation are similar in the short-term and medium-term for donors aged 55 to 65 years and for younger donors. Therefore, the use of OLD kidneys should be encouraged in China.

Expression of receptor activator of nuclear factor-kappa B ligand in leukocytes during acute kidney rejection after transplantation in rats

BACKGROUND

Acute cellular rejection of the transplanted kidney is an important cause of impaired graft function. One of the basic characteristics of acute cellular rejection according to the latest Banff classification of renal allograft pathology is the presence of a large number of T lymphocytes in the allografted tissue. Osteoprotegerin, receptor activator of nuclear factor-kappa B (RANK) and RANK ligand (RANKL), three relatively novel members of the tumor necrosis factor superfamily, have crucial roles not only in physiologic and pathologic bone metabolism but also in immunologic processes. The aim of our study was to determine the expression of RANKL and RANK by T lymphocytes and macrophages in acute cellular kidney allograft rejection in rats.

METHODS

The study included 15 male Wistar rats of 3 months old and 250-300 g as recipients and 15 male DA rats donors of 3 months old; and weight 250-300 g. When animals were sacrificed at 3 weeks to extract the transplanted kidney for pathohistologic analysis and immunoflorescence. all samples showed acute cellular rejection. Kidney sections were examined by dual-labeled immunofluorescence to detect CD4, CD8, or CD68 (red) and RANK or RANKL (green) with coexpressing cells as orange.

RESULTS

RANKL-positive expression colocalized with CD4(+) and CD8(+) T lymphocytes in acutely rejected kidney tissue. There was no association between CD4(+) and CD8(+) T cells with RANK expression, which was evident by infiltrating CD68-positive macrophages in the kidney tissue interstitium.

CONCLUSION

RANK and RANKL were expressed by T lymphocytes and macrophages in acute cellular kidney rejection after transplantation in rats.