Impact of amyloidosis on long-term survival in kidney transplantation

Complications of Renal Transplantation in Patients With Amyloidosis

OBJECTIVE

Renal transplantation in patients with end-stage renal failure (ESRF) secondary to amyloidosis carries a high risk of postoperative complications. Preoperative investigations are crucial for a successful perioperative course. There are limited data studying the outcome of patients with amyloid nephropathy who undergo renal transplantation. Therefore, we undertook this retrospective review of our experience to highlight the difficulties.

MATERIALS AND METHODS

Thirteen patients with AA amyloid-induced ESRF underwent cadaveric renal transplantation from 1985 to 2001 in the Irish transplant population. The perioperative course of these patients was compared to an age-matched control group of 142 nonamyloid patients who had cadaveric renal transplantation during the same time period. Both groups were followed annually for 5 years.

RESULTS

The 1- and 5-year patient survival rates were 69% and 69% in the amyloid as compared with 97% and 87% for the control group. In the amyloid group, early death was primarily due to cardiac causes followed by complications of sepsis. Graft survival at 1 and 5 years was 56% and 56% in the amyloid group as compared with 87% and 59% in the control group (P = .0027). Four deaths with a functioning graft contributed to the early graft losses.

CONCLUSION

Increased complications, especially cardiac, are noted post-renal transplantation among patients with renal amyloidosis. However, appropriate guideline, for the perioperative management of these patients has yet to be established.

Effect of Amyloidosis on Long-Term Survival in Kidney Transplantation

Amyloidosis is characterized by the accumulation of an amorphous material in various organs and tissues secondary to a variety of inflammatory, immune, infectious, and hereditary diseases. Since 1975, our transplantation team has performed 1470 renal transplantations. Between 1985 and July 2004, among 1159 kidney transplantations, 953 (82.3%) were from living donors and 206 (17.7%) from cadaveric donors. There were 32 recipients (28 men, 4 women; mean age, 31.4 +/- 1.7 years; range, 21 to 48 years) with amyloidosis, including, 28 (87.5%) who received grafts from living donors and 4 (12.5%) from cadaveric donors. Amyloidosis was secondary to familial Mediterranean fever in 22 (68.7%) patients and rheumatoid arthritis in 1 (3.1%). The remaining 9 (28.1%) patients had primary amyloidosis. The mean follow-up time was 51.2 +/- 5.7 months (range, 2-124 months). Mean HLA mismatch rate was 2.2 +/- 1. Twenty-six (81.2%) patients are alive at this time with functioning grafts, and a mean serum creatinine value of 2.1 +/- 1.5 ng/dL. The 1- and 5-year patient and graft survival rates were 90.6% and 84.3%, and 81.2% and 68.7%, respectively. We conclude that patients with amyloidosis may undergo kidney transplantation safely expecting outcomes similar to those patients who receive transplantations for other reasons.

Renal transplantation for apolipoprotein AII amyloidosis

Apolipoprotein AII (ApoAII) amyloidosis, first reported in 2001 in a family with renal amyloidosis, is associated with mutations in the stop codon of the apolipoprotein AII gene resulting in a carboxyl terminal peptide extension of 21 amino acid residues in the protein. Since death from this form of amyloidosis is due to renal failure, kidney dialysis and renal transplantation are presently the only two therapeutic options. We report the case of a Caucasian man who developed proteinuria in his late 20's, had renal biopsy at the age of 33 which gave the diagnosis of renal amyloidosis, and required continuous ambulatory peritoneal dialysis by age 45. He received a cadaver renal transplant at age 47 and has maintained stable renal function for nine years without other evidence for organ system dysfunction from amyloidosis. Laboratory studies confirmed persistence of the ApoAII variant in the patient's plasma in addition to the normal ApoAII protein. This is in agreement with the DNA analysis which showed the patient to be heterozygous for the ApoAII stop78Gly mutation. These results indicate that renal transplantation is an effective therapy for apolipoprotein AII amyloidosis since recurrence of amyloid in the graft and progression of other organ involvement may be very slow.

Long-term outcome of live donor kidney transplantation for renal amyloidosis

BACKGROUND

The short-term outcome of kidney transplantation in patients with amyloidosis has been reported. The aim of this study is to investigate long-term results in patients with renal amyloidosis.

METHODS

We studied results of renal transplantation in 23 amyloidotic transplant recipients compared with those in a control group of 47 nonamyloidotic patients. Amyloidosis was secondary to familial Mediterranean fever (FMF) in 16 patients, whereas it was primary (idiopathic) in 7 transplant recipients. The 2 groups were homogeneous regarding age, sex, HLA matching, immunosuppression, and duration of transplantation.

RESULTS

Five- and 10-year actuarial graft survival rates were similar in both groups (79.35% versus 84.04% and 65.92% versus 56.61%, respectively ). Five- and 10-year actuarial patient survival rates also were similar (80% versus 94% and 68% versus 87%, respectively). Moreover, 72.4% of controls experienced at least 1 rejection episode, whereas only 43.5% of amyloidotic transplant recipients experienced 1 or more such events (P = 0.02). Nonetheless, mean serum creatinine concentrations did not differ between the 2 groups during the observation period. Maintenance colchicine therapy prevented the recurrence of both FMF symptoms and amyloidosis. Recurrence was documented in only 1 amyloidotic transplant recipient (4.3%) 10 years posttransplantation. Significant gastrointestinal (GI) problems were more frequent in amyloidotic patients (65% versus 38%; P = 0.03). Amyloidotic patients with GI problems, except for 2 patients, were administered cyclosporine. Eleven of these patients had FMF, which appeared to reflect the effects of both cyclosporine and colchicine. Infections were similar in the groups; whereas amyloidotic patients had significantly lower blood pressures.

CONCLUSION

In our experience, long-term (5 to 10 years) outcome of live related donor kidney transplantation in patients with amyloidosis is similar to that in the general transplant population.