LIVING UNRELATED DONOR RENAL TRANSPLANTATION

Comparison of outcomes of living and deceased donor kidney grafts surviving longer than 5 years in Korea

BACKGROUND

It is generally recognized that living donor kidney transplantation (LDKT) grafts are superior to deceased donor kidney transplantation (DDKT) grafts. We compared survival and functional outcomes of LDKT and DDKT grafts.

METHODS

Among 1000 kidneys transplanted from 1995 to 2008, we selected grafts surviving >5 years, excluding pediatric, multi-organ transplantation, and retransplantations (n=454).

RESULTS

There were 179 kidneys from deceased donors and 275 from living donors. Recipients showed no difference in age, gender, or cause of renal failure. Donors were younger in the DDKT group (30.6 vs 38.5 years; P<.05). There were more male donors in the DDKT group (73.2% vs 54.5%; P<.05). Deceased donors showed a greater mean number of HLA mismatches (4.2 vs 2.7; P<.05). Death-censored graft survival at 10 years showed no difference (DDKT 88.9% vs LDKT 88.9%; P=.99). Mean serum creatinine at 5 years was 1.41 mg/dL for DDKT and 1.44 mg/dL for LDKT (P=.75). Mean estimated glomerular filtration rate at 5 years was 67.8 mL/min/1.73 m2 for DDKT and 62.1 mL/min/1.73 m2 for LDKT (P=.23). Twenty-three DDKT grafts (12.8%) and 47 LDKT grafts (17.1%) experienced acute rejection episodes (P=.22). DDKT recipients showed more cases of viral and bacterial infections compared with LDKT recipients (viral, 11.7% vs 2.2% [P<.05]; bacterial, 21.8% vs 7.3% [P<.05]).

CONCLUSION

Among kidney grafts surviving >5 years, there was no difference in survival or serum creatinine levels at 5 and 10 years between DDKT and LDKT grafts.

Does cadaveric donor renal transplantation ever provide better outcomes than live-donor renal transplantation?

BACKGROUND

Live donor renal transplantation (LRT) now comprises more than 40% of all kidney transplants performed in the United States. Many patients on the cadaveric waiting list have a prospective live kidney donor. This study determines whether cadaveric donor renal transplantation (CRT) can demonstrate better outcomes than LRT.

METHODS

From the United States Renal Data System registry, 31,909 adult recipients of a first-time kidney transplant from 1995 to 1998 were analyzed. Recipients were followed until December 31, 2000.

RESULTS

CRT, more human leukocyte antigen (HLA) mismatches, increased donor age, cold ischemia time greater than 24 hr, African American recipient, and a history of diabetic nephropathy all increased the risk of graft failure, return to dialysis, and death. Nevertheless, in specific circumstances, CRT could provide better outcomes than LRT. For example, in recipients aged 18 to 59 years with a hypothetical live kidney donor aged 50 years and four HLA mismatches, the relative risk of graft loss with LRT is comparable or increased compared with CRT if the cadaveric kidney donor is much younger or with fewer HLA mismatches. On the other hand, for recipients aged 60 years or older, CRT never provides better outcomes than LRT. All analyses were adjusted for recipient race, gender, and history of diabetic nephropathy. There were no significant interactions among donor type, HLA mismatches, donor age, and cold ischemia time.

CONCLUSIONS

The elderly recipient with an imminent LRT should never be offered CRT. A combination of recipient and donor factors can make CRT preferable to LRT in younger patients.

Expanded criteria donors: attempts to increase the renal transplant donor pool

There is a growing disparity between the demand for and the supply of kidneys for transplantation. The demographics of the donor pool are also changing. The average potential cadaveric organ donor is now more likely to be older, at greater risk for co-morbid conditions such as hypertension or viral infections, and more likely to die from cerebrovascular disease. These factors have led to an expansion of the criteria that defines the suitable organ donor. Expanded criteria donors are defined as the following: (1) at the upper and lower extremes in age; (2) having a history of hypertension or diabetes; (3) hemodynamically unstable; (4) non-heartbeating (cardiopulmonary death rather than brain death); (5) seropositive for hepatitis B or C; (6) having systemic infections; (7) having displayed high-risk social behavior for HIV infection; (8) having a history of malignancy; (9) having abnormal organ function; or (10) with renal anatomic anomalies or injuries. Use of kidneys from these "expanded criteria donors" is a two-edged sword. While they provide more organs for transplantation, the risk of suboptimal recipient outcome is increased. A rational approach to the use of each of these types of kidneys and proper selection of recipients is essential to obtain acceptable results. The article reviews the factors that have contributed to the successful transplantation of kidneys procured from expanded criteria organ donors and how these organs can be allocated most efficaciously to the appropriate recipients.

Management of renal cell carcinoma in von Hippel-Lindau disease

BACKGROUND

An evaluation of nephron-sparing surgery (NSS) or radical nephrectomy (RN) for treating renal cell carcinoma (RCC) in patients with von Hippel-Lindau disease (VHL) was carried out.

METHODS

Between 1976 and 1997, 10 patients with RCC from four VHL families, of whom seven were from one family, were studied by clinical and histopathological examination. Before 1991, three patients were treated using RN, and thereafter five patients were treated using NSS. Two patients were not operated on.

RESULTS

RCCs in our patients showed a slow growth rate (on average 0.3 cm year-1), and asymptomatic patients presented with tumours of low-grade malignancy. In all patients, tumours were surrounded by a fibrous pseudocapsule. In 5 out of 17 tumours, pseudocapsular invasion was observed, and three of these five tumours broke through the pseudocapsule. To date, these patients have not shown a less favourable outcome than those without pseudocapsular involvement by tumour growth. Multicentricity of RCC was relatively low (4.6 lesions per kidney). In two of the three RN patients, only a single satellite lesion, in the direct vicinity of a RCC, was found in one kidney. Six tumours (1.8-5.5 cm) were enucleated by NSS. During a mean follow-up of 30 months, renal function in these patients was well preserved.

CONCLUSIONS

In our patients, RCCs grew slowly, were of low grade, had a dense fibrous pseudocapsule and were thus good candidates for NSS.

Do U.S. transplant centers encourage emotionally related kidney donation?

Stimulated by a severe organ shortage and an improving ability to successfully transplant poorly matched donor-recipient pairs, many transplant centers are now willing to accept emotionally related (but genetically unrelated) people (e.g., spouses) as kidney donors. To see whether this practice is encouraged, a survey was mailed to all 209 adult renal transplant centers in the United States. Of the 154 (74%) responding centers, 90% said they accept emotionally related donors and 60% said they actually encourage this practice. Nearly 40% prefer spouses to cadavers, while only 21% prefer friends to cadavers. To further explore the degree to which emotionally related donation is encouraged, a second questionnaire was sent to a sample of centers (n = 51) that support this practice; 94% responded. While only 44% said they encourage the use of friends, nearly all of these preselected centers said they encourage spouses to donate. On the other hand, judging from their stated approach to this issue, only about half of these supportive centers seem to actively encourage emotionally related donation. These data suggest that, overall, at most only about one third of U.S. transplant centers actively encourage spousal donation and at most about one quarter encourage the use of friends. Consistent with these results, emotionally related donors contribute only a small fraction of all kidneys transplanted in this country. If the large potential contribution of emotionally related donors is ever to be realized, transplant centers must go beyond simply accepting such individuals and begin to actively encourage their participation. Medical and ethical considerations strongly support this proposal.