The spectrum of long-term renal transplantation: Outcomes, complications, and clinical studies

Over 5 Years of Excellent Graft Kidney Function Determinants: Baskent University Experience

OBJECTIVES

Kidney graft survival may be evaluated according to the duration of time with a functioning graft. Survival alone may not satisfy expectations of a successful kidney transplant if the graft kidney does not show excellent function. In our study, we analyzed the characteristics of kidney transplant recipients who showed excellent graft function after 5 to 10 years of follow-up in an aim to improve graft survival and to ensure the best kidney function in the long term.

MATERIALS AND METHODS

We retrospectively evaluated graft function and demographic characteristics of 288 patients who underwent kidney transplant between January 2008 and December 2012.

RESULTS

We found that 149 patients (51.7%) had excellent graft function, 88 patients (30.5%) had a functioning graft with a glomerular filtration rate lower than 60 mL/min and/or had signs of graft kidney dysfunction, and 45 patients (15.6%) experienced graft loss. Of 288 kidney transplant recipients enrolled in the study, most were male (56%), and mean age was 30.47 ± 14.36 years at time of transplant. Median time on dialysis was 39.09 ± 59.30 months. The overall graft survival rate in the patient group was 82.2% after 5 to 10 years of follow-up. Multivariate analysis showed that excellent graft survival predictors beyond 5 years were negative panel reactive antibody levels, lower donor age, shorter duration on dialysis, absence of acute rejection episodes, 3 or less HLA mismatches, lower immunosuppressive levels, and lower recipient age at transplant.

CONCLUSIONS

Lower panel reactive antibody levels, lower donor age, shorter duration on dialysis, absence of acute rejection episodes, 3 or less HLA mismatches, and lower recipient age at transplant are major determinants of excellent graft survival in our kidney transplant recipients.

Risk Factors of Graft Survival After Diagnosis of Post-kidney Transplant Malignancy: Using Cox Proportional Hazard Model

BACKGROUND

All recipients of kidney transplantation, especially those with posttransplant malignancy, are at risk of long-term graft failure.

OBJECTIVES

The purpose of our study was to evaluate the risk factors associated with graft survival after diagnosis of malignancy.

PATIENTS AND METHODS

To reach this purpose, we conducted a historical cohort study in Iran and 266 cases with posttransplant malignancy were followed up from diagnosis of malignancy until long-term graft loss or the date of last visit. These patients were taken as a census from 16 Transplant Centers in Iran during 22 years follow-up period since October 1984 to December 2008. A Cox proportional hazards model was performed to determine the important independent predictors of graft survival after malignancy.

RESULTS

At the end of the study, long-term graft failure was seen in 27 (10.2%) cases. One-year and 2-year graft survival after diagnosis of cancer were 93.6% and 91.7%, respectively. The univariate analysis showed that the incidence of chronic graft loss was significantly higher in male patients with solid cancers, withdrawal of immunosuppressant regimen, no response to treatment, and tumor metastasis. In continuation, the Cox model indicated that the significant risk factors associated with graft survival were type of cancer (P < 0.0001), response to treatment (P < 0.0001, HR = 0.14, 95% CI: 0.06 - 0.32), metastasis (P < 0.0001, HR = 5.68, 95% CI: 2.24 - 14.42), and treatment modality (P = 0.0001).

CONCLUSIONS

By controlling the modifiable risk factors and modality of treatment in our study, physicians can reach more effective treatment.

Chronic graft loss and death in patients with post-transplant malignancy in living kidney transplantation: a competing risk analysis

Background:

Malignancy is a common complication after renal transplantation. Death with functioning graft and chronic graft loss are two competing outcomes in patients with post-transplant malignancies.

Objectives:

The purpose of our study was to evaluate the risk factors associated with cumulative incidence of these two outcomes.

Patients and Methods:

Fine-Gray model was used for 266 cases with post-transplant malignancy in Iran. These patients were followed-up from the diagnosis until the date of last visit, chronic graft loss, or death, subsequently.

Results:

At the end of the study, as competing events, chronic graft loss and death with functioning graft were seen in 27 (10.2%) and 53 cases (19.9%), respectively, while 186 cases (69.9%) were accounted as censored. The incidence rate of death was approximately two-time of the incidence rate of chronic graft loss (8.6 vs. 4.4 per 100 person-years). In multivariate analysis, significant risk factors associated with cumulative incidence of death included age (P < 0.007, subhazard ratio (SHR) = 1.03), type of cancer (P < 0.0001), and response to treatment (P < 0.0001, SHR = 0.027). The significant risk factors associated with cumulative incidence of chronic graft loss were gender (P = 0.05, SHR = 0.37), treatment modality (P < 0.0001), and response to treatment (P = 0.048, SHR = 0.47).

Conclusions:

Using these factors, nephrologists may predict the occurrence of graft loss or death. If the probability of graft loss was higher, physicians can decrease the immunosuppressive medications dosage to decrease the incidence of graft loss.

Three solid malignancies and a myelodysplastic syndrome with a protracted course after kidney transplantation

Although a well-known complication after transplantation, multiple non-skin malignancies within a patient are rare. We report on a kidney transplant recipient who over the course of 20 years developed breast cancer twice, a uroepithelial carcinoma, and myelodysplasia transforming into acute leukaemia. Breast cancer was treated as usual. The transitional cell carcinoma was managed with partial cyst ureterectomy with transposition of the native ureter to the graft. Withdrawal of immunosuppression followed under a “watchful waiting” regime. In conclusion, alertness is requested regarding development of malignancies. Creative solutions are necessary in the management of such patients. Under exceptional circumstances, withdrawal of immunosuppression may be an option.

Twenty-year survivors of kidney transplantation

There have been few studies of patients with renal allografts functioning for more than 20 years. We sought to identify clinical factors associated with ultra long-term (>20 year) renal allograft survival and to describe the clinical features of these patients. We performed a retrospective analysis of the Irish Renal Transplant Database and included 1174 transplants in 1002 patients. There were 255 (21.74%) patients with graft function for 20 years or more. Multivariate analysis identified recipient age (HR 1.01, CI 1.01-1.02), gender (male HR 1.25, CI 1.08-1.45), acute rejection (HR 1.26, CI 1.09-1.45) and transplant type (living related donor vs. deceased donor) (HR 0.52, CI 0.40-0.66) as significantly associated with long-term graft loss. Median serum creatinine was 115 μmol/L. The 5-year graft survival in 20-year survivors was 74.7%. The mean age at death was 62.7 years (±10.6). The most common causes of death were cardiovascular disease and malignancy. The two major causes of graft loss were death (with function) and interstitial fibrosis/tubular atrophy. Comorbidities included skin cancer (36.1%), coronary heart disease (17.3%) and other malignancies (14.5%). This study identifies factors associated with long-term allograft survival and a high rate of morbidity and early mortality in long-term transplant recipients.

Renal transplantation: basic concepts and evolution of therapy

Within the last 5 years, dramatic changes in the area of renal transplantation have occurred. There have been shifts in the dominant types of rejection, and in the types and utilization of immunosuppressants. Hyperacute rejection is now rarely seen, and acute cellular rejection within the first 6 to 12 months has been reduced to about 10%. However, humoral/antibody-mediated rejection has become a more prevalent problem. In the area of immunosuppressants, the ability to reduce acute cellular rejection to about 10% has been achieved through more judicious use of calcineurin inhibitors (cyclosporine and tacrolimus), increased use of mycophenolate mofetil, and the recent introduction of sirolimus (rapamycin). The polyclonal antibody (antithymocyte globulin), as well as monoclonal antibodies directed against the alpha chain of CD25 (daclizumab and basilixamab), have added substantially to the improved success of renal allografts. Because of numerous serious toxicities from glucocorticoids and calcineurin inhibitors, particularly cyclosporine, new studies are utilizing calcineurin-free and/or glucocorticoid avoidance or rapid elimination protocols often in combination with a monoclonal antibody and sirolimus. New immunosuppressants such as FTY720 and Campath-1 are also under study. In addition to its use in treating patients with low-level donor-specific antibody before transplantation in order to avoid hyperacute rejection, apheresis is utilized in various combination protocols after transplantation in the management of humoral/antibody-mediated rejection, in the treatment of hemolytic uremia syndrome that sometimes occurs with calcineurin inhibitors and sirolimus, as well as in the treatment of focal segmental glomerulosclerosis that has a major risk of recurrence in renal transplants.