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Imamovic S, Ljuca F, Imamovic G, Iljazagic Halilovic F, Krdzalic A, Hasukic S, Mesic D, Zerem E. Influence of donor age on renal graft function in first seven post transplant days. Bosn J Basic Med Sci 2010; 10:73-7. [PMID: 20192936 PMCID: PMC5596616 DOI: 10.17305/bjbms.2010.2741] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Increasing gap between demand and availability of human kidneys for transplantation has forced a re-evaluation of the limits on donor age acceptability. The present study included 74 patients who underwent kidney transplantation in University Clinical Centre Tuzla. In an observational cohort study we assessed impact of donor age on post transplant renal function by analyzing following parameters: 24 hour urine output, creatinine clearance (Cr Cl) and glomerular filtration rate (GFR). Depending on donor age recipients were allocated in to two groups. Group I included patients who received renal graft from donors age up to 55 years, and Group II encountered recipients who received renal graft from donors older than 55 years. Our goal was to determine whether donor age over 55 years significantly diminishes renal graft function in first seven post transplant days. No statistically significant difference was found between Group I and II regarding 24 hour urine output. From second to fifth postoperative day creatinine clearance values were higher in the group of patients who received kidney from donors older than 55 years (47+/-19, 1 vs. 44, 4+/-20, 8). On the fifth, sixth and seventh post operative day GFR was significantly higher in patients who received renal graft from donors age up to 55 years (p<0, 0161). Our data showed no significant difference in observed variables between the two groups, thus indicating that utilization of renal grafts from donors' age > 55 years is acceptable and may considerably expand the donor pool.
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Affiliation(s)
- Semir Imamovic
- Clinic for of Anaesthesiology and Reanimatology, University Clinical Centre Tuzla, Trnovac bb, 75 000 Tuzla, Bosnia and Herzegovina
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Saidi R, Kennealey P, Elias N, Kawai T, Hertl M, Farrell M, Goes N, Hartono C, Tolkoff-Rubin N, Cosimi A, Ko D. Deceased Donor Kidney Transplantation in Elderly Patients: Is There a Difference in Outcomes? Transplant Proc 2008; 40:3413-7. [DOI: 10.1016/j.transproceed.2008.08.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 08/29/2008] [Indexed: 10/21/2022]
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Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors. Am J Kidney Dis 2008; 52:553-86. [PMID: 18725015 DOI: 10.1053/j.ajkd.2008.06.005] [Citation(s) in RCA: 226] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 06/04/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND During the past few years, there has been renewed interest in the use of expanded criteria donors (ECD) for kidney transplantation to increase the numbers of deceased donor kidneys available. More kidney transplants would result in shorter waiting times and limit the morbidity and mortality associated with long-term dialysis therapy. STUDY DESIGN Systematic review of the literature. SETTING & POPULATION Kidney transplantation population. SELECTION CRITERIA FOR STUDIES Studies were identified by using a comprehensive search through MEDLINE and EMBASE databases. Inclusion criteria were case series, cohort studies, and randomized controlled trials assessing kidney transplantation in adult recipients using ECDs. PREDICTOR A special focus was given to studies comparing the evolution of kidney transplantation between standard criteria donors (defined as a donor who does not meet criteria for donation after cardiac death or ECD) and ECDs (defined as any brain-dead donor aged > 60 years or a donor aged > 50 years with 2 of the following conditions: history of hypertension, terminal serum creatinine level >or= 1.5 mg/dL, or death resulting from a cerebrovascular accident). OUTCOMES Criteria used to define and select ECDs, practice patterns, long-term outcomes, early complications, and some patient issues, such as selection criteria and immunosuppressive management. RESULTS ECD kidneys have worse long-term survival than standard criteria donor kidneys. The optimal ECD kidney for donation depends on adequate glomerular filtration rate and acceptable donor kidney histological characteristics, albeit the usefulness of biopsy is debated. LIMITATIONS This review is based mainly on data from observational studies, and varying amounts of bias could be present. We did not attempt to quantitatively analyze the effect of ECD kidneys on kidney transplantation because of the huge heterogeneity found in study designs and definitions of ECD. CONCLUSIONS Based on the available evidence, we conclude that patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy.
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Affiliation(s)
- Julio Pascual
- Servicio de Nefrología, Hospital Ramón y Cajal, Madrid, Spain
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Anil Kumar MS, Irfan Saeed M, Ranganna K, Malat G, Sustento-Reodica N, Kumar AMS, Meyers WC. Comparison of four different immunosuppression protocols without long-term steroid therapy in kidney recipients monitored by surveillance biopsy: five-year outcomes. Transpl Immunol 2008; 20:32-42. [PMID: 18773960 DOI: 10.1016/j.trim.2008.08.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 08/01/2008] [Accepted: 08/08/2008] [Indexed: 12/18/2022]
Abstract
Induction and maintenance immunosuppression protocols with or without long-term steroid therapy in kidney transplant recipients are variable and are transplant center-specific. The aim of this prospective randomized pilot study was to compare 5-year outcomes in kidney recipients maintained on 4 different calcineurin inhibitor (CNI)-based immunosuppression protocols without long-term steroid therapy. Two hundred consenting patients who received kidney transplants between June 2000 and October 2004 were enrolled in 4 immunosuppression protocol groups, with 50 patients in each group: cyclosporine (CSA)/mycophenolate mofetil (MMF), CSA/sirolimus (SRL), tacrolimus (TAC)/MMF, and TAC/SRL. Induction therapy was done with basiliximab and methylprednisolone. Steroids were withdrawn on post-transplant day 2, and long-term steroid therapy was not used. Demographic characteristics among the four groups were comparable; approximately 50% of the recipients were African American and > or =80% of the kidneys transplanted were from deceased donors. Clinical acute rejection (CAR) was confirmed by biopsy and treated with intravenous pulse steroid therapy. Steroid-unresponsive CAR was treated with Thymoglobulin. Surveillance biopsies were performed at 1, 6, 12, 24, 36, 48, and 60 months to evaluate subclinical acute rejection (SCAR), chronic allograft injury (CAI), and other pathological changes per the Banff 2005 schema. The primary end point was CAR, and secondary end points were 5-year patient and graft survival rates, renal function, SCAR, CAI, and adverse events. In the first year post-transplant, the incidence of CAR was 18% in the CSA/MMF group, 8% in the CSA/SRL group, 14% in the TAC/MMF group, and 4% in the TAC/SRL group (CSA/MMF vs. TAC/SRL; p=0.05). The incidence of SCAR was 22% in the CSA/MMF group, 8% in the CSA/SRL group, 16% in the TAC/MMF group, and 6% in the TAC/SRL group (CSA/MMF vs. CSA/SRL and TAC/SRL; p=0.05). After the first year, the incidences of CAR and SCAR decreased and were comparable in all 4 groups. At 5 years post-transplant, cumulative CAI due to interstitial fibrosis/tubular atrophy (IF/TA), hypertension (HTN), and chronic calcineurin inhibitor (CNI) toxicity was observed in 54%, 48%, and 8% of the CSA/MMF group vs. 16%, 36%, and 12% of the CSA/SRL group vs. 38%, 24% and 6% of the TAC/MMF group vs. 14%, 25% and 12% of the TAC/SLR group (IF/TA: CSA/MMF vs. CSA/SRL and TAC/SRL; p=0.04, HTN: CSA/MMF vs. TAC/MMF and TAC/SRL; p=0.05, CNI toxicity: TAC/SRL and CSA/SRL vs. TAC/MMF; p=0.05). Five-year patient and graft survival rates were 82% and 60% in the CSA/MMF group, 82% and 60% in the CSA/SRL group, 84% and 62% in the TAC/MMF group, and 82% and 64% in the TAC/SRL group (p=0.9). Serum creatinine levels and creatinine clearances at 5 years were comparable among the groups. Our data show that the rates of CAR and SCAR in the first year post-transplant were significantly lower in the CSA/SRL and TAC/SRL groups and that cumulative CAI rates due to IF/TA and HTN at 5 years were significantly lower in the TAC/MMF, TAC/SRL, and CSA/SRL groups than in the CSA/MMF group. Despite significant differences in the incidences of CAR and SCAR and prevalence of different types of CAI at 5 years, renal function and patient and graft survival rates at 5 years were comparable among kidney recipients maintained on 4 different immunosuppression protocols without long-term steroid therapy.
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Affiliation(s)
- Mysore S Anil Kumar
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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Abstract
To date, there have been no reports of successful ABO blood group incompatible renal transplantation in HIV patients. We describe a case of a 47-year-old African American man with end-stage renal disease secondary to HIV-induced nephropathy who underwent a live unrelated (spouse) donor ABO blood group incompatible transplant using an intravenous immunoglobulin/plasmapheresis preconditioning regimen with interleukin-2 receptor antagonist induction along with tacrolimus and mycophenolate mofetil maintenance. The postoperative course was complicated by two acute cellular rejection (Banff Ia) episodes that were successfully managed with corticosteroid boluses and the addition of corticosteroids to maintenance immunosuppression. Antibody-mediated rejection was not observed on biopsy. The patient reached a serum creatinine nadir of 2.0 mg/dL on postoperative day 20, which has now been maintained for 170 days. His current CD4 count was 410 cells/microL.
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Anil Kumar MS, Khan SM, Jaglan S, Heifets M, Moritz MJ, Saeed MI, Fyfe B, Sustento-Reodica N, Kumar A. Successful Transplantation of Kidneys from Deceased Donors with Acute Renal Failure: Three-Year Results. Transplantation 2006; 82:1640-5. [PMID: 17198251 DOI: 10.1097/01.tp.0000250908.62948.8f] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Kidneys from deceased donors with acute renal failure (ARF) are generally not accepted for transplantation because of the expected poor outcome. This prospective study examined the utilization of kidneys from donors with ARF for transplantation and the outcomes. METHODS Fifty-five kidneys from donors with ARF were transplanted. The outcome was compared with concurrent and matched 55 recipients of standard criteria donor (SCD) kidneys and 55 expanded criteria donor (ECD) kidneys. ARF kidneys were accepted from donors aged <50 years, a negative history for kidney disease, and a negative pretransplant biopsy for chronic structural changes. The immunosuppression was similar in all three groups. The outcome measurements included three-year patient and graft survival, biopsy-proven acute rejection (BPAR), subclinical acute rejection (SCAR), and chronic allograft nephropathy (CAN), serum creatinine, and creatinine clearance. RESULTS Three-year patient and graft survival was 90% and 90% in ARF group, 100% and 89% in SCD group and 83% and 66% in ECD group. BPAR and SCAR were comparable in the groups but CAN was significantly higher in ECD group. Mean serum creatinine levels were 1.9+/-1.1, 1.9+/-0.9, and 2.2+/-1.3 mg/dl and mean creatinine clearances were 66+/-15, 68+/-14, and 58+/-10 mls/minute in ARF, SCD, and ECD groups, respectively (SCD and ARF vs. ECD P = 0.04). CONCLUSIONS Transplantation of kidneys from selected deceased donors with ARF provides comparable survival and function compared to kidneys from non-ARF donors and may be considered for transplantation to expand the donor pool to overcome the current acute shortage of kidneys.
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Affiliation(s)
- Mysore S Anil Kumar
- Division of Transplantation, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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Esquena S, Planas J, Abascal JM, Trilla E, Cecchini L, Raventós CX, Morote J. Correlation Between the Biopsies in Marginal Donor Kidneys for Transplantation: Is It Necessary to Biopsy Both Kidneys? Transplant Proc 2006; 38:1270-3. [PMID: 16797279 DOI: 10.1016/j.transproceed.2006.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The objective of this study was to analyze the correlation between histological findings in both transplanted kidneys from marginal donors. METHODS We retrospectively reviewed the histological information on 92 kidneys obtained between January 2001 and January 2004, corresponding to 46 marginal donors. Criteria for biopsy were age greater than 55 years, hypertension, diabetes, and proteinuria. Scores were established by the pathologist including glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arteriosclerosis. The score for each lesion was classified as 0 if absent; 1 if <20%; 2 if >20% and <50%; and 3 if >50%. Finally, we defined an index of renal severity damage (RSD) in order to classify the kidneys for single transplantation (0), double transplantation (1), and unsuitable for transplantation (2). RESULTS Of the kidneys studied, 82.6% of both kidneys showed similar degrees of glomerulosclerosis (<20% in 71.7% and >20% in 10.9%), while 17.4% showed discrepancies (> vs <20%; P=.008). On the other hand, RSD correlated in 82.6% of both kidneys (in 69.6% RSD=0; in 8.7% RSD=1; and in 4.3% RSD=2), while 17.4% showed discrepancies (P=.001). In one case (2.2%), a great discrepancy was observed; one kidney was valid for single transplantation, and the other one not valid for any transplantation, single or double. CONCLUSIONS This study demonstrated a correlation between the biopsy findings in both kidneys in 82.6% of marginal organ donors. However, in 17.4% of cases we observed discrepancies. The degree of glomerulosclerosis seemed to be a powerful parameter to define renal severity damage. According to these results we would recommend biopsy of both kidneys.
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Affiliation(s)
- S Esquena
- Hospital Vall d'Hebron, Barcelona, Spain.
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Kumar MSA, Heifets M, Moritz MJ, Saeed MI, Khan SM, Fyfe B, Sustento-Riodeca N, Daniel JN, Kumar A. Safety and efficacy of steroid withdrawal two days after kidney transplantation: analysis of results at three years. Transplantation 2006; 81:832-9. [PMID: 16570004 DOI: 10.1097/01.tp.0000203558.34739.c6] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic steroid therapy in spite of myriad side effects is widely used in kidney transplantation. This prospective controlled study evaluated safety and efficacy of steroid withdrawal at 2 days in kidney recipients monitored by surveillance biopsy. METHODS In all, 300 kidney recipients were studied; 150 in second-day steroid withdrawal group and 150 in steroid treated group (control group). Immunosuppression was basiliximab induction and maintenance was a calcineurin inhibitor and mycophenolate mofetil or sirolimus. Biopsy-proven acute rejection (BPAR) was treated by methylpredisolone. Surveillance biopsies were completed to evaluate subclinical acute rejection (SCAR) and chronic allograft nephropathy (CAN). Primary end point was acute rejection. Three-year patient and graft survival, new onset diabetes mellitus (NODM), serum creatinine and creatinine clearance were evaluated. RESULTS Acute rejection was diagnosed in 14% in control group and 16% in steroid withdrawal group. Three-year patient and graft survival was 89% and 79% in control and 91% and 78% in steroid withdrawal group. Serum creatinine and creatinine clearance was 1.9+/-0.8 and 59+/-11 in control group and 1.8+/-0.9 mg/dl and 61+/-10 mls/minute in steroid withdrawal group. Incidence of SCAR and progression of CAN were comparable in the 2 groups. At 3-years NODM was diagnosed in 21% in control group and 4% in steroid withdrawal group (P<0.01). CONCLUSIONS Two-day steroid withdrawal in kidney transplant recipients did not affect BPAR, SCAR, CAN, graft function and patient and graft survival compared to control group up to 3 years. NODM was significantly less in steroid withdrawal group. Two-day steroid withdrawal is safe and beneficial in kidney transplant recipients.
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Affiliation(s)
- Mysore S Anil Kumar
- Division of Transplantation, Drexel University College of Medicine, Feinstein Building, Broad & Vine Streets, Philadelphia, PA 19102, USA.
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Naumovic R, Djukanovic L, Marinkovic J, Lezaic V. Effect of donor age on the outcome of living-related kidney transplantation. Transpl Int 2005; 18:1266-74. [PMID: 16221157 DOI: 10.1111/j.1432-2277.2005.00201.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The study compared the results of kidney transplantation from living-related donors older and younger than 60 years. The 273 kidney graft recipients were divided into group 1 (115 recipients of older grafts) and group 2 (158 recipients of younger grafts). The frequency of acute rejection (AR) episodes was similar in both groups but slow graft function occurred more frequently in group 1. The frequency of chronic renal allograft dysfunction in the first post-transplant year was significantly higher in group 1 than in group 2. Patient and graft survival was significantly worse in group 1. Risk factors for graft loss were the difference between donor and recipient age and AR. Donor age and graft function were risk factors for patient death. Although kidneys from older donors provide a statistically poorer transplant outcome, they are clinically acceptable, especially when waiting time is prolonged and access to dialysis limited.
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Affiliation(s)
- Radomir Naumovic
- Department of Nephrology, University Clinical Center, Beograd, Serbia and Montenegro.
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Anil Kumar MS, Heifets M, Fyfe B, Saaed MI, Moritz MJ, Parikh MH, Kumar A. Comparison of Steroid Avoidance in Tacrolimus/Mycophenolate Mofetil and Tacrolimus/Sirolimus Combination in Kidney Transplantation Monitored by Surveillance Biopsy. Transplantation 2005; 80:807-14. [PMID: 16210969 DOI: 10.1097/01.tp.0000173378.28790.0b] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic steroid therapy in kidney transplantation has myriad side effects and steroid avoidance has become feasible. This prospective study compared the safety and efficacy of steroid avoidance in tacrolimus (TAC)/mycophenolate mofetil (MMF) and TAC/sirolimus (SRL) combinations in kidney transplantation. METHODS In all, 150 kidney recipients were analyzed: 75 each in TAC/MMF and TAC/SRL groups. The primary endpoint was acute rejection. Surveillance biopsies were completed to analyze subclinical acute rejection (SCAR) and chronic allograft nephropathy (CAN). Acute rejection and SCAR were treated by methylprednisolone. Two-year patient and graft survival, renal function, and adverse effects were monitored. RESULTS Acute rejection was seen in 12% of TAC/MMF and 8% of TAC/SRL patients. Two-year actuarial patient survival was 95% and 97%, and graft survival 90% and 90% in TAC/MMF and TAC/SRL groups, respectively. Surveillance biopsy showed cumulative incidence of SCAR was 27 % in TAC/MMF and 16 % in TAC/SRL groups at 2 years (P = 0.04). Overall, 33% of recipients in TAC/MMF and 20% in TAC/SRL received methylprednisolone for acute rejection/SCAR. Moderate/severe CAN was 10% in TAC/SRL group and 22% in TAC/MMF group(P = 0.06). New-onset diabetes mellitus (NODM) was 4% each in both groups. All recipients remain free of maintenance steroid therapy. CONCLUSIONS Steroid avoidance in tacrolimus-based immunosuppression with MMF or SRL provides equivalent 2-year patient and graft survival with a low incidence of acute rejection and NODM. SCAR and CAN are lower in TAC/SRL compared to TAC/MMF group. The impact of decreased SCAR and CAN in TAC/SRL group on longer-term graft survival and function is to be evaluated.
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Affiliation(s)
- Mysore S Anil Kumar
- Division of Transplantation, Department of Surgery and Transplantation, Drexel University College of Medicine and Hahnemann University Hospital, Philadelphia, PA 19102, USA.
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Kumar MSA, Sierka DR, Damask AM, Fyfe B, McAlack RF, Heifets M, Moritz MJ, Alvarez D, Kumar A. Safety and success of kidney transplantation and concomitant immunosuppression in HIV-positive patients. Kidney Int 2005; 67:1622-9. [PMID: 15780120 DOI: 10.1111/j.1523-1755.2005.00245.x] [Citation(s) in RCA: 180] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Human immunodeficiency virus-associated nephropathy (HIVAN) has become the third leading cause of end-stage renal disease (ESRD) in African Americans, and is expected to grow exponentially. Highly active antiretroviral therapy (HAART) has significantly prolonged the survival of patients with HIV infection. Despite the growing number of HIV-positive dialysis patients with prolonged life expectancy, kidney transplantation with immunosuppression has been declined because it is considered a waste of scarce donor kidneys due to potential increases in morbidity and mortality. METHODS The institutional review board of Drexel University College of Medicine and Hahnemann University Hospital approved this prospective study. The aim was to find out safety and success of kidney transplantation, and the effect of immunosuppression on HIV infection. Forty HIV-positive dialysis patients received kidney transplantation between February 2001 and January 2004. Patient inclusion criteria were maintenance of HAART, plasma HIV-1 RNA of <400 copies/mL, absolute CD4 counts of 200 cells/muL or more. Immunosuppression was basiliximab induction and maintenance with cyclosporine, sirolimus, and steroids. HAART was continued post-transplant. Acute rejections were diagnosed by biopsy and treated with methylprednisolone. Surveillance biopsies were completed at 1, 6, 12, and 24 months, and evaluated for subclinical acute rejection, chronic allograft nephropathy, and HIVAN. RESULTS One- and 2-year actuarial patient survival was 85% and 82%, respectively, and graft survival was 75% and 71%, respectively. Plasma HIV-1 RNA remained undetectable, and CD4 counts remained in excess of 400 cells per muL with no evidence of AIDS for up to 2 years. CONCLUSION One- and 2-year graft survival is comparable to other high-risk populations receiving kidney transplantation. One- and 2-year patient survival is higher than HIV patients maintained on dialysis. Immunosuppression does not adversely affect HIV recipients maintained on HAART in the short term.
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Affiliation(s)
- Mysore S Anil Kumar
- Department of Surgery/Transplantation, Drexel University College of Medicine and Hahnemann University Hospital, Philadelphia, PA 19102, USA.
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Anil Kumar MS, Moritz MJ, Saaed MI, Heifets M, Sustento-Reodica N, Fyfe B, Kumar A. Avoidance of chronic steroid therapy in african american kidney transplant recipients monitored by surveillance biopsy: 1-year results. Am J Transplant 2005; 5:1976-85. [PMID: 15996248 DOI: 10.1111/j.1600-6143.2005.00984.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
African American (AA) kidney recipients receive chronic steroid therapy to improve outcomes, despite their high susceptibility to side effects, particularly diabetes and hypertension. This study evaluated the safety and efficacy of avoidance of chronic steroid therapy in AA compared to non-AA kidney recipients. Two hundred and six kidney recipients were studied; 103 AA recipients versus 103 non-AA recipients. Induction was basiliximab and maintenance was a calcineurin inhibitor plus mycophenolate mofetil or sirolimus. Surveillance biopsies were preformed at 1, 6 and 12 months to assess subclinical acute rejection (SCAR) and chronic allograft nephropathy (CAN). Biopsy-proven acute rejection (AR) and SCAR were treated by methylprednisolone. The primary end point was AR. Secondary end points were graft function, 1-year patient and graft survival. AR was observed in 16% of AA and 13% of non-AA recipients. SCAR at 1 month was significantly higher in the AA group (p=0.04). One-year actual patient and graft survival in the AA group was 96% and 88% and in the non-AA group 97% and 89%, respectively. Avoidance of chronic steroid therapy directed by surveillance biopsies provides equivalent AR, CAN and 1-year patient and graft survival in AA versus non-AA recipients and a 5% incidence of new onset diabetes mellitus. All recipients remain free of chronic steroid therapy. Longer-term follow-up is ongoing.
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Affiliation(s)
- Mysore S Anil Kumar
- Department of Surgery/Transplant, Drexel University College of Medicine and Hahnemann University Hospital, Philadelphia, Pennsylvania, USA.
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Boggi U, Barsotti M, Collini A, Bernini M, Vistoli F, Paleologo G, Bianchi AM, Tregnaghi C, Nerucci B, Ruggieri G, Carmellini M, Rizzo G, Mosca F. Kidney Transplantation From Donors Aged 65 Years or More as Single or Dual Grafts. Transplant Proc 2005; 37:577-80. [PMID: 15848462 DOI: 10.1016/j.transproceed.2005.01.085] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
AIM The organ shortage and aging donor population force transplant centers to accept donors previously considered unusable for kidney transplantation. We report the experience of two Italian transplant centers with single (SKTx) and dual (DKTx) kidney transplantation from donors aged 65 years or more. METHODS The study population comprised 75 SKTx (mean donor age 70.5 years) and 28 DKTx (mean donor age 75.0 years). Kidneys from donors with a calculated admission creatinine clearance <50 mL/min, a Karpinski's score on kidney biopsy between 5 and 7, or both were allocated to DKTx. Grafts with better function or lower biopsy scores were employed for SKTx. RESULTS Delayed graft function occurred in 45.3% of SKTx and in 39.3% of DKTx. After a mean follow-up period of 30.0 +/- 19.5 months, the acute rejection rate was 24.0% in SKTx and 7.1% in DKTx. Mean serum creatinine was 1.8 +/- 0.9 and 1.8 +/- 1.3 mg/dL in SKTx, and 1.8 +/- 1.6 mg/dL and 1.3 +/- 0.2 mg/dL in DKTx at 1 and 5 years, respectively. Patient survival was 93.3% and 91.2% in SKTx, and 92.9% and 92.9% in DKTx at 1 and 5 years, respectively. Graft survival was 92.0% and 88.3% in SKTx, and 89.3% and 89.3% in DKTx at the same time intervals. Keeping preservation time below 16 hours and avoiding calcineurin inhibitors were both associated with improved graft survival and function. CONCLUSION Careful donor selection, short preservation time, and tailored immunosuppression allow safe and efficient use of elderly donor kidneys.
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Affiliation(s)
- U Boggi
- Department of Surgery and Transplantation, University of Pisa, Pisa, Italy
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Vistoli F, Boggi U, Vanadia Bartolo T, Del Chiaro M, Croce C, Gremmo F, Coletti L, Tregnaghi C, Paleologo G, Barsotti M, Rizzo G, Mosca F. Kidney transplantation from donors aged more than 65 years. Transplant Proc 2004; 36:481-4. [PMID: 15110564 DOI: 10.1016/j.transproceed.2004.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND There are no agreed criteria to predict the outcome of elderly donor kidneys or to decide between single (SKG) or dual (DKG) kidney graft transplantation. METHODS Between January 1999 and January 2003, 46 SKG and 14 DKG were performed from elderly donors (mean donor age 71.6 years; range: 66 to 87). Kidney biopsies were scored according to Karpinski. A calculated admission creatinine clearance <50 mL/min and/or a biopsy score of 5 or 6 were used to select kidneys for DKG. Grafts with better function or lower biopsy scores were employed for SKG. RESULTS Mean cold ischemia time (CIT) was 16.8 hours (range 8.1 to 28.6) in SKG, and 16.3 hours (range 4.6 to 24.3) for the first kidney and 17.4 hours (range 5.1 to 25.9) for the second graft in DKG. Delayed graft function (DGF) occurred in 34.1% SKG and in 28.5% DKG. Acute rejection rates were 9.1% for SKG and 0% for DKG. Three-year actuarial patient survival rates were 97.7% for SKG and 92.9% for DKG; for kidneys, 95.4% and 92.9%. One-year mean serum creatinine levels were 1.8 mg/dL (range 1.1 to 4.0) for SKG and 1.2 mg/dL (range 1.0 to 1.8) for DKG (P =.01). CIT longer than 16 hours was related to increased rates of DGF for both SKG (45.4% vs 22.7%) or DKG (42.9% vs 14.3%) and reduced 3-year graft survival rates (SKG: 90.9% vs 100%; DKG: 85.7% vs 100%). CONCLUSIONS With stringent selection criteria and short CIT (<16 hours), elderly donor kidneys may show good results, thus meaningfully expanding the donor pool.
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Affiliation(s)
- F Vistoli
- Divisione di Chirurgia Generale e Trapianti, Università di Pisa, Pisa, Italy.
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18
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Diene E, Chalem Y, Cohen S, Hiesse C, Tuppin P. Organ donors > or = 60 years: harvesting disparities in French regional areas. Transplant Proc 2002; 34:839-40. [PMID: 12034201 DOI: 10.1016/s0041-1345(01)02928-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- E Diene
- Etablissement français des Greffes, Paris, France
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19
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Kasiske BL, Snyder J. Matching older kidneys with older patients does not improve allograft survival. J Am Soc Nephrol 2002; 13:1067-1072. [PMID: 11912268 DOI: 10.1681/asn.v1341067] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Centers may restrict the use of some donor kidneys on the belief that overall graft survival is improved by giving older kidneys to older recipients and vice versa. The prevalence and the effect on graft survival (determined by death, return to dialysis, or retransplantation) of this practice among 74,297 first cadaver kidney transplantations in 1988 to 1998 was examined by using data from the United States Renal Data System. Giving older kidneys to older recipients is common; recipients > or =55 yr old received donor kidneys that were > or =55 yr old 46.2% more often than expected, but they received kidneys that were 18 to 29 yr old 33.6% less often than expected (chi(2) P < 0.0001). Both recipient and donor age have important effects on graft survival, although the effects of donor age are much stronger than those of recipient age. Compared with recipients 18 to 29 yr old, recipients > or =55 yr old were 25% (95% confidence interval, 15 to 35%, P < 0.0001) more likely to have graft failure (adjusted for donor age and other risk factors). On the other hand, donor kidneys > or =55 yr old were 78% (95% confidence interval, 58 to 99%, P < 0.0001) more likely to fail compared with kidneys 18 to 29 yr old. However, giving older kidneys to older recipients had little independent effect on graft survival, once the intrinsic effects of recipient and donor age were taken into account. For example, transplanting donor kidneys > or =55 yr old into recipients > or =55 yr old reduced the risk of graft failure only -6% (95% confidence interval, -18 to 8%, P = 0.3923) after the independent effects of donor and recipient age per se were taken into account. Thus, giving older kidneys to older recipients is a common practice that does not improve overall graft survival.
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Affiliation(s)
- Bertram L Kasiske
- *United States Renal Data System Coordinating Center, Minneapolis, Minnesota; and Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jon Snyder
- *United States Renal Data System Coordinating Center, Minneapolis, Minnesota; and Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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20
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Gain P, Thuret G, Chiquet C, Rizzi P, Pugniet JL, Acquart S, Colpart JJ, Le Petit JC, Maugery J. Cornea procurement from very old donors: post organ culture cornea outcome and recipient graft outcome. Br J Ophthalmol 2002; 86:404-11. [PMID: 11914209 PMCID: PMC1771071 DOI: 10.1136/bjo.86.4.404] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To study the suitability of corneas from very old donors for graft after banking and their clinical and endothelial outcomes in recipients. METHODS 419 corneas stored in organ culture were divided into group 1, donors under 85 years (330 corneas) and group 2, "very old" donors aged 85 years and over (89 corneas). Endothelial cell density (ECD) before and after organ culture, discard rate before and after storage, and clinical and endothelial outcomes of the 196 penetrating keratoplasties (PKP) (158 in group 1 and 38 in group 2) were compared in a prospective longitudinal study. RESULTS Initial ECD was lower in group 2 than in group 1 and elimination for low ECD was more frequent in group 2 (respectively 38% v 20.2%, p=0.001). At the end of storage, because very old corneas lost fewer ECs than younger ones (respectively 4.2% v 9.5%, p=0.022), ECD was comparable between the two groups. The corneas of very old donors had a poorer macroscopic appearance at procurement and during surgery. Despite this, in grafted patients, overall graft survival in groups 1 and 2 (respectively 87.4% v 80.6%, p=0.197), visual acuity, and ECD did not differ at completion of the study (mean follow up 25 months). CONCLUSION This study suggests that endothelial cell count during banking ensures that functional and cellular results of PKPs are not dramatically influenced by very old donor age. Considering Europe's ageing population, the very elderly should not be deemed off limits for corneal procurement.
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Affiliation(s)
- P Gain
- Department of Ophthalmology, Bellevue Hospital, University of Saint-Etienne, France.
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21
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Pokorná E, Schück O, Vitko S, Ekberg H. Estimated and measured donor creatinine clearance are poor predictors of long-term renal graft function and survival. Am J Transplant 2002; 2:373-80. [PMID: 12118861 DOI: 10.1034/j.1600-6143.2002.20414.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The objective of this study was to evaluate estimated and measured donor renal function in predicting graft function long-term and to identify donor criteria associated with nonacceptable graft prognosis. In 200 consecutive cadaver donors creatinine clearance was measured at explantation and estimated using the Cockcroft formula on admission serum creatinine. Graft function was evaluated in recipients (n = 387) by 24-h creatinine clearance regularly during 3 years after transplantation. Measured creatinine clearance correlated to some extent with long-term graft function, while Cockcroft estimation was slightly superior and similar to using donor age only. Kidneys from donors with intra-operative creatinine clearance < or = 55 mL/min (median 50 mL/min) produced acceptable recipient graft function of 48 mL/min at 3 years and 76% 3-year graft survival. Donor age > or =60 years resulted in clearance at 3 years of 29 mL/min and 78% 3-year graft survival; adding the criteria of admission Cockcroft < or =60 mL/min, graft function at 3 years (28 mL/min) and 3-year graft survival (76%) were similar. In conclusion, creatinine-based estimates of the functional capacity of the donor kidney, calculated or intra-operatively measured, do little to improve the ability of donor age alone to predict long-term allograft function after renal transplantation, and nonacceptable donors are not discriminated.
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Affiliation(s)
- Eva Pokorná
- Transplant Center, Institute of Clinical and Experimental Medicine, Prague, Czech Republic.
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22
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Modlin CS, Goldfarb DA, Novick AC. The use of expanded criteria cadaver and live donor kidneys for transplantation. Urol Clin North Am 2001; 28:687-707. [PMID: 11791487 DOI: 10.1016/s0094-0143(01)80026-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The use of expanded criteria donors (non-traditional donors) can help lessen the current shortage of kidneys available for transplantation. The use of older donors has accounted for a large measure of the increase in the organ donation rate; however, the most significant factors found to impact on transplant success negatively traditionally have been shown to be extremes of donor age and last-hour urine output. Less significant variables affecting success rates are average systolic blood pressure, terminal serum creatinine, and days of hospitalization. With the appropriate selection of organs from expanded donors, acceptable outcomes can be obtained. When living donors are selected properly, kidneys with anatomic variants without pathologic significance can be used safely. Kidneys with a heightened potential for the development of progressive disease should not be transplanted. Efforts to decrease the cold ischemia time by increasing the use of kidneys from expanded criteria donors may improve the outcome of transplantation further. Advances in surgical techniques, preservation solutions, and methods for predicting eventual long-term renal function in kidneys from expanded donors will be critical in allowing precise selection criteria for kidneys for transplantation, resulting in the optimum use of a scarce and precious resource. Until options such as xenotransplantation become clinically feasible, the challenge will be to identify which donor organs previously considered suboptimal can be used safely to expand the organ donor pool.
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Affiliation(s)
- C S Modlin
- Section of Renal Transplantation, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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23
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Kumar AM, Fa K, Vankawala R, Vora M, Kode RK, Pankewycz OG, Lattavi MR, Fyfe B, Damask AM, Ferry E, Stabler S, Tomeny MB, Phillips K, Lingaraju R, Kumar MS. Simulect, calcineurin inhibitor, mycophenolate mofetil, and prednisone is more effective than OKT3, calcineurin inhibitor, hycophendate mofetil, and prednisone in African American kidney recipients in reducing acute rejections and prolonging graft survival. Transplant Proc 2001; 33:3195-6. [PMID: 11750370 DOI: 10.1016/s0041-1345(01)02359-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- A M Kumar
- Department of Transplantation, MCP Hahnemann University, Philadelphia, Pennsylvania 19102, USA
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Saudan P, Berney T, Leski M, Morel P, Bolle JF, Martin PY. Renal transplantation in the elderly: a long-term, single-centre experience. Nephrol Dial Transplant 2001; 16:824-8. [PMID: 11274281 DOI: 10.1093/ndt/16.4.824] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND End-stage renal failure increases with advancing age and renal transplantation should be considered in end-stage renal failure patients older than 60 years. However, there is a paucity of data on long-term patient and graft survival in this population. METHODS From October 1983 to March 1999, 310 renal transplantations were performed at Geneva University Hospital in 283 patients, of which 49 were done in 48 patients older than 60 years (mean age 65.6+/-4.1 years). The following data were analysed at 1, 5, and 10 years, and compared between the patients >60 years and <60 years old: actuarial patient and graft survival, serum creatinine, causes of graft loss, and patient death. RESULTS Patient survival at 10 years was 81% for patients <60 years and 44% for patients >60 years. Graft survival at 10 years was 59% for patients <60 years and 32% for patients >60 years. Graft survival at 10 years censored for death with functioning graft was 65% for patients <60 years and 81% for patients >60 years. Main causes of mortality in the older patients were related to cardiovascular events (47%), neoplasia (41%), and sepsis (18%). Overall, recipient and donor age were not predictive factors for graft survival, as shown by multiple logistic regression. CONCLUSIONS Renal transplantation should be considered in patients older than 60 years, since graft survival is excellent in this population. Although these patients have a shorter life expectancy, they benefit from renal transplantation similarly to younger kidney transplant recipients.
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Affiliation(s)
- P Saudan
- Division of Nephrology, Department of Medicine, University Hospital, Geneva, Switzerland
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25
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Abstract
As the number of elderly patients suffering from end-stage renal disease has increased almost threefold during the past 20 years all over the world, new strategies for the treatment of such patients have been developed. Better screening has made renal transplantation a valuable resource in elderly end-stage renal disease patients. Improved immunosuppressive protocols as well as the expansion of the donor pool by using older and living donors for older recipients have improved patient survival rates as well as the quality of life in this patient population.
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Affiliation(s)
- V Fabrizii
- Department of Medicine, Division of Nephrology and Dialysis, University of Vienna, Vienna, Austria.
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26
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Sánchez-Fructuoso AI, Prats D, Marques M, Pérez-Contín MJ, Fernández-Pérez C, Contreras E, Blanco J, Barrientos A. Does renal mass exert an independent effect on the determinants of antigen-dependent injury? Transplantation 2001; 71:381-6. [PMID: 11233897 DOI: 10.1097/00007890-200102150-00007] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this retrospective study was to determine whether nephron mass may exert a direct, independent effect on immunological tolerance. To this end, data corresponding to patients transplanted with en block pediatric kidneys (EBPK) (n=48) were compared with those of renal transplants with a low risk of hyperfiltration (LRH) comprised of recipients of a kidney from young donors (age 5-40 years) (n=173), and transplants with a high risk of hyperfiltration (HRH) comprised of patients who had received a graft from an elderly donor (older than 55 years) (n=91). All the patients had been subjected to the same immunosuppressive treatment. The median follow-up period was 54 months (6-127 months). The EBPK group showed lowest serum creatinine and highest creatinine clearance levels at each follow-up time. The rate of proteinuria >500 mg/day was 5.7% in EBPK, 7.4% in LRH, and 27.3% in HRH (P=0.000). The incidence of acute corticoresistant rejection was minor in EBPK (7.0% in EBPK, 21.3% in LRH, and 23.3% in HRH; P=0.04). Logistic regression analysis showed that the type of transplant was predictive of acute corticoresistant rejection [RR 5.33 (95% confidence interval (CI) 1.15-24.62) for HRH and RR 4.75 (95%CI 1.06-21.27) for LRH, P=0.03]. Multivariate analyses for graft failure due to chronic rejection and for graft failure due to acute rejection according to Cox's regression analysis demonstrated that HRH transplant was a significant predictive variable of both types of failure [4.08 (95%CI 1.27-13.04) for graft loss due to chronic rejection and 8.69 (95%CI 1.69-44.67) for graft loss due to acute rejection]. The present stratification of data according to nephronal mass would appear to indicate that the greater the mass, the lower the incidence of both acute and chronic rejection. This finding lends support to the hypothesis that a large mass of transplanted tissue relative to recipient mass may dampen the immune response.
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27
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Kode RK, Foster CE, Kumar AM, Vankawala R, Damask AM, Fyfe BS, Seirka D, Laftavi MR, Brezin J, Pankewycz O, Chvala R, Kumar MS. Nine year experience with kidney transplantation in patients with positive hepatitis C virus antibody. Transplant Proc 2001; 33:1186-7. [PMID: 11267250 DOI: 10.1016/s0041-1345(00)02378-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- R K Kode
- Division of Transplantation, MCP Hahnemann University, Philadelphia, Pennsylvania, USA
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28
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Chowdhury S, Kode RK, Ranganna K, Damask AM, Lam A, Fyfe B, Stabler S, Kumar AM, Tomeny MB, Kumar MS, Pankewycz O. Induction strategy using basiliximab combined with mycophenolate MMF and immediate low-dose cyclosporin is steroid sparing and more effective than OKT3. Transplant Proc 2001; 33:1057-8. [PMID: 11267189 DOI: 10.1016/s0041-1345(00)02414-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S Chowdhury
- Division of Transplantation, MCP Hahnemann University, Philadelphia, PA, USA
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29
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Verran DJ, deLeon C, Chui AK, Chapman JR. Factors in older cadaveric organ donors impacting on renal allograft outcome. Clin Transplant 2001; 15:1-5. [PMID: 11168308 DOI: 10.1034/j.1399-0012.2001.150101.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Transplantation of renal allografts (RA) from older donors has become more common, despite conflicting data on outcome between reports from large series versus individual centres. Factors other than donor age per se may contribute to RA outcome. The outcome of RA procured from 114 older donors over 55 yr of age in NSW, between 1990 and 1997, was analysed. Corresponding donor factors, including demographics, medical history, inotrope use, major hypotension and findings at procurement, were also analysed. Of the potential RA, 8% were discarded and the remainder transplanted. Factors significantly associated with renal discard were pre-transplantation donation biopsy abnormality (p < 0.001) and a history of cardiovascular (CV) disease in the donor (p < 0.02). Donor aortorenal atherosclerosis (AS; p < 0.09) and a donor age of 65 yr or older (p < 0.08) were common in the discard group. The never function rate was 7.6% and was associated with a history of a discarded partner kidney (p < 0.05). The delayed graft function rate was 33% and was associated with a history of donor CV disease. At a median follow up of 5 yr, the death censored allograft failure rate was 24%. Allograft failure was associated with a history of donor hypertension (p < 0.05). Donor AS (p < 0.7) tended to have been more common in the allograft failure group. A number of cadaveric organ donor factors documented at procurement may be associated with inferior outcome of RA. These include biopsy abnormality, history of donor CV disease and history of donor hypertension. A donor age of 65 yr or older or significant visible aortorenal AS may also be factors. This retrospective review of kidneys procured from 114 older cadaveric organ donors identifies factors apart from donor age, which may have a negative impact on both allograft utilisation and outcome. Theses factors include renal biopsy abnormality, history of donor CV disease, discard of a partner kidney and donor hypertension. Visible AS in the donor aorta documented at renal procurement may also be a factor.
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Affiliation(s)
- D J Verran
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Camperdown, NSW.
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30
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Affiliation(s)
- J M Grinyó
- Hospital de Bellvitge, University of Barcelona, Barcelona, Spain
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31
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Bosmans JL, Woestenburg A, Ysebaert DK, Chapelle T, Helbert MJ, Corthouts R, Jürgens A, Van Daele A, Van Marck EA, De Broe ME, Verpooten GA. Fibrous intimal thickening at implantation as a risk factor for the outcome of cadaveric renal allografts. Transplantation 2000; 69:2388-94. [PMID: 10868646 DOI: 10.1097/00007890-200006150-00030] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND During the past decade, the donor age of cadaveric renal allografts steadily increased. Because cerebrovascular injury is the main cause of death in this donor population, an increased prevalence of atherosclerotic lesions in the retrieved grafts could be anticipated. In a prospective study, we investigated the predictive value of morphologic lesions at implantation for the functional and morphologic outcome of cadaveric renal allografts at 1 1/2 years. METHODS In 50 consecutive adult recipients of a cadaveric renal allograft, under cyclosporine-based regimen, implantation biopsies and subsequent protocol biopsies at 18 months were performed, and morphometrically analyzed for the extent of glomerulosclerosis, interstitial fibrosis, and atherosclerosis. Risk factors were assessed at implantation and during the subsequent observation period of 18 months. Endpoints for this study were: the 24-hr creatinine clearance (normalized for body surface area) and the fractional interstitial volume at 1 1/2 years. RESULTS In multivariate analysis, fibrous intimal thickening at implantation (FIT) was the main determinant of the functional and morphologic outcome at 1 1/2 years. FIT represented a relative risk of 4.55 for interstitial fibrosis (95% CI=1.855-11.138), and 1.89 for impaired renal function (95% CI=1.185-3.007) at 1 1/2 years. FIT adversely affected fractional interstitial volume at 1 1/2 years (34.3 vs. 27.7%, P=0.004), as well as renal function (54 vs. 68 ml/min/1.73 m2, P=0.028). CONCLUSIONS Fibrous intimal thickening at implantation is a determinant risk factor for the functional and morphologic outcome of cadaveric renal allografts at 1 1/2 years.
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Affiliation(s)
- J L Bosmans
- Department of Nephrology, University of Antwerp, Belgium
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Vera-Sempere F, Vicente JL, Prieto M, Gironés P, Jordá M. [Frozen section biopsy in the assessment of organs for transplantation]. Med Clin (Barc) 2000; 114:81-4. [PMID: 10736792 DOI: 10.1016/s0025-7753(00)71199-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The success of transplantation and the increase in its indications has caused organ donations to be unable to meet the global demand. By broadening the donor selection criteria and accepting so-called suboptimal donors in an attempt to solve this problem, a careful individualized assessment is required of the validity of each donor. This often implies the need for a pretransplantation biopsy study. MATERIAL AND METHODS Evaluation of frozen-section biopsy studies in the assessment of graft and donor validness in the the transplantation program of the La Fe University Hospital (Valencia, Spain) during 1998, when a total of 301 solid organ transplantations were performed. RESULTS Sixty pretransplantation frozen-section biopsies were performed (29 of the liver, 21 renal, 3 lymph nodes, 3 brain, 2 prostatic, 1 myometrial and 1 pericardial). As a result of the bioptic study, 18 transplantations were invalidated (30% of all biopsies). The most frequent causes of invalidation were liver macroesteatosis (7 cases), malignancies (5 cases) and renal parenchymal lesions (5 cases). Among the tumor diagnosis there were one false-positive and one false-negative results of malignancy. CONCLUSION Frozen-section biopsies evaluation in suboptimal organ donors or donors suspected of suffering disease integrates morphological analysis in the transplantation team decision process, and affords a quality factor in the selection of donors.
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Affiliation(s)
- F Vera-Sempere
- Servicio de Anatomía Patológica, Hospital Universitario La Fe, Valencia
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Pokorná E, Vítko S, Chadimová M, Schück O, Ekberg H. Proportion of glomerulosclerosis in procurement wedge renal biopsy cannot alone discriminate for acceptance of marginal donors. Transplantation 2000; 69:36-43. [PMID: 10653377 DOI: 10.1097/00007890-200001150-00008] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The shortage of available kidneys for renal transplantation could be addressed, to some extent, by expanding the criteria for acceptance of marginal donors. The study of these criteria is limited by the selection of grafts actually retrieved and transplanted, therefore reduced to a study of risk factors. We have evaluated the potential of procurement renal biopies as an instrument for acceptance or refusal of donor kidneys for transplantation. METHODS This was a prospective study of a consecutive series of 200 donors. Biopsies were performed by wedge technique at the donor operation and were evaluated for proportion of glomerulosclerosis, vascular and tubular changes, and interstitial fibrosis. The study included 387 renal grafts with a representative biopsy, transplanted, and followed-up for survival and functional evaluation; 24 hr creatinine clearance at 1 and 3 weeks, and 3, 6, 12, 18, and 24 months. RESULTS Factors associated with initial graft function included cold ischemia time, number of DR mismatches, tubular changes, although donor age showed the strongest correlation with short- and long-term level of graft function. DR mismatches and retransplantation appeared to be the only significant risk factors for graft loss. The proportion of glomerulosclerosis (mean 8%, range 0-48%) correlated with graft function in the simple regression analysis. However, when age was taken into account glomerulosclerosis did not correlate significantly with graft function. Furthermore, glomerulosclerosis as high as 25% or more had an acceptable 3-year graft survival rate of 74.7%. CONCLUSION Procurement biopsy provides only limited information for the decision whether or not to accept a kidney donor.
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Affiliation(s)
- E Pokorná
- Transplant Centre, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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Shimmura H, Tanabe K, Ishikawa N, Kanematsu A, Tokumoto T, Oshima T, Fuchinoue S, Toma H. Influence of donor renal reserve on the long-term results of living kidney transplantation from elderly donors. Transplant Proc 1999; 31:2874-6. [PMID: 10578322 DOI: 10.1016/s0041-1345(99)00598-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- H Shimmura
- Department of Urology, Tokyo Women's Medical University, Japan
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35
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Lee CM, Carter JT, Weinstein RJ, Pease HM, Scandling JD, Pavalakis M, Dafoe DC, Alfrey EJ. Dual kidney transplantation: older donors for older recipients. J Am Coll Surg 1999; 189:82-91; discussion 91-2. [PMID: 10401744 DOI: 10.1016/s1072-7515(99)00073-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Dual kidney transplantation, the transplantation of both donor kidneys into a single recipient, allows increased use of expanded criteria donors (eg, older donors with a history of hypertension) to alleviate the disparity between available donors and potential recipients. We evaluated outcomes in our dual kidney transplant program that started in 1995. STUDY DESIGN A retrospective comparison of donor and recipient data between recipients of dual (n = 41) versus single (n = 199) cadaveric renal transplants from February 1, 1995, to March 22, 1998, was performed. Dual kidney transplantation was selectively performed when the calculated donor admission creatinine clearance was less than 90 mL/min and the donor age was greater than 60 years, or if the donor had an elevated terminal serum creatinine. Every attempt was made to age- and size-match the donor and recipients. RESULTS Recipients of dual kidneys had donors who were older than single kidney donors (59 +/- 12 versus 42 +/- 17 years respectively, p < 0.0001) and had more hypertension (51% versus 29%, p = 0.024). Average urine output was lower in the dual versus single kidney group (252 +/- 157 versus 191 +/- 70 mL/hr, p = 0.036). Donors for dual kidney recipients had a lower donor admission creatinine clearance of 82 +/- 28 mL/min versus 105 +/- 45 mL/min in the single kidney group (p = 0.005). Recipients of dual versus single kidneys were older (58 +/- 11 versus 47 +/- 12 years, p > 0.0001). Dual versus single kidney recipients had similar serum creatinines up to 2 years posttransplant (1.6 +/- 0.3 versus 1.6 +/- 0.7 mg/dL at 2 years, p = NS) and a comparable incidence of delayed graft function (24% versus 33%, p = NS) and 3-month posttransplant creatinine clearance (54 +/- 23 versus 57 +/- 25 mL/min, p = NS). One-year patient and graft survival for single kidney transplantation was 97% and 90%, respectively, and 98% and 89% for dual kidney transplantation (p = NS). CONCLUSIONS Dual kidney donors were significantly older, had more hypertension, lower urine outputs, and lower donor admission creatinine clearance. Despite these differences, dual kidney recipients had comparable postoperative function, outcomes, and survival versus single kidney recipients. We believe selective use of dual kidney transplantation can provide excellent outcomes to recipients of kidneys from older donors with reduced renal function.
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Affiliation(s)
- C M Lee
- Department of Surgery, University of California-San Francisco, USA
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Malaise J, Cosyns J, Lallier M, De Meyer M, Mourad M. Baseline biopsy for the quality assessment of kidney graft. Curr Opin Organ Transplant 1999. [DOI: 10.1097/00075200-199906000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Karpinski J, Lajoie G, Cattran D, Fenton S, Zaltzman J, Cardella C, Cole E. Outcome of kidney transplantation from high-risk donors is determined by both structure and function. Transplantation 1999; 67:1162-7. [PMID: 10232568 DOI: 10.1097/00007890-199904270-00013] [Citation(s) in RCA: 171] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
METHOD Despite the need to expand the donor pool, it is unclear what parameters should be used. The value of donor renal pathology and calculated creatinine clearance (CrCl) in determining recipient outcome was assessed in 57 kidney transplants from 34 donors in whom pretransplant renal biopsies were performed because of age > or =60, hypertension, and/or vascular disease. We retrospectively compared clinical outcomes in these recipients and 57 control recipients selected to have the same baseline demographics but receiving transplants from low risk donors who were significantly younger (32+/-13.9 vs. 61+/-7.3 years) and lighter weight (71+/-18.1 vs. 84+/-20.2 kg) than the high-risk donors (P<.001 for both). RESULTS Recipients of high-risk kidneys had a higher incidence of delayed graft function, defined by a <10% fall in serum creatinine (Cr) in the first 24 hr, (56% vs. 30%, P<.01), a higher incidence of rejection (60% vs. 37%, P = .02) and a higher Cr level (197+/-64 vs. 144+/-54 micromol/L at 18 months, P<.005). Graft and patient survival were similar; 12% and 5% vs. 91% and 9% in high-risk vs. control groups, respectively (P = NS). Donor renal pathology was scored 0-3 (none to severe disease) in four areas: glomerulosclerosis, interstitial fibrosis, tubular atrophy, and vascular disease. A donor vessel score of 3/3 was associated with a 100% incidence of delayed graft function and a mean 1-year Cr level of 275+106 micromol/L (compared with 43% and 192+54 micromol/L in those with lower vessel scores, P<.05). Calculated donor CrCl <100 ml/min was associated with higher recipient Cr levels at 1 year, 240+/-95 micromol/L vs. 180+/-54 micromol/L in recipients of kidneys from donors with CrCl levels >100 ml/min (P<.05). The mean 1-year Cr level was 320+/-102 micromol/L in recipients with both a vascular score of 3/3 and a donor CrCl <100 ml/min and 184+/-63 micromol/L in those with neither factor (P = .001). CONCLUSION Calculated donor CrCl and donor vascular pathology predict recipient graft function and may be helpful in selecting high-risk donors for single kidney transplantation.
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Affiliation(s)
- J Karpinski
- Renal Transplantation Program, University of Toronto, Ontario, Canada
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Affiliation(s)
- L W Teperman
- Department of Surgery, New York University Medical School, NY, USA
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