A comparison of the effects of dialysis and renal transplantation on the survival of older uremic patients

Improving Surgical Safety in Living Donor Renal Transplantation With Antiseptic Skin Preparation, Bladder Irrigation, Corner-Saving Vascular Anastomosis, DJ Stenting, and Extravesical Ureteroneocystostomy Modifications: A Comprehensive Approach

Introduction The antiseptic skin preparation, bladder irrigation, corner-saving vascular anastomosis, DJ stenting, and extravesical ureteroneocystostomy (ABCDE) approach encompasses a range of modifications applied during different stages of the surgical procedure in renal transplantation. These modifications include the following: A, antiseptic skin preparation sequentially with cetrimide 3.35%, chlorhexidine scrub 4%, spirit, and povidone-iodine 10%; B, bladder irrigation with amikacin and betadine solution; C, corner-saving end-to-side vascular anastomosis; D, DJ stenting with early postoperative removal within three weeks; and E, extravesical ureteroneocystostomy using our institute's modified Lich-Gregoir technique. Methods This prospective observational study was conducted at our institution between March 2021 and May 2023. Data were collected from the patients' medical records and analyzed using Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY, USA). Statistical tests, including t-test, Mann-Whitney test, chi-square test, and Fisher's exact test, were used for analysis. The study assessed various recipient, donor, intraoperative, and post-transplant factors, as well as surgical complications and stent-related factors. Results Out of 72 renal transplantations, 12 (16.6%) had the following surgical complications: urinary (n = 4; 5.5%), wound-related (n = 3; 4.1%), and lymphocele (n = 5; 6.9%). The most common complications were lymphocele (n = 5; 6.9%) and urinary leak (n = 4; 5.5%). Surgical complications were more common in male recipients (91.6% versus 8.3%), as well as in recipients with longer dialysis duration (24 ± 17 versus 11.0 ± 7 months) and had extended hospitalization time (16.4 ± 8.6 versus 8.0 ± 2.9 days) (p < 0.05). Wound infection correlated with longer surgeries (>300 minutes) and other complications. Lymphocele patients had higher drain output (>500 mL) on day 1 and longer hospital stays (>15 days). Urinary tract infections (UTIs) were linked to dialysis duration (>24 months), diabetes, and longer indwelling times of DJ stents and urinary catheters. Early DJ stent removal (<3 weeks) reduced UTI incidence and symptoms (p < 0.05). All complications were categorized as minor (3a or less), according to the Clavien-Dindo classification. Conclusion The modified ABCDE surgical approach in renal transplantation decreased the complications, showing favorable outcomes compared to those in the literature.

The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation

In testing the prognostic value of the occurrence of an intervening event (clinical event that occurs post-transplant), 3 proper statistical methodologies for testing its prognostic value exist (time dependent covariate, landmark, and semi-Markov modelling methods). However, time-dependent bias has appeared in many clinical reports, whereby the intervening event is statistically treated as a baseline variable (as if it occurred at transplant). Using a single-center cohort of 445 intestinal transplant cases to test the prognostic value of 1^st acute cellular rejection (ACR) and severe (grade of) ACR on the hazard rate of developing graft loss, we demonstrate how the inclusion of such time-dependent bias can lead to severe underestimation of the true hazard ratio (HR). The (statistically more powerful) time dependent covariate method in Cox's multivariable model yielded significantly unfavorable effects of 1^st ACR (P<.0001; HR=2.492) and severe ACR (P<.0001; HR=4.531). In contrast, when using the time-dependent biased approach, multivariable analysis yielded an incorrect conclusion for the prognostic value of 1^st ACR (P=.31, HR=0.877, 35.2% of 2.492) and a much smaller estimated effect of severe ACR (P=.0008; HR=1.589; 35.1% of 4.531). In conclusion, this study demonstrates the importance of avoiding time-dependent bias when testing the prognostic value of an intervening event.

Distinct phenotypes of kidney transplant recipients aged 80 years or older in the USA by machine learning consensus clustering

Objectives

This study aimed to identify distinct clusters of very elderly kidney transplant recipients aged ≥80 and assess clinical outcomes among these unique clusters.

Design

Cohort study with machine learning (ML) consensus clustering approach.

Setting and participants

All very elderly (age ≥80 at time of transplant) kidney transplant recipients in the Organ Procurement and Transplantation Network/United Network for Organ Sharing database database from 2010 to 2019.

Main outcome measures

Distinct clusters of very elderly kidney transplant recipients and their post-transplant outcomes including death-censored graft failure, overall mortality and acute allograft rejection among the assigned clusters.

Results

Consensus cluster analysis was performed in 419 very elderly kidney transplant and identified three distinct clusters that best represented the clinical characteristics of very elderly kidney transplant recipients. Recipients in cluster 1 received standard Kidney Donor Profile Index (KDPI) non-extended criteria donor (ECD) kidneys from deceased donors. Recipients in cluster 2 received kidneys from older, hypertensive ECD deceased donors with a KDPI score ≥85%. Kidneys for cluster 2 patients had longer cold ischaemia time and the highest use of machine perfusion. Recipients in clusters 1 and 2 were more likely to be on dialysis at the time of transplant (88.3%, 89.4%). Recipients in cluster 3 were more likely to be preemptive (39%) or had a dialysis duration less than 1 year (24%). These recipients received living donor kidney transplants. Cluster 3 had the most favourable post-transplant outcomes. Compared with cluster 3, cluster 1 had comparable survival but higher death-censored graft failure, while cluster 2 had lower patient survival, higher death-censored graft failure and more acute rejection.

Conclusions

Our study used an unsupervised ML approach to cluster very elderly kidney transplant recipients into three clinically unique clusters with distinct post-transplant outcomes. These findings from an ML clustering approach provide additional understanding towards individualised medicine and opportunities to improve care for very elderly kidney transplant recipients.

Kidney utility and futility

Changes in kidney allocation coupled with the COVID-19 pandemic have placed tremendous strain on current systems of organ distribution and logistics. Although the number of deceased donors continues to rise annually in the United States, the proportion of marginal deceased donors (MDDs) is disproportionately growing. Cold ischemia times and kidney discard rates are rising in part related to inadequate planning, resources, and shortages. Complexity in kidney allocation and distribution has contributed to this dilemma. Logistical issues and the ability to reperfuse the kidney within acceptable time constraints increasingly determine clinical decision-making for organ acceptance. We have a good understanding of the phenotype of "hard to place" MDD kidneys, yet continue to promote a "one size fits all" approach to organ allocation. Allocation and transportation systems need to be agile, mobile, and flexible in order to accommodate the expanding numbers of MDD organs. By identifying "hard to place" MDD kidneys early and implementing a "fast-track" or open offer policy to expedite placement, the utilization rate of MDDs would improve dramatically. Organ allocation and distribution based on location, motivation, and innovation must lead the way. In the absence of change, we are sacrificing utility for futility and discard rates will continue to escalate.

Three-dimensional Augmented Reality-guided Robotic-assisted Kidney Transplantation: Breaking the Limit of Atheromatic Plaques

BACKGROUND

Robotic-assisted kidney transplantation (RAKT) has shown solid results as a minimally invasive alternative to the standard open approach (open kidney transplantation [OKT]). However, RAKT is still limited in those cases where the recipient's iliac vessels present atherosclerotic plaques, frequently found in elder patients and in those subjected to long-term hemodialysis. Unlike OKT, where the surgeon can palpate the arterial plaques, in minimally invasive surgery the haptic feedback is missing, making the vascular clamping and arteriotomy unsafe.

OBJECTIVE

To employ three-dimensional (3D) imaging reconstruction using augmented reality (AR) to intraoperatively locate the plaques during the crucial steps of kidney transplantation.

DESIGN, SETTING, AND PARTICIPANTS

Our study was conducted according to the Idea, Development, Exploration, Assessment, and Long-term follow-up (IDEAL) model for surgical innovation. Three-dimensional virtual models were obtained from high-accuracy computed tomography scan imaging and superimposed on the vessels during RAKT using the Da Vinci console software.

SURGICAL PROCEDURE

Three-dimensional AR-guided robotic-assisted kidney transplantation.

MEASUREMENTS

The correspondence of virtual models with the real anatomy of patients was assessed comparing vessels' and plaques' measures.

RESULTS AND LIMITATIONS

We tested the possibility of using the AR in the setting of vascular surgery by checking the correspondence of the virtual models to the real vessels. During the accuracy assessment, we investigated the anatomy of the iliac plaques and the capacity of the virtual models to correctly represent them. Finally, we tested the efficacy of the virtual model superimposition on the real vessels with plaques during RAKT in the recipients of living donor grafts. The main limitation consists in training needed to correctly superimpose virtual models on the real field.

CONCLUSIONS

The employment of 3D AR allowed surgeons to overcome one of the main limitations of RAKT, setting the foundation to expand its indications to patients with advanced atheromatic vascular disease.

PATIENT SUMMARY

The use of three-dimensional augmented reality guidance during kidney transplantation (KT) has the potential to "navigate" the surgeon during KT, allowing a safer procedure in patients with atheromatic vascular disease.

Small renal masses in kidney transplantation: overview of clinical impact and management in donors and recipients

Kidney transplantation is the best replacement treatment for the end-stage renal disease. Currently, the imbalance between the number of patients on a transplant list and the number of organs available constitutes the crucial limitation of this approach. To expand the pool of organs amenable for transplantation, kidneys coming from older patients have been employed; however, the combination of these organs in conjunction with the chronic use of immunosuppressive therapy increases the risk of incidence of graft small renal tumors. This narrative review aims to provide the state of the art on the clinical impact and management of incidentally diagnosed small renal tumors in either donors or recipients. According to the most updated evidence, the use of grafts with a small renal mass, after bench table tumor excision, may be considered a safe option for high-risk patients in hemodialysis. On the other hand, an early small renal mass finding on periodic ultrasound-evaluation in the graft should allow to perform a conservative treatment in order to preserve renal function. Finally, in case of a renal tumor in native kidney, a radical nephrectomy is usually recommended.

Dual kidney transplants from adult marginal donors: Review and perspective

The practice of dual kidney transplantation (DKT) from adult marginal deceased donors (MDDs) dates back to the mid-1990s with initial pioneering experiences reported by the Stanford and Maryland groups, at which time the primary indication was estimated insufficient nephron mass from older donors. Multiple subsequent studies of short and long-term success have been reported focusing on three major aspects of DKT: Identifying appropriate selection criteria and developing scoring systems based on pre- and post-donation factors; refining technical aspects; and analyzing mid-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. Deceased donors with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or non-recovery. However, DKT may reduce organ discard and optimize the use of kidneys from MDDs. In an attempt to promote utilization of MDD kidneys, the United Network for Organ Sharing introduced new allocation guidelines pursuant to DKT in 2019. The purpose of this review is to chronicle the history of DKT and identify opportunities to improve utilization of MDD kidneys through DKT. This article is protected by copyright. All rights reserved.

Multiorgan Transplant From a Donor With Solid Renal Masses: An Initial Experience and Clinical Considerations

BACKGROUND

Patients with early-stage renal cell carcinoma (RCC) are considered to be eligible donors. Although preliminary experience in using kidneys of specific pathologic types, mainly those with small renal masses (SRMs), have been established, multiorgan utilization of the same donor with SRMs is limited.

METHODS

One deceased donor whose left-side kidney was diagnosed with Fuhrman grade I RCC was included. The tumor mass in the kidney was removed through partial nephrectomy according to the gold standard. Then, 3 transplant surgeries were performed, in which 1 recipient accepted kidney transplant after tumor exeresis, 1 simultaneous heart-kidney (the contralateral one) transplant, and 1 liver transplant. Recipients were followed up according to our standard protocol for renal cancers. (All allografts were allocated in compliance with the Declaration of Helsinki and the Declaration of Istanbul.) RESULTS: After 32 months, no radiographic findings showed any morphologic changes of the lesion, and all patients were in good condition, with neither tumor recurrence nor allograft rejection or infection. No complaints such as pain, oliguria, dyspnea, nausea, or fatigue were recorded.

CONCLUSIONS

To the best of knowledge, this initial work takes the lead in elaborating the organ utilization of multiorgan donors with SRMs. We hope the experience will provide support for cross discussion concerned with multiorgan transplant from tumor-affected donors in clinical practices, further expand the donor pool and address the donor shortage problem.

Immunosuppression Regimen Use and Outcomes in Older and Younger Adult Kidney Transplant Recipients: A National Registry Analysis

BACKGROUND

Although the population of older transplant recipients has increased dramatically, there are limited data describing the impact of immunosuppression regimen choice on outcomes in this recipient group.

METHODS

National data for US Medicare-insured adult kidney recipients (N = 67 362; 2005-2016) were examined to determine early immunosuppression regimen and associations with acute rejection, death-censored graft failure, and mortality using multivariable regression analysis in younger (18-64 y) and older (>65 y) adults.

RESULTS

The use of antithymocyte globulin (TMG) or alemtuzumab (ALEM) induction with triple maintenance immunosuppression (reference) was less common in older compared with younger (36.9% versus 47.0%) recipients, as was TMG/ALEM + steroid avoidance (19.2% versus 20.1%) and mammalian target of rapamycin inhibitor (mTORi)-based (6.7% versus 7.7%) treatments. Conversely, older patients were more likely to receive interleukin (IL)-2-receptor antibody (IL2rAb) + triple maintenance (21.1% versus 14.7%), IL2rAb + steroid avoidance (4.1% versus 1.8%), and cyclosporine-based (8.3% versus 6.6%) immunosuppression. Compared with older recipients treated with TMG/ALEM + triple maintenance (reference regimen), those managed with TMG/ALEM + steroid avoidance (adjusted odds ratio [aOR], 0.440.520.61) and IL2rAb + steroid avoidance (aOR, 0.390.550.79) had lower risk of acute rejection. Older patients experienced more death-censored graft failure when managed with Tac + antimetabolite avoidance (adjusted hazard [aHR], 1.411.782.25), mTORi-based (aHR, 1.702.142.71), and cyclosporine-based (aHR, 1.411.782.25) regimens, versus the reference regimen. mTORi-based and cyclosporine-based regimens were associated with increased mortality in both older and younger patients.

CONCLUSIONS

Lower-intensity immunosuppression regimens (eg, steroid-sparing) appear beneficial for older kidney transplant recipients, while mTORi and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes.

Immunosuppression Considerations for Older Kidney Transplant Recipients

PURPOSE OF REVIEW

While kidney transplantation improves the long-term survival of the majority of patients with end-stage kidney disease (ESKD), age-related immune dysfunction and associated comorbidities make older transplant recipients more susceptible to complications related to immunosuppression. In this review, we discuss appropriate management of immunosuppressive agents in older adults to minimize adverse events, avoid acute rejection, and maximize patient and graft survival.

RECENT FINDINGS

Physiological changes associated with senescence can impact drug metabolism and increase the risk of posttransplant infection and malignancy. Clinical trials assessing the safety and efficacy of immunosuppressive agents in older adults are lacking. Recent findings from U.S. transplant registry-based studies suggest that risk-adjusted death-censored graft failure is higher among older patients who received antimetabolite avoidance, mammalian target of rapamycin inhibitor (mTORi)-based, and cyclosporine-based regimens. Observational data suggest that risk-adjusted mortality may be increased in older patients who receive mTORi-based and cyclosporine-based regimens but lower in those managed with T-cell induction and maintenance steroid avoidance/withdrawal.

SUMMARY

Tailored immunosuppression management to improve patient and graft survival in older transplant recipients is an important goal of personalized medicine. Lower intensity immunosuppression, such as steroid-sparing regimens, appear beneficial whereas mTORi- and cyclosporine-based maintenance are associated with greater potential for adverse effects. Prospective clinical trials to assess the safety and efficacy of immunosuppression agents in older recipients are urgently needed.

Factors Affecting Access to the Kidney Transplant Waiting List in Eastern Hungary

Kidney transplantation is the best available treatment choice for patients suffering from end-stage renal disease; however, not all patients with end-stage renal disease have equal access to it. The aim of the study was to measure the factors that may influence access to the kidney transplant waiting list in eastern Hungary. A total of 254 patients with renal failure between 18 and 75 years old from 8 dialysis centers participated in the study. The factors associated with access to the waiting list were identified by univariate descriptive analysis and multivariate logistic regression analysis where the outcome variable was placement on the kidney transplant waiting list. Our findings demonstrates that patients registered on the waiting list were younger (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.94-0.98), were male (OR = 0.54; 95% CI, 0.30-0.98), were economically active (OR = 0.53; 95% CI, 0.29-0.98), and had greater knowledge in the field (OR = 1.17; 95% CI, 1.03-1.33). Disparity in access to the kidney transplant waiting list in Hungary does exist.

Quantifying the Treatment Effect of Kidney Transplantation Relative to Dialysis on Survival Time: New Results Based on Propensity Score Weighting and Longitudinal Observational Data from Sweden

Using observational data to assess the treatment effects on outcomes of kidney transplantation relative to dialysis for patients on renal replacement therapy is challenging due to the non-random selection into treatment. This study applied the propensity score weighting approach in order to address the treatment selection bias of kidney transplantation on survival time compared with dialysis for patients on the waitlist. We included 2676 adult waitlisted patients who started renal replacement therapy in Sweden between 1 January 1995, and 31 December 2012. Weibull and logistic regression models were used for the outcome and treatment models, respectively. The potential outcome mean and the average treatment effect were estimated using an inverse-probability-weighted regression adjustment approach. The estimated survival times from start of renal replacement therapy were 23.1 years (95% confidence interval (CI): 21.2-25.0) and 9.3 years (95% CI: 7.8-10.8) for kidney transplantation and dialysis, respectively. The survival advantage of kidney transplantation compared with dialysis was estimated to 13.8 years (95% CI: 11.4-16.2). There was no significant difference in the survival advantage of transplantation between men and women. Controlling for possible immortality bias reduced the survival advantage to 9.1-9.9 years. Our results suggest that kidney transplantation substantially increases survival time compared with dialysis in Sweden and that this consequence of treatment is equally distributed over sex.

Association of Physical Function and Survival in Older-Adult Renal Transplant Recipients

There is an increase in older-adult renal transplant recipients in United States. The objective of this study was to assess the association between physical function (PF) and patient survival in renal transplant recipients who are aged 65 years or older. Using United Network for Organ Sharing (UNOS) data from 2007 to 2016, renal transplant recipients aged 65 years or older were included. Multivariable Cox regression was used to assess associations between survival and functional status adjusted for age, sex, race, donor quality, diabetes, and dialysis vintage. The study identified 26,721 patients. Patient survival was significantly higher in recipients who needed no assistance and lowest in patients in need of total assistance (P < .0001). In deceased donor (DD) transplants, the relative risk for mortality was 2.06 (1.74-2.43) for total assistance and 1.17 (1.08-1.28) for moderate assistance compared to no assistance (P < .0001). In living donor (LD) transplants, the relative risk of mortality was 1.38 (0.78-2.42) for patients needing total assistance and 1.37 (1.14-1.65) for patients needing moderate assistance compared to patients who did not need assistance (0.003). PF is an independent predictor of post-transplant mortality. Assessment of older potential renal transplant recipients should include assessment and standardization of functional status to counsel about post-transplant survival.

Long-term outcome of kidney transplant by using restored kidney grafts after tumour ex vivo excision - a prospective study

The aim of this study is to report long-term outcomes of kidney transplantation by using the kidney graft after a small tumour ex vivo excision. A structured programme was established to use the restored kidney graft from urological referral after radical nephrectomy. The criteria were defined as tumour size ≤3 cm, margin clear on frozen section and recipients aged ≥60 years or those on the urgent list for transplantation as a result of imminent lack of dialysis access. The recipients were followed up regularly for surveillance of tumour recurrence. Between February 2007 and February 2018, 28 recipients had kidney transplantation by using the restored kidney grafts. The tumour size was 2.6 ± 0.7 cm. The follow-up was median 7 years without evidence of tumour recurrence. The patient and graft survival was satisfactory. Kidney transplantation by using restored kidneys after a small tumour excision is a novel source for selected recipients. The long-term patient and graft survival is satisfactory. Although there is a risk of tumour recurrence, it is rare event. Together with literature review, we would support use of kidney graft after a small tumour excision for selected recipients.

Psychological and Psychopathological Aspects of Kidney Transplantation: A Systematic Review

Kidney transplantation is a serious event that involves profound psychological, relational and social changes both for the patient and his family context. Assessment of personality profile, awareness of disease, family and social support of the patient candidate for kidney transplantation are necessary because factors not adequately considered, can influence the success of the transplant and alter the psychological stability of the patient. The present study aims to provide a systematic review of the literature of the last twelve years (2006-2018), focusing in particular on patient's readiness level and illness management and on possible psychopathology. Sixty-two studies were examined. Based on the Downs and Black checklist, most studies (n = 32) were of high quality; 15 of which related to lifestyle, health education, and therapeutic adherence in post-renal transplantation, 17 studies concerned the possible existence of psychopathology and cognitive impairment of renal deceased transplanted subjects. The literature used has shown that the population of kidney transplant patients is exposed to a high risk of psychiatric disorders with repercussions on the quality of life and the risk of rejection. Therefore, an adequate pre-transplant psychosocial assessment is necessary, which allows a more in-depth knowledge of the candidate to plan coping strategies and possible post-transplant psychotherapy.

Characterizing the pharmacokinetics and pharmacodynamics of immunosuppressant medicines and patient outcomes in elderly renal transplant patients

This review examines what is currently known about the pharmacokinetics and pharmacodynamics of commonly prescribed immunosuppressant medicines, tacrolimus, cyclosporine, mycophenolate and prednisolone, in elderly renal transplant recipients, and reported patient outcomes in this cohort. Renal transplantation is increasing rapidly in the elderly, however, currently, long-term patient outcomes are relatively poor compared to younger adults. Some studies have suggested that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors tacrolimus and cyclosporine; with one study reporting up to 50% reduction in tacrolimus exposure in the elderly. Elderly transplant recipients do not appear to have higher dosage-adjusted exposure to mycophenolic acid (MPA). The effects of ageing on the pharmacokinetics of prednisolone are unknown. Only one study has examined how aging effects drug target enzymes, reporting no difference in baseline inosine 5'-monophosphate dehydrogenase (IMPDH) activity and MPA-induced IMPDH activity in elderly compared to younger adult renal transplant recipients. In elderly transplant recipients, immunosenescence likely lowers the risk of acute rejection, but increases the risk of drug-related adverse effects. Currently, the three main causes of death in elderly renal transplant recipients are cardiovascular disease, infection and malignancy. One study has showed that renal transplant recipients aged over 65 years are seven times more likely to die with a functioning graft compared with young adults (aged 18-29 years). This suggests that an optimal balance between immunosuppressant medicine efficacy and toxicity is not achieved in elderly recipients, and further studies are needed to foster long-term graft and patient survival. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established.

Propensity Score-Matched Analysis of the Survival Benefit from Kidney Transplantation in Patients with End-Stage Renal Disease

BACKGROUND

Several comparison studies have suggested that kidney transplantation (KT) could reduce mortality in patients with end-stage renal disease (ESRD). Selection criteria bias is common in the selection of dialysis patients for control groups. In this study, we compared the survival outcome between KT recipients and comparable propensity score-matched dialysis patients.

METHODS

We used Taiwan's National Health Insurance Research Database to identify patients newly diagnosed with ESRD between 2000 and 2010. We separated them into two groups: a KT group and non-KT dialysis-only group. To evaluate the survival outcome, we compared each patient with KT to a patient on dialysis without KT using propensity score matching.

RESULTS

In total, 1276 KT recipients and 1276 propensity score-matched dialysis patients were identified. Compared with the propensity score-matched dialysis patients, the patients who underwent KT exhibited significantly higher 5-year and 10-year survival rates (88% vs. 92% and 74% vs. 87%, both p < 0.05). The crude and adjusted hazard ratios for mortality were 0.55 and 0.52 in patients with KT (both p < 0.001). Mortality was insignificantly higher for patients who were on dialysis for longer than 1 year prior to KT compared with those on dialysis for less than 1 year.

CONCLUSION

This study used a propensity score-matched cohort to confirm that KT is associated with lower risk of mortality than dialysis alone in patients newly diagnosed with ESRD.

Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk?

The number of elderly patients on the waiting list (WL) for kidney transplantation (KT) has risen significantly in recent years. Because KT offers a better survival than dialysis therapy, even in the elderly, candidates for KT should be selected carefully, particularly in older waitlisted patients. Identification of risk factors for death in WL patients and prediction of both perioperative risk and long-term post-transplant mortality are crucial for the proper allocation of organs and the clinical management of these patients in order to decrease mortality, both while on the WL and after KT. In this review, we examine the clinical results in studies concerning: a) risk factors for mortality in WL patients and KT recipients; 2) the benefits and risks of performing KT in the elderly, comparing survival between patients on the WL and KT recipients; and 3) clinical tools that should be used to assess the perioperative risk of mortality and predict long-term post-transplant survival. The acknowledgment of these concerns could contribute to better management of high-risk patients and prophylactic interventions to prolong survival in this particular population, provided a higher mortality is assumed.

Advances in the Knowledge about Kidney Decellularization and Repopulation

End-stage renal disease (ESRD) is characterized by the progressive deterioration of renal function that may compromise different tissues and organs. The major treatment indicated for patients with ESRD is kidney transplantation. However, the shortage of available organs, as well as the high rate of organ rejection, supports the need for new therapies. Thus, the implementation of tissue bioengineering to organ regeneration has emerged as an alternative to traditional organ transplantation. Decellularization of organs with chemical, physical, and/or biological agents generates natural scaffolds, which can serve as basis for tissue reconstruction. The recellularization of these scaffolds with different cell sources, such as stem cells or adult differentiated cells, can provide an organ with functionality and no immune response after in vivo transplantation on the host. Several studies have focused on improving these techniques, but until now, there is no optimal decellularization method for the kidney available yet. Herein, an overview of the current literature for kidney decellularization and whole-organ recellularization is presented, addressing the pros and cons of the actual techniques already developed, the methods adopted to evaluate the efficacy of the procedures, and the challenges to be overcome in order to achieve an optimal protocol.

Experiences of renal transplants from donors with renal cell carcinoma after ex vivo partial nephrectomy

Purpose

Routine evaluation of kidney donors occasionally reveals an incidental renal mass with an otherwise satisfactory kidney function. The use of such a kidney with an enhancing mass for transplantation is a matter of debate owing to a possible risk of transmission of donor malignancies. We report our experience of kidney transplants from donors with renal cell carcinoma, after ex vivo resection of the renal mass.

Methods

Two women aged 44 and 56 years were diagnosed with enhancing renal masses measuring 0.9 cm and 0.7 cm, respectively, during donor evaluation for kidney transplantation. Both patients and their families were informed of a potential risk of recurrent renal cell carcinoma following transplantation.

Results

Renal function test results of both donors satisfied the living donor selection criteria. Laparoscopic live donor nephrectomy was performed with ex vivo resection of renal masses on the bench table. Immediate pathological analysis revealed a renal cell carcinoma with a margin of normal renal parenchyma before transplantation. Regimens based on mammalian target of rapamycin inhibitors, which are known for their antitumoral properties, were used for immunosuppression in both recipients. None of the recipients showed recurrence or metastasis during the follow-up period, which was longer than 3 years after transplantation.

Conclusion

In light of the ongoing shortage of kidney donors, kidneys with small renal cell carcinoma could be considered for transplantation after appropriate removal of the lesion, with a very low risk of recurrent disease.

Immunosuppressive Therapy for Elderly Kidney Transplant Recipients

OBJECTIVES

In elderly kidney transplant (KT) recipients, the incidence of acute rejection is decreased, while that of fatal infections is increased. There are currently no guidelines for an upper age limit for KT, which is very difficult to determine. Here we examined several cases of elderly KT recipients.

METHODS

We evaluated 127 KT patients treated at our department between 2003 and 2012 and followed them for 3 years post-transplant. The subjects were divided into two groups by age: ≥60 years (elderly group; n = 24); and <59 years (non-elderly group; n = 103). The presence or absence of acute rejection and infection, dose of immunosuppressive drugs, trough calcineurin inhibitor level, renal function, and graft and patient survival rates were retrospectively examined.

RESULTS

Our basic immunosuppressive regimen was a combination of calcineurin inhibitor, methylprednisolone, mycophenolate mofetil, and basiliximab. At 1 year post-transplantation, the average tacrolimus and cyclosporine dose and trough levels were not significantly different. The mean dose of mycophenolate mofetil in the elderly group at 1 year post-transplantation was significantly lower than that of the non-elderly group. The incidences of cytomegalovirus infection and acute rejection during follow-up did not differ significantly between groups. There were no significant differences in creatinine level between the two groups. In the elderly group, the graft survival rates at 1 and 5 years were 100% and 95.4%, respectively, while those in the non-elderly group were 98.1% and 92.5%, respectively.

CONCLUSION

Using our current immunosuppressive protocol, the outcomes of patients in the elderly group were considered acceptable.

Temporal Changes in Deceased Kidney Donor Characteristics in Australia

Background

Demand for deceased donor kidneys has exceeded supply in Australia over the past 2 decades. With a desire to use as many donor organs as possible, the health characteristics of accepted donors may have changed over time.

Methods

All deceased kidney donors actually transplanted in Australia between January 1, 1994, and December 31, 2013, were retrospectively analyzed, using data from the Australian and New Zealand Organ Donor Registry.

Results

Of 4172 deceased donors, 57% were men. Mean donor age increased from 37.2 ± 16.8 years to 46.1 ± 17.7 years over time, and donor numbers increased from 162 in 1994 to 334 in 2013. As the primary cause of death, motor vehicle accidents decreased from 27% to 12%, whereas cerebral pathology persisted at 50%. There was an increase in the proportion of donors with hypertension (12% to 24%), diabetes (2% to 7%), and an increase in mean body mass index (24.4 ± 4.4 kg/m² to 27.5 ± 6.3 kg/m²) between 1994 and 2013. These changes were reflected by an increase in the median kidney donor risk index from 1.08 (interquartile range, 0.85-1.25) to 1.32 (interquartile range, 0.95-1.53). The proportion of medically higher risk donors increased over time.

Conclusions

Because deceased kidney donor numbers have increased, the range of donor quality has broadened, with an increase in both the proportion and number of high-risk donors, as well as a decline in donor quality. These data highlight the need for kidney allocation algorithms to evolve to ensure appropriate allocation of deceased donor kidneys.

Survival of Elderly Adults Undergoing Incident Home Hemodialysis and Kidney Transplantation

OBJECTIVES

To compare the mortality of elderly adults with end-stage renal disease (ESRD) treated with home hemodialysis (HD) with that of those receiving a kidney transplant (KTx).

DESIGN

Prospective cohort.

SETTING

Pertinent data for the two groups were obtained from electronic medical records from a large dialysis provider and the U.S. Renal Data System.

PARTICIPANTS

Using data from elderly adults (aged ≥65) who started home HD and underwent KTx in the US between 2007 and 2011, a 1:1 propensity score (PS)-matched cohort of 960 elderly adults was created, and the association between treatment modality and all-cause mortality was examined using Cox proportional hazards and competing risk regression survival models using modality failure as a competing event.

MEASUREMENTS

Modality of renal replacement therapy.

RESULTS

The baseline mean age ± standard deviation of the PS-matched individuals undergoing home HD was 71 ± 6, and that of KTx recipients was 71 ± 5, 69% of both groups were male, 81% of those undergoing home HD and 79% of KTx recipients were white, and 11% and 12%, respectively, were African American. Median follow-up time was 205 days (interquartile range (IQR) 78-364 days) for those undergoing home HD and 795 days (IQR 366-1,221 days) for KTx recipients. There were 97 deaths (20%, 253/1,000 patient-years, 95% confidence interval (CI) = 207-309/1,000 patient-years) in the home HD group and 48 deaths (10%, 45/1,000 patient-years, 95% CI = 34-60/1,000 patient-years) in the KTx group. Elderly adults undergoing home HD had a risk of mortality that was almost five times as high as that of KTx recipients (hazard ratio = 4.74, 95% CI = 3.25-6.91). Similar results were seen in competing risk regression analyses (subhazard ratio = 4.71, 95% CI = 3.27-6.79). Results were consistent across different types of kidney donors and subgroups divided according to various recipient characteristics.

CONCLUSION

Elderly adults with ESRD who receive a KTx have greater survival than those who undergo home HD. Further studies are needed to assess whether KTx receipt is associated with other benefits such as better quality of life and lower hospitalization rates.

Rapamycin safeguards lymphocytes from DNA damage accumulation in vivo

Several studies reported the benefits of switching from anticalcineurins to mTOR inhibitors to avoid cancer occurrence after organ transplantation. The purpose of our study was to determine in vivo biological markers to explain these benefits. Cellular changes related to cellular senescence and DNA damage were analyzed in peripheral blood lymphocytes. Thirty-five kidney transplanted patients receiving anticalcineurins were investigated: 17 patients were proposed to switch to rapamycin and 18 patients with similar age and transplantation duration, continued anticalcineurins. Rapamycin effects were studied one year after the switch. Thirteen healthy volunteers and 18 hemodialyzed patients were evaluated as control. Compared with the healthy group, hemodialyzed and transplanted patients exhibited a significant decrease in telomere length, an increase in p16(INK4A) mRNA expression and in lymphocytes with 53BP1 foci. A destabilization of the shelterin complexes was suggested by a significant TIN2 mRNA decrease in transplanted patients compared with controls and a significant increase in TRF1, TRF2 and POT1 expression in switch-proposed patients compared with the non-switched subgroup. Rapamycin treatment resulted in a significant decrease in DNA damage and a slight TIN2 increase. In vitro experiments strengthened in vivo results showing that rapamycin but not FK506 induced a significant DNA damage decrease and TIN2 expression increase compared with controls. The roles of rapamycin in the decrease in DNA damage in vivo and the rescue of shelterin gene expression are demonstrated for the first time. These data provide new insights into understanding of how rapamycin may overcome genomic injuries.

Transplantation of Restored Kidneys From Unrelated Donors After Resection of Renal Cell Carcinoma: Results From 10 Patients

PURPOSE

To relieve the chronic shortage of donor kidneys, we conducted a prospective kidney transplantation trial using kidneys removed from 10 unrelated patients (51 to 79 years of age) who had undergone nephrectomy for small renal cell carcinoma (1.5 to 3.9 cm) of low-to-moderate complexity based on RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior location relative to polar lines) nephrometry (objective description helpful for operative indication and planning).

METHODS

Donors were selected from among 15 patients who opted to undergo nephrectomy for small renal cell carcinoma. A total of 76 dialysis patients 34 to 85 years of age who agreed to undergo restored kidney transplantation were recruited as transplant candidates.

RESULTS

In stage 1 (5 cases), high-risk patients were selected without human leukocyte antigen testing, and accelerated acute rejection occurred in 4 of 5 recipients. This trial was subsequently extended with human leukocyte antigen testing, and an additional 5 patients were enrolled in stage 2. Eight recipients, including 4 recipients with a history of renal transplantation, experienced rejection; 1 patient resumed dialysis 35 months after transplantation. The most recent serum creatinine levels ranged from 1.10 to 3.19 mg/dL in the 9 recipients with functioning grafts and from 0.84 to 4.68 mg/dL in the 10 donors. No tumor recurrence was noted at 32 to 58 months after surgery in either the recipients or the donors.

CONCLUSIONS

Restored kidney transplantation using kidneys with a small renal tumor seems suitable for carefully selected high-risk recipients and, in particular, elderly kidneys can also function well. Avoiding cancer transmission, fair recipient selection, close follow-up, and a well-organized tracking system warrant further study.

Dual kidney transplants from adult marginal donors successfully expand the limited deceased donor organ pool

BACKGROUND

The need to expand the organ donor pool remains a formidable challenge in kidney transplantation (KT). The use of expanded criteria donors (ECDs) represents one approach, but kidney discard rates are high because of concerns regarding overall quality. Dual KT (DKT) may reduce organ discard and optimize the use of kidneys from marginal donors.

STUDY DESIGN

We conducted a single-center retrospective review of outcomes in adult recipients of DKTs from adult marginal deceased donors (DD) defined by limited renal functional capacity. If the calculated creatinine clearance in an adult DD was <65 mL/min, then the kidneys were transplanted as a DKT.

RESULTS

Over 11.5 yr, 72 DKTS were performed including 45 from ECDs, 17 from donation after cardiac death (DCD) donors, and 10 from standard criteria donors (SCD). Mean adult DD and recipient ages were both 60 yr, including 29 DDs and 26 recipients ≥65 yr of age. Mean pre-DKT waiting and dialysis vintage times were 12 months and 25 months, respectively. Actual patient and graft survival rates were 84.7% and 70.8%, respectively, with a mean follow-up of 58 months. One yr and death-censored graft survival rates were 90% and 80%, respectively. Outcomes did not differ by DD category, recipient age, or presence of delayed graft function (DGF). Eleven patients died at a mean of 32 months post-DKT (eight with functioning grafts) and 13 other patients experienced graft losses at a mean of 33 months. The incidence of DGF was 25%; there were two cases (2.8%) of primary non-function. Mean length of initial hospital stay was 7.2 d. Mean serum creatinine and glomerular filtration rate levels at 12 and 24 months were 1.5 and 53 and 1.5 mg/dL and 51 mL/min/1.73 m(2) , respectively. DKT graft survival and function were superior to concurrent single ECD and similar to concurrent SCD KTs. Two patients underwent successful kidney retransplantation, so the dialysis-free rate in surviving patients was 87%. The proportion of total renal function transplanted from adult DD to DKT recipients was 77% compared to 56% for patients receiving single KTs.

CONCLUSIONS

Dual kidney transplantation using kidneys from adult marginal DDs that otherwise might be discarded offer a viable option to counteract the growing shortage of acceptable single kidneys. Excellent medium-term outcomes can be achieved and waiting times can be reduced in a predominantly older recipient population.

Clinical outcomes in Asian elderly kidney transplant recipients: a multicenter cohort study

BACKGROUND

The kidney transplantation rate in elderly patients is increasing rapidly. However, the clinical outcomes of kidney transplantation in elderly patients have not yet been thoroughly evaluated.

METHODS

This multicenter cohort study included adult kidney transplant recipients (KTRs) admitted to five major tertiary hospitals in Korea between 1997 and 2012. A total of 3,565 adult participants were enrolled. Patient survival, allograft survival, and biopsy-proven acute rejection (BPAR) of 242 elderly recipients (≥ 60 years) were assessed and compared with those of a younger population.

RESULTS

Patients were divided into five groups according to age at time of transplantation. The proportion of elderly patients was 6.7 % (mean age, 63.1 ± 2.7 years; n = 242). The numbers of male patients (69.4%), those with diabetes mellitus history (36.3%), and those with pretransplantation ischemic heart disease history (17.7%) were significantly higher in the elderly group than in the younger age groups. Elderly patients were more likely to receive a cadaveric kidney, and overall mortality rates were significantly higher in the elderly patients (1-year survival 93.3%, 5-year survival 91.3%). However, death-censored allograft survival rate and BPAR were not affected by patient age (P = .104 and .501, respectively). Among the elderly, BPAR and female donors were independent risk factors for allograft loss.

CONCLUSION

The overall survival rate of the elderly KTRs was significantly lower than that of younger KTRs. However, the death-censored allograft survival rate did not differ between groups. Kidney transplantation should not be stagnated especially in elderly patients with end-stage renal disease.

Trends in kidney transplant outcomes in older adults

OBJECTIVES

To estimate mortality and death-censored graft loss according to year of kidney transplant (KT) between 1990 and 2011.

DESIGN

Cohort study.

SETTING

The Scientific Registry of Transplant Recipients (SRTR).

PARTICIPANTS

KT recipients aged 65 and older at the time of transplantation (N = 30,207).

MEASUREMENTS

Mortality and death-censored graft loss ascertained through center report and linkage to Social Security Death Master File and to Medicare.

RESULTS

Older adults currently account for 18.4% of KT recipients, up from 3.4% in 1990; similar increases were noted for deceased donor (5.4 times percentage increase) and live donor (9.1 times percentage increase) transplants. Current recipients are not only older, but also more likely to be female and African American, have lengthier pretransplant dialysis, have diabetes mellitus or hypertension, and receive marginal kidneys. Mortality for older deceased donor recipients between 2009 and 2011 was 57% lower (hazard ratio (HR) = 0.43, 95% confidence interval (CI) = 0.33-0.56, P < .001) than between 1990 and 1993; mortality for older live donor recipients was 50% lower (HR = 0.50, 95% CI = 0.36-0.68, P < .001). Death-censored graft loss for older deceased donor recipients between 2009 and 2011 was 65% lower (HR = 0.35, 95% CI = 0.29-0.42, P < .001) than between 1990 and 1993; death-censored graft loss for older live donor recipients was 59% lower (HR = 0.41, 95% CI = 0.24-0.70, P < .001).

CONCLUSION

Despite a major increase in number of older adults transplanted and an expanding window of transplant eligibility, mortality and graft loss have decreased substantially for this recipient population. These trends are important to understand for patient counseling and transplant referral.

Recipient-related risk factors for graft failure and death in elderly kidney transplant recipients

BACKGROUND

Elderly patients with end-stage renal disease have become the fastest growing population of kidney transplant candidates in recent years. However, the risk factors associated with long-term outcomes in these patients remain unclear.

METHODS

We retrospectively analyzed 166 recipients aged 60 years or older who underwent primary deceased kidney transplantation between 2002 and 2013 in our center. The main outcomes included 1-, 3- and 5-year patient survival as well as overall and death-censored graft survival. The independent risk factors affecting graft and patient survival were analyzed using Cox regression analysis.

RESULTS

The 1-, 3-, 5-year death-censored graft survival rates were 93.6%, 89.4% and 83.6%, respectively. Based on the Cox multivariate analysis, panel reactive antibody (PRA)>5% [hazard ratio (HR) 4.295, 95% confidence interval (CI) 1.321-13.97], delayed graft function (HR 4.744, 95% CI 1.611-13.973) and acute rejection (HR 4.971, 95% CI 1.516-16.301) were independent risk factors for graft failure. The 1-, 3-, 5-year patient survival rates were 84.8%, 82.1% and 77.1%, respectively. Longer dialysis time (HR 1.011 for 1-month increase, 95% CI 1.002-1.020), graft loss (HR 3.501, 95% CI 1.559-7.865) and low-dose ganciclovir prophylaxis (1.5 g/d for 3 months) (HR 3.173, 95% CI 1.063-9.473) were risk factors associated with patient death.

CONCLUSIONS

The five-year results show an excellent graft and patient survival in elderly kidney transplant recipients aged ≥60 years. PRA>5%, delayed graft function, and acute rejection are risk factors for graft failure, while longer duration of dialysis, graft loss and low-dose ganciclovir prophylaxis are risk factors for mortality in elderly recipients. These factors represent potential targets for interventions aimed at improving graft and patient survival in elderly recipients.

Advanced age is not an exclusion criterion for kidney transplantation

INTRODUCTION

Renal transplantation in patients older than 60 years has long been regarded with skepticism owing to the increased risk of complications although, as compared with dialysis treatment, a graft seems to improve not only the quality of life but also long-term patient survival. This study sought to analyze the impact of recipient age older than 60 years on patient and graft outcomes.

MATERIALS AND METHODS

We retrospectively investigated the outcomes of 761 kidney transplant recipients from cadaveric donors performed between February 1998 and July 2011. While 69 subjects were at least 60 years of age (group A), 692 were younger than 60 years (group B) at the time of transplantation.

RESULT

Mean follow-up was 60.1 ± 38.5 months. Delayed graft function (DGF) requiring dialysis was observed in 36 group A (52.1%) and 205 group B (29.6%) subjects (P = .001). However, there were also significant differences between group A and group B in terms of mean donor age (60.3 vs 44.6 years; P < .001) and mean donor estimated creatinine clearance (57.8 vs 83.4 mL/min; P < .001). There were no significant differences in death-censored graft survival between the two groups, but elderly patients experienced worse survival (P = .0005). The most common causes of patient death were myocardial infarction, other cardiovascular complications, and tumors.

CONCLUSION

Kidney transplantation is a good option for elderly recipients with end-stage renal disease, providing long graft survival and a good quality of life, although these patients are more likely to develop cancer or cardiovascular disease. Our findings suggested that older patients should not be excluded a priori from transplantation, but meticulous screening for cancer and heart disease should be always be performed to improve outcomes.

Outcome of live and deceased donor renal transplantation in patients aged ≥55 years: A single-center experience

Renal transplantation (RTx) has now become an accepted therapeutic modality of choice for elderly ESRD patients. This single-center study was undertaken to evaluate the outcome of RTx in ESRD patients ≥55 years. A total of 103 patients underwent RTx 79 living related living donors [LD], 24 deceased donors [DD]) at our center. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age was 58.3 years in the LD group and 59.5 years in the DD group. Male recipients constituted 92% in LD and 75% in DD group. In living donor renal transplantation, 1- and 5-year patient survival was 93% and 83.3% respectively and death-censored graft survival was 97.3% and 92.5% respectively. There were 12.6% biopsy proven acute rejection (BPAR) episodes and 12.6% patients were lost, mainly due to infections. In deceased donor renal transplantation, 1- and 5-year patient survival was 79.1% and 74.5% respectively and death-censored graft survival was 95.8% and 85.1% respectively. There were 12.5% BPAR episodes and 25% of patients were lost, mainly due to infections. RTx in ESRD (≥55 years) patients has acceptable patient and graft survival if found to have cardiac fitness and therefore should be encouraged.

Increased recipient body mass index is associated with acute rejection and other adverse outcomes after kidney transplantation

BACKGROUND

Outcomes of kidney transplant recipients with increased body mass index (BMI) remain controversial. We studied the relationship between BMI and clinically relevant outcomes among kidney transplant recipients at a large center.

METHODS

We performed an observational cohort study of all recipients of kidney transplants at our center from January 1, 2000 to December 31, 2010 to determine if increased BMI at transplantation is associated with adverse outcomes, including delayed graft function and biopsy-proven acute rejection (BPAR). Recipient BMI was categorized as <20, 20 to 24.9 (reference), 25 to 29.9, 30 to 34.9, and ≥35 kg/m. Potential confounders were included in logistic and Cox proportional hazards models.

RESULTS

A total of 1151 patients were studied. Recipient BMI of 30 to 34.9 and ≥35 kg/m were associated with an increased risk of delayed graft function (odds ratio [95% confidence interval [CI], 1.92 [1.16-3.19] and 4.49 [2.24-9.00], respectively). BMI≥35 kg/m was also associated with an increased risk of BPAR (hazard ratio [HR; 95% CI], 2.43 [1.48-3.99]), all-cause graft failure (HR [95% CI], 1.97 [1.09-3.56]), and death-censored graft failure (HR [95% CI], 2.43 [1.07-5.51]). Adjustment for acute rejection as a time-varying covariate significantly attenuated the association with graft failure endpoints. There was no significant relation between BMI and death with graft function.

CONCLUSIONS

Increased BMI at kidney transplantation is a predictor of adverse outcomes, including BPAR. The role of pretransplantation weight reduction in improving graft and patient outcomes requires further study.

Survival of renal transplantation patients older than 60 years: a single-center experience

BACKGROUND

Elderly patients are the fastest growing population requiring renal replacement therapy. It has been stated that renal transplantation may be the best treatment option for these patients. However, it has been observed that older patients have a higher mortality rate than those who are younger. Yet the factors that determine post-transplantation outcomes in this population remain poorly defined. The aims of this study were to evaluate the graft and patient survival in kidney transplant recipients who are older than 60 years of age to identify relevant predictive factors.

METHODS

In this population-based retrospective cohort study of 201 kidney transplantations performed in elderly patients from January 2002 throughout June 2009, we estimated the 1-,3-,and 5-year patients and graft survival rates. We also evaluated the complications and the predictors of poor outcomes. Survival times were analyzed using the Kaplan-Meier method and survival differences assessed with Mantel-Cox log rank-test. We performed a Cox proportional hazards regression models to evaluate the impact of baseline and treatment characteristics on patient and graft survival.

RESULTS

Graft and patient survival rates at 1, 3, and 5 years were 76.4%, 71.3%, and 54.3%, and 78.2%, 73.8%, and 56.4%, respectively. Graft survival rates censored for patient death with a functioning graft were 93.1, 92.1, and 89%. Patient survival rates differed between diabetic and nondiabetic subjects at 1, 3 and 5 years (69.5% versus 83.6%; 59.8% versus 72.3%; 43.6% versus 65.7%; P = .008). On multivariate analysis, the factors associated with patients survival were diabetes mellitus (hazard ratio [HR] 2.058, 95% confidence interval [CI] 1.173-3.611, P = .012) and the 1-month serum creatinine value was > 1.6 mg/dL (HR 2.108 for each point increase, 95% CI 1.521-2.921, P = .000). Furthermore, there was an insignificant trend forward an association between active or past smoker and lower patient survival (HR 1.689, 95% CI 0.937-3.043, P = .08). The main causes of graft loss were patient death (79.5%). acute rejection (6.8%), and chronic allograft nephropathy (5.5%).

CONCLUSION

Renal transplantation can be performed safely and with acceptable outcomes in elderly patients after appropriate clinical evaluation. The grafts show excellent survival albeit that deaths with a functional graft continue to be an important issue.

Benign and malignant renal cells are differentially inhibited during prolonged organ preservation

The worry of potential residual renal cancer cells in donor kidney after resection of small renal cancer impedes the extensive use of such controversial donor source. To explore the impacts of organ preservation process on the survival of renal cancer cells, we detected cell proliferation and viability of benign and malignant renal cell lines and clinical renal samples after treated with simulated organ preservation process. It was found that the viability and proliferation of malignant renal cells are inhibited much more than that of benign renal cells during prolonged organ preservation. The inhibition of proliferation in benign renal cells is fully reversible, while in malignant renal cancer cells is not fully reversible after a certain time. So potential residual renal cancer cells could be partly inhibited and eliminated by organ preservation process.

Optimizing utilization of kidneys from deceased donors over 60 years: five-year outcomes after implementation of a combined clinical and histological allocation algorithm

This 5 year observational multicentre study conducted in the Nord Italian Transplant programme area evaluated outcomes in patients receiving kidneys from donors over 60 years allocated according to a combined clinical and histological algorithm. Low-risk donors 60-69 years without risk factors were allocated to single kidney transplant (LR-SKT) based on clinical criteria. Biopsy was performed in donors over 70 years or 60-69 years with risk factors, allocated to Single (HR-SKT) or Dual kidney transplant (HR-DKT) according to the severity of histological damage. Forty HR-DKTs, 41 HR-SKTs and 234 LR-SKTs were evaluated. Baseline differences generally reflected stratification and allocation criteria. Patient and graft (death censored) survival were 90% and 92% for HR-DKT, 85% and 89% for HR-SKT, 88% and 87% for LR-SKT. The algorithm appeared user-friendly in daily practice and was safe and efficient, as demonstrated by satisfactory outcomes in all groups at 5 years. Clinical criteria performed well in low-risk donors. The excellent outcomes observed in DKTs call for fine-tuning of cut-off scores for allocation to DKT or SKT in high-risk patients.

Recipient-related predictors of kidney transplantation outcomes in the elderly

BACKGROUND

It is not clear whether in old people with end-stage renal disease kidney transplantation is superior to dialysis therapy.

METHODS

We compared mortality rates between kidney transplant recipients (KTRs) and the general population across different age categories. We also examined patient and allograft survival in 15 667 elderly KTRs (65-<90 yr old, 36% female) within three age subgroups (65-<70, 70-<75, and ≥75 yr).

RESULTS

The rise in the relative risk of death in older age groups was substantially less in KTRs than in the general population, that is, 1.8 and 2.0 vs. 21.4 and 76.6 in those aged 65-<75 and ≥75 yr, respectively, compared with 15- to <65-yr-old people (reference group). In 65- to <70-yr-old KTRs, obesity (BMI>30 kg/m(2) ) was associated with 19% higher risk of graft failure (HR: 1.19 [1.07-1.33], p = 0.002). Diabetes was a predictor of worse patient survival in all age groups but poorer allograft outcome in the youngest age group (65-<70 yr old) only. None of the examined risk factors affected allograft outcome in the oldest group (≥75 yr old) although there was a 49% lower trend of graft failure in very old Hispanic recipients (HR: 0.51 [0.26-1.01], p = 0.05).

CONCLUSIONS

Kidney transplantation may attenuate the age-associated increase in mortality, and its superior survival gain is most prominent in the oldest recipients (≥75 yr old). The potential protective effect of kidney transplantation on longevity in the elderly deserves further investigation.

Transplant of kidneys with small renal cell carcinoma in incompatible, heavily immunosuppressed recipients

Renal cell carcinoma (RCC) is considered a contraindication for transplant. However, an increasing number of cases of transplant kidneys with RCC have been reported with encouraging results. We present our experience of two cases of transplanting kidneys with small RCCs. Donors and recipients were aware of the presence and possible consequences of RCC in the transplanted kidney before transplantation. Cases were discussed in the multidisciplinary team meetings. Regular, 6-12 monthly follow-up of donors and recipients was carried out with ultrasonography and/or computed tomography to detect recurrence of RCC or new tumours in the recipients' transplant kidneys or the donors' native kidneys. The outcome was recorded. There were no suspicious masses in the any of the kidneys during the follow-up period. The transplant kidneys are functioning.