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Zoccali C, Mallamaci F, Lightstone L, Jha V, Pollock C, Tuttle K, Kotanko P, Wiecek A, Anders HJ, Remuzzi G, Kalantar-Zadeh K, Levin A, Vanholder R. A new era in the science and care of kidney diseases. Nat Rev Nephrol 2024; 20:460-472. [PMID: 38575770 DOI: 10.1038/s41581-024-00828-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/06/2024]
Abstract
Notable progress in basic, translational and clinical nephrology research has been made over the past five decades. Nonetheless, many challenges remain, including obstacles to the early detection of kidney disease, disparities in access to care and variability in responses to existing and emerging therapies. Innovations in drug development, research technologies, tissue engineering and regenerative medicine have the potential to improve patient outcomes. Exciting prospects include the availability of new drugs to slow or halt the progression of chronic kidney disease, the development of bioartificial kidneys that mimic healthy kidney functions, and tissue engineering techniques that could enable transplantable kidneys to be created from the cells of the recipient, removing the risk of rejection. Cell and gene therapies have the potential to be applied for kidney tissue regeneration and repair. In addition, about 30% of kidney disease cases are monogenic and could potentially be treated using these genetic medicine approaches. Systemic diseases that involve the kidney, such as diabetes mellitus and hypertension, might also be amenable to these treatments. Continued investment, communication, collaboration and translation of innovations are crucial to realize their full potential. In addition, increasing sophistication in exploring large datasets, implementation science, and qualitative methodologies will improve the ability to deliver transformational kidney health strategies.
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Affiliation(s)
- Carmine Zoccali
- Kidney Research Institute, New York City, NY, USA.
- Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy.
- Associazione Ipertensione Nefrologia Trapianto Kidney (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy.
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit Azienda Ospedaliera "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
- CNR-IFC, Institute of Clinical Physiology, Research Unit of Clinical Epidemiology and Physiopathology of Kidney Diseases and Hypertension of Reggio Calabria, Reggio Calabria, Italy
| | - Liz Lightstone
- Department of Immunology and Inflammation, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Vivek Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Medical Education, Manipal, India
| | - Carol Pollock
- Kolling Institute, Royal North Shore Hospital University of Sydney, Sydney, NSW, Australia
| | - Katherine Tuttle
- Providence Medical Research Center, Providence Inland Northwest, Spokane, Washington, USA
- Department of Medicine, University of Washington, Seattle, Spokane, Washington, USA
- Kidney Research Institute, Institute of Translational Health Sciences, University of Washington, Seattle, Washington, USA
| | - Peter Kotanko
- Kidney Research Institute, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027, Katowice, Poland
| | - Hans Joachim Anders
- Division of Nephrology, Department of Medicine IV, Hospital of the Ludwig Maximilians University Munich, Munich, Germany
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCSS, Bergamo, Italy
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, California, USA
- Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, Irvine, USA
- Veterans Affairs Healthcare System, Division of Nephrology, Long Beach, California, USA
| | - Adeera Levin
- University of British Columbia, Vancouver General Hospital, Division of Nephrology, Vancouver, British Columbia, Canada
- British Columbia, Provincial Kidney Agency, Vancouver, British Columbia, Canada
| | - Raymond Vanholder
- European Kidney Health Alliance, Brussels, Belgium
- Nephrology Section, Department of Internal Medicine and Paediatrics, University Hospital Ghent, Ghent, Belgium
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Fragale G, Laham G, Raffaele P, Fortunato M, Villamil S, Giordani MC, Taylor M, Ciappa J, Rodriguez M, Maldonado R, Trimarchi H, Pomeranz V, Ellena V, De La Fuente J, Bisigniano L, Antik A, Soler Pujol G. Renal Transplantation in the Elderly: Are They All the Same? A Multicenter, Comorbidity-Based Study. Nephron Clin Pract 2023; 147:550-559. [PMID: 37231956 DOI: 10.1159/000531178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION The age for kidney transplantation (KT) is no longer a limitation and several studies have shown benefits in the survival of elderly patients. The aim of this study was to examine the relationship of the baseline Charlson comorbidity index (CCI) score to morbidity and mortality after transplantation. METHODS In this multicentric observational retrospective cohort study, we included patients older than 60 years admitted on the waiting list (WL) for deceased donor KT from January 01, 2006, to December 31, 2016. The CCI score was calculated for each patient at inclusion on the WL. RESULTS Data for analysis were available of 387 patients. The patients were divided in tertiles of CCI: group 1 (CCI: 1-2) n = 117, group 2 (CCI: 3-4) n = 158, and group 3 (CCI: ≥5) n = 112. Patient survival was significantly different between CCI groups at 1, 3, and 5 years, respectively: 90%, 88%, and 84% for group 1, 88%, 80%, and 72% for group 2, and 87%, 75%, and 63% for group 3 (p < 0.0001). Variables associated with mortality were CCI score (p < 0.0001), HLA mismatch (p = 0.014), length of hospital stay (p < 0.0001), surgical complications (p = 0.048). CONCLUSION Individualized strategies to modify these variables may improve patient's morbidity and mortality after KT.
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Affiliation(s)
- Guillermo Fragale
- Nefrología y Trasplante renal, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Gustavo Laham
- Sección Nefrología, Centro de Educación Médica e Investigaciones Clínicas, "Norberto Quirno", Buenos Aires, Argentina
| | - Pablo Raffaele
- Unidad renal, Fundación Favaloro, Buenos Aires, Argentina
| | | | - Susana Villamil
- Trasplante renal, Hospital Italiano, Buenos Aires, Argentina
| | | | - Marcelo Taylor
- Centro Regional de Ablación e Implante Sur, Hospital San Martín, La Plata, Buenos Aires, Argentina
| | - Julio Ciappa
- Centro Regional de Ablación e Implante Sur, Hospital San Martín, La Plata, Buenos Aires, Argentina
| | - Marisol Rodriguez
- Nefrología y Trasplante renal, Clínica Vélez Sarsfield, Córdoba, Argentina
| | - Rafael Maldonado
- Nefrología y Trasplante renal, Clínica Vélez Sarsfield, Córdoba, Argentina
| | - Hernán Trimarchi
- Servicio de Nefrología, Hospital Británico, Buenos Aires, Argentina
| | - Vanesa Pomeranz
- Servicio de Nefrología, Hospital Británico, Buenos Aires, Argentina
| | - Virginia Ellena
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba, Cordoba, Argentina
| | - Jorge De La Fuente
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba, Cordoba, Argentina
| | - Liliana Bisigniano
- Dirección Científico Técnica, Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Ariel Antik
- Dirección Científico Técnica, Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Gervasio Soler Pujol
- Sección Nefrología, Centro de Educación Médica e Investigaciones Clínicas, "Norberto Quirno", Buenos Aires, Argentina
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3
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Gaynor JJ, Tabbara MM, Ciancio G, Selvaggi G, Garcia J, Tekin A, Vianna R. The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation. Am J Transplant 2023:S1600-6135(23)00308-8. [PMID: 36871628 DOI: 10.1016/j.ajt.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
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 1st 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 1st 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 1st 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.
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Affiliation(s)
- Jeffrey J Gaynor
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL.
| | - Marina M Tabbara
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gaetano Ciancio
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gennaro Selvaggi
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Jennifer Garcia
- Miami Transplant Institute, Department of Pediatrics, University of Miami Miller School of Medicine; Miami, FL
| | - Akin Tekin
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Rodrigo Vianna
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
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Koch M, Zecher D, Lopau K, Weinmann-Menke J, Schulze A, Nashan B, Wenzel U, Banas B, Zeier M, Thaiss F, Sommerer C. Human Leucocyte Antigen-Matching Can Improve Long Term Outcome of Renal Allografts from Donors Older Than 75 Years. Transplant Proc 2023; 55:309-316. [PMID: 36801175 DOI: 10.1016/j.transproceed.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/21/2022] [Accepted: 12/09/2022] [Indexed: 02/21/2023]
Abstract
BACKGROUND Renal transplantation is the therapy of choice for kidney failure. The Eurotransplant Senior Program (ESP) has been established to allocate kidneys ≥65 years to recipients of the same age group considered a regional allocation with short cold ischemia (CIT) but not human-leukocyte-antigen (HLA)-matching. The acceptance of organs aged ≥75 years is also still controversial within the ESP. METHODS In a multicenter approach, 179 kidney grafts ≥75 years (mean donor age 78 years) that were transplanted in 174 patients in 5 German transplant centers were analyzed. The primary focus of the analysis was long-term outcome of the grafts and the impact of CIT, HLA matching, and recipient related risk factors. RESULTS The mean graft survival was 59 months (median 67 months) with a mean donor age of 78.3 ± 2.9 years. Grafts with 0 to 3 HLA-mismatches had a significantly better overall graft survival compared to grafts with ≥4 mismatches (69 months vs 54 months; P = .008). The mean CIT was short (11.9 ± 5.3 hours) and had no impact on graft survival. CONCLUSION Recipients receiving a kidney graft from donors aged ≥75 years can benefit from nearly 5 years of survival with a functioning graft. Even minimal HLA matching may improve long term allograft survival.
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Affiliation(s)
- Martina Koch
- General-, Visceral- and Transplantation Surgery, University Medical Center, Mainz, Germany; Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Germany.
| | - Daniel Zecher
- Department of Nephrology, University Medical Center Regensburg, Germany
| | - Kai Lopau
- Department of Nephrology, University Medical Center Würzburg, Germany
| | - Julia Weinmann-Menke
- Department of Medicine, Section Nephrology; University Medical Center, Mainz, Germany
| | - Alicia Schulze
- Institute of Medical Biostatistics, Epidemiology and Informatics; University Medical Center, Mainz, Germany
| | - Björn Nashan
- Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Germany; Clinic of Hepato-pancreatico-biliary Surgery and The Transplantation Center First Affiliated Hospital, School of Life Sciences and Medical Center University of Sciences & Technology of China, Hefei, Anhui, China
| | - Ulrich Wenzel
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernhard Banas
- Department of Nephrology, University Medical Center Regensburg, Germany
| | - Martin Zeier
- Nephrology Unit, Renal Center Heidelberg, University Medical Center Heidelberg, Germany
| | - Friedrich Thaiss
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Sommerer
- Nephrology Unit, Renal Center Heidelberg, University Medical Center Heidelberg, Germany
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Cuadrado-Payán E, Montagud-Marrahi E, Casals-Urquiza J, del Risco-Zevallos J, Rodríguez-Espinosa D, Cacho J, Arana C, Cucchiari D, Ventura-Aguiar P, Revuelta I, Piñeiro GJ, Esforzado N, Cofan F, Bañon-Maneus E, Campistol JM, Oppenheimer F, Torregrosa JV, Diekmann F. Outcomes in older kidney recipients from older donors: A propensity score analysis. FRONTIERS IN NEPHROLOGY 2022; 2:1034182. [PMID: 37675023 PMCID: PMC10479569 DOI: 10.3389/fneph.2022.1034182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/06/2022] [Indexed: 09/08/2023]
Abstract
Background The age of patients referred for kidney transplantation has increased progressively. However, the precise influence of age on transplant outcomes is controversial. Methods Etrospective study in which graft and recipient survival were assessed in a cohort of ≥75 years old kidney recipients and compared with a contemporary younger one aged 60-65 years through a propensity score analysis. Results We included 106 recipients between 60-65 and 57 patients of ≥75 years old with a median follow-up of 31 [13-54] months. Unadjusted one- and five-year recipient survival did not significantly differ between the older (91% and 74%) and the younger group (95% and 82%, P=0.06). In the IPTW weighted Cox regression analysis, recipient age was not associated with an increased risk of death (HR 1.88 95%CI [0.81-4.37], P=0.14). Unadjusted one- and five-year death-censored graft survival did not significantly differ between both groups (96% and 83% for the older and 99% and 89% for the younger group, respectively, P=0.08). After IPTW weighted Cox Regression analysis, recipient age ≥75 years was no associated with an increased risk of graft loss (HR 1.95, 95%CI [0.65-5.82], P=0.23). Conclusions These results suggest that recipient age should not be considered itself as an absolute contraindication for kidney transplant.
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Affiliation(s)
- Elena Cuadrado-Payán
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
| | - Enrique Montagud-Marrahi
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
| | - Joaquim Casals-Urquiza
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | | | - Diana Rodríguez-Espinosa
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Judit Cacho
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Carolt Arana
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
| | - David Cucchiari
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
| | - Pedro Ventura-Aguiar
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Ignacio Revuelta
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Gaston J. Piñeiro
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Nuria Esforzado
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Frederic Cofan
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Elisenda Bañon-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Josep M. Campistol
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Federico Oppenheimer
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
| | - Josep-Vicens Torregrosa
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clinic Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi iSunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
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Heleniak Z, Illersperger S, Małgorzewicz S, Dębska-Ślizień A, Budde K, Halleck F. Arterial Stiffness as a Cardiovascular Risk Factor After Successful Kidney Transplantation in Diabetic and Nondiabetic Patients. Transplant Proc 2022; 54:2205-2211. [PMID: 36064673 DOI: 10.1016/j.transproceed.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is known that kidney transplantation (KTx) decreases mortality rate and increases life expectancy about 10 years compared with dialysis, particularly in patients with diabetes. However, cardiovascular disease is still the most common cause of death after transplantation. PURPOSE The evaluation of the cardiovascular risk after successful KTx in diabetic and nondiabetic patients. METHODS We enrolled 344 patients after KTx (mean age 52.7 years, M -62.5%). The cohort was divided into 2 groups diabetes (+) and diabetes (-). Arterial stiffness parameters (brachial-ankle and carotid-femoral pulse wave velocity, pulse pressure, pulsatile stress was assessed by an automated oscillometric device. All body composition parameters were evaluated based on bioelectrical impedance analysis and laboratory parameters were obtained from medical files of the patients. RESULTS Arterial stiffness parameters were higher in the diabetes (+) compared with diabetes (-) group, significantly. Body mass index was significantly higher in the diabetes (+) group, as well as body fat mass and visceral fat area. In the diabetes (+) group compared with the diabetes (-) group, whole-body phase angle was lower (4.54 vs 4.90 P = .006). Visceral fat area and whole-body phase angle correlated significantly with arterial stiffness parameters. CONCLUSIONS The evaluation of arterial stiffness and phase angle is a useful method for identifying patients at high cardiovascular risk. Therefore, we suggest that patients with diabetes after successful KTx due to the baseline high cardiolovascular risk, should be regularly assessed to monitor changes in blood vessels, body composition and undergo dietary intervention.
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Affiliation(s)
- Zbigniew Heleniak
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, Poland.
| | - Sarah Illersperger
- Department of Nephrology and Internal Medicine, Charite-University of Medicine, Berlin, Germany
| | | | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, Poland
| | - Klemens Budde
- Department of Nephrology and Internal Medicine, Charite-University of Medicine, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Internal Medicine, Charite-University of Medicine, Berlin, Germany
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7
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A Comorbidity Index and Pretransplant Physical Status Predict Survival in Older Kidney Transplant Recipients: A National Prospective Study. Transplant Direct 2022; 8:e1307. [PMID: 35350108 PMCID: PMC8947685 DOI: 10.1097/txd.0000000000001307] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/29/2022] [Accepted: 01/27/2022] [Indexed: 12/15/2022] Open
Abstract
Kidney transplantation (KT) is considered the best treatment for end-stage kidney disease (ESKD). In the increasing elderly ESKD population, KT should be reserved for carefully selected candidates who are expected to experience favorable outcomes. We aimed to prospectively evaluate pretransplant recipient factors that may predict patient survival and can eventually guide therapeutic decisions in elderly with ESKD.
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8
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Chaudhry D, Chaudhry A, Peracha J, Sharif A. Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis. BMJ 2022; 376:e068769. [PMID: 35232772 PMCID: PMC8886447 DOI: 10.1136/bmj-2021-068769] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To investigate the survival benefit of transplantation versus dialysis for waitlisted kidney failure patients with a priori stratification. DESIGN Systematic review and meta-analysis. DATA SOURCES Online databases MEDLINE, Ovid Embase, Web of Science, Cochrane Collection, and ClinicalTrials.gov were searched between database inception and 1 March 2021. INCLUSION CRITERIA All comparative studies that assessed all cause mortality for transplantation versus dialysis in patients with kidney failure waitlisted for transplant surgery were included. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Meta-analysis was done using the DerSimonian-Laird random effects model, with heterogeneity investigated by subgroup analyses, sensitivity analyses, and meta-regression. RESULTS The search identified 48 observational studies with no randomised controlled trials (n=1 245 850 patients). In total, 92% (n=44/48) of studies reported a long term (at least one year) survival benefit associated with transplantation compared with dialysis. However, 11 of those studies identified stratums in which transplantation offered no statistically significant benefit over remaining on dialysis. In 18 studies suitable for meta-analysis, kidney transplantation showed a survival benefit (hazard ratio 0.45, 95% confidence interval 0.39 to 0.54; P<0.001), with significant heterogeneity even after subgroup/sensitivity analyses or meta-regression analysis. CONCLUSION Kidney transplantation remains the superior treatment modality for most patients with kidney failure to reduce all cause mortality, but some subgroups may lack a survival benefit. Given the continued scarcity of donor organs, further evidence is needed to better inform decision making for patients with kidney failure. STUDY REGISTRATION PROSPERO CRD42021247247.
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Affiliation(s)
- Daoud Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abdullah Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Javeria Peracha
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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9
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Coca A, Arias-Cabrales C, Pérez-Sáez MJ, Fidalgo V, González P, Acosta-Ochoa I, Lorenzo A, Rollán MJ, Mendiluce A, Crespo M, Pascual J, Bustamante-Munguira J. Impact of intra-abdominal pressure on early kidney transplant outcomes. Sci Rep 2022; 12:2257. [PMID: 35145181 PMCID: PMC8831606 DOI: 10.1038/s41598-022-06268-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 01/06/2022] [Indexed: 12/13/2022] Open
Abstract
Increased intra-abdominal pressure (IAP) is common among post-surgical patients and may cause organ dysfunction. However, its impact after kidney transplantation on early postoperative complications and graft recovery remains unclear. We designed a prospective, observational cohort study to describe the prevalence and determinants of IAP, as well as its effect on delayed graft function, postoperative complications, and graft recovery. IAP was measured in 205 kidney transplant recipients every 8 h during the first 72 h after surgery using the urinary bladder technique. Intra-abdominal hypertension was defined as IAP ≥ 12 mmHg. Patients were followed for 6 months or until graft failure/death. Mean IAP was 12 ± 3.3 mmHg within the first 24 h. 78% of subjects presented with intra-abdominal hypertension during the first 72 h. Increased IAP was associated with higher renal resistive index [r = 0.213; P = 0.003] and lower urine output [r = - 0.237; P < 0.001]. 72 h mean IAP was an independent risk factor for delayed graft function [OR: 1.31; 95% CI: 1.13-1.51], postoperative complications [OR: 1.17; 95% CI: 1.03-1.33], and absence of graft function recovery [HR for graft function recovery: 0.94; 95% CI: 0.88-0.99]. Increased IAP was highly prevalent after transplantation and was independently associated with delayed graft function, postoperative complications, and absence of graft function recovery. Routine IAP monitoring should be considered post-transplantation to facilitate early recognition of relevant complications.
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Affiliation(s)
- Armando Coca
- Department of Nephrology, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47003, Valladolid, Spain.
| | - Carlos Arias-Cabrales
- Department of Nephrology, Hospital del Mar, Paseo Marítimo de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Paseo Marítimo de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Verónica Fidalgo
- Department of Nephrology, Hospital General, C/ Luis Erik Clavería Neurólogo s/n, 40002, Segovia, Spain
| | - Pablo González
- Department of Nephrology, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Isabel Acosta-Ochoa
- Department of Nephrology, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Arturo Lorenzo
- Department of Nephrology, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - María Jesús Rollán
- Department of Nephrology, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Alicia Mendiluce
- Department of Nephrology, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Paseo Marítimo de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Paseo Marítimo de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Juan Bustamante-Munguira
- Department of Cardiac Surgery, Hospital Clínico Universitario, Avda. Ramón y Cajal 3, 47003, Valladolid, Spain
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10
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Beerli N, Denhaerynck K, Binet I, Dahdal S, Dickenmann M, Golshayan D, Hadaya K, Huynh-Do U, Schnyder A, De Geest SM, Mauthner O. Age at Time of Kidney Transplantation as a Predictor for Mortality, Graft Loss and Self-Rated Health Status: Results From the Swiss Transplant Cohort Study. Transpl Int 2022; 35:10076. [PMID: 35185365 PMCID: PMC8842256 DOI: 10.3389/ti.2021.10076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/01/2021] [Indexed: 12/04/2022]
Abstract
Introduction: The effect of age on health outcomes in kidney transplantation remains inconclusive. This study aimed to analyze the relationship between age at time of kidney transplantation with mortality, graft loss and self-rated health status in adult kidney transplant recipients. Methods: This study used data from the Swiss Transplant Cohort Study and included prospective data of kidney transplant recipients between 2008 and 2017. Time-to-event analysis was performed using Cox’ regression analysis, and -in the case of graft loss- competing risk analysis. A random-intercept regression model was applied to analyse self-rated health status. Results: We included 2,366 kidney transplant recipients. Age at transplantation linearly predicted mortality. It was also predictive for graft loss, though nonlinearly, showing that recipients aged between 35 and 55 years presented with the lowest risk of experiencing graft loss. No relationship of age with self-rated health status was detected. Conclusion: Higher mortality in older recipients complies with data from the general population. The non-linear relationship between age and graft loss and the higher scored self-rated health status at all follow-up time-points compared to the pre-transplant status -regardless of age- highlight that age alone might not be an accurate measure for risk prediction and clinical decision making in kidney transplantation.
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Affiliation(s)
- Nadine Beerli
- Institute of Nursing Science, University of Basel, Basel, Switzerland
- University Department of Geriatric Medicine Felix Platter, Basel, Switzerland
| | - Kris Denhaerynck
- Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Isabelle Binet
- Clinic of Nephrology and Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Suzan Dahdal
- University Clinic for Nephrology and Hypertension, University Hospital Bern, Bern, Switzerland
| | - Michael Dickenmann
- Department for Transplantation-Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Delaviz Golshayan
- Transplantation Centre and Transplantation Immunopathology Laboratory, University Hospital Lausanne, Lausanne, Switzerland
| | - Karine Hadaya
- Department of Nephrology, University Hospital Geneva, Geneva, Switzerland
| | - Uyen Huynh-Do
- University Clinic for Nephrology and Hypertension, University Hospital Bern, Bern, Switzerland
| | - Aurelia Schnyder
- Clinic of Nephrology and Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Sabina M. De Geest
- Institute of Nursing Science, University of Basel, Basel, Switzerland
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Oliver Mauthner
- Institute of Nursing Science, University of Basel, Basel, Switzerland
- University Department of Geriatric Medicine Felix Platter, Basel, Switzerland
- *Correspondence: Oliver Mauthner,
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11
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Živčić-Ćosić S, Süsal C, Döhler B, Katalinić N, Markić D, Orlić L, Rački S, Španjol J, Trobonjača Z. Kidney Transplants from Elderly Donors: The Experience of a Reference Center in Croatia. EXP CLIN TRANSPLANT 2022; 20:19-27. [DOI: 10.6002/ect.2021.0366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Tsarpali V, Midtvedt K, Lønning K, Bernklev T, Lippe NVD, Reisæter AV, Brunborg C, Heldal K. Health-Related Quality of Life in Older Kidney Transplant Recipients: A National Cohort Study of Short- and Longer-Term Outcomes. Kidney Med 2021; 3:974-983.e1. [PMID: 34939006 PMCID: PMC8664696 DOI: 10.1016/j.xkme.2021.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Rationale & Objective Assessing the optimal therapy for older patients (aged ≥65 years) with end-stage kidney disease requires knowledge of longevity and health-related quality of life (HRQoL) outcomes. Kidney transplantation prolongs survival but its long-term impact on HRQoL in older recipients is not well defined. We aimed to prospectively evaluate HRQoL changes from enlisting until 3 years posttransplantation and examine pretransplantation predictors of posttransplantation outcomes. Study Design Prospective cohort study. Setting & Participants Patients 65 years and older enlisted at the Norwegian National Transplant Center between January 2013 and November 2016. Predictors Kidney transplantation, dialysis vintage, and pretransplantation comorbidity assessed using the Liu Comorbidity Index. Outcomes HRQoL, assessed using the Kidney Disease Quality of Life Short Form, version 1.3. Analytical Approach HRQoL scores obtained at 3 years posttransplantation were compared with those obtained pretransplantation and after 1 year using a paired-sample t test. Multivariable linear mixed-effect models were used to identify possible predictors of HRQoL changes over time. Results Among 289 patients included, 220 (mean age, 71.5 years) had undergone transplantation and 136 had completed the 3-year HRQoL follow-up by October 2020. Posttransplant HRQoL, both generic and kidney specific, substantially improved and the benefit persisted for 3 years. For wait-listed candidates remaining on dialysis, HRQoL gradually deteriorated, and recipients who died within 3 years posttransplantation experienced no improvement during the first year. Moderately elevated pretransplantation comorbidity scores and prolonged dialysis vintage independently predicted poor HRQoL outcomes posttransplantation. Recipients receiving dialysis for 1 year or longer with pretransplantation comorbidity scores ≥ 7 experienced a marked and sustained physical deterioration after transplantation. Limitations Homogenous and highly selected population. Conclusions Transplantation is associated with a sustained HRQoL improvement and should be the preferred treatment for selected older patients. The value of a pretransplant comorbidity score to predict posttransplantation outcomes warrants further evaluation and may improve the selection process.
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Affiliation(s)
- Vasiliki Tsarpali
- Clinic of Internal Medicine, Telemark Hospital Trust, Skien, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Kjersti Lønning
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Tomm Bernklev
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Research and Innovation, Vestfold Hospital Trust, Tønsberg, Oslo University Hospital, Oslo, Norway
| | - Nanna von der Lippe
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Anna Varberg Reisæter
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Kristian Heldal
- Clinic of Internal Medicine, Telemark Hospital Trust, Skien, Norway.,Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
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13
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Yemini R, Rahamimov R, Ghinea R, Mor E. Long-Term Results of Kidney Transplantation in the Elderly: Comparison between Different Donor Settings. J Clin Med 2021; 10:jcm10225308. [PMID: 34830587 PMCID: PMC8618615 DOI: 10.3390/jcm10225308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 12/25/2022] Open
Abstract
With scarce organ supply, a selection of suitable elderly candidates for transplant is needed, as well as auditing the long-term outcomes after transplant. We conducted an observational cohort study among our patient cohort >60 years old with a long follow up. (1). Patients and Methods: We used our database to study the results after transplant for 593 patients >60 years old who underwent a transplant between 2000–2017. The outcome was compared between live donor (LD; n = 257) recipients, an old-to-old (OTO, n = 215) group using an extended criteria donor (ECD) kidney, and a young-to-old (YTO, n = 123) group using a standard-criteria donor. The Kaplan−Meir method was used to calculate the patient and graft survival and Cox regression analysis in order to find risk factors associated with death. (2). Results: The 5- and 10-year patient survival was significantly better in the LD group (92.7% and 66.9%) compared with the OTO group (73.3% and 42.8%) and YTO group (70.9% and 40.6%) (p < 0.0001). The 5- and 10-year graft survival rates were 90.3% and 68.5% (LD), 61.7% and 30.9% (OTO), and 64.1% and 39.9%, respectively (YTO group; p < 0.0001 between the LD and the two DD groups). There was no difference in outcome between patients in their 60’s and their 70’s. Factors associated with mortality included: age (HR-1.060), DM (HR-1.773), IHD (HR-1.510), and LD/DD (HR-2.865). (3). Conclusions: Our 17-years of experience seems to justify the rational of an old-to-old allocation policy in the elderly population. Live-donor transplant should be encouraged whenever possible. Each individual decision of elderly candidates for transplant should be based on the patient’s comorbidity and predicted life expectancy.
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Affiliation(s)
- Renana Yemini
- Department of Surgery, Samson Assuta Ashdod University Hospital, Ashdod 7747629, Israel;
- Faculty of Health Sciences, Ben Gurion University of the Negev, Be’er Sheva 8410501, Israel
| | - Ruth Rahamimov
- Institute of Nephrology, Beilinson Medical Center, Petach-Tikva 49100, Israel;
- Sackler Medical School, Tel-Aviv University, Tel-Aviv 6997801, Israel;
| | - Ronen Ghinea
- Sackler Medical School, Tel-Aviv University, Tel-Aviv 6997801, Israel;
- Transplant Unit, Department of Surgery B, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Eytan Mor
- Institute of Nephrology, Beilinson Medical Center, Petach-Tikva 49100, Israel;
- Sackler Medical School, Tel-Aviv University, Tel-Aviv 6997801, Israel;
- Correspondence:
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14
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Pérez-Sáez MJ, Juega J, Zapatero A, Comas J, Tort J, Lauzurica R, Pascual J. Kidney transplant outcomes in elderly recipients with controlled donation after circulatory death or donation after brain death donors: a registry cohort study. Transpl Int 2021; 34:2507-2514. [PMID: 34664327 DOI: 10.1111/tri.14141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/01/2021] [Accepted: 10/12/2021] [Indexed: 11/25/2022]
Abstract
The number of kidney transplant (KT) procedures with controlled donation after circulatory death (cDCD) donors has exponentially increased in Spain in recent years, with a parallel increase in donor and recipient acceptance criteria. The outcomes of cDCD-KT have been reported to be comparable to those of KT with donation after brain death (DBD) donors. However, studies in elderly recipients have yielded contradictory results. We performed a registry analysis of 852 KT recipients aged ≥65 years (575 in the DBD-KT group, 277 in the cDCD-KT group) in Catalonia, Spain. Clinical outcomes and survival were compared between DBD-KT and cDCD-KT recipients. The donor and recipient ages were similar between the two groups (71.5 ± 8.7 years for donors, 70.8 ± 4.1 years for recipients). Delayed graft function (DGF) was more frequent among cDCD-KT recipients, without a difference in the rate of primary nonfunction. The 3-year patient and death-censored graft survival rates were similar between DBD-KT and cDCD-KT recipients (78.8% vs. 76.4% and 90.3% vs. 86.6%, respectively). In multivariable analysis, previous cardiovascular disease and DGF were independent risk factors for patient death. The type of donation (cDCD vs. DBD) was not an independent risk factor for patient survival or graft loss. cDCD-KT and DBD-KT provide comparable patient and graft survival in elderly recipients.
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Affiliation(s)
| | - Javier Juega
- Nephrology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Ana Zapatero
- Transplant Coordination Unit & Intensive Care Department, Hospital del Mar, Barcelona, Spain
| | - Jordi Comas
- Departament de Salut, Organització Catalana de Trasplantaments, Barcelona, Spain
| | - Jaume Tort
- Departament de Salut, Organització Catalana de Trasplantaments, Barcelona, Spain
| | - Ricardo Lauzurica
- Nephrology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
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15
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Liu L, Cheng K, Huang J. Effect of Long Cold Ischemia Time of Kidneys from Aged Donors on Prognosis of Kidney Transplantation. Ann Transplant 2021; 26:e928735. [PMID: 34663778 PMCID: PMC8540027 DOI: 10.12659/aot.928735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
With the increasing incidence of end-stage renal disease (ESRD), patients' life span and life quality are significantly reduced. Kidney transplantation has gradually become the ideal method for treating ESRD, and the shortage of organ sources has become the main problem. In recent years, China has successfully realized the transformation of organ sources. Voluntary donation after the death of citizens has increased year by year, and the number of kidney transplantations has increased, which alleviates the organ shortage to a certain extent, but compared with the past, the increasing proportion of aged donors has also become an inevitable global problem. At the same time, due to the sudden and widespread distribution of voluntary donation, most donor kidneys have the problem of longer cold ischemic time (CIT). The probability of adverse events, such as delayed renal function recovery after transplantation, was also significantly increased. At present, there is little research on the effect of donor's aging and long CIT on the prognosis of renal transplantation. This paper reviews the literature in recent years and explore this problem from 2 aspects: the elderly donor and the long CIT.
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Affiliation(s)
- Lian Liu
- Center for Organ Transplantation, 3rd Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland).,Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, 3rd Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland).,Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, Hunan, China (mainland)
| | - Ke Cheng
- Center for Organ Transplantation, 3rd Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland).,Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, 3rd Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Jufang Huang
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, Hunan, China (mainland)
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16
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Erlandsson H, Qureshi AR, Scholz T, Lundgren T, Bruchfeld A, Stenvinkel P, Wennberg L, Lindnér P. Observational study of risk factors associated with clinical outcome among elderly kidney transplant recipients in Sweden - a decade of follow-up. Transpl Int 2021; 34:2363-2370. [PMID: 34346109 DOI: 10.1111/tri.14004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/05/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Kidney transplantation (Ktx) in elderly has become increasingly accepted worldwide despite their higher burden of comorbidities. We investigated important risk factors affecting long-term patient and graft survival. METHODS We included all (n=747) Ktx patients >60 years from 2000 to 2012 in Sweden. Patients were age-stratified; 60-64, 65-69 and >70 years. Follow-up time was up to 10 years (median 7.9 years, 75% percentile >10 years). Primary outcome was 10-year patient survival in age-stratified groups. Secondary outcomes were 5- year patient and graft-survival in age-stratified groups and the impact of risk factors including Charlson comorbidity index on patient and graft-survival. RESULTS Mortality was higher in patients >70 years, after 10 years (HR 1.94; 95% CI 1.24-3.04; p=0.004). Males had a higher 10-year risk of death (HR 1.39; CI 95% 1.04-1.86; p=0.024). Five-year patient survival did not differ between age-groups. In multivariate Cox analysis (n=500) hazard ratio for 10-year mortality was 4.6 in patients with Charlson comorbidity index ≥7 vs <4 (95% CI 2.42-8.62; p=0.0001) CONCLUSION: Higher Charlson comorbidity index identified ESKD patients with 4.6 times higher risk of death after Ktx. We suggest that this index should be used as a part of the pre-operative evaluation in elderly.
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Affiliation(s)
- Helen Erlandsson
- Division of Transplantation Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Department of Health, Medicine and Caring Sciences, Linköping University, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Tim Scholz
- Department of Transplantation, Uppsala University Hospital, Uppsala, Sweden
| | - Torbjörn Lundgren
- Division of Transplantation Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Lars Wennberg
- Division of Transplantation Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Per Lindnér
- The Transplant Institute, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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17
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Hellemans R, Kramer A, De Meester J, Collart F, Kuypers D, Jadoul M, Van Laecke S, Le Moine A, Krzesinski JM, Wissing KM, Luyckx K, van Meel M, de Vries E, Tieken I, Vogelaar S, Samuel U, Abramowicz D, Stel VS, Jager KJ. Does kidney transplantation with a standard or expanded criteria donor improve patient survival? Results from a Belgian cohort. Nephrol Dial Transplant 2021; 36:918-926. [PMID: 33650633 PMCID: PMC8075371 DOI: 10.1093/ndt/gfab024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Changes in recipient and donor factors have reopened the question of survival benefits of kidney transplantation versus dialysis. METHODS We analysed survival among 3808 adult Belgian patients waitlisted for a first deceased donor kidney transplant from 2000 to 2012. The primary outcome was mortality during the median waiting time plus 3 years of follow-up after transplantation or with continued dialysis. Outcomes were analysed separately for standard criteria donor (SCD) and expanded criteria donor (ECD) kidney transplants. We adjusted survival analyses for recipient age (20-44, 45-64 and ≥65 years), sex and diabetes as the primary renal disease. RESULTS Among patients ≥65 years of age, only SCD transplantation provided a significant survival benefit compared with dialysis, with a mortality of 16.3% [95% confidence interval (CI) 13.2-19.9] with SCD transplantation, 20.5% (95% CI 16.1-24.6) with ECD transplantation and 24.6% (95% CI 19.4-29.5) with continued dialysis. Relative mortality risk was increased in the first months after transplantation compared with dialysis, with equivalent risk levels reached earlier with SCD than ECD transplantation in all age groups. CONCLUSIONS The results of this study suggest that older patients might gain a survival benefit with SCD transplantation versus dialysis, but any survival benefit with ECD transplantation versus dialysis may be small.
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Affiliation(s)
- Rachel Hellemans
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Anneke Kramer
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Johan De Meester
- Nederlandstalige Belgische Vereniging voor Nefrologie, Sint-Niklaas, Belgium
| | - Frederic Collart
- Groupement des Néphrologues Francophones de Belgique, Liège, Belgium
| | - Dirk Kuypers
- Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Michel Jadoul
- Département de Néphrologie, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Steven Van Laecke
- Department of Internal Medicine, Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Alain Le Moine
- Département de Néphrologie, Hôpital Erasme-Université Libre de Bruxelles, Bruxelles, Belgium
| | | | | | - Kim Luyckx
- Department of Informatics, Antwerp University Hospital, Edegem, Belgium
| | - Marieke van Meel
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Erwin de Vries
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Ineke Tieken
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Serge Vogelaar
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Undine Samuel
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Vianda S Stel
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Kitty J Jager
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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18
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Doucet BP, Cho Y, Campbell SB, Johnson DW, Hawley CM, Teixeira-Pinto ARM, Isbel NM. Kidney Transplant Outcomes in elderly Recipients: An Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry Study. Transplant Proc 2021; 53:1915-1926. [PMID: 34275599 DOI: 10.1016/j.transproceed.2021.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/14/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND There is an increase in elderly patients receiving kidney transplant internationally. This study describes elderly kidney transplant recipient outcomes in Australia and New Zealand. METHODS The study included all adult first kidney transplant recipients in Australia and New Zealand from 2000 to 2015. Survival and graft outcomes were compared between elderly (≥70 years) and younger (18-69 years) recipients using Cox proportional hazards regression. RESULTS Overall, 10651 kidney transplant recipients were included, of which 279 (2.6%) were elderly adults. The proportion of elderly recipients increased from 0.6 to 4.4% from 2000 to 2015. Compared with younger recipients, elderly recipients were more likely to receive kidneys from deceased donors, elderly donors, and expanded criteria donors. Elderly recipients experienced poorer patient survival with 1- and 5-year survival ranging from 96% to 97% and 79% to 81%, respectively, compared with 97% to 99% and 90% 95% in younger recipients, respectively. Elderly recipients experienced comparable rates of delayed graft function and, in living donor kidney recipients, lower rates of acute rejection. CONCLUSIONS Kidney transplantation in the elderly population is increasing. Although elderly recipients had inferior survival and graft outcomes, elderly recipients generally received poorer quality kidneys. The outcomes achieved in this cohort of elderly adults are encouraging, and improving elderly recipient outcomes should be an important focus for research.
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Affiliation(s)
- Brian Percy Doucet
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Scott Bryan Campbell
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | - David Wayne Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Carmel Mary Hawley
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia; Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Armando Rogerió Martins Teixeira-Pinto
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole Maree Isbel
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Translational Research Institute, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, The University of Queensland, Brisbane, Queensland, Australia
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19
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Impaired renal function before kidney procurement has a deleterious impact on allograft survival in very old deceased kidney donors. Sci Rep 2021; 11:12226. [PMID: 34108573 PMCID: PMC8190122 DOI: 10.1038/s41598-021-91843-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/24/2021] [Indexed: 11/16/2022] Open
Abstract
As the use of elderly kidney donors for transplantation is increasing with time, there is a need to understand which factors impact on their prognosis. No data exist on the impact of an impaired renal function (IRF) in such population. 116 kidney recipients from deceased kidney donors over 70 years were included from 2005 to 2015 in a single-center retrospective study. IRF before organ procurement was defined as a serum creatinine above 1.0 mg/dl or a transient episode of oligo-anuria. Mean ages for donors and recipients were respectively 74.8 ± 3.5 and 66.7 ± 8.0. Graft survival censored for death at 5 years was of 77%. Using a multivariate analysis by Cox model, the only predictor of graft loss present in the donor was IRF before organ procurement (HR 4.2 CI95[1.8–9.7]). IRF was also associated with significant lower estimated glomerular filtration rates up to 1 year post-transplantation. By contrast, KDPI score (median of 98 [96–100]), was not associated with the risk of graft failure. Then, IRF before kidney procurement may define a risk subgroup among very-old deceased kidney donors, in whom pre-implantatory biopsies, dual kidney transplantation or calcineurin inhibitor-free immunosuppressive regimen could help to improve outcomes.
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Cheungpasitporn W, Lentine KL, Tan JC, Kaufmann M, Caliskan Y, Bunnapradist S, Lam NN, Schnitzler M, Axelrod DA. Immunosuppression Considerations for Older Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2021; 8:100-110. [PMID: 34211822 PMCID: PMC8244945 DOI: 10.1007/s40472-021-00321-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 02/06/2023]
Abstract
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.
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21
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KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2021; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 257] [Impact Index Per Article: 85.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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22
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Schachtner T, Otto NM, Reinke P. Two decades of the Eurotransplant Senior Program: the gender gap in mortality impacts patient survival after kidney transplantation. Clin Kidney J 2020; 13:1091-1100. [PMID: 33391754 PMCID: PMC7769544 DOI: 10.1093/ckj/sfz118] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/09/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Long-term outcomes of the Eurotransplant Senior Program (ESP) are urgently needed to improve selection criteria and allocation policies in the elderly. METHODS We analysed patient and allograft outcomes of 244 ESP-kidney transplant recipients (KTRs) between 1999 and 2019 and assessed quality of living compared with 82 ESP-waitlisted dialysis patients using standardized short form-8. RESULTS We observed 1-, 5- and 10-year patient survival of 91.7, 66.3 and 38.0%, respectively. Mortality risk factors included male gender (P = 0.006) and T-cell-mediated rejection (P < 0.001). Median patient survival of male ESP-KTRs was 80 versus 131 months for female ESP-KTRs (P = 0.006). 1-, 5- and 10-year death-censored allograft survival was 93.3, 82.6 and 70.4%. Risk factors included high body mass index (P < 0.001) and T-cell-mediated rejection (P < 0.001). After re-initiation of dialysis median patient survival was 58 months. Change of estimated glomerular filtration rate showed a mean decline of 2.3 and 6.8 mL/min at 5 and 10 years. Median physical and mental component scores of ESP-KTRs were 40.2 and 48.3, significantly higher compared with dialysis patients (P < 0.05). Of ESP-KTRs, 97.5% who underwent transplantation would again do so. CONCLUSIONS Long-term outcomes of ESP-KTRs ultimately support the effectiveness of an age-matched allocation system. Our data suggest that the survival advantage of women is maintained after kidney transplantation and calls for gender-specific care.
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Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
- Berlin-Brandenburg Center of Regenerative Therapies, Berlin, Germany
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Natalie M Otto
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
- Berlin-Brandenburg Center of Regenerative Therapies, Berlin, Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care, Charité University Medicine Berlin, Berlin, Germany
- Berlin-Brandenburg Center of Regenerative Therapies, Berlin, Germany
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23
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[Very-old deceased donors in kidney transplantation: How far can we go?]. Nephrol Ther 2020; 16:408-413. [PMID: 33203614 DOI: 10.1016/j.nephro.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 11/23/2022]
Abstract
In order to increase the pool of organ donors, kidney transplantation from very old-donors, notably aged more than 70, is increasing. Compared to the United States, where the use of these grafts does not reach 5%, in France it reaches over 20%. Kidney aging is determined by a progressive glomerusclerosis, interstitial fibrosis, and nephrosclerosis, responsible of a linear decrease of glomerular filtration rate with time. Aging in kidney transplantation goes along also with an increased immunogenicity and risk of ischemia-reperfusion injuries. Hence, the prognosis of these transplantations is worse than those from younger donors, even though it remains better than dialysis. Data is lacking on risk factors of graft loss in this specific population. Hypothermic perfusion machine, pre-implantation kidney biopsy, dual kidney transplantation and immunosuppressive strategies have been evaluated to improve the long-term prognosis of these grafts.
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24
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Cabrera J, Fernández-Ruiz M, Trujillo H, González E, Molina M, Polanco N, Hernández E, Morales E, Gutiérrez E, Rodríguez Mori J, Canon A, Rodríguez-Antolín A, Praga M, Andrés A. Kidney transplantation in the extremely elderly from extremely aged deceased donors: a kidney for each age. Nephrol Dial Transplant 2020; 35:687-696. [PMID: 32049336 DOI: 10.1093/ndt/gfz293] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/10/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Advances in life expectancy have led to an increase in the number of elderly people with end-stage renal disease (ESRD). Scarce information is available on the outcomes of kidney transplantation (KT) in extremely elderly patients based on an allocation policy prioritizing donor-recipient age matching. METHODS We included recipients ≥75 years that underwent KT from similarly aged deceased donors at our institution between 2002 and 2015. Determinants of death-censored graft and patient survival were assessed by Cox regression. RESULTS We included 138 recipients with a median follow-up of 38.8 months. Median (interquartile range) age of recipients and donors was 77.5 (76.3-79.7) and 77.0 years (74.7-79.0), with 22.5% of donors ≥80 years. Primary graft non-function occurred in 8.0% (11/138) of patients. Cumulative incidence rates for post-transplant infection and biopsy-proven acute rejection (BPAR) were 70.3% (97/138) and 15.2% (21/138), respectively. One- and 5-year patient survival were 82.1 and 60.1%, respectively, whereas the corresponding rates for death-censored graft survival were 95.6 and 93.1%. Infection was the leading cause of death (46.0% of fatal cases). The occurrence of BPAR was associated with lower 1-year patient survival [hazard ratio (HR) = 4.21, 95% confidence interval (CI) 1.64-10.82; P = 0.003]. Diabetic nephropathy was the only factor predicting 5-year death-censored graft survival (HR = 4.82, 95% CI 1.08-21.56; P = 0.040). CONCLUSIONS ESRD patients ≥75 years can access KT and remain dialysis free for their remaining lifespan by using grafts from extremely aged deceased donors, yielding encouraging results in terms of recipient and graft survival.
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Affiliation(s)
- Jimena Cabrera
- Programa de Prevención y Tratamiento de las Glomerulopatías, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay.,Department of Nephrology, Hospital Evangélico, Montevideo, Uruguay.,Department of Nephrology, Hospital Militar, Montevideo, Uruguay
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - María Molina
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Nephrology, Hospital Universitari "Arnau de Vilanova", Lleida, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Eduardo Hernández
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Juan Rodríguez Mori
- Department of Nephrology, Hospital Nacional "Alberto Sabogal Sologuren", EsSalud, Callao, Peru
| | - Alejandra Canon
- Department of Nephrology, Hospital Evangélico, Montevideo, Uruguay.,Department of Nephrology, Hospital Militar, Montevideo, Uruguay
| | - Alfredo Rodríguez-Antolín
- Department of Urology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
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25
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Abstract
PURPOSE OF REVIEW The kidney transplantation landscape has changed dramatically over the last 2 decades. First, transplantation is performed in patients previously considered ineligible for transplantation, including older patients and patients with multiple comorbidities. Second, organ shortages have increased the use of less-than-optimal donor kidneys, like organs from expanded criteria donors or donors after cardiac death. Third, improvements in managing chronic kidney disease and dialysis have improved survival on dialysis. Therefore, the question arises: does transplantation currently benefit older transplant candidates? RECENT FINDINGS The current review describes important changes in transplantation over the last 20 years. We review recent data on survival with dialysis versus transplantation in older individuals. Finally, we consider methodological issues that might influence conclusions drawn in current studies. SUMMARY Limited data are available to assess the potential survival benefit of kidney transplantations in older individuals. The available evidence suggests that transplantation might provide survival benefit in older individuals, even with aged kidney donors, but risks vary widely with donor quality and recipient health status. More research is needed to make adequate predictions of which donor kidneys might lead to good outcomes and which patient characteristics might define a good transplant candidate.
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26
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Coca A, Arias-Cabrales C, Valencia AL, Burballa C, Bustamante-Munguira J, Redondo-Pachón D, Acosta-Ochoa I, Crespo M, Bustamante J, Mendiluce A, Pascual J, Pérez-Saéz MJ. Validation of a survival benefit estimator tool in a cohort of European kidney transplant recipients. Sci Rep 2020; 10:17109. [PMID: 33051519 PMCID: PMC7555860 DOI: 10.1038/s41598-020-74295-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 09/21/2020] [Indexed: 12/21/2022] Open
Abstract
Pre-transplant prognostic scores help to optimize donor/recipient allocation and to minimize organ discard rates. Since most of these scores come from the US, direct application in non-US populations is not advisable. The Survival Benefit Estimator (SBE), built upon the Estimated Post-Transplant Survival (EPTS) and the Kidney Donor Profile Index (KDPI), has not been externally validated. We aimed to examine SBE in a cohort of Spanish kidney transplant recipients. We designed a retrospective cohort-based study of deceased-donor kidney transplants carried out in two different Spanish hospitals. Unadjusted and adjusted Cox models were applied for patient survival. Predictive models were compared using Harrell’s C statistics. SBE, EPTS and KDPI were independently associated with patient survival (p ≤ 0.01 in all models). Model discrimination measured with Harrell’s C statistics ranged from 0.57 (KDPI) to 0.69 (SBE) and 0.71 (EPTS). After adjustment, SBE presented similar calibration and discrimination power to that of EPTS. SBE tended to underestimate actual survival, mainly among high EPTS recipients/high KDPI donors. SBE performed acceptably well at discriminating post-transplant survival in a cohort of Spanish deceased-donor kidney transplant recipients, although its use as the main allocation guide, especially for high KDPI donors or high EPTS recipients requires further testing.
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Affiliation(s)
- Armando Coca
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal SN, 47003, Valladolid, Spain. .,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain.
| | - Carlos Arias-Cabrales
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
| | - Ana Lucía Valencia
- Nephrology Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Carla Burballa
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
| | | | - Dolores Redondo-Pachón
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
| | - Isabel Acosta-Ochoa
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal SN, 47003, Valladolid, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Jesús Bustamante
- Medicine, Dermatology and Toxicology Department, School of Medicine, Universidad de Valladolid, Valladolid, Spain
| | - Alicia Mendiluce
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal SN, 47003, Valladolid, Spain
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - María José Pérez-Saéz
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
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27
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Kidney After Liver Transplantation Matched-pair Analysis: Are Kidneys Allocated to Appropriate Patients to Maximize Their Survival? Transplantation 2020; 104:804-812. [PMID: 31335766 DOI: 10.1097/tp.0000000000002870] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Kidney after liver transplantation (KALT) is the best therapeutic option for patients with end-stage renal disease after orthotopic liver transplantation (OLT). New allocation policies prioritize kidneys to patients in renal failure within the first year following OLT. There is little data on how kidney quality, measured by kidney donor profile index (KDPI), impacts KALT survival outcomes. METHODS The United Network for Organ Sharing database was queried for adult KALT recipients from 1988 to 2015 and compared to their paired kidney transplant alone (KTA) recipients. Seven hundred forty-five pairs were stratified into 3 KDPI subgroups and compared patient survival, graft survival, and death-censored graft survival among matched-paired recipients. RESULTS Overall, KTA recipients had superior patient and graft survival compared with the KALT group. KTA patient survival was superior for all 3 KDPI subgroups analysis. KTA graft survival was superior compared with KALT recipients of KDPI 21%-85% kidneys. Inferior graft half-life was observed in KALT versus KTA recipients with KDPI 21%-85% and >85%. CONCLUSIONS From a utilitarian perspective, it is important that kidneys are allocated to recipients that are able to maximize their benefit from the full life of the organ. In KTA recipients, graft quality correlates directly to graft survival. However, in KALT patients receiving the matched-pair kidneys of the KTA recipients, patient mortality, rather than kidney quality, dictates graft survival significantly. As allocation practices continue developing, utilization of expanded criteria kidneys that better match anticipated patient and graft survival should be strongly considered to maximize the benefits of limited resources for the greatest number of patients.
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28
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Buxeda A, Velis G, Arias-Cabrales C, Zapatero A, Burballa C, Redondo-Pachón D, Mir M, Crespo M, Pascual J, Pérez-Sáez MJ. Kidney transplantation outcomes from elderly donors after circulatory death: a comparison with elderly brain-dead donors. Clin Kidney J 2020; 14:1181-1189. [PMID: 33841864 PMCID: PMC8023186 DOI: 10.1093/ckj/sfaa114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/13/2020] [Indexed: 02/07/2023] Open
Abstract
Background The use of kidneys from elderly controlled donation after circulatory death (cDCD) donors has increased significantly in recent years. Concerns about outcomes achieved with these elderly cDCD kidneys have arisen. We aimed to compare outcomes from elderly cDCD kidney transplant recipients (KTrs) and elderly donation after brain death donors (DBDs) in KTrs. Methods We conducted a single-centre retrospective study including 87 cDCD-KTrs (46 from donors ≥65 years of age and 41 from <65 years) and 126 DBD-KTrs from donors ≥65 years of age from 2013 through 2017). Young cDCD-KTrs were used as controls. The median follow-up was 27.1 months for all cDCD-KTrs and 29.7 months for DBD-KTrs ≥65 years of age. Results Donors >65 years of age represented more than half of our global cDCD cohort (52.9%). KTs from elderly cDCDs had similar rates of delayed graft function, primary non-function and vascular complications compared with young cDCD-KTrs and elderly DBD-KTrs. Short and medium-term graft survival from elderly cDCD kidneys are excellent and are comparable to those from young cDCD and elderly DBD kidneys (90% young cDCD versus 88% elderly cDCD versus 80% elderly DBD at 36 months, P = 0.962 and 0.180, respectively). Although recipients from cDCDs ≥65 years of age showed lower 3-year patient survival (78% versus 87% in elderly DBD-KTrs; P = 0.01), recipient age was the only determinant of patient survival [hazard ratio 1.10 (95% confidence interval 1.02–1.17); P < 0.01], without any influence of donor characteristics. Conclusions The use of kidneys from elderly cDCDs is increasing in Spain. Short- and medium-term graft outcomes are similar when comparing kidneys from elderly cDCDs and DBDs. Recipient age is the only determinant of patient survival. Additional studies are needed to assess long-term outcomes.
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Affiliation(s)
- Anna Buxeda
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Gonzalo Velis
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | - Ana Zapatero
- Department of Critical Care, Hospital del Mar, Barcelona, Spain.,Transplant Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Carla Burballa
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | - Marisa Mir
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
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29
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Fragale GD, Pujol GS, Laham G, Raffaele P, Fortunato M, Imperiali N, Giordani MC, Taylor M, Ciappa J, Matamala N, Maldonado R, Trimarchi H, Pomeranz V, Naser S, De La Fuente J, Bisigniano L, Antik A. Renal Transplantation in Patients Older Than 60 Years With High Comorbidity. Is There a Survival Benefit? A Multicenter Study in Argentina. Transplantation 2020; 104:1746-1751. [PMID: 32732855 DOI: 10.1097/tp.0000000000003070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impact of renal transplantation (RT) in the elderly with many comorbid conditions is a matter of concern. The aim of our study was to assess the impact of RT on the survival of patients older than 60 years compared with those remaining on the waiting list (WL) according to their comorbidities. METHODS In this multicentric observational retrospective cohort study, we included all patients older than 60 years old admitted on the WL from 01 January 2006 to 31 December 2016. The Charlson comorbidity index (CCI) score was calculated for each patient at inclusion on the WL. Kidney donor risk index was used to assess donor characteristics. RESULTS One thousand and thirty-six patients were included on the WL of which 371 (36%) received an RT during a median follow-up period of 2.5 (1.4-4.1) years. Patient survival was higher after RT compared to patients remaining on the WL, 87%, 80%, and 72% versus 87%, 55%, and 30% at 1, 3, and 5 years, respectively. After RT survival at 5 years was 37% higher for patients with CCI ≥ 3, and 46% higher in those with CCI < 3, compared with patients remaining on the WL. On univariate and multivariate analysis, patient survival was independently associated with a CCI of ≥3 (hazard ratio 1.62; confidence interval 1.09-2.41; P < 0.02) and the use of calcineurin-based therapy maintenance therapy (hazard ratio 0.53; confidence interval 0.34-0.82; P < 0.004). CONCLUSIONS Our study showed that RT improved survival in patients older than 60 years even those with high comorbidities. The survival after transplantation was also affected by comorbidities.
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Affiliation(s)
| | - Gervasio Soler Pujol
- Sección Nefrología, Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno", Buenos Aires, Argentina
| | - Gustavo Laham
- Sección Nefrología, Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno", Buenos Aires, Argentina
| | - Pablo Raffaele
- Unidad renal, Fundación Favaloro, Buenos Aires, Argentina
| | | | - Nora Imperiali
- Trasplante renal, Hospital Italiano, Buenos Aires, Argentina
| | | | - Marcelo Taylor
- Centro Regional de Ablación e Implante Sur, Hospital San Martín, La Plata, Buenos Aires, Argentina
| | - Julio Ciappa
- Centro Regional de Ablación e Implante Sur, Hospital San Martín, La Plata, Buenos Aires, Argentina
| | - Natalia Matamala
- Nefrología y Trasplante renal, Clínica Vélez Sarsfield, Córdoba, Argentina
| | - Rafael Maldonado
- Nefrología y Trasplante renal, Clínica Vélez Sarsfield, Córdoba, Argentina
| | - Hernán Trimarchi
- Servicio de Nefrología, Hospital Británico, Buenos Aires, Argentina
| | - Vanesa Pomeranz
- Servicio de Nefrología, Hospital Británico, Buenos Aires, Argentina
| | - Sofia Naser
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba, Argentina
| | - Jorge De La Fuente
- Servicio de Nefrología, Hospital Privado Universitario de Córdoba, Argentina
| | - Liliana Bisigniano
- Dirección Científico Técnica, Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Ariel Antik
- Dirección Científico Técnica, Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
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30
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Süsal C, Kumru G, Döhler B, Morath C, Baas M, Lutz J, Unterrainer C, Arns W, Aubert O, Bara C, Beiras-Fernandez A, Böhmig GA, Bösmüller C, Diekmann F, Dutkowski P, Hauser I, Legendre C, Lozanovski VJ, Mehrabi A, Melk A, Minor T, Mueller TF, Pisarski P, Rostaing L, Schemmer P, Schneeberger S, Schwenger V, Sommerer C, Tönshoff B, Viebahn R, Viklicky O, Weimer R, Weiss KH, Zeier M, Živčić-Ćosić S, Heemann U. Should kidney allografts from old donors be allocated only to old recipients? Transpl Int 2020; 33:849-857. [PMID: 32337766 DOI: 10.1111/tri.13628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/06/2019] [Accepted: 04/22/2020] [Indexed: 02/05/2023]
Abstract
In several deceased donor kidney allocation systems, organs from elderly donors are allocated primarily to elderly recipients. The Eurotransplant Senior Program (ESP) was implemented in 1999, and since then, especially in Europe, the use of organs from elderly donors has steadily increased. The proportion of ≥60-year-old donors reported to the Collaborative Transplant Study (CTS) by European centers has doubled, from 21% in 2000-2001 to 42% in 2016-2017. Therefore, in the era of organ shortage it is a matter of debate whether kidney organs from elderly donors should only be allocated to elderly recipients or whether <65-year-old recipients can also benefit from these generally as "marginal" categorized organs. To discuss this issue, a European Consensus Meeting was organized by the CTS on April 12, 2018, in Heidelberg, in which 36 experts participated. Based on available evidence, it was unanimously concluded that kidney organs from 65- to 74-year-old donors can also be allocated to 55- to 64-year-old recipients, especially if these organs are from donors with no history of hypertension, no increased creatinine, no cerebrovascular death, and no other reasons for defining a marginal donor, such as diabetes or cancer.
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Affiliation(s)
- Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gizem Kumru
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marije Baas
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jens Lutz
- Division of Nephrology and Infectious Diseases, Medical Clinic, Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany
| | | | - Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Center, Cologne, Germany
| | - Olivier Aubert
- Service de Transplantation Rénale et Unité de Soins Intensifs, AP-HP, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | - Christoph Bara
- Division of Thoracic Transplantation and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andres Beiras-Fernandez
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Johannes Gutenberg University, Mainz, Germany
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Claudia Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Fritz Diekmann
- Department of Nephrology and Renal Transplantation, ICNU, Hospital Clinic, Barcelona, Spain
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Ingeborg Hauser
- Department of Nephrology, Medinizische Klinik III, UKF, Goethe University, Frankfurt, Germany
| | - Christophe Legendre
- Service de Transplantation Rénale et Unité de Soins Intensifs, AP-HP, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | - Vladimir J Lozanovski
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Thomas Minor
- Department of Surgical Research, Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Germany
| | - Thomas F Mueller
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Przemyslaw Pisarski
- Department for General and Visceral Surgery, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Lionel Rostaing
- Service de Néphrologie, Dialyse, Aphérèses et Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Peter Schemmer
- Department of Surgery, General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Stefan Schneeberger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vedat Schwenger
- Department of Nephrology and Autoimmune Diseases, Transplantation Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Claudia Sommerer
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Richard Viebahn
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Rolf Weimer
- Department of Internal Medicine, University of Giessen, Giessen, Germany
| | - Karl-Heinz Weiss
- Department of Internal Medicine IV, Gastroenterology and Hepatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stela Živčić-Ćosić
- Department of Nephrology, Dialysis and Kidney Transplantation, Faculty of Medicine, Clinical Hospital Center Rijeka, University of Rijeka, Rijeka, Croatia
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Skrabaka D, Franczyk S, Kolonko A, Sekta S, Czerwiński J, Owczarek A, Valenta Z, Król R, Więcek A, Ziaja J. Early Complications After Kidney Transplantation in Patients Aged 60 Years and Older: A Single-Center, Paired-Kidney Analysis. Transplant Proc 2020; 52:2376-2381. [PMID: 32334795 DOI: 10.1016/j.transproceed.2020.01.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/26/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES As the population ages, the number of people suffering from cardiovascular diseases (CVD) and diabetes mellitus (DM) increases. The coexistence of these diseases can affect the results of kidney transplantation (KT) in the elderly. The aim of this study was to analyze surgical and nonsurgical complications in the early period after KT and to identify the factors that influence their development in recipients aged ≥ 60 years compared to younger recipients < 60 years. METHODS One hundred seventy-five recipients of KT ≥ 60 years and 175 recipients of KT < 60 years who received kidneys from the same deceased donor were enrolled into the study. The incidence of surgical and nonsurgical complications, factors that may influence their development, early graft function, and patient and kidney-graft survival were analyzed during a 3-month follow-up period. Donor sources complied with the Helsinki Congress and Istanbul Declaration and organs were not procured from prisoners and individuals who were coerced or paid. RESULTS Older recipients were characterized by higher body mass index ± SD (26.1 ± 3.5 vs 24.7 ± 3.4 kg/m2) and suffered more often from pretransplant DM (20.6% vs 11.4%) and CVD (34.3% vs 10.3%) and less frequently underwent previous KT (6.3% vs 20.0%). There were no differences between the ≥ 60 year old and < 60 year old groups in reference to surgical (20.6% vs 24%) and nonsurgical complications (28.6% vs 27.4%), early graft function, serum creatinine, and proteinuria. Recipients (95.4% vs 97.1%) and kidney-graft survival (93.1% vs 95.4%) were similar in both groups. The recipient factors that influenced the development of infectious complications were age, dialysis duration, pretransplant DM, and CVD. CONCLUSIONS Despite higher co-incidence of CVD and DM, the risk of surgical and nonsurgical complications in elderly recipients is comparable to younger recipients in the early period after KT.
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Affiliation(s)
- Damian Skrabaka
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland.
| | - Szymon Franczyk
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Sylwia Sekta
- The Polish Transplant Coordinating Centre Poltransplant, Warsaw, Poland
| | | | - Aleksander Owczarek
- Department of Statistics, Department of Instrumental Analysis, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, Katowice, Poland
| | - Zdenek Valenta
- Department of Statistical Modelling, Institute of Computer Science of the Czech Academy of Sciences, Prague, Czech Republic
| | - Robert Król
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Jacek Ziaja
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
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Long-Term Redistribution of Peripheral Lymphocyte Subpopulations after Switching from Calcineurin to mTOR Inhibitors in Kidney Transplant Recipients. J Clin Med 2020; 9:jcm9041088. [PMID: 32290462 PMCID: PMC7230655 DOI: 10.3390/jcm9041088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 01/04/2023] Open
Abstract
Classical immunosuppression based on steroids, calcineurin inhibitors, and mycophenolate results in several unwanted effects and unsatisfactory long-term outcomes in kidney transplantation (KT). New immunosuppressors search for fewer adverse events and increased graft survival but may have a distinct impact on graft function and immunological biomarkers according to their mechanism of action. This prospective study evaluates the immunological effect of tacrolimus to serine/threonine protein kinase mechanistic target of rapamycin inhibitors (mTORi) conversion in 29 KT recipients compared with 16 controls maintained on tacrolimus. We evaluated renal function, human leukocyte antigen (HLA) antibodies and peripheral blood lymphocyte subsets at inclusion and at 3, 12, and 24 months later. Twenty immunophenotyped healthy subjects served as reference. Renal function remained stable in both groups with no significant change in proteinuria. Two patients in the mTORi group developed HLA donor-specific antibodies and none in the control group (7% vs. 0%, p = 0.53). Both groups showed a progressive increase in regulatory T cells, more prominent in patients converted to mTORi within the first 18 months post-KT (p < 0.001). All patients showed a decrease in naïve B cells (p < 0.001), excepting those converted to mTORi without receiving steroids (p = 0.31). Transitional B cells significantly decreased in mTORi patients (p < 0.001), independently of concomitant steroid treatment. Finally, CD56bright and CD94/NK group 2 member A receptor positive (NKG2A+) Natural Killer (NK) cell subsets increased in mTORi- compared to tacrolimus-treated patients (both p < 0.001). Patients switched to mTORi displayed a significant redistribution of peripheral blood lymphocyte subpopulations proposed to be associated with graft outcomes. The administration of steroids modified some of these changes.
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33
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Renal transplantation in the elderly: Outcomes and recommendations. Transplant Rev (Orlando) 2020; 34:100530. [DOI: 10.1016/j.trre.2020.100530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/09/2019] [Accepted: 12/18/2019] [Indexed: 12/20/2022]
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34
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Troubleshooting Complex Vascular Cases in the Kidney Transplant Recipient: Vascular Anomalies, Challenging Vessel Diseases, and Procedural Disasters. Curr Urol Rep 2020; 21:7. [DOI: 10.1007/s11934-020-0958-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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35
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Varas J, Pérez-Sáez MJ, Ramos R, Merello JI, de Francisco ALM, Luño J, Praga M, Aljama P, Pascual J. Returning to haemodialysis after kidney allograft failure: a survival study with propensity score matching. Nephrol Dial Transplant 2020; 34:667-672. [PMID: 30053152 DOI: 10.1093/ndt/gfy215] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Patients who return to dialysis after kidney allograft failure (KAF) are classically considered to have lower survival rates than their transplant-naïve incident dialysis counterparts. However, this observation in previous comparisons could be due to poor matching between the two populations. METHODS To compare survival rates between patients who returned to haemodialysis (HD) after KAF versus transplant-naïve incident HD patients, we performed a retrospective study using the EuCliD® database (European Clinical Database) that collects data from Fresenius Medical Care (FMC) outpatient HD facilities in Spain. Propensity score matching (PSM) was performed to homogenize both populations. RESULTS This study included 5216 patients from 65 different FMC clinics between 2009 and 2014. Naïve incident HD patients were mostly male, older, comorbid and more commonly had catheters as vascular access. During the study follow-up, 3915 patients exited, of whom 1534 died. The mean survival time for the entire cohort was 4.86 years [95% confidence interval (CI) 4.78-4.94]. Univariate Cox analysis indicated higher mortality risk among transplant-naïve incident HD patients [hazard ratio (HR) 1.728; 95% CI 1.35-2.21; P < 0.001). However, this difference was no longer significant after multivariate adjustment. After applying PSM to minimize the bias due to indication issue, we obtained an adjusted population composed of 480 naïve and 240 KAF patients. The results analysing the PSM-adjusted cohort confirmed similar survival in both cohorts (log-rank, 3.34; P = 0.068; HR 1.382; 95% CI 0.97-1.95; P = 0.069). CONCLUSIONS When comparing properly matched patient groups, patients who return to HD after KAF present similar survival than survival than transplant-naïve incident patients.
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Affiliation(s)
- Javier Varas
- Medical Direction, Fresenius Medical Care, Madrid, Spain
| | | | - Rosa Ramos
- Medical Direction, Fresenius Medical Care, Madrid, Spain
| | | | | | - José Luño
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,RedInRen, Instituto de Salud Carlos III, Córdoba, Spain
| | - Manuel Praga
- RedInRen, Instituto de Salud Carlos III, Córdoba, Spain.,Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pedro Aljama
- RedInRen, Instituto de Salud Carlos III, Córdoba, Spain.,Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain.,Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,RedInRen, Instituto de Salud Carlos III, Córdoba, Spain
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36
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Assessing the Limits in Kidney Transplantation: Use of Extremely Elderly Donors and Outcomes in Elderly Recipients. Transplantation 2020; 104:176-183. [DOI: 10.1097/tp.0000000000002748] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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37
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Gandolfini I, Regolisti G, Bazzocchi A, Maggiore U, Palmisano A, Piotti G, Fiaccadori E, Sabatino A. Frailty and Sarcopenia in Older Patients Receiving Kidney Transplantation. Front Nutr 2019; 6:169. [PMID: 31781571 PMCID: PMC6861371 DOI: 10.3389/fnut.2019.00169] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 12/14/2022] Open
Abstract
Kidney transplantation is the treatment of choice for most of the patients with end-stage renal disease (ESRD). It improves quality of life, life expectancy, and has a lower financial burden to the healthcare system in comparison to dialysis. Every year more and more older patients are included in the kidney transplant waitlist. Within this patient population, transplanted subjects have better survival and quality of life as compared to those on dialysis. It is therefore crucial to select older patients who may benefit from renal transplantation, as well as those particularly at risk for post-transplant complications. Sarcopenia and frailty are frequently neglected in the evaluation of kidney transplant candidates. Both conditions are interrelated complex geriatric syndromes that are linked to disability, aging, comorbidities, increased mortality, and graft failure post-transplantation. Chronic kidney disease (CKD) and more importantly ESRD are characterized by multiple metabolic complications that contribute for the development of sarcopenia and frailty. In particular, anorexia, metabolic acidosis and chronic low-grade inflammation are the main contributors to the development of sarcopenia, a key component in frail transplant candidates and recipients. Both frailty and sarcopenia are considered to be reversible. Frail patients respond well to multiprofessional interventions that focus on the patients' positive frailty criteria, while physical rehabilitation and oral supplementation may improve sarcopenia. Prospective studies are still needed to evaluate the utility of formally measuring frailty and sarcopenia in the older candidates to renal transplantation as part of the transplant evaluation process.
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Affiliation(s)
- Ilaria Gandolfini
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Umberto Maggiore
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alessandra Palmisano
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giovanni Piotti
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma & Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Alice Sabatino
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
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38
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Golshayan D, Pascual M. Burden of end-stage renal disease and evolving challenges in kidney transplantation. Transpl Int 2019; 32:889-891. [PMID: 31393653 DOI: 10.1111/tri.13490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Dela Golshayan
- Transplantation Centre and Transplantation Immunopathology Laboratory, Departments of Medicine and Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Centre and Transplantation Immunopathology Laboratory, Departments of Medicine and Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
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39
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Basu A, Rosen LM, Tan HP, Fishbein J, Wu CM, Donaldson JB, Stuart S, Shah NA, McCauley J, Humar A, Shapiro R. Outcomes of Deceased Donor Kidney Transplantation Using Expanded Criteria Donor Kidneys Following Pulsatile Preservation. Cureus 2019; 11:e5091. [PMID: 31523526 PMCID: PMC6728786 DOI: 10.7759/cureus.5091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim We compared the outcomes of transplanting expanded criteria donor (ECD) kidneys undergoing machine perfusion (MP) versus cold storage (CS). Material and methods Data on all expanded criteria deceased donor kidney transplants performed at the University of Pittsburgh Medical Center from January 2003 through December 2012 were collected from an in-house electronic repository. There were 78 patients in the MP group and 101 patients in the CS group. The majority of the ECD kidneys were imported from other organ procurement organizations: 69 of 73 in the MP group (94.5%, 5 from unknown sources); and 90 of 99 in the CS group (91%), 2 from an unknown source). Most of the patients in the MP group (77 of 78) received a combination of MP and static CS. MP was performed just prior to transplantation in all MP patients. We used descriptive statistics to characterize our sample. We used logistic regression analysis to model the binary outcome of delayed graft function (DGF; i.e., “yes/no”) and Cox (proportional hazard) regression to model time until graft failure. The Kaplan-Meier product-limit method was used to estimate survival curves for graft and patient survival. Results A total of 179 transplants were done from ECD donors (MP, 78; CS, 101). The mean static cold storage time was 14 ± 4.1 hours and the mean machine perfusion time was 11.2 ± 6.3 hours in the MP group. The donor creatinine was higher (1.3 ± 0.6 mg/dl vs. 1.2 ± 0.4 mg/dl, p = 0.01) and the cold ischemia time was longer (28.9 ± 10 hours vs. 24 ± 7.9 hours, p = 0.0003) in the MP patients. There were no differences between the two groups in DGF rate (20.8% [MP] vs. 25.8% [CS], p = 0.46), six-year patient survival (74% [MP] vs. 63.2% [CS], p = 0.11), graft survival (64.3% [MP] vs. 51.5% [CS], p = 0.22), and serum creatinine levels (1.5 mg/dl vs. 1.5 mg/dl) on univariate analysis. On unadjusted analysis, MP subjects without DGF had longer graft survival compared to CS subjects with DGF (p < 0.0032) and MP subjects with DGF (p < 0.0005). MP subjects without DGF had longer death-censored graft survival compared to CS subjects with DGF (p < 0.0077) and MP subjects with DGF (p < 0.0016). However, on regression analysis, MP subjects had longer graft survival than CS subjects when DGF was not present. MP subjects without DGF had longer patient survival compared to CS subjects with DGF (p < 0.0289), on unadjusted analysis. MP subjects had a reduced risk of graft failure (hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.17, 0.68) and death-censored graft failure (HR, 0.44; 95% CI, 0.19, 1.00), compared to CS subjects when DGF was not present. Conclusions Reduction of DGF rates for imported ECD kidneys is vital to optimize outcomes and increase their utilization. One strategy to decrease DGF rates may be to reduce static CS time during transportation, by utilizing a portable kidney perfusion machine.
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Affiliation(s)
- Amit Basu
- Surgery, Jamaica Hospital Medical Center, New York, USA
| | | | - Henkie P Tan
- Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Joanna Fishbein
- Biostatistics, Feinstein Institute of Medical Research, Manhasset, USA
| | - Christine M Wu
- Nephrology, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Joseph B Donaldson
- Bio-Informatics, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Susan Stuart
- Miscellaneous, Organ Procurement Organization, Center for Organ Recovery and Education, Pittsburgh, USA
| | - Nirav A Shah
- Nephrology, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Jerry McCauley
- Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Abhinav Humar
- Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Ron Shapiro
- Surgery, Recanati-Miller Transplantation Institute, the Mount Sinai Hospital, New York, USA
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40
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Pérez-Sáez MJ, Lafuente Covarrubias O, Hernández D, Moreso F, Melilli E, Juega J, de Sousa E, López-Sánchez P, Rodríguez-Ferrero ML, Maruri-Kareaga N, Navarro MD, Valero R, Mazuecos MA, Llamas F, Martín-Moreno P, Fernández-García A, Espí J, Jiménez C, Ramos A, Gavela E, Pascual J, Portolés JM. Early outcomes of kidney transplantation from elderly donors after circulatory death (GEODAS study). BMC Nephrol 2019; 20:233. [PMID: 31242927 PMCID: PMC6593497 DOI: 10.1186/s12882-019-1412-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 06/06/2019] [Indexed: 01/20/2023] Open
Abstract
Background Spain has dramatically increased the number of controlled circulatory death donors (cDCD). The initial selection criteria for considering cDCD for kidney transplantation (KT) have been expanded progressively, with practically no limits in donor age during the last years. We aimed to analyze the early clinical outcomes using expanded (> 65 years) cDCD in comparison with standard ones. Methods Observational multicenter study including 19 transplant centers in Spain. We performed a systematic inclusion in a central database of every KT from expanded cDCD at each participant unit from January-2012 to January-2017. Surgical procedures and immunosuppressive protocols were based on local practices. Data was analyzed in the central office using logistic and Cox regression or competitive-risk models for multivariate analysis. Median time of follow-up was 18.1 months. Results 561 KT were performed with kidneys from cDCD, 135 from donors older than 65 years. As expected, recipients from older cDCD were also older (65.8 (SD 8.8) vs 53.7 (SD 11.4) years; p < 0.001) and with higher comorbidity. At 1 year, no differences were found amongst older and younger cDCD KT recipients in terms of serum creatinine (1.6 (SD 0.7) vs 1.5 (SD 0.8) mg/dl; p = 0.29). Non-death censored graft survival was inferior, but death-censored graft survival was not different (95.5 vs 98.2% respectively; p = 0.481). They also presented a trend towards higher delayed graft function (55.4 vs 46.7%; p = 0.09) but a similar rate of primary non-function (3.7 vs 3.1%; p = 0.71), and acute rejection (3.0 vs 6.3%; p = 0.135). In the multivariate analysis, in short follow-up, donor age was not related with worse survival or poor kidney function (eGFR < 30 ml/min). Conclusions The use of kidneys from expanded cDCD is increasing for older and comorbid patients. Short-term graft outcomes are similar for expanded and standard cDCD, so they constitute a good-enough source of kidneys to improve the options of KT wait-listed patients.
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Affiliation(s)
- María José Pérez-Sáez
- Nephrology Department and Kidney Transplantation Program, Hospital del Mar, Parc de Salut Mar, Universitat Autónoma Barcelona and Universitat Pompeu Fabra, Nephropaties Research Group Institute Mar for Medical Research, Passeig Maritim 25-29, 08003, Barcelona, Spain
| | - Omar Lafuente Covarrubias
- Nephrology & Transplant Department, University Hospital Puerta de Hierro, Universidad Autónoma Madrid, Public Research Net RedInRen ISCIII 016/009, C/Manuel de Falla s/n, 28222, Majadahonda, Madrid, Spain
| | | | | | | | | | | | - Paula López-Sánchez
- Nephrology & Transplant Department, University Hospital Puerta de Hierro, Universidad Autónoma Madrid, Public Research Net RedInRen ISCIII 016/009, C/Manuel de Falla s/n, 28222, Majadahonda, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | - Julio Pascual
- Nephrology Department and Kidney Transplantation Program, Hospital del Mar, Parc de Salut Mar, Universitat Autónoma Barcelona and Universitat Pompeu Fabra, Nephropaties Research Group Institute Mar for Medical Research, Passeig Maritim 25-29, 08003, Barcelona, Spain.
| | - Jose M Portolés
- Nephrology & Transplant Department, University Hospital Puerta de Hierro, Universidad Autónoma Madrid, Public Research Net RedInRen ISCIII 016/009, C/Manuel de Falla s/n, 28222, Majadahonda, Madrid, Spain.
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Llinàs-Mallol L, Redondo-Pachón D, Pérez-Sáez MJ, Raïch-Regué D, Mir M, Yélamos J, López-Botet M, Pascual J, Crespo M. Peripheral blood lymphocyte subsets change after steroid withdrawal in renal allograft recipients: a prospective study. Sci Rep 2019; 9:7453. [PMID: 31092833 PMCID: PMC6520389 DOI: 10.1038/s41598-019-42913-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 04/10/2019] [Indexed: 12/19/2022] Open
Abstract
Several studies have assessed clinical outcomes after steroid withdrawal (SW) in kidney transplant (KT) recipients, but little is known about its potential impact on lymphocyte subpopulations. We designed a prospective study to evaluate the long-term impact of SW in 19 KT recipients compared to 16 KT recipients without changes in immunosuppression (steroid maintenance, SM). We assessed renal function, presence of HLA antibodies and peripheral blood lymphocyte subsets at time of inclusion, and 3, 12 and 24 months later. The immunophenotype of 20 healthy subjects was also analyzed. Serum creatinine and proteinuria remained stable in SW and SM patients. SW did not associate with generation of de novo donor-specific antibodies. SW patients showed decreases in T-lymphocytes (p < 0.001), and in the CD4+ T cell subpopulation (p = 0.046). The proportion of B-lymphocytes (p = 0.017), and both naïve and transitional B cells increased compared to SM patients (p < 0.001). Changes in B cell subsets were detected 3 months after SW and persisted for 24 months. No changes were observed in NK cells related to steroid withdrawal. SW patients displayed significant changes in peripheral T and B cell subsets, transitioning to the phenotype detected in healthy subjects. This may be considered as a maintained positive effect of SW previously unnoticed.
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Affiliation(s)
- Laura Llinàs-Mallol
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Institute Hospital del Mar for Medical Research, Barcelona, Spain
| | - Dolores Redondo-Pachón
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Institute Hospital del Mar for Medical Research, Barcelona, Spain
| | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Institute Hospital del Mar for Medical Research, Barcelona, Spain
| | - Dàlia Raïch-Regué
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Institute Hospital del Mar for Medical Research, Barcelona, Spain
| | - Marisa Mir
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - José Yélamos
- Institute Hospital del Mar for Medical Research, Barcelona, Spain
- Department of Immunology, Hospital del Mar, Barcelona, Spain
| | - Miguel López-Botet
- Institute Hospital del Mar for Medical Research, Barcelona, Spain
- Department of Immunology, Hospital del Mar, Barcelona, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.
- Institute Hospital del Mar for Medical Research, Barcelona, Spain.
| | - Marta Crespo
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.
- Institute Hospital del Mar for Medical Research, Barcelona, Spain.
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Immune Responses of HLA Highly Sensitized and Nonsensitized Patients to Genetically Engineered Pig Cells. Transplantation 2019; 102:e195-e204. [PMID: 29266033 DOI: 10.1097/tp.0000000000002060] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND We investigated in vitro whether HLA highly sensitized patients with end-stage renal disease will be disadvantaged immunologically after a genetically engineered pig kidney transplant. METHODS Blood was drawn from patients with a calculated panel-reactive antibody (cPRA) 99% to 100% (Gp1, n = 10) or cPRA 0% (Gp2, n = 12), and from healthy volunteers (Gp3, n = 10). Serum IgM and IgG binding was measured (i) to galactose-α1-3 galactose and N-glycolylneuraminic acid glycans by enzyme-linked immunosorbent assay, and (ii) to pig red blood cell, pig aortic endothelial cells, and pig peripheral blood mononuclear cell from α1,3-galactosyltransferase gene-knockout (GTKO)/CD46 and GTKO/CD46/cytidine monophosphate-N-acetylneuraminic acid hydroxylase-knockout (CMAHKO) pigs by flow cytometry. (iii) T-cell and B-cell phenotypes were determined by flow cytometry, and (iv) proliferation of T-cell and B-cell carboxyfluorescein diacetate succinimidyl ester-mixed lymphocyte reaction. RESULTS (i) By enzyme-linked immunosorbent assay, there was no difference in IgM or IgG binding to galactose-α1-3 galactose or N-glycolylneuraminic acid between Gps1 and 2, but binding was significantly reduced in both groups compared to Gp3. (ii) IgM and IgG binding in Gps1 and 2 was also significantly lower to GTKO/CD46 pig cells than in healthy controls, but there were no differences between the 3 groups in binding to GTKO/CD46/CMAHKO cells. (iii and iv) Gp1 patients had more memory T cells than Gp2, but there was no difference in T or B cell proliferation when stimulated by any pig cells. The proliferative responses in all 3 groups were weakest when stimulated by GTKO/CD46/CMAHKO pig peripheral blood mononuclear cell. CONCLUSIONS (i) End-stage renal disease was associated with low antipig antibody levels. (ii) Xenoreactivity decreased with increased genetic engineering of pig cells. (iii) High cPRA status had no significant effect on antibody binding or T-cell and B-cell response.
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Lemoine M, Titeca Beauport D, Lobbedez T, Choukroun G, Hurault de Ligny B, Hazzan M, Guerrot D, Bertrand D. Risk Factors for Early Graft Failure and Death After Kidney Transplantation in Recipients Older Than 70 Years. Kidney Int Rep 2019; 4:656-666. [PMID: 31080920 PMCID: PMC6506713 DOI: 10.1016/j.ekir.2019.01.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 01/23/2023] Open
Abstract
Introduction Although kidney transplantation carries a survival benefit compared with dialysis, mortality, especially the first year after transplantation, is high in recipients older than 70. The aim of this study was to evaluate early death and graft failure, and to determine the risk factors associated with these events in this specific population. Methods All patients older than 70 years who received a kidney transplant between January 2000 and December 2014 in the North-West of France were included (n = 171). Baseline characteristics and outcomes after transplantation were studied. Kaplan-Meier analysis was performed to assess patient and graft survival, and Cox regression analysis to evaluate risk factors for graft failure and patient death. Results The mean recipient age was 73.3 ± 2.5 years. Death-censored graft survival at 1, 3, and 5 years were 82.6%, 78.7%, and 75.4%, respectively. Patient survival at 1, 3, and 5 years was 90.1%, 82.5%, and 68.1%, respectively. One year after transplantation, 17 patients (9.9%) were dead, mainly from infectious (58.5%) or cardiovascular disease (29.4%). According to the Cox multivariate analysis, the independent risk factors for death or graft failure during the first year were arrhythmia (odds ratio [OR] 2.26; 95% confidence interval [CI] 1.08–4.8), left-ventricular ejection fraction (LVEF) under 56% (OR 2.38; 95% CI 1.18–4.83), human leucocyte antigen (HLA) antibodies (OR 2.1; 95% CI 1.04–4.2), deceased donor from cardiovascular cause (OR 5.18; 95% CI 1.22–6.3), and acute rejection (OR 2.77; 95% CI 1.2–6.3). Conclusion In kidney transplant recipients older than 70 years, cardiac evaluation and immunosuppression optimization seem to be crucial to improve short-term patient and graft survival.
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Affiliation(s)
- Mathilde Lemoine
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
| | | | - Thierry Lobbedez
- Department of Nephrology, Centre Hospitalo-Universitaire de Caen, Caen, France
| | - Gabriel Choukroun
- Department of Nephrology, Centre Hospitalo-Universitaire d'Amiens, Amiens, France
| | | | - Marc Hazzan
- Department of Nephrology, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Dominique Guerrot
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France.,INSERM U1096, Rouen, France
| | - Dominique Bertrand
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
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44
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Kidney Transplantation in Elderly Recipients: A Single-Center Experience. Transplant Proc 2019; 51:132-135. [DOI: 10.1016/j.transproceed.2018.04.081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/02/2018] [Accepted: 04/13/2018] [Indexed: 02/02/2023]
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Abstract
Human immunodeficiency virus (HIV) has become a chronic disease with a near normal life span resulting in increased risk of organ failure. HIV organ transplantation is a proven and accepted intervention in appropriately selected cases. HIV-positive organ transplantation into HIV-positive recipients is in its nascent stages. Hepatitis C virus, high rates of organ rejection, and immune dysregulation are significant remaining barriers to overcome. This article provides an overview of the transplantation needs in the HIV population focusing on kidney and liver transplants.
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Affiliation(s)
- Alan J Taege
- Department of Infectious Disease, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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46
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Portolés JM, Pérez-Sáez MJ, López-Sánchez P, Lafuente-Covarrubias O, Juega J, Hernández D, Espí J, Navarro MD, Mazuecos MA, Rodríguez-Ferrero ML, Maruri-Kareaga N, Moreso F, Melilli E, de Souza E, Ruiz JC, Llamas F, Gutiérrez-Dalmau A, Guirado L, Martín-Moreno P, Pérez Flores I, Fernández-García A, Jiménez C, Gavela E, Ramos A, Pascual J. Kidney transplant from controlled donors following circulatory death: Results from the GEODAS-3 multicentre study. Nefrologia 2018; 39:151-159. [PMID: 30497696 DOI: 10.1016/j.nefro.2018.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/16/2018] [Accepted: 07/31/2018] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Many European countries have transplant programmes with controlled donors after cardiac death (cDCD). Twenty-two centres are part of GEODAS group. We analysed clinical results from a nephrological perspective. METHODS Observational, retrospective and multicentre study with systematic inclusion of all kidney transplant recipients from cDCD, following local protocols regarding extraction and immunosuppression. RESULTS A total of 335 cDCD donors (mean age 57.2 years) whose deaths were mainly due to cardiovascular events were included. Finally, 566 recipients (mean age 56.5 years; 91.9% first kidney transplant) were analysed with a median of follow-up of 1.9 years. Induction therapy was almost universal (thymoglobulin 67.4%; simulect 32.8%) with maintenance with prednisone-MMF-tacrolimus (91.3%) or combinations with mTOR (6.5%). Mean cold ischaemia time (CIT) was 12.3h. Approximately 3.4% (n=19) of recipients experienced primary non-function, essentially associated with CIT (only CIT ≥ 14 h was associated with primary non-function). Delayed graft function (DGF) was 48.8%. DGF risk factors were CIT ≥ 14 h OR 1.6, previous haemodialysis (vs. peritoneal dialysis) OR 2.1 and donor age OR 1.01 (per year). Twenty-one patients (3.7%) died with a functioning graft, with a recipient and death-censored graft survival at 2-years of 95% and 95.1%, respectively. The estimated glomerular filtration rate at one year of follow-up was 60.9 ml/min. CONCLUSIONS CIT is a modifiable factor for improving the incidence of primary non-function in kidney transplant arising from cDCD. cDCD kidney transplant recipients have higher delayed graft function rate, but the same patient and graft survival compared to brain-dead donation in historical references. These results are convincing enough to continue fostering this type of donation.
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Affiliation(s)
| | | | | | | | - Javier Juega
- Hospital Universitario Germán Trías y Pujol, Barcelona, España
| | | | - Jordi Espí
- Hospital Universitario La Fe, Valencia, España
| | | | | | | | | | | | | | - Erika de Souza
- Hospital Universitario Clinic de Barcelona, Barcelona, España
| | | | | | | | | | | | | | | | | | - Eva Gavela
- Hospital Universitario Dr. Peset, Valencia, España
| | - Ana Ramos
- Fundación Jiménez Díaz, Madrid, España
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47
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Legeai C, Andrianasolo RM, Moranne O, Snanoudj R, Hourmant M, Bauwens M, Soares J, Jacquelinet C, Couchoud C, Macher MA. Benefits of kidney transplantation for a national cohort of patients aged 70 years and older starting renal replacement therapy. Am J Transplant 2018; 18:2695-2707. [PMID: 30203618 DOI: 10.1111/ajt.15110] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/20/2018] [Accepted: 08/08/2018] [Indexed: 02/06/2023]
Abstract
Our objectives were to evaluate kidney transplantation survival benefit in people aged ≥70 who were receiving renal replacement therapy (RRT) and to identify their risk factors for posttransplant mortality. This study included all patients in the national French Renal Epidemiology and Information Network registry who started RRT between 2002 and 2013 at age ≥70. Mortality risk was compared between patients with transplants; on the waiting list; and on dialysis matched for age, gender, comorbidities, and time on dialysis. Of the 41 716 elderly patients starting RRT, 1219 (2.9%) were on the waiting list and 877 (2.1%) underwent transplantation during the follow-up. Until month 3, transplant patients had a risk of death triple that of the wait-listed group. Although the risk was halved at month 9, the perioperative risk was still not offset by month 36. Compared with matched dialysis patients (n = 2183), transplant patients were not at significantly increased perioperative risk and had a lower mortality risk starting at month 3. Risk factors for posttransplant mortality were diabetes, cardiovascular comorbidities, and dialysis duration >2 years. Among older dialysis patients, 20% had neither cardiovascular comorbidity nor diabetes. Systematic early assessment of the eligibility of elderly patients for kidney transplantation is recommended to expand registration to patients with poor survival on dialysis and no cardiovascular comorbidity.
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Affiliation(s)
- Camille Legeai
- Organ and Tissue Procurement and Transplantation Department, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Roland M Andrianasolo
- Organ and Tissue Procurement and Transplantation Department, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Olivier Moranne
- Nephrologie-Dialyses-Apherese Department, Carémeau University Hospital, Nîmes, France.,IURC, EA 2415, LBERC, Montpellier University, Nîmes, France
| | - Renaud Snanoudj
- Nephrology and Transplantation Department, Foch Hospital, Suresnes, France.,Inserm U1018, Team 5, CESP, Versailles Saint-Quentin-en-Yvelines University, Paris Saclay University, Villejuif, France
| | | | | | - Joaquim Soares
- National Federation for Aid to Renal Insufficiency patients, Paris, France
| | | | - Cécile Couchoud
- REIN registry, Agence de la biomédecine, Saint Denis la Plaine, France
| | - Marie-Alice Macher
- Organ and Tissue Procurement and Transplantation Department, Agence de la biomédecine, Saint Denis La Plaine, France
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Development and validation of a prognostic model for kidney function 1 year after combined pancreas and kidney transplantation using pre-transplant donor and recipient variables. Langenbecks Arch Surg 2018; 403:837-849. [PMID: 30338375 PMCID: PMC6244698 DOI: 10.1007/s00423-018-1712-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 09/17/2018] [Indexed: 01/20/2023]
Abstract
Purpose The widening gap between demand and supply of organs for transplantation provides extraordinary challenges for ethical donor organ allocation rules. The transplant community is forced to define favorable recipient/donor combinations for simultaneous kidney-pancreas transplantation. The aim of this study is the development of a prognostic model for the prediction of kidney function 1 year after simultaneous pancreas and kidney transplantation using pre-transplant donor and recipient variables with subsequent internal and external validation. Methods Included were patients with end-stage renal failure due to diabetic nephropathy. Multivariable logistic regression modeling was applied for prognostic model design with retrospective data from Hannover Medical School, Germany (01.01.2000–31.12.2011) followed by prospective internal validation (01 Jan. 2012–31 Dec. 2015). Retrospective data from another German transplant center in Kiel was retrieved for external model validation via the initially derived logit link function. Results The developed prognostic model is able to predict kidney graft function 1 year after transplantation ≥ KDIGO stage III with high areas under the receiver operating characteristic curve in the development cohort (0.943) as well as the internal (0.807) and external validation cohorts (0.784). Conclusion The proposed validated model is a valuable tool to optimize present allocation rules with the goal to prevent transplant futility. It might be used to support donor organ acceptance decisions for individual recipients. Electronic supplementary material The online version of this article (10.1007/s00423-018-1712-z) contains supplementary material, which is available to authorized users.
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Cimeno A, Munley J, Drachenberg C, Weir M, Haririan A, Bromberg J, Barth RN, Scalea JR. Diabetic nephropathy after kidney transplantation in patients with pretransplantation type II diabetes: A retrospective case series study from a high-volume center in the United States. Clin Transplant 2018; 32:e13425. [PMID: 30326148 DOI: 10.1111/ctr.13425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with type II diabetes mellitus (DM) undergoing renal transplantation are at risk of diabetic nephropathy (DN) in the transplanted kidney. The true risk of developing post-transplantation DN is unknown, and post-transplantation DN is poorly characterized in the literature. METHODS The biopsy database at the University of Maryland Medical Center was queried for kidney transplant biopsies which demonstrated evidence of DN. The time from transplantation to biopsy-proven DN (time to diagnosis, TTD) was calculated and analyzed in the context of demographics, serum creatinine, and onset of diabetes. By extrapolating the total number of patients who developed DN in the last 2 years, we estimated the recurrence rate of DN. RESULTS Sixty patients whose renal biopsies met criteria were identified. The mean age was 56.6 (±1.58) years, and the mean creatinine level at time of biopsy was 1.65 (±0.12) mg/dL. Simultaneous pathological diagnoses were frequent on kidney biopsy; rejection was present at variable rates: classes I, IIA, IIB, and III were 5.0%, 66.7%, 18.4%, and 10%, respectively. The mean TTD was 1456 (±206) days. TTD was significantly shorter for patients receiving a cadaveric vs living donor renal transplant (1118 ± 184 vs 2470 ± 547 days, P = 0.004). Older patients (r = 0.378, P = 0.003) and patients with higher serum creatinine (r = 0.282, P = 0.029) had shorter TTDs. Extrapolations showed that 74.7% of patients would be free of DN 10 years after renal transplantation. CONCLUSIONS Diabetic nephropathy occurs after transplantation, and this appears to be due to both donor and recipient-derived factors. Encouragingly, our estimates suggest that as many as 75% of patients may be free of DN at 10 years following kidney transplantation.
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Affiliation(s)
- Arielle Cimeno
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Munley
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cinthia Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew Weir
- Department of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Abdolreza Haririan
- Department of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf N Barth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph R Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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50
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Franczyk S, Skrabaka D, Jędrusik E, Ziaja J, Kolonko A, Świder R, Sekta S, Czerwiński J, Owczarek A, Durlik M, Więcek A, Cierpka L, Król R. Results of Transplantation of Kidneys Procured From Donors After Brain Death Aged 60 Years and Older. Transplant Proc 2018; 50:1674-1679. [DOI: 10.1016/j.transproceed.2018.02.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/06/2018] [Indexed: 12/17/2022]
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