Living donor age and kidney transplant outcomes

An observational cohort study examined the change point of kidney function stabilization in the initial period after transplantation

Baseline kidney function following kidney transplantation is often used in research and clinical decision-making yet is not well defined. Here, a method to determine baseline function was proposed and validated on three single-center retrospective cohorts consisting of 922 patients from Belgium (main cohort) and two validation cohorts of 987 patients from the Netherlands and 519 patients from Germany. For each transplant, a segmented regression model was fitted on the estimated glomerular filtration rate (eGFR) evolution during the first-year post-transplantation. This yielded estimates for change point timing, rate of eGFR change before and after change point and eGFR value at change point, now considered the "baseline function". Associations of eGFR evolution with recipient/donor characteristics and the graft failure rate were assessed with linear regression and Cox regression respectively. The change point occurred on average at an eGFR value of 43.7±14.6 mL/min/1.73m2, at a median time of 6.5 days post-transplantation. Despite significant associations with several baseline donor-recipient characteristics (particularly, donor type; living vs deceased), the predictive value of these characteristics for eGFR value and timing of the change point was limited. This followed from a large heterogeneity within eGFR trajectories, which in turn indicated that favorable levels of kidney function could be reached despite a suboptimal initial evolution. Segmented regression consistently provided a good fit to early eGFR evolution, and its estimate of the change point can be a useful reference value in future analyses. Thus, our study shows that baseline kidney function after transplantation is heterogeneous and partly related to pretransplant donor characteristics.

Clinical relevance of the living kidney donor profile index in Korean kidney transplant recipients

BACKGROUND

The Living Kidney Donor Profile Index (LKDPI) was developed in the United States to predict graft outcomes based on donor characteristics. However, there are significant differences in donor demographics, access to transplantation, proportion of ABO incompatibility, and posttransplant mortality in Asian countries compared with the United States.

METHODS

We evaluated the clinical relevance of the LKDPI score in a Korean kidney transplant cohort by analyzing 1860 patients who underwent kidney transplantation between 2000 and 2019. Patients were divided into three groups according to LKDPI score: <0, 1-19.9, and ≥20.

RESULTS

During a median follow-up of 119 months, 232 recipients (12.5%) experienced death-censored graft loss, and 98 recipients (5.3%) died. High LKDPI scores were significantly associated with increased risk of death-censored graft loss independent of recipient characteristics (LKDPI 1-19.9: HR 1.389, 95% CI 1.036-1.863; LKDPI ≥20: HR 2.121, 95% CI 1.50-2.998). High LKDPI score was also significantly associated with increased risk of biopsy-proven acute rejection and impaired graft renal function. By contrast, overall patient survival rates were comparable among the LKDPI groups.

CONCLUSION

High LKDPI scores were associated with an increased risk of death-censored graft loss, biopsy-proven acute rejection, and impaired graft renal function among a Korean kidney transplant cohort.

Living Donors' Age Modifies the Impact of Pre-Donation Estimated Glomerular Filtration Rate on Graft Survival

BACKGROUND

The global scarcity of organs for kidney transplants (KTs) has led to the increased acceptance of living donors (LDs) with minor abnormalities to increase the donor pool.. We sought to evaluate the effects of some of these LDs' clinical characteristics (older age, borderline renal function, hypertension, dyslipidemia, smoking, and obesity) on graft outcomes.

METHODS

We studied 352 recipients of LDKTs (1998-2020). Firstly, considering the recipients and KT variables, we identified relevant predictors of overall and censored graft failure (GF). Then, adjusting for these predictors, we explored LD variables as predictors of overall and censored GF in a multivariable Cox model.

RESULTS

The recipients from LD with higher eGFR (≥90 mL/min/1.73 m2) had significantly better overall and censored graft survival GS) at 15 y after KT (respectively, 67 and 75% vs. 46 and 46%, p < 0.001). Importantly, none of the remaining LD factors which were evaluated (hypertension, dyslipidemia, smoking, proteinuria, and obesity) were independent predictors of GF. In recipients from LDs < 50 y, having an eGFR < 90 was an independent predictor of overall GF [adjusted HR (95%CI) of 2.578 (1.120-5.795)] and censored GF [adjusted HR (95%CI) of 3.216 (1.300-7.959)], compared to recipients from LDs with eGFR ≥ 90. Contrarily, when donors were older, no difference in the risk of GF was observed between eGFR categories.

CONCLUSION

In our cohort, lower pre-donation eGFR had an impact on GS only in younger LDs. An age-adjusted eGFR cutoff may be pursued for improved donor admissibility.

Pathophysiology of Rejection in Kidney Transplantation

Kidney transplantation has been the optimal treatment for end-stage kidney disease for almost 70 years, with increasing frequency over this period. Despite the prevalence of the procedure, allograft rejection continues to impact transplant recipients, with consequences ranging from hospitalization to allograft failure. Rates of rejection have declined over time, which has been largely attributed to developments in immunosuppressive therapy, understanding of the immune system, and monitoring. Developments in these therapies, as well as an improved understanding of rejection risk and the epidemiology of rejection, are dependent on a foundational understanding of the pathophysiology of rejection. This review explains the interconnected mechanisms behind antibody-mediated and T-cell-mediated rejection and highlights how these processes contribute to outcomes and can inform future progress.

The Kidney Donor Profile Index (KDPI) Correlates With Histopathologic Findings in Post-reperfusion Baseline Biopsies and Predicts Kidney Transplant Outcome

Background

The increasing organ shortage in kidney transplantation leads to the necessity to use kidneys previously considered unsuitable for transplantation. Numerous studies illustrate the need for a better decision guidance rather than only the classification into kidneys from standard or expanded criteria donors referred to as SCD/ECD-classification. The kidney donor profile index (KDPI) exhibits a score utilizing a much higher number of donor characteristics. Moreover, graft biopsies provide an opportunity to assess organ quality.

Methods

In a single center analysis 383 kidney transplantations (277 after deceased and 106 after living donation) performed between January 1st, 2006, and December 31st, 2016, retrospectively underwent SCD/ECD and KDPI scoring. Thereby, the quality of deceased donor kidneys was assessed by using the KDPI and the living donor kidneys by using the living KDPI, in the further analysis merged as (L)KDPI. Baseline biopsies taken 10 min after the onset of reperfusion were reviewed for chronic and acute lesions. Survival analyses were performed using Kaplan-Meier analysis and Cox proportional hazards analysis within a 5-year follow-up.

Results

The (L)KDPI correlated with glomerulosclerosis (r = 0.30, p < 0.001), arteriosclerosis (r = 0.33, p < 0.001), interstitial fibrosis, and tubular atrophy (r = 0.28, p < 0.001) as well as the extent of acute tubular injury (r = 0.20, p < 0.001). The C-statistic of the (L)KDPI concerning 5-year death censored graft survival was 0.692. Around 48% of ECD-kidneys were classified as (L)KDPI<85%. In a multivariate Cox proportional hazard analysis including (preformed) panel reactive antibodies, cold ischemia time, (L)KDPI, and SCD/ECD-classification, the (L)KDPI was significantly associated with risk of graft loss (hazard ratio per 10% increase in (L)KDPI: 1.185, 95% confidence interval: 1.033–1.360, p = 0.025). Survival analysis revealed decreased death censored (p < 0.001) and non-death censored (p < 0.001) graft survival in kidneys with an increasing (L)KDPI divided into groups of <35, 35–85, and >85%, respectively.

Conclusion

With a higher granularity compared to the SCD/ECD-classification the (L)KDPI is a promising tool to judge graft quality. The correlation with chronic and acute histological lesions in post-reperfusion kidney biopsies underlines the descriptive value of the (L)KDPI. However, its prognostic value is limited and underlines the urgent need for a more precise prognostic tool adopted to European kidney transplant conditions.

Clinical Events and Renal Function in the First Year Predict Long-Term Kidney Transplant Survival

BACKGROUND

Estimated glomerular filtration rate (eGFR) at 1 year post transplantation has been shown to be a strong predictor of long-term graft survival. However, intercurrent events (ICEs) may affect the relationship between eGFR and failure risk.

METHODS

The OPTN and USRDS databases on single-organ kidney transplant recipients from 2012 to 2016 were linked. Competing risk regressions estimated adjusted subhazard ratios (SHRs) of 12-month eGFR on long-term graft failure, considering all-cause mortality as the competing risk, for deceased donor (DD) and living donor (LD) recipients. Additional predictors included recipient, donor, and transplant characteristics. ICEs examined were acute rejection, cardiovascular events, and infections.

RESULTS

Cohorts comprised 25,131 DD recipients and 7471 LD recipients. SHRs for graft failure increased rapidly as 12-month eGFR values decreased from the reference 60 ml/min per 1.73 m². At an eGFR of 20 ml/min per 1.73 m², SHRs were 13-15 for DD recipients and 12-13 for LD recipients; at an eGFR of 30 ml/min per 1.73 m², SHRs were 5.0-5.7 and 5.0-5.5, respectively. Among first-year ICEs, acute rejection was a significant predictor of long-term graft failure in both DD (SHR=1.63, P<0.001) and LD (SHR=1.51, P=0.006) recipients; cardiovascular events were significant in DD (SHR=1.24, P<0.001), whereas non-CMV infections were significant in the LD cohort (SHR=1.32, P=0.03). Adjustment for ICEs did not significantly reduce the association of eGFR with graft failure.

CONCLUSIONS

Twelve-month eGFR is a strong predictor of long-term graft failure after accounting for clinical events occurring from discharge to 1 year. These findings may improve patient management and clinical evaluation of novel interventions.

Personalized Prediction of Kidney Function Decline and Network Analysis of the Risk Factors after Kidney Transplantation Using Nationwide Cohort Data

We developed a machine-learning-based model that could predict a decrease in one-year graft function after kidney transplantation, and investigated the risk factors of the decreased function. A total of 4317 cases were included from the Korean Organ Transplant Registry (2014−2019). An XGBoost model was trained to predict the recipient’s one-year estimated glomerular filtration rate (eGFR) below 45 mL/min/1.73 m2 using 112 pre- and peri-transplantation variables. The network of model factors was drawn using inter-factor partial correlations and the statistical significance of each factor. The model with seven features achieved an area under the curve of 0.82, sensitivity of 0.73, and specificity of 0.79. The model prediction was associated with five-year graft and rejection-free survival. Post-transplantation hospitalization >25 days and eGFR ≥ 88.0 were the prominent risk and preventive factors, respectively. Donor age and post-transplantation eGFR < 59.8 were connected to multiple risk factors on the network. Therefore, careful donor−recipient matching in older donors, and avoiding pre-transplantation risk factors, would reduce the risk of graft dysfunction. The model might improve long-term graft outcomes by supporting early detection of graft dysfunction, and proactive risk factor control.

Elderly kidney transplant recipients have favorable outcomes but increased infection-related mortality

Background

The number of elderly patients with end-stage kidney disease has been increasing, but the outcomes of kidney transplants (KT) remain poorly understood in elderly patients. Therefore, we evaluated the clinical outcomes of elderly KT recipients and analyzed the impact of elderly donors.

Methods

This retrospective cohort study included patients who underwent KT between 2000 and 2019. KT recipients were divided into four groups according to a combination of recipient and donor age (≥60 or <60 years); elderly recipients: old-to-old (n = 46) and young-to-old (n = 83); young recipients: old-to-young (n = 98) and young-to-young (n = 796). We compared the risks of mortality, graft failure, and acute rejection between groups using Cox regression analysis.

Results

The incidence of delayed graft function, graft failure, and acute rejection was not different among groups. Annual mean tacrolimus trough level was not lower in elderly recipients than young recipients during 10-year follow-up. Mortality was significantly higher in elderly recipients (p = 0.001), particularly infection-related mortality (p < 0.001). In multivariable Cox regression analysis, old-to-old and young-to-old groups had increased risk of mortality (adjusted hazard ratio [aHR], 2.89; 95% confidence interval [CI], 1.14–7.32; p = 0.03; aHR, 3.06; 95% CI, 1.51–6.20; p = 0.002). However, graft failure and acute rejection risks were not increased in elderly recipients.

Conclusion

In elderly recipients, graft survival and acute rejection-free survival were not inferior to those of young recipients. However, mortality, especially risk of infection-related death, was increased in elderly recipients. Thus, low immunosuppression intensity might help decrease mortality in elderly recipients.

Feasible kidney donation with living marginal donors, including diabetes mellitus

Objectives

To compare the donor outcomes of living donor kidney transplantation between standard donors (SDs) and marginal donors (MDs) including diabetic patients (MD + DM).

Methods

MDs were defined according to Japanese guideline criteria: (a) age >70‐years, (b) blood pressure ≤130/80 mmHg on hypertension medicine, (c) body mass index >25 to ≤32 kg/m², (d) 24‐h creatinine clearance ≥70 to <80 ml/min/1.73 m², and (e) hemoglobin A1c > 6.2 or ≤6.5 with oral diabetic medicine. Fifty‐three of 114 donors were MDs. We compared donor kidney functions until 60 months postoperatively.

Results

No kidney function parameters were different between SDs and MDs. When comparing SD and MD + DM, MD + DM had a lower postoperative eGFR (48 vs. 41 (1 (month), p = .02), 49 vs. 40 (12, p < .01), 48 vs. 42 (24, p = .04), 47 vs. 38 (36, p = .01)) and the percentage of residual eGFR (SD vs. MD + DM: 63 vs. 57 (1 (month), p < .01), 63 vs. 57 (2, p < .01), 64 vs. 56 (12, p < .01), 63 vs. 57 (24, p < .01), 63 vs. 52 (36, p = .02)). However, when MD with a single risk factor of DM was compared to SD, the difference disappeared. Nine out of 12 (75%) MD + DM had ≥2 risk factors.

Conclusions

Although long‐term observation of donor kidney function is necessary, careful MD + DM selection had the potential to expand the donor pool.

HbA1c and Aortic Calcification Index as Noninvasive Predictors of Pre-Existing Histopathological Damages in Living Donor Kidney Transplantation

We previously reported that allografts from living donors may have pre-existing histopathological damages, defined as the combination of interstitial fibrosis (ci), tubular atrophy (ct), and arteriolar hyalinosis (ah) scores of ≧1, according to the Banff classification. We examined preoperative characteristics to identify whether the degree of these damages was related to metabolic syndrome-related factors of donors. We conducted a single-center cross-sectional analysis including 183 living kidney donors. Donors were divided into two groups: chronic change (ci + ct ≧ 1 &cap; ah ≧ 1, n = 27) and control (n = 156). Preoperative characteristics, including age, sex, blood pressure, hemoglobin A1c (HbA1c), aortic calcification index (ACI), and psoas muscle index (PMI), were analyzed. Comparing the groups, the baseline estimated glomerular filtration rate was not significantly different; however, we observed a significant difference for ACI (p = 0.009). HbA1c (p = 0.016) and ACI (p = 0.006) were independent risk factors to predict pre-existing histopathological damages, whereas PMI was not. HbA1c correlated with ct scores (p = 0.035), and ACI correlated with ci (p = 0.005), ct (p = 0.021), and ah (p = 0.017). HbA1c and ACI may serve as preoperative markers for identifying pre-existing damages on the kidneys of living donors.

Ten Years of Kidney Paired Donation at Mayo Clinic: The Benefits of Incorporating ABO/HLA Compatible Pairs

BACKGROUND

We examined the 10-year experience of Mayo Clinic's kidney paired donation (KPD).We aimed to determine the benefits for the recipients of enrolled ABO/HLA compatible pairs and determine the factors associated with prolonged KPD waiting time.

METHODS

We performed a retrospective study of 332 kidney transplants facilitated by the Mayo 3-site KPD program from September 2007 to June 2018.

RESULTS

The median (interquartile range) time from KPD entry to transplantation was 89 days (42-187 days). The factors independently associated with receiving a transplant >3 months after KPD entry included recipient blood type O and calculated panel reactive antibodies ≥98%. Fifty-four ABO/HLA compatible pairs participated in KPD for the following reasons: cytomegalovirus mismatch (18.5% [10/54]), Epstein-Barr virus (EBV) mismatch (EBV) (9.3% [5/54]), age/size mismatch (51.9% [28/54]), or altruistic reasons (20.3% [11/54]). Cytomegalovirus and EBV mismatch were avoided in 90% (9/10) and 100% (5/5) of cases. Recipients who entered KPD for age/size mismatch and altruistic reasons received kidneys from donors with lower Living Kidney Donor Profile Index scores than their actual donor (median [interquartile range] 31.5 [12.3-47]; P < 0.001 and 26 (-1 to 46); P = 0.01 points lower, respectively). Median time to transplant from KPD entry for compatible pair recipients was 70 days (41-163 days), and 44.4% (24/54) of these transplants were preemptive. All chains/swaps incorporating compatible pairs included ABO/HLA incompatible pairs.

CONCLUSIONS

KPD should be considered for all living donor/recipient pairs because the recipients of these pairs can derive personal benefit from KPD while increasing the donor pool for difficult to match pairs.

Donor Age Amplifies the Detrimental Effects of Cold Ischemia Time on Long-Term Kidney Allograft Survival Independently of the Occurrence of Delayed Graft Function or Early Acute Rejection

OBJECTIVES

We investigated the influence of the interaction between donor age and cold ischemia time on allograft survival in the absence of delayed graft function, early acute rejection, or the combination of both.

MATERIALS AND METHODS

We conducted a retrospective analysis of a cohort of patients first transplanted with living-related and deceased-donor allografts between 2001 and 2016. Predictors included cold ischemia time, donor and recipient age and sex, body mass index, renal replacement therapy duration, cause of end-stage renal disease, HLA class I and II mismatches, panel of reactive antibodies score, donor creatinine concentration, development of delayed graft function, and biopsy-proven acute rejection. The response variable was time until return to renal replacement therapy. Patients who died with functioning allografts were censored at the time of death. Analyses included multivariate Cox proportional hazards regression.

RESULTS

The study included 498 patients followed for median of 4.1 years with median cold ischemia time of 17.0 hours. On multivariate analysis, allograft survival was negatively affected by the cold ischemia time-donor age interaction (P = .026), acute rejection (P = .043), delayed graft function (P = .001), and acute rejection combined with delayed graft function (P = .002). Restricted mean allograft survival times in patients who developed neither delayed graft function nor acute rejection decreased from 13.6 to 8.6 years when cold ischemia time increased from 12 to 36 hours and donor age increased from 30 to 60 years.

CONCLUSIONS

Allograft survival was negatively affected by donor age-cold ischemia time interaction independently of the development of delayed graft function, acute rejection, or their combination.

Validation of the Living Kidney Donor Profile Index in a European cohort and comparison of long-term outcomes with US results

BACKGROUND

Recently, a risk index for living donor kidney (LDK) transplantation [living kidney donor profile index (LKDPI)] was proposed to compare LDKs with each other and with deceased donor kidneys (DDKs). Until now, the LKDPI has not been validated externally.

METHODS

This long-term retrospective analysis included 1305 consecutive adult kidney transplant recipients who were transplanted 2000-16 in our centre. The Kidney Donor Profile Index (KDPI) was calculated in 889 DDKs and the LKDPI in 416 LDKs. Outcome was followed over a median of 6.5 years.

RESULTS

The median LKDPI was 17 and the median KDPI was 69, with a high proportion of donor kidneys with a very high KDPI (40% KDPI ≥ 80). Categorization of LDK into LKDPI quartiles (LKDPI -45-3, 3-17, 17-33, 33-90) revealed a significant difference in death-censored graft survival. Comparing corresponding subgroups of the LKDPI and KDPI (LKDPI/KDPI 0-20 or 20-40) showed comparable graft survival. A multivariate analysis adjusting for relevant recipient factors revealed the KDPI [hazard ratio (HR) 1.21; P < 0.001) and LKDPI (HR 1.15; P = 0.049) as significant independent predictors of graft loss. Time-to-event receiver operating characteristic analyses for graft survival demonstrated lower predictive discrimination of the LKDPI [area under the curve (AUC) 0.55] compared with the KDPI (AUC 0.66). The 10-year graft survival of LDK recipients was inferior in the USA compared with our centre (79% versus 84%).

CONCLUSIONS

These results provide external validation of the LKDPI to predict death-censored graft survival and confirm comparability of the LKDPI with the KDPI to discriminate post-transplant outcome.

Determinants of the intercept and slope of glomerular filtration rate in recipients of a live donor kidney transplant

Background

Donor kidney function is considered a critical determinant of allograft survival after live donor (LD) kidney transplantation, but its independent impact on the evolution of graft function is less well defined. The objective of this study was to dissect the relative contribution of LD kidney function to baseline estimated glomerular filtration rate (eGFR) of recipients and its decline.

Methods

In this study 91 LD kidney transplantations performed between 2007 and 2015 were included. The eGFR of donated kidneys (eGFR-dk) was calculated from total LD eGFR (eGFR-dt) based on the results of isotope nephrography. Recipient eGFR (eGFR-r) determined 6‑monthly until 36 months posttransplantation served as dependent variable in mixed linear models estimating changes in baseline allograft function (intercept) and eGFR‑r slope. Models were adjusted either for eGFR-dk or eGFR-dt, in addition to other potential confounders.

Results

Overall, unadjusted mean eGFR‑r at baseline (6 months) and its annual decline in allograft function were 56.5 mL/min/1.73 m² and −0.2 mL/min/1.73 m², respectively. In multivariate analysis, eGFR-dk impacted on baseline eGFR‑r (0.6 mL/min/1.73 m² mean estimated increase per unit; P = 0.02) but not on its slope. In the eGFR-dt-adjusted model, a marginal effect was observed for LD age (P = 0.05). Both models identified antibody-mediated rejection (ABMR) as the strongest risk factor of accelerated loss of allograft function (eGFR‑r slope: approximately −6 mL/min/1.73 m² per year; P ≤ 0.02).

Conclusion

Donor-related characteristics, most prominently the function of donated kidneys and LD age, were predictive of eGFR at baseline. The ABMR was identified as the cardinal cause of progressive deterioration of allograft function.

Development and validation of a new prediction model for graft function using preoperative marginal factors in living-donor kidney transplantation

BACKGROUND

Recently, living-donor kidney transplantation from marginal donors has been increasing. However, a simple prediction model for graft function including preoperative marginal factors is limited. Here, we developed and validated a new prediction model for graft function using preoperative marginal factors in living-donor kidney transplantation.

METHODS

We retrospectively investigated 343 patients who underwent living-donor kidney transplantation at Kyushu University Hospital (derivation cohort). Low graft function was defined as an estimated glomerular filtration rate of < 45 mL/min/1.73 m² at 1 year. A prediction model was developed using a multivariable logistic regression model, and verified using data from 232 patients who underwent living-donor kidney transplantation at Tokyo Women's Medical University Hospital (validation cohort).

RESULTS

In the derivation cohort, 89 patients (25.9%) had low graft function at 1 year. Donor age, donor-estimated glomerular filtration rate, donor hypertension, and donor/recipient body weight ratio were selected as predictive factors. This model demonstrated modest discrimination (c-statistic = 0.77) and calibration (Hosmer-Lemeshow test, P = 0.83). Furthermore, this model demonstrated good discrimination (c-statistic = 0.76) and calibration (Hosmer-Lemeshow test, P = 0.54) in the validation cohort. Furthermore, donor age, donor-estimated glomerular filtration rate, and donor hypertension were strongly associated with glomerulosclerosis and atherosclerotic vascular changes in the "zero-time" biopsy.

CONCLUSIONS

This model using four pre-operative variables will be a simple, but useful guide to estimate graft function at 1 year after kidney transplantation, especially in marginal donors, in the clinical setting.

Nonimmunologic Factors Affecting Long-Term Outcomes of Deceased-Donor Kidney Transplant

OBJECTIVES

We investigated the impact of nonimmuno-logic factors on patient and graft survival after deceased-donor kidney transplant.

MATERIALS AND METHODS

All deceased-donor kidney transplants performed between January 2004 and December 2015 were included in our analyses. We used the independent t test to calculate significant differences between means above and below medians of various parameters.

RESULTS

All study patients (N = 205; 58.7% males) received antithymocyte globulin as induction therapy and standard maintenance therapy. Patients were free from infection, malignancy, and cardiac, liver, and pulmonary system abnormalities. Most patients (89.2%) were recipients of a first graft. Median patient age, weight, and cold ischemia time were 38 years, 65 kg, and 15 hours, respectively. Delayed graft function, diabetes mellitus, and hypertension occurred in 19.1%, 43.4%, and 77.9% of patients, respectively. The 1- and 5-year graft survival rates were 95% and 73.8%. Graft survival was not affected by donor or recipient sex or recipient diabetes or hypertension. However, graft survival was longer in patients who received no graft biopsy (8.2 vs 6.9 y; P = .027) and in those who had diagnosis of calcineurin inhibitor nephrotoxicity versus antibody-mediated rejection after biopsy (8.19 vs 3.66 y; P = .0047). Longer survival was shown with donors who had traumatic death versus cerebro-vascular accident (5.9 vs 5.3 y; P = .029) and donors below the 50th percentile in age (8.23 and 7.14 y; P = .0026) but less with donors who had terminal acute kidney injury (6.97 vs 8.16 y; P = .0062). We found a negative correlation between graft survival and donor age (P = .01) and 1-year serum creatinine (P = .01).

CONCLUSIONS

Donor age, cause of brain death, and acute kidney injury affected graft survival in our study cohort but not donor or recipient sex or posttransplant or donor blood pressure.

Assessment of Postdonation Outcomes in US Living Kidney Donors Using Publicly Available Data Sets

Importance

There are limited resources providing postdonation conditions that can occur in living donors (LDs) of solid-organ transplant. Consequently, it is difficult to visualize and understand possible postdonation outcomes in LDs.

Objective

To assemble an open access resource that is representative of the demographic characteristics in the US national registry, maintained by the Organ Procurement and Transplantation Network and administered by the United Network for Organ Sharing, but contains more follow-up information to help to examine postdonation outcomes in LDs.

Design, Setting, and Participants

Cohort study in which the data for the resource and analyses stemmed from the transplant data set derived from 27 clinical studies from the ImmPort database, which is an open access repository for clinical studies. The studies included data collected from 1963 to 2016. Data from the United Network for Organ Sharing Organ Procurement and Transplantation Network national registry collected from October 1987 to March 2016 were used to determine representativeness. Data analysis took place from June 2016 to May 2018. Data from 20 ImmPort clinical studies (including clinical trials and observational studies) were curated, and a cohort of 11 263 LDs was studied, excluding deceased donors, LDs with 95% or more missing data, and studies without a complete data dictionary. The harmonization process involved the extraction of common features from each clinical study based on categories that included demographic characteristics as well as predonation and postdonation data.

Main Outcomes and Measures

Thirty-six postdonation events were identified, represented, and analyzed via a trajectory network analysis.

Results

The curated data contained 10 869 living kidney donors (median [interquartile range] age, 39 [31-48] years; 6175 [56.8%] women; and 9133 [86.6%] of European descent). A total of 9558 living kidney donors with postdonation data were analyzed. Overall, 1406 LDs (14.7%) had postdonation events. The 4 most common events were hypertension (806 [8.4%]), diabetes (190 [2.0%]), proteinuria (171 [1.8%]), and postoperative ileus (147 [1.5%]). Relatively few events (n = 269) occurred before the 2-year postdonation mark. Of the 1746 events that took place 2 years or more after donation, 1575 (90.2%) were nonsurgical; nonsurgical conditions tended to occur in the wide range of 2 to 40 years after donation (odds ratio, 38.3; 95% CI, 4.12-1956.9).

Conclusions and Relevance

Most events that occurred more than 2 years after donation were nonsurgical and could occur up to 40 years after donation. Findings support the construction of a national registry for long-term monitoring of LDs and confirm the value of secondary reanalysis of clinical studies.

Recipient Outcomes From Nondirected Live Kidney Donors: A UK-based Cohort Study

Background

Increasing numbers of patients with end-stage renal failure are receiving kidneys from nondirected kidney donors (NKDs), also known as altruistic donors. Transplant outcomes for recipients of such kidneys are largely inferred from studies on specified kidney donors (SKDs), which may be inaccurate due to differences in donor, recipient and transplant specific factors. We report the outcomes for recipients of NKD in the United Kingdom.

Methods

Outcomes for 6861 patients receiving a living donor kidney transplant between January 2007 and December 2014 were analyzed using both the National Health Service Blood and Transplant and the UK Renal Registry datasets. Graft and patient outcomes were compared for patients receiving NKD and SKD organs using univariable and multivariable analyses.

Results

There was significant discordance between the NKD and SKD donors and recipients. These included increased donor age (median, 58 years vs 47 years; P < 0.001) and higher rates of hemodialysis and previous transplants in the NKD group (both P < 0.001). Despite such markers of increased risk among both donors and recipients of NKD kidneys, there was no difference in graft survival on univariable (hazard ratio, 1.20; 95% confidence interval, 0.77-1.86; P = 0.419) or multivariable analysis (hazard ratio, 1.13; 95% confidence interval, 0.65-1.95; P = 0.665).

Conclusions

Despite some markers of transplant complexity, nondirected kidney donor organs are an excellent source of organs for transplantation.

Safety of Elderly Living Kidney Donors: 2 Cases of Donors Older Than 80 Years: A Case Report

Much controversy exists over the performance of elderly living donor kidney transplantation. We report the safety of 2 cases of elderly living kidney donations in our hospital. CASE 1: An 82-year-old man was a living kidney donor for his 56-year-old son. The donor suffered from hypertension, but has successfully managed his blood pressure with only one medication. His serum creatinine was 0.7 mg/dL and inulin clearance was 122.5 mL/min, which met the usual criteria for living kidney donors. This was his son's secondary kidney transplantation, and no other donors existed. CASE 2: An 80-year-old woman was a living kidney donor for her 45-year-old son. Her serum creatinine was 0.61 mg/dL and inulin clearance was 71.7 mL/min, which met the marginal kidney donor criteria. In both cases, we determined that the donor kidney function was acceptable. Though we explained the risks of the transplantation thoroughly, the patients' strong will to offer a kidney to their family member did not change. We decided to carry out the transplantation. At the time of publication, nearly 2 years have passed since the transplantation, but both donors and recipients are doing well. In the future, it seems more likely that the number of elderly living donor kidney transplantation will rise. On one hand, there is no absolute contraindication for elderly donors, while on the other hand, the criteria for a living kidney donor must be strictly examined. Furthermore, careful observation of both donors and recipients after transplantation is required.

Living donor risk model for predicting kidney allograft and patient survival in an emerging economy

AIM

Living donor kidney is the main source of donor organs in low to middle income countries. We aimed to develop a living donor risk model that predicts graft and patient survival in an emerging economy.

METHODS

We used data from the Sindh Institute of Urology and Transplantation (SIUT) database (n = 2283 recipients and n = 2283 living kidney donors, transplanted between 1993 and 2009) and conducted Cox proportional hazard analyses to develop a composite score that predicts graft and patient survivals.

RESULTS

Donor factors age, creatinine clearance, nephron dose (estimated by donor/recipient body weight ratio) and human leukocyte antigen (HLA) match were included in the living donor risk model. The adjusted hazard ratios (HRs) for graft failures among those who received a kidney with living donor scores (reference to donor score of zero) of 1, 2, 3 and 4 were 1.14 (95%CI: 0.94-1.39), 1.24 (95%CI:1.03-1.49), 1.25 (95%CI:1.03-1.51) and 1.36 (95%CI:1.08-1.72) (P-value for trend =0.05). Similar findings were observed for patient survival.

CONCLUSIONS

Similar to findings in high income countries, our study suggests that donor characteristics such as age, nephron dose, creatinine clearance and HLA match are important factors that determine the long-term patient and graft survival in low income countries. However, other crucial but undefined factors may play a role in determining the overall risk of graft failure and mortality in living kidney donor transplant recipients.

Tubular maximum phosphate reabsorption capacity in living kidney donors is independently associated with one-year recipient GFR

The donor glomerular filtration rate (GFR) measured before kidney donation is a strong determinant of recipient graft outcome. No tubular function markers have been identified that can similarly be used in donors to predict recipient outcomes. In the present study we investigated whether the pre-donation tubular maximum reabsorption capacity of phosphate (TmP-GFR), which may be considered a functional tubular marker in healthy kidney donors, is associated with recipient GFR at 1 yr after transplantation, a key determinant of long-term outcome. We calculated the pre-donation TmP-GFR from serum and 24-h urine phosphate and creatinine levels in 165 kidney donors, and recipient ¹²⁵I-iothalamate GFR and eGFR (CKD-EPI) at 12 mo after transplantation. Kidney donors were 51 ± 10 yr old, 47% were men, and mean GFR was 118 ± 26 ml/min. The donor TmP-GFR was associated with recipient GFR 12 mo after transplantation (GFR 6.0 ml/min lower per 1 mg/dl decrement of TmP-GFR), which persisted after multivariable adjustment for donor age, sex, pre-donation GFR, and blood pressure and other potential confounders. Results were highly similar when eGFR at 12 mo was taken as the outcome. Tubular damage markers kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin were low and not associated with recipient GFR. A lower donor TmP-GFR before donation, which may be considered to represent a functional measure of tubular phosphate reabsorption capacity, is independently associated with a lower recipient GFR 1 yr after transplantation. These data are the first to link donor tubular phosphate reabsorption with recipient GFR post-transplantation.

Patient and Graft Survival Among Sexagenarian and Septuagenarian Renal Transplant Recipients and Donors: The Context for Older Recipients

Due to the increasing number of patients with end-stage renal disease, there is a growing demand for transplants for recipients and donors aged 60 years and older. Using data from the Scientific Registry of Transplant Recipients, we performed survival analyses and multivariate logistic regression to help guide transplant professional decisions regarding the selection of graft type (living vs deceased) and donor age (60-69 vs 70+ years) for recipients aged 60 years and older.

Clinical outcomes of ABO- and HLA-incompatible kidney transplantation: a nationwide cohort study

This was a nationwide cohort study to investigate the impact of anti-A/B and donor-specific anti-HLA (HLA-DSA) antibodies on the clinical outcomes in kidney transplant recipients (KTRs). We classified a total of 1964 KTRs into four groups: transplants from ABO-incompatible donors (ABOi, n = 248); transplants in recipients with HLA-DSA (HLAi, n = 144); transplants from combined ABOi and HLAi donors (ABOi + HLAi, n = 31); and a control group for whom neither ABOi nor HLAi was applicable (CONT, n = 1541). We compared the incidence of biopsy-proven acute rejection (BPAR), allograft and patient survival rates. The incidence of BPAR was higher in the HLAi and ABOi + HLAi groups relative to the CONT group; in contrast, it was not higher in the ABOi group. Death-censored graft survival rates did not differ across the four groups. However, relative to the CONT group, patient survival rate was reduced in the ABOi and ABOi + HLAi groups, and with infection being the most common cause of death. Further, multivariable analysis revealed that desensitization therapy because of ABOi or HLAi was independent risk factors for patient mortality. HLAi was a more important risk factor for BPAR compared with ABOi. However, pretransplant desensitization therapy for either ABOi or HLAi significantly increased the risk of infection-related mortality.

Acceptability of older adults as living kidney donors

PURPOSE OF REVIEW

Kidney transplantation from a living kidney donor (LKD) is associated with better long-term survival and quality of life for a patient with end-stage renal disease (ESRD) than dialysis. We reviewed recent literature on the acceptability and outcomes of older adults as LKDs, which may be misunderstood in routine care.

RECENT FINDINGS

Studies report that receiving a kidney from an older LKD is associated with worse recipient and graft survival compared with receiving a kidney from a younger LKD, but similar recipient and graft survival to receiving a kidney from a standard criteria deceased donor. A kidney from a younger vs. older LKD results in better graft survival in younger recipients, whereas the graft survival is similar in older recipients. Compared with healthy matched nondonors, older LKDs have a similar risk of death and cardiovascular disease and the absolute risk of ESRD after 15 years remains less than 1%. The estimated predonation and postdonation lifetime risk of ESRD varies by age, sex and race with lower incidences in individuals who are older, female and white (vs. African-American).

SUMMARY

Donor and recipient outcomes from several studies support the acceptability of older adults as LKDs.

Unique Considerations When Managing Hypertension in the Transplant Patient

For the select fortunate recipients of organ transplants, transplantation affords the rare opportunity for a new life. Given the scarcity of organs for transplantation, it is imperative that the health of transplant recipients be optimized in order to fully benefit from this gift of life. Unfortunately, hypertension is highly prevalent in the transplant population and it is considered a major cardiovascular risk factor contributing to mortality and morbidity in this population. In this chapter, we expound on the epidemiology, unique pathophysiology, evaluation, and management of hypertension as it pertains to the solid organ transplant recipient. In addition, a brief commentary is made on the subject of hypertension following living kidney donation, and practical aspects of management of hypertension in the solid organ recipient are summarized at the end of the chapter.

Living Donor Transplantation: Long-Term Evolution Related to Age Matching

The lack of donors is favoring living kidney donor (LKD) transplantation worldwide, quite often beyond the classic age-matching rules. We analysed renal function (RF) at 1 and 5 years in all donor and recipients as well as death-censored graft and patient survival. LKD recipients were divided into 4 subgroups: young recipients-young donors (YR-YD; N = 355), elderly recipients-young donors (ER-YD; N = 13), young recipients-elderly donors (YR-ED; N = 67), and elderly recipients-elderly donors (ER-ED; N = 38). "Elderly" was defined as ≥60 years. RF was better in those who received a young allograft (YR-YD/ER-YD) at any time (P < .001). There was a trend toward higher proteinuria among the recipients of an old allograft (YR-ED/ER-ED) at any time (P = not significant [NS]). However, our population showed low levels of proteinuria and this was not a risk factor for graft failure. Logistic regression model showed that creatinine level at 1 year is a good predictor of graft losses. Graft survival was worse in the allografts from elderly donors (P < .001). Analysing the young recipients, renal survival was inferior in those who received an old kidney (YR-ED; P < .00005) as well as mortality rates at 14 years (P = .03). The RF of young (N = 295) and elderly donors (N = 98) was optimal with no progression to ESRD or deaths registered during follow-up. In conclusion, young recipients of elderly kidneys pay the price of a worse RF, allograft prognosis, and patient prognosis. The pair YR-ED is a doable option, but we recommend age matching when it is possible.

[Rehabilitation after kidney transplantation: Old problems and new structures]

Kidney transplantation is currently the best therapeutic option for patients with end stage renal disease. Alternative treatment with hemo- or peritoneal dialysis is associated with higher comorbidities, higher morbidity/mortality, and reduced quality of life. Thus, a major aim in posttransplant care is to develop strategies to increase transplant survival and reduce known risk factors and comorbidities. In this overview, we propose a concept to include rehabilitation clinics in all aspects of the transplant process. This concept includes pretransplant care on the waiting list to prepare the patient for the transplant, the direct postoperative treatment phase, and repeated and risk adapted stays in rehabilitation clinics during long-term follow-up to address specific and individual problems.

Kidneys from Older Living Donors Provide Excellent Short and Intermediate Outcomes--A Single China Center's Experience

BACKGROUND

Transplantation with kidneys from older living donors is on the rise, yet controversy still exists over whether the outcomes are as satisfactory as with kidneys from younger donors.

METHODS

We retrospectively analyzed 1009 living donor kidney transplants performed at our center between 2006 and 2013. Graft and patient outcomes were compared between transplants with kidneys from old living donors (OLD, 55-65 years) (n = 264) and from young living donors (YLD, <55 years) (n = 745).

RESULTS

The age was 32.80 ± 9.71 years and 33.91 ± 5.98 years for recipient in YLD and OLD group, respectively. Death-censored graft survival at 1, 3, and 5 years was 98.8%, 97.1%, and 95.8% in patients receiving YLD kidneys, similar to the corresponding values of 97.6%, 95.5% and 95.5% in patients receiving OLD kidneys (P = 0.356). Patient survival at 1, 3, and 5 years after transplantation was also similar for patients receiving YLD kidneys (98.5%, 97.1%, and 96.7%) and for patients receiving OLD kidneys (99.6%, 99.6%, and 96.8%; P = 0.110). The OLD kidneys were not associated with increased risk of death-censored graft failure (hazard ratio, 2.5; 95% confidence interval, 0.57 to 11.11) and patient death (hazard ratio, 1.67; 95% confidence interval, 0.75 to 3.73). In addition, there is no increased graft loss or patient death for each 10-year increase in donor age. Transplantation with OLD kidneys was not associated with reduced patient or graft outcomes in the short term (≤ 12 months) or medium term (>1 year).

CONCLUSIONS

Graft and patient outcomes after living-donor kidney transplantation are similar in the short-term and medium-term for donors aged 55 to 65 years and for younger donors. Therefore, the use of OLD kidneys should be encouraged in China.

Midterm Outcome of Living-Related Kidney Transplantation From Aged Donors: A Single-Center Experience

BACKGROUND

Kidney transplantation (KT) is the most effective treatment of end-stage renal disease (ESRD). Using grafts from aged donors is increasing worldwide. Our aim was to better understand the safety and effectiveness of aged living donors.

METHODS

First, 482 cases with living-related kidney transplantation were analyzed retrospectively. The cases were divided into 2 groups by donor age ≥ 55 years (aged donor group, 136 cases) and <55 years (young donor group, 346 cases). Then donor and recipient characteristics were summarized. In addition, the renal function of graft was compared between young donor group and aged donor group. Finally, patient and graft survivals were examined with the use of Kaplan-Meier analysis and compared with the use of the log-rank test.

RESULTS

The mean donor estimated glomerular filtration rate (eGFR) was lower in the aged donor group compared with in the young donor group. After KT, the mean eGFR of the graft in the recipient was also lower in the aged donor group than in the young donor group. To confirm the effect of aged kidney grafts on renal function, we measured proteinuria. Compared with the young donor group, in the aged donor group incidence of proteinuria and 24-hour urinary protein were significantly higher. However, the incidence of delayed graft function was not significantly different between the 2 groups. We found that aged kidney grafts had no significant effect on long-term patient and graft survivals.

CONCLUSIONS

With the current lack of organs, aged kidney grafts are an acceptable alternative. Use of organs from aged donors safely expands the living donor pool.

Outcomes in kidney transplant recipients from older living donors

BACKGROUND

Previous studies demonstrate that graft survival from older living kidney donors (LD; age>60 years) is worse than younger LD but similar to deceased standard criteria donors (SCD). Limited sample size has precluded more detailed analyses of transplants from older LD.

METHODS

Using the United Network for Organ Sharing database from 1994 to 2012, recipients were categorized by donor status: SCD, expanded criteria donor (ECD), or LD (by donor age: <60, 60-64, 65-69, ≥70 years). Adjusted models, controlling for donor and recipient risk factors, evaluated graft and recipient survivals.

RESULTS

Of 250,827 kidney transplants during the study period, 92,646 were LD kidneys, with 4.5% of these recipients (n=4,186) transplanted with older LD kidneys. The use of LD donors 60 years or older increased significantly from 3.6% in 1994 to 7.4% in 2011. Transplant recipients with older LD kidneys had significantly lower graft and overall survival compared to younger LD recipients. Compared to SCD recipients, graft survival was decreased in recipients with LD 70 years or older, but overall survival was similar. Older LD kidney recipients had better graft and overall survival than ECD recipients.

CONCLUSIONS

As use of older kidney donors increases, overall survival among kidney transplant recipients from older living donors was similar to or better than SCD recipients, better than ECD recipients, but worse than younger LD recipients. With increasing kidney donation from older adults to alleviate profound organ shortages, the use of older kidney donors appears to be an equivalent or beneficial alternative to awaiting deceased donor kidneys.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcome of renal transplantation from older living donors compared to younger living donor in developing country

OBJECTIVES

To evaluate whether the outcomes of renal grafts from living related donors older than 60 years are acceptable, in terms of renal function and patient/graft survival.

MATERIAL AND METHODS

One hundred and forty-seven patients who received kidneys from donor age ≥60 years constituted the study group (group 1). The control group (group 2) consisted of 1310 patients who received renal transplants from donor age <60 years. Outcome measures included graft, patient survival, acute rejection rate and serum creatinine (SCr) in patients/donors. Graft and patient survivals were compared using the Kaplan-Meier method.

RESULTS

The mean age of donors was 62.7 ± 3.39 years in group 1 and 43.45 ± 9.65 years in group 2. Patient survival at 1, 3 and 5 years was 95.7%, 89.4% and 82.6% in group 1 and 93.8%, 89.1% and 83.1% in group 2 (p = 0.785), respectively. Death-censored graft survival at 1, 3 and 5 years was 98.5%, 94.8% and 94.8% in group 1 and 96.1%, 92.9% and 89% in group 2 (p = 0.166), respectively. Biopsy-proven acute rejections were 21% and 16.8% (p = 0.206) and chronic rejections 5% and 3.4% in group 1 and 2, respectively (p = 0.542). Recipient SCr (mg/dL) was 1.8 ± 0.31 in group 1 and 1.58 ± 0.37 in group 2. The donor SCr levels at the last follow-up were 1 mg/dL and 0.9 mg/dL in group 1 and 2, respectively.

CONCLUSIONS

Donor age did not affect patient and graft survival in the 5-year follow-up in our study. Age alone seems not to be an exclusion criterion to living kidney donation.

Mechanisms and consequences of injury and repair in older organ transplants

Donor organ scarcity remains a significant clinical challenge in transplantation. Older organs, increasingly utilized to meet the growing demand for donor organs, have been linked to inferior transplant outcomes. Susceptibility to organ injury, reduced repair capacity, and increased immunogenicity are interrelated and impacted by physiological and pathological aging processes. Insights into the underlying mechanisms are needed to develop age-specific interventional strategies with regards to organ preservation, immunosuppression, and allocation. In this overview, we summarize current knowledge of injury and repair mechanisms and the effects of aging relevant to transplantation.

The Outcomes of Living Kidney Donation from Medically Complex Donors: Implications for the Donor and the Recipient

Living kidney donation is an important option for patients with end-stage renal disease (ESRD), and has improved life expectancy and quality for patients otherwise requiring maintenance dialysis or deceased-donor transplantation. Given the favorable outcomes of live donation and the shortage of organs to transplant, individuals with potentially unfavorable demographic and clinical characteristics are increasingly being permitted to donate kidneys. While this trend has successfully expanded the live donor pool, it has raised concerns as to which acceptance criteria are safe. This review aims to summarize the existing literature on the outcomes of transplantation from medically complex, living kidney donors, including both donor and recipient outcomes when available.

Patient Survival in Renal Allograft Failure: A Time-dependent Analysis

Background:

To improve patient survival after a renal transplant, it is important to detect which variables affect it.

Objectives:

This study aimed to assess the effect of renal allograft failure on patient survival.

Patients and Methods:

This retrospective cohort study included 405 renal transplant patients from Kerman University of Medical Sciences hospital, Kerman, Iran from 2004 to 2010. Kaplan-Meier method was used to estimate survival rates of patients, and time-dependent Cox regression was used to examine the effect of allograft failure on patient survival.

Results:

During 4.06 years (median) of follow-up 28 (6.9%) patients died and 20 (71.4%) of dead patients had allograft failure. Survival rate of patients with allograft failure at 1-, 3-, 5-, and 7-year were 0.98, 0.8, 0.53, and 0.53, respectively; in patients with allograft function these values were 0.99, 0.98, 0.97, and 0.96, respectively. The unadjusted death rate was 0.5 per 100 patient years for the maintained allograft function, which increased to 9 per 100 patient years for patients following allograft failure. In fully adjusted model the risk of death increased in patients with allograft failure (HR = 2.09; 95% CI: 1.56-2.81), pretransplant diabetes (HR = 2.81; 95% CI: 1.2-6.7), patients with BMI ≥ 25 (vs. 18.5 ≤ BMI < 25) (HR = 3.56; 95% CI: 1.09-11.6). With an increase in recipient age this risk increased (HR = 1.04 per year increase; 95% CI: 1.01-6.7). Receiving a living kidney transplant decreased this risk (HR = 0.52; 95% CI: 0.39-0.69).

Conclusions:

An increase in recipient age and BMI, affliction with diabetes, allograft failure, and receiving deceased kidney transplant increased the risk of death.

Renal transplantation from elderly living donors

Acceptance of elderly living kidney donors remains controversial due to the higher incidence of comorbidity and greater risk of postoperative complications. This is a review of publications in the English language between 2000 and 2013 about renal transplantation from elderly living donors to determine trends and effects of donation, and the outcomes of such transplantation. The last decade witnessed a 50% increase in living kidney donor transplants, with a disproportionate increase in donors >60 years. There is no accelerated loss of kidney function following donation, and the incidence of established renal failure (ERF) and hypertension among donors is similar to that of the general population. The overall incidence of ERF in living donors is about 0.134 per 1000 years. Elderly donors require rigorous assessment and should have a predicted glomerular filtration rate of at least 37.5 mL/min/1.73 m(2) at the age of 80. Though elderly donors had lower glomerular filtration rate before donation, proportionate decline after donation was similar in both young and elderly groups. The risks of delayed graft function, acute rejection, and graft failure in transplants from living donors >65 years are significantly higher than transplants from younger donors. A multicentred, long-term, and prospective database addressing the outcomes of kidneys from elderly living donors is recommended.

Impact of donor and recipient age difference on long-term allograft survival after living donor renal transplantation: analysis of 478 cases

INTRODUCTION

Either deceased or living-related renal transplantation constitutes the best therapeutic option for patients with end-stage renal disease. In this retrospective study, an attempt to identify parameters that affect allograft survival in living donor renal transplantation was made.

METHODS

Between January 2000 and July 2012, 478 adult patients received a renal transplant from a living-related donor in our center and their records were retrospectively reviewed in November 2012. Data concerning donor age, recipient age, donor/recipient age difference, donor/recipient gender, and ABO compatibility/incompatibility were recorded and associated with renal allograft survival rate.

RESULTS

Renal allograft survival rate was 96%, 89.5%, and 77.7% in the first, fifth, and 10th yr after transplantation, respectively. Only the difference between donor and recipient age was statistically significant in relation to graft survival. In cases with age difference >13 yr, graft survival rate was lower from the third yr onward.

CONCLUSIONS

Only the age difference between donor and recipient exerts an adverse impact on graft outcome after living donor renal transplantation, whereas donor age, recipient age, donor/recipient gender, and ABO incompatibility do not significantly influence renal allograft survival.

Factors affecting graft survival among patients receiving kidneys from live donors: a single-center experience

Introduction. The aim of this report is to study the graft and patient survival in a large cohort of recipients with an analysis of factors that may affect the final outcomes. Methods. Between March 1976 and March 2008, 1967 consecutive live-donor renal transplants were carried out. Various variables that may have an impact on patients and/or graft survival were studied in two steps. Initially, a univariate analysis was carried out. Thereafter, significant variables were embedded in a stepwise regression analysis. Results. The overall graft survival was 86.7% and 65.5%, at 5 and 10 years, respectively. The projected half-life for grafts was 17.5 years and for patients was 22 years. Five factors had an independent negative impact on graft survival: donor's age, genetic considerations, the type of primary immunosuppression, number of acute rejection episodes, and total steroid dose during the first 3 months after transplantation. Conclusions. Despite refinements in tissue matching techniques and improvements in immunosuppression protocols, an important proportion of grafts is still lost following living donor kidney transplantation, presumably due to chronic allograft nephropathy.

Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients

Kidney transplantation (KT) is the therapy of choice for end-stage renal disease (ESRD). The ESRD population is aging and so are patients waiting for KT. New strategies have been made for increasing the donor and recipient pools, and as a consequence kidneys from older donors or donors with significant comorbidities, the so-called “expanded criteria donor” (ECD) kidneys, are used for transplantation. Although good outcomes have been achieved from ECD, several issues are still waiting for clarification and need to be discussed. The concept of age matching is accepted as a method to ameliorate utilization of these allografts, but an optimal and widely accepted strategy is still not defined. The development of machine perfusion and the dual kidney transplantation are techniques which further improve the outcome of transplants from ECD, but the described experiences are scarce or coming from small single institutional reports. Also due to age-related immune dysfunction and associated comorbidities, the elderly recipients are more susceptible to immunosuppression related complications (e.g., infections and malignancy), although a widely accepted and validated immunosuppressive regimen is still lacking. In this paper, we review the issues related to KT employing allografts from marginal donors with a particular interest for the elderly patients.