Efficacy and Safety of ATG-Fresenius as an Induction Agent in Living-Donor Kidney Transplantation

BACKGROUND

Induction therapy is mostly recommended for deceased-donor transplantation, whereas it has some controversies in live-donor transplantation. In this study, we described the outcomes of live-donor renal transplant recipients who received ATG-Fresenius (ATG-F) induction.

METHODS

Live-donor transplantations in patients over 18 years old with ATG-F induction between 2009 and 2015 were included. All patients received quadruple immunosuppression, one of which was ATG-F induction. Biopsies after the artery anastomosis (zero hour) and protocol biopsies at the 6th month and at the 1st first year were obtained. Acute graft dysfunction was defined as a 20% to 25% increase in creatinine level from baseline. All acute rejection episodes were biopsy-confirmed. All episodes were initially treated with intravenous methyl prednisolone (MP) or ATG-F if resistant to MP. Four hundred twenty-two patients with live-donor transplantation were evaluated. The mean age was 40 ± 13 (18-73) years. The mean panel-reactive antibody levels were 42% ± 30% and 45% ± 30% for class I and II, respectively.

RESULTS

The mean mismatch number for living unrelated donors (n = 112) was 4.6 ± 1.0. Acute rejection rate was 29.1% (123 patients) within the first year. The mean cumulative ATG-F doses for per patient and per kilogram were 344 ± 217 mg and 5.1 ± 2.7 mg, respectively. Patient survival rates were 98.3% and 96.7% for 12 months and 60 months, respectively. Death-censored graft survival rates were 97.6% and 92.1% for 12 months and 60 months, respectively.

CONCLUSIONS

ATG-F induction provided excellent graft and patient survival rates without any significantly increased side effects. Increasing sensitized patient numbers, more unrelated donors, increasing re-transplantation numbers, and more desensitization protocols make ATG-F more favorable in an induction regimen.

Use of suicidal deaths as kidney donors: a single-center experience

OBJECTIVE

Although the number of end-stage renal disease patients on the waiting list has increased, the number of deceased kidney donors has not increased proportionately. Therefore, the use of kidney donors defined as "marginal" has become an issue. Since the acceptance of deaths due to poisoning or suicide as donors has been proposed, we evaluated the clinical courses of kidney transplantations from suicidal death donors.

PATIENTS AND METHODS

We analyzed retrospectively the outcomes of nine deceased donor kidneys (8 males) from suicide victims between 2001 and 2012. Demographic and clinical characteristics of donors and recipients were collected from medical files.

RESULTS

The mean donor age was 27.8 ± 11.9 years. Causes of death were: gunshot wounds to the head (n:4), pesticide intoxication (n:2), methanol intoxication (n:1), hanging (n:1), or carotid artery laceration (n:1). Mean donor creatinine level, urine output per hour, and 24-hour urine volume were 0.94 ± 0.53 mg/dL, 270 ± 113 mL, and 5496 ± 832 mL, respectively. Mean cold ischemia time was 12.3 ± 5.7 hours. Primary allograft nonfunction occurred in one recipient requiring nephrectomy. The average posttransplantation creatinine level at 1 year was 1.19 ± 0.62 mg/dL. The mean follow-up was 55 ± 49 months. Allograft loss occurred due to chronic rejection in three patients at 10, 37, and 40 months. Five patients are still undergoing follow-up with functioning grafts.

CONCLUSION

Brain death cases caused by the suicide should be considered for organ donation.

Incidence and importance of c4d deposition in renal allograft dysfunction

Recent studies showed that peritubular capillary deposition of C4d is a marker of humoral immune responses directed against a renal allograft. The aim of this retrospective study was to investigate the incidence, clinical features, and prognostic implications of C4d deposition in renal allograft biopsy specimens. The biopsies had been performed due to acute graft dysfunction. This study of 104 renal allograft biopsies performed in 2004 classified histopathological findings according to Banff criteria. All paraffin-embedded biopsy samples were stained with an immunohistochemical method for C4d deposition. Demographic data, clinical findings, and biochemical findings were obtained from patients' charts. C4d staining was positive in 15/104 (14%) samples. The staining pattern was diffuse in 8 and focal in 7 patients. Nine patients were males. The overall mean age was 33 +/- 6 years. Ten received live-donor grafts. The biopsy occurred at a mean of 1007 +/- 1415 (range, 15-4712) days after the operation with a mean serum creatinine (SCr) level of 2.8 +/- 1.5 (1.25-6.0) mg/dL. Patients were divided into 2 groups according to the occurrence time: early (before 100 days) and late (after 100 days). Among the early group (n = 5), the mean SCr level was 2.8 +/- 1.5 mg/dL; a diffuse staining pattern was seen in 4 (80%) patients. Histological findings were acute rejection in 3, borderline changes in 1, or thrombotic microangiopathy in 1 patient. Two patients were treated with pulse steroids and 3 with ATG, intravenous immunoglobulin, and plasmapheresis. Three patients lost their grafts at the mean of 118 +/- 100 days after the biopsy. In the late group (n = 10), the mean SCr level was 2.8 +/- 1.7 mg/dL with a diffuse staining pattern in 4 (40%) patients. The histological findings included acute rejection in 6, chronic vascular rejection in 2, thrombotic microangiopathy in 1, and chronic allograft nephropathy in 1 patient. Six patients were treated with pulse steroids, and 3 with ATG and intravenous immunoglobulin. Five patients lost their grafts at a mean of 200 +/- 270 days. The overall incidence of C4d deposition was 14%; it was seen both in the early and late posttransplantation period. Although a diffuse staining pattern was more frequently seen in the early period, C4d deposition indicated a poor allograft prognosis in both periods. Introduction of C4d staining into the routine may guide more specific treatments directed toward the humoral alloresponse.

Efficacy and safety of enteric-coated mycophenolate sodium in de novo and maintenance renal transplant patients

Enteric-coated mycophenolate sodium (ECMPS) has been developed as an alternative agent to mycophenolate mofetil (MMF), with the aim to provide reduction in gastrointestinal side effects. This open-label, single-arm, two-center prospective study sought to investigate the efficacy and safety of ECMPS used in combination with steroid and cyclosporine (CyA) in de novo and maintenance renal transplant patients with 12 months' follow-up. Twenty-one patients were recruited (mean age, 39 +/- 8 years) into the de novo group. Of these patients, 66% were male and 76.2% underwent living related kidney donation. The induction immunosuppression was ATG in 10 and basiliximab in 6 patients. At 12 months' posttransplantation, there was no graft or patient loss and two (10%) acute rejection episodes. None of the patients in this group discontinued the study medication due to drug-induced adverse events. One patient was excluded from the study because of recurrent oxalosis. Serum creatinine (SCr) levels at 3, 6, and 12 months after renal transplant were 1.30 +/- 0.3, 1.40 +/- 0.3, and 1.40 +/- 0.3 mg/dL, respectively. The maintenance group included 20 patients. Time posttransplantation (mean +/- SD) was 27 +/- 25 months. All patients in this group had been on maintenance azathioprine or MMF in combination with steroid and CyA. These patients were switched to ECMPS. They mean age was 36 +/- 8 years. Sixty-six percent of the patients were male and 57% received living donor kidneys. Acute rejection was nil, whereas two patients lost their grafts owing to chronic rejection in this group. Three patients were excluded from the study, one to discontinuation of the drug because of intractable diarrhea, the second to loss to follow-up, and the last case due to withdrawal of informed consent. Leukopenia was not observed in this group. The SCr levels prior to and at 3, 6, and 12 months after conversion to ECMPS were 1.80 +/- 1.0, 1.95 +/- 1.5, 1.50 +/- 0.8, and 1.60 +/- 0.8 mg/dL, respectively. This is the first phase IV study with ECMPS in the Turkish population. Renal function was preserved in both groups. Only 2.5% of patients were excluded because of side effects. Use of ECMPS in combination with prednisolone and CyA is an effective and safe therapeutic choice for both de novo and maintenance renal transplant patients.

Comparison of tacrolimus and cyclosporin in renal transplantation by the protocol biopsies

Acute and chronic lesion scores on renal allograft protocol biopsies may predict long-term graft function. The aim of this study was to compare the effects of tacrolimus (Tac) and cyclosporine microemulsion (CsA) based immunosuppressive protocols using protocol biopsies from well-functioning renal allografts. 35 consecutive renal transplant patients were randomized to Tac (n: 17) versus CsA (n: 18) treatment arms. Patient age and sex, donor type and age, histocompatibility, cold ischemia time and prior delayed graft function were similar between the two groups. Treatment protocol consisted of prednisolone, azathioprine and Tac or CsA. Biopsies performed on the third, sixth and twelfth months were blindly evaluated by the same pathologist. The incidences of acute rejection (AR) episodes among CsA vs Tac groups were 33% vs 29%, respectively (NS). The Creatinine level was lower in Tac than CsA, although it was not significant (Table). Subclinical AR and subclinical chronic allograft nephropathy were detected on protocol biopsies in 3 (2 CsA, 1 Tac) and 12 (7 CsA, 5 Tac) patients, respectively. Acute lesion score at the third month PBx was significantly lower in the Tac group (p < 0.05). Chronic lesion scores in all biopsies were lower in the Tac group, although not significantly. The protocol biopsy findings suggest that graft injury may be less pronounced among the Tac group.

Is “zero-hour” biopsy of the transplanted kidney risky?

"Zero-hour" renal allograft biopsy provides valuable diagnostic information for comparison to subsequent kidney material. However, the invasive nature of the biopsy procedure tends to limit its widespread use in many centers. We undertook this retrospective study to examine the rate and clinical importance of complications in our series of patients routinely undergoing zero-hour biopsies performed between 1994 and 2001. Two hundred thirty-six zero-hour biopsies included only one sample performed with a 14G needle from lower posterior part of kidney by using a manual tru-cut technique. Doppler ultrasonography was performed after first 5 days. An average of 34 +/- 19 glomeruli were obtained in the biopsies. The biopsy specimens were adequate for diagnosis in 77% of the procedures. Ten (4%) patients experienced complications of intraparenchymal arteriovenous fistula (n = 4), which regressed spontaneously; perirenal hematoma (n = 4); intraparenchymal hematoma (n = 2); and a minimal perirenal collection (n = 41). We conclude that zero-hour biopsy is a safe diagnostic method. The rate of complications is low, as well as generally mild and self-limiting.