Reciprocity to Increase Participation of Compatible Living Donor and Recipient Pairs in Kidney Paired Donation

Inclusion of compatible living donor and recipient pairs (CPs) in kidney paired donation (KPD) programs could increase living donor transplantation. We introduce the concept of a reciprocity-based strategy in which the recipient of a CP who participates in KPD receives priority for a repeat deceased donor transplant in the event their primary living donor KPD transplant fails, and then we review the practical and ethical considerations of this strategy. The strategy limits prioritization to CPs already committed to living donation, minimizing the risk of unduly influencing donor behavior. The provision of a tangible benefit independent of the CP's actual KPD match avoids many of the practical and ethical challenges with strategies that rely on finding the CP recipient a better-matched kidney that might provide the CP recipient a future benefit to increase KPD participation. Specifically, the strategy avoids the potential to misrepresent the degree of future benefit of a better-matched kidney to the CP recipient and minimizes delays in transplantation related to finding a better-matched kidney. Preliminary estimates suggest the strategy has significant potential to increase the number of living donor transplants. Further evaluation of the acceptance of this strategy by CPs and by waitlisted patients is warranted.

Living anonymous kidney donation: what does the public think?

BACKGROUND

Health professionals are increasingly turning to living organ donation to augment cadaveric donation. Although living donation is currently performed with donors who are either genetically or emotionally related to the recipient, a 1997 British Columbia Transplant Society survey indicated that 32% of BC residents would be willing to donate a kidney, while alive, to a stranger (unpublished data). The goal of this study is to tap the public pulse about the living anonymous donor (LAD) by replicating and expanding the 1997 findings.

METHODS

Five hundred BC residents completed a telephone survey including demographic information, questions about their organ donation behaviors and attitudes, and their willingness to donate a kidney, while alive, to particular individuals (child, spouse, parent, relative, friend, and stranger). To improve the methodological rigor of the 1997 study, an informed condition was added in the current study where participants learned about living donation before being asked about their willingness to donate.

RESULTS

There were no differences among the 1997 results and the two conditions in the 2000 survey. Twenty-eight percent of participants in the uninformed condition and 29% of participants in the informed condition indicated that they would be willing to be LADs. LADs were more likely than self-reported non-donors to have registered as cadaveric donors and to endorse attitudes that were congruent with wanting to donate to a stranger.

CONCLUSIONS

This study replicates the 1997 findings and increases confidence that a significant minority of British Columbians support living anonymous donation and that some would consider becoming LADs themselves.

Post-transplant diabetic ketoacidosis--a possible consequence of immunosuppression with calcineurin inhibiting agents: a case series

Post-transplant diabetes mellitus, a complication due to corticosteroids and the calcineurin inhibitors, cyclosporine and tacrolimus (FK506), is commonly regarded as a form of type-2 (adult-onset) diabetes mellitus. Diabetic ketoacidosis, which requires relative insulin deficiency to impair fatty acid metabolism, is a complication of type-1 diabetes mellitus. We report three patients who presented with diabetic ketoacidosis post-transplant. All three patients presented with severe hyperglycemia, significant ketosis and metabolic acidosis of variable severity. One patient was a renal transplant recipient on a cyclosporine-based regimen. The other two patients were liver transplant recipients receiving either cyclosporine or tacrolimus-based immunosuppression. Both of the liver transplant recipients were found to have moderate to high serum levels of calcineurin inhibitors on presentation. The liver recipient on cyclosporine (Neoral) had a 4 hour post-dose level of 388 ng/ml and the patient on tacrolimus was found to have a trough level of 21.2 ng/ml. Our experience suggests that post-transplant diabetes mellitus, in association with calcineurin inhibition, may result in ketoacidosis either secondary to relative beta cell dysfunction, peripheral insulin resistance, or a combination of the two effects. Post-transplant diabetes mellitus can be an atypical form of adult-onset diabetes with features of both type I and type II diabetes mellitus.

Racial differences between solid organ transplant donors and recipients in British Columbia: a five-year retrospective analysis

BACKGROUND

We attempted to determine whether significant racial differences exist between organ donors and transplant recipients in British Columbia, and whether differences exist between individual organ transplant programs (lung, heart, kidney, liver, and pancreas). The design of the study was a retrospective review.

METHODS

We used the database of the British Columbia Transplant Society, a provincial agency, for the years 1992 to 1997 inclusive. The outcome measures were a comparison of racial characteristics of organ donors and transplant recipients collectively and by individual organ transplant program.

RESULTS

There were 236 organ donors and 766 transplant recipients. Comparing racial groups between donors and recipients, Caucasians contributed the most donors (93.2%) but received proportionately fewer organs (73.4%, P<0.000001). Orientals donated 3.4% of all organs but constituted 14.4% of all recipients (P<0.00001). Non-Oriental, non-Caucasians (predominantly Asian Indians and Native Aboriginals) constituted 3.4% of all donors and 12.2% of all recipients (P=0.0001). Among the individual organ transplant programs, lung, heart, and pancreas recipients were predominantly Caucasian (148 of 156 recipients). Oriental recipients were more likely to be kidney recipients (19.8% of all kidney recipients) compared with all Oriental recipients (P<0.000001). Likewise, Asian Indians were more likely to be kidney recipients (7.2% of all kidney recipients) compared with all Asian Indian recipients (P<0.0001). Native Aboriginals, however, were more likely to be liver allograft recipients (8.3% of all liver transplants) than nonliver allograft recipients (P=0.017).

CONCLUSIONS

In British Columbia, disparity exists between Oriental and non-Oriental, non-Caucasian donors and recipients. Orientals and Asian Indians were more likely to be kidney graft recipients than nonkidney graft recipients, whereas Native Aboriginal recipients seemed more likely to have undergone liver transplantation.

Successful renal transplantation with ipsilateral femoral arteriovenous grafts

BACKGROUND

The choice of location for revascularization of a renal allograft is frequently influenced by the presence of previous pelvic surgery or failed allografts that remain in situ. The presence of polytetrafluoroethylene (PTFE) loop grafts in the femoral vessels may potentially result in iliac venous hypertension, thereby compromising the function of a renal allograft placed nearby. The purpose of this study is to report the hemodynamic changes within the iliac veins as a result of PTFE femoral grafts and report the outcome of renal allografts placed ipsilateral to such grafts.

METHODS

THREE patients with a failed renal allograft in the right iliac fossa and functioning left groin PTFE loop grafts underwent left iliac venography and hemodynamic measurements of the iliac venous system. All three patients underwent renal transplantation in the left iliac fossa without ligation or alteration of the loop graft. Standard clinical data were collected after transplantation.

RESULTS

All three patients demonstrated widely patent external iliac and common iliac veins ipsilateral to the loop graft. Elevated pressures measured within the venous limb of the loop graft dissipated rapidly within the common femoral and external iliac veins. All three kidneys were well perfused, as documented by posttransplant technetium 99m-diethylenetriaminepentaacetic acid nuclear renography. All three patients have normal renal function past 7 months after transplant, and all three femoral loop grafts are still functioning.

CONCLUSIONS

PTFE loop grafts to the femoral vessels are not associated with local venous hypertension in the ipsilateral external iliac veins. Revascularization of a renal allograft may be performed ipsilateral to a femoral loop graft provided other venous diseases, such as strictures, have been excluded.

The quality of initial function following renal transplantation determined by creatinine elimination kinetics. Comparison of Minnesota antilymphocyte globulin and cyclosporine induction immunosuppression

To compare the effect of type of induction immunosuppression on the quality of initial renal allograft function, we identified 35 cadaver donor kidney pairs in which one recipient of a kidney from a given pair received induction immunosuppression with Minnesota antilymphocyte globulin (MALG group) while the recipient of the contra-lateral kidney received cyclosporine from day zero (CsA group). In the absence of an existing quantitative measure to assess and compare the status of those grafts that function primarily, we defined the half-life of creatinine elimination (t1/2SCr) as such an outcome measure based on a review of creatinine elimination kinetics. All organs were procured with in-situ perfusion and en-bloc removal. Total cold storage times, rewarm times, and perioperative management were comparable for the two groups. In the MALG group, the mean t1/2SCr) was not different from that in the CsA group (1.38 +/- 0.96 days vs 1.35 +/- 1.2 days P = NS). Multiple regression analysis performed on the differences in recipient age, number of DR-B locus matches, total cold ischemia time, rewarm time, and central venous pressure at reperfusion of a given donor pair demonstrated no significant impact of any of these differences on the difference in t1/2SCr for the same pair set in this sample. The nadir of serum creatinine achieved in the first five days posttransplant was somewhat higher in the CsA group (234 +/- 131 mumol/L) as compared with the MALG group (200 +/- 132 mumol/L) but the difference was not significant. A similar nonsignificant trend was observed in the comparison of mean serum creatinine values at 30 days posttransplant (MALG group: 158 +/- 62 mumol/L vs. CsA group: 200 +/- 141 mumol/L). Only one of seventy recipients (CsA group) was dialyzed within the first 5 days posttransplant for an overall incidence of ATN of less than 2%. Fourteen of 35 (40%) recipients in both groups received treatment for acute rejection. The mean time to first treatment for acute rejection episode was shorter in the CsA group than the MALG group (10 +/- 8 days vs 23 +/- 24 days, P = 0.055). Graft survival at one year was not different for the two groups (92% vs. 87% for the MALG and CsA groups respectively, P = NS).(ABSTRACT TRUNCATED AT 400 WORDS)

Prostatic carcinoma following renal transplantation

A case of prostatic carcinoma diagnosed after renal transplantation is described. Treatment was chosen according to current principles of staging of the disease, and radical prostatectomy proved to be technically feasible after renal transplantation. Immunosuppressive therapy has been continued without apparent consequence to the disease so far. Until there is definite evidence that immunosuppression adversely affects the prognosis of prostatic carcinoma, the decision to terminate immunosuppressive therapy should be based on individual circumstances, such as the response to treatment, the rate of progression of the disease, and the availability of additional treatment for the disease that would be expected to improve prognosis in the absence of immunosuppression.

In vitro immunoglobulin production in long-term renal transplant recipients

The difference in immunoregulation between stable renal transplant recipients and patients undergoing chronic rejection is unknown. In stable transplant recipients humoral responses to the allograft are controlled, but in patients with chronic rejection this control appears to be lost. In this study we evaluate B cell function in 24 stable transplant recipients and 5 patients with chronic rejection, using pokeweed mitogen (PWM)-stimulated in vitro lymphocyte production of immunoglobulin (Ig). Stable patients and patients with chronic rejection were similar with respect to time posttransplant, age, degree of HLA-A and B matching and immunosuppressive therapy. Unstimulated immunoglobulin production and serum immunoglobulin levels were similar in both groups and within the normal range. PWM stimulated IgG, and IgM production was significantly depressed in stable patients compared with normal controls and patients with chronic rejection. Patients with chronic rejection had normal PWM-stimulated Ig production. Mononuclear cell subsets--as determined by the monoclonal antibodies T4, T8, T11, B1, and M02, as well as the ratio of T4 to T8--were similar in the two patient groups and within the normal range. There was no correlation between decreased Ig production and decreased T4/T8 ratio. We conclude that stable renal transplant recipients have impaired in vitro humoral responses that may be important in maintaining allograft tolerance. In patients with chronic rejection PWM-stimulated responses have escaped control, and this may be important in the pathogenesis of antibody-mediated graft damage. Impaired Ig production in stable patients may be due to a suppressor cell mechanism--however, quantitative measurements of suppressor cells and the T4/T8 ratio do not predict humoral unresponsiveness.