Background During the past few years, there has been renewed interest in the use of expanded criteria donors (ECD) for kidney transplantation to increase the numbers of deceased donor kidneys ...available. More kidney transplants would result in shorter waiting times and limit the morbidity and mortality associated with long-term dialysis therapy. Study Design Systematic review of the literature. Setting & Population Kidney transplantation population. Selection Criteria for Studies Studies were identified by using a comprehensive search through MEDLINE and EMBASE databases. Inclusion criteria were case series, cohort studies, and randomized controlled trials assessing kidney transplantation in adult recipients using ECDs. Predictor A special focus was given to studies comparing the evolution of kidney transplantation between standard criteria donors (defined as a donor who does not meet criteria for donation after cardiac death or ECD) and ECDs (defined as any brain-dead donor aged > 60 years or a donor aged > 50 years with 2 of the following conditions: history of hypertension, terminal serum creatinine level ≥ 1.5 mg/dL, or death resulting from a cerebrovascular accident). Outcomes Criteria used to define and select ECDs, practice patterns, long-term outcomes, early complications, and some patient issues, such as selection criteria and immunosuppressive management. Results ECD kidneys have worse long-term survival than standard criteria donor kidneys. The optimal ECD kidney for donation depends on adequate glomerular filtration rate and acceptable donor kidney histological characteristics, albeit the usefulness of biopsy is debated. Limitations This review is based mainly on data from observational studies, and varying amounts of bias could be present. We did not attempt to quantitatively analyze the effect of ECD kidneys on kidney transplantation because of the huge heterogeneity found in study designs and definitions of ECD. Conclusions Based on the available evidence, we conclude that patients younger than 40 years or scheduled for kidney retransplantation should not receive an ECD kidney. Patients 40 years or older, especially with diabetic nephropathy or nondiabetic disease, but a long expected waiting time for kidney transplantation, show better survival receiving an ECD kidney than remaining on dialysis therapy.
This research study was conducted to investigate whether serum albumin levels predict allograft/patient outcomes in the new era of transplant medicine and immunology.
The association of 1-year ...post-transplant serum albumin, and patient and graft outcomes was retrospectively analyzed in 500 kidney transplant recipients between 1998 and 2005. Albumin was used as a categorical and a continuous variable in univariate and multivariate Cox regression and Kaplan-Meier survival analyses.
The average (±SE) age at transplant was 47 ± 12 years. Patients were followed up for 63.4 ± 28 months after transplant. There were 56 graft losses and 38 patient deaths. In univariate analysis, the following variables were associated with the composite endpoint of patient death or allograft loss: 1-year serum albumin (hazard ratio HR = 0.52, P = .0009), 1-year serum albumin <4.0 g/dL (HR = 1.81, P = .02), 1-year serum creatinine (HR = 3.55, P < .00001), angiotensin converting enzyme inhibitors or angiotensin receptor blockers use (HR = 1.61, P = .03), a history of previous transplant (HR = 1.54, P = .04), months of dialysis before transplant (HR = 1.01, P = .00003), type of transplant (deceased donor HR = 1.64, P = .02), and acute rejection (HR = 1.52, P = .0000003). Of these, multivariable Cox regression analyses retained 1-year serum albumin (HR = 1.4, P < .0001), serum creatinine (HR = 2.7, P < .0001), and acute rejection (HR = 1.7, P = .02) as significant predictors of patient/graft loss.
One-year serum albumin is an independent predictor of poor outcomes in the contemporary era of transplant medicine and immunosuppression. Further studies are needed to separate the role of this biomarker in inflammation and nutrition in kidney transplant recipients.
The best induction agent for simultaneous pancreas-kidney transplantation (SPKT) remains the subject of debate. Alemtuzumab is effective in preventing acute cellular rejection (ACR) in SPK recipients ...and has been used to prevent antibody-mediated rejection (AMR) in sensitized kidney transplant candidates.
A retrospective cohort study was performed including 136 SPK recipients receiving maintenance immunosuppression with tacrolimus, mycophenolic acid prodrugs, and prednisone. Two groups were compared: those who received induction with alemtuzumab (n=97) and those induced with basiliximab (n=39).
Kidney ACR was more frequent in SPKT induced with basiliximab (2-year 12.8% vs. 3.1%, P=0.04), but the incidence of AMR was similar (2-year 18% with basiliximab vs. 13.8% with alemtuzumab, P=NS). Kidney rejection was associated with clinical pancreas rejection in 70% of cases, without differences between the groups. Postrejection kidney graft survival was similar in both groups (2-year basiliximab/alemtuzumab 94.7%/91.2%), but death-censored kidney graft survival was lower with alemtuzumab (100%/91.2%, P=0.056). In the basiliximab group, the predominant cause of kidney loss was death-with-function, whereas in the alemtuzumab group AMR accounted for all losses. Pancreas graft survival was similar in both groups, yet more pancreas losses due to acute rejection occurred in alemtuzumab-treated patients (4 vs. 1).
Kidney AMR is more common than ACR in SPKT recipients treated with alemtuzumab, tacrolimus, mycophenolic acid, and steroids. ACR is better prevented by alemtuzumab than basiliximab, but no relevant difference is found in prevention of AMR. Despite the high incidence of AMR, survival rates are excellent in both groups.
An increase in the incidence of autoimmune diseases has been described in patients receiving alemtuzumab.
To determine whether induction with alemtuzumab increases recurrence of glomerular disease, ...we performed a retrospective study in 443 patients with biopsy-proven glomerular diseases undergoing kidney transplantation. Patients receiving alemtuzumab (n=161) were compared with those receiving interleukin (IL)-2-receptor antagonists (n=217) or antithymocyte globulin (n=64).
Biopsy-proven glomerular disease recurrence was similar in patients induced with alemtuzumab or IL-2 receptor antagonists. Patients receiving antithymocyte antibody had a lower recurrence rate than patients treated with other induction agents, with borderline significance (hazard ratio HR 0.13, 95% confidence interval 95% CI 0.02-0.98, P=0.047). Patients with systemic lupus treated with alemtuzumab had a similar re-emergence of autoreactive antibodies to patients treated with other agents. Recurrent disease increased the risk of allograft failure (HR 2.36, 95% CI 1.28-4.32, P=0.0056). The development of acute rejection and the use of deceased (vs. living) donor kidneys were also significant factors influencing graft survival. A greater risk of mortality was detected in those patients with recurrent glomerular disease (HR 3.76, 95% CI 1.37-10.35, P=0.01), whereas increased age at transplantation (HR 1.05) and the use of deceased (vs. living) donor kidneys (HR 3.20) also increased mortality. No specific induction agent significantly affected graft loss or mortality when using adjusted or unadjusted hazard ratios.
In this retrospective analysis, induction with alemtuzumab did not increase the rate of re-emergence of autoantibodies or biopsy-proven recurrence of glomerular disease. A slight reduction in the incidence of recurrence was observed in patients treated with thymoglobulin, yet this observation can only be validated in a prospective randomized trial.
Pancreas after kidney transplantation Hariharan, Sundaram; Pirsch, John D; Lu, Christopher Y ...
Journal of the American Society of Nephrology,
04/2002, Letnik:
13, Številka:
4
Journal Article
Three hundred and four patients underwent 362 liver transplants between July 1984 and April 1992. Fifty-eight retransplants were performed in 44 patients (14.5%). Thirty-four patients underwent two ...(77.3%), seven patients three (15.9%), two patients four (4.5%), and one patient five (2.3%) transplants. Poor function accounted for 23 retransplants (6.4%), technical problems for 19 retransplants (5.2%), and rejection for 15 retransplants (4.1%). One-month patient survivals after retransplantation for poor function, technical problems, or rejection were similar (79.0%, 73.4%, and 80.0%, respectively). No difference in retransplantation rates were seen between adults and children receiving whole liver transplants (WLT) (11.6% versus 19.1%). However, retransplantation for poor function was more common in pediatric recipients receiving reduced-size liver transplants (RLT) (20.0% versus 0.0%, P < 0.01), while retransplantation for hepatic artery thrombosis (HAT) was more common in pediatric recipients receiving WLT (16.7% versus 2.8%, P < 0.05). The presence of multiorgan system failure of greater than four was associated with a high mortality (90%), whereas patients undergoing emergent retransplantation who had less than four systems fail had a survival of 73.9% and patients who underwent elective retransplantation had a survival rate of 81.8%. Length of stay and cost of liver transplantation was higher in patients undergoing retransplantation when compared with primary transplants (29.7 +/- 14.9 days versus 58.4 +/- 38.9 days and $122,358 +/- 59,782 versus $289,302 +/- 126,907, P < 0.01). The overall actuarial one-year patient survival in primary transplants was 86.6% and in retransplants 74.8%, and at five years these were 71.4% versus 62.5%, respectively (P < 0.05). Our results support continued retransplantation of the liver unless the patient's medical condition dictates otherwise.
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