Effects of blood transfusion on cadaver renal transplantation: the Southeastern Organ Procurement Foundation prospective study (1977 to 1979).

Abstract

The dominant beneficial effect of blood transfusions on cadaver renal allograft survival is now well established, although the mechanism of this phenomenon is unexplained. We evaluated data from a multicenter prospective series of 1,101 primary cadaver renal transplants done in the Southeastern Organ Procurement Foundation over a 30-month period. Data on pretransplant blood transfusions were obtained prospectively for transfusions given during the study period and retrospectively for blood transfusions given prior to the study. The administration of pretransplant blood transfusions was not randomized. The transfusion effect accounted for a 20% improved 1-year graft survival rate when the effect of antilymphocyte sera (ALS) and histocompatibility matching were factored out. The type of blood product was important. In patients who received only one type of blood product pretransplant, packed red blood cells (PRBC), washed red blood cells (WRBC), and mixed varieties of blood products (MRBC) were more effective than frozen red cells (FRBC) in achieving improved graft survival. The timing of pretransplant transfusions was important. PRBC, WRBC, and MRBC given 10 to 365 days pretransplant were highly effective while blood products administered at the time of renal transplantation and up to 10 days or over 1 year prior to transplant were less effective. ALS accounted for an average of 15% improved graft survival, but was most effective in the presence of previous transfusions and/or a high HLA match (0 or 1 HLA-A or B antigens mismatched). High HLA match accounted for a 9% improvement in graft survival in the transfused or ALS-treated recipient groups. Our study suggests that blood transfusions are the dominant beneficial factor in primary cadaver renal transplants, and that ALS and high HLA matching provide additional benefit. The best graft survival rates occurred with a combination of transfusions, ALS treatment, and high HLA match; the worst occurred with nontransfused recipients who did not receive ALS and had low HLA match. We showed no graft effects relative to age, HBsAg antigenemia, sex, parity, blood group, or preformed cytotoxic antibody status. It is now clear from reports of over 100 transplant centers that blood transfusions before cadaver renal transplantation exert a beneficial transfusion effect (TE) on graft survival. The practical implications of this finding are still being critically assessed, since the accuracy of the report data is inherently subject to recording errors, and various factors influencing the success of renal transplantation are easily confounded with TE. Few randomized prospective studies have been done on a large enough scale for interpretation, and much of the transfusion history of renal transplant recipients is necessarily retrospective (1). Furthermore, there is caution in accepting a liberal transfusion policy since preformed antileukocyte antibodies may make it difficult or impossible to obtain a cadaver kidney for presensitized patients. Also, hyperacute rejections may occasionally occur even when antibodies cannot be detected by the usual tests. Finally, the risk of hepatitis transmission is as high as 10%, a substantial danger (2). How efficacious is blood transfusion for cadaver renal transplantation, and how can we separate its effects from those of ALS, HLA matching, and other treatment variables? Is the TE synergistic with or antagonistic against other graft-enhancing therapeutic options? In order to assess these questions, the data from a prospective study of the Southeastern Organ Procurement Foundation were critically analyzed. This preliminary report covers 1,101 primary cadaver renal allografts. It confirms the dominant effects of transfusion on cadaver renal grafts and further clarifies the therapeutic value of ALS and HLA matching.