Organ transplantation after cardiac death

Abstract

In the paper by Dominic Summers and colleagues (Oct 16, p 1303), it is intriguing to note that, in fi rst graft recipients, kidneys from brain-death donors carry a higher risk of acute rejection than do kidneys donated after cardiac death, but that the increased risk of acute rejection in the former donors did not translate into an increased risk of graft loss. Other registry data also showed a dissociation between rejection risk and risk of graft loss. Additionally, the registry study by Summers and colleagues confi rms the fi ndings of a prospective study in deceaseddonor kidney transplantation which showed that better HLA matching was not associated with increased graft survival. In these studies, donor graft quality seems to be more important for renal allograft outcome than acute rejection, and the risk of acute rejection associates closely with these donor factors. Does this mean that acute rejection is no longer an independent predictor of graft survival in deceased-donor kidney trans plant ation with the use of powerful immunosuppressive protocols and altered donor–recipient demo graphics? Is acute rejection still a valid endpoint for intervention studies in deceased-donor kidney trans plantation? Despite this circumstantial evidence that acute rejection becomes less important for graft outcome of fi rsttime deceased-donor kidney transplantation, there are only very limited data published that have directly addressed this issue. In practice, it would be necessary to approach this issue with a multivariate hazard analysis for graft survival including acute rejection next to base line donor–recipient demo graphics. Summers and col leagues’ cohort is perfectly suited to addressing this important question.