5-year Graft Survival Rates Research Articles

CON: Liver Transplant Alone.

CON: Liver Transplant Alone.

Impact of donor kidney weight to recipient body weight ratio on long-term graft outcomes in live donor kidney transplantation

Background: Kidney weight has been suggested as a surrogate marker for nephron numbers and renal function. Small donor kid ney sizes relative to recipient body size is an important contributor to short-term graft renal function, but the impact of size mis matching on long-term graft outcomes remains unknown. This study is aimed to evaluate the impact of the donor kidney weight to recipient body weight ratio (KW/BW) on long-term graft survival in live donor kidney transplantation. Methods: We performed a longitudinal cohort study in 1,397 patients who underwent live donor kidney transplantation between 2000 and 2016 at Severance Hospital. Following cold perfusion and back table surgery, the kidney was weighted on the same electronic weighting scale by the surgeon. Patients were grouped into four groups according to KW/BW quartiles. Results: During a median follow-up period of 127 months, 245 graft losses occurred (172 graft failures and 73 patient deaths). The 10-year death-censored graft survival rates were 86.9% in the lowest quartile, 90.4% in the second quartile, 90.5% in the third quartile, and 92.4% in the highest quartile (P=0.002). Multivariable analysis revealed that the lowest KW/BW (hazard ratio [HR], 2.16; 95% confidence interval [CI], 1.33-3.48; P=0.002) and second lowest KW/BW (HR, 1.69; 95% CI, 1.06-2.70; P=0.029) groups were significantly associated with death-censored graft failure compared with the highest KW/BW group. Patients with lower KW/BW exhibited consistently lower estimated glomerular filtration rates than those with higher KW/BW. Conclusions: Low KW/BW ratio is significantly associated with long-term graft outcome in live donor kidney transplantation.

Post-hoc analysis of a randomized controlled trial on the impact of pre-transplant use of probiotics on outcomes after liver transplantation

Perioperative use of probiotics serves as efficient prophylaxis against postoperative infections after liver transplantation, yet data on long-term effects of pre-transplant probiotic intake is lacking.The aim of this study was to assess the effects of pre-transplant probiotic administration on long-term results of liver transplantation. This was secondary analysis of a randomized trial. Patients were randomized to receive either 4-strain probiotic or placebo before liver transplantation. Five year graft survival was set as the primary end-point. Secondary end-points comprised serum bilirubin and C-reactive protein (CRP) concentration, international normalized ratio (INR), serum transaminases and gamma-glutamyl transferase (GGT) activity. Study group comprised 44 patients, of whom 21 received probiotics and 23 received placebo with 5-year graft survival of 81.0% and 87.0%, respectively (p = 0.591). Patients in the probiotic arm exhibited lower INR (p = 0.001) and CRP (p = 0.030) over the first 6 post-transplant months. In the absence of hepatitis B or C virus infection, pre-transplant administration of probiotics also reduced aspartate transaminase activity (p = 0.032). In the intervention arm, patients receiving probiotics for under and over 30 days had 5-year graft survival rates of 100% and 66.7%, respectively (p = 0.061). Duration of probiotic intake > 30 days was additionally associated with increased INR (p = 0.031), GGT (p = 0.032) and a tendency towards increased bilirubin (p = 0.074) over first 6 post-transplant months. Pre-transplant administration of probiotics has mild positive influence on 6-month allograft function, yet should not exceed 30 days due to potential negative effects on long-term outcomes. (ClinicalTrials.gov Identifier: NCT01735591).

Impact of Preexisting Inflammatory Bowel Disease on the Outcome of Liver Transplantation for Primary Sclerosing Cholangitis.

Approximately 80% of patients with primary sclerosing cholangitis (PSC) also have inflammatory bowel disease (IBD), and its effect on the outcomes of liver transplantation (LT) for PSC is unclear. We retrospectively collected data from adults who underwent LT for PSC from 1989 to January 2018 in 4 French LT centers. We compared the rates of patient and graft survivals and of complications after LT. Among 87 patients, 52 (60%) had preexisting IBD. Excluding those who died within the first 3months, the 10-year patient survival and graft survival rates were 92.6% (95% confidence interval [CI], 84.3%-100%) and 77.1% (53.8%-85.3%), respectively, in the PSC with IBD (PSC-IBD) group and 97.1% (91.4%-100%; P=0.44) and 83.2% (69.6%-96.9%; P=0.43) in the isolated PSC group, respectively. Exposure to azathioprine after LT was significantly associated with mortality (odds ratio [OR], 15.55; 1.31-184.0; P=0.03), whereas exposure to mycophenolate mofetil was associated with improved survival (OR, 0.17; 95% CI, 0.04-0.82; P=0.03), possibly an era effect. The rate of recurrent PSC was 21% in the PSC-IBD group and 11% in the isolated PSC group (P=0.24). Severe infections occurred in 125 per 1000 person-years in both groups. Exposure to mycophenolate mofetil was associated with a lower risk of infection (OR, 0.26; 95% CI, 0.08-0.85; P=0.03). The presence of IBD was associated with cytomegalovirus (CMV) infection (OR, 3.24; 95% CI, 1.05-9.98; P=0.04). IBD prior to LT for PSC may not affect patient or transplant survival but may increase the risk of CMV infection.

Surgical complications in pediatric kidney transplantation-Incidence, risk factors, and effects on graft survival: A retrospective single-center study.

The field of pediatric kidney transplantation remains challenging due to an ongoing lack of size-matched grafts and anatomical peculiarities. In the current study, we investigated the incidence of surgical complications in pediatric recipients, with a focus on risk factors and effects on graft outcome. We retrospectively reviewed all 2386 kidney transplantations at our institution from January 2005 until December 2018. Of these, 221 transplants were performed in pediatric recipients, defined as under the age of 18years. Donor-recipient body surface area ratios were calculated to evaluate the effects of size mismatching. Regression analyses were performed to identify independent risk factors for surgical complications and graft survival, respectively. Perioperative surgical complications requiring revision were observed in 34 (15.4%) cases. Leading cause for revision were vascular complications such as thrombosis or stenosis (n=15 [6.8%]), which were significantly more frequent in case of young donors, (ie, donor age <6years; OR: 4.281; CI-95%:1.385-13.226; P=.012), previous nephrectomy (OR: 3.407; CI-95%:1.019-11.387; P=.046), and en-bloc grafts (OR: 4.923; CI-95%:1.355-17.884; P=.015), followed by postoperative hemorrhage (n=10 [4.5%]), ureteral complications (n=8 [3.6%]), and lymphoceles (n=7 [3.2%]). Median follow-up was 84.13 (0.92-175.72) months. One-, 5-, and 10-year graft survival rates were 97.1%, 88.9%, and 65.1%, respectively. Except for vascular complications (HR: 4.727; CI-95%:1.363-16.394; P=.014), none of the analyzed surgical morbidities significantly influenced graft survival. In conclusion, pediatric kidney transplantation achieves excellent long-term results. However, meticulous surgical technique and continuous postoperative monitoring are imperative for early detection and treatment of imminent vascular complications, especially in case of young donors and en-bloc grafts.

Acute Rejection and Infectious Complications in ABO- and HLA-Incompatible Kidney Transplantations.

BackgroundPatients receiving ABO-incompatible (ABOi) or human leukocyte antigen (HLA)-incompatible (HLAi) kidney transplantation (KT) require potent immunosuppression and are thus at a higher risk of infectious complications. We evaluated the clinical outcomes of KT stratified by ABO and HLA incompatibilities and identified the factors associated with the clinical outcomes.Material/MethodsRecipients who underwent living-related KT between 2012 and 2017 were included and classified into 4 groups: ABO-compatible and HLA-compatible (ABOc/HLAc), HLA-incompatible (ABOc/HLAi), ABO-incompatible (ABOi/HLAc), and ABO-incompatible and HLA-incompatible (ABOi/HLAi). Cox proportional hazards regression analyses were carried out to evaluate the risk factors of acute rejection. Out of the 1732 patients who underwent KT, 1190, 131, 358, and 53 were in the ABOc/HLAc, ABOi/HLAc, ABOc/HLAi, and ABOi/HLAi groups, respectively.ResultsThe ABO/HLAi group showed the lowest 5-year graft survival rate (91.7%). Death-censored graft survival was not significantly different among the groups. The mortality rate from infections was significantly higher in the ABOi/HLAi group (7.5%) than the other groups. Antibody-mediated rejection-free graft survival was the lowest in the ABOi/HLAi group, with significant differences compared with the ABOi/HLAc group (P=0.02) and the ABOc/HLAi group (P=0.03). ABOi/HLAi (hazard ratio [HR], 2.63; 95% confidence interval [CI], 1.04–6.65; P<0.01) and combined infection (HR, 1.91; 95% CI, 1.45–2.51; P<0.01) were significant risk factors for acute rejection.ConclusionsPatients with both ABO and HLA incompatibilities showed inferior rates of overall patient and graft survival due to infectious complications. Infection was a prominent risk factor of acute rejection following KT after adjusting for possible confounders including ABO and HLA incompatibility.

Combined Liver-Kidney Transplantation With Preformed Anti–human Leukocyte Antigen Donor-Specific Antibodies

IntroductionThe impact of preformed donor-specific anti–human leukocyte antigen (HLA) antibodies (pDSAs) after combined liver-kidney transplantation (CLKT) is still uncertain.MethodsWe conducted a retrospective study in 8 European high-volume transplant centers and investigated the outcome of 166 consecutive CLKTs, including 46 patients with pDSAs.ResultsPatient survival was lower in those with pDSAs (5-year patient survival rate of 63% and 78% with or without pDSA, respectively; P = 0.04). The presence of pDSAs with a mean fluorescence intensity (MFI) ≥ 5000 (hazard ratio 4.96; 95% confidence interval: 2.3–10.9; P < 0.001) and the presence of 3 or more pDSAs (hazard ratio 6.5; 95% confidence interval: 2.5–18.8; P = 0.05) were independently associated with death. The death-censored liver graft survival was similar in patients with or without pDSAs. Kidney graft survival was comparable in both groups. (The 1- and 5-year death-censored graft survival rates were 91.6% and 79.5%, respectively, in patients with pDSAs and 93% and 88%, respectively, in the donor-specific antibody [DSA]-negative group, P = not significant). Despite a higher rate of kidney graft rejection in patients with pDSAs (5-year kidney graft survival rate without rejection of 87% and 97% with or without pDSAs, respectively; P = 0.04), kidney function did not statistically differ between both groups at 5 years post-transplantation (estimated glomerular filtration rate 45 ± 17 vs. 57 ± 29 ml/min per 1.73 m2, respectively, in patients with and without pDSAs). Five recipients with pDSAs (11.0%) experienced an antibody-mediated kidney rejection that led to graft loss in 1 patient.ConclusionOur results suggest that CLKT with pDSAs is associated with a lower patients’ survival despite good recipients’, liver and kidney grafts’ outcome.

Effect of donor kidney morphology parameters on the prognosis in living kidney transplantation recipients.

BackgroundThe effect of donor kidney morphology parameters on the prognosis of renal transplant recipients remains unclear.MethodsWe conducted a retrospective cohort study consisting of 290 pairs of donors and recipients who underwent living related renal transplantation in our center between December 2013 and December 2015. The donor kidney morphology parameters, demographic characteristics and renal function of the included participants were collected and analyzed.ResultsThe univariate linear regression analysis revealed that the donor kidney weight (DKW)/recipient body weight (RBW), DKW/recipient body surface area (RBSA), DKW/recipient body mass index (RBMI), donor kidney volume (DKV)/RBW, DKV/RBSA, DKV/RBMI, and donor body weight (DBW)/RBW were significantly correlated with estimated glomerular filtration rate (eGFR) and serum creatinine in recipients within two years of transplantation. In our multivariate linear regression analysis, DKW/RBW and donor age significantly correlated with eGFR at 6, 12, 18 and 24 months after transplantation. DKW/RBW had the best prediction performance for good renal allograft function at 12 months after transplantation. We found that when the age of the donor was 55 years and above, the prediction performance of the nephron dosing to the recipient’s metabolic demands mismatch was elevated. After grouping according to the donor’s age and DKW/RBW, the allograft function from different donor ages improved as DKW/RBW increased. The number of recipients who were rejected in the high DKW/RBW group was significantly fewer than those in the low and medium groups the 1, 2, and 3-year graft and patient survival rates were comparable among these groups. Furthermore, we also identified that when the age of the donor was 55 years and above, the threshold of DKW/RBW was 3.09 g/kg via the receiver operating characteristic curve, which predicted a good renal function 12 months after transplantation.ConclusionsThe donor kidney morphology parameters were significantly associated with early renal allograft function, especially when the age of the donor was 55 years and above.

Clinical outcomes of the first 300 cases of kidney transplantation: a single-center retrospective cohort study

BackgroundKidney transplantation (KT) is regarded as the most effective treatment for end-stage renal disease. The annual number of KT cases in South Korea has increased rapidly as more centers are implementing a transplantation program. The objective of this study was to determine clinical outcomes of the first 300 consecutive cases of KT in a single center.MethodsClinical data of 300 cases of KT at Seoul National University Bundang Hospital from January 2004 to March 2018 were obtained from a prospectively collected database and retrospectively reviewed.ResultsThe mean age of patients was 47.7±12.9 years, and 59% of patients were male. There were 225 living donors and 75 deceased donors. A total of 42 cases were from ABO-incompatible donors. During a mean follow-up of 68.6±43.5 months, 38 patients (12.7%) experienced rejection. The most common cause was acute T-cell mediated rejection (9.0%). Eighteen patients experienced graft loss. One-year and 5-year death-censored graft survival rates were 99% and 96.6%, respectively. One-year and 5-year patient survival rates were 98.3% and 96.6%, respectively. Multivariate analysis revealed that graft weight-to-recipient weight ratio and rejection were significant factors affecting graft survival.ConclusionsThis single-center review demonstrates clinical outcomes comparable to other major centers. Such good outcomes were obtained by good patient selection, dedicated transplant physicians, and adequate use of immunosuppressive therapy.

Association of graft survival with tacrolimus exposure and late intra-patient tacrolimus variability in pediatric and young adult renal transplant recipients-an international CTS registry analysis.

Adolescent and young adult age is a high-risk window with an alarmingly increased likelihood of premature kidney graft loss due to immunological rejection. Using the large database of the Collaborative Transplant Study, we analyzed whether a more intense and less variable exposure to tacrolimus could counteract this young age-related enhanced immunoreactivity. Kidney graft recipients aged 12-23years (n=964) with a 1-year tacrolimus trough level between 4.0 and 10.9ng/ml had a 5-year graft survival rate of 85.1%, significantly better than the poor 66.1% rate in patients with a trough level below 4.0ng/ml who showed a 2.38-fold increased risk of graft loss in the multivariable analysis (P<0.001). This association was not apparent in young children aged 0-11years (n=455) and less pronounced in adults aged 24-34years (n=1466). However, an intra-patient variability of tacrolimus (IPV) trough level ≥1.5 at post-transplant years 1 and 2 was associated with an increased graft loss risk in both 12- to 23-year-old and 0- to 11-year-old recipients (P<0.001 and P=0.045). Patients with high IPV made up as many as 30% of kidney graft recipients, indicating that a more intense and less variable exposure to tacrolimus could improve graft survival strongly in this high-risk group.

Ten-Year Survival of Optical Penetrating Keratoplasty and Risk Factors for Graft Failure in Thai Patients

Objective: To determine long-term graft survival and identify risk factors for secondary graft failure of optical penetrating keratoplasty (PK) in Thai patients. Materials and Methods: A Retrospective study of patients that underwent optical PK at Siriraj Hospital between January 2002 and December 2005 was done. Results: Of 131 eyes, primary graft failure was found in two eyes (1.5%) thus, 129 eyes were recruited. The three most common surgical indications were pseudophakic or aphakic bullous keratopathy (33.3%), corneal scars (post-trauma, post-infection) (20.9%), and regrafts (16.3%). Mean follow-up period was 93.2 months (1 to 183 months). One-year, 2-year, 5-year, and 10-year graft survival rates were 84.5%, 73.2%, 50.2%, and 24.7%, respectively. The leading cause of graft failure was irreversible allograft rejection (62.5%). Most (56.0%) of the first graft rejection happened within one year post-operatively. Graft survival was lower in eyes with regrafts, history of glaucoma, deep corneal vascularization, peripheral anterior synechiae, and occurrence of one or more rejection episodes. Multivariate regression analysis demonstrated that peripheral anterior synechiae and occurrence of one or more rejection episodes were the significant independent risk factors for graft failure. Considering patients with the clear grafts at the last follow-up, the final best-corrected visual acuity was 6/36 or better in 66.7% eyes and 6/18 or better in 31.6% eyes. Comparing to pre-operative vision, patients with the clear grafts at the last follow-up had improved visual outcome in most eyes (82.5%). Conclusion: Ten-year survival and visual outcome of optical PK showed successful outcome, however, the survival rate decreased over time. The significant risk factors for graft failure should be cautiously evaluated before surgery. Keywords: Corneal graft survival, Keratoplasty outcome, Optical penetrating keratoplasty

The role of the comprehensive complication index for the prediction of survival after liver transplantation

In the last years, several scoring systems based on pre- and post-transplant parameters have been developed to predict early post-LT graft function. However, some of them showed poor diagnostic abilities. This study aims to evaluate the role of the comprehensive complication index (CCI) as a useful scoring system for accurately predicting 90-day and 1-year graft loss after liver transplantation. A training set (n = 1262) and a validation set (n = 520) were obtained. The study was registered at https://www.ClinicalTrials.gov (ID: NCT03723317). CCI exhibited the best diagnostic performance for 90 days in the training (AUC = 0.94; p < 0.001) and Validation Sets (AUC = 0.77; p < 0.001) when compared to the BAR, D-MELD, MELD, and EAD scores. The cut-off value of 47.3 (third quartile) showed a diagnostic odds ratio of 48.3 and 7.0 in the two sets, respectively. As for 1-year graft loss, CCI showed good performances in the training (AUC = 0.88; p < 0.001) and validation sets (AUC = 0.75; p < 0.001). The threshold of 47.3 showed a diagnostic odds ratio of 21.0 and 5.4 in the two sets, respectively. All the other tested scores always showed AUCs < 0.70 in both the sets. CCI showed a good stratification ability in terms of graft loss rates in both the sets (log-rank p < 0.001). In the patients exceeding the CCI ninth decile, 1-year graft survival rates were only 0.7% and 23.1% in training and validation sets, respectively. CCI shows a very good diagnostic power for 90-day and 1-year graft loss in different sets of patients, indicating better accuracy with respect to other pre- and post-LT scores.Clinical Trial Notification: NCT03723317.

Donor Age, Donor-Recipient Size Mismatch, and Kidney Graft Survival.

Small donor and/or kidney sizes relative to recipient size are associated with a higher risk of kidney allograft failure. Donor and recipient ages are associated with graft survival and may modulate the relationship between size mismatch and the latter. The aim of this study was to determine whether the association between donor-recipient size mismatch and graft survival differs by donor and recipient age. We performed a retrospective cohort study of first adult deceased donor kidney transplantations performed between 2000 and 2018 recorded in the Scientific Registry of Transplant Recipients. We used multivariable Cox proportional hazards models to assess the association between donor-recipient body surface area ratio and death-censored graft survival, defined as return to dialysis or retransplantation. We considered interactions between donor-recipient body surface area ratio and each of recipient and donor age. Among the 136,321 kidney transplant recipients included in this study, 23,614 (17%) experienced death-censored graft loss over a median follow-up of 4.3 years (interquartile range, 1.9-7.8 years). The three-way donor-recipient body surface area ratio by donor age by recipient age interaction was statistically significant (P=0.04). The magnitude of the association between severe size mismatch (donor-recipient body surface area ratio <0.80 versus ≥1.00) and death-censored graft survival was stronger with older donor age and recipient age. In all recipient age categories except the youngest (18-30 years), 5- and 10-year graft survival rates were similar or better with a size-mismatched donor aged <40 years than a nonsize-mismatched donor aged 40 years or older. The association of donor-recipient size mismatch on long-term graft survival is modulated by recipient and donor age. Size-mismatched kidneys yield excellent graft survival when the donor is young. Donor age was more strongly associated with graft survival than size mismatch.

Kidney transplantation with allografts from infant donors-Small organs, big value.

Although infant organ donors remain a rare source of organs for transplantation, technical challenges have resulted in increased rates of complications and inferior graft function. The aim of the present study was to investigate the outcomes of kidneys procured from juvenile and infant donors. We evaluated all kidney transplants from deceased donors<16years of age performed at our center between 01/2008 and 08/2019. We defined three groups based on quartiles of donor body weight: <13kg (infant donors), 13-40kg (juvenile donors), and>40kg (standard criteria donors). Clinical characteristics and outcomes were compared between groups. Ninety-two transplants were included in this study. Out of 92 recipients, there were 32 (34.8%) adult and 60 (65.2%) pediatric patients. All groups demonstrated excellent graft function and survival on both short and long-term follow-up. 1-year, 3-year, and 5-year graft survival rates for the standard criteria donor group were 100%, 95.2%, and 88.4%, respectively, compared with 95.8% for infant and 95% for juvenile donors at all times (P=.79). eGFR at 5years was 98.9±5.5, 74.1±6.2, and 81.6±6.9mL/min/1.73m2 for infant, juvenile, and standard criteria donors, respectively (P<.01). Infant donor allografts can be transplanted with excellent long-term outcomes in both pediatric and adult recipients. Implanting them as single allografts onto pediatric candidates allows for the transplantation of two patients. As such, pediatric recipients should be prioritized for these donor organs.

Laparoscopic Live Donor Nephrectomy: Single-Center Experience of 200 Consecutive Cases.

Background: Renal transplantation is the ideal treatment method for end-stage renal disease. Since deceased organ donation rates cannot meet the demand, live donor kidney transplantation (LDKT) is commonly performed worldwide. Laparoscopic donor nephrectomy (LDN) is currently the most commonly preferred minimally invasive donor nephrectomy technique. However, experienced surgeons should perform this procedure since the safety of the live donor is the priority in transplant practice. In this study, we aimed to investigate this procedure's safety at the hands of a surgeon during the transition period from open donor nephrectomy (ODN) to LDN. Methods: Data of the donors and recipients who underwent LDN and LDKT in Ankara Medicana Hospital between 2016 and 2019 were included in this study. Demographic, surgical, and immunological data of the donors and recipients were collected retrospectively. Donor data, including duration of surgery, warm ischemia time (WIT), complication rates, duration of hospital stay, and recipient data such as patient and graft survival rates, were compared with the published literature. Results: Two hundred donors and 200 recipients were included. The complication rate, surgical time, WIT at the donor site, and 1- and 3-year patient and graft survival rates were all comparable with the literature. Survival rates were irrespective of the relationship status of the donors with recipients. Conclusions: The LDN procedure can be safely performed by a surgeon with extensive laparoscopic surgery experience in general surgery cases and ODN.

N-glycosylated IgG in patients with kidney transplants increases calcium/calmodulin kinase IV in podocytes and causes injury.

Transplant glomerulopathy (TG) is a major cause of late allograft loss. Increased urine podocin/creatinine ratio in TG signifies accelerated podocyte loss. The mechanisms that lead to podocyte injury in TG remain unclear. We report that IgG from kidney transplant recipients with TG, but not from those without TG, cause a reduction in the expression of nephrin, significant podocyte actin cytoskeleton, and motility changes. These changes are preceded by increased expression of calcium/calmodulin kinase IV (CAMK4). Mechanistically, we found that CAMK4 phosphorylates GSK3β (glycogen synthase kinase 3 beta), activates the Wnt pathway and stabilizes the nephrin transcriptional repressor SNAIL. Silencing neonatal Fc Receptor (FcRn) or CAMK4 prevented the podocyte-damaging effects of IgG from patients with TG. Furthermore, we show that removal of N-linked glycosyl residues from these IgG did not interfere with its entry into the podocytes but eliminated its ability to upregulate CAMK4 and cause podocyte injury. The translational value of these findings is signified by the fact that CAMK4 is increased in podocytes of patients with TG but not in those without TG despite other forms of renal dysfunction. Our results offer novel considerations to limit podocyte injury in patients with kidney transplants, which may lead to eventual glomerular destabilization and transplant glomerulopathy.

Splenic Artery Transposition for Arterial Reconstruction in Living Donor Liver Transplantation

PurposeIn living donor liver transplantation, poor compatibility of the recipient hepatic artery remains a technical challenge. Here, we analyzed our 14 years of experience with extra-anatomic hepatic artery reconstruction. MethodsBetween July 2004 and December 2018, there were 1063 liver transplantations at our center. All patients with an extra-anatomic hepatic artery reconstruction were identified. The gastroduodenal artery and the transposed splenic artery were the primary options for extra-anatomic arterial reconstruction. Patient characteristics, operative data, and post-transplant outcome were reviewed retrospectively. ResultsThere were 22 patients with extra-anatomic hepatic artery reconstruction, 6 with gastroduodenal artery, and 16 with splenic artery. There were 2 major complications: 1 patient underwent early reoperation due to bleeding from the splenic artery trunk and another had an iatrogenic injury to the transposed splenic artery during conversion hepaticojejunostomy. Both were treated successfully with surgery. One patient died perioperatively due to sepsis. The 1- and 3-year graft survival rates of these 16 patients were 93.7% and 87.5%. ConclusionIf the hepatic arteries are not suitable for anastomosis, then we consider the gastroduodenal artery and the splenic artery to be the conduits of choice for extra-anatomic arterial reconstruction. The transposed splenic artery is very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.

P1647CHANGES IN CAUSES OF EARLY GRAFT LOSS IN LIVING DONOR KIDNEY TRANSPLANT RECIPIENTS, 1972-2018

Abstract Background and Aims In living donor kidney transplantation, the progress of immunosuppressants in recent decades has led to an average graft survival period more than 15 years. However, the rate of graft loss (GL) within 5 years is still about 5%. Since the incidence of early GL is low, clinical evidence of causes and risk factors are limited and it remains unclear whether early GL was predictable before transplantation. Our purposes were to characterize a patient population with GL, to identify risk factors associated with early (&amp;lt;5 years) GL. Method The subjects were 1,779 patients who underwent living donor kidney transplantation at Japanese Red Cross Nagoya Daini hospital and Masuko Memorial Hospital from January 1, 1972 to December 31, 2018 (former group (1972-1999) : 503, latter group (2000-2018) : 1,276). We retrospectively examined patient characteristics, timing and causes of GL in 445 cases with GL by December 31, 2019 (GL cases in former group : 335, GL cases in latter group : 110). Results The 5- and 10-year graft survival rates were on an increasing trend, with 74.7% and 58.3% in former group and 95.2% and 88.7% in latter group, respectively. In latter group, T cell-mediated rejection and recurrence of primary diseases were significantly more frequent in GL cases within 5 years after transplantation than over 5 years (10% vs 0%, p=0.02 and 6% vs 0%, p=0.04). Although not significant, GL due to antibody-mediated rejection tended to more frequent in over 5 years after transplantation (22% vs 45%). Compared the causes of GL within 5 years after transplantation between GL cases in former group and latter group, rate of allograft rejection significantly reduced (88％ vs 44%, p&amp;lt;0.001), and infections (especially BK polyomavirus infection), medication nonadherence and recurrence of primary diseases tended to increase (0%, 4% and 3% vs 8%, 16% and 8%, respectively). Conclusion Our analysis suggests that management of infections, medication nonadherence and recurrence of primary diseases have become more important for living donor kidney transplant recipients in recent years with improved immunosuppressants.

P1727DECEASED DONOR KIDNEY CHARACTERISTICS AND IMPACT ON 10-YEAR GRAFT SURVIVAL - A LONG-TERM OBSERVATIONAL STUDY

Abstract Background and Aims The long waiting list for deceased donor kidney transplantation has prompted the use of Expanded Criteria Donors (ECD) though it is possibly associated with worse graft function and outcomes than Standard Criteria Donors (SCD). Our centre had also implemented a protocol kidney biopsy at implantation from 2005 to 2009. The aim of this study was to evaluate the impact of donor factors and donor kidney histology on 10-year graft outcomes. Method A retrospective analysis was performed on 108 kidney transplant recipients who underwent a protocol biopsy at implantation from November 2005 to November 2009. The biopsy sample was evaluated for glomerulosclerosis, tubular atrophy, interstitial fibrosis and arteriolar narrowing and scored according to Remuzzi et al., N Engl J Med. 2006;354(4):343 (Remuzzi score). Donor factors evaluated were donor age, hypertension, diabetes mellitus, and terminal serum creatinine. The 10-year graft survival and estimated glomerular filtration rate (eGFR) was the main outcome of interest. Results The deceased donors included 58% males, 85% Chinese, with a median age of 49 (IQR 12) years. There were 13% diabetics, 51% hypertensive donors and the median terminal creatinine was 95 umol/L. The recipients were 51% male, 79% Chinese, with a median age of 47 (IQR 11) years at transplant. The time interval to transplant was 9.2 (IQR 3.0) years and the overall 10-year graft survival was 67.6%. Remuzzi score of ≤3 was associated with better 10-year graft survival compared with Remuzzi score of &amp;gt;3 (76.6% versus 45.2%, P =0.02). 10-year graft survival for SCD and ECD was not statistically different (71.6% versus 58.8%, P=0.187). A multivariate analysis was performed which included donor status (ECD vs SCD), Remuzzi score (&amp;gt;3 vs ≤3), donor age (≥60 or &amp;lt;60 years), donor hypertension, donor diabetes mellitus and terminal serum creatinine (≥133 umol/L versus &amp;lt;133 umol/L). Only Remuzzi score correlated with a better 10-year graft survival rate (P=0.020). All other factors did not correlate with 10-year graft survival. Amongst the 73 ten-year graft survivors, the median eGFR at year 10 was 47.5 (IQR 20.3) ml/min if the Remuzzi Score was ≤3 while the eGFR was 39.7 (IQR 33.0) ml/min if Remuzzi score was &amp;gt;3. However, this difference was not statistically significant (P=0.570). The 10-year eGFR was 45.8 (IQR 22.2) for SCD kidney recipients vs 49.5 (IQR 25.6) for ECD kidney recipients. Paradoxically, the median eGFR was higher with the ECD cohort but this was not statistically significant (P=0.443). Conclusion An implantation Remuzzi score of more than 3 is associated with poorer long-term graft survival as compared to other donor factors evaluated on 10-year graft survival or eGFR. Where possible, assessment of the kidney histology should be included as part of the kidney selection and allocation process in order to determine long term outcomes.

Outcome of ABO Blood Type–Incompatible Living-Related Donor Kidney Transplantation Under a Contemporary Immunosuppression Strategy in Japan

BackgroundBecause of the serious donor shortage in Japan, there is an increasing need for ABO blood type–incompatible kidney transplantation (ABOi-KT) in living-related donor kidney transplantation. We evaluated the outcomes of ABOi-KT performed at our hospitals using a contemporary immunosuppression strategy with low-dose rituximab. Patients and MethodsBetween June 2006 and April 2019, 107 patients underwent living-related donor kidney transplantation at our hospitals. The patients were divided into ABO-compatible (ABOc) and ABOi groups. The basic immunosuppression regimen differed between the 2 groups in the use of low-dose rituximab and therapeutic apheresis in the ABOi group. We compared graft survival, patient survival, rejection, viral infection, and posttransplant renal function between the 2 groups. ResultsOf 107 recipients, 37 (35%) underwent ABOi-KT. The 5-year graft survival rates in the ABOc and ABOi group were 91% and 100%, respectively. The Kaplan-Meier analyses showed no difference in graft survival (P = .168) or patient survival (P = .873) between the groups. Biopsy-proven rejection in the ABOc and ABOi groups was observed in 13 (19%) and 7 (19%) patients, respectively (P = .965), and viral infection was observed in 21 (30%) and 10 (27%) patients (P = .747), respectively. Renal function by estimated glomerular filtration rate from 1 week to 5 years after transplantation was similar in both groups. ConclusionsThe outcomes of ABOi-KT with low-dose rituximab were comparable with those of ABOc-KT at our hospitals. ABOi-KT with proper immunosuppression may be an option to help resolve the severe donor shortage in Japan.