Actuarial 1-year Graft Survival Research Articles

Pancreas transplantation from marginal donors

BackgroundMarginal donor organs are a supplementary source of grafts that has not been fully exploited for pancreas transplantation (PTx). MethodsA total of 100 PTx were performed with grafts procured from either 48 nonmarginal donors (NMD) or 52 marginal donors (MD), namely age greater than 45 years and/or severe hemodynamic instability at the time of procurement. PTx outcome was evaluated as the incidence of delayed endocrine pancreas function (DEPF), the complication rate, and the patient and graft survivals. ResultsThe DEPF rate was 6.2% for NMD as compared to 0 for MD (P > .05). Relaparotomy rate was 12.5% for NMD and 9.6% for MD (P > .05). Actuarial 1-year graft survival was 91.7% and 94.2% for NMD and MD, respectively (P > .05). Equivalent figures for patients were 97.9% and 98.1%, respectively (P > .05). ConclusionsPancreas from MD may be safely employed and significantly expand the donor pool for PTx.

Living donor liver transplantation of the right liver lobe between adults

Adult living donor liver transplantation has been established in an increasing number of transplant centres during the last few years. Donor safety and risks are important criteria influencing the further development. We report our experience with 43 adult-to-adult right lobe living donor liver transplantations. 43 patients (mean age: 49,8 +/- 16,0 years; f:m = 14:29) with end-stage liver disease received a right lobe liver graft from an adult living donor (mean age: 42,4 +/- 13,4 years; f:m = 27:16) between December 1999 and December 2001. An approval by the local ethics committee was obtained prior to the start of the programme and each donation. None of the donors experienced fatal or long-term complications. The rate of surgical complications in donors (biliary leakage, bleeding) was 9 %. Actuarial recipient survival was 93 % after three months and 88 % after one year. Five patients had to be re-transplanted. Thus the actuarial 1-year graft survival was 79 %. Biliary complications occurred in 14 % of all recipients. According to our experience, living donor liver transplantation of the right hepatic lobe is a safe and effective procedure. Especially for patients in acute and chronic liver failure, who otherwise would have died on the waiting list, this approach offers a life-saving option.

Tumor necrosis factor beta gene polymorphisms associated with urinary tract infections after renal transplantation.

We investigated whether tumor necrosis factor (TNF) beta(low) or TNFbeta(high) alleles predicted susceptibility to infection or rejection after renal transplantation. TNFbeta alleles were determined in 137 (ESRD) patients and correlated with urinary tract infections and rejection within 60 days among 75 consecutive renal transplant recipients. TNFbeta low was more prevalent among African-Americans than caucasians (83 vs. 63%, P=0.02). After renal transplantation, patients with TNFbeta low experienced more urinary tract infections (50 vs. 10%, P=0.002). The incidence of TNFbeta low and urinary tract infections were equivalent in patients treated with mycophenolate mofetil/cyclosporine (CsAA) (n=37) versus mycophenolate mofetil/tacrolimus (n=38). TNFbeta low was not associated with the incidence of delayed graft function (5 vs. 2, P=NS), early rejection (21 vs. 18%, P=NS) or actuarial 1-year graft survival (96 vs. 90%, P=NS). TNFbeta low was associated with urinary tract infections and TNFbeta high was associated with freedom from urinary tract infections. Neither gene correlated with rejection or l-year graft survival.

Renal transplantation across the ABO barrier using A2 kidneys.

The waiting list for cadaveric kidney transplantation has continued to grow, and with the relative scarcity of cadaver donors, the median waiting time for patients in the United States increased to 824 days in 1994. The median waiting times for patients with blood groups B or O were 1329 and 1007 days, respectively. Allocation of blood group A2 kidneys (20% of group A) to blood group O and B patients expands their potential donor pool and shortens their waiting time for a kidney transplantation. Between May 1991 and June 1998, we transplanted 15 A2 kidneys into 6 blood group O and 9 blood group B patients. Anti-A isoagglutinins were measured before transplantation, and patients with anti-A1 titers > or = 1:8 underwent plasmapheresis (PP). One patient with high titer anti-A antibodies, who did not receive PP, lost her allograft because of hyperacute rejection. Allograft function was excellent in the remaining 14 patients, with a mean serum creatinine level of 1.7 (+/-0.89) mg/dl at 1 month and 1.3 (+/-0.34) mg/dl at 1 year. The actuarial 1-year graft survival rate was 93.3+/-6.4% and the patient survival rate was 100%. We conclude that the allocation of blood group A2 kidneys for blood group O and B recipients is a practical way to expand the donor pool for these transplant candidates. PP may be important for reducing the levels of anti-A1 and anti-A2 antibodies and for reducing the risk of hyperacute rejection. Splenectomy seems to be unnecessary.

Double renal allografts successfully increase utilization of kidneys from older donors within a single organ procurement organization.

In 1994, a policy of double renal allografting (DUAL) was used at two centers within our local organ procurement organization to increase utilization of kidneys from older donors that would otherwise be discarded. Both kidneys from an older donor (age > 60 years) were selectively transplanted into a single adult recipient. The relative impact of a DUAL policy on the utilization of older donor kidneys is examined for the period of April 1994 to April 1996. Actual utilization is compared with the hypothetical case in which a DUAL policy is not present. In the actual setting, a total of 75 kidneys from older donors (> 60 years) were accepted for transplantation. Thirty-six kidneys were transplanted as singlets, and 16 additional kidneys were transplanted as DUAL renal allografts. Thus, a 44% increase in transplantable kidneys, and a 22% increase in patients transplanted with kidneys from older donors, was realized. In the actual setting, 23 older kidneys were discarded; without the DUAL policy, 39 kidneys would have been deemed untransplantable. When compared with the actual (n = 52) and hypothetical number of kidneys transplanted without a policy of DUAL transplantation (n = 36), the DUAL policy significantly increased the utilization of older donor kidneys (P = 0.01). The actuarial 1-year graft survival rate of the dual kidneys was 100%, with a mean follow-up of 11.1 +/- 2.9 months. Mean 6-month and 1-year serum creatinine level were 1.76 +/- 0.4 and 1.63 +/- 0.6 mg/dl, respectively. A DUAL policy significantly increased the number of older donor kidneys transplanted in a single organ procurement organization and reduced the rate of discard of older donor kidneys over a 2-year period. Long-term follow-up is necessary to substantiate satisfactory graft function in DUAL from older donors.

A COMPARISON OF RABBIT ANTITHYMOCYTE SERUM ANE OKT3 AS PROPHYLAXIS AGAINST RENAL ALLOGRAFT REJECTION

A total 166 first cadaveric renal allograft recipients were randomly assigned to receive either rabbit antithymocyte serum (RATS) (n = 83) or OKT3 (n = 83) for 10 to 14 days after transplant as prophylaxis against rejection. Both groups were similar with respect to age, sex, donor age, diabetes, time on dialysis, panel-reactive antibody, HLA matching, and transfusion before transplantation. All patients were followed for 1 year after transplantation. A comparison of the rejection rates between the 2 groups of patients showed that patients receiving OKT3 had a rate of first rejection 1.87 times higher than those receiving RATS (95% confidence interval 1.18-2.8, P = 0.007). Twenty-five steroid-resistant rejections occurred in OKT3-treated patients as compared with 12 in the RATS-treated group (P < 0.05). There was no significant difference in early or late renal function between the 2 groups of patients. Actuarial 1-year graft survival for the RATS group was 78% and for the OKT3 group, 80.7% (P = NS). Actuarial 1-year patient survival was similar: 89.5% in the RATS group and 94.6% in the OKT3 group (P = NS). Total hospitalization time was 29.8 +/- 19.9 days for RATS vs. 39.5 +/- 22.1 days for those treated with OKT3 (P < 0.006). A number of infections were observed but there were no significant differences between the groups. We conclude that RATS provides better prophylaxis than OKT3 in first cadaveric renal transplants because it is associated with fewer rejection episodes, less hospitalization, and no additional morbidity or mortality.

Renal retransplantation in patients with HLA-antibodies.

The results of 92 consecutive renal retransplantations, performed during a 5-year period in recipients with HLA-antibodies, were retrospectively analysed. The actuarial 1-year graft survival (1-y GS) was 65% for all retransplantations, as compared with 63% for first grafts in sensitized recipients. For the second (n = 56), third (n = 24) and fourth-fifth (n = 12) grafts 1-y GS was 64%, 71% and 58%, respectively. Acute rejection was the major cause of graft loss (45%). Recipients with > 3 years GS of the preceding transplant had significantly better GS at retransplantation. Also, grafts with no HLA mismatches had significantly prolonged GS. One-y GS was 78% when PRA (panel reacting antibody) was less than 50%, and 60% when PRA was more than 50%. A benefit of repeated mismatches was demonstrated in the subgroup with PRA < 50%, in contrast to recipients with PRA > 50%, suggesting that, in some patients, an absence of antibody response against certain antigens might be used as a basis for future deliberate mismatching.

Results of acute heart retransplantation in Eurotransplant.

In 1988 a special programme for acute retransplantation was introduced in Eurotransplant, giving patients awaiting acute retransplantation priority in the selection procedure. Due to scarcity of donor hearts the question arose whether graft survival after acute retransplantation justified the use of these hearts for this category of patient. A retrospective analysis on the results of transplantations performed in patients who were awaiting acute retransplantation within Eurotransplant was done. In 18 out of 46 cases the patient was treated prior to retransplantation with some kind of mechanical support device. Of the 46 grafts, 28 failed. The actuarial 1-year graft survival in this study group was 36%. In comparison, graft survival for primary cardiac transplantation is approximately 81%. Graft survival after acute heart retransplantation is very poor, especially when the patient has been pretreated with a severe mechanical support system.

Results of acute heart retransplantation in Eurotransplant

In 1988 a special programme for acute retransplantation was introduced in Eurotransplant, giving patients awaiting acute retransplantation priority in the selection procedure. Due to scarcity of donor hearts the question arose whether graft survival after acute retransplantation justified the use of these hearts for this category of patient. A retrospective analysis on the results of transplantations performed in patients who were awaiting acute retransplantation within Eurotransplant was done. In 18 out of 46 cases the patient was treated prior to retransplantation with some kind of mechanical support device. Of the 46 grafts, 28 failed. The actuarial 1-year graft survival in this study group was 36%. In comparison, graft survival for primary cardiac transplantation is approximately 81%. Graft survival after acute heart retransplantation is very poor, especially when the patient has been pretreated with a severe mechanical support system.

The Current Role of Pre-Transplant Blood Transfusions and Tissue Typing in Cadaveric Renal Transplantation

In a retrospective analysis of 74 consecutive cadaveric renal transplants performed at our center during a 38-month period we assessed the influence of random blood transfusions and tissue matching on graft and patient survival. All patients received cyclosporine and low dose prednisone with or without azathioprine as immunosuppressive therapy. Actual patient survival was 100 per cent at 1 year and actuarial 1-year graft survival was 82 per cent. Random blood transfusions and histocompatibility matching at the HLA-DR locus did not influence graft survival. Matching at 2 or more HLA-A and B loci was associated with a significant detrimental influence (p less than 0.05) on graft survival. We conclude that the use of cyclosporine-based immunosuppression overcomes much of the adverse effect of poor tissue matching and may obviate the need for random blood transfusions in cadaveric renal transplantation during the first year of engraftment.

Experience with 49 segmental pancreas transplants in 45 diabetic patients.

Forty-nine pancreas transplants were performed in 45 patients between July 23, 1978 and May 14, 1982, 18 from related donors. Currently (June 1982), 13 patients have functioning grafts and are insulin independent between 1 and 46 months after transplantation, 5 for more than 1 year. Nineteen patients lost graft function between 1 and 7 months. Sixteen grafts failed for technical reasons. Eight patients died between 1 and 21 months from infections or preexisting complications or for unknown reasons, three with functioning grafts. Actuarial 1-year graft survival is 24% and patient survival is 84%. A variety of techniques were used to handle exocrine secretions of 41 hemipancreas segmental grafts, 4 extended segmental grafts, and 4 whole pancreas grafts. Currently, 3 of 14 duct-open, 0 of 2 duct-ligated, 0 of 4 prolamine-injected, 6 of 19 silicone rubber-injected, and 4 of 10 jejunal anastomosed pancreatic grafts are functioning. Of 33 technically successful allografts, 5 in 12 conventionally immunosuppressed and 8 in 21 cyclosporin A (Cy A)-immunosuppressed recipients are functioning. Most technically successful grafts that failed were not biopsied or removed. In those that were biopsied, fibrosis was a dominant feature in all but one patient. In this patient endocrine and exocrine tissue was normal except for the absence of insulin-positive (beta) cells in the islets and an increase in glucagon-positive (alpha) cells, in contrast to the normal appearance of alpha and beta cells in islets at the time of the pancreas transplant. Currently, we perform pancreas transplants in diabetic patients who have previously received kidney transplants and therefore already require immunosuppression. For nonuremic patients, we perform pancreas transplant only if it is judged that their complications of diabetes exceed, or predictably will exceed, the potential side effects of chronic immunosuppression.