Five-year Graft Survival Research Articles

Liver Transplantation for Cholangiocarcinoma: Charting a Path With Lessons Learned From Center Experience.

While liver transplantation (LT) with neoadjuvant chemoradiation is increasingly utilized for the management of unresectable cholangiocarcinoma (CCA), data on post-LT survival are limited. We identified 844 patients who underwent LT (2002-2019) for nonincidental (CCA listing) or incidental (CCA on explant, not at listing) CCA in the Scientific Registry of Transplant Recipients. Kaplan-Meier and multivariable proportional hazards regression methods evaluated the effects of patient characteristics, donor type, transplant era (before/after 2010), and center volume (center-level CCALTs/active year) on the risk of graft failure and patient mortality. One center performed >12 CCALTs/y, and the rest performed ≤4. Five-year graft survival was 50.6%. Multivariable models demonstrated laboratory model of end-stage liver disease ≥40 versus <15 and center volumes of 1, >1 to ≤2, and >2 to ≤4 CCALTs/y compared to >12 were associated with increased risk of graft failure and mortality (all P ≤ 0.002). Extra vessel use was associated with center volume. Among all recipients, extra vessel use occurred in 55.4% of CCALTs performed at the highest volume center and in 14.0% of cases at centers having ≤4 CCAs/y (P < 0.05). Center volume-related differences in outcomes and extra vessel use highlight the importance of establishing a unified, effective treatment protocol and the potential utility of regionalization of LT for CCA.

Cardiac Allograft Vasculopathy in Pediatric Heart Transplant Recipients: Does Early Onset Portend a Worse Prognosis?

<h3>Purpose</h3> We sought to evaluate the association between early-onset cardiac allograft vasculopathy (CAV) [<3 years post heart transplant (HT)] & graft survival (freedom from death & re-transplantation), compared with CAV development at later time-points in pediatric HT recipients. <h3>Methods</h3> Data from the Pediatric Heart Transplant Society (PHTS) for pediatric (<18 years old) HT recipients between 1993-2019 with available angiographic data were obtained (N = 5,075). Patients with a diagnosis of CAV were categorized according to the timing of disease post-HT; <3 years; 3-<5 years; 5-<10 years; & ≥10 years. CAV severity was graded at each assessment (CAV 1-3). Kaplan-Meier survival curves were generated to evaluate the association between CAV timing & graft survival (primary outcome). A competing risk analysis was used to evaluate the association between CAV timing & the progression of CAV severity (secondary outcome). <h3>Results</h3> Over a median follow-up period of 4.1 (IQR 1.3 - 8.3) years, angiographic evidence of CAV was identified in 17% (885/5,075) of patients, 28% (252/885) of which were early-onset CAV. Compared to those who developed CAV >10 years post HT, patients with early-onset CAV were older at transplant (8.3 +/- 6.2 vs. 3.8 +/- 4.8 years, p < .0001). Five-year graft survival following CAV diagnosis at any time point was 68.7% (66.8% - 70.4%). Graft survival post-CAV diagnosis was not significantly different for early-onset CAV compared with CAV at later time points (Figure). For patients with CAV-1, freedom from progression to CAV-2 did not vary according to the timing of CAV onset, with an overall five-year freedom from CAV-2 of 75.4% (73.1%-77.6%). <h3>Conclusion</h3> Following diagnosis, the progression of CAV & graft survival was similar for patients with early-onset CAV compared with CAV at other time points. These findings suggest that early-onset CAV does not necessarily represent a more aggressive phenotype of disease.

Post-transplant complications, patient, and graft survival in pediatric and adolescent kidney transplant recipients at a tropical tertiary care center across two immunosuppression eras.

We report pediatric PAKT patient and graft outcomes at a large tropical tertiary center spanning two transplant eras. In this retrospective cohort study, all children ≤18years who underwent kidney transplantation at our center between 1991 and 2016 were included. Data pertaining to their baseline characteristics, post-transplant events, and outcome were retrieved from transplant records and compared between transplant eras (1991-2005 and 2006-2016). A total of 139 children (mean age 15.2±2.9years) underwent PAKT during this period. The incidence of UTIs, CMV disease, BKVN, invasive fungal infections, new-onset diabetes after transplant, leucopenia, and recurrent NKD was higher in the 2006-2016 era (P<.001 for all), while 1-year cumulative BPAR was comparable (P=.100). Five-year graft and patient survival in the two eras were 89.9% and 94.2% (P=.365) and 92.1% and 95.3% (P=.739), respectively. Incidence of CMV disease, BKVN, graft loss, and death was lower in the calcineurin withdrawal group. Non-adherence accounted for 36% of graft loss; infections caused 43.7% of deaths. On multivariate Cox proportional hazards analysis, independent predictors for graft loss were UTIs and blood transfusion naïve status and for death were serious infections and glomerular NKD. PAKT in India has excellent long-term graft outcomes, though patient outcomes remain suboptimal owing to a high burden of infections. Current immunosuppression protocols need to be re-examined to balance infection risk, graft, and patient survival.

Kidney transplantation after rescue allocation-meticulous selection yields the chance for excellent outcome.

The small number of organ donors forces transplant centres to consider potentially suboptimal kidneys for transplantation. Eurotransplant established an algorithm for rescue allocation (RA) of kidneys repeatedly declined or not allocated within 5 h after procurement. Data on the outcomes and benefits of RA are scarce to date. We conducted a retrospective 8-year analysis of transplant outcomes of RA offers based on our in-house criteria catalogue for acceptance and decline of organs and potential recipients. RA donors and recipients were both older compared with standard allocation (SA). RA donors more frequently had a history of hypertension, diabetes or fulfilled expanded criteria donor key parameters. RA recipients had poorer human leucocyte antigen (HLA) matches and longer cold ischaemia times (CITs). However, waiting time was shorter and delayed graft function, primary non-function and biopsy-proven rejections were comparable to SA. Five-year graft and patient survival after RA were similar to SA. In multivariate models accounting for confounding factors, graft survival and mortality after RA and SA were comparable as well. Facing relevant comorbidities and rapid deterioration with the risk of being removed from the waiting list, kidney transplantation after RA was identified to allow for earlier transplantation with excellent outcome. Data from this survey propose not to reject categorically organs from multimorbid donors with older age and a history of hypertension or diabetes to aim for the best possible HLA matching and to carefully calculate overall expected CIT.

Lungs from polytrauma donors with significant chest trauma can be safely used for transplantation

BackgroundThe use of organs from polytrauma donors for lung transplantation is controversial in the literature. For many centers, the radiologic manifestation of lung contusions is a clear reason to reject an organ offer. This results in the loss of potentially viable organs for the donor pool. MethodsWe analyzed 1152 donor lungs procured by our transplant center between January 2010 and June 2018. These included 118 lungs with a history of polytrauma involving the chest. Sixteen polytrauma donor lungs were rejected after procurement. A total of 102 lungs were transplanted, divided into 2 groups: the polytrauma contusion group (n = 44), comprising polytrauma donors with radiologic signs of lung contusion at the time of offer, and the polytrauma clear group (n = 58), comprising polytrauma donors without lung contusion. Nontrauma donor lungs transplanted during the study period were assigned to a polytrauma control group (n = 650). Short- and long-term outcomes of the 3 groups were compared. ResultsBasic demographic data and preoperative factors were similar in the 3 groups. Rates of primary graft dysfunction grade 3 at 72 hours did not differ among the 3 groups (0.0% vs 3.4% vs 3.9%; P = .409). The duration of ventilation was similar the 3 groups: 45 hours (interquartile range [IQR], 28-94 hours), 37 hours (IQR, 22-71 hours), and 42 hours (IQR, 22-96 hours), respectively (P = .674). Long-term graft survival was not impaired in the trauma groups compared with controls. One-year survival rates were 84.1% for the polytrauma contusion group, 93.1% for the polytrauma clear group, and 83.1% for the no polytrauma group. Five-year graft survival in the 3 groups was 74.7%, 87.2%, and 70.0%, respectively. ConclusionsLung transplantation using organs from polytrauma donors is associated with similar short- and long-term results as transplantation from nontrauma donors. The presence or absence of radiologic signs of lung contusion at the time of offer has no impact on primary graft function and long-term survival.

Recurrent Autoimmune Hepatitis and De Novo Autoimmune Hepatitis in the Liver Allograft.

Autoimmune hepatitis (AIH) is a form of severe hepatitis that can recur after orthotopic liver transplant (OLT). Presentation of AIH in patients with OLT who do not have a history of AIH is called de novo AIH (DNAIH). We evaluated the clinicopathologic characteristics of AIH and DNAIH. Clinicopathologic and outcome measures of 11 patients with recurrent AIH (RAIH) and 22 with DNAIH identified between 2000 and 2017 were compared. Both cohorts showed female predominance. The mean clinical follow-up was 13 and 7.8 years in the in the RAIH and DNAIH groups, respectively (P = .1). Moderate portal inflammation was more common in patients with RAIH (64% vs 27%, P = .043). A trend was observed for more cases of DNAIH showing severe inflammation (36% vs 9%, P = .09) and submassive necrosis compared with RAIH (23% vs 0%, P = .086). A trend for more advanced fibrosis was also noted in the RAIH group (27% vs 5%, P = .059). Three patients with RAIH lost their grafts because of RAIH. Five-year disease-specific graft survival (GS) (P = .012) and overall GS (P = .015) were worse in patients with RAIH. Complement component 4d immunohistochemistry was positive in 2 patients with RAIH and 3 with DNAIH but showed no correlation with GS or other parameters. RAIH seems to have a more aggressive clinical course than DNAIH and warrants closer clinical follow-up and aggressive treatment.

IMPACT OF AGE OF THE ADULT DECEASED DONOR AND AGE AND SEX OF THE ADULT RECIPIENT ON KIDNEY GRAFT SURVIVAL

Introduction: The purpose of this study was to investigate the impact, on kidney graft survival, of age and sex of the adult deceased donor, donor-recipient sex mismatch, and age and sex of the adult recipient. Materials and Methods: The study was conducted in a single-center cohort with 6,006 kidney transplants from adult (age ≥ 18 years) deceased donors performed in adult recipients, from January 1, 2002 to December 31, 2017. There were 3,189 transplants from 18-49-year old (younger donors) and 2,817 transplants from ≥ 50-year old (older donors) donors. The recipients were divided into three age categories: 18-49, 50-59 and ≥ 60 years of age. Graft failure was defined as patient death or return to dialysis. Five-year graft survival curves were constructed with the Kaplan-Meier method and compared with log-rank test or Cox regression analysis. Statistical significance was set at p <0.05. Results: (1) Donor and recipient age ≥ 50 years and recipient male sex, but not donor sex or donor-recipient sex mismatch, had a negative impact on 5-year graft survival, in the univariate analysis; (2) Cox regression analysis showed that donor age ≥ 50 years, recipient age between 50-59 years, ≥ 60 years, and recipient male sex were independently associated with lower graft survival, with hazard ratios (HR) of 1.41, 1.23, 1.69 and 1.13, respectively; (3) older age of the donor was associated with poorer graft survival in transplants in 18-49-year old (HR=1.63) and in 50-59-year old (HR=1.56) recipients, but did not impact on graft survival in recipients with 60 or more years of age; (4) male sex of the recipient was a risk factor only in recipients with 50 or more years of age that received a transplant from a younger donor: HR of 1.61, in 50-59-year old recipients, and of 1.44, in ≥ 60-year old recipients. Conclusion: The main findings of this study are that (a) the inferior graft survival in male than in female recipients is restricted to transplants from younger donors into ≥ 50-year old recipients and (b) there is no difference in graft survival from younger and older donors when the recipients are ≥ 60-year old. The results of this study underline the importance of analyzing combinations of age and sex of donor and recipient in order to better estimate the risks conferred by these variables. Future studies, with larger number of transplants, are warranted to confirm the finding of our study and to explore the mechanisms behind the negative effect of the older age of the donor and the male sex of the recipient on graft survival.

PRE-KIDNEY TRANSPLANT LATENT TUBERCULOSIS INFECTION SCREENING AND POSTTRANSPLANT ACTIVE TUBERCULOSIS

Background: Tuberculosis (TB) is an important infectious complication after kidney transplantation (KT). Latent tuberculosis infection (LTI) screening and treatment is fundamental to prevent post-transplant active disease. Methods: We described a cohort of adult KT recipients from April 4th, 2014 to October 31st, 2018, with follow-up until October 31st, 2019, regarding pre-transplant LTI screening and posttransplant active tuberculosis. Results: There were 986 KT performed in the study period. There were 189 KT with positive LTI screening, 488 with negative and 309 with incomplete screening.Most KT recipients were male (63.3%), Caucasian (78.7%), with deceased donors (91.5%). Median age was 50yo. LTI treatment was provided to 79% of patients with indication, and 1.8% of them developed active TB. There were 16 cases of active tuberculosis, 50% pulmonary.Cumulative 5-year TB incidence in positive LTI screening patients was 1.7%; in patients with negative screening was 1.4%, and in those with incomplete screening was 2.9% (p = 0.25).TB incidence rate in positive LTI screening patients was 624.1 cases per 100.000 patients-year; in negative screening was 405.9 cases per 100.000 patients-year; and in incomplete screening was 935.8 cases per 100.000 patients-year (p < 0.0001). TB patients had inferior although non-significant five-year graft survival (62.5% vs. 77.4%, p = 0.07). Twenty-five percent of TB patients died. Conclusion: One third of our patients had incomplete LTI screening, and this group had a significantly higher TB incidence rate. A considerable proportion of patients with positive LTI screening completed INH treatment. Only 1.3% of KT that received INH treatment developed TB, in a short period after transplantation. There was a high incidence of post-transplant TB in this cohort and high mortality. Fapergs - Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul.

Paediatric end-stage renal disease and renal replacement therapy in Switzerland: survival and treatment trends over four decades.

Renal replacement therapy for paediatric end-stage renal disease (ESRD) has developed steadily since its introduction five decades ago. Continuous and long-term analysis of patient outcomes is essential for quality control. The Swiss Paediatric Renal Registry, founded in 1970, includes patients diagnosed with ESRD, defined as dialysis for more than three months or renal transplantation, at age &lt;20 years. Here we describe the incidence, primary renal disease, treatment modalities and long-term outcomes over 45 years. This paper reports on 367 children and adolescents treated with chronic renal replacement therapy in Switzerland. Incidence was 5.4 per million children per year, with a tendency to increase over time. The primary renal disease was congenital anomalies of the kidney and the urinary tract in 133 (36%), monogenetic hereditary diseases in 122 (33%) and acquired diseases in 112 (31%) patients. The first renal replacement therapy was haemodialysis in 194 (53%), peritoneal dialysis in 116 (32%) and pre-emptive renal transplantation in 57 (15%) patients. Over the years, pre-emptive renal transplantation became more frequent (34% of all first renal replacement therapies in 2006&ndash;2015), reducing the duration of dialysis. Median time on dialysis until transplantation decreased from 1.60 years in 1981&ndash;90 to 0.34 years in 2010&ndash;15. Over the four decades 1970&ndash;80, 1981&ndash;90,1991&ndash;2000 and 2001&ndash;10, the one-year graft survival rate improved from 0.76 to 0.80, 0.89 and then 0.96; and the five-year graft survival rate improved from 0.44 to 0.64, 0.84 and 0.89, respectively. The five-year patient survival rates for the four decades were 0.83, 0.99, 0.93 and 0.94; and the 10-year patient survival rates were 0.75, 0.96, 0.88 and 0.94, respectively. In the four cohorts starting renal replacement therapy in the 70s, 80s, 90s and 00s, the number of children alive after five years of renal replacement therapy increased from 15 to 24, 47 and then 45 respectively. In total, 29 patients (8%) died during chronic renal replacement therapy with ESRD before the age of 20 years. Over time, a higher number of children on renal replacement therapy survived, graft survival improved, and the duration of dialysis before renal transplantation decreased.

Comparison of kidney allograft survival in the Eurotransplant senior program after changing the allocation criteria in 2010-A single center experience.

The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome. Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation. Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards. nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.

Factors Associated With 5- and 10-Year Survival After Intestinal Transplantation in Infants and Children.

Intestinal transplantation is an option for permanent intestinal failure with parenteral nutrition intolerance. We sought to determine long-term intestinal graft survival in pediatric patients at our center and to identify factors influencing survival. Retrospective chart review of 86 patients transplanted between 2003 and 2013, targeting potential explanatory variables related to demographics, perioperative factors, and postoperative complications. Intestinal graft survival was 71% and 65% after 5 and 10 years, respectively. Five-year graft survival was attained in 79% of patients with a history of anatomic intestinal failure compared with 45% with functional intestinal failure (P = 0.0055). Compared with nonsurvival, 5-year graft survival was also associated with reduced incidences of graft-versus-host disease (2% vs 16%, P = 0.0237), post-transplant lymphoproliferative disorder (3% vs 24%, P = 0.0067), and de novo donor-specific antibodies (19% vs 57%, P = 0.0451) plus a lower donor-recipient weight ratio (median 0.727 vs 0.923, P = 0.0316). Factors not associated with 5-year intestinal graft survival included graft rejection of any severity and inclusion of a liver graft. Factors associated with graft survival at 10 years were similar to those at 5 years. In our experience, outcomes in pediatric intestinal transplantation have improved substantially for anatomic but not functional intestinal failure. Graft survival depends on avoidance of severe infectious and immunological complications including GVHD, whereas inclusion of a liver graft provides no obvious survival benefit. Reduced success with functional intestinal failure may reflect inherently increased susceptibility to complications in this group.

Kidney transplantation using alemtuzumab, belatacept, and sirolimus: Five-year follow-up.

Kidney transplant outcomes are limited by toxicities associated with calcineurin inhibitors and steroids. This trial was conducted to determine whether a costimulation blockade (CoB)-based regimen could achieve acceptable long-term outcomes and graft survival could be maintained solely with CoB. Forty patients underwent alemtuzumab induction followed by belatacept and sirolimus maintenance therapy. Patients were offered weaning to belatacept monotherapy after 1year and followed for 5years. Five-year patient and graft survival rates were 100% and 95%, respectively. Graft function remained stable with a mean estimated glomerular filtration rates of 67±21 and 71±19 at 36 and 60months, respectively. There was no clinical rejection in the first year; subclinical rejection was detected by protocol biopsy in 4 patients. Twelve patients were successfully weaned to belatacept monotherapy. Cytomegalovirus and Epstein-Barr virus reactivations were well controlled, but 9 patients experienced transient BK viremia during the first year. Alemtuzumab produced profound lymphopenia followed by gradual T cell and more rapid B cell reconstitution to a repertoire deviated toward naïve cells with increased regulatory T cells. This regimen effectively prevents allograft rejection without using steroids or calcineurin inhibitors, enriches for naïve cells susceptible to control with CoB, and permits control of rejection with belatacept monotherapy in selected patients.

C3d-positive donor-specific antibodies have a role in pretransplant risk stratification of cross-match-positive HLA-incompatible renal transplantation: United Kingdom multicentre study.

Anti-HLA-antibody characteristics aid to risk-stratify patients and improve long-term renal graft outcomes. Complement activation by donor-specific antibody (DSA) is an important characteristic that may determine renal allograft outcome. There is heterogeneity in graft outcomes within the moderate to high immunological risk cases (cross-match-positive). We explored the role of C3d-positive DSAs in sub-stratification of cross-match-positive cases and relate to the graft outcomes. We investigated 139 cross-match-positive living-donor renal transplant recipients from four transplant centres in the United Kingdom. C3d assay was performed on serum samples obtained at pretreatment (predesensitization) and Day 14 post-transplant. C3d-positive DSAs were found in 52 (37%) patients at pretreatment and in 37 (27%) patients at Day 14 post-transplant. Median follow-up of patients was 48months (IQR 20.47-77.57). In the multivariable analysis, pretreatment C3d-positive DSA was independently associated with reduced overall graft survival, the hazard ratio of 3.29 (95% CI 1.37-7.86). The relative risk of death-censored five-year graft failure was 2.83 (95% CI 1.56-5.13). Patients with both pretreatment and Day 14 C3d-positive DSAs had the worst five-year graft survival at 45.5% compared with 87.2% in both pretreatment and Day 14 C3d-negative DSA patients with the relative risk of death-censored five-year graft failure was 4.26 (95% CI 1.79, 10.09). In this multicentre study, we have demonstrated for the first time the utility of C3d analysis as a distinctive biomarker to sub-stratify the risk of poor graft outcome in cross-match-positive living-donor renal transplantation.

Living Kidney Transplantation From Marginal Donors Presents Feasible Donor Renal Function Despite Inferior Recipient Renal Function

IntroductionKidney transplantation from marginal donors is an important solution for organ shortage problems. In this study, we evaluated the safety and effectiveness of living kidney transplantation from marginal donors at our hospitals. MethodsBetween June 2006 and April 2019, 107 patients underwent living kidney transplantation at our hospitals. Marginal donors were defined as those with 1. age >70 years, 2. hypertension, 3. creatinine clearance <80 mL/min, 4. body mass index >30 kg/m2, or 5. hemoglobin A1c >6.2%. We retrospectively compared renal function and its chronological changes between marginal and standard donors. We also compared graft survival and recipient renal function between the groups. ResultsThirty-one (29%) donors were defined as marginal. The primary reason for being defined as marginal was hypertension (74%). The mean age of the marginal donors (62 ± 10 years) was higher than that of standard donors (52 ± 12 years, P < .001). The estimated glomerular filtration rate (eGFR) before and after transplantation was lower in the marginal group, whereas the decline ratio of eGFR was not different between the marginal and standard donors. Five-year graft survival of transplantations from marginal donors (89%) was not significantly inferior to that from standard donors (95%). Meanwhile, recipient eGFR was lower in transplantation from marginal donors than standard donors from 1 month through 5 years after transplantation. ConclusionsNo significant differences were observed between the groups regarding the decline ratios of donor eGFR and graft survival. Thus, transplantation from marginal donors may be a feasible solution for donor shortage problems.

Results in the ESPN/ERA-EDTA Registry suggest disparities in access to kidney transplantation but little variation in graft survival of children across Europe

One of the main objectives of the European health policy framework is to ensure equitable access to high-quality health services across Europe. Here we examined country-specific kidney transplantation and graft failure rates in children and explore their country- and patient-level determinants. Patients under 20 years of age initiating kidney replacement therapy from January 2007 through December 2015 in 37 European countries participating in the ESPN/ERA-EDTA Registry were included in the analyses. Countries were categorized as low-, middle-, and high-income based on gross domestic product. At five years of follow-up, 4326 of 6909 children on kidney replacement therapy received their first kidney transplant. Overall median time from kidney replacement therapy start to first kidney transplantation was 1.4 (inter quartile range 0.3-4.3) years. The five-year kidney transplantation probability was 48.8% (95% confidence interval: 45.9-51.7%) in low-income, 76.3% (72.8-79.5%) in middle-income and 92.3% (91.0-93.4%) in high-income countries and was strongly associated with macro-economic factors. Gross domestic product alone explained 67% of the international variation in transplantation rates. Compared with high-income countries, kidney transplantation was 76% less likely to be performed in low-income and 58% less likely in middle-income countries. Overall five-year graft survival in Europe was 88% and showed little variation across countries. Thus, despite large disparities transplantation access across Europe, graft failure rates were relatively similar. Hence, graft survival in low-risk transplant recipients from lower-income countries seems as good as graft survival among all (low-, medium-, and high-risk) graft recipients from high-income countries.

Long-Term Outcome of Heart Transplant Recipients with Acute Graft Dysfunction Requiring Temporary Mechanical Circulatory Support

Mechanical circulatory support for acute graft dysfunction in heart transplant recipients is associated with increased early mortality and morbidity. Long-term outcome in patients who are successfully discharged from hospital is less well known. We performed a retrospective review of results in all adult patients (age > 18) who received first time heart transplant at our institution between 2007 and 2017. We compared graft survival and freedom from acute cellular and antibody mediated rejection of 90-day survivors who required mechanical support for graft failure with those who did not. We performed 243 first time adult heart transplantations over the study period with 6% 90-day mortality and 68±5% 5-year patient survival. (62±5% graft survival with 4 patients necessitating re-transplantation for severe CAV). Short-term outcome of patients supported with various types of MCS is depicted in Table 1. Five-year graft survival, freedom from ACR and freedom from AMR was 87±3%, 82±3% and 92±2% in patients without the need for post-transplant MCS and 53±15%, 49±17% and 75±13% in patients requiring MCS (Figure 1). Heart transplant recipients who require post-operative mechanical support and survive 90 days experience decreased long-term survival and less freedom from both acute cellular and antibody mediated rejection.

Molecular Fingerprints of Borderline Changes in Kidney Allografts Are Influenced by Donor Category.

The fate of transplanted kidneys is substantially influenced by graft quality, with transplantation of kidneys from elderly and expanded criteria donors (ECDs) associated with higher occurrence of delayed graft function, rejection, and inferior long-term outcomes. However, little is known about early molecular fingerprints of these events in different donor categories. Borderline changes represent the most frequent histological finding early after kidney transplantation. Therefore, we examined outcomes and transcriptomic profiles of early-case biopsies diagnosed as borderline changes in different donor categories. In this single-center, retrospective, observational study, we compared midterm outcomes of kidney transplant recipients with early borderline changes as a first pathology between ECD (n = 109), standard criteria donor (SCDs, n = 109), and living donor (LD, n = 51) cohorts. Intragraft gene expression profiling by microarray was performed in part of these ECD, SCD, and LD cohorts. Although 5 year graft survival in patients with borderline changes in early-case biopsies was not influenced by donor category (log-rank P = 0.293), impaired kidney graft function (estimated glomerular filtration rate by Chronic Kidney Disease Epidemiology Collaboration equation) at M3, 1, 2, and 3 years was observed in the ECD cohort (P < 0.001). Graft biopsies from ECD donors had higher vascular intimal fibrosis and arteriolar hyalinosis compared to SCD and LD (P < 0.001), suggesting chronic vascular changes. Increased transcripts typical for ECD, as compared to both LD and SCD, showed enrichment of the inflammatory, defense, and wounding responses and the ECM–receptor interaction pathway. Additionally, increased transcripts in ECD vs. LD showed activation of complement and coagulation and cytokine–cytokine receptor pathways along with platelet activation and cell cycle regulation. Comparative gene expression overlaps of ECD, SCD, and LD using Venn diagrams found 64 up- and 16 down-regulated genes in ECD compared to both LD and SCD. Shared increased transcripts in ECD vs. both SCD and LD included thrombospondin-2 (THBS2), angiopoietin-like 4 (ANGPTL4), collagens (COL6A3, COL1A1), chemokine CCL13, and interleukin IL11, and most significantly, down-regulated transcripts included proline-rich 35 (PRR35) and fibroblast growth factor 9. Early borderline changes in ECD kidney transplantation are characterized by increased regulation of inflammation, extracellular matrix remodeling, and acute kidney injury transcripts in comparison with both LD and SCD grafts.

Strategies to Perform Pure Retroperitoneoscopic Donor Nephrectomy: A Single-Center Cohort Study.

Background: Considering the increase in a number of vascular complications, right laparoscopic donor nephrectomy is less preferred due to achieving not only shorter renal vein but also longer renal artery. However, recent studies have indicated that the side of the surgery would not affect the outcomes. Aim: The aim of this study is to evaluate the outcomes and strategies to increase the safety of pure retroperitoneoscopic donor nephrectomy (RDN). Methods: We analyzed the prospectively collected medical records of 158 kidney donors who underwent RDN from January 2010 to August 2018. The patients were divided into two groups based on their side of surgery. Right- and left-sided RDNs were compared in terms of demographics, intraoperative, and postoperative data, including the development of incisional hernia (IH). The outcomes of the recipients were also evaluated. Results: Right RDN was performed in 40 (25.3%) and left RDN was performed in 118 (74.7%) donors. Operation time (P = .593), warm ischemia time (P = .271), blood loss (P = .787), and length of hospital stay (P = .908) were statistically similar in right and left RDN groups. Intraoperative and postoperative complications were statistically showed no difference between right and left RDNs. No IH was observed in any group. One-year and five-year patient survival and graft survival rates were 100% versus 97% (P = .299) and 100% versus 95% (P = .126) on both sides, respectively. Conclusion: Right RDN is an effective and safe method as on the left side. RDN has an additional advantage in the absence of IH. Experience with other retroperitoneoscopic urological interventions may have had a positive effect on the outcomes of pure RDN.

Results of Pediatric Kidney Transplants in an 8-Year Period: A Retrospective Study

BackgroundPatient survival and quality of life is better after a kidney transplant compared with dialysis. In this retrospective study, we analyzed the results of pediatric kidney transplants in an 8-year period in our center. MethodsWe reviewed the files of 166 children and adolescents who had undergone kidney transplants between 2008 and 2015 in our center. All the patients were younger than 18 years old and had been followed up for at least 2 years. ResultsThe transplanted kidneys were taken from live donors in 146 (88%) of the cases and from cadavers in 20 (12%) of the cases. They were procured from unrelated and related donors in 129 (90%) and 17 (10%) of the cases, respectively. Laparoscopic nephrectomy was done on 141 donors. The kidney vessels were anastomosed to the aorta, the common iliac, and the internal iliac in 3.6%, 56%, and 40.4% of cases, respectively. Preemptive kidney transplants were performed on 62 patients. The mean of patient survival was 124 ± 1.37 months. One- and five-year patient survival rates were 99% and 97%, respectively. The mean of graft survival was 118.29 ± 2.47 months. One- and five-year graft survival rates were 94% and 93%, respectively. Preemptive kidney transplants had a higher graft survival rate (P < .02). ConclusionKidney transplant is a safe and feasible procedure in children and adolescents based on patient and graft survival outcomes. In our center, surgery complications led to kidney loss in very few cases.

Impact of One-Year Serum Creatinine on Long-term Renal Graft Survival in a Living-Related Renal Transplant Program.

This study was carried out to determine the impact of one-year posttransplant serum creatinine (SCr) levels on the long-term outcomes of living-related donor kidney transplants. A retrospective cohort study included 773 adult living-related renal transplant recipients from 2010 to 2012, with a minimum follow-up period of five years. Demographics and posttransplantation follow-up data including immunosuppression regimens, rejection episodes, and survival rates were evaluated. Patients were divided into four cohorts (G1, G2, G3, and G4 based on SCr at the end of the 1st year: G1, SCr <88.4 μ mol/L; G2, 88.5≤ SCr ≤ 132.6 μmol/L; G3, 132.7≤ SCr ≤176.8 mol/L; and G4, SCr ≥176.9 μ mol/L). Comparisons between the groups used the Chi-square test for qualitative parameters and analysis of variance for continuous variables. Five-year graft survival for G1 was 98% as compared to 76% in G4 (P <0.001). Recipients of G4 encountered more acute rejection episodes in 21% of the cases as compared to 7.3% in G1 (P = 0.001). Donors were older in G4 (42.07 ± 10.4 years) as compared to G1 (30.1 ± 8.5 years) (P = 0.001). A third of the donors in G1 were HLA identical as compared to 7% in G4. Prediction of long-term graft survival is possible by the SCr level at one year post transplant. This can be of great importance, especially to identify those patients who require close monitoring in follow-up. Donor age, HLA, and acute rejection impact SCr at one year and hence graft outcome.