Patient Graft Survival Research Articles

Are Octogenarians With End-Stage Renal Disease Candidates for Renal Transplantation?

BackgroundElderly patients are the fastest-growing group in need of renal transplantation. This study puts focus on renal transplant recipients in their 80th year or longer at time of engraftment. Is there evidence to support an absolute upper age limit for renal transplantation?MethodsRecipients in their 80th year or longer, transplanted between 1983 and 2015, were included. Data were retrieved from the Norwegian Renal Registry in the end of October 2015. Graft and patient survivals were compared with recipients aged 70 to 79 years at transplantation.ResultsForty-seven patients older than 79 years were transplanted in the defined period. Median age 80.1 years, 81% were men. Median time on dialysis before transplantation was 18.5 months. All patients received an allograft from a deceased donor (median donor age, 61.8 years). In the death-censored graft survival model, there was no statistical difference between the groups. We found improved patient and graft survivals after introduction of mycophenolate mofetil and induction with basiliximab. Patients transplanted before 2000 had increased risk of death compared with those transplanted after 2000 (hazard ratio, 3.2; 95% confidence interval, 1.2-8.7). Median uncensored graft survival for patients transplanted after the year 2000 was 5.0 year (95% confidence interval, 2.4-7.6). Median patient survival was 5.0 years (3.1-6.9) and 5-year patient survival was 55%.ConclusionsAge by itself should not be an absolute contraindication against renal transplantation. An estimated 5-year survival rate of 55% post-engraftment for an 80-year-old patient is in our opinion more than acceptable.

Phenotyping Chronic Lung Allograft Dysfunction Using Body Plethysmography and Computed Tomography.

Restrictive subtype of chronic lung allograft dysfunction (CLAD) was recently described after lung transplantation. This study compares different definitions of a restrictive phenotype in CLAD patients and impact on survival. Eighty-nine CLAD patients out of 1191 screened patients (September 1987 to July 2012) were included as complete longitudinal lung volume measurements and chest computed tomography (CT) after CLAD onset was available. CT findings and lung volumes were quantified and survival was calculated for distinctive groups and predictive factors for worse survival were investigated. Graft survival in patients with total lung capacity (TLC) between 90% and 81% of baseline (BL) (n = 13, 15%) in CLAD course was similar to those with TLC >90% BL (n = 64, 56%; log-rank test p = 0.9). Twelve patients (13%) developed a TLC ≤80% BL and 10 (11%) had significant parenchymal changes on CT, of whom 6 (46%) also had TLC ≤80% BL. CT changes correlated with TLC ≤80% BL (Φ-coefficient = 0.48, p = 0.001). Patients with either TLC ≤80% or significant CT changes (n = 16, 18%) had a significantly reduced survival (log-rank p < 0.001). Forced vital capacity loss at CLAD onset was associated with poorer survival but did not correlate with the TLC or CT changes. A restrictive subtype of CLAD may be defined by either TLC ≤80% BL or severe parenchymal changes on chest CT.

Simultaneous Native Nephrectomy and Kidney Transplantation in Patients With Autosomal Dominant Polycystic Kidney Disease.

IntroductionTo evaluate the feasibility of simultaneous unilateral nephrectomy with kidney transplantation and to determine the effect of this procedure on perioperative morbidity and mortality and graft and patient survival.MethodsBetween January 2000 and May 2015, 145 patients with autosomal dominant polycystic kidney disease (ADPKD) underwent kidney transplantation. Of those, 40 (27.5%) underwent concurrent ipsilateral native nephrectomy (group NT). Patients in group NT were compared with patients with ADPKD not undergoing concurrent nephrectomy (group NT-) and asymptomatic patients undergoing pretransplant nephrectomy (group PNT).ResultsThe average follow-up was 66 months. The graft survival rate at 1 and 5 years was 95% and 87.5% versus 93% and 76.2% in the NT and NT- groups, respectively (P = .903 and P = .544, respectively); 1-year patient survival was 100% for NT and 97% for NT- patients (P = .288), whereas 5-year patient survival was 100% and 92% for NT and NT- groups, respectively (P = .128). After propensity score matching (34 patients per group) no significant differences were observed in 1-year (97.1% in NT and 94.1%; P = 1) and 5-year (88.2% in NT and 91.2% in NT-; P = 1) graft survival, and in 1-year (100% for both groups; P = 1) and 5-year (100% in NT and 94.1% in NT-; P = 1) patient survival. Perioperative mortality was 0% among NT and 1.2% among NT- patients, whereas perioperative surgical complications were similar in both groups. One- and 5-year graft and patient survival were similar between the NT and PNT groups, but patients in the PNT group had significantly lower levels of hemoglobin and residual diuresis volumes at the time of transplant. Moreover, PNT patients had a longer pretransplant dialysis and a longer time on the waiting list.ConclusionsSimultaneous unilateral nephrectomy does not have a negative effect on patient and graft survival in patients with ADPKD and is associated with low morbidity. Pretransplant nephrectomy should be restricted only to highly symptomatic patients, whereas unilateral nephrectomy in asymptomatic patients should be performed during kidney transplantation only if massive kidney size precludes graft positioning.

Long-Term Outcomes of Kidney and Simultaneous Pancreas–Kidney Transplantation in Recipients With Type 1 Diabetes Mellitus: Silesian Experience

BackgroundKidney transplantation (KTx) markedly reduces mortality in patients with end-stage kidney disease (ESKD) caused by type 1 diabetes mellitus (T1DM). The outstanding issue is whether transplantation should be limited only to KTx, with further insulinotherapy, or combined with pancreas transplantation in patients with ESKD/T1DM. The goal of this study was to compare the results of simultaneous pancreas–kidney transplantation (SPKTx) and deceased donor KTx and to identify factors affecting patient and kidney graft survival in patients with ESKD/T1DM. MethodsEighty-seven deceased donor KTx and 66 SPKTx operated on in the Silesia region of Poland between 1998 and 2013 were included in the retrospective analysis. ResultsDuring the mean 6.7 ± 3.6 years of follow-up, fewer cardiovascular episodes were observed in SPKTx recipients than in KTx recipients (1.5% vs 12.6%; P < .05). Five-year patient survival (80.7% in SPKTx vs 77.5% in KTx) and kidney graft survival (66.1% in SPKTx vs 70.4% in KTx) did not differ between study groups. There were no differences in patient survival (log-rank test, P = .99) or kidney graft survival (P = .99) based on Kaplan-Meier curves. Multivariable Cox proportional hazard analysis failed to identify factors explaining patient and kidney graft survival. Five-year pancreas graft survival was 58.9%. SPKTx recipients had significantly higher estimated glomerular filtration rates during the 7-year posttransplant period and less frequently developed proteinuria (6.1% vs 23%; P < .01). ConclusionsPancreas transplantation reduced cardiovascular risk and prevented the development of proteinuria but did not improve patient and kidney graft survival in recipients with T1DM in the 7-year follow-up period.

Results of the TOP Study: Prospectively Randomized Multicenter Trial of an Ex Vivo Tacrolimus Rinse Before Transplantation in EDC Livers.

BackgroundOrgan shortage results in the transplantation of extended donor criteria (EDC) livers which is associated with increased ischemia-reperfusion injury (IRI). Experimental studies indicate that an organ rinse with the calcineurin inhibitor tacrolimus before implantation protects against IRI. The tacrolimus organ perfusion study was initiated to examine the effects of ex vivo tacrolimus perfusion on IRI in transplantation of EDC livers.MethodsA prospective randomized multicenter trial comparing ex vivo perfusion of marginal liver grafts (≥2 EDC according to Eurotransplant manual) with tacrolimus (20 ng/mL) or histidine-tryptophane-ketoglutarate solution (control) was carried out at 5 German liver transplant centers (Munich Ludwig-Maximilians University, Berlin, Heidelberg, Mainz, Regensburg) between October 2011 and July 2013. Primary endpoint was the maximum alanine transaminase (ALT) level within 48 hours after transplantation. Secondary endpoints were aspartate transaminase (AST), prothrombine ratio, and graft-patient survival within an observation period of 1 week. After an interim analysis, the study was terminated by the scientific committee after the treatment of 24 patients (tacrolimus n = 11, Control n = 13).ResultsTacrolimus rinse did not reduce postoperative ALT peaks compared with control (P = 0.207; tacrolimus: median, 812; range, 362-3403 vs control: median, 652; range, 147-2034). Moreover, ALT (P = 0.100), prothrombine ratio (P = 0.553), and bilirubin (P = 0.815) did not differ between the groups. AST was higher in patients treated with tacrolimus (P = 0.011). Survival was comparable in both groups (P > 0.05).ConclusionsContrary to experimental findings, tacrolimus rinse failed to improve the primary endpoint of the study (ALT). Because 1 secondary endpoint (AST) was even higher in the intervention group, the study was terminated prematurely. Thus, tacrolimus rinse cannot be recommended in transplantation of EDC livers.

Pretransplant Hepatitis B Viral Infection Increases Risk of Death After Kidney Transplantation: A Multicenter Cohort Study in Korea.

Clinical outcomes in kidney transplant recipients (KTRs) with hepatitis B virus (HBV) have not been thoroughly evaluated. Here, we investigated recent posttransplant clinical outcomes of KTRs with HBV and compared them with KTRs with hepatitis C virus (HCV) and seronegative KTRs.Of 3855 KTRs from April 1999 to December 2011, we enrolled 3482 KTRs who had viral hepatitis serology data; the patients were followed up for 89.1 ± 54.1 months. The numbers of recipients with HBV and HCV were 160 (4.6%) and 55 (1.6%), respectively. We analyzed the clinical outcomes, including overall mortality and graft failure, among patients who had undergone kidney transplantation.Patients with HBV showed poorer survival (P = 0.019; adjusted hazard ratio [HR] = 2.370; 95% confidence interval [CI]: 1.155-4.865) than KTRs without HBV. However, the graft survival of patients with chronic hepatitis B did not differ from that of patients without HBV. Hepatic complications were the primary causes of mortality of KTRs with HBV. Mortality significantly correlated with a higher grade of inflammation (P = 0.002) and with the use of lamivudine or adefovir antiviral treatment (P = 0.016). HBV-positive KTRs treated with the new-generation antiviral agent entecavir showed improved patient survival compared with KTRs receiving lamivudine (log-rank P = 0.050). HCV did not affect patient survival; however, it increased the incidence of graft failure (P = 0.010; adjusted HR = 2.899; 95% CI: 1.289-6.519). KTRs with HCV had an increased incidence of acute rejection (log-rank P = 0.005, crude HR = 2.144; 95% CI: 1.341-3.426; P = 0.001).KTRs with chronic hepatitis B may exhibit poor survival due to post-transplantation hepatic complications. Pretransplant histological liver evaluations and adequate antiviral management with potent nucleoside/nucleotide analogues are needed to improve the survival of KTRs with chronic hepatitis B even when liver function is within the normal range.

Donor-specific antibodies present at the time of kidney transplantation in immunologically unmodified patients increase the risk of acute rejection

BackgroundHuman leukocyte antigens (HLA) class II donor-specific antibodies (DSAs) are associated with microcirculation inflammation, transplant glomerulopathy and ultimately graft loss. There is however no data on allograft outcomes in deceased donor kidney transplant recipients who have not received any desensitization prior to transplantation. MethodsWe prospectively evaluated the association of HLA DR and DQ DSAs on rejection and short-term graft survival in patients who did not receive desensitization prior to transplantation. On the basis of their cumulative strength of HLA DR and/or DQ DSA, the patients were dichotomized into: 1) median fluorescence intensity (MFI)<1000 and 2) MFI≥1000. ResultsIn the two year study period, 50 consecutive patients with HLA DR and/or DQ sensitization were transplanted in our two centers. Post-transplantation, the incidence of acute rejection was significantly greater in the MFI≥1000 group (35%; 8/22) compared to the MFI<1000 group (7%; 2/28) (p<0.001). There were two graft losses, both in the MFI≥1000 group. ConclusionThe strength of DR and/or DQ DSA at the time of renal transplantation influences the risk of rejection in non-desensitized recipients with HLA class II DSA.

Impact of Pretransplant Panel-Reactive Antibody Level on Renal Graft Survival in Patients With a Negative Crossmatch and No Donor-Specific Antibody

BackgroundPatients with high panel-reactive antibody (PRA) levels before transplantation tend to remain on the waiting list longer when considering cadaveric donor transplantation and have worse outcomes than those with lower PRA levels. This study investigated the impact of the pretransplantation PRA level on rejection and graft survival after kidney transplantation in patients with a negative crossmatch (CXM−) and no donor-specific antibody (DSA−). MethodsWe retrospectively analyzed 513 recipients of kidney allograft treated from January 2009 to April 2013. Those who tested positive on crossmatching, had donor-specific antibodies, were ABO incompatible, or had no PRA level data were excluded (n = 130). The remaining patients were stratified into 3 groups according to their PRA levels: group I, PRA = 0 (314 [80.1%]); group II, PRA ≤50% (27 [7.2%]); and group III, PRA >50% (27 [7.2%]). Graft failure was defined as a return to dialysis, transplant nephrectomy, or death with a functioning kidney. ResultsThe mean patient follow-up was 30.4 ± 4.6 months. The rejection rate was 20.1% (group I, 18.5% [n = 58] vs group II, 23.8% [n = 10] vs group III, 33.3% [n = 9] [P = .053]). The graft failure rate was 21.7% (group I, 6.4% [n = 20] vs group II. 7.1% [n = 3] vs group III, 7.4% [n = 7] [P = .792]), and the 3-year graft survival rates were 96.3, 92.4, and 92.5%, respectively (P = .851). ConclusionsThe pretransplant PRA level was not significantly associated with graft survival in patients with CXM− and DSA−. However, the rejection rate tended toward significance as the PRA level increased (P = .053).

MP32-01 PERCUTANEOUS NEPHROSTOMY PLACEMENT AFTER RENAL TRANSPLANTATION: INDICATIONS AND IMPLICATIONS FOR LONG-TERM GRAFT SURVIVAL

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery II1 Apr 2016MP32-01 PERCUTANEOUS NEPHROSTOMY PLACEMENT AFTER RENAL TRANSPLANTATION: INDICATIONS AND IMPLICATIONS FOR LONG-TERM GRAFT SURVIVAL Jeffrey Pearl, Joshua Finkle, Mikin Patel, Thuong Van Ha, Jeffrey Leef, Kenneth Ogan, and Jonathan Lorenz Jeffrey PearlJeffrey Pearl More articles by this author , Joshua FinkleJoshua Finkle More articles by this author , Mikin PatelMikin Patel More articles by this author , Thuong Van HaThuong Van Ha More articles by this author , Jeffrey LeefJeffrey Leef More articles by this author , Kenneth OganKenneth Ogan More articles by this author , and Jonathan LorenzJonathan Lorenz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1296AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urologic intervention after renal transplantation is a rare requirement often utilizing a multidisciplinary approach between interventional radiologists and urologists. Frequently, prior to definitive treatment of transplant ureteral obstruction or urinary leak, urinary diversion by percutaneous nephrostomy is required. The purpose of our study is to identify indications and factors predictive of long-term graft survival in patients requiring percutaneous nephrostomy placement after renal transplantation. METHODS A retrospective chart review was performed to identify renal transplant patients who underwent subsequent nephrostomy placement between July 1, 2005 and June 30, 2015. Patient and procedure related variables, imaging of the transplant graft, and graft survival data were collected. Kaplan-Meier analysis was performed to assess our primary outcome, which was the relationship between factors surrounding nephrostomy placement and graft survival. RESULTS 51 patients received percutaneous nephrostomy tubes with a technical success rate of 98% and complication rate of 27%. Indications included ureteral stricture in 63%, urolithiasis in 25%, and urine leak in 12%. Median graft survival was 11.9 years (IQR 4.7 to 17.9 years) versus 10.5 years as reported in the general transplant population. Factors associated with worse graft survival included age greater than 60 years (HR 2.9 [CI 1.3-6.1, p<.05]), moderate or greater hydronephrosis (HR 3.8 [CI 1.5-9.8, p<.01]), serum creatinine (SCr) greater than 2 ng/dL (HR 5.3 [CI 1.3-22.4, p<.05]), no post-procedural drop in SCr (HR 2.8 [CI 1.3-6.0, p<.01]), and a nephrostomy related complication (HR 2.7 [CI 1.2-6.3, p<.05]). Patients with ureteral stricture had worse graft survival than those with stones (HR 6.4 [CI 1.9-21.7, p<.01]). Patients with stricture underwent either dilation by interventional radiology (28%), endourologic treatment (12.5%), open repair (9%), had graft failure or death prior to repair (12.5%), or did not undergo repair (38%). There was not a significant difference in graft survival between types of stricture repair. CONCLUSIONS Renal transplant patients requiring nephrostomy have similar graft survival compared to the general transplant population. In our population, ureteral stricture was the most common indication for nephrostomy tube, and a variety of approaches were implemented for repair without significant differences in graft survival. Multiple patient-related factors may be predictive of long-term graft survival in this setting. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e427-e428 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Jeffrey Pearl More articles by this author Joshua Finkle More articles by this author Mikin Patel More articles by this author Thuong Van Ha More articles by this author Jeffrey Leef More articles by this author Kenneth Ogan More articles by this author Jonathan Lorenz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Use of Renal Replacement Therapy May Influence Graft Outcomes following Liver Transplantation for Acute Liver Failure: A Propensity-Score Matched Population-Based Retrospective Cohort Study.

IntroductionAcute kidney injury is associated with a poor prognosis in acute liver failure but little is known of outcomes in patients undergoing transplantation for acute liver failure who require renal replacement therapy.MethodsA retrospective analysis of the United Kingdom Transplant Registry was performed (1 January 2001–31 December 2011) with patient and graft survival determined using Kaplan-Meier methods. Cox proportional hazards models were used together with propensity-score based full matching on renal replacement therapy use.ResultsThree-year patient and graft survival for patients receiving renal replacement therapy were 77.7% and 72.6% compared with 85.1% and 79.4% for those not requiring renal replacement therapy (P<0.001 and P = 0.009 respectively, n = 725). In a Cox proportional hazards model, renal replacement therapy was a predictor of both patient death (hazard ratio (HR) 1.59, 95% CI 1.01–2.50, P = 0.044) but not graft loss (HR 1.39, 95% CI 0.92–2.10, P = 0.114). In groups fully matched on baseline covariates, those not receiving renal replacement therapy with a serum creatinine greater than 175μmol/L had a significantly worse risk of graft failure than those receiving renal replacement therapy.ConclusionIn patients being transplanted for acute liver failure, use of renal replacement therapy is a strong predictor of patient death and graft loss. Those not receiving renal replacement therapy with an elevated serum creatinine may be at greater risk of early graft failure than those receiving renal replacement therapy. A low threshold for instituting renal replacement therapy may therefore be beneficial.

Repeat liver retransplantation: rationale and outcomes.

Liver retransplantation remains the only option for recurrent graft failure. The aim of our study is to identify predictive factors involved in patients and graft survival for patients undergoing repeat retransplantation (RRT). From January 1985 to December 2012, 2940 liver transplantations were performed in 2477 patients at Paul Brousse Hospital, Villejuif, France. All patients who underwent third, fourth, and fifth transplantation were included in the study and retrospectively analyzed. In the univariate analysis, the factors that were associated with 90-d patient post-operative survival were pre-operative vasopressors support, pre-operative extra hepatic sepsis, primary non-function (PNF) as indication of RRT, recipient's model of end stage liver disease (MELD), urgent RRT, creatinine value at RRT, and prothrombin ratio. The multivariate logistic regression confirmed the role of systemic septic status (OR = 12.8, p = 0.01) and vasopressor drug support (OR = 4.7, p = 0.05) as predictors of post-operative mortality. In the univariate analysis, the factors that were associated with patient 10 yr long-term survival (were vasopressor support, systemic septic patient, PNF as indication of RRT, RRT occurred between 1985 and 1999, recipient's MELD, creatinine value at RRT, and prothrombin ratio. The multivariate logistic regression confirmed the role of systemic septic patient (OR = 6.4, p = 0.03) and the RRT between 1985 and 1999 (OR = 3.6, p = 0.05) as predictors of long-term mortality. RRT represent a valid alternative in selected patients. Selection should be oriented on patients needing third transplant without extra hepatic sepsis and vasoactive drug support at moment of RRT. If necessary, fourth and fifth RRT could be performed with a decision made on case-by-case basis, despite a high post-operative mortality.

Graft Outcomes in Kidney Transplantation Alone with Concomitant Cirrhosis

aim: The influence of cirrhosis on kidney graft survival post-transplantation has not been well defined. As previously demonstrated, lower rates of patient overall survival (31%) were in conjunction with lower rates of 5-year graft survival (31%) in cirrhotic patients who received a kidney transplant alone. Unfortunately, there is scarce data on the graft survival in patients who receive a kidney transplant alone with concomitant cirrhosis. Methods: Among 131 patients with kidney transplantations at Methodist Specialty Hospital in San Antonio, TX between January 1999 and December 2011 with serological evidence of hepatitis B or C, 12 patients were found to have concomitant cirrhosis at time of transplantation. Rates of survival at 3-years were compared to the national average and overall for Methodist Specialty Hospital. Results: In the 12 patients, cirrhosis etiologies included hepatitis B (n=2), hepatitis C (n=7) and cryptogenic (n=3). All were confirmed by histology at or within 6 months prior to kidney transplantation. The median graft survival was 8.1 years and graft survival at 3- and 5-years were 75% and 58%, respectively. Conclusion: Preliminary data suggests that cirrhotic patients might be considered for combined liver and kidney transplantation. Graft survival at 3 years is far below the national average (85%) and Methodist Hospital overall (89%). Study also demonstrates the benefit of a liver biopsy with or without portal pressure measurement prior to transplantation in patients with viral hepatitis and/or other hepatic disease to accurately stage fibrosis.

Graft Survival in Patients With Polycystic Kidney Disease With Nephrectomy of Native Kidney Pretransplant

IntroductionAutosomal-dominant polycystic disease (ADPKD) represents 5%–10% of cases of end-stage renal failure. However, management of these patients in terms of whether or not to perform a transplant and optimal timing remains controversial. The objective of our analysis was to evaluate graft survival in patients with ADPKD in which we conduct pretransplant nephrectomy. MethodsThis retrospective study including renal transplant patients secondary to ADPKD in our hospital between January 2000 and December 2012. Pretransplant native kidney nephrectomy was indicated in cases of need for space or repeated complications (cysts). We compared the initial function and graft survival between groups of transplanted based on whether nephrectomy had been performed or not. ResultsEighty-seven patients underwent a kidney transplant owing to ADPKD; 62% (n = 54) were male, with an average age of 55.22 years. Twenty-seven patients (30%) underwent nephrectomy native kidneys before transplantation. There were no serious postoperative complications. Patients who underwent nephrectomy (group 1) showed values of creatinine of 1.57 and 1.50 mg/dL at 3 and 6 months, respectively. In the no nephrectomy group, these values were 2.03 and 1.83 mg/dL, respectively. Graft survival after the first year was of 98% for group 1 and 95% for group 2. The 5-year implant survival was 95% and 80%, respectively. ConclusionsNative kidney nephrectomy before transplantation in ADPKD is safe in an experienced center, both in terms of surgery-related morbidity and mortality and graft survival and function.

Donor-specific antibodies in kidney deceased donor transplantation

Aim Pre-sensitization against a broad array of HLA is associated with prolonged waiting times and inferior kidney allograft survival. Although the use of solid phase assay (SPA) for the detection and characterization of anti-HLA antibodies provides greater sensitivity than complement-dependent lymphocytotoxicity (CDC) assay, it often detects donor specific antibodies (DSA) which turn out to be clinically irrelevant. In this study, our aim is to determine whether kidney deceased donor recipients with preformed DSA detectable in serum obtained prior to transplant are at an increased risk of graft failure. Methods We studied 640 patients who received a kidney transplant from a deceased donor between January 1, 2009 and December 31, 2014 at Columbia University Medical Center. Sera collected from the recipients prior to transplantation were tested for DSA by CDC and SPA with single antigen coated beads. All patients were transplanted with negative CDC crossmatch. Results We analyzed the actuarial graft survival in patients with a primary allograft ( n = 525) and in patients with a secondary allograft ( n = 115). Kidney allograft survival was significantly higher in primary allograft recipients (85%) than in secondary allograft recipients (71%) at 6 years. ( P = 0.02) Forty-six out of 525 (8.7%) primary kidney allograft recipients and sixty-two out of 115 (53.9%) secondary kidney allograft recipients had SPA-detectable DSA in sera collected prior to transplantation. Six years following transplantation of primary kidney allografts the actuarial graft survival was 83% and 85%, respectively, regardless of whether DSA were detectable in recipients’ pre-transplantation sera. ( P = 0.39) In recipients of secondary kidney allografts with and without SPA-detectable DSA, the actuarial graft survival was 67% and 77% at 6 years, respectively. ( P = 0.12) Conclusions The presence of SPA-detectable DSA in recipients of kidney allografts from deceased donors is associated with lower long term (6 year) actuarial graft survival although the difference does not reach statistical significance.

Factors Predicting Risk for Antibody-mediated Rejection and Graft Loss in Highly Human Leukocyte Antigen Sensitized Patients Transplanted After Desensitization.

Desensitization with intravenous immunoglobulin and rituximab (I+R) significantly improves transplant rates in highly sensitized patients, but antibody-mediated rejection (ABMR) remains a concern. Between July 2006 and December 2012, 226 highly sensitized patients received transplants after desensitization. Most received alemtuzumab induction and standard immunosuppression. Two groups were examined: ABMR (n = 181) and ABMR (n = 45, 20%). Risk factors for ABMR, pathology, and outcomes were assessed. Significant risks for ABMR included previous transplants and pregnancies as sensitizing events, donor-specific antibody (DSA) relative intensity scores greater than 17, presence of both class I and II DSAs at transplant and time on waitlist. The ABMR showed a significant benefit for graft survival and glomerular filtration rate at 5 years (P < 0.0001). Banff pathology characteristics for ABMR patients with or without graft loss did not differ. C4d versus C4d ABMR did not predict graft loss (P = 0.086). Thrombotic microangiopathy (TMA) significantly predicted graft failure (P = 0.045). The ABMR episodes were treated with I+R (n = 25), or, in more severe ABMR, plasma exchange (PLEX)+I+R (n = 20). Graft survival for patients treated with I+R was superior (P = 0.028). Increased mortality was seen in ABMR patients experiencing graft loss after ABMR treatment (P = 0.004). The PLEX + Eculizumab improved graft survival for TMA patients (P = 0.036). Patients desensitized with I+R who remain ABMR have long-term graft and patient survival. The ABMR patients have significantly reduced graft survival and glomerular filtration rate at 5 years, especially TMA. Severe ABMR episodes benefit from treatment with PLEX + Eculizumab. The DSA-relative intensity scores at transplant was a strong predictor of ABMR. Donor-specific antibody avoidance and reduction strategies before transplantation are critical to avoiding ABMR and improving long-term outcomes.

Long-term kidney allograft survival in patients with transplant glomerulitis.

Renal transplant glomerulitis (G) is associated with acute antibody-mediated rejection (ABMR) in the presence of donor-specific antibodies. However, the long-term prognosis of isolated G (isG) in the absence of donor-specific antibodies or G in combination with T cell-mediated rejection (TCMR) remains unexplored. Seventy recipients with G were included in this retrospective study and subdivided into 3 groups: isG, G with TCMR (G+TCMR), and G with acute ABMR. The control groups were: patients with TCMR Banff type I or II without G (TCMR) and patients without rejection (NR). Kaplan-Meier death-censored survival plots and Cox regression were used to analyze graft survival. The combined graft survival endpoint was defined as a return to dialysis or estimated glomerular filtration rate less than 15 mL/min/1.73 m. The median follow-up was 37 (14; 77) months from biopsy. Graft survival was significantly lower in patients with G than in the NR and TCMR groups. No significant differences were observed among the isG, G+TCMR, and ABMR groups. Graft survival was lower in the G+TCMR group than in the TCMR group. Glomerulitis was independently associated with the risk of adverse graft outcome in a multivariate Cox regression model adjusted for other confounders (hazard ratio, 4.52 [95% confidence interval, 2.37-8.68] vs controls; P<0.001). Glomerulitis is strongly associated with increased risk of graft failure. Graft survival in patients with isG that do not meet the Banff criteria for acute/active ABMR and in patients with G accompanying TCMR is comparable to the ABMR group.

The impact of acute rejection in kidney transplantation on long-term allograft and patient outcome.

Background:Patients with end stage renal disease (ESRD) can be sustained with dialysis therapy.Objectives:In this study, we followed up the effect of early acute and late acute rejections on survival rates of patients’ grafts.Patients and Methods:We investigated the timing and frequency of acute rejection episodes related to long-term patient-graft survival in Taleghani hospital between 1990 and 2011. Recipients were divided into three groups as Group-1 (no rejection), Group-2 (early acute rejection [EAR]: less than 3-months) and Group-3 (late acute rejection [LAR]: after 3 months of transplant).Results:One and five-year patient’s survival rates were 94.87% and 93.8%, and graft survival (GS) rates were 92.6% and 81.9%. EAR and LAR occurred in 125 (18.8%) and 77 (11.7%) patients, respectively. Graft and patient survival rates at one and five years were as follows; Group-1 (Graft 96.7% and 94.5% patient: 97.4% and 96.8%), Group-2 (Graft: 72% and 61%, patient: 85.6% and 84%), Group-3 (Graft: 84.4% and 36.8%, patient: 92.2% and 89.4%). Recipient age, type and length of dialysis, number of transplantations and the status of panel reactivity antibody (PRA) had no effect on the type of rejection. LAR was more commonly associated with males (P = 0.001) and donors’ age was associated with rejection (P = 0.0002). Five-year GS rate among the three groups was lower in the LAR group (P < 0.0001).Conclusions:LAR had a negative impact on long-term renal allograft survival and the risk of chronic graft dysfunction increased in patients with a history of LAR.

Tyrosine-Phosphatase and Glutamate-Decarboxylase Antibodies After Simultaneous Pancreas Kidney Transplantation: Do They Have an Impact on Pancreas Graft Survival?

IntroductionThe pathogenesis of type 1 diabetes mellitus (T1DM) is associated with auto-antibodies. These auto-antibodies contribute to pancreatic ß-cell destruction. Tyrosine-phosphatases (IA-2) and glutamic acid decarboxylase (GAD65) are the most frequently used by clinicians. When T1DM patients develops advanced chronic kidney disease, simultaneous pancreas-kidney (SPK) transplantation becomes the best option. However, pancreatic graft survival is limited. The role of the auto-antibodies on pancreas graft survival remains controversial. ObjectiveThe aim of this study was to assess pancreas graft survival according to the presence of GAD65 and IA-2 auto-antibodies after SPK transplantation. MethodsWe analyzed all SPK transplantations performed in our hospital since January 1990 to December 2013 with at least 30 days of pancreas graft survival. We collected demographic and clinical variables from donors and recipients. Graft failure was defined as complete insulin independence after transplantation. Pancreatic graft survival was analyzed using the Kaplan-Meier method. ResultsOverall, 152 SPK transplantations were performed during the period. One hundred sixteen were accessed for de novo post-transplantation auto-antibodies. Also, 17.8% (n = 27) were positive for anti-GAD65, 13.8% (n = 20) for IA-2, 3.9% (n = 6) were positive for both, and the rest were negative for any auto-antibody (n = 63). Kaplan-Meier survival curves estimated a worst pancreas graft survival for patients with positive IA-2 antibodies versus those patients with negative auto-antibodies and GAD65+auto-antibodies (P = .003 and .022, respectively, by log-rank). Mean pancreas graft survival rates at first and fifth year were 72% and 64%, respectively, for those patients with positive IA-2. ConclusionsIA-2 antibodies after SPK transplantation are associated with long-term graft lost compared with the rest of the groups. Monitoring of these auto-antibodies after SPK may help to identify patients with a higher risk of graft failure.

Thrombocytopenia, Platelet Transfusion, and Outcome Following Liver Transplantation.

Thrombocytopenia affects patients undergoing liver transplantation. Intraoperative platelet transfusion has been shown to independently influence survival after liver transplantation at 1 and 5 years. We examined the impact of thrombocytopenia and intraoperative platelet transfusion on short-term graft and overall survival after orthotopic liver transplantation (OLT). A total of 399 patients undergoing first OLT were studied. Graft and overall survival in patients with different degrees of thrombocytopenia and with or without intraoperative platelet transfusion were described. The degree of thrombocytopenia prior to OLT did not affect graft or overall survival after transplant. However, graft survival in patients receiving platelets was significantly reduced at 1 year (P= .023) but not at 90 days (P= .093). Overall survival was significantly reduced at both 90 days (P= .040) and 1 year (P= .037) in patients receiving platelets. We conclude that a consistently lower graft and overall survival were observed in patients receiving intraoperative platelet transfusion.

Efficacy and safety of systemic tacrolimus in high-risk penetrating keratoplasty after graft failure with systemic cyclosporine.

The aim of this study was to investigate the efficacy and safety of systemic tacrolimus for the treatment of eyes that developed graft failure despite treatment with cyclosporine (CsA). Ten eyes of 10 patients who underwent high-risk penetrating keratoplasty (PKP) and developed graft failure despite treatment with systemic CsA were included in this study. The patients underwent PKP and were treated with systemic tacrolimus according to the standardized protocol. Treatment with tacrolimus was continued for 18.1 ± 13.9 months. The median duration of corneal graft clarity was 34.5 months. Graft rejection occurred in 2 of 10 eyes during a mean follow-up period of 48.9 ± 22.9 months. Kaplan-Meier survival plots showed significantly fewer graft rejection episodes (P = 0.033) and longer graft survival (P = 0.042) after treatment with tacrolimus compared those with CsA. Tacrolimus was discontinued in 2 patients; 1 had renal dysfunction and the other had muscle pain and fatigue. These side effects subsided after discontinuation of tacrolimus. Treatment with systemic tacrolimus is possibly safe and effective in reducing graft rejection and prolonging graft survival in patients with high-risk PKP after graft failure with systemic CsA.