Kidney Graft Survival In Recipients Research Articles

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.

Influence of Surgical Complications on Kidney Graft Survival in Recipients of Simultaneous Pancreas Kidney Transplantation

PurposeSimultaneous pancreas-kidney transplantation is the gold standard treatment for patients with end-stage renal failure secondary to insulin-dependent diabetes mellitus. This kind of transplantation is a complex operation associated with a high incidence of surgical complications and mortality risk which could influence graft survival. The aim of this study was to establish the influence of different grades of postoperative complications, classified according to Clavien-Dindo, on the rate of kidney graft loss. MethodsWe performed an observational retrospective review of all simultaneous transplantations performed between February 1989 and May 2012. Factors examined were related to recipient and donor characteristics, surgical procedures, and postoperative outcomes. For this purpose, Kaplan-Meier analyses and Cox-Regression tests are used. ResultsOne hundred thirty-nine transplantations were performed. Complications grades I, II, and IIIa were experienced in 81 (58.3%) patients, and grades IIIb and IVa-b in 55 (39.6%). Multivariate analysis showed an influence of panel reactive antibody (hazard ratio [HR]: 10.79; P = .003), incidence of acute rejection (HR: 2.55; P = .03), and complications grouped into grades IIIb and IVa-b (HR: 3.63; P = .02). Kaplan Meier analysis showed worse kidney graft survival rate in groups grades IIIb and IVa-b compared to grades I, II, and IIIa (86.6% vs 98.7% at 1 year and 81.8% vs 97.3% at 5 years; P = .001). ConclusionsDespite being the gold standard treatment for these patients, pancreas and kidney transplantations have numerous complications which could influence the prognosis of graft kidney survival.

MP72-12 OUTCOMES OF KIDNEY TRANSPLANT RECIPIENTS WITH BLADDER DYSFUNCTION AND BLADDER SUBSTITUTION

INTRODUCTION AND OBJECTIVES: A substantial proportion of kidney transplantation recipients have bladder dysfunction or have had bladder substitutions. We compared graft survival and post operative morbidity of these recipients after transplant to recipients with normal bladder function. METHODS: Electronic records of 1,753 patients who received a kidney-alone transplant at a single center between January 2000 and December 2008 were reviewed. Among these patients, 1652 were identified with normal bladder function, 80 with bladder dysfunction (defined as any disorder of urinary storage or emptying), and 21 with a bladder substitute (enterocystoplasty, continent pouch, orthotopic bladder substitution, ileal or colon conduit). Kaplan-Meier curves were generation that compared transplant kidney survival between groups. Multivariable regression modeling was also performed to identify variables associated with graft survival. RESULTS: Graft survival at 1 and 5 years was 93% and 77% for normal bladder function; 86% and 67% for bladder substitute; and 95% and 86.3% for bladder dysfunction (p 1⁄4 0.17). Patient survival at 1 and 5 years was 96% and 84% for normal bladder function; 91% and 75% for bladder substitute; and 96% and 90% for bladder dysfunction. Multivariate analysis demonstrated a trend toward inferior graft survival in recipients with bladder substitute (HR 1.9, 95% CI 0.88-4.09, p 1⁄40.09) but not bladder dysfunction. In normally functioning bladders, the most common cause of graft failure was chronic rejection (17%); in the bladder dysfunction and bladder substitute groups the most common cause of graft failure was infection (21%, 29%). Recipients with bladder dysfunction (OR: 3.65, p1⁄4.07) or bladder substitutes (OR: 7.47, p1⁄4.13) demonstrated a trend toward more post operative urinary tract infections and surgical complications, compared to normal bladder function. CONCLUSIONS: There was a trend toward decreased kidney graft survival in recipients with bladder substitution. Recipients with bladder dysfunction or substitution had a higher percentage of graft failure from infection and were more likely to have post operative urinary tract infections or surgical complications.

Donor Desmopressin Is Associated With Superior Graft Survival After Kidney Transplantation

A recent randomized trial showed that pretreatment of the brain-dead donor with low-dose dopamine improves immediate kidney graft function, by limiting injury from cold storage (ClinicalTrials.gov Identifier: NCT00115115). This study determines whether donor exposure to desmopressin (1-deamino-8-d-arginine-vasopressin [DDAVP]) before organ retrieval affects renal transplant outcome. This retrospective multicenter cohort study, nested in the database of the dopamine trial, includes 264 deceased heart-beating donors with confirmed brain death and corresponding 487 renal allograft recipients transplanted at 60 European centers between March 2004 and August 2007. We assessed differences in delayed graft function, biopsy-proven acute rejections, and 2-year kidney graft survival in recipients of a DDAVP-exposed versus unexposed graft. DDAVP was associated with improved graft survival (85.4% vs. 73.6%, P=0.003). This survival benefit persisted after censoring for death with functioning graft (91.1% vs. 82.0%, P=0.01) and after adjustment for confounders including covariate adjustment from propensity scoring (hazard ratio 0.40, 95% confidence interval [CI] 0.21-0.77; P=0.006). Delayed graft function (odds ratio 0.97, 95% CI 0.57-1.65; P=0.92) and biopsy-proven acute rejections (odds ratio 1.32, 95% CI 0.70-2.49; P=0.40) were unaffected. The survival effect was enhanced after a shorter cold ischemic time less than 14 hr (91.3% vs. 77.8%, P=0.008) and after dopamine pretreatment (92.7% vs. 78.6%, P=0.006). By contrast, prolonged cold ischemic time more than or equal to 14 hr (91.2% vs. 86.5%, P=0.39) and assignment to the nondopamine group (89.7% vs. 84.8%, P=0.37) abrogated the survival advantage. Donor DDAVP seems to improve renal allograft survival. Combined use of donor DDAVP and low-dose dopamine should receive further evaluation.

Predicting Three-Year Kidney Graft Survival in Recipients with Systemic Lupus Erythematosus

Predicting the outcome of kidney transplantation is important in optimizing transplantation parameters and modifying factors related to the recipient, donor, and transplant procedure. As patients with end-stage renal disease (ESRD) secondary to lupus nephropathy are generally younger than the typical ESRD patients and also seem to have inferior transplant outcome, developing an outcome prediction model in this patient category has high clinical relevance. The goal of this study was to compare methods of building prediction models of kidney transplant outcome that potentially can be useful for clinical decision support. We applied three well-known data mining methods (classification trees, logistic regression, and artificial neural networks) to the data describing recipients with systemic lupus erythematosus (SLE) in the US Renal Data System (USRDS) database. The 95% confidence interval (CI) of the area under the receiver-operator characteristic curves (AUC) was used to measure the discrimination ability of the prediction models. Two groups of predictors were selected to build the prediction models. Using input variables based on Weka (a open source machine learning software) supplemented with additional variables of known clinical relevance (38 total predictors), the logistic regression performed the best overall (AUC: 0.74, 95% CI: 0.72-0.77)-significantly better (p < 0.05) than the classification trees (AUC: 0.70, 95% CI: 0.67-0.72) but not significantly better (p = 0.218) than the artificial neural networks (AUC: 0.71, 95% CI: 0.69-0.73). The performance of the artificial neural networks was not significantly better than that of the classification trees (p = 0.693). Using the more parsimonious subset of variables (six variables), the logistic regression (AUC: 0.73, 95% CI: 0.71-0.75) did not perform significantly better than either the classification tree (AUC: 0.70, 95% CI: 0.68-0.73) or the artificial neural network (AUC: 0.73, 95% CI: 0.70-0.75) models. We generated several models predicting 3-year allograft survival in kidney transplant recipients with SLE that potentially can be used in practice. The performance of logistic regression and classification tree was not inferior to more complex artificial neural network. Prediction models may be used in clinical practice to identify patients at risk.

Factors impacting short and long-term kidney graft survival: Modification by single intra-operative ­high-dose induction with ATG-Fresenius

A majority of recipients benefited from the intra-operative single high-dose induction (HDI) with ATG-Fresenius (ATG-F) still leaving a group of recipients who did not profit from this kind of induction. Therefore the aim of this retrospective analysis was 1st to identify the risk factors impacting short and long-term graft survival, and 2nd to assess the efficacy of this type of induction in kidney graft recipients with or without these risk factors. A total of 606 recipients receiving two different immunosuppressive treatment regimens (1st: Triple drug therapy [TDT, n=196] consisting mainly of steroids, azathioprine and cyclosporine; 2nd: TDT + 9 mg/kg ATG-F intra-operatively [HDI, n=410]) were included in this analysis and grouped according to their kidney graft survival time (short GST: ≤1 yr, n=100 and long GST: >5 yrs, n=506). The main risk factors associated with a shortened graft survival were pre-transplant sensitization, re-transplantation, rejections (in particular vascular or mixed ones) and the necessity of a long-term anti-rejection therapy. Adding ATG-F single high dose induction to TDT was more efficient in prolonging kidney graft survival than TDT alone not only in recipients without any risk factors (p<0.005) but also in recipients with at least one risk factor (p<0.021). Only in 4.6% of recipients having two or more risk factors this effect could not be demonstrated. The intra-operative single high-dose induction with ATG-F significantly improves the kidney graft survival in recipients with or without risk factors and can therefore be recommended.