Long-term Outcome Of Kidney Transplantation Research Articles

Uncontrolled donation after circulatory death: A cohort study of data from a long-standing deceased-donor kidney transplantation program.

Despite good long-term outcomes of kidney transplants from controlled donation after circulatory death (DCD) donors, there are few uncontrolled DCD (uDCD) programs. This longitudinal study compares outcomes for all uDCD (N=774) and all donation after brain death (DBD) (N=613) kidney transplants performed from 1996 to 2015 at our center. DBD transplants were divided into those from standard-criteria (SCD) (N=366) and expanded-criteria (N=247) brain-dead donors (ECD). One-, 5-, and 10-year graft survival rates were 91.7%, 85.7%, and 80.6% for SCD; 86.0%, 75.8%, and 61.4% for ECD; and 85.1%, 78.1%, and 72.2% for uDCD, respectively. Graft survival was worse in recipients of uDCD kidneys than of SCD (P=.004) but better than in transplants from ECD (P=.021). The main cause of graft loss in the uDCD transplants was primary nonfunction. Through logistic regression, donor death due to pulmonary embolism (OR 4.31, 95% CI 1.65-11.23), extrahospital CPR time ≥75minutes (OR1.94, 95%CI 1.18-3.22), and in-hospital CPR time ≥50minutes (OR 1.79, 95% CI 1.09-2.93) emerged as predictive factors of primary nonunction. According to the outcomes of our long-standing kidney transplantation program, uDCD could help expand the kidney donor pool.

Furosemide Stress Test as a Predicting Biomarker for Delayed Graft Function in Kidney Transplantation

Background: Delayed graft function (DGF) could worsen early and long-term outcomes of kidney transplantation (KT). DGF is caused by several pre-transplantation and perioperative factors in both donors and recipients. At present, there are no biomarkers or tests during the immediate post-KT period that can accurately predict the development of DGF. Materials and methods: This prospective study was conducted in deceased donor KT (DDKT) at King Chulalongkorn Memorial Hospital, Thailand. All recipients underwent furosemide stress test (FST) by receiving a single dose of intravenous furosemide, 1.5 mg/kg at 3 h after allograft reperfusion. We determined the correlations between DGF (requiring dialysis within the first week after transplantation) and the values of urine volume recorded hourly after FST until 6 h, the parameters of postoperative dynamic tests, including resistive index (RI) of renal arteries and effective renal plasma flow (ERPF), and urine neutrophil gelatinase-associated lipocalin (NGAL). Results: Of the 59 total DDKT recipients enrolled, 24 developed DGF. The FST is a more accurate biomarker than urine NGAL, RI of renal arteries, and ERPF in the prediction of DGF. The 4-h urine volume less than 350 mL (FST non-responsive) was the best cut-off value in predicting DGF with 87.5% sensitivity, 82.9% specificity, and 82.5% accuracy. Multiple logistic regression analyses showed an odds ratio of 0.993 (0.986–0.999, p = 0.035) for the 4-h urine volume to predict DGF. Conclusions: The FST is a simple and accurate biomarker for predicting DGF in early post-KT period. Close monitoring and well prepared dialysis are suggested in patients with urine volume < 350 mL after 4 h of FST. The FST non-responsive patients could be the target for further DGF preventive intervention. ClinicalTrials.gov identifier: NCT03071536.

Is preimplantation renal biopsy essential prior to deceased donor renal transplant?

The striking discrepancy in the number of end-stage renal disease patients added to the transplant wait list and the shortage of standard criteria donors has stimulated the development of strategies aimed to expand acceptance criteria from marginal deceased donors. Renal biopsy done before transplant will be useful to predict short- and long-term outcomes of kidney transplantation. It also serves as a reference in interpretation of subsequent biopsies. It also helps in deciding whether it should be discarded. However, systemic reviews concluded that there was no consistent association between donor biopsy findings and posttransplant outcomes. A well-designed randomized control trial could ascertain the extent of procurement biopsy leading to discards, whether outcomes are indeed better when preimplantation biopsies are used to justify declining kidneys for transplantation.

Pediatric kidney transplantation: early and long-term outcomes following 1187 procedures

To estimate short- and long-term outcomes of pediatric kidney transplants in Russia considering the maximum available number of cases. Retrospective, observational, multi-center study included data about 1187 kidney transplantation procedures (866 - deceased donor, 281 - living donor and 40 - AB0-incompatible living donor) performed in 1065 patients (age 0-17 years) since 1990 till 2017. Patient and graft survival, causes of recipient deaths and graft losses, as well as, the influence of donor type, blood group incompatibility and recipient age on outcomes were analyzed. Results of redo transplantations (n=131) were also investigated. Annual, 5- , 10- , and 15-year survival of patient was 94, 86, 79 and 69%, respectively; graft survival - 85, 67, 53 and 33%, respectively. Transplantation from related donors including AB0-incompatible cases was associated with 15-30% increase of graft survival (p<0.0001). Up to 23% of children required redo transplantation within 4-5 years after primary procedure and 2/3 of patients - after 10-15 years. There were no significant differences in outcomes after primary and redo procedures: annual, 5-, 10- and 15-year graft survival was 85, 68, 55, 42 and 85, 62, 45, 19%, respectively (p=0.1164). It is reasonable to consider the outcomes of transplantations as satisfactory in Russia. However, there is a great potential for improvement. The main problems are high incidence of infectious complications followed by fatal outcomes (41% of all fatal outcomes) and loss of allograft due to primary dysfunction and death of recipients with functioning allografts (19 and 23%, respectively). Primary use of living-related donors for pediatric kidney transplantation seems to be the most effective way to improve both short- and long-term outcomes.

Long-term outcome of kidney transplantation in AL amyloidosis

Therapies for AL amyloidosis have dramatically improved, leading to longer patient survival; however, more AL amyloidosis patients are reaching end-stage renal disease (ESRD). There are no clear guidelines regarding eligibility for kidney transplantation in patients with AL amyloidosis, and data on outcomes are limited. We evaluated the clinical and laboratory data of 49 patients who were followed in the Amyloidosis Center at Boston University and underwent kidney transplantation at a center in the United States between 1987-2017. During a median follow-up of 7.2 years (range 0-19), the median patient survival from diagnosis was 15.4 years, and from kidney transplantation was 10.5 years. One, three, and five-year graft survival were 94%, 89%, and 81%, respectively. Patients with hematologic complete response or very good partial response prior to kidney transplantation had significantly better patient survival than patients with partial response or no response, and the median time to graft loss was 10.4 years versus 5.5 years, respectively. This is the largest published series of kidney transplantation in patients with AL amyloidosis, suggesting that kidney transplantation can have a good outcome in carefully selected patients, particularly in those who have achieved a complete response or very good partial response at the time of kidney transplantation.

Long-term Outcomes of Kidney Transplantation in Fabry Disease.

Fabry disease (FD) is a rare X-linked lysosomal storage disorder caused by mutations in the α-galactosidase A gene that obliterate or markedly reduce α-galactosidase A activity. This results in the systemic accumulation of its glycosphingolipid substrates in body fluids and organs, including the kidney. Fabry nephropathy can lead to end-stage renal disease requiring kidney transplantation. Little is known about its long-term outcomes and the overall patient survival after kidney transplantation. Here, we report 17 Fabry patients (15 male and 2 female subjects) who received kidney transplants and their long-term treatment and follow-up at 4 specialized Fabry centers. The posttransplant follow-up ranged to 25 years, with a median of 11.5 (range, 0.8-25.5] years. Graft survival was similar, and death-censored graft survival was superior to matched controls. Fabry patients died with functioning kidneys, mostly from cardiac causes. In 2 male subjects 14 and 23 years posttransplant, the grafts had a few typical FD lamellar inclusions, presumably originating from invading host macrophages and vascular endothelial cells. We conclude that kidney transplantation has an excellent long-term outcome in FD.

The Presence of Urinary Renal Progenitor Cells in Stable Kidney Transplant Recipients Anticipates Allograft Deterioration.

Long-term kidney transplant outcomes have reached mild improvements recently. Parietal epithelial cells (PECs) are progenitor cells located along the Bowman’s capsule that can be isolated in urine, and display the capability to replace podocytes, but in certain situations cause glomerulosclerosis. In this study, a cohort of stable kidney transplant recipients with 6 months protocol biopsy was divided in two groups depending on the presence (uPEC+; n = 41) or absence (uPEC-; n = 25) of PECs in urine and followed for 2 years. No differences were found between groups at 6 months after transplantation considering clinical variables, alloimmune response, renal function, albuminuria and graft pathology. However, uPEC+ group showed increased podocyturia and a higher rate of proliferating PECs along the Bowman’s capsule, without concomitant enhancement of the CD44 pro-sclerotic activation marker. Accordingly, 2 years follow up evidenced poorer outcomes in the uPEC+ group with worse renal function, increased albuminuria, wider mesangial expansion and more severe IFTA. In summary, chronic allograft damage can progress in certain stable-supposed grafts by podocyte detachment and reactive PECs proliferation, being the uPEC presence a biomarker of this process. This damage-response regenerative process, if sustained in time, might fail in preserve the allograft function and histology. Our study raises new prospects to overcome current limits on long-term allograft results.

The Effect of Pregnancy on the Long-term Risk of Graft Loss, Cardiovascular Disease, and Death in Kidney Transplanted Women in Norway: A Retrospective Cohort Study.

Kidney transplant recipients have now conceived for almost 50 years. Nevertheless, few studies have evaluated long-term health outcomes for kidney transplanted women after pregnancies. We conducted a retrospective cohort study of all Norwegian women receiving a kidney transplant before the age of 50 years between 1969 and 2013, with graft loss, cardiovascular disease, and death as outcomes. Baseline characteristics for all women were ascertained at first transplantation, with information about exposure, outcomes, and potential confounders collected from medical records. To account for changes in pregnancy status, data were analyzed using proportional hazard Cox regression with pregnancy status as a time-dependent covariate changing at the time of pregnancy. Of 650 women studied, 124 had a pregnancy after kidney transplantation. During the study period, graft loss, cardiovascular disease, and death occurred in 237, 73, and 274 women, respectively. Pregnancy was associated with 54% lower risk of graft loss (95% confidence interval [CI]: 25% to 71%) and 72% lower risk of death (95% CI, 53%-84%). Adjusting for possible confounders had a minimal impact on estimated values. There were considerable uncertainties and no statistically significant results regarding the estimated risk of cardiovascular disease after pregnancy (univariate hazard ratio, 0.91; 95% CI, 0.43-1.92; multivariate hazard ratio, 0.71; 95% CI, 0.32-1.60). Kidney transplanted women with pregnancies have a low risk of subsequent graft loss or death. These results are reassuring for the current clinical practice.

The impact of donor/recipient age difference and HLA mismatch on graft outcome in pediatric kidney transplantation.

Understanding the relationship between the factors that influence long-term kidney transplant survival remains a key priority for pediatric nephrologists. We assessed the relative impact of donor/recipient age difference and HLA matching on long-term graft outcomes. We conducted a retrospective cohort study of pediatric and adolescent recipients who received a primary kidney transplant in Australia and New Zealand between January 1, 1990, and December 31, 2015. The primary outcome was graft survival analyzed by Kaplan-Meier method. During the 26-year period, 1134 primary (395 DD and 739 LD) kidney transplants were performed in recipients less than 20years of age. The median follow-up time was 10.2years. Overall, 405 patients (35.7%) lost their transplant with graft survival 93.8% at 1year, 82.5% at 5years, 65.8% at 10years, and 49.9% at 15years post-transplant. There was consistently higher graft loss of DD kidneys as compared to LD kidneys at each time point. Both increasing donor/recipient age difference (aHR 1.11 per 10years; 95% CI, 1.02-1.20; P=0.009) and increasing HLA mismatch (aHR 1.20 per mismatch; 95% CI, 1.10-1.30; P<0.001) were associated with decreased graft survival. Donor/recipient age difference and HLA matching are important factors influencing long-term graft outcomes in pediatric kidney transplantation. HLA mismatch remains a strong predictor of graft loss. For patients without the option of a LD, we suggest that the degree of HLA mismatch should not be discounted as part of the decision-making process of organ allocation.

Long-Term Outcome of Kidney Transplantation for IgA Nephropathy

Background Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide, with a high recurrence rate after kidney transplantation (KTx). The aim of this study was to assess allograft survival, impact of recurrence on allograft function, and risk factors for post-transplant IgAN recurrence. Methods A total of 443 patients received KTx between March 1998 and August 2017 in Niigata University in Japan. We identified 104 patients with primary IgAN who underwent KTx and diagnosed recurrence of IgAN in 26 patients by graft biopsies. Graft biopsies were performed when urinary tests showed abnormal after KTx. Recurrence rate of IgAN, graft survival, the risk factors of recurrent IgAN and the results of treatment for recurrent IgAN were investigated. Results Median duration of follow-up was 119.5 months (1-259). Graft survival was not significantly different between the patients with primary IgAN compared with those with other primary diseases. IgAN recurrence rate at 1, 5, 10, and 20 years after KTx was 2 %, 16.5 %, 30.2 %, and 42.4 %, respectively. When graft survival was compared between the patients with IgAN recurrence and non-IgAN recurrence in the patients with primary IgAN, they were not significantly different (87.8 % vs 88.4 % at 10 years after KTx, respectively). The older age more than 30 y.o at KTx, the use of mycophenorate mofetil and basiliximab were associated with a lower risk of IgAN recurrence. Twenty patients underwent tonsillectomy and 24 patients received steroid pulse therapy (19 patients received both therapies). One patient didn’t receive any treatment for IgAN recurrence. Median follow-up period was 51 months (2-175) after treatment for IgAN recurrence. The improvement of mesangial IgA deposition showed in 6 out of 15 patients who underwent graft biopsy after treatment. Five patients (19.2 % in recurrent IgAN patients) lost their graft function due to IgAN recurrence during follow-up periods. Conclusions Recurrent IgAN remains a significant cause of graft loss in transplant recipients. Recipients with recurrent IgAN after KTx, especially younger patients, need to be followed up carefully.

Kidney Transplantation from Uncontrolled Donors after Circulatory Death

Kidney transplantation from controlled donors after circulatory death (DCD) has substantially increased in Europe and the USA in the last decade, allowing for an increase in the amount of kidney transplants performed, obtaining good long-term results. However, there is scarce information on the long-term results of kidney transplantation from uncontrolled DCD (uDCD) We report the largest single-center series of kidney transplants from uDCD. Aim To analyze the factors that can be predictive of graft loss due to TMA in uDCD. Methods Observational cohort study that included all kidney recipients from uDCD (n=774) and from donors after brain death (DBD) (N=613) performed in our center between 1996 and 2015. Recipients from DBD were divided into two groups: standard criteria brain death donors (SCBD) (n=366), and expanded criteria brain death donors (ECBD) (n=247). Clinical outcomes were compared. Results After the introduction of kidney transplantation from uDCD, the median waiting time on the kidney transplant list for patients in dialysis decreased from 25.1 months (IQR 13.0-54.9) to 12.9 months (IQR 5.6-24.8), and 107 patients were transplanted pre-emptively. One, 5 and 10-year graft survival rates for SCBD were 91.7%, 86.2% and 81.3% respectively versus 86.0%, 75.7% and 61.3% for ECBD and 85.1%, 79.2% and 73.3% for uDCD (p<0.001). Graft survival in transplants from uDCD donors was worse than those from SCBD (p=0.028) but better than in those from ECBD (p=0.028). The main cause of graft loss in uDCD was primary nonfunction, mainly due to thrombotic microangiopathy. Multivariate Cox regression analysis for graft loss (censored for death) showed an association between the presence of delayed graft function (DGF) and donor type. In presence of DGF, kidney transplant recipients from DBD had a higher risk of graft loss, both those from SCBD (HR 1.79 95% CI 1.08-2.99) and ECBD (HR 2.75,95% CI 1.67-4.51). In absence of DGF, recipients from ECBD had a higher risk of graft loss.

Efficacy and Safety of Early Mammalian Target of Rapamycin Inhibitors with Minimization of Calcineurin Inhibitors in Kidney Transplant Recipients

Background To improve the long-term results of kidney transplantation, interstitial fibrosis and renal tubular atrophy should be suppressed. Purpose To investigate the effect of interstitial fibrosis/renal tubular atrophy (IF/TA) in a protocol that involves calcineurin inhibitor (CNI) reduction and everolimus (EVL) addition in kidney transplant patients. Materials and Methods In 96 cases of kidney transplantation performed at the Tokyo Medical University Hachioji Medical Center between November 2012 and December 2016, we examined 78 patients who underwent renal biopsy 3 (pre-transplantation) and 12 months (post-transplantation). The introductory immunosuppressant treatments combined 4 agents (CNI + MPSL + MMF + basiliximab). We performed a protocol-based renal biopsy for the patients 90 days post transplantation. For patients who did not show signs of organ rejection, we reduced the doses of CNI and MMF, and then added EVL to the regimen. We grouped the patients according to the presence/absence of EVL administrations and examined renal function, organ rejection, and IF/TA 3 and 12 months later. Results The mean ages of the patients in the EVL (n=39) and non-EVL groups (n=39) were 48.2 and 48.2 years, respectively. In the EVL group, 16 patients (16/39: 41.0%) received cyclosporine (CyA), whereas 19 patients (19/39: 48.7%) received the same in the non-EVL group. Organ rejection (acute T-cell-mediated rejection, ATMR) prior to the 90-day protocol was observed in 8 patients in the EVL group and in 14 patients in the control group. IF/TA was observed in 2 patients in the EVL group and in 4 patients in the control group. During the 1-year protocol, organ rejection (ATMR) was observed in 4 patients in the EVL group and in 5 patients in the control group. IF/TA occurred in 20 patients in the EVL group and in 20 patients in the control group. The change in IF/TA score in the EVL group was ci;4/2 (mean: 2.0), ct;4/2 (mean: 2.0) after 3 months and ci;15/20 (mean: 0.75), ct;13/20 (mean: 0.65) after 12 months. In the control group, the change in IF/TA score was ci;4/4 (mean: 1.0), ct;4/4 (mean: 1.0) after 3 months and ci;17/20 (mean: 0.85), ct; 20/20 (mean: 1.0) after 12 months. The risk factors of pre-ATMR were CyA (2.6 times) and HLA mismatch (2.4 times). The risk factor of post-ATMR was pre-ATMR. The risk factors of post-IF/TA were donor age (2.3 times) and presence of donor-specific antibody I (DSA-I; 1.6 times). Conclusion CyA and HLA mismatch were found to be risk factors of ATMR during the early phase post transplantation. History of ATMR was a risk factor of post-ATMR. By adding EVL to CyA, the manifestation of ATMR was suppressed. We observed no difference in renal function between the two groups. Post-administration CNI reduction and EVL addition did not contribute to the suppression of IF/TA.

The Impact of Donor/Recipient Age Difference and HLA Matching on Graft Outcome in Pediatric Kidney Transplantation

Introduction Understanding the relationship between the factors that influence long-term kidney transplant survival in order to appropriately select the optimal initial graft remains a key priority for pediatric nephrologists. Materials and Methods Using the ANZDATA database, we conducted a retrospective cohort study of pediatric and adolescent primary kidney transplant recipients to assess the relative impact of donor/recipient age difference and HLA mismatches on long-term graft outcomes. The study population included all kidney transplant recipients less than 20 years of age who received a primary kidney transplant in Australia and New Zealand between January 1, 1990 and December 31, 2015. The primary outcome was graft survival following first kidney transplant analysed according to the Kaplan-Meier method. Secondary outcomes included delayed graft function (requiring dialysis in the first 72 hours post-transplant) and graft function at 12 months, as a surrogate marker of long term graft survival. Results and Discussion During this 26-year period, 1134 primary kidney transplants were performed in recipients less than 20 years of age. The median follow-up time after the first graft transplant was 10.2 years (IQR 4.2-16.3 years), with 30 recipients lost to follow up (2.6%). During the study period, 405 patients (35.7%) lost their graft with graft survival of 93.8% (95% CI, 92.4%-95.2%) at 1 year post-transplant, 82.5% (95%CI 80.6%-84.4) at 5-years, 65.8% (95% CI, 62.5-69.1%) at 10 years and 49.9% (95% CI, 46.9-54.1%) at 15 years. There was consistently higher graft loss of deceased donor kidneys as compared to live donor kidneys at each time point. On Cox proportional hazards regression, both increasing donor/recipient age difference (adjusted hazard ratio [aHR] 1.09 per 10 years; 95%CI, 1.01-1.18; p=0.03) and increasing HLA mismatch (aHR 1.19 per mismatch; 95%CI, 1.10-1.30; p<0.001) were associated with decreased graft survival. In addition, graft failure was associated with the following factors: Indigenous/Pacific Islander race (when compared to Caucasian race, p<0.001), glomerulonephritis as a cause of ESKD (when compared to CAKUT; p=0.01), use of T-cell or other induction agents (when compared to basiliximab; p=0.009) and increasing recipient age at kidney transplant (p<0.001), when adjusted for baseline immunosuppression. Conclusion Both donor/recipient age difference and HLA matching are important factors influencing long-term graft outcomes in pediatric kidney transplantation and HLA mismatch remains a strong predictor of graft loss. For pediatric patients without the option of a live donor, we suggest that along with age of the donor and other markers of kidney quality, the degree of HLA mismatch should not be discounted as part of the decision making process in deceased donor allocation. ANZDATA.

Social Aspects of Long-Term Kidney Transplant Outcomes

Social Aspects of Long-Term Kidney Transplant Outcomes

Long-term Outcome of 1-step Kidney Transplantation and Bladder Augmentation Procedure in Pediatric Patients.

Guidelines for bladder augmentation (BA) in kidney transplantation (KT) recipients are not well-defined. In our center, simultaneous BA with KT (BA-KT) is performed. We assessed transplantation outcomes of this unique extensive procedure. A case-control single center retrospective study. Transplantation outcomes were compared with those of KT recipients who did not need BA. Compared with 22 patients who underwent KT only, for 9 who underwent BA-KT, surgical complications and the need for revision in the early posttransplantation period were similar; early graft function was better: estimated glomerular filtration rate, 96.5 ± 17.1 versus 79.4 ± 16.6 mL/min at 0 to 6 months (P = 0.02); posttransplantation clean intermittent catheterization was more often needed: by 78% (7/9) versus 13% (3/22); and asymptomatic bacteriuria was more common: 100% versus 9% during the first 6 months (P < 0.001), 55% versus 9% (P = 0.02) and 66.6% versus 9% during the first and second years, respectively (P = 0.004). Urinary tract infection (UTI) incidence was also higher: 100% versus 23% during the first 6 months and 44% versus 9% during the second year posttransplantation. Graft function deteriorated significantly in the BA-KT group by the fifth posttransplantation year: estimated glomerular filtration rate was 47.7 ± 39.7 mL/min versus 69 ± 21.3 mL/min, with only 6 (66%) of 9 functioning grafts versus 100% in the KT only group. Causes of graft loss were noncompliance with drug therapy in 2 patients and recurrent UTIs in 2 patients. Excellent short-term outcome for simultaneous BA-KT is threatened by graft loss due to a high prevalence of UTIs and patient noncompliance with the demanding complex posttransplantation therapy.

Renal resistance thresholds during hypothermic machine perfusion and transplantation outcomes - a retrospective cohort study.

Renal resistance (RR), of allografts undergoing hypothermic machine perfusion (HMP), is considered a measure of organ quality. We conducted a retrospective cohort study of adult deceased donor kidney transplant (KT) recipients whose grafts underwent HMP. Our aim was to evaluate whether RR is predictive of death-censored graft failure (DCGF). Of 274 KT eligible for analysis, 59% were from expanded criteria donor. RR was modeled as a categorical variable, using a previously identified terminal threshold of 0.4, and 0.2mmHg/ml/min (median in our cohort). Hazard ratios (HR) of DCGF were 3.23 [95% confidence interval (CI): 1.12-9.34, P=0.03] and 2.67 [95% CI: 1.14-6.31, P=0.02] in univariable models, and 2.67 [95% CI: 0.91-7.86, P=0.07] and 2.42 [95% CI: 1.02-5.72, P=0.04] in multivariable models, when RR threshold was 0.4 and 0.2, respectively. Increasing risk of DCGF was observed when RR over the course of HMP was modeled using mixed linear regression models: HR of 1.31 [95% CI: 1.07-1.59, P<0.01] and 1.25 [95% CI: 1.00-1.55, P=0.05], in univariable and multivariable models, respectively. This suggests that RR during HMP is a predictor of long-term KT outcomes. Prospective studies are needed to assess the survival benefit of patients receiving KT with higher RR in comparison with staying wait-listed.

Kidney Transplantation From Old Deceased Donors: Impact of Uric Acid Level—A Quarter-Century of Experience in One Transplant Center

BackgroundThe long-term burden of higher donor age on graft function and survival after kidney transplantation remains uncertain. Because both recipient and donor characteristics have evolved and the general population age is on the increase, we looked at the causes of kidney graft outcome. AimThe aim of this study was to evaluate the impact of different clinical parameters on long-term outcome of older-donor kidney transplantation. This retrospective study included 345 adult patients (58 patients received kidney from donors at least 55 years old) transplanted between January 1993 and December 2005 and were followed in one center throughout the post-transplant course (median, 9.4 years). Data included recipient and donor age, cold ischemia time, delayed graft function, panel reactive antibodies, HLA mismatch, time on dialysis, graft function at different time points, uric acid level, proteinuria, immunosuppression, and biopsy-proven rejection. ResultsImprovement of estimated glomerular filtration rate at 36 months after transplantation was a good prognostic factor for long-term kidney function. Higher donor age decreased the chance for improvement of kidney function by 2.8% per year of life (P = .0244). Hyperuricemia was found in 46% of the study population; estimated glomerular filtration rate less than 50 mL/min/1.72 m2 was associated with hyperuricaemia. A higher uric acid level was associated with inferior kidney function in recipient of older kidneys. Graft failure occurred late (median, 6.3 years post-transplantation) in 26 (44.8%) of older-donor recipients and in 87 (30.3%) of the remaining patients. ConclusionsOur results suggest an important association between older donor age and decreased allograft function in kidney recipients with elevated uric acid level. Recipients of older kidneys with normal uric acid level presented satisfactory outcomes.

Limitation of Terminal Serum Creatinine as a Kidney Donor Profile Index Variable in Predicting Long-Term Kidney Transplant Outcomes

BackgroundDonor final serum creatinine (SCr) is a dynamic variable and is 1 of 10 factors used in calculating kidney donor profile index (KDPI). We hypothesize that deceased-donor kidneys (DDKs) with higher SCr were likely accepted for transplantation if procurement biopsy findings were favorable and with long-term outcomes no worse than kidneys with lower final SCr within a KDPI group. MethodsUsing the Organ Procurement and Transplant Network/United Network for Organ Sharing database, we identified DDK transplant recipients from 2000 to 2015 who received induction and calcineurin inhibitor/mycophenolate mofetil maintenance. Patients were divided into 4 KDPI groups: 0–20%, 21%–50%, 51%–85%, and >85%. In each KDPI category, long-term outcomes were compared, with the use of Cox models, between patients who received kidneys with final SCr >2 versus ≤2 mg/dL. ResultsA total of 59,644 patients were divided into KDPI groups 0–20% (SCr >2 mg/dL, n = 478; SCr ≤2 mg/dL, n = 14,769), 21%–50% (SCr >2 mg/dL, n = 1,592; SCr ≤2 mg/dL, n = 17,762), 51%-85% (SCr >2 mg/dL; n = 1,388, SCr ≤2 mg/dL, n = 18,024), and >85% (SCr >2 mg/dL, n = 349; SCr ≤2 mg/dL, n = 5,282). Adjusted overall graft failure risks (hazard ratio [HR] 0.88, P = .04; HR, 0.86, P = .007) and patient death risks (HR, 0.86, P = .04; HR, 0.84, P = .01) for final SCr >2 versus ≤2 mg/dL groups were lower in KDPI categories 21%-50% and 51%-85%, respectively, with similar death-censored graft failure risks. DiscussionOutcomes of transplanting DDKs with elevated final SCr are no worse than transplanting kidneys with lower final SCr, highlighting the limitation of the single value of final SCr as a variable for calculating KDPI.

Improved Outcomes of Kidney Transplantation in Infants (Age < 2 years): A Single-Center Experience.

Infants (age, < 2 years) with end-stage renal disease (ESRD) have increased morbidity and mortality. We evaluated our long-term outcomes of kidney transplants (KTx) in infants. Between 1984 and 2014, 136 infants underwent KTx. We examined trends in survival rates and complications by era (1984-1993 [era 1], 1994-2003 [era 2], 2004-2014 [era 3]). Patients were 92.6% white and 70.6% males. Posttransplant (Tx) initial length of hospital stay declined 37% over the 30-year period (P <0.01). Ten-year death-censored graft survival improved from 60% (era 1) to 80% (era 2) (P = 0.04). The incidence of acute rejection, graft thrombosis, cytomegalovirus, and urine leaks did not significantly change across eras. Frequency of Epstein-Barr virus diagnosis (era 2 vs era 3, P < 0.01) increased. Post-Tx lymphoproliferative disorder incidence was increased in era 2 compared with eras 1 and 3 (P = 0.03). Infants deserve earlier consideration for KTx. Length of initial hospital stay and patient and graft survival rates after KTx have improved in infants since 1984.

Long-term outcomes of kidney transplantation in Fabry disease

Long-term outcomes of kidney transplantation in Fabry disease