Retransplant Group Research Articles

First Series of Living Donor Liver Retransplants From India: Challenges and Outcomes

BackgroundThere is paucity of Indian data on long term survival after living donor liver transplant (LDLT) or the need for retransplant. In this article, we report the first series of retransplants from India with focus on indications, technical challenges and results. MethodsRetrospective study on 29 patients undergoing a liver retransplant (re-LT) was analysed with respect to survival outcomes and post operative complications. Patients were divided into early and late retransplant groups based on whether re-LT was performed within or beyond 30 days of primary transplant. ResultsLiver retransplant was performed in 29 (0.81%) patients out of a total of 3563 liver transplants ( 28 living donor and 1 deceased donor liver transplant). The primary transplant was a LDLT in 27 (93%) patients. Retransplant was performed at a median of 26 days after the first transplant. Re-LT was performed early (within 30 days) in 17 (59%) patients and late (beyond 30 days) in 12 (41%). Hepatic artery thrombosis (53%) and early graft dysfunction (47%) were the indications for early retransplant while biliary complications (50%) and chronic rejection (33%) were primary indications for late retransplant. Post retransplant complications occurred in 22 (75%) patients, the commonest being gram negative bacterial sepsis.The 30-day mortality following retransplant was 27% (8 of 29). The primary cause of mortality was gram negative septicemia. The mortality in the late retransplant group (2, 16.6%) was lower compared to the early retransplant group (6,35%). ConclusionRe-transplant using living donors is a viable option in properly selected patients with prior LDLT.

Kidney re-transplantation in the ipsilateral iliac fossa: a surgeon's perspective on perioperative outcome.

Compared with primary transplantation, ipsilateral renal re-transplantation is associated with an increased risk of surgical complications and inferior graft outcomes. This study investigates whether an ipsilateral re-transplantation approach per se is an independent risk factor for surgical complications and early graft loss. In this retrospective, single-centre analysis, surgical complications and early graft outcomes of ipsilateral kidney re-transplantations from January 2007 to December 2017 were compared with primary transplantations and contralateral re-transplantations. Univariate and multivariate binary logistic regression analyses were performed to identify risk factors for surgical complications requiring surgical revision and graft loss within the first year after transplantation. Of the 1489 kidney transplantations, 51 were ipsilateral, 159 were contralateral re-transplantations and 1279 were primary transplantations. Baseline characteristics did not differ between the ipsilateral and contralateral re-transplant recipients except for current and highest panel reactive antibody levels. Major complications requiring surgical revision were significantly more frequent in ipsilateral re-transplantations (P=.010) than in primary transplantations but did not differ between ipsilateral and contralateral re-transplantations (P=.217). Graft loss within the first year after transplant was 15.7% in the ipsilateral versus 8.8% in the contralateral re-transplant group (P=.163) versus 6.4% in the primary transplantation group (P=.009). In a multivariate regression model, ipsilateral re-transplantation was not identified as an independent risk factor for complications requiring surgical revision or first-year graft loss. Ipsilateral renal re-transplantation is not a risk factor for inferior outcomes. Graft implantation into a pre-transplanted iliac fossa is a feasible and valid therapeutic option.

Kidney retransplantation outcomes in adults aged 70 and older: Analysis of risk factors and survival.

An increasing number of older patients are undergoing kidney transplant. Because of a finite longevity, more patients will be faced with failing allografts. At present there is a limited understanding of the benefits and risks associated with kidney retransplantation in this challenging population. We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of all adults ≥70 undergoing kidney retransplant from January 1, 2014 to December 31, 2022. We examined patient and graft survival of retransplanted patients compared to first time transplants. We also analyzed the risk factors that impacted the survival. During the study period there has been a significant rise in the number of retransplants performed, with 631 patients undergoing the procedure. Although clinically insignificant, overall graft, and patient survival rates were slightly lower in the retransplant group compared to the primary transplant group. With retransplant, patient survival was 91.3%, 75.6%, and 56.9% compared to 93.4%, 81.4%, and 64.4% with primary transplant at 1, 3, and 5 years, respectively. With retransplant, graft survival was 89.5%, 73.5%, 57.4% compared to 91.5%, 79.0%, and 63.6% in a primary transplant group at 1, 3, and 5 years, respectively. Multivariable analysis showed that factors predicting poor survival included longer time on dialysis before retransplantation and decreased functional capacity. No survival difference was noted between recipients of deceased versus living donor kidneys. Patients who underwent retransplantation before initiating dialysis had better patient and graft survival. Patients aged ≥70 achieve satisfactory outcomes following kidney retransplantation, highlighting that chronologic age should not preclude this medically complex population from this life-saving procedure. Improvement in functional status and timely retransplantation are the key factors to successful outcome.

Kidney Retransplant: Not Too Old for a Second Chance

Kidney retransplant outcomes in the elderly are not well established. Our aim was to compare major clinical outcomes between patients older and younger than 60 years old at retransplant and between first and second kidney transplant (KT) for recipients older than 60 years old. We performed a retrospective, longitudinal study that included all patients who underwent KT between January 2008 and December 2019. We defined 3 groups according to recipient age and retransplant status: group 1, patients ≥60 years old and retransplant; group 2, patients <60 years old and retransplant; group 3, patients ≥60 years old and first kidney transplant. We compared clinical outcomes such as acute rejection, death-censored graft survival, and patient survival between groups. We included 109 patients with a second KT, including 13 older than 60 years old (group 1) and 96 younger than 60 years old (group 2). There were no differences in death-censored graft survival or patient survival. There were no biopsy-proven acute rejections for older patients compared with 21 events in the younger group. Regarding differences between retransplant (group 1, n=13) and first kidney transplant (group 3, n=390) in patients older than 60 years old, there were no differences in death-censored graft survival at 1 and 5 years or in patient survival. In our study, major clinical outcomes of retransplant in the elderly were similar to those of their younger counterparts with a second graft and with those of older patients with a first graft.

Azacitidine for the treatment of patients with relapsed acute myeloid leukemia after allogeneic stem cell transplantation

We retrospectively analyzed 38 patients with AML who received azacitidine (AZA) to treat disease relapse after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Patients with objective response (OR) (n = 20) after AZA had significantly higher 2-year overall survival (OS) (45.0% vs 5.6%; p = 0.004) than progressive disease. The 2-year OS was significantly higher in the retransplant group (n = 23) than in the nonretransplant group (n = 15) (34.8% vs 13.3%; p = 0.034). We analyzed 167 patients who underwent the second allo-HSCT to clarify the impact of pretransplant AZA after the second allo-HSCT. Patients in the AZA group (n = 21) had significantly higher 2-year disease-free survival (DFS) (32.7% vs 14.5%; p = 0.012) and OS (38.1% vs 17.5%; p = 0.044) than those in the SOC group (n = 146). Our data demonstrate that AZA is an effective and well-tolerated bridging therapy to the second allo-HSCT.

Liver retransplantation in adult recipients: analysis of a 38-year experience in the Netherlands.

Liver retransplantation (re-LT) accounts for up to 22% after primary liver transplantation (LT), and using donor livers for retransplantation can only be justified by successful outcomes. A total of 2,387 adult recipients with 2,778 LT, between 1979 and 2017, were analyzed to determine risk factors and outcome of re-LT in the Netherlands. Of 2,778 LT, 336 (12.1%) were first, 43 (1.5%) were second, and 12 (0.5%) were third or fourth re-LT. The 5-year patient survival for primary LT, and first, second, and third or fourth re-LT were 74.0%, 70.8%, 63.3%, and 57.1%, respectively (P=0.10). Recipient age (≤60years) (OR 1.96, P<0.001), era (1979-2006) (OR 1.56, P=0.003), donor after circulatory death (DCD) (OR 1.96, P<0.001), and cold ischemia time (CIT) (>9h) (OR 1.42, P=0.007) were significant risk factors for retransplantation after primary LT. Recipient age, era, DCD, and prolonged CIT were identified as parameters for retransplantation. The outcome after the first re-LT was good, and comparable to those of primary transplants. Survival after multiple re-LT was not significantly different from the first retransplant group, legitimizing third and fourth re-LT to well-selected patients.

Reoperative sternotomy is associated with increased early mortality after cardiac transplantation.

Outcomes of cardiac transplantation in patients undergoing reoperative sternotomy are often worse than primary transplants. However, the risks imposed by a prior sternotomy, left ventricular assist device (LVAD) or retransplantation have not been independently analysed. Using the United Network for Organ Sharing (UNOS) database, a retrospective propensity-matched cohort analysis was performed on 14 730 patients who received a heart transplant between 2005 and 2017. Of 7365 patients who underwent a reoperative sternotomy, 4526 (61%) patients had previous cardiac surgery, 2364 (32%) patients had an LVAD and 475 (6%) patients had a previous transplant. Baseline characteristics were compared, and survival was analysed using a Cox model. Compared to patients who underwent a primary transplant, patients with a prior sternotomy had a worse long-term survival (P < 0.001). There was no significant difference in survival between patients who had an LVAD and those who had a previous cardiac operation. However, all subgroups had better survival compared to patients who underwent a retransplant (P < 0.05). On the multivariable analysis, prior sternotomy and radiation demonstrated an increased risk of death compared to primary transplants [prior cardiac surgery: hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.05-1.22; P = 0.001; LVAD: HR 1.19, 95% CI 1.08-1.32; P = 0.001; retransplant: HR 1.68, 95% CI 1.42-1.99; P < 0.001; radiation: HR 1.82, 95% CI 1.00-3.30; P = 0.04]. When excluding patients who died in the first year, there were no significant differences in survival between the primary transplant, prior cardiac surgery, LVAD and retransplant groups. Prior sternotomy is a risk factor for worse survival after cardiac transplantation, mainly due to increased early postoperative mortality. A history of prior transplant confers the greatest risk compared to those who received an LVAD or had prior cardiac surgery.

Factors Associated With Waiting Time to Deceased Donor Kidney Transplantation in Transplant Candidates

Although a nationwide activation system has been developed to increase deceased donor kidney transplantation (DDKT), there is still enormous discrepancy between transplant need and deceased donor supply in Korea, and therefore waiting time to DDKT is still long. We need to determine the current status of waiting time and the risk factors for long waiting time. We retrospectively analyzed the medical records of the patients on the wait list for DDKT at the Seoul National University Hospital from 2000 to 2017. Among 2,211 wait-listed patients, 606 (27.5%) received DDKT and mean waiting time to DDKT was 45 months. Among them, blood type A was most prevalent (35.6%) and type AB was the least (14.0%). Panel-reactive assay (PRA) was positive in 59 (11.0%) in the first transplant group and 25 (35.0%) in retransplant group. Waiting time in PRA-positive recipients was 63 and 66 months in the first transplant group and retransplant group, respectively. However, waiting time for patients with negative PRA was 42.8 months. Waiting time was shorter in blood type AB (39 months) than other types (46 months). Waiting time was the shortest in children and adolescents. Among patients who were still on the wait list, retransplantation candidates, especially with PRA higher than 50%, had longer waiting time than first transplant candidates. In conclusion, non-AB blood type, positive PRA, and adult age were significantly associated with long waiting time. Therefore, it is necessary to establish a management strategy such as tailored desensitization for highly sensitized patients on the wait list to reduce their waiting time.

Hepatic Transplants in Espirito Santo State, Brazil

BackgroundThe Meridional Hospital Liver transplant unit is the only one active in all Espírito Santo State, Brazil, since 2004. ObjectiveThe aim is to analyze data of the first 250 transplants performed by the team. MethodsThis retrospective study reviewed files from patients transplanted in the Meridional Hospital from January 2005 to December 2015. ResultsThere were 250 liver transplants in 236 patients and 14 retransplants. 72.4% were male recipients, with average age of 51.1 years (1–70 years), and the main etiology was alcoholic cirrhosis (33.6% of the cases). Surgical reintervention occurred in 58 patients (include retransplantations) during the same hospitalization, with revision of homeostasis and retransplant as main indications. In the retransplant group, 73.3% of patients died within 2 months. Thrombosis of the hepatic artery was responsible for 40% of the indications for retransplant. The average time between first and second transplant was 223 days (median 14 days). Currently 152 of 236 patients are living, with 1-year life expectancy of approximately 71%. The mortality peak occurred from the immediate postoperative period to 2 months post-transplant (63.8% of the deaths). 32% of subjects did not need intraoperative blood transfusion. The average time of intensive care unit stay was of 8.52 days, and overall hospital stay was 21.7 (median 15 days). ConclusionDespite the logistic difficulties and lack of donors our unit, keep in advance with survival comparable to other national centers (68% to 74% in 1-year).

The Optimal Procedure for Retransplantation After Single Lung Transplantation

Retransplantation has emerged as a therapeutic option for patients experiencing respiratory failure after single lung transplantation. However, outcomes associated with the surgical option (ipsilateral, contralateral, or bilateral lung retransplantation) has not been well evaluated. The Organ Procurement and Transplantation Network database (1994 to 2012) was queried for all lung transplant procedures performed after an initial single lung transplantation. Donor and recipient demographics, before and after transplant characteristics, and outcomes were stratified by retransplant procedural choice and by interval between transplants. Risk factors for mortality were evaluated by Cox proportional hazards regression analysis. Of 325 prior single lung transplant recipients, 50 underwent ipsilateral, 175 contralateral, and 100 bilateral lung retransplantation. The number of retransplant procedures performed per year increased from 3 in 1994 to 31 in 2012, with an increasing proportion of contralateral retransplantation and declining proportions of ipsilateral and bilateral retransplantation. Survival was significantly better in the contralateral and bilateral retransplant groups than in the ipsilateral retransplant group at 30 days (94% and 89% versus 80%), 1 year (72% and 67% versus 50%), and 5 years (41% and 42% versus 20%). Ipsilateral retransplantation (hazard ratio 1.48; p=0.042), mechanical ventilation before retransplant (hazard ratio 2.39; p < 0.001), and retransplantation performed in the first half of the study period (hazard ratio 1.45; p= 0.027) were associated with increased mortality. After an initial single lung transplant, both the incidence of retransplantation and postoperative survival have increased with time. Although ipsilateral lung retransplantation may be the best available alternative in particular circumstances, this analysis suggests that contralateral or bilateral lung retransplantation may be preferable in patients for whom those options are medically sensible.

Era effect on survival following paediatric heart transplantation.

Paediatric heart transplantation is performed to salvage children with end-stage heart failure from various underlying pathologies. Despite several developments in all management aspects of transplantation candidates, the effect of those advances on outcomes has not been consistent. We report our institutional experience with focus on examining era effect on early and late survival. Between 1988 and 2015, 320 children underwent heart transplantation. Competing risk analysis modelled events after transplantation (retransplantation, death without retransplantation). Multivariable parametric risk hazard analysis examined the risk factors affecting survival. Patients were divided to three groups based on underlying pathology: congenital group (n = 132, 41%), acquired group (n = 153, 48%) and retransplant group (n = 35, 11%). Competing risk analysis showed that at 10 years following transplantation, 11% of patients had undergone retransplantation, 39% had died without retransplantation and 44% were alive without retransplantation. Ten-year survival was 61, 51 and 45% for acquired, congenital and retransplant groups, respectively. Overall, survival following heart transplantation for the late era (2005-15) was 63% compared with 49% for the early era (1988-2004) at 10 years (P = 0.022). Compared with early era, 1-year survival in the late era was 84 vs 79% {odds ratio (OR): 0.72 [95% confidence interval (CI) 0.3-1.8], P = 0.470} for congenital, 98 vs 86% [OR: 0.14 (95% CI 0.03-0.68), P = 0.006] for acquired and 73 vs 88% [OR: 2.6 (95% CI 0.4-1.9), P = 0.282] for retransplant. The effect of late era on survival was not significant for congenital [hazard ratio (HR) 0.6 (95% CI 0.2-1.4), P = 0.206] or retransplant patients [HR: 1.7 (95% CI 0.5-5.5), P = 0.400], but showed improvement trend for acquired patients [HR: 0.53 (95% CI 0.3-1.0), P = 0.052]. The era effect on early survival following heart transplantation is related to underlying pathology; there is a significant improvement in early survival in children with acquired pathology, whereas there is no significant change in early survival in children with congenital pathology or failed prior transplantation. This suggests a potential area for improvement that might include pretransplant stabilization and management of immunosuppression. On the other hand, era effect on late survival is not significant. This demonstrates that advances in the care of paediatric heart transplantation patients have not affected ongoing problems that diminish late survival.

Patterns of Early Rejection in Renal Retransplantation: A Single-Center Experience.

It has been reported that kidney retransplant patients had high rates of early acute rejection due to previous sensitization. In addition to the acute antibody-mediated rejection (ABMR) that has received widespread attention, the early acute T-cell-mediated rejection (TCMR) may be another important issue in renal retransplantation. In the current single-center retrospective study, we included 33 retransplant patients and 90 first transplant patients with similar protocols of induction and maintenance therapy. Analysis focused particularly on the incidence and patterns of early acute rejection episodes, as well as one-year graft and patient survival. Excellent short-term clinical outcomes were obtained in both groups, with one-year graft and patient survival rates of 93.9%/100% in the retransplant group and 92.2%/95.6% in the first transplant group. Impressively, with our strict immunological selection and desensitization criteria, the retransplant patients had a very low incidence of early acute ABMR (6.1%), which was similar to that in the first transplant patients (4.4%). However, a much higher rate of early acute TCMR was observed in the retransplant group than in the first transplant group (30.3% versus 5.6%, P < 0.001). Acute TCMR that develops early after retransplantation should be monitored in order to obtain better transplant outcomes.

Highly Sensitized Patients: Targeting Alloreactive T-Cells in Renal Re-Transplantation.

Kidney transplant recipients (KTRs) undergoing re-transplantation are at increased risk of poorer graft outcome. Despite undetectable donor-specific antibodies, many KTRs express high frequencies of donor-reactive T-cells pre-transplantation. Current induction strategies, however, fail to target these cells. Here, we studied 40 KTRs with detectable donor-reactive T-cells undergoing re-transplantation. Our immunosuppressive strategy included lymphocyte depletion induction, anti-TNF treatment, IVIG, and a tacrolimus-based triple-drug maintenance immunosuppression. An age, gender, and maintenance immunosuppression matched control group of 40 KTRs undergoing re-transplantation and 120 KTRs undergoing first transplantation receiving standard immunosuppression were used for comparison. Samples were collected before transplantation, at +1, +2, +3 months posttransplantation. CMV-specific and alloreactive T-cells were measured using an IFNg Elispot assay. The extent of immunosuppression was quantified by lymphocyte subpopulations. No differences were observed for 5-year graft survival and eGFR between highly sensitized KTRs and the first transplant control group (p>0.05). However, 5-year graft survival in the highly-sensitized group was significantly better compared to the re-transplant control group (p=0.02). No differences were observed concerning the incidence of acute rejection, septic complications, CMV, BKV, or EBV viremia (p>0.05). Donor-reactive T-cells in highly sensitized KTRs decreased significantly after transplantation (p=0.001). Highly sensitized KTRs show an absolute lymphopenia with significantly decreased CD4+ T-cells posttransplantation with a long-lasting down-regulation of IFNg and TNFa levels (p<0.05). No differences were observed for CMV-specific immune responses (p>0.05). Our data suggest that a combination of lymphocyte depletion and anti-TNF treatment effectively depletes donor-reactive T-cells. Targeting donor-reactive T-cells in highly sensitized KTRs results in graft function, graft survival, and incidence of acute rejection episodes comparable to first transplant KTRs receiving standard immunosuppression.This approach is safe regarding pathogen control, and could improve allograft outcome in re-transplantation.

Efficacy of extracorporeal membrane oxygenation as a bridge to lung transplantation

Preoperative extracorporeal membrane oxygenation (ECMO) is a risk factor for poor outcome and currently considered a contraindication to lung transplantation. The lung allocation score system was introduced in May 2005 and prioritizes lung allocation to those with the greatest respiratory impairment. The purpose of this study is to determine whether ECMO as a bridge to lung transplantation is an acceptable option to support those in respiratory failure until donor lungs become available in the lung allocation score era. A retrospective review of 715 consecutive lung transplants performed between May 2005 and September 2011 was conducted using a prospectively collected institutional registry database. Twenty-four lung transplants (3.4%) were performed in the 31 patients with attempted pretransplant ECMO; 7 patients who received ECMO patients did not survive or were deemed unfit for transplantation. These patients were compared with a control group of 691 patients who did not receive pretransplant ECMO. The duration of pretransplant ECMO was 171 ± 242 hours (median, 91 hours). Venovenous ECMO was used for respiratory failure in 15 patients, whereas venoarterial ECMO was used for circulatory collapse due to pulmonary hypertension in 9 patients. Patients in the retransplant ECMO group were younger (46 ± 15 years vs 57 ± 14 years, P < .01) compared with the control group, with no difference in recipient gender (male/female: 10/14 vs 380/311), donor age (33 ± 14 years vs 36 ± 15 years), or donor gender (male/female: 10/14 vs 352/339). Emphysema was less common (1, 4% vs 260, 38%, P < .01), and cystic fibrosis (5, 21% vs 72, 10%, P = .09), redo lung transplant (3, 13% vs 28, 4%, P = .08), and bronchiectasis (2, 8% vs 6, 1%, P = .03) were more common in the pretransplant ECMO group. Patients in the pretransplant ECMO group had a significantly higher lung allocation score (87 ± 9 vs 44 ± 15, P < .01). All patients in the pretransplant ECMO group underwent double lung transplants on pump (cardiopulmonary bypass/ECMO), and single lung transplants were performed in 171 patients (25%) and pump was used in 243 patients (35%) in the control group. The cardiopulmonary bypass time was longer in the pretransplant ECMO group (277 ± 69 minutes vs 225 ± 89 minutes, P = .02), with no difference in ischemic time (343 ± 93 minutes vs 330 ± 98 minutes, P = .54). Cadaveric lobar lung transplants were performed because of the urgency to overcome size mismatch with an oversized donor more frequently in 25% (n = 6, no mortality with the longest follow-up at 6 years) of patients in the pretransplant ECMO group versus 0.3% (n = 2) of patients in the control group (P < .01). Post-transplant ECMO was used for primary graft dysfunction in 13 patients (54%) in the pretransplant ECMO group and 41 patients (6%) in the control group (P < .01). The median hospital stay was 46 days in the pretransplant ECMO group versus 27 days in the control group (P = .16). The actuarial survivals after lung transplants at 1, 3, 6, 12, and 24 months were 96%, 88%, 83%, 74%, and 74%, respectively, in the pretransplant ECMO group, and 97%, 94%, 90%, 83%, and 74%, respectively, in the control group (P = .787). Although the incidence of primary graft dysfunction requiring post-transplant ECMO is higher and the hospital stay is longer in patients receiving pretransplant ECMO, the graft survival is good (2-year survival, 74%). ECMO is efficacious as a bridge to lung transplantation with good post-lung transplant outcomes.

Satisfactory outcomes with usage of extended criteria donor (ECD) kidneys in re-transplant recipients

The use of extended criteria donor (ECD) kidneys have increased substantially and the benefit recognized in certain populations. Our institution has maintained a policy of aggressively utilizing ECD kidneys, even among those who have failed a previous transplant. Previous reports on the benefit of ECD in re-transplants have shown equivocal outcomes. We sought to determine if our experience would support or refute this finding. This is a retrospective study of 19 ECD re-transplants between 2002 and 2010. We compared 1 and 3 year outcomes with 95 patients with standard criteria donor (SCD) re-transplant and 169 patients with first time transplant using ECD kidneys. Outcomes and demographics were evaluated including delayed graft function (DGF), HTN, DM, cold ischemia time (CIT), BMI, donor age and prior allograft nephrectomies using a Cox Proportional Hazard model. We compared patient and graft survival using the log rank test. Patient survival were similar among the first time ECD and ECD re-transplant groups at 1 year (p=0.9547) and at 3 years (p=0.8287). Graft survival was also similar between first time ECD and ECD re-transplant groups at 1 year (p=0.4781) and at 3 years (p=0.8519). As expected, SCD re-transplant had better outcomes than the other groups. 1 and 3 years graft and patient survival among first time ECD transplants and ECD re-transplants are similar. As the list of patients on dialysis is ever growing, it may be prudent to aggressively explore the utility of using ECD kidneys in re-transplant patients.

Long-Term Outcome of Kidney Re-Transplantation in Comparison with First Kidney Transplantation: a Report from Thai Transplant Registry

Introduction: Kidney re-transplantation is a high-risk procedure which is increasingly performed because of previous graft failure. The aim of this study was to determine the long term outcomes of kidney retransplantation compared with the first kidney transplantation under the current era of new immunosuppressions. Methods: Since the first re-transplantation in Thailand was performed in 1993, this study included all consecutive cases registered in the Thai Transplant Registry database from January 1993 to December 2011. A total of 3,337 kidney transplants were available for the analysis. Graft loss was defined as return to dialysis or graft removal. Death with functioning graft was considered as censored. Results: Of 3,337 kidney transplantations between study periods, 113 were second and 3 were third transplantation. Among these 116 re-transplantation recipients, the most common identified causes of the end-stage renal disease included chronic glomerulonephritis (38.8%), followed by hypertensive nephropathy (13.0%), diabetic nephropathy (6.0%) and lupus nephritis (1.7%). The re-transplanted recipients were older (mean age 46.2 + 12.8 years) than first transplant group (mean age 42.2 + 12.8 years). The proportion of living-related kidney transplant and male gender were similar between first kidney transplant recipients and retransplanted recipients. Fourteen percent of re-transplant recipients showed high immunologic risk as defined by current panel reactive antibodies (PRA) > 30% compared with 3% of those in first transplant group (P< 0.001). The percentages of induction therapy with antithymocyte globulin and anti-interleukin 2 antibody in re-transplant group and first transplant group were 18.3% vs. 4.3% and 60.0% vs. 32.6%, respectively. In addition, retransplant group had higher proportion of induction therapy with antithymocyte globulin (18.3%) and anti-interleukin 2 antibody (60.0%) when compared with those in first transplant group(. The graft survival rates (95%CI) at 1, 5 and 10 years were 88.6% (80.7-93.3), 87.3% (79.1-92.5) and 74.4%(53.7-86.9) among re-transplants, versus 95.0% (94.1-95.7), 87.0% (85.5-88.5) and 70.7%(67.4-73.8) in first transplant group, respectively (P=0.63). Patient survival rates were 95.1%(88.6-97.9), 95.1%(88.6-97.9) and 90.9%(76.6-96.7) in re-transplant group, versus 96.1%(95.4-96.8), 90.9%(89.6-92.1) and 83.7%(81.2-86.0) in first transplant group at 1, 5 and 10years respectively(P=0.42). The leading cause of graft loss among re-transplant group was chronic allograft nephropathy (21%) whereas infection (14%) was the major cause of death among this group. Conclusion: The 10 year patient and graft survival of kidney retransplantation is good. Combination of induction therapy, CNI and MMF/MPA based regimens can lead the outcomes comparable with the nonsensitized first kidney transplantation in our cohort of 3337 patients.

32-P

Aim 16% of adult kidney alone registrations in the US are broadly sensitized (80%+ CPRA). But some programs have a much lower percentage of such registrations. The aim of this study was to compare positive crossmatch rates and allocation in programs grouped according to their percentage of broadly sensitized patients. Methods Data for adult kidney alone registrations were compared for three groups of large transplant programs (100+ candidates). Group 1 included programs with Results On 12/31/11, groups 1 and 2 had similar percentages of retransplant and female registrations (12% vs. 12%, 35% vs. 37%) and group 3 had higher percentages (15% for retransplant and 41% for females). In 2011, transplant rates were not significantly different between three groups. Group 1 had a significantly higher percentage of offers refused due to a positive crossmatch compared to groups 2 and 3 (1.5% vs. 0.3% and 0.4% for all offers, and 21% vs. 5% and 8% for offers to 80%+ CPRA patients). Group 1 also had a significantly higher percentage of offers accepted for transplant but kidneys not transplanted into the intended recipient (43% of all accepted offers vs. 21% and 5% for all offers, and 81% vs. 31% and 9% for offers accepted for 80%+ CPRA patients). In 2011, group 1 refused 191 offers due to a positive crossmatch and in 137 cases, an offer was accepted but the kidney was not ultimately transplanted into the intended recipient. Conclusions The data seem to suggest that centers with a very low percentage of broadly sensitized candidates (group 1) may not be listing a realistic number of unacceptable antigens for their patients. High rates of refusals due to a positive crossmatch and offers accepted but kidneys not transplanted into the intended recipient can have a negative impact on the efficiency of kidney allocation.

Cadaver Donor Kidney Retransplantation in the Pediatric Patient: Complications and Long-Term Outcome

We compared the outcome of second and third kidney allografts with that of the first kidney allograft in pediatric recipients. We classified 173 cadaveric kidney recipients into 2 groups. Group 1 comprised 120 first transplants and group 2 comprised 53 retransplants, including 43 second and 10 third transplants. We compared demographic characteristics and survival in groups 1 and 2. Group 1 consisted of 78 boys and 42 girls with a mean ± SD age of 11.5 ± 4.2 years. Group 2 consisted of 37 boys and 16 girls with a mean age of 10.4 ± 4.7 years. One, 5, 10 and 15-year graft survival rates were 78.7%, 64.3%, 54.5% and 50.7% for first transplants vs 82.8%, 57.8%, 57.8% and 41.3%, respectively, for retransplants (p = 0.757). Patient survival at 1, 5 and 15-year was 95.8%, 89.6%, 84.9% in the first transplant group vs 93.6%, 93.6% and 93.6%, respectively, in the retransplant group (p = 0.0.63). Graft survival was significantly higher in patients who did vs did not receive calcineurin inhibitors in the 2 groups (p = 0.02). Kidney retransplantation in the pediatric population can yield excellent long-term outcomes, especially in patients treated with calcineurin inhibitors.

Cardiac surgery late after heart transplantation: A safe and effective treatment option

Owing to the improved long-term outcome after cardiac transplantation, cardiac allograft vasculopathy or valvular disease is developing late after heart transplantation in a growing number of patients. In this study, we evaluated our results of nonretransplant cardiac surgery in these patients and compared them with those after retransplantation. Since 1983, a total of 867 heart transplantations have been performed at our institution. Among them, 44 patients underwent nonretransplant cardiac surgery, 4 of them repeatedly. The procedures included 19 coronary artery revascularizations, 20 tricuspid valve procedures, 4 other valvular procedures, 4 aortic operations, and 1 right atrial thrombectomy. Long-term results of these patients were compared with those of 20 patients after late cardiac retransplantation. Indications for nonretransplant surgery included cardiac allograft vasculopathy, tricuspid regurgitation, aortic and mitral valve insufficiency, as well as acute aortic dissection type A. Mean interval between heart transplantation and reoperation was 8.4 years. Mean follow-up was 5.8 years. Early mortality was 4.5% (2/44). The early deaths were caused by intracerebral bleeding and acute rejection. Actuarial survivals at 1, 5, and 7 years were 84%, 64%, and 58%, respectively. In comparison, early mortality in the retransplant group was 20% (4/20) and survivals at the same time points were 70%, 70%, and 47%, respectively. According to these results, we consider nonretransplant surgical options for cardiac allograft vasculopathy and valvular disease a safe and effective therapeutic approach with low early mortality and acceptable long-term results.

The Recall Alloresponse Following Retransplantation is More Intense Compared with the T cell Memory-Transfer Model

The presence of alloreactive memory T cells in recipient is a critical handicap to achieving transplantation tolerance. To make a mouse model that can as closely as possible mimic the presensitized transplant patient is important for research on this subject. Thus, we developed a novel retransplant model and compared the alloresponse in this model with that in the memory T cells-transfer model (transfer control). Mean survival time of allograft was compared between 3 groups, including blank transplant control, memory transfer control and retransplant groups. Cellular rejection activity in allografts was evaluated via HE staining of cardiac graft section. Proliferation and differentiation of the alloreactive effector T cells were assayed by in vitro mixed lymphocyte reaction and flow cytometry, respectively. Real-time quantitive RT-PCR was used to assess gene expression of cytokines and surum IFN-γ was measured via ELISA. It showed that the median survival time of allograft in retransplant recipients was significantly shortened compared to that of transfer control, and it was the same in rejection score of graft. Moreover, proliferation and differentiation of the alloreactive effector T cells were more intensive in retransplant recipients than that in transfer control, which was confirmed by in vitro mixed lymphocyte reaction and by flow cytometry of the splenocytes for detecting CD44highCD62L- memory/effector phenotype cells. Furthermore, activation of CD4+ memory T cells is reflected by high level of surum IFN-γ and the intensive gene expression of IFN-γ and IL-2 at cardiac allograft in retransplant recipients. Collectively, the recall alloresponse in retransplantation is more intensive than that in a memory-transfer setting, and this retransplant model is closer to the clinic situation than the memory-transfer model in rodents.