Retransplant Patients Research Articles

Soluble CD30 and Hepatocyte growth factor as predictive markers of antibody-mediated rejection of the kidney allograft

Our retrospective study was aimed to assess the relevance of pre- and post-transplant measurements of serum concentrations of the soluble CD30 molecule (soluble CD30, sCD30) and the cytokine Hepatocyte growth factor (HGF) for prediction of the risk for development of antibody-mediated rejection (AMR) in kidney transplant patients. Evaluation of sCD30, HGF levels and the presence of HLA-specific antibodies in a cohort of 205 patients was performed before, 2 weeks and 6 months after transplantation. Patients were followed up for kidney graft function and survival for two years. We found a tendency of higher incidence of AMR in retransplanted patients with elevated pre-transplant sCD30 (≥ 100 U/ml) (p = 0.051), however no such correlation was observed in first-transplant patients. Kidney recipients with simultaneously high sCD30 and HLA-specific antibodies (sCD30+/Ab+) before transplantation had significantly lower AMR-free survival compared to the other patient groups (p < 0.001). HGF concentrations were not associated with the incidence of AMR at any time point of measurement, nevertheless, the combined analysis HGF and sCD30 showed increased incidence of AMR in recipients with elevated pretransplant sCD30 and low HGF levels. Conclusion: the predictive value of pretransplant sCD30 for the development of antibody-mediated rejection after transplantation is significantly potentiated by the co-presence of HLA specific antibodies. The role of HGF as a rejection-protective factor in patients with high pretransplant HGF levels would need further investigation.

Extracapsular versus intracapsular allograft nephrectomy: impact on allosensitization and surgical outcomes.

Our objective was to compare the impact of extra-capsular (ECAN) versus intracapsular allograft nephrectomy (ICAN) on allosensitization and surgical outcomes. Between 1990 and 2004, 96 allograft nephrectomies were performed at our institution. Of these, 29 procedures were performed within 1 month of the transplant and were therefore omitted from analysis. Overall, the results of 44 ECAN and 23 ICAN were reviewed. The mean operative times were 110.9 versus 130.4 min for ICAN versus ECAN (p = 0.02) and the estimated blood loss was 226 mL for ICAN versus 483 mL for ECAN (p = 0.004). Intraoperative and postoperative complications were low using either technique and differences were not statistically significant. Overall, the preoperative to postoperative change in the percentage of panel reactive antibody was +2.1% for ICAN versus +1.2% for ECAN (NS) at 3 to 12 months postoperatively, respectively (NS). The percentage of patients relisted was 33.3% versus 54.3% (NS), and the percentage of patients re-transplanted once relisted was also very similar: 63.2% for ECAN versus 66.7% for ICAN (NS), after a mean follow-up of 4.5 and 8.4 years, respectively. ICAN can be performed with shorter operative times and less blood loss versus the extracapsular approach. As well, this operative approach does not appear to affect allosensitization and the ability to re-transplant patients.

Outcomes of renal transplantation in recipients with peak panel reactive antibody &gt;30% under tacrolimus-based immunosuppression

Renal transplant recipients with high panel reactive antibodies (PRA) have worse outcomes than those with lower PRA. High PRA re-transplant recipients are thought to have worse outcomes than high PRA first transplant recipients. In this study, we examined outcomes of renal transplantation recipients with a peak PRA >30% and compared the outcomes of first and re-transplanted recipients. Survival outcomes between recipients of first transplants (n=68) and re-transplants (n=155) operated between June 1990 and August 2000 were compared. Sub-group analysis was done based on patient's gender, race and first/re-transplant. All patients received tacrolimus-based immunosuppression. No difference in graft survival was noted between first and re-transplanted patients. Ten-year patient survival was better in the re-transplanted group (p<0.004). Factors affecting patient survival on univariate analysis were age >55 years (p=0.015), deceased donor transplant (p=0.009), first transplant patient (p=0.004) and diabetes mellitus (DM) as the cause of End Stage Renal Disease (ESRD) (p=0.005). On multivariable analysis, factors affecting patient survival were number of the transplant (re-transplant versus first transplant, Relative risk [RR]=0.54, p=0.009) and cause of ESRD (DM versus no DM, RR=1.91, p=0.012).Diabetes as a cause for ESRD was the only factor affecting graft survival on univariate(p=0.015) and multivariable analysis (DM versus no DM, RR=1.63, p=0.017). High PRA recipients of first transplants had poorer patient survival than high PRA re-transplants. On multivariable analysis, diabetes etiology of ESRD and first transplantation were found to be independent risk factors for poorer patient survival.

Biliary Complications After Orthotopic Liver Transplantation From Donors After Cardiac Death: Broad Spectrum of Disease

Background Donation-after-death liver transplantation (DCD-LT) carries higher complication rates compared with donation-after-brain death liver transplantation (DBD-LT). In this report we describe our experience with biliary complications in DCD-LT with emphasis on anatomical patterns and outcomes. Materials and Methods We performed retrospective review of patients' medical records from August 2004 to December 2008, during which time total of 26 DCD-LTs were performed. Mean follow-up was 29 months (range 3 to 51 months). Results Biliary complications occurred in 12 patients (46%), of whom 9 were related to DCD (35%). Four patients had more than 1 biliary complication, and 4 had concomitant arterial problems (stricture/thrombosis). Treatment of complications included: ERCP (n = 5, 3 resolved), conversion to roux (n = 5, 2 resolved), revision of roux (n = 1), percutaneous transhepatic cholangiography (n = 1), artery revision (n = 3). Three patients with casts had operative extraction of casts depicting a mummified biliary tree; histology showed casts and fibrosis and anastomotic suture material. Six patients underwent retransplantation (23%). Among retransplanted patients, 2 deaths occurred (7.7%). Conclusion Our experience with DCD-LT reveals a high prevalence of biliary complications with a new and wide spectrum of clinicopathologic findings. Better strategies for prevention of these unique biliary complications are needed to better justify the added risks and costs for performance of DCD-LT.

The Registry of the International Society for Heart and Lung Transplantation: Twenty-seventh official adult heart transplant report—2010

The Registry of the International Society for Heart and Lung Transplantation: Twenty-seventh official adult heart transplant report—2010

Renal transplant outcomes in Spain

Renal transplantation has experienced important modifications during the last two decades. Donor and recipient characteristics have been modified during this period of time. Donor age, a major determinant of graft outcome, has increased as well as the proportion of donors dying of stroke. Recipients are older, and their cardiovascular risk burden has also steadily increased. On the other hand, new immunosuppressants have allowed a dramatic reduction in the prevalence of acute rejection. In this changing situation, it is necessary to monitor how these modifications influence patient and graft survival [1]. Additionally, transplant policies in different countries differ in many aspects. The consequences of these policies on outcome are important to understand since this knowledge is necessary to fine-tune the organization of renal transplantation in the future. Renal transplantation in Spain has some special characteristics. The Spanish system has favoured local harvesting and local implantation. This policy has been successful in increasing the number of cadaveric donors. However, as a consequence of this success, the number of kidney transplants obtained from living donors is lower than in other countries [2]. In order to monitor a time-dependent modification in donor and recipient characteristics and treatment modifications in Spain, the Spanish Chronic Allograft Dysfunction Study Group was created as a study group of the Spanish Society of Nephrology in year 2000. For this purpose, a detailed database was created, thanks to an unrestricted grant from Wyeth Farma Spain (currently Pfizer), and all Spanish adult transplant centres were invited to participate. Patients transplanted in 1990, 1994 and 1998 were considered for the present study and were followed up until June 2001. The general results of this study were published in 2003, and the particular aspects of this cohort were published in Volume 19, Supplement 3 of Nephrology, Dialysis and Transplantation in 2004. In 2003, it was decided to include the cohort of patients transplanted in Spain in 2002, and all cohorts were followed up until December 2005. The first publication describing risk factors associated with outcome in this second phase of the study was recently published, in which a novel score for mortality in renal transplant recipients beyond the first year was described [3]. In the present supplement, specific aspects regarding the updated study are presented. The analysis has focused on the evolution of treatment attitudes in Spain between 1990 and 2002. In this regard, the evolution of the use of statins and its association with graft survival, death censored graft survival, and patient survival have been analysed. Similarly, in another article, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and its association with outcome are presented. Steroid withdrawal in Spain is also reviewed. Selection criteria for steroid withdrawal are analysed, and the outcome after steroid withdrawal is thoroughly described. The evolution of induction therapy in Spain during the study period is also reviewed, its indications and its relationship with outcome. Additionally, other topics such as outcome in re-transplant patients, relationship between new onset diabetes after transplant and weight gain, outcome in hepatitis C-positive recipients and factors associated with renal function decline are analysed.

Results of renal re-transplant in Spain (1990-2002)

Background. Renal re-transplants are increasing in number, due to many first renal transplant patients coming back to dialysis treatment. There are controversial opinions about the evolution of these re-transplanted patients. The aim of our study is to analyse the prognosis of patients and grafts under a renal re-transplant.Methods. This was a retrospective study of 579 renal re-transplants realized in 15 Spanish different centres in the years 1990, 1994, 1998 and 2002 including all renal re-transplants realized in the above-mentioned centres during the same periods.Results. During the follow-up period, 8.81% of patients died. The actuarial patient survival was 85% at 10 years and 80% at 15 years. Principal reasons of death were the same as normal for the renal transplanted patient: cardiovascular (30.77%), infectious (13.46%) and neoplastic (13.46%). During the period of follow-up, 28.6% of the grafts were lost. The actuarial graft survival was 75% at 10 years and 58% at 15 years. Causes of graft loss are very similar to those described in literature.Conclusion. Renal re-transplant is a kind of substitute renal treatment with excellent clinical results that allow to take it as a first-order modality of treatment when the first renal transplant has failed.

Indicaciones y resultados de retrasplante hepático: experiencia del hospital universitario La Fe (1.181 pacientes)

Liver retransplantation (LrT) is the only therapeutic option for irreversible failure of a hepatic graft and accounts for 2.9%–24.0% of all liver transplantations (LT). It is technically difficult and has a high level of immediate morbidity and a lower survival than primary LT. Our aim was to determine the rate of LrT and its indications, morbidity, post-operative mortality and actuarial survival in the retransplanted patient. Patients and method A historical cohort study of 1181 patients transplanted between 1991 and 2006. Results Of the 1260 LT performed, 79 were LrT. At the time of the first LT there were no differences between those patients and those that did not require an LrT. The LrT rate was 6.3% and the most frequent causes were: hepatic artery thrombosis (31.6%), recurrence of cirrhosis due the HVC (30.4%) and primary graft (21.5%). The ischemia times, perfusion syndrome and hepatic congestion were no different between the primary LT and the LrT. On the other hand, red cell transfusions were higher in LrT (6.3±4.9 vs. 3.5±3.0 units, P<0.001). The post-operative morbidity and morbidity (up to 30 days after the LT) was higher in retransplanted patients (68.4% vs. 57.0%, P=0.04 and 25.3% vs. 10.9%, P<0.001; respectively). The actuarial survival at 1 and 5 years was 83% and 69% in those without LrT, 71% and 61% in early LrT and 64% and 34% in delayed LrT ( P<0.001). Conclusions Despite the increased morbidity and mortality of LrT, it appears that this treatment alternative is still valid in those patients with an early loss of the liver graft. On the other hand, when the graft loss is delayed, it needs to be defined, what would be the minimum acceptable results to indicate LrT and which patients could benefit from this treatment.

Human leukocyte antigen crossmatch testing is important for liver retransplantation

Although human leukocyte antigen (HLA) crossmatching is often thought to be unnecessary for liver transplants (LTs), we provide evidence that for retransplants, it is essential. Sera from 139 retransplant patients who had received livers from deceased donors were retrospectively analyzed with single antigen beads on a Luminex platform for HLA antibodies. Each patient received at least 2 transplants and was followed up for at least 6 months from the second LT, which was deemed to have failed if the patient had a third LT or died. Second LT survival was calculated from the date of the second LT to the date of the third LT or death. Our study cohort consisted of 118 adult patients (> or = 18 years old) as well as 21 pediatric patients (<18 years old). Class I HLA antibodies were associated with significantly poorer regraft survival in adults [survival differences of 21.3% (P = 0.046), 22.1% (P = 0.042), and 23.7% (P = 0.033) at 1, 3, and 5 years, respectively]; however, the presence of these antibodies was not associated with significant survival differences in the pediatric population. A univariate analysis of the effect of class I antibodies on second LT survival in adults showed a hazard ratio of 2.0 (95% confidence interval = 1.0-3.8, P = 0.028). Graft survival in patients with and without HLA antibodies or class II antibodies was similar. Because class I antibodies have a deleterious effect on liver regraft survival, crossmatch testing should be performed before liver retransplantation.

Indications for and Survival After Liver Retransplantation

Introduction Orthotopic liver retransplantation (re-OLT) is the therapeutic option for hepatic graft failures. Survival after re-OLT is poorer than after primary OLT. Given that there is an organ shortage, it is essential that we optimize our use of this scarce resource. We evaluated the results of re-OLT among 58 consecutive Re-OLT. Materials and Methods Using registry data from our Liver Transplantation Unit, we performed a retrospective cohort study of adult urgent versus elective re-OLT between 1991 and 2008. We recorded the indications for the initial OLT, and the intervals from OLT to re-OLT as well as age and gender. Using the Rosen model to stratify patients into low-intermediate-, and high-risk groups we calculated survivals. Results Among 661 adult liver transplantations, 56 patients (8.4%) underwent late re-OLT at a median of 654.4 days post-OLT. There were 17 (29%) urgent re-OLT and 41 elective cases (71%). Vascular complications were the most common cause of urgent re-OLT (64%); elective re-OLT was primarily due to chronic rejection (56.1%). Overall survival for retransplanted patients was significantly lower among urgent procedures (82.4% vs 48.8%), as well as for overall survival after re-OLT for patients with hepatitis C virus (HCV) versus other etiologies. Conclusion These data confirmed the utility of retransplantation in elective and emergency situations. Liver re-transplantation has a high morbidity and mortality. It requires multidisciplinary experience to decide inclusion and prioritization criteria for re-OLT, especially among patients with HCV.

Indications and results of liver retransplantation: experience with 1181 patients in the hospital universitario La Fe

Liver retransplantation (LrT) is the only therapeutic option for irreversible failure of a hepatic graft and accounts for 2.9%–24.0% of all liver transplantations (LT). It is technically difficult and has a high level of immediate morbidity and a lower survival than primary LT. Our aim was to determine the rate of LrT and its indications, morbidity, post-operative mortality and actuarial survival in the retransplanted patient. Patients and methodA historical cohort study of 1181 patients transplanted between 1991 and 2006. ResultsOf the 1260 LT performed, 79 were LrT. At the time of the first LT there were no differences between those patients and those that did not require an LrT. The LrT rate was 6.3% and the most frequent causes were: hepatic artery thrombosis (31.6%), recurrence of cirrhosis due the HVC (30.4%) and primary graft (21.5%). The ischemia times, perfusion syndrome and hepatic congestion were no different between the primary LT and the LrT. On the other hand, red cell transfusions were higher in LrT (6.3±4.9 vs 3.5±3.0 units, P<.001). The post-operative morbidity and morbidity (up to 30 days after the LT) was higher in retransplanted patients (68.4% vs 57.0%, P=.04 and 25.3% vs 10.9%, P<.001; respectively). The actuarial survival at 1 and 5 years was 83% and 69% in those without LrT, 71% and 61% in early LrT and 64% and 34% in delayed LrT (P<.001). ConclusionsDespite the increased morbidity and mortality of LrT, it appears that this treatment alternative is still valid in those patients with an early loss of the liver graft. On the other hand, when the graft loss is delayed, it needs to be defined, what would be the minimum acceptable results to indicate LrT and which patients could benefit from this treatment.

Long-term outcome of renal transplantation in adults with focal segmental glomerulosclerosis

Little information is available about the long-term results of kidney transplantation in adults with focal segmental glomerulosclerosis (FSGS). The outcomes of 52 renal transplants performed between 1988 and 2008 in 47 adults with FSGS were compared with those of 104 matched controls (median follow-up 93.4 vs. 109.4 months respectively). At 15 years, patient survival was 100% and graft survival 56% in FSGS patients vs. 88.3% and 64% respectively in controls (P = NS). FSGS recurred in 12 out of 52 grafts (23%) and led to graft failure in seven within 10 months (median). In the other five cases, proteinuria remitted and grafts are functioning 106 months (median) after transplantation. A second recurrence developed in five out of eight re-transplanted patients (62.5%) who lost their first graft because of recurrence; only one graft was lost. Patients with recurrence were more frequently male subjects (83% vs. 40%, P = 0.02), younger at diagnosis of FSGS (16.3 +/- 6.8 vs. 24.1 +/- 11.5 years, P = 0.03) and of younger age at transplantation (28.4 +/- 7.8 vs. 35.8 +/- 12.2 years, P = 0.05). Treatment with plasmapheresis plus ACE inhibitors achieved either complete or partial remission in 80% of the cases. Long-term patient and renal allograft survivals of adults with FSGS were comparable to those of controls. Recurrence was more frequent in young patients and in patients who lost a previous graft from recurrence. Graft loss resulting from a second recurrence is lower than expected.

Higher Rate of Comorbidities After Cardiac Retransplantation Contributes to Decreased Survival

Cardiac retransplantation is the definitive treatment for allograft failure despite decreased long-term survival in these patients. The cause of the poorer outcomes in cardiac retransplant patients is unclear. This study was a retrospective analysis of 859 adult cardiac transplant patients. Of these, 45 (5.7%) underwent cardiac retransplantation at 8.2 +/- 5.3 (mean +/- SD) years after the first transplant, primarily for severe transplant vasculopathy (n = 42). One-year survival for retransplant patients was significantly lower compared with de novo transplant patients (75% vs 87%; p < 0.003). Twenty-three patients died due to either malignancy (n = 8), infection (n = 6), rejection (n = 3), sudden death (n = 2), recurrent transplant coronary artery disease (n = 2) or post-operative bleeding (n = 1). Although cardiac retransplantation has immediate life-saving benefits, survival is lower compared with de novo cardiac transplantation due to higher rates of malignancy and infection.

Antifungal prophylaxis in liver transplant recipients

Although the overall incidence of fungal infections in liver transplant recipients has declined, these infections still contribute significantly to the morbidity and mortality of patients with risk factors for infection. Although antifungal prophylaxis has been widely studied and practiced, no consensus exists on which patients should receive prophylaxis, with which agent, and for what duration. Numerous studies have attempted to ascertain independent risk factors for invasive fungal infections in liver transplant patients, and these data, in addition to clinical trials, identify several patient groups at exceedingly high risk of fungal infection. These include retransplant patients, patients with renal failure requiring hemodialysis or renal replacement therapy, and those requiring reoperations after transplant. Because the majority of infections occur in the first month after transplantation, prophylaxis should be continued for 4-6 weeks. However, local epidemiology and research should guide decisions regarding choice of agent as well as overall development of interinstitutional guidelines, because the incidence and spectrum of infection may differ dramatically among institutions. Liver Transpl 15:842-858, 2009. (c) 2009 AASLD.

Post‐transplant lymphoproliferative disease in pediatric lung transplant recipients: Recent advances in monitoring

To investigate the clinical validity of newer diagnostic tests such as monitoring of EBVqPCR and lymphocyte function assay ImmuKnow in helping to diagnose PTLD in pediatric lung transplant recipients. Single-center, retrospective case-control study. CsA trough levels, EBVqPCR and ImmuKnow (Cyclex Inc., Columbia, MD, USA) levels were measured serially as part of routine care. Re-transplant patients and patients who did not reach 12 months post-transplant at the time of analysis were excluded. Twenty-seven patients met the inclusion criteria. The study group consisted of seven patients who developed PTLD, five of which were EBV- recipients who received EBV+ lungs. The rest of the eligible patients served as controls. Median time to develop PTLD was 273 days (range: 166-343). One, two, three, six, and nine months after transplant, mean (+/-s.d.) CsA trough whole blood levels (ng/mL) were not different between the two groups: 378 +/- 38, 390 +/- 52, 402 +/- 89, 359 +/- 42, and 342 +/- 115, vs. 416 +/- 105, 347 +/- 64, 337 +/- 78, 333 +/- 86, and 281 +/- 54 [PTLD vs. no-PTLD, respectively (p > 0.05 for all time points)]. Mean (+/-s.d.) EBVqPCR levels (copies/mL) measured at three, six, and nine months post-transplant were significantly elevated in PTLD group compared to no-PTLD group: 84 +/- 99, 3384 +/- 7428 and 839 +/- 1444 vs. 9 +/- 26, 8 +/- 36 and 32 +/- 136, respectively (p < 0.05 for all time points). Mean (+/-s.d.) ImmuKnow levels (ATP ng/mL) at three, six, and nine months post-transplant were significantly lower in the PTLD group when compared with no-PTLD group: 144 +/- 67, 137 +/- 110, and 120 +/- 153 vs. 290 +/- 161, 300 +/- 162, and 293 +/- 190, respectively (p < 0.05 for all time points). Close monitoring of EBV viral load by qPCR and the degree of immunosuppression via ImmuKnow may guide physicians to reach the diagnosis of PTLD early.

Hepatitis C

Hepatitis C virus (HCV) is a leading cause of end-stage liver disease worldwide and the most common indication for liver transplantation in the United States and Europe. HCV nearly always recurs in liver-transplanted patients, and 10 to 25% of them develop cirrhosis within 5 to 10 years. One of the strategies suggested to limit virological HCV recurrence is pretransplant antiviral treatment, but studies are warranted on the pharmacokinetics of antiviral drugs in cirrhotic patients, the benefits of fixed or escalating antiviral drug dosage schedules, the duration of the treatment, and the indications for using growth factors. Several risk factors are associated with a more aggressive recurrent HCV and early allograft failure, such as an older donor age. The relationship between immunosuppression and fibrosis progression in HCV recurrence remains uncertain. Concerning the antiviral treatment, treating established recurrent disease with a combination of interferon and ribavirin has been the mainstay of management to date, but when it is best to start and how to manage the side effects are still controversial issues. Antiviral treatment should be started once the disease has been confirmed by a biopsy when the fibrosis develops, providing that ongoing acute or chronic rejection, biliary obstruction, vascular damage, autoimmune diseases and sepsis, and any other standard contraindications for antiviral therapy, have been excluded. HCV recurrence after liver transplantation may well lead to graft failure and become an indication for retransplantation, but this is done in a relatively small number of cases, accounting for only 3 to 5% of retransplanted patients, since retransplantation is associated with much worse results than primary liver transplant procedures. We must be prepared for the fact that increasing numbers of HCV-positive recipients with allografts failing due to recurrent HCV will be asking to be retransplanted-and we do not know yet how to respond to this request.

T H17 Versus Treg Cells in Renal Transplant Candidates: Effect of a Previous Transplant

Introduction The T H1 and T H2 cells were described several years ago. However, this dichotomy has been disrupted by the description of other CD4 + T cell subsets: the proinflammatory interleukin (IL)-17-producing T cells (T H17) and regulatory T cells (Tregs). The latter group inhibits the immune responses driven by T H1, T H2, and T H17 cells. IL-6 is involved in T H17 development, down-regulating Treg differentiation. Our hypothesis suggested that an imbalance between T H17 and Tregs enhances immune responses among renal transplant patients. Materials and methods We studied 26 end-stage renal disease (ESRD) subjects and 10 patients awaiting a second renal transplant after previous graft dysfunction. We assessed the number of CD4 +CD25 +Foxp3 + cells and serum levels of IL-17, the prototypic interleukin of T H17 cells. Results We observed a lower number of CD4 +CD25 +Foxp3 + T cells among patients with previous graft dysfunction than those with ESRD (median 3.37 vs 8.63 cells/mm 3, P = .008). In contrast, IL-17 serum levels were augmented in graft dysfunction (median 4.45 pg/mL) compared with ESRD patients (1.39 pg/mL, P = .036), suggesting a proinflammatory state in patients awaiting a second renal transplant. Conclusion The emerging alloresponse from a previous transplant favors the generation of T H17 instead of Treg cells. The enhanced activity of T H17 cells in retransplanted patients may down-regulate Treg cells, producing a proinflammatory environment that favors rejection of the next transplant.

Incidence of Liver Retransplantation and Its Effect on Patient Survival

Purpose The purpose of this study was to review our institutional experience with re–liver transplantation (OLT) after split and full-size OLT. Patients and methods We evaluated data corresponding to retransplanted patients over an 8-year period who underwent deceased donor OLT at our institution. Variables analyzed included indications for primary OLT, and re-OLT, the type of graft used during the initial versus re-OLT, the time from initial to re-OLT, and patient survival after re-OLT. Results Sixty-four of 697 first OLT (9.2%) required re-OLT. Forty-nine cases were among 637 (7.6%) full-size OLT, while 15 were among 60 (25%) split OLT ( P < .001). Median time to re-OLT was 8 days (range = 1–1885 days). Main indications for re-OLT were primary nonfunction/initial poor function (44%), hepatic artery thrombosis (26%), biliary complications (11%), and hepatitis C recurrence (6%). Forty-eight percent of the re-OLTs were performed within the first posttransplant week. The overall survival for these 64 patients was 55% and 48% at 1 and 3 years after the primary OLT, and 44% at both 1 and 3 years after the re-OLT, respectively. Conclusions The overall incidence of re-OLT remains 9%. Approximately half of all re-OLT occured within the first posttransplant week. Early retransplantation was associated with the best patient survival. Overall survival after re-OLT was about 10% to 20% lower than that after primary OLT.

Renal Retransplantation: A Retrospective Monocentric Study

Approximately 10% to 20% of all annual renal transplantations are retransplantations and up to 20% of patients on waiting lists need a repeat kidney because of previous graft failure. The immunological risk is much greater among retransplanted patients than first-time kidney recipients. It is likely that retransplantation will become even more prevalent in the future. However, clinical studies or retrospective data are rare in this patient population. We retrospectively investigated 50 recipients after second or third renal transplantations in our center since 2001. Immunosuppression was performed with corticosteroids, mycophenolate mofetil (MMF), tacrolimus, and induction therapy with either thymoglobulin (2.5 mg/kg body weight; n = 27) or 20 mg basiliximab on days 0 and 4 (n = 22) after renal transplantation; 1 patient was treated with antithymoglobulin Fresenius after combined liver–kidney transplantation. Acute rejection occurred in 12 recipients (44.4%) after thymoglobulin and in 7 recipients (31.8%) after basiliximab induction therapy ( P < .05). In 4 (14.8%) thymoglobulin- and 5 (22.7%) basiliximab-treated recipients, vascular rejections were observed ( P = NS). Patients with basiliximab treatment showed improved renal function at 1 year after transplantation: serum creatinine 134.3 μmol/L versus 199.6 μmol/L in the thymoglobulin group ( P < .05). Over the observation period the renal function remained stable or improved in both groups if rejection treatment was successful. However, allograft failure was higher in the basiliximab-treated group, namely, 18.1% versus 14.8% in thymoglobulin-treated patients, but the difference did not reach statistical significance. In 3 (11.1%) thymoglobulin- and 4 (18.2%) basiliximab-treated patients cytomegalovirus (CMV) infections complicated the follow-up ( P = NS). In the follow-up period of 5 years, no malignant diseases were seen in either group. Three basiliximab-treated recipients died in the first year due to sepsis or cardiovascular complications. Two thymoglobulin-treated patients developed BK virus nephropathy in the follow-up period. In conclusion, we observed a high immunological risk and rejection risk among retransplanted kidney recipients in our center. Particularly, severe vascular rejections with a harmful long-term impact on allograft function were observed in this population. Induction treatment seems to be successful to reduce risk and achieve better results. Single-shot thymoglobulin may be preferable to reduce severe vascular rejection and prevent allograft failure than basiliximab with the same infection rate.

Outcomes after Lung Retransplantation in the Modern Era

Characteristics of and survival estimates for recipients of lung retransplantation in the modern era are unknown. To compare lung retransplant patients in the modern era with historical retransplant patients, to compare retransplant patients with initial transplant patients in the modern era, and to determine the predictors of the risk of death after lung retransplantation. We performed a retrospective cohort study of patients who underwent lung retransplantation between January 2001 and May 2006 in the United States (modern retransplant cohort). The characteristics and survival of this cohort were compared with those of patients who underwent first lung retransplantation between January 1990 and December 2000 (historical retransplant cohort) and patients who underwent initial lung transplantation between January 2001 and May 2006 (modern initial transplant cohort). Modern retransplant recipients (n = 205) had a lower risk of death compared with that of the historical retransplant cohort (n = 184) (hazard ratio, 0.7; 95% confidence interval, 0.5-0.9; P = 0.006). However, modern retransplant recipients had a higher risk of death than that of patients who underwent initial lung transplantation (n = 5,657) (hazard ratio, 1.3; 95% confidence interval, 1.2-1.5; P = 0.001), which appeared to be explained by a higher prevalence of certain comorbidities. Retransplantation at less than 30 days after the initial transplant procedure was associated with worse survival. Outcomes after lung retransplantation have improved; however, retransplantation continues to pose an increased risk of death compared with the initial transplant procedure. Retransplantation early after the initial transplant poses a particularly high mortality risk.