Kidney Transplant Survival Rates Research Articles

COMPARAISON DES RESULTATS A LONG TERME DE LA TRANSPLANTATION RENALE ENTRE CONJOINTS ET DONNEURS VIVANTS APPARENTES: EXPERIENCE MONOCENTRIQUE AU MAROC

Objective: End-stage kidney disease is a serious medical condition that often requires a kidney transplant. This single-center study, conducted in Morocco, examines the long-term outcomes of kidney transplants from spouses and related living donors. The goal is to enhance access to organ transplantation by assessing the success of transplants using spouses as donors. Patients and methods:A total of 117 patients were eligible for a kidney transplant from their spouses kidneys. Out of these, 36 received a transplant and were compared to 56 patients who received a kidney from a related donor. Demographic, clinical, and immunological data, as well as long-term outcomes, including graft survival, were analyzed. Results: Recipientswerepredominantly male in both groups (69.6% versus 83.3%). Recipients in the related group wereyoungerthanthose in the unrelated group (39.80 versus 56.56 years). Relatedgraftsshowed more HLA matchingthanunrelatedgrafts (4.45 versus 1.64). The occurrence of DSA after transplantation wasslightlylower in the relatedgraft (16.1% versus 19.4%). Graftsurvival at 1, 3, 5, and 10 yearswassimilar in both groups, with a slight favorable trend for the related group. Conclusion: Kidney transplant survival rates are broadlysimilarbetweenspouses and related living donors. This suggeststhatspousal donation can compensate for the scarcity of cadaveric donation, particularly in Morocco.

Facilitators and barriers to living donor kidney transplantation

Facilitators and barriers to living donor kidney transplantation

Isolated endarteritis and kidney transplant survival: a multicenter collaborative study.

Isolated endarteritis of kidney transplants is increasingly recognized. Notably, microarray studies revealed absence of immunologic signatures of rejection in most isolated endarteritis biopsy samples. We investigated if isolated endarteritis responds to rejection treatment and affects kidney transplant survival. We retrospectively enrolled recipients of kidney transplant who underwent biopsies between 1999 and 2011 at seven American and Canadian centers. Exclusion criteria were recipients were blood group-incompatible or crossmatch-positive or had C4d-positive biopsy samples. After biopsy confirmation, patients were divided into three groups: isolated endarteritis (n=103), positive controls (type I acute T cell-mediated rejection with endarteritis; n=101), and negative controls (no diagnostic rejection; n=103). Primary end points were improved kidney function after rejection treatment and transplant failure. Mean decrease in serum creatinine from biopsy to 1 month after rejection treatment was 132.6 µmol/L (95% confidence interval [95% CI], 78.7 to 186.5) in patients with isolated endarteritis, 96.4 µmol/L (95% CI, 48.6 to 143.2) in positive controls (P=0.32), and 18.6 µmol/L (95% CI, 1.8 to 35.4) in untreated negative controls (P<0.001). Functional improvement after rejection treatment occurred in 80% of patients with isolated endarteritis and 81% of positive controls (P=0.72). Over the median 3.2-year follow-up period, kidney transplant survival rates were 79% in patients with isolated endarteritis, 79% in positive controls, and 91% in negative controls (P=0.01). In multivariate analysis, isolated endarteritis was associated with an adjusted 3.51-fold (95% CI, 1.16 to 10.67; P=0.03) risk for transplant failure. These data indicate that isolated endarteritis is an independent risk factor for kidney transplant failure.

Projecting Long-Term Graft and Patient Survival after Transplantation

ObjectiveIn spite of increases in short-term kidney transplant survival rates and reductions in acute rejection rates, increasing long-term graft survival rates remains a major challenge. The objective here was to project long-term graft- and survival-related outcomes occurring among renal transplant recipients based on short-term outcomes including acute rejection and estimated glomerular filtration rates observed in randomized trials. MethodsWe developed a two-phase decision model including a trial phase and a Markov state transition phase to project long-term outcomes over the lifetimes of hypothetical renal graft recipients who survived the trial period with a functioning graft. Health states included functioning graft stratified by level of renal function, failed graft, functioning regraft, and death. Transitions between health states were predicted using statistical models that accounted for renal function, acute rejection, and new-onset diabetes after transplant and for donor and recipient predictors of long-term graft and patient survival. Models were estimated using data from 38,015 renal transplant recipients from the United States Renal Data System. The model was populated with data from a 3-year, randomized phase III trial comparing belatacept to cyclosporine. ResultsThe decision model was well calibrated with data from the United States Renal Data System. Long-term extrapolation of Belatacept Evaluation of Nephroprotection and Efficacy as Firstline Immunosuppression Trial was projected to yield a 1.9-year increase in time alive with a functioning graft and a 1.2 life-year increase over a 20-year time horizon. ConclusionsThis is the first long-term follow-up model of renal transplant patients to be based on renal function, acute rejection, and new-onset diabetes. It is a useful tool for undertaking comparative effectiveness and cost-effectiveness studies of immunosuppressive medications.

Strategies to increase living donor kidney transplants

There is an insufficient supply of deceased donor kidneys for transplantation. One solution is to increase the number of living donor kidney transplants. Our kidney transplant database was reviewed for 3 periods of 12 months each, separated by 5 years, to show the trends in kidney transplant donor sources and the influence of biologically unrelated living renal donors, minimally invasive living renal donor surgery, transplantation of ABO-incompatible kidneys from living donors, and transplantation in spite of positive cross-matches on the numbers of renal transplants and 1-year kidney transplant survival rates at our center. When results for 1993 were compared with 2003, the annual number of living donor renal transplants increased from 25 to 86, and the annual number of deceased donor renal transplants decreased from 108 to 63. The total number of kidney transplants increased by 12%. However, 1-year living donor kidney transplant survivals were not significantly different (94% for transplants done in 1993 vs 98% for transplants done in 2003). The strategies of living donor renal transplants from genetically unrelated donors, ABO-incompatible donors, and cross-match positive donors as well as the introduction of hand-assisted laparoscopic donor nephrectomy increased the number of living renal donor renal transplants at our center without compromising short-term kidney transplant survival rates.

Pediatric Renal Transplantation: Comparative Study With Renal Transplantation in the Adult Population

Purpose To retrospectively review our experience with pediatric renal transplantation and to compare the results with the adult population. Patients and methods Between January 1981 and August 2003, 74 renal transplants were performed in patients ≤18 years at the time of the transplant—the pediatric group versus 1153 patients in the adult group. We analyzed various risk factors for actuarial kidney graft and patient survivals using the Kaplan-Meier method. Results Median ages were 13.8 ± 3.5 and 42.6 ± 2.4 years, respectively. There was no statistically significant difference in the human leukocyte antigen matching or immunosuppression. There was, however, a younger donor age and shorter ischemia time in the pediatric group. Overall, kidney transplant survival rates for patients ≤18 years at 1, 2, 5, and 10 years were 94.4%, 91.3%, 70.6%, and 58.2%, respectively, with no significant difference for patients older than 18 (91.2%, 89.3%, 78.8%, 60.5%, P = .4325). There was a significantly decreased graft survival in the adult group at 10 years when the donor age was over 60 years and when the ischemia time was ≥20 hours. The incidence of delayed graft function and the creatinine levels of functioning grafts did not differ between the two groups. During the follow-up, acute rejections were more frequent in the younger group. Patient survival in the pediatric group at 1, 2, 5, and 10 years was 98.6%, 98.8%, 98.6%, and 90.3%, respectively, significantly lower in the adult group (95.3%, 94.0%, 87.9%, 76.8%, P < .02). Conclusions Renal transplantation may be successfully performed in the pediatric patients with end-stage renal disease. Overall graft survival at 10 years did not differ significantly between the two groups. There is a higher incidence of acute rejections but longer patient survival in the pediatric population.

Surrogate Markers for Long-Term Renal Allograft Survival

Progressive improvement in kidney transplant survival rates and reduction in acute rejection rates have ironically restricted our ability to evaluate newer therapy. Current short-term endpoints such as acute rejection rates have reduced utility in predicting long-term survival. Long-term graft survival is an ideal endpoint, but is limited by longer follow-up requirements and the large cohort of patients required for such studies. Newer short-term surrogate markers should be identified and these markers should correlate with long-term graft failure. Hence, identification of short-term surrogate markers is critical to test newer immunosuppressive strategies over current therapies, and should also predict long-term transplant outcome. Potential surrogate markers are clinical parameters such as renal function, renal histological findings of fibrosis and immunological markers. Post-transplant renal function estimated by serum creatinine within 1 year has been shown to correlate with long-term survival. Alternative evaluation of renal function such as clearance studies and cystatin C, which are more accurate, could potentially be useful in clinical trials. Renal histological indices such as fibrosis measured as Chronic Allograft Disease Index score or Banff score correlate with long-term graft survival. Immunological markers such as antidonor antibodies, levels of blood and urine cytokines, real time PCR, ELISPOT and microarrays are attractive surrogates to consider. Measurement of morbidity and mortality after transplantation is critical to further enhance long-term survival. Thus, there are many potential surrogate markers and these individually or in combination with conventional endpoints should be implemented in clinical trials and validated in long-term studies.

PEDIATRIC RENAL TRANSPLANTATION: COMPARATIVE STUDY WITH RENAL TRANSPLANTATION IN THE ADULT POPULATION

P365 Aims: To retrospectively review our experience with Pediatric renal transplantation and to compare the results with the Adult Population. Methods: Between January 1981 and August 2003, 1227 renal transplants were done in our Department. Seventy four patients ≤ 18 years at the time of the transplant were included in the Pediatric Group and compared with 1153 patients over 18 years included in the Adult Group. The actuarial kidney graft survival and patient survival were calculated by the Kaplan-Meier method and we analyzed various risk factors. Results: Median age was 13.8 ± 3.5 and 42.6 ± 2.4 years, respectively. There was no statistically significant difference in the HLA matching (2.3±0.95vs 2.4±1.0, P>0.05) or immunosuppression. There was however a lower donor age (26.0±10.1 vs 32.3±14.9 years, P<0.05) and shorter ischaemia time (17.9±8.1 vs 20.7 ± 6.6 hours, P<0.05) in the Pediatric Group. Overall, kidney transplant survival rates for patients ≤ 18 years at 1, 2, 5 and 10 years were 94.4%, 91.3%, 70.6% and 58.2% respectively, with no significant difference for patients older than 18 (91.2%, 89.3%, 78.8%, 60.5%, P=0.4325). Patients were further divided according to donor age (≤18; 19-59; ≥ 60 years) and cold ischaemia time of the graft (< 20; ≥ 20 hours). There was a significant graft survival decrease in the Adult Group at 10 years when the donor age was over 60 years (61.5 vs 37.7%, P<0.05) and when ischaemia time was ≥ 20 hours (63.6 vs 58.4%, P<0.05). In the Pediatric patients, there were no donor over 60 years and ischaemia time did not influence graft survival. The incidence of acute tubular necrosis (0.12±0.33 vs 0.17±0.38, P=0.19) and the creatinine levels of functioning grafts did not differ between the two groups. During the follow up (6.03±5.05 vs 5.96±4.53 years, P>0.05), acute rejections were more frequent in the younger group (0.49±0.50 vs 0.32±0.47, P<0.01). Patient survival in the Pediatric group at 1, 2, 5 and 10 years was 98.6%, 98,8%, 98.6% and 90.3%, respectively, significantly lower in the Adult group (95.3%, 94.0%, 87.9%, 76.8%, P<0.02). Conclusions: Renal transplantation may be successfully performed in the Pediatric patients with end stage renal disease. Although overall graft survival at 10 years did not differ significantly between the two groups, there is a decreased graft survival in the Adult patients when the donor age is over 60 years and cold ischaemia time is more than 20 hours. There is a higher incidence of acute rejections and longer patient survival in the Pediatric population.

Expanding the kidney donor pool: Ethical and medical considerations

year later, proteinuria developed. She had an uncomplicated pregnancy in 1990. Five years later, arterial hypertension required treatment with enalapril. Her serum creatinine then was 1.2 mg/dL. The serum creatinine rose to 1.3 mg/dL two years ago and to 1.5 mg/dL last year. Earlier this year, a 24-hour urine collection contained 810 mg protein; the serum creatinine was 1.6 mg/dL and the creatinine clearance was 31 mL/min/ 1.73 m 2 . Her urine sediment was benign. A further increase in her blood pressure necessitated treatment with lisinopril, 10 mg each morning, and amlodipine, 5 mg each night. She says that she has no regrets about her decision to donate despite the outcome. Five years ago, her husband’s brother developed renal failure; with her encouragement, her husband donated a kidney. Her husband, now age 44, is in good health and has normal blood pressure, normal serum creatinine, and no proteinuria.

Fit and match hypothesis for kidney transplantation.

The importance of HLA matching for cadaver-donor transplants is often ignored due to the small (10%) difference in graft survival rates between the best and worst matched pairs. A new "fit and match" hypothesis is proposed to improve the predictive value of matching. Graft and functional survival rates of kidney transplants were calculated for living and cadaver-donors by the standard Kaplan and Meier methods. Mean discharge serum creatinine (SCr) values were computed after excluding patients who died or lost their grafts before discharge. Donor size, recipient size, age of donor kidney, damage caused by cold ischemia time, and mode of donor death all had substantial effects on the average SCr levels at discharge. These SCr levels correlated with one- and five-year graft survival rates. Transplants that had extremely different graft survival rates, such as those from living donors and cadaver donors, were found to have similar rates when reclassified by SCr levels at discharge. By examining the combined effects of the fit and match factors, transplants with the best fit and match exhibited a 95% one-year graft survival rate, whereas those with the worst fit and match had a 75% survival rate. This 20% difference increased to 36% after five years (84% vs. 48%). We conclude that the fit and match hypothesis provides a theoretical basis for devising a more critical method of predicting cadaver kidney transplant survival rates. Furthermore, it suggests a vital need to develop methods for estimating functional donor renal mass.

High survival rates of kidney transplants from spousal and living unrelated donors: Terasaki P.I.; Cecka J.M.; Gjertson D.W.; Takemoto S. New Engl J Med 1995 333/6 (333–336)

High survival rates of kidney transplants from spousal and living unrelated donors: Terasaki P.I.; Cecka J.M.; Gjertson D.W.; Takemoto S. New Engl J Med 1995 333/6 (333–336)

Immunosuppressive drugs in renal transplantation. A review of the regimens.

Currently, expected 10-year first graft survival rates for kidneys from HLA-identical sibling, 1-haplotype-matched relative, and cadaver donors are 74, 51, and 40%, respectively. Histocompatibility, immunological conditioning with blood products, and immunosuppression with glucocorticoids, azathioprine, cyclosporin, and the antithymocyte (antilymphocyte) antibody preparations have been significant factors in the gradual improvement of kidney graft survival rates. Nearly all immunosuppression regimens are cyclosporin-based. Antithymocyte antibody induction therapy with delayed administration of cyclosporin is widely practised to avoid cyclosporin nephrotoxicity while the kidney graft is recovering from preservation injury. Late cyclosporin withdrawal results in inferior cadaver kidney transplant survival rates. Rejection crises usually respond to high dose glucocorticoid therapy. Glucocorticoid-resistant rejection usually responds to treatment with antithymocyte antibody. FK-506 is a promising new immunosuppressant that has properties similar to cyclosporin. Prophylaxis against viral, bacterial and fungal infections is necessary to reduce the morbidity of immunosuppression. The incidence of malignant conditions associated with viral infections is significantly increased with immunosuppression. New immunopharmacological agents and advances in genetic procedures may allow the induction of specific transplantation tolerance and successful xenotransplantation within the next decade.

Pancreas transplantation: indications and outcomes.

Nearly all uraemic diabetic candidates for kidney transplants are candidates for a pancreas transplant. The best treatment option is to receive a living related donor kidney transplant first, followed later by a pancreas transplant from either a living related (segmental graft) or cadaver (whole organ or segmental) donor [22, 28]. For those without a living related donor for a kidney, a pancreas transplant can be performed simultaneously with a renal transplant from a cadaver donor. This approach promotes the highest kidney transplant survival rates and, coupled with pancreas transplantation, ensures the best overall outcome for the patient. The incentive to perform a living related donor kidney transplant is now even more compelling since the insulin-independence rates with a PAK can be as good as with a SPK transplant.

INDUCTION OF HIGH KIDNEY GRAFT SURVIVAL RATE BY MULTIPLE TRANSFUSION

In 33 centres that adopted a policy of liberal preoperative blood transfusion 174 recipients of cadaver donor transplants were followed up. Those who received no pretransplant transfusions had a 23% 1-year graft survival rate whereas those who had >10 transfusions had an 87% survival rate (p<0.000001). 3% of those transfused acquired highly reactive cytotoxic antibodies and >70% had no antibodies, so transfusions do not exert their beneficial effect by excluding strong immune responders. Since transplant survival rates improved with the number of transfusions, they probably produce their beneficial effect by inducing a state of unresponsiveness. Multiple transfusion seems a simple and effective way of improving kidney transplant survival rates. Moreover, the immunosuppressive effect is specific in that it does not alter the immune response to infectious agents.

Kidney Transplantation

Since 1954, more than 26,000 kidney transplants have been performed and transplantation is now an accepted method for the treatment of end-stage renal disease. Recent advances in transplantation include operation not only on ideal recipients, but also on a much broader group of patients; an improved understanding of rejection mechanisms; better employment of standard immunosuppressive drugs; identification of an additional major histocompatibility antigen system; appreciation that blood transfusions prior to transplantation may facilitate acceptance of cadaver kidneys; and development of intracellular washout solutions for kidney preservation. Although the overall functional survival rates of kidney transplants have not improved recently, there has been a significant improvement in patient survival, especially after transplantation of cadaver kidneys.

Comparison of male and female kidney transplant survival rates.

SUMMARY No difference in human kidney transplant survival rates could be shown between male and female recipients of transplants despite the fact that pre formed cytotoxins were found at twice the frequency among females. The survival rate of male recipients with pre formed cytotoxins was consistently lower than males without cytotoxins. With female recipients, however, in the parent to child (P:C) and sibling to sibling (S:S) situation, the presence of cytotoxins was not deleterious to transplants. Eight unusual transplants which functioned in the face of a positive cross match test were found to have been done in females. In contrast to these indications of a non deleterious effect of pre formed antibodies to female recipients, kidney transplants from cadaver donors in females with cytotoxins had as low a survival rate as in males with cytotoxins. Thus, an “enhancement” effect appeared to be present in patients with cytotoxins for 1-HL-A haplotype different transplants but this effect could not be shown with 2-haplotype different transplants.