Beneficial effect of pre-transplant splenectomy for leukopenia in primary cadaver kidney transplants

Pre-transplant splenectomy is controversial. We compared 21 nondiabetic, transfused recipients of first cadaver kidney grafts who underwent pre-transplant splenectomy for steroid-resistant leukopenia to 114 without steroid-resistant leukopenia. Kidney graft survivals at 2 years were 80.2 plus or minus 8.9 and 48.5 plus or minus 5.3 per cent, respectively (p less than 0.05). The 2-year actuarial patient survivals were not significantly different (89.6 plus or minus 7.0 versus 87.8 plus or minus 3.9 per cent). Azathioprine doses and serum creatinine levels at 1 year were not significantly different. Pre-transplant splenectomy for steroid-resistant leukopenia resulted in a significant decrease in kidney graft losses owing to rejection without an increased risk of death of sepsis or thromboembolism.     

Pediatric cadaver kidney transplants into adults

During a 5-year period 77 adults received single kidney cadaver transplants from donors 16 months to 16 years old. Cyclosporin immunosuppression was not used. Three recipients had ischemic ureteral complications, 1 of which resulted in allograft loss. Of the kidney grafts 34 were from donors 8 years old or younger, and comparison of renal function was made with the 43 adult recipients of cadaver kidneys from older children. The mean 1-month serum creatinine nadir was significantly higher in the recipients of kidneys from the younger children (2.6 plus or minus 1.6 versus 1.9 plus or minus 0.8 mg./per dl.). There were no statistically significant differences in 1-week dialysis requirement, 1-month kidney graft function or actuarial kidney graft survivals and serum creatinine levels at 3, 6, 12 and 24 months after grafting. Cadaver kidneys from young donors can be transplanted successfully into adults.     

Effect of donor surgeon on first cadaver kidney transplant function

Community urologists and general surgeons were recruited into a cadaver kidney program in 1976. This study from 1 center compares 41 primary cadaver kidney grafts retrieved by community hospital retrieval teams to 60 primary cadaver kidney grafts retrieved by a center-based transplant team. Of the kidneys 100 were preserved with Collins' C2 flushing followed by simple cold storage and 1 was preserved with pulsatile machine perfusion. Cold storage time ranged from 9 to 44.5 hours in the community hospital kidney group and from 11 to 44 hours in the university hospital group. There was no significant difference between the 2 kidney retrieval teams with respect to 1) incidence of acute tubular necrosis, 2) 1-month serum creatinine nadir of surviving grafts, 3) 1 and 2-year serum creatinine levels and 4) actuarial graft survivals up to 5 years. Community hospital retrieval teams can provide kidneys as satisfactory for transplantation as a center-based transplant team and are a valuable resource for cadaver kidney transplant programs.     

The incidence and impact of early rejection episodes on graft outcome in recipients of first cadaver kidney transplants.

The objective of this study was to define the incidence and significance of acute rejection occurring in the first year following transplantation. The influence of contemporary induction immunosuppression on rejection, as well as the effect of rejection on graft and patient loss, renal function, and maintenance immunosuppression during the first year in 110 recipients of first cadaver renal transplants were analyzed. All patients received CsA, Aza, and prednisone for 30 days with withdrawal of Aza at 30 days and then prednisone at 105 days; 57 patients were prospectively randomized to receive ALG (Merieux) until serum creatinine was less than 300 mumol/L. Short-term ALG administration did not influence the incidence, severity, nature, or outcome of rejection episodes. Fifty-five (50%) patients had at least 1 rejection in the first 90 days. All patients with delayed graft function and 7/8 (88%) sensitized patients (current PRA greater than 50%) had at least 1 rejection episode; 71% (n = 35) of all rejection episodes occurred in the first 30 days posttransplant. Patients rejection free at 90 days remained rejection free the entire first year. Graft loss was 18% for rejections in the first month, 13% for rejections occurring later (P = NS); 20% (n = 11) of patients had a second rejection and 1% (n = 2) had a third rejection. The risk of graft loss was 9% with a first rejection, 38% with a second rejection, and 50% with a third rejection. Of 12 (22%) rejections that were steroid resistant, 10 (83%) were reversed with OKT3. One-year graft survival for patients without rejection, with steroid-sensitive rejection, and with steroid-resistant rejection was 96%, 88% (P = ns), and 58% (P less than 0.001), respectively; 1 year SCr was 168 +/- 93, 196 +/- 77 (P = ns), and 268 +/- 96 microMol/L (P less than 0.05), respectively. Patients free of rejection and with stable renal function continued to do well on maintenance CsA monotherapy, and they were more likely to be on CsA monotherapy than those with rejection episodes (P less than 0.01).     

Strategies for compensating for the declining numbers of cadaver donor kidney transplants.

BACKGROUND: The living-donor and dual kidney transplantation programmes were initiated in the transplantation centre of Münster (TCM) as two approaches to compensate for the declining numbers of cadaver donor kidney transplants after the implementation of the new Eurotransplant Kidney Allocation System (ETKAS). We analysed the outcome of cadaver, living-donor and dual kidney transplantation and their effects on the waiting list in the TCM. METHODS: Between January 1990 and December 2000, 1184 kidney transplants were performed in the TCM. They were subdivided into cadaver, living-donor and dual kidney transplants and retrospectively analysed in terms of the number of kidney transplants performed, waiting time and waiting coefficient. In addition four representative groups were formed to reflect donor origin (I: cadaver kidney transplants allocated by the old ETKAS, n = 180; II: cadaver kidney transplants allocated by the new ETKAS, n = 139; III: living-donor kidney transplantation, n = 59; IV: dual kidney transplantation, n = 31) and compared according to graft function (initial diuresis, creatinine, 3-year graft function), patient survival and median waiting time. RESULTS: After the implementation of the new ETKAS, the number of cadaver donor kidney transplants at the TCM almost halved, but the proportion of living-donor kidney transplantations increased significantly by 12.8% and of dual kidney transplantations by 8.5%. Patients who had received kidneys from cadaver donors allocated by the new ETKAS (group II) had a better survival rate, short- and long-term function but a longer waiting time than in group I (old ETKAS). Patients with dual kidney transplants (group IV) showed the lowest survival and short-term function rate, but had long-term function equivalent to that of cadaver kidney transplants (groups I and II). Patients who had received kidneys from living donors (group III) had the best survival, and short- and long-term function rate as well as the shortest mean waiting time. CONCLUSIONS: Living-donor and dual kidney transplantation proved to be functionally equivalent alternatives and successful strategies for compensating the declining numbers of cadaver donor kidney transplants.     

The influence of recipient body mass on the outcome of cadaver kidney transplants

Background. It is well known that a cadaver kidney transplant from an aged donor will result in lower graft survival. However, such marginal kidneys should not be easily given up, and it is important to explore ways to make the best use of them. Against this background, the present study was carried out to examine the relationship between recipient body mass and cadaver kidney transplant outcome. Methods. All 63 cadaver kidney transplant recipients at our institutions were studied. These patients were divided into two groups according to the age of the donor: group A (under age 60 years; n = 48) and group B (age 60 years and over; n = 15). Each of the groups was subdivided into two groups according to the mean body mass index (BMI) and body surface area (BSA) values, and the effects of BMI and BSA on graft survival were also studied. Results. There was no correlation between BMI and lowest serum creatinine (nadir S-Cr) in group A, but there was a positive correlation in group B. Similarly, there was a positive correlation between BSA and nadir S-Cr only in group B. In group A, there was no difference in graft survival between the recipients with a smaller BMI (BMI < 21.0) and larger BMI (BMI ≧ 21.0) or BSA. However, in group B, the 5-year graft survival of the recipients with a smaller BMI was 60.0%, and it was significantly better than that of the recipients with a larger BMI. Similarly, the 5-year graft survival of the recipients with a smaller BSA (BSA < 1.54 m²) was 62.5%, which was also significantly better than that of the recipients with a larger BSA (BSA ≧ 1.54 m²). Conclusions. In the recipients whose donor was aged 60 and over, recipient BMI and BSA affected posttransplant kidney function and graft survival. These results strongly suggest that the lower graft survival due to an aged donor can be improved if a recipient with a smaller body size can be selected. Received: January 10, 2001 / Accepted: March 28, 2002     

Significance of delayed graft function in cyclosporine-treated recipients of cadaver kidney transplants

Many transplant teams are reluctant to initiate cyclosporine immunosuppression in recipients of cadaver kidney grafts with delayed graft function (DGF). The renal function of cadaver kidney grafts in cyclosporine-treated recipients was compared in 47 recipients with DGF and 57 without DGF. Regardless of initial renal function, all recipients received prednisone, azathioprine, and oral cyclosporine 5 mg/kg/day or its intravenous equivalent. All kidneys were flushed with ice-cold intracellular electrolyte solution and cold-stored for 15-54 hr (mean of 31 hr) prior to transplantation at our hospital between April 10, 1985 and November 30, 1986. Rejection crises were treated with high-dose steroids or OKT3. Cyclosporine was discontinued during courses of OKT3. Recipients with DGF had significantly higher one-month serum creatinine nadirs (2.6 +/- 1.8 mg/dl vs. 1.5 +/- 0.5 mg/dl). Actuarial graft survivals were not significantly different at one year (82.2 +/- 5.5% vs. 82.6 +/- 6.4%, all graft losses included). Mean serum creatinine levels at six months and twelve months after grafting were not significantly different (1.7 +/- 0.4 mg/dl vs. 1.8 +/- 1.2 mg/dl and 2.0 +/- 0.5 vs. 1.7 +/- 0.7 mg/dl, respectively). Delayed graft function following cadaver kidney transplantation does not adversely affect intermediate term function of kidney grafts flushed with intracellular electrolyte solution and cold-stored until transplantation when a low-dose cyclosporine induction protocol is used and cyclosporine is discontinued during OKT3 administration.     

Effect of blood transfusions on survival of cadaver and living related renal transplants.

The effect of blood transfusion was analyzed in 194 first cadaver renal transplants and 86 living related renal transplants. The association of blood transfusion with HLA genotyping and poor risk recipients was analyzed. Exclusion of poor risk recipients improved graft survival among the transfused group of patients but not in the small subgroup of nontransfused recipients. No effect of blood transfusion was observed in the living related group. Improved graft survival was observed in both the haplotype-matched and nonhaplotype-matched transfused cadaver recipients. The haplotype-transfused recipients had grafts survival rates of 69 and 66% at 1 and 2 years, respectively. The greatest beneficial effect was seen in the double haplotype-transfused cadaver recipients with graft survival rates of 80 and 71% for the same period. The lack of beneficial effect of transfusion in the living related patients is felt to be a result of the fact that the maximum effect had already been achieved by a far superior donor-recipient histocompatibility than is able to be achieved in a large group of cadaver recipients.     

Influence of acute tubular necrosis on first cadaver kidney transplant function

Prolonged cold storage following intracellular electrolyte flushing increases the probability of significant acute tubular necrosis after cadaver kidney transplantation. The renal function of primary cadaver kidney grafts was compared in 68 recipients who required dialysis and 92 who did not require dialysis during the first week after transplantation. All kidneys were retrieved from beating-heart cadaver donors by our center, flushed with ice-cold intracellular electrolyte solution and cold-stored until transplantation at our hospital. Recipients requiring dialysis during the first week after transplantation received kidneys with a significantly longer cold storage time (27.4 plus or minus 10.2 versus 23.2 plus or minus 7.6 hours) and had significantly higher 1-month serum creatinine nadirs (2.1 plus or minus 1.3 versus 1.5 plus or minus 0.6 mg./dl.). Actuarial kidney graft survivals and serum creatinine levels 1 to 5 years after grafting were not significantly different. Acute tubular necrosis following primary cadaver kidney transplantation does not adversely affect long-term function of kidney grafts flushed with intracellular electrolyte solution and cold-stored until transplantation.     

Use of anticoagulation in cadaver renal transplants

The effect of anticoagulation was studied in 92 consecutive cadaver renal transplants performed in 90 patients from 1977 to 1980. Patients were randomized to receive prophylactic anticoagulation with warfarin and antiplatelet drugs beginning on the second post-transplant day, or therapeutic heparin for acute rejection episodes with vascular involvement, only. These patients were later converted to long-term anticoagulation with warfarin and antiplatelet drugs. All first rejection episodes were diagnosed by percutaneous renal biopsy and scored as to the degree of cellular infiltrate and vascular change. Immunosuppression consisted of azathioprine, prednisone, methylprednisolone, and, in 19 patients, antilymphoblast globulin (ALG) given for 14 days post-transplant. Rejection episodes were treated in 76 patients. Severe rejection did not respond to any form of treatment and all these grafts failed in less than 3 months. Severe cellular rejection did not occur in ALG-treated patients. Heparin treatment improved the 3-month graft survival in patients with acute rejection and mild vascular changes but did not alter the results in any other category. Chronic rejection was not prevented by any method of anticoagulation. Bleeding complications occurred in 18.4% of patients receiving warfarin and 7.7% of the patients receiving heparin. Anticoagulation with heparin may be useful in the treatment of acute rejection with mild vascular changes. Biopsy-proven severe rejection accurately predicts early graft failure regardless of treatment and should prompt transplant nephrectomy.     

Long-term success with double pediatric cadaver donor renal transplants.

Many institutions are reluctant to use pediatric cadaver kidneys for transplantation because of a fear of an increased risk of technical complications or because these grafts leave the recipient with a relatively small amount of functioning renal tissue. From 1971 to 1981 the authors performed 21 double pediatric cadaver donor renal transplants. Eleven of these grafts are currently functioning for periods up to 11 years post-transplant. Only one graft was lost due to a technical complication. Using actuarial analysis, the graft survival and patient survival in this group of patients was compared with a control group of 39 computer matched and randomly selected recipients of adult cadaver kidneys and to all nonmatched recipients of cadaver kidneys during the same time period. There were no statistically significant differences among the three groups in graft survival or in patient survival. It is concluded that the long-term results with double pediatric cadaver kidney transplants are the same as those using single adult cadaver kidneys. Pediatric kidneys should be used whenever they are available so that transplantation can be extended to more patients.