Unrelated living donor kidney transplantation

Since 1966, we have performed 41 renal transplants from unrelated living donors (ULD), 39 of which were emotionally related. All donor-recipient pairs included in the present series were AB0-compatible. Recipients included 37 with primary and 4 with secondary transplants; 2 of the latter were diabetics. We compared these results to those of 41 recipients of cadaver donor kidneys matched for age, sex, immunosuppressive regimen, rank, and year of transplant, focusing our attention of the subgroups of patients under cyclosporin A (CyA) therapy (n=24). We found that ULD transplantation was as successful as cadaver transplantation with good HLA matching: at 3 years, graft survival rates were 81% in ULD versus 86% in the control group under CyA. Moreover, grafts from ULD functioned more rapidly (no post-transplant dialysis and 70% of the patients with serum creatinine below 2 mg/dl within 3 days post-transplant). Graft tolerance was equivalent in both groups (50% of the patients experienced no rejection). We conclude that despite poor HLA matching, ULD transplantation with CyA as the basic immunosuppressive agent offers good results: benefiting from the quality of living donor kidney grafts, it helps to alleviate the persistent shortage of cadaver donors.     

亲属活体肾移植的临床分析和移植肾组织病理分析

目的 总结亲属活体肾移植后移植肾组织活检资料，并结合临床进行回顾性分析。方法亲属活体肾移植55例，其中有血缘的亲属供肾移植53例，夫妻间供肾移植2例。供、受者间HLA配型，1条单倍型相同者45例，2条单倍型相同者6例，5个抗原错配者3例，完全错配者1例。除1例采用腹腔镜取肾外，其余均采取开放手术取肾。供肾热缺血时间1～8min，冷缺血时间1～2h。术后应用环孢素A（或他克莫司）、硫唑嘌呤（或霉酚酸酯）及泼尼松预防排斥反应。结果 55例中，有10例接受16次移植肾活检，结果 4例次为急性排斥反应（Banff分级均为Ⅰ级），3例次经甲泼尼龙冲击治疗逆转，1例合并慢性移植肾肾病，治疗无效，恢复透析；3例次为移植肾退行性病变（其中2例合并急性环孢素A肾毒性损伤），2例减少环孢素A用量，并加用西罗莫司，效果良好，1例将环孢素A转换为西罗莫司，效果不佳，恢复透析；4例次为急性肾小管坏死，采用他克莫司和霉酚酸酯联合用药，并辅以透析治疗，肾功能恢复正常。结论 虽然亲属活体肾移植术后急性排斥反应和移植肾功能恢复延迟的发生率低，但仍应重视术后移植肾组织活检，将被动活检转为主动的计划性活检，以提高亚临床排斥反应的检出率。     

Ethical issues in living donor kidney transplantation

The ethical issues of living donor kidney transplantation, which is the treatment of choice for patients with end-stage renal failure, are the focus of intense debate. Some of those issues are related to the safety of the operation for the donor, and others are related to the motivation of the donor, the approach to and evaluation of the donor, donation by strangers, the commercialization of donation, surrogate consent for donation, and the acceptance of minors as donors. The lack of clear consensus regarding these issues results in differences in practice, not only among countries but also among transplant centers. We believe that after an open debate, agreement on certain generally accepted principles can be achieved. Such an agreement would protect potential donors and recipients and would ensure the future of living donor kidney transplantation.     

Potential benefits of living donor kidney transplantation

Living donor kidney transplantation is the best therapeutic option for endstage renal failure. In spite of being an underused option in our country, it acquires an important role reducing the waiting lists for transplantation because cadaver donation is not enough. Living donor kidney transplantation offers multiple advantages when compared with cadaver donor transplantation: longer graft and patient survival on the short, mid and long-term; the fact that a scheduled procedure allows us to optimize donor and receptor's conditions; and ischemia time between nephrectomy and transplantation can be shortened to a minimum. A good initial function without need of dialysis (up to 90%) and lower incidence of rejection, which diminishes the need of antirejection drugs, should also be emphasized.     

Glomerular disease and living donor kidney transplantation

Glomerular diseases are an important and frequent cause of renal transplant graft loss in the mid-long term, mainly due to primary renal disease recurrence. Glomerular diseases have particular connotations in living donor kidney transplantation, due to the risk of primary disease recurrence and subsequent graft loss, and also the risk of development of glomerular disease related donors have for their genetic similitude. The incidence of glomerular disease recurrence after transplantation varies with type, being especially frequent in IgA nephropathy and type II membranous proliferative glomerulopathy. The difference between histological and clinical recurrence should always be established, being much more frequent the first. Renal biopsy is the essential diagnostic test to detect and confirm the existence of glomerular disease after transplant, with immunofluorescence study being necessary to determine the type of glomerular disease.     

活体肾移植血管重建69例临床分析

目的 介绍活体肾移植血管重建的临床经验.方法 自2005年12月至2008年11月共行活体肾移植69例,供者手术均采用十一肋间小切口开放手术.58例单支肾动脉除2例外均采用肾动脉与髂外动脉端侧吻合重建血管,用4 mm打孔器作髂外动脉开口;6例副肾动脉分别采用原位（肾下极副肾动脉）或离体腹壁下动脉（肾上极副肾动脉）重建血管;3例双支肾动脉根据两支动脉口径不同采用不同方法重建血管;2例3支肾动脉采用受者离体髂内动脉重建血管.结扎多支肾静脉中较小的肾静脉只吻合其较大的主干,当两支肾静脉口径相近时,则将其整形为一个开口后吻合.结果 所有血管吻合均一次完成,开放血流时吻合口均通畅;所有供者和受者术后均恢复顺利,受者未发生血管重建相关并发症;随访1个月～3年,供受者均存活, 受者除1例血肌酐250～300 μmol/L外,68例血肌酐维持在70～150 μmol/L.结论 该活体肾移植血管重建方式安全、实用、操作方便,多支供肾动脉及多支供肾静脉均能较好重建,移植肾功能良好.     

Cadaveric kidney transplantation: a model with limitations

The first successful kidney transplant in Spain was performed in 1965. It's been forty years already and currently Spain is the country with the highest cadaver donation rates worldwide. The so-called Spanish model of transplantation is well known for its organization and excellent results. These results are the consequence of a perfect network organization. Furthermore, the organ procurement organization--Organización Nacional de Trasplantes--, regional coordinators, national health system hospital network, hospital transplant coordinators, and all professionals involved in the process of donation and transplantation have perfectly well defined functions and work with the common objective of optimizing resources and making the most of the opportunities. Provided that one of the main characteristics of the Spanish model is the possibility of adaptation to the moments necessities, we proceed to review and evaluate it from its beginning to current days.     

Impact of donor age on living related donor kidney transplantation

Two comparable groups of kidney transplant recipients were identified according to the age of their kidney donors. The first group (A) comprised 42 recipients of donors aged < 40 years, and the second group (B) comprised 48 recipients of donors aged > 50 years. The patients were followed for a mean period of 26 months (range 13–50 months). Post-transplant renal function and graft survival were assessed together with the frequency of post-transplant proteinuria and hypertension. More-over, the functional reserve of the grafts was determined by comparing the clearance values, obtained by both isotope and chemical means, before and after a combined infusion of dopamine and an amino acids preparation. The graft function was significantly better in group A according to the serum creatinine levels (µmol/l) at 1 month (107 ± 4.5 vs. 134 ± 10.7, P < 0.01), 12 months (119 ± 5.3 vs. 181 ± 88, P < 0.05) and at last follow-up visit (118 ± 6.2 vs. 223 ± 63, P < 0.03) for groups A and B, respectively. The graft survival in group A was significantly higher than that in group B (100 % vs. 87 % at 1 year, P < 0.05). The graft functional reserve was significantly better in group A than in group B. Post-transplant proteinuria was significantly more frequent in group B recipients (70 % vs. 40 %, P < 0.03). The age of the donors had no impact on the incidence of post-transplant hypertension. These observations suggest that the transplantation of a kidney from an older live kidney donor is associated with an inferior post-transplant outcome.     

Evaluation of candidates for living donor kidney transplantation

Living donor kidney transplantation has become the option of preference for the treatment of endstage renal disease, whenever its performance is possible. The advantages of patient and graft survival should be balanced with risks associated with donation. Therefore, the evaluation of candidates for living donor kidney transplantation is mainly the comprehensive evaluation of these risks: medical, psychological, social and economic. Evaluating risks implies we are treating a controversial process, the medical progress, which is modifiable with time, even in the family and/or social environment of the donor-receptor couple. Short and long-term safety of living donor nephrectomy is directly engaged to the existence of a healthy donor. This he is the main objective of standard evaluation of candidates. Currently, with a growing demand of this option, minor abnormalities or risk factors detected during evaluation do not always become a formal contraindication, but we should try to establish a most objective threshold for the acceptance of donors in all evaluated spheres, for surgical risks and others directly related or not with renal mass reduction, and even for those engaged to the existence of a genetic link between donor and receptor, which might determine the presence of any future primary renal disease. As for other donation types, the process of evaluation should also ensure minimal risks for the receptor, with the same safety criteria applied to cadaver donors. We can conclude that careful evaluation of candidates for living kidney donation is the best guarantee for their safety and transplant success, and, in our opinion, it is the best instrument to offer an adequate informed consent.     

Outcome in emotionally related living kidney donor transplantation

Background. The growing shortage of cadaver kidneys, the limited possibilities to expand the living related donor pool and the good results obtained in our centre with poorly matched cadaver kidneys, led us in 1991 to begin accepting highly motivated, unrelated, living kidney donors who had a strong emotional bond with the recipients. Methods. Between 1 January 1991 and 1 January 1996, 46 potential living kidney donors and their emotionally related recipients were evaluated. Twenty-three cases were accepted for renal transplantation after thorough somatic and psychological evaluation. The mean post-transplant follow-up until 1 April 1996 was of 28±3 months. Compatible blood groups and a negative cross-match were mandatory, but no minimal HLA matching was required. Results. There was a 50% drop-out rate following the initial screening. The main reasons for not performing transplantation were immunological contraindications in 39% of the cases, somatic in 30.5%, psychological in 26% and socioeconomic in 4.5%. In the accepted group of recipients, 48% (11/23) received transplants without chronic dialysis. Donor survival was 91%; two deaths unrelated to nephrectomy occurred 1 year after donation. The 2-year actuarial recipient and graft survivals were 100% and 91% respectively, compared to 99% (recipients) and 93% (grafts) in the non-HLA-identical living related kidney transplant group, and to 93% (recipients) and 83% (grafts) in the cadaver kidney transplant group. Recipient rehabilitation was completed after 4±1 months. Emotionally related donors returned to work 5±2 weeks after nephrectomy, and no donor regretted his decision, even in the case of failure. Conclusions. Kidney transplantation from emotionally related living donors represents a valuable option, allowing more patients with end-stage renal disease to avoid chronic dialysis. Recipient and graft outcome were superior to cadaver kidney transplantation. Motivated and emotionally related donors should be allowed to donate one of their kidneys provided that they are carefully selected and thoroughly informed.     

Development of malignancy following living donor kidney transplantation

BACKGROUND: Malignancy following renal transplantation is an important medical problem during the long-term follow-up. We studied some features of the cancers that developed in our patients. METHODS: We retrospectively reviewed all patients who underwent renal transplantation and developed malignancy from July 1984 to July 2004. RESULTS: The 2117 patients who underwent living donor kidney transplantation during the 19-year period had a mean follow-up of 81.1 +/- 61 months. During the follow-up, 38 patients (1.8%) developed cancer: 14 Kaposi's sarcomas, 11 lymphoproliferative diseases, four squamous cell carcinomas of the skin, two basal cell carcinomas, one breast, one ovary, one melanoma, one seminoma, one lung, and one ovary. Mean age at transplantation in the malignancy cases was higher than the other recipients (43.5 +/- 12.1 vs 32 +/- 13.9 years) (P = .000). A Kaposi's sarcoma occurred earlier compared with the other cancers (23 +/- 22 vs 62 +/- 44 months P < .05); most of these patients were over 40 years at transplantation (P < .05). We also observed that patients treated with mycophenolate mofetil developed cancer earlier than the others (19 vs 52 months; P = .001). None of the cases with lymphoma had a history of antilymphocytic agent therapy. The 10-year patient survival was 73%. CONCLUSION: The prevalence of cancer (1.8%) was among the lowest compared with other studies possibly due to implementing a living donor kidney transplantation program that required a low frequency of induction therapy.