DCD donor hemodynamics as predictor of outcome after kidney transplantation

Insufficient hemodynamics during agonal phase—ie, the period between withdrawal of life‐sustaining treatment and circulatory arrest—in Maastricht category III circulatory‐death donors (DCD) potentially exacerbate ischemia/reperfusion injury. We included 409 Dutch adult recipients of DCD donor kidneys transplanted between 2006 and 2014. Peripheral oxygen saturation (SpO2‐with pulse oximetry at the fingertip) and systolic blood pressure (SBP‐with arterial catheter) were measured during agonal phase, and were dichotomized into minutes of SpO2 > 60% or SpO2 < 60%, and minutes of SBP > 80 mmHg or SBP < 80 mmHg. Outcome measures were and primary non‐function (PNF), delayed graft function (DGF), and three‐year graft survival. Primary non‐function (PNF) rate was 6.6%, delayed graft function (DGF) rate was 67%, and graft survival at three years was 76%. Longer periods of agonal phase (median 16 min [IQR 11‐23]) contributed significantly to an increased risk of DGF (P = .012), but not to PNF (P = .071) and graft failure (P = .528). Multiple logistic regression analysis showed that an increase from 7 to 20 minutes in period of SBP < 80 mmHg was associated with 2.19 times the odds (95% CI 1.08‐4.46, P = .030) for DGF. In conclusion, duration of agonal phase is associated with early transplant outcome. SBP < 80 mmHg during agonal phase shows a better discrimination for transplant outcome than SpO2 < 60% does.     

Preemptive transplantation and long-term outcome in living donor kidney transplantation, single-center experience

Although preemptive transplantation of kidneys from living donors without the previous initiation of dialysis is associated with longer allograft survival in a USRDS cohort, the effect of pretransplantation dialysis on graft outcome is still controversial in Korea. The purpose of this study was to evaluate the differential effects on long-term outcomes of living donor kidney transplantation according to initiation of dialysis and its duration or no dialysis. We performed a retrospective cohort study of 494 patients who received a first kidney transplant from a living donor between 1990 and 2006. The mean duration for dialysis was 14.5+/-22.2 months. The 10-year patient survival of 98.0% in the preemptive group was not significantly higher than the dialysis group (91.2%, P>.05). However, 10-year graft survival was higher in the preemptive than the dialysis group (preemptive 94.4%, dialysis 76.5%; P<.05). The differential effect of pretransplant dialysis either by hemodialysis or peritoneal dialysis was not significant, although peritoneal dialysis as a pretransplant treatment seemed to be beneficial on long-term graft survival (5-year graft survival; peritoneal 94.8% and hemodialysis 89.2%). The duration of dialysis did not affect graft survival in our study cohort. In conclusion, we suggest that preemptive transplantation should be applied to eligible patients.     

Risk factors among donor characteristics which affect graft outcome in paired kidney transplantation

OBJECTIVE: The goal of this study was to identify risk factors among donor characteristics which affect short- and long-term graft outcomes and patient survivals. MATERIALS AND METHODS: This is a retrospective analysis of cases where the kidneys were retrieved from the same donor. We evaluated donor variables including age, sex, cytomegalovirus (CMV) status, infection, blood pressure, electrolyte, urine output, transfusion, cause of death, creatinine level, and cold ischemia time. We also analyzed recipient outcomes and graft function. RESULTS: We analyzed 21 donor and 42 recipient records. The majority of donors (85.0%) were <50 years old. The mean donor urine output was 169 mL/h. Delayed graft function was not affected by donor variables. The serum Na and CMV status of the donor were related to the occurrence of an acute rejection episode, but only CMV status showed a significant influence in the multivariate analysis. Among different groups of donor creatinine, better donor function (creatinine <1.0 vs >1.0 mg/dL) was associated with better posttransplantation graft function (creatinine 1.18 vs 2.26 mg/dL). In long-term graft function and survival, donor creatinine showed no significant impact. According to the sequence of transplantation, recipients were divided into group 1 (first kidney transplantation: mean ischemia time, 207 minutes) vs group 2 (second kidney transplantation: mean ischemia time, 441 minutes). Group 1 showed better graft function and survival time. CONCLUSIONS: Only CMV status of the donor was related to acute rejection episodes after renal transplantation. The donor creatinine data also affected initial posttransplantation creatinine. There was no significant difference in long-term graft survival among various levels of donor kidney function.     

嵌合体与同种异体肾移植免疫耐受相关性的研究

目的　探讨同种异体肾移植术后嵌合体表达情况与免疫耐受的相关性。　方法　采用3对引物 ,应用PCR和RT PCR方法 ,检测接受男性供体肾移植的女性受者外周血及尿沉渣Y染色体特异片段DNA和mRNA表达 ,进行嵌合体与免疫耐受相关性研究。　结果　 176例女性受者嵌合阳性 137例 ( 77.84 % ) ,阴性 39例 ( 2 2 .16 % )。阳性组平均存活时间 ( 8.9± 3.7)年 ,阴性组 ( 5 .2± 3.9)年 ,差异有显著性意义 (P <0 .0 5 ) ;阳性组发生排斥反应 15例 ( 10 .9% ) ,阴性组 11例 ( 2 8.2 % ) ,差异有显著性意义 (P <0 .0 5 )。　结论　肾移植术后受者体内嵌合状态与免疫耐受相关 ,微嵌合体可以作为器官移植免疫耐受监测的生物学参考指标     

甲状腺激素水平与移植肾功能关系的临床研究

目的 探讨肾移植受者的血清甲状腺激素水平与移植肾功能的关系.方法 57例肾移植受者根据移植后肾功能恢复情况分为移植肾功能恢复延迟(DGF)组(7例)和稳定组(50例).检测两组术前及术后不同时间的血清三碘甲状腺原氨酸(T3)、甲状腺素(T4)、促甲状腺素(TSH)和血清肌酐(Scr)水平.另检测30名健康志愿者的4项指标水平,作为正常对照.将稳定组术后第10天甲状腺激素水平与Scr水平进行相关性分析.结果 稳定组和DGF组术前血清T3、T4水平低于对照组(P＜0.01),而两组术前TSH水平与对照组相比较,差异无统计学意义(P＞0.05).稳定组与DGF组间术前各指标的差异无统计学意义(P＞0.05).稳定组术后第1天T3较术前下降约30％(P＜0.05),下降幅度大于其他指标,直到术后1周开始上升,术后2周接近正常水平,术后3周时已高于术前(P＜0.01);T4术后早期降低,10d后呈上升趋势,术后3周才接近术前水平;术后各时间段TSH水平与术前相比较,差异均无统计学意义(P＞0.05);Scr于术后7d恢复至正常水平.DGF组T3于术后21 d达到正常水平,T4于术后30 d达到术前水平;Scr于术后30 d达到正常水平.术后第10天,稳定组受者血清T3与Scr呈负相关(相关系数=0.546,P＜0.01),T4与Scr呈负相关(相关系数=0.423,P＜0.01).TSH与Scr无相关性.结论 T3、T4水平与移植后肾功能有相关性,要重视肾移植受者术后早期甲状腺功能状态及对受者恢复的影响.     

影响尸体肾移植长期疗效和患者预后的因素分析

目的 探讨影响尸体肾移植长期疗效和患者预后的危险因素.方法 对1984年2月至2006年4月间的2256例尸体肾移植患者的资料进行回顾性分析,其中首次肾移植2164例,二次肾移植91例,三次肾移植1例.术前行血液透析者1653例(73.3%),行腹膜透析者319例(14.1%),未进行透析者284例(12.6%).1996年之前组织配型主要采用ABO血型和淋巴细胞毒交叉配合试验;1996年后采用HIA配型和群体反应性抗体(PRA)检测,HLA抗原错配<3个者占60%.免疫抑制方案主要有由环孢素A(CsA)和泼尼松(Pred)组成的二联用药,CsA(或他克莫司)、硫唑嘌呤(或霉酚酸酯)和Pred组成的三联用药,部分病例加用抗淋巴细胞球蛋白(ALG)或抗胸腺细胞球蛋白(ATG),2001年后将ALG(或ATG)改为达利珠单抗.应用Kaplan-Meier分析计算患者及移植肾的1、3、5、10及15年存活率以及移植肾半寿期,对影响受者和移植肾存活率的危险因素进行Log-Rank单因素分析和Cox模型多因素回归分析.结果 术后随访1～20年,患者的1、3、5、10及15年存活率分别为95.3%、89.6%、86.0%、71.3%和61.3%,移植肾的1、3、5、10及15年存活率分别为91.3%、79.3%、74.0%、52.6%和44.8%,移植肾半寿期为(11.58±0.26)年.1984-1995年、1996-2000年与2001-2006年间移植者,其移植肾1、3和5年存活率呈上升趋势(P<0.01).移植肾功能恢复延迟、急性排斥反应、感染、糖尿病及术前PRA阳性是导致移植肾存活率降低的独立危险因素(P<0.05),霉酚酸酯可显著提高移植肾存活率(P<0.01).感染、糖尿病及心脑血管疾病是导致患者存活率下降的独立危险因素(P<0.01).结论 随着移植肾存活率的上升,积极防治感染、糖尿病和心脑血管疾病等并发症,是进一步提高人、肾存活率的关键.     

Living unrelated donor kidney transplantation between spouses

From November 3, 1975 to November 3, 1990, 874 kidney transplants were performed at our centers. Of these, 675 (77.2%) were from living donors and 199 (22.8%) were from cadaver donors. Five hundred eighty (66.4%) of the living donors were first degree related while 99 (11.3%) were unrelated or second degree related donors, 29 of which were spouses. All donor recipient pairs were ABO-compatible, with the exception of one pair. Donor recipient relations were wife to husband in 25 cases and husband to wife in 4 cases. All were first grafts and started functioning during surgery. In this series, the follow-up for the recipients was 4 to 64 months (mean 33.5 ± 4.5 months). One-year patient survival and graft survival rates were 92.4% and 81.9%, respectively. Two-year patient survival and graft survival rates were 92.4% and 78.2%, respectively. The single ABO-incompatible case is also doing well, 21 months postoperatively. This study demonstrates that the interspouse kidney transplantation may be used when cadaver organ shortage is a problem. While providing the couple with a better quality of life, interspouse kidney transplantation also enables the couple to share the joy of giving and receiving the gift of life from one another.

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Resumen En nuestro centro se efectuaron 874 trasplantes renales entre noviembre 3 de 1975 y noviembre 3 de 1990; 675 (77.2%) fueron de donantes vivos y 199 (22.8%) de donantes cadavéricos; 580 (66.4%) de los donantes vivos fueron familiares de primer grado y 99 (11.3%) fueron donantes no relacionados familiarmente o familiares de segundo grado, de los cuales 29 eran cónyuges. Todas las parejas donante-recipiente exhibieron compatibilidad ABO, con excepción de una. La relación donante-recipiente fue esposa a esposo en 25 casos y esposo a esposa en 4 casos. Todos los injertos eran de primera vez y todos comenzaron a funcionar en la mesa de cirugía. El seguimiento osciló entre 4 y 64 meses (33.5 ± 4.5). Las tasas de sobrevida a un año del paciente y del injerto fueron 92.4% y 81.9% respectivamente; las tasas a dos años fueron 92.4% y 78.2% respectivamente. El único caso ABO no compatible también se encuentra bien, a 21 meses en la actualidad. El presente estudio demuestra que el trasplante renal entre esposos puede ser utilizado cuando haya escases de órganos cadavéricos. Al tiempo que permite una mejor calidad de vida, el procedimiento da a la pareja la oportunidad de gozar el hecho de otorgar y de recibir el regalo de la vida entre uno y otro.

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Résumé Nous avons effectué 874 transplantations rénales dans nos centres de transplantation entre le 3 Nov, 1975 et le 3 Nov, 1990. Parmi celles-ci, 675 (77.2%) provenaient de donneurs vivants et 199 (22.8%) des reins provenaient de cadavres. Cinq cent quatre vingt des donneurs vivants (66.4%) étaient parents au premier degré alors que 99 (11.3%) étaient parents au 2è degré ou n'étaient pas parents, parmi lesquels 29 étaient des époux. Tous les couples donneur/receveur, sauf un, étaient compatibles dans le système ABO. Le couple donneur/receveur était femme à mari dans 25 cas et mari à femme dans quatre. Il s'agissait dans tous les cas d'une première greffe et qui a commencé à bien fonctionner sur la table d'opération. Dans cette série, le suivi des receveurs allait de 4 à 64 (33.5 ± 4.5) mois. Les taux de survie des malades et des greffes à un an étaient respectivement de 92.4% et 81.9%. Les taux de survie des malades et des greffes à deux ans étaient respectivement de 92.4% et 78.2%. Le seul cas avec incompatabilité ABO va très bien avec un recul de 21 mois. Cette étude montre que la transplantation entre époux est une solution valable en cas de manque de reins. En plus d'améliorer la qualité de survie du receveur et par là même du couple, cette variété de transplantation donne également au couple la possibilité d'avoir la joie de donner et de recevoir un cadeau de vie de leur époux.

     

活体肾移植和尸体肾移植术后疗效和安全性比较

近年来随着尸体供肾的日益短缺,国内活体肾移植例数迅速增加,但活体肾移植术后疗效和安全性尚有待进一步探讨.本研究回顾分析我院过去4年多来肾移植资料,比较两组患者术后长期疗效和安全性差异.     

HLA配型与肾移植术后早期急性排斥反应的关系

目的 研究ＨＬＡ配型与尸体肾移植术后早期急性排斥反应的关系。方法 将２６２例尸体肾移植受者按ＨＬＡ配型的误配率（ＭＭ）进行分组,统计各组术后１～２个月内急性排斥反应的发生次数。结果 当ＭＭ〉３时,若接受的器官ＨＬＡ抗原／基因为可接受性,术后急性排斥反应的发生率为１６．４％;若供体器官ＨＬＡ抗原／基因具免疫原性,则急性排斥反应的发生率为３３．１％,两者比较,Ｐ〈０．０５。结论 供受者间ＨＬＡ配型越好     

Chronic renal outcome after living donor liver transplantation

Chronic kidney disease (CKD) is one of the common complications after deceased donor liver transplantation. Although the worldwide pressing shortage in deceased donors has directed attention to living donor liver transplantation (LDLT), LDLT cohort data focusing on chronic renal dysfunction is limited. A total of 280 adult LDLT recipients (median 49 yr, 156 men) at the University of Tokyo hospital between 1996 and 2006 were reviewed. A total of 224 pre‐transplant liver failure patients (80.0%) showed an estimated glomerular filtration rate (eGFR) of more than 60 mL/min/1.73 m². However, during follow‐up at a mean of 1222 d after transplantation, eGFR declined to 60 mL/min/1.73 m² and 30 mL/min/1.73 m² in 150 (53.2%) and 21 (7.5%), respectively, and four patients (1.4%) required maintenance renal replacement therapy. Multivariate Cox proportional hazard model regression analysis revealed that recipient age (HR, 3.42 per 10‐yr increment; p < 0.001) and pre‐transplant eGFR (HR, 0.85 per 10‐mL/min/1.73 m² increment; p = 0.04) were associated independently with a post‐transplant decrease in eGFR to less than 30 mL/min/1.73 m². We conclude that higher age and lower pre‐transplant eGFR of an LDLT recipient indicate a high likelihood of subsequent development of advanced CKD. Preventive or therapeutic intervention should be optimized for these high‐risk patients.     

Charcot neuroarthropathy after simultaneous pancreas–kidney transplantation: risk factors,prevalence, and outcome

We retrospectively analyzed outcome and risk factors of developing Charcot foot (CF) in 100 patients with type 1 diabetes mellitus who underwent a simultaneous pancreas–kidney (SPK) transplantation. Patients who developed CF after SPK transplantation had significantly higher mortality (56% vs. 18%) and more frequently graft failure (44% vs. 13%). Recipients with CF also experienced acute rejections more frequently (78% vs. 41%). They furthermore had higher pre‐transplant values of HbA_1c, received cyclosporine and azathioprine more often, and had significantly higher cumulative corticosteroid use. Patients transplanted in an earlier era (1992–1998) received cyclosporine and azathioprine more often and had a significantly higher cumulative corticosteroid use with the higher prevalence of CF. Conversely, patients with diabetes transplanted more recently (1999–2012) received lower doses of corticosteroids as part of their tacrolimus‐based immunosuppressive therapy, resulting in fewer CF attacks. In conclusion, development of CF after SPK is associated with poor patient and graft outcome. Poor pre‐transplant diabetic control and the use of high‐dose corticosteroids are risk factors for the development of CF. We recommend reduction in or even total avoidance of corticosteroids after SPK transplantation. Given the importance of the diagnosis of CF on outcome, a systematic examination of SPK patients' feet is recommended.     

Relationship between compensatory hypertrophy of the remnant kidney after donor nephrectomy and albuminuria

Clinical and Experimental Nephrology -     

Renal outcome after simultaneous heart and kidney transplantation

Simultaneous heart‐kidney transplant (HKTx) is a valid treatment for patients with coexisting heart and renal failure. The aim of this study was to assess renal outcome in HKTx and to identify predictive factors for renal loss. A retrospective study was conducted among 73 HKTx recipients: Donors’ and recipients' records were reviewed to evaluate patients’ and renal transplants’ survival and their prognostic factors. The mean follow‐up was 5.36 years. Renal primary non‐function occurred in 2.7%, and complications Clavien IIIb or higher were observed in 67.1% including 16 (22%) postoperative deaths. Five‐year overall survival and renal survival were 74.5% and 69.4%. Among survivors, seven returned to dialysis during follow‐up. The postoperative use of ECMO (HR = 6.04, P = 0.006), dialysis (HR = 1.04/day, P = 0.022), and occurrence of complications (HR = 31.79, P = 0.022) were independent predictors of postoperative mortality but not the history of previous HTx or KTx nor renal function prior to transplantation. History of KTx (HR = 2.52, P = 0.026) and increased delay between the two transplantations (HR = 1.25/hour, P = 0.018) were associated with renal transplant failure. HKTx provides good renal transplant survival and function, among survivors. Early mortality rate of 22% underlines the need to identify perioperative risk factors that would lead to more judicious and responsible allocation of a scarce resource.     

Living donor and kidney transplantation

The medical, immunological and surgical histories of the transplantation of kidneys from a living donor have been developed differently. Living kidney transplantation involves better organ quality and also better kidney function than postmortem kidney transplantation. In Germany, living kidney transplantation is legally based on the transplantation statute of 1997. Traditionally, retroperitoneoscopic open nephrectomy is the gold standard used by most transplantation centers in Germany. The laparoscopic hand-assisted nephrectomy is a very good alternative to other surgical methods, but must be applied by experience surgeons. Digital subtraction angiography gives the best information on the maintenance of the vessels of the kidney, the vessels to the upper or lower poles and the retrocaval course of the venous vessels. The rate of postoperative complications for transplantation from a living kidney donor is lower than that for postmortem kidney transplantation. The formation of a donor organ registry can be very helpful in the evaluation and handling of information on organ donation.