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.

     

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     

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.     

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

Clinical and Experimental Nephrology -     

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.     

Living donor kidney transplantation

Living donor kidney transplantation is the optimum treatment for the uremic patient. Successful kidney transplantations started in 1953 in Boston and in Sweden in 1964. This article showed data on the selection of the donor, surgical techniques for the removal of the kidney, and follow-up of short-term complications. The long-term results included the number of donors who developed hypertension and the few donors who developed end-stage renal failure (ESRF) and the reasons for this. Finally, new groups of donors such as blood group-incompatible donors and anonymous donors have been accepted, each of whom have their own programs. This article also discussed our responsibilities as renal specialists or transplant surgeons for kidney donors at surgery and postsurgery.     

Hemolytic anemia after ABO nonidentical living donor kidney transplantation

Introduction  ABO compatible non-identical kidney transplants are used frequently. Acquired hemolytic anemia has been reported after ABO mismatched transplantation. Patients of A, B or AB blood groups may receive organs from ABO-compatible, but non-identical donors, mostly from O blood group donors. It may also occur in patients of the AB blood group who receive a kidney from a donor of the A or B blood groups. Patients and methods  ABO non-identical living donor kidney transplantation was done in 214 cases. All studied patients received kidneys from one haplotype HLA mismatched living donors and had pretransplant non-specific blood transfusions. There were 164 males and 50 females with a mean age of 30 years. Ten patients with cyclosporine (CsA)-based therapy developed hemolysis. CsA was stopped in patients maintained on triple immunosuppression (pred, CsA, AZA) and shifted to azathioprine in patients maintained on pred CsA therapy. In all patients pretransplant antibody screen, direct antiglobulin test (DAT) and cytotoxic cross match were all negative. Results  The prognosis was excellent in nine patients, and one died from severe hemolysis. Hemolytic anemia was more frequent among blood group A recipients (60% of our cases) and more severe among recipient blood group B. Six patients received antigen-negative packed RBCs. Univariate analysis demonstrated significant impact for recipient age, donor sex, number of pretransplant blood transfusions, primary immunosuppression, time to onset of diuresis, recipient and donor blood groups. Multivariate analysis restricted the significance to blood group of donor and recipient, time to onset of diuresis and primary immunosuppression. Conclusions  Post transplant hemolysis is infrequent after renal transplantation; however, it may occur with compatible, non-identical ABO blood group donors. Blood group of donor and recipient, time to onset of diuresis and primary immunosuppression (mainly CsA) were significant risk factors in hemolytic anemia in patients after ABO non-identical living donor kidney transplantation. The condition is usually mild and self limited, and change of immunosuppression (stop CsA) can treat the condition.