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.     

肾移植术后妊娠对移植肾的影响

目的 探讨肾移植术后妊娠对移植肾的影响。方法 对1978年4月至2002年3月妊娠超过5个月的13例肾移植受者资料进行回顾性分析。结果 免疫抑制方案，4例采用环孢素A（CsA)及泼尼松（Pred)。5例为CsA，霉酚酸酯（MMF）及Pred。4例为他他克莫司（FK506），MMF及Pred。13例中，10例患者妊娠足月，生产，母，婴均存活，移植肾功能稳定；1例产后2周因并发肺部感染，心力衰竭死亡，死亡时移植肾有功能，婴儿存活；2例妊娠中期出现蛋白尿，病理证实移植肾发生慢性排斥反应，终止妊娠，但抗排斥治疗无效，切除移植肾，恢复血液透析，目前11名子女健康，无发育异常。结论 肾移植患者若情况允许，在严重监护下是可以妊娠的。     

Hypertension two years after renal transplantation: causes and consequences

The incidence of hypertension 2 years after renal transplantation and the possible causes of hypertension were studied retrospectively. A group of 93 patients treated with cyclosporin (CyA), azathioprine (Aza), and/or prednisolone (Pred) were compared to a group of 31 patients treated with Aza and Pred. There were more patients with hypertension in the CyA group (73%) than in the Aza group (58%). Hypertension before transplantation predisposed to hypertension after transplantation. After transplantation, hypertension was most common among patients with polycystic kidney disease (46%), chronic glomerulonephritis (67%), and diabetes (71%). The accumulated immunosuppressive medication (CyA/Pred) did not affect the occurrence of hypertension. Hypertensive patients had significantly poorer graft function than did normotensive patients (serum creatinine level 229 mol/l vs 162 mol/l, P<0.01). The 10-year graft survival was markedly impaired in the group with hypertension (42% vs 65% for normotensives, P<0.05). The 10-year patient survival was 59% vs 79% (P=NS). The study further confirms the frequent finding that hypertension has a negative effect on graft and patient survival rates.     

Treatment and outcome of invasive bladder cancer in patients after renal transplantation

PURPOSE: Optimal management and clinical outcome of bladder cancer in renal transplant recipients are not well-defined. We analyzed single institution treatment strategies and outcomes of these patients. MATERIALS AND METHODS: We retrospectively reviewed the University of California, San Francisco transplant database which contains information on 6,288 renal transplants performed between 1964 and 2002. The United Network for Organ Sharing database and Israel Penn International Transplant Tumor Registry were also queried to characterize the global nature of bladder cancer in renal transplant recipients. RESULTS: The United Network for Organ Sharing database (1986 to 2001) contained information on 31 patients who were found to have bladder cancer (0.024% prevalence) and the Israel Penn International Transplant Tumor Registry (1967 to 2001) contained information on 135 patients representing 0.84% of all reported malignancies. We identified 7 renal transplant recipients with bladder cancer at our institution. Invasive transitional cell carcinoma developed in 5 patients at a median of 2.8 years after transplant. Three patients underwent uncomplicated radical cystectomy and preservation of the renal allograft. Overall survival at 48 months was 60%. CONCLUSIONS: Bladder cancer after renal transplantation is not common. For patients who present with invasive disease, traditional extirpative surgery should be considered. Moreover, the allograft is rarely the source of transitional cell carcinoma and can be preserved. In our experience the cancer and urinary outcomes compare favorably with nontransplant patient outcomes after treatment.     

Impact of the ratio of graft kidney volume to recipient body surface area on graft function after live donor kidney transplantation

Functioning nephron mass is a determinant of the graft function of kidney transplant recipients. The graft kidney volume and its weight have been reported to be surrogates of the nephron mass. To investigate the impact of the ratios of the surrogates to recipient body surface area (BSA) and body weight on the graft function within six months post-transplantation, we measured the graft kidney volume, using computed tomography with 3-dimensional reconstruction before transplantation, and measured the graft kidney weight during surgery. Ninety-four cases of live donor kidney transplants were included in this study. The graft kidney volume/recipient BSA ratio was correlated with the glomerular filtration rate (GFR) of recipients at one and six months post-transplantation (r = 0.416, p < 0.001 and r = 0.381, p < 0.001, respectively). We found a difference in the graft function between recipients with a graft kidney volume/recipient BSA ratio of ≥90.9 mL/m(2) and those with a ratio of <90.9 mL/m(2) (p < 0.001). Multivariate analysis demonstrated that the graft kidney volume/recipient BSA ratio and donor age are independent predictors of recipient GFR at one and six months post-transplantation (p < 0.05). During living donor and recipient matching, both the potential volume of the donated kidney and the body size of recipient should be considered.     

The influence of obesity on short- and long-term graft and patient survival after renal transplantation

To determine short- and long-term patient and graft survival in obese [body mass index (BMI) >or= 30 kg/m(2)] and nonobese (BMI < 30 kg/m(2)) renal transplant patients we retrospectively analyzed our national-database. Patients 18 years or older receiving a primary transplant after 1993 were included. A total of 1,871 patients were included in the nonobese group and 196 in the obese group. In the obese group there were significantly more females (52% vs. 38.6%, P < 0.01) and patients were significantly older [52 years (43-59) vs. 48 years (37-58); P < 0.05]. Patient survival and graft survival were significantly decreased in obese renal transplant recipients (1 and 5 year patient survival were respectively 94% vs. 97% and 81% vs. 89%, P < 0.01; 1 and 5 year graft survival were respectively 86% vs. 92% and 71% vs. 80%, P < 0.01). Initial BMI was an independent predictor for patient death and graft failure. This large retrospective study shows that both graft and patient survival are significantly lower in obese renal transplant recipients.     

Indication, surgical technique and outcome of orthotopic renal transplantation

PURPOSE: We review the indication, surgical technique and outcome of orthotopic renal transplantation. MATERIALS AND METHODS: The medical records of 1,000 patients who underwent renal transplantation at our institution between August 24, 1993 and August 1, 2000, as well as orthotopic renal transplantation were reviewed. RESULTS: Orthotopic renal transplantation was performed in 4 males and 1 female with severe iliac atherosclerosis or retained bilateral iliac fossa kidney transplant. Mean patient age was 56 years. There were 2 patients who received kidneys from living related donors, and 3 underwent cadaveric renal transplantation. Left orthotopic renal transplantation was successful in 4 cases, and 1 was converted to iliac fossa renal transplant because of a pulseless splenic artery and renal artery thrombosis after native renal endarterectomy. Orthotopic renal revascularization was done with splenic artery in 2, native renal artery in 2 and left renal vein in all 4 patients. Urinary tract reconstruction was performed with stented (2) or nonstented (2) ureteroureterostomy. Antibody induction, purine antagonists, calcineurin inhibitors and glucocorticoids were used for immunosuppression. Mean preoperative and 1-month postoperative serum creatinine was 7.9 and 1.3 mg./dl., respectively. Patient and graft survival was 100% during followup, which ranged from 6 months to 5 years. CONCLUSIONS: Despite the technical challenges, orthotopic renal transplantation in patients with unsuitable pelvic vessels can result in excellent patient and graft survival.     

Segmental infarction with graft dysfunction: an emerging syndrome in renal transplantation?

BACKGROUND: Segmental allograft infarction is a poorly characterized complication following renal transplantation. The present study was undertaken with the goal of defining the incidence, clinical characteristics, pathogenesis, and prognosis of this entity. METHODS: A retrospective study was performed, reviewing the renal scans performed on all renal transplant recipients at our institution, from January 1997 to January 2000. Segmental infarction was diagnosed on the basis of a significant elevation in lactate dehydrogenase (>500 U/l) together with a photopenic perfusion defect. In these patients, graft characteristics, operative details, clinical course, and long-term outcomes were evaluated. RESULTS: Segmental infarction was identified in 13 of 277 consecutive renal transplant recipients (4.7%). In nine recipients the onset of infarction occurred within 24 h after transplantation. All received marginal grafts, and in five recipients the transplant operation was complicated by major blood loss. Eight of these recipients exhibited primary non-function, or developed dialysis-dependent renal failure after the onset of infarction. In four patients, the onset of infarction occurred after 24 h (35 h to 10 days). One recipient demonstrated primary non-function, and renal function deteriorated after the onset of infarction in the remaining three. Overall, long-term graft function was impaired. Two allografts never functioned, and six recipients had nadir creatinine clearances below 60 ml/min. CONCLUSIONS: The pathogenesis of segmental infarction appears to be multi-factorial, reflecting the combination of an initiating anatomic lesion and potentiating thrombogenic milieu. Segmental infarction typically occurs in the early postoperative period, and prompt diagnosis is difficult to obtain. In view of this, prophylactic heparin may be warranted for those at highest risk. There was no correlation between the infarct area and the graft function, and the long-term graft function is compromised out of proportion to the extent of parenchymal loss. This finding highlights the role of predisposing factors, particularly marginal graft quality, in determining the functional outcome. Segmental infarction may be more frequently encountered as cadaveric organ shortages encourage greater use of marginal donor kidneys.     

肾移植术后并发恶性肿瘤6例报告

目的 提高肾移植术后发生恶性肿瘤的诊疗水平。方法 结合献回顾性分析我院肾移植术后发生的6例恶性肿瘤的诊疗资料。结果 1002例肾移植受术后共发生恶性肿瘤6例，发生时间于移植术后9～96(平均47．2)个月，其中左肾透明细胞癌1例、膀胱癌2例、食道癌1例、皮肤癌1例、肝癌1例。4例手术治疗，3例无瘤存活至今，1例术后肺广泛转移死亡。1例放疗，生存一年后癌转移死亡，1例未手术于短期内癌广泛转移死亡。结论 肾移植受术后免疫功能低下，容易发生恶性肿瘤，随诊时应引起足够的重视。早期发现、早期治疗，减少免疫抑制剂用量可取得较好疗效。     

Impact of schistosomiasis on patient and graft outcome after kidney transplantation.

In this work the impact of schistosomiasis on kidney transplantation was investigated by comparing two groups of patients, group 1 (Schistosoma-infected cases) and group 2 (control cases). In group 1, schistosomiasis was diagnosed in both donor and recipient in 63 cases, in recipient only in 65 cases, and in donor only in eight cases. Schistosomal infection among kidney transplant recipients was S. haematobium in 17 cases, S. mansoni in 58 cases, and mixed in 53 cases. Schistosomiasis was diagnosed by finding Schistosoma eggs in urine, stools, rectal mucosal biopsy, recipient bladder mucosal biopsy, or in the donor ureter obtained during surgery. Patients and donors with active lesions were treated at least 3 weeks before transplantation by the antischistosomal drugs praziquantel and oxamniquine. Follow-up after kidney transplantation showed no significant difference between the two groups regarding the incidence of acute and chronic rejection. Nevertheless, dose of cyclosporin, HBs antigenaemia, incidence of urinary tract infection, renal stones, ureteric stricture, and urinary leakage were significantly greater among schistosomal patients when compared to control cases. Schistosomal reinfection was observed in 23% of cases at high risk. Antischistosomal treatment did not affect the graft function. We have concluded that schistosomiasis may affect the outcome of kidney transplantation.     

Importance of renal mass on graft function outcome after 12 months of living donor kidney transplantation.

BACKGROUND: Few studies have directly measured the kidney weight and investigated donor parameters related to it. The aim of this study was to evaluate the kidney weight and its relationship to creatinine clearance (CrCl) after 12 months post-transplantation. METHODS: A total of 123 recipients of renal transplantation from living donors were evaluated. Demographic and anthropometric data from donors and recipients were collected in the pre-operative phase. Data about kidney weight were obtained through kidney measurement using an electronic weighing machine at the moment of transplantation. Glomerular filtration rate (GFR) was estimated through CrCl (modification of diet in renal disease formula) at the 1st, 6th, 12th and 18th month post-transplantation. RESULTS: The mean value of kidney weight was 170 +/- 31 g (166.4 +/- 29.2 g in women and 177.5 +/- 32.5 g in men). The kidney weight had a correlation with the donor's BMI (r = 0.43, P < 0.001) and with the CrCl on the 12th month (r = 0.31, P = 0.001). Using multiple linear regression, the kidney weight could be predicted through the BMI and donor's gender (R(2) = 0.21; P < 0.01). The CrCl after 12 months had a significant correlation with the graft weight/recipient weight ratio and with the donor age (R(2) = 0.22; P < 0.01). CONCLUSION: The kidney weight can be estimated using the donor's gender and BMI. The kidney weight significantly influences the CrCl 12 months after transplantation.     

Vascular complications after live donor renal transplantation: study of risk factors and effects on graft and patient survival

We evaluated the incidence and management of vascular complications after live donor renal transplantation. Possible risk factors and their effects on patient and graft survival were also assessed. MATERIALS AND METHODS: A total of 1,200 consecutive live donor renal transplants were performed in 1,152 patients at a single institution. The incidence of different types of vascular complications were determined and correlated with relevant risk factors. The impact on patient and graft survival was also studied. RESULTS: There were 34 vascular complications (2.8%). Stenotic or thrombotic complications were recorded in 11 cases (0.9%), including renal artery stenosis in 5 (0.4%), renal artery thrombosis in 5 (0.4%) and renal vein thrombosis in 1 (0.1%). Hemorrhagic complications were observed in 23 patients (1.9%). Although no risk factors could be identified that were related to stenotic or thrombotic complications, grafts with multiple renal arteries were significantly associated with hemorrhagic complications (p = 0.04). Stenotic and thrombotic complications as well as hemorrhagic complications were significantly associated with subsequent biopsy proved acute tubular necrosis (p <0.001). The mean 5-year patient and graft survival rates +/- SD for those with vascular complications were 71.9% +/- 1.9% and 41.6% +/- 8.9% compared with 86.3% +/- 1.1% and 76.8% +/- 1.4% for the remainder of our transplant population, respectively (p <0.001). The deleterious impact on survival was not only observed in recipients with thrombotic or stenotic crises, but also in those with hemorrhagic sequelae. CONCLUSIONS: Hemorrhagic crises are as serious as the stenotic and thrombotic complications affecting patient and graft survival. Because they are a significant factor in the development of hemorrhagic complications, grafts with multiple renal arteries should be managed critically.     

Impact of post-transplant anemia on patient and graft survival rates after kidney transplantation: a meta-analysis

The impact of post-kidney transplant anemia (PTA) on patient and graft survival rates remains controversial. We performed a meta-analysis to evaluate its impact in causing death of a patient with a functioning graft (DPWFG) and death-censored graft loss (DCGL). A systematic review of 11 observational studies (11,632 kidney transplant patients) that reported the impact of PTA or hemoglobin (Hb) level on these endpoints was performed. Using the World Health Organization (WHO) definition (Hb <12 g/dL in women and Hb <13 g/dL in men), PTA was not associated with DPWFG when results were expressed as an adjusted hazard ratio (aHR: 1.23 [0.97-1.57]), but was associated with higher DPWFG when results were expressed as unadjusted rates (aHR: 2.48 [1.36-4.52]) and when cut-off level for anemia was lower than the WHO definition (aHR: 3.12 [1.92-5.07]). A -1 g/dL decrease in Hb level was associated with higher DPWFG rates (aHR: 1.19 [1.12-1.26]). Using WHO criteria, PTA was associated with higher DCGL rates when results were expressed as aHR (aHR: 1.53 [1.26-1.85]) or as unadjusted rates (aHR: 3.55 [2.36-5.33]); a -1 g/dL decrease in Hb level was associated with higher DCGL rates (aHR: 1.14 [1.11-1.16]). This meta-analysis reveals that the association between PTA and DPWFG varies with PTA definition and adjustment for confounders. In all sub-meta-analyses, PTA was significantly associated with DCGL.     

Fifteen years' experience with renal transplantation in systemic amyloidosis

At our center 62 renal transplantations (31 living donor and 31 cadaveric donor grafts) have been performed in 58 patients with amyloid renal disease since 1974. The amyloidosis was secondary to rheumatic disease in 74% of the patients. Predialytic transplantation was performed in 28% of the patients. Mean follow-up time was 5.1 years (0.3–14.5 years). One-year actuarial patient survival was 79%, decreasing to 65% after 5 years. First graft survival was 74% at 1 year and 62% at 5 years. Patient death with a functioning graft caused 16 out of 25 graft losses. Infections caused 11 out of 18 deaths (61%), more than half of them within 3 months. Renal transplant amyloid was diagnosed in about 10% of the cases (6/62); however, only about 3% of the grafts (2/62) were lost. These long-term results encourage transplantation in amyloid renal end-stage disease.     

规律随访对肾移植受者术后生存质量的影响

肾移植技术的飞速发展使终末期肾病患者得到了理想的救治。但是仅追求肾移植手术的成功是不够的,肾移植受者还将面临排斥反应以及长期服用免疫抑制剂所带来的感染、心血管疾病、内分泌代谢异常、造血系统异常、新发肿瘤等问题。来自家庭、经济与社会等方面的压力,也严重影响肾移植受者的生存质量。     

Allocation procedure has no impact on patient and graft outcome after liver transplantation

The aim of our study was to compare the postoperative outcome after liver transplantation (LT) in patients who received a donor liver via standard or rescue allocation (RA). Special emphasize was laid on the effect extended donor criteria might have on the outcome. One hundred and ten LTs have been performed at the University Hospital Aachen, Germany. A total of 49 patients were included in the standard allocation (SA) group and 53 patients in the RA group. The outcome of LT in both groups was evaluated by the length of stay on the intensive care unit (ICU), duration of hospitalization, 1‐year patient survival, 1‐year graft survival, incidence of primary nonfunction and major complications. Patients in group RA had a significant shorter ICU and overall hospital stay. The 1‐year graft survival was 87.8% in group SA and 88.7% in group RA. The 1‐year patient survival was 87.9% in group SA and 96.2% in group RA. The number of re‐LT was 2% in group SA and 7.5% in group RA. Organs that were rejected for transplantation several times can successfully be transplanted through the RA procedure, thereby enlarging the donor pool without negative effects on the quality of LT.     

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.