Renal transplantation in children under 5 years of age

Between March 1987 and December 1997, 59 renal transplants [49 cadaveric, 10 live related (LRD)], were performed in 54 children aged 5 years and younger. Six children required a second transplant. The median (range) age of the recipients was 2.9 (1.4–5.0) years; mean weight was 12.6 kg (7.4–23) and donor age 11 (2–50) years. Immunosuppression was cyclosporin or FK506, prednisolone, and azathioprine. Antithymocyte globulin was given as induction therapy for second transplants. Patient survival was 98.3%; 1 patient died from upper gastrointestinal haemorrhage. Graft survival was 67.7% at 1 year, 57.4% at 5 years, and 45.2% at 10 years. No LRD graft was lost during 7 years of follow-up. Thrombosis was the main cause of graft loss (10 cases) followed by vascular rejection (2 cases). There was no significant difference in graft survival between recipients aged less than 2, 2–3, and 3–5 years. The height standard deviation score (±SD) improved from –2.1±1.3 at transplantation to –1.0±1.3 at 1 year, –1.1±1.5 at 5 years, and to –0.14±1.1 at 10 years. Received: 19 August 1998 / Revised: 18 November 1998 / Accepted: 18 November 1998     

Low-dose OKT3 induction therapy following renal transplantation: a controlled study

In a prospective clinical study we tested the immunosuppressiveproperties and toxicity of low-dose OKT3 induction therapy inrenal transplant recipients. 50 consecutive renal transplantrecipients were alternat ingly assigned to low-dose OKT3 inductionor prednisolone/cyclosporin. Low-dose OKT3 induction treatmentconsisted of 0.5 mg OKT3 twice daily for 10 days, initiallycombined with azathioprine and prednisolone maintenance immunosuppressionthat was converted to prednisolone/cyclosporin at the end ofthe course. During a 15–29-month follow-up period, low-doseOKT3 induction therapy was found to reduce significantly theincidence of acute rejections, as com-pared to the usual prednisolone/cyclosporinmainten ance immunosuppression (21 versus 52%, P=0.02). Therealso was a tendency towards an improved graft function afterlow-dose OKT3, although no signific ance was reached. Furthermore,compared to a histor ical control group of renal transplantpatients in whom acute rejection was treated with 5 mg OKT3daily, low-dose OKT3 appeared to cause fewer side-effects. Weconclude that low-dose OKT3 induction therapy is superior toprednisolone/cyclosporin in preventing acute rejection afterrenal transplantation and that it is better tolerated than conventionalOKT3 treatment.     

Bone loss after kidney transplantation: a longitudinal study in 115 graft recipients

BACKGROUND.: Bone loss is an important problem in renal transplant recipientsimmediately after surgery. No data are available about the boneloss beyond the first post-transplantation year. METHODS.: In a longitudinal, uncontrolled observational study bone mineraldensity (BMD) was measured by dual X-ray absorptiometry in 115renal graft recipients starting at different times after transplantation(0–20 years after transplantation) with a follow-up timeof 12 months. RESULTS.: A total of 56 patients showed a reduction of BMD during theobservation period. Bone loss depended on the time after transplantation.Mean reduction of BMD at lumbar spine was 7±10%, 1±9%during the first and second postoperative year. Beyond the thirdyear bone mineral density did not change or even increased slightly(0±4% during 3–5th year, 1±6% during 6–10thyear and 2±4% during 11–20th year after transplantation).Decrease of BMD correlated with a higher mean daily prednisonedosage (P<0.001), a higher cumulative prednisone dose (P<0.01),a more frequent and more steroid-resistant rejection (P<0.001)and a higher initial parathyroid hormone level (P<0.001).Patients with 25-OH-cholecalciferol therapy (P<0.05) or morephysical activity (P<0.05) had a smaller bone loss. CONCLUSIONS.: Reduction of BMD after transplantation is highest within thefirst post-transplant year. The effects of acute graft rejection,prednisone dosage and initial parathyroid hormone level arepredominant among the multiple factors associated with pronouncedbone loss.     

A double-blind, randomized, placebo-controlled study of nifedipine on early renal allograft function

A double-blind, randomized, placebocontrolled study was conductedto determine the effect of nifedipine on early renal allograftfunction when added to a triple therapy immunosuppression regimecomprising low-dose cyclosporin (CsA), prednisolone and azathioprine.Fifty adult cadaveric renal allograft recipients were randomizedto placebo (group P n=17), nifedipine 10 mg preoperatively and20 mg b.d. postoperatively for 48 h, followed by matching placebofor 3 months (group NS n=16) or nifedipine 10 mg preoperativelyand 20 mg b.d. postoperatively for 3 months (group NL n=17).Donor and recipient exclusion criteria included recent calciumantagonist treatment. At 3 months after transplantation meanGFR adjusted for graft loss was significantly higher in groupNL than in NS (mean ± SD 61±28 versus 34 ±25 ml/min/1.73 m²; P<0.05), group P being intermediate (45± 34ml/min/1.73 m²). Similarly, effective renal bloodflow (ERBF) at 3 months was higher ingroup NL than in groupsP and NS (mean ± SD 351 ± 175 versus 216±166and 220±162 ml/min/ 1.73 m²; P<0.05). The differenceswere not significant by 6 months post-transplantation. Thisstudy suggests that oral nifedipine commenced preoperativelyand continued for 3 months following transplantation has beneficialeffects on early renal allograft function whenincorporated aspart of an immunotherapy regimen based on cyclosporin.     

肾移植术后环孢素向硫唑嘌呤转换的临床研究

目的 观察肾移植木后环孢素向硫唑嘌呤转换的临床效果。方法 选择60例术后1年以上、肾功能稳定的肾移植受者进行免疫抑制剂从环孢素向唷唑嘌呤的转换。结果 60例病人平均血清肌酐在转换后1个月明显下降(148±58.5至132±86.9mmol/L,P<0.01),并在以后几年内继续下降,转换后6年时平均血清肌酐为112±39.8mmol/L。转换后平均血压也明显下降,并且抗高血压药物数量逐渐减少(P<0.01)。分别有9例(15％)和3例(6.7％)病人在转换后3个月内和3个月后发生急性排斥反应。转换后1年、5年人/肾存活率分别为95％/81.7％、86.7％/78.3％。5例(8.7％)病人因药物副作用和慢性排斥反应从硫唑嘌呤再转换为环孢素。结论 肾移植受者在术后一定时间将免疫抑制剂从环孢素转换为硫唑嘌呤是一种安全的免疫抑制方案,具有较好的移植肾长期存活。     

Adverse Effect of Cyclosporin on Plasma Cholesterol in Renal Transplant Recipients

A prospective study of changes in plasma lipids after renaltransplantation was performed in order to compare the effectsof cyclosporin and conventional immunosuppression. Twenty-eightpatients were studied, 18 of whom were allocated randomly toimmunosuppression with either cyclosporin alone (nine subjects)or azathioprine and prednisolone (nine subjects). A furtherten patients received cyclosporin and prednisolone. Total cholesterol,triglycerides and HDL, LDL and VLDL cholesterol subfractionswere measured before transplantation, 21 and 90 days after transplantation,and also, in 12 patients (six on cyclosporin and prednisolone,and six on azathioprine and prednisolone), 2 years after transplantation. Triglycerides were initially elevated, and decreased after transplantationin all three groups. Total cholesterol was unchanged in theazathioprine and prednisolone group, whereas it increased significantlyby 90 days in both the cyclosporin group and the cyclosporinand prednisolone group. This was due primarily to LDL cholesterol,which increased by 45% in the cyclosporin group and 28% in thecyclosponn and prednisolone group. Both total and LDL cholesterolremained elevated 2 years after transplantation in patientsreceiving cyclosporin and prednisolone, but were unchanged inthe azathioprine and prednisolone group. There was no relationshipbetween renal function and plasma lipid changes.     

Cadaveric renal transplantation in children under 5 years of age

From March 1987 to August 1990 23 cadaveric renal transplants were performed in 19 children under the age of 5 years at the time of transplantation. The mean age of the recipients was 3.3 years (range 1.3–4.7) and the mean weight 13.0 kg (range 9.3–19.2). The mean donor age was 7.8 years (range 1.5–25). All children received triple immunosuppression with prednisolone, cyclosporin A and azathioprine, and 4 who had 2 grafts during this period also received antithymocyte globulin at the time of the second transplant. Patient survival is 100%. Actuarial first cadaveric graft survival was 57% at 1 year and remains unchanged at 3 years. There were 10 graft losses, 4 were associated with renal venous thrombosis without apparent rejection. Two were lost due to acute vascular rejection with associated renal venous thrombosis, and the remaining 4 losses followed cellular or chronic vascular rejection. The mean glomerular filtration rate ±SD was 51.4±23.6 ml/min per 1.73 m² (n=11) at 1 year and 43.5±25.3 at 2 years (n=6). The mean height standard deviation score improved from –2.2±1.1 at the time of transplantation to –1.3±1.0 1 year post transplant (n=11). The immunosuppression was well tolerated with a low incidence of side effects. Cadaveric renal transplantation remains a difficult but rewarding undertaking in children under 5 years of age.     

Acute rejection episodes after renal transplantation in children under cyclosporin A treatment

Thirty-two pediatric renal transplant patients receiving cyclosporin and 34 receiving azathioprine treatment (historical controls) were investigated for the occurrence of rejection episodes; their clinical symptoms and findings, time of onset, influence of donorship, relation to cyclosporin blood levels and graft function outcome were also studied. In the cyclosporin group, four grafts were lost in the 2nd year, while in the azathioprine group five grafts were lost within the first 5 weeks after transplantation due to acute irreversible rejection. Clinical signs of rejection episodes under cyclosporin were mild and usually presented a silent increase of serum creatinine. First rejection episodes occurred later in patients treated with cyclosporin than in azathioprine-treated patients (50% probability after 7 weeks as opposed to 2 weeks). The percentage of patients receiving cyclosporin who had experienced no rejection episodes was 18,8% as opposed to 11,8% of patients receiving azathioprine. The lowest incidence of rejection episodes was observed in patients with living related grafts receiving cyclosporin treatment, 75% of whom were free of rejection episodes after 2 years. Cyclosporin blood levels below 400 ng/ml were observed in 74% of rejection episodes. Biopsies were often used to differentiate between cyclosporin nephrotoxicity and rejection when the cyclosporin levels were above 400 ng/ml. Both treatment groups exhibited a parallel decline in graft function, which correlated with the number of rejection episodes.     

Long-term outcome of focal segmental glomerulosclerosis after pediatric renal transplantation

Recurrence of focal segmental glomerulosclerosis (FSGS) after renal transplantation can limit graft survival. Despite new immunosuppressive agents, the incidence of recurrence remains relatively high. To identify risk factors for recurrence and efficacy of treatment, we reviewed the outcome of 23 grafts in 16 children with FSGS who had undergone transplantation between 1985 and 2007 at La Paz Children’s Hospital. Recurrence was 56.3% after the first transplantation. We did not find significant differences in age at diagnosis, age at transplantation, age at end-stage renal disease (ESRD), progression to ESRD, bilateral nephrectomy of native kidneys prior to transplantation, use of induction therapy or of different immunosuppressive regimens between patients with and without recurrence. Plasmapheresis (PP) was carried out in seven of nine patients who had suffered recurrence, achieving remission in six of them. One patient received high doses of cyclosporin (CsA) and plasmapheresis, attaining remission. Graft survival was lower (P = 0.043) in patients with FSGS than in those with other ESRD etiologies (first year 75% vs 91%; fifth year 44% vs 78%). Recurrence of FSGS limited graft survival (first year 66% vs 85%; third year 20% vs 68%) (P = 0.07). In our experience, PP can be effective in treating FSGS recurrence, although its effect on long-term graft survival seems more limited.     

Late conversion from steroids to azathioprine in cyclosporin-treated renal graft recipients

In renal graft recipients primarily treated with cyclosporin and low-dose methylprednisolone, withdrawal of the long-term steroid medication increases the likelihood of developing rejection episodes. In order to determine the predictive value of clinical parameters and routine prewithdrawal graft biopsies for the risk of rejection, the authors studied 141 kidney recipients from whom steroids were with-drawn 7–9 months after transplantation in a clinically stable situation. Both the quality of the HLA-match and the results of prospective graft biopsies were found to correlate significantly to the occurrence of acute rejection. In order to investigate the influence of additional azathioprine medication on the incidence of acute rejections in recipients not receiving steroids, immunosuppression was continued with cyclosporin monotherapy in 88 patients and with cyclosporin plus azathioprine in 53 patients. The risk of developing rejection episodes was significantly reduced from 48% after 1 year on monotherapy to 28% after the addition of azathioprine medication.     

A randomized multicenter trial of cyclosporin and prednisolone versus cyclosporin,azathioprine, and prednisolone following primary living donor renal transplantation

A total of 195 consecutive recipients of primary living donor renal transplants were randomized to receive either cyclosporin (CyA) and prednisolone (double therapy) or CyA, prednisolone, and azathioprine (triple therapy). There was no significant difference in patient or graft survival, incidence of acute rejection episodes, or major complications between the groups. The graft survival at 5 years was 71.5% in patients receiving double therapy and 71.6% in patients receiving triple therapy. In a Cox regression analysis, recipient age and occurrence of acute rejection were the only independently significant variables affecting graft survival, whereas treatment schedule did not. Renal function was stable throughout the observation period and did not differ between the double and triple therapy groups. A linear regression analysis showed that recipient age, donor age, gender, and occurrence of acute rejection significantly influenced the serum creatinine level. This and previous similar prospective studies in cadaveric renal transplantation indicate that there is no advantage of routinely adding azathioprine to a double drug regimen.     

Triple therapy in cadaver renal transplantation

One hundred consecutive first (n = 72) and regrafted (n = 28) cadaver renal allograft recipients were immunosuppressed with cyclosporin, azathioprine and prednisolone (triple therapy) and followed for a median of 17.3 months (range, 7-26 months). Actuarial patient survival at 12 and 24 months was 97.7 per cent. Actuarial graft survival at 12 and 24 months was 79.5 per cent (first graft recipients 81.3 per cent and regrafted recipients 75 per cent). HLA-DR matching significantly improved graft survival which was 93 per cent at 1 year in patients given HLA-DR compatible kidneys, compared with 83 and 54 per cent, respectively, in patients who received kidneys mismatched for one or two HLA-DR antigens. There were 0.8 (s.d. = 0.7) episodes of acute rejection per patient during the first 3 months after transplantation. Triple therapy provides effective immunosuppression without evidence of over immunosuppression and reduces the incidence of cyclosporin side-effects. Although acute nephrotoxicity was uncommon, serum creatinine remained elevated 6 and 12 months after transplantation.     

Renal transplantation without steroids

Cyclosporin has been in use in our unit since 1982 to treat renal transplant recipients. In two controlled clinical trials cyclosporin monotherapy was compared with cyclosporin with steroids, and with cyclosporin with azathioprine. The addition of steroids did not improve graft survival but did increase the incidence of infection. The addition of azathioprine also had no effect upon graft outcome. We conclude that cyclosporin monotherapy provides very adequate immunosuppression in the majority of cases giving an 80% survival rate for cadaveric kidney transplants at 1 year. Triple therapy has been used successfully by other centres although graft survival rates are no different from our own. Such treatment does, however, provide more powerful immunosuppression and is appropriate for previously sensitised patients and for children. Under this regimen steroids can be withdrawn at a later date. Sequential therapy with four agents is highly immunosuppressive. The long-term results are uncertain at the present time, and this expensive treatment needs careful evaluation. In our experience it is perfectly possible to undertake cadaveric renal transplantation without having to prescribe regular steroid therapy for the majority of patients. We have been impressed by the lack of serious side effects with this treatment and would still regard cyclosporin monotherapy as the treatment of choice for unsensitised renal transplant patients.     

Five-year results of renal transplantation on immunosuppressive triple therapy with mycophenolate mofetil

Mycophenolate mofetil (MMF) combined with cyclosporine and prednisolone significantly lowers acute rejection frequency in the early post-renal transplantation phase. To date only registry data with very high transplant numbers have shown that MMF significantly influences long-term outcome. A comparative retrospective analysis of the 5-yr results with MMF in a single transplant center was thus undertaken vs. other standard immunosuppressive regimens. The results of 1579 renal transplantations were grouped by treatment modality, subjected to Kaplan-Meier analysis, and compared using the log rank test. Both the total population and subgroups showed a non-significant trend towards better graft survival with MMF, evident at 2 yr and persisting for 5 yr. Extrapolation indicates that on combination therapy with MMF vs. azathioprine, approximately 10% more patients will be alive at 10 yr with a functional graft.     

Randomized trial of conversion from mycophenolate mofetil to azathioprine 6 months after renal allograft transplantation.

BACKGROUND: In the first year after renal allograft transplantation, triple therapy immunosuppression with cyclosporin (CsA), prednisone (P), and mycophenolate mofetil (MMF) is superior to a triple therapy treatment that includes azathioprine (AZA) instead of MMF. Whether long-term treatment with CsA-P-MMF is better than treatment with CsA-P-AZA is a matter of debate, as 3-year graft survival is similar in MMF- and AZA-treated patients. The purpose of the present study was to examine the short-term effect of changing MMF to AZA in low-risk renal allograft recipients 6 months after transplantation. METHOD: This was a randomized, open-label single-centre study, recruiting 48 low risk renal allograft recipients on CsA-P-MMF therapy 6 months after transplantation, comparing the outcome with continued MMF treatment (2 g b.i.d.) (group A, n=22) or switching MMF to AZA (1 mg/kg) treatment (group B, n=26). RESULTS: The outcome after a 6-months follow-up of patients in group A and group B was similar. Treatment failure rates (defined as clinically diagnosed acute rejection episodes) were 4.5% in group A and 3.8% in group B. There were no patient deaths and no graft failures during the 6-months observation period. Graft function was excellent and similar in both groups. CONCLUSION: Replacing MMF with AZA 6 months after transplantation in low-risk renal allograft recipients is safe and is not associated with altered graft function in the short term.     

Selective Conversion from Azathioprine to Cyclosporin for Steroid-resistant Rejection in Renal Transplants: An Alternative Therapy

In 153 consecutive renal allograft recipients whose initialimmunosuppression was prednisolone and azathioprine, 41 developedacute rejection episodes that were not reversed by 5–9g of intravenous methylprednisolone. Renal histology showedcellular rejection in ten patients, vascular rejection in 12,and mixed cellular and vascular rejection in 16. Thirty-onepatients were converted to cyclosporin in the first month post-transplantand ten in the second month. At the time of conversion, 20 patientswere dialysis dependent and in the remainder the mean serumcreatinine was 353 µmol/l (range 139–548 µmol/l).Renal function improved in 31 patients after conversion. Tenpatients lost their grafts, of whom seven were on dialysis.There were no deaths and the 1-year graft survival was 75%. These data suggest that conversion from azathioprine to cyclosporinbecause of steroid-resistant rejection is an effective and safestrategy in patients whose initial immunosuppression is prednisoloneand azathioprine.     

Reduction of delayed renal allograft function using sequential immunosuppression

Previous data suggested that outcome in small children with cadaveric renal transplantation might be improved with sequential therapy. This protocol combines augmented immunosuppression [by including antibody induction (ATG)] with avoidance of nephrotoxic medication in the immediate postoperative phase (by delayed start of cyclosporin therapy). In this report, we describe effects of this approach in 12 consecutively transplanted small children of less than 5 years of age (mean 3.2 years) who received a cadaveric renal graft at our institution between 1991 and 1998. Up to 1996 triple therapy (prednisolone, azathioprine, cyclosporin) and since 1997 sequential therapy (prednisolone, azathioprine, ATG until serum creatinine <2 mg/dl, then cyclosporin) was used for immunosuppression. Five children had delayed graft function (45.4%), all of whom were treated with triple therapy including cyclosporin from the very beginning, whereas children treated by the sequential protocol gained immediate graft function (P<0.05). There was no statistical difference between the two protocols concerning frequency or severity of rejections (67% vs. 60%, all steroid responsive), difference in the incidence of either bacterial or viral infections, or between the incidence of hypertension. Although not reaching statistical significance, 1-year graft survival rates also increased from 60% for triple therapy to 80% for sequential therapy. In conclusion, our findings confirm previous studies showing that outcome in small children undergoing renal transplantation may be improved by specially tailored treatment protocols such as sequential therapy.     

Cyclosporin in primary haploidentical live-donor kidney transplantation: is it worthwhile?

Two consecutive prospective randomized trials were performedto study three immunosuppres-sive protocols in 195 kidney transplantrecipients. Only adult primary renal transplant recipients withone haplotype HLA mismatch were included. All patients receivedkidneys from living related donors and had previous donor non-specificblood transfusions. Study I included 112 recipients who wererandomly assigned to receive either azathioprine (Aza) and prednisolone(P) (n =54) or cyclosporin (CsA) and P (n =58). Patients inthis study were followed up for 3–6 years (mean 50 ±8months). Study II included 83 recipients who were randomly assignedto receive either triple therapy of Aza-CsA-P (n =41) or conventionaltherapy of Aza-P (n =42). Patients in this study were followedup for a period of 32 ±10 (range 26–43) months. Analysis of data in the two studies demonstrated the absenceof statistically significant differences in graft or patientsurvival rates over short- and long-term follow-up periods amongrecipients of the conventional immunotherapy and those receivingthe CsA-P or the triple therapy. The overall frequency of acuterejection episodes was not significantly different between thetwo treatment groups of each study. Serum creatinine was significantlyhigher in the CsA-P group while the incidence of infection wassignificantly lower in the triple group. When switching from one regimen to another is considered, atleast 75% of the one-haplotype HLA mismatched live-related donorrenal transplants could be maintained on conventional immunotherapywith comparable degree of success to those treated with theCsA-P or the triple therapy. However, in at least 15% of patientswith conventional immunotherapy, CsA could reverse ongoing rejectionsand can therefore be considered as a rescue treatment.     

Cyclosporin A in pediatric kidney transplantation and its effect on posttransplantation growth

Results of cyclosporin A (CyA) treatment following kidney transplantation in 28 children were compared with those of conventional immunosuppression with azathioprine (Aza) in 34 children. CyA was given in combination with low-dose prednisolone. Under CyA the 2-year survival rate of patients and grafts was 96%, under Aza the 2-year survival rate of patients was 94% and of grafts 68% (p less than 0.01). Graft function was slightly lower in the CyA than in the Aza group. Growth after kidney transplantation was evaluated in those patients with a first graft and a function of longer than 1 year. Annual growth velocity for bone age was normal or even accelerated in all children treated with CyA and significantly better than in the children treated with Aza. It is concluded that CyA treatment combined with low-dose prednisolone yields excellent results and allows normal growth rates after kidney transplantation.     

Relationship between donor renal interstitial surface and post-transplant function

Forty-three biopsies were performed between 30 and 60 min afterreperfusion. Patients (22 males/21 females, mean age 41 ±12years, mean donor age 32 ±14 years) were treated eitherwith antilymphocytic globulin, cyclosporin, and prednisolone(24 cases), or OKT3, cyclosporin, and prednisolone (19 cases).Ten patients had delayed post-transplant renal function (DPRF),defined as haemodialysis requirements after surgery, and sevenpatients had acute rejection 11 ±16 days post-transplant.Kidneys were perfused with a hypertonic solution containingmannitol. All patients were followed up for at least 30 months.During follow-up, five patients lost their grafts due chronicrejection, two patients due to non-compliance and one due torecurrence of focal seg-mental glomerulosclerosis. One patientdied from heart infarction. Biopsies were stained with H&E,Masson's trichrome, periodic acid-Schiff (PAS) and silver methenamine.Interstitial fibrosis, interstitial oedema, tubular vacuolization,and peritubular capillary oedema were measured using a semiquantitativescale. Five 400 x magnification micrographs of cortical inter-stitiumfrom silver-methenamine-stained sections were used to measurepercentage of interstitial surface with a morphometer. Interstitial surface was 18.7 ±6.2% (range 3.2–35.3%).A positive correlation was found between interstitial surfaceand donor age (r= 0.469, P=0.0015). No relationship was foundbetween warm and cold ischaemia times and tubular vacuolizationor peritubular capillary oedema. Patients with DPRF had a significantlyincreased interstitial surface (23 ±8%) when comparedwith patients without DPRF (17 ±5%), (P=0.014). Therewas a positive relationship between interstitial surface andnumber of days required to achieve a plasma creatinine of 300µmol/1 after surgery, this fitted an exponential curve(r=0.578, P=0.0012). Patients who had an episode of acute rejectionwere not included in this calculation. A positive correlationwas also found between interstitial surface and plasma creatinineat 12 months (r=0.692, P=0.0001), 18 months (r=0.713, P=0.0001),and 24 months (r=0.586, P=0.0023) after surgery. Patients wholost their grafts during follow-up were not included in thiscalculation. The relationship between interstitial surface andplasma creatinine 30 months after transplantation was not significant.There was no relation between tubular vacuolization or peritubularcapillary oedema and number of days required to achieve a plasmacreatinine of 300 µmol/1 or plasma creatinine 12, 18,24, and 30 months after transplantation. We conclude that assessment of donor renal biopsies may helpto predict post-transplant renal function. The increase of interstitialsurface due to pre-existing fibrosis is associated with poorpost-transplant graft performance.