20-Year Analysis of Kidney Transplantation: A Single Center in Japan

Background

Patient and graft survival after successful kidney transplantation (KT) have improved despite an increase in the number of challenging cases. Various factors have evolved during the long history of kidney transplantation.

Methods

Between 1988 and 2012, a total of 292 living donor and 56 deceased donor KTs were performed at Niigata University Hospital. Long-term patient and graft survival and changes in background during a 20-year period in a single center were retrospectively analyzed.

Results

Excellent patient survival rates of 95.1% at 20 years for living donor KT and 96.2% at 15 years for deceased donor KT were observed. Graft survival rates at 1, 5, 10, 15, and 20 years were 96.8%, 95.4%, 83.1%, 61.8%, and 56.2% in living donor KT, respectively. In contrast, graft survival rates at 1, 5, 10, and 15 years in deceased donor KT were 89.0%, 80.3%, 77.3%, and 33.8%, respectively. These survival rates have dramatically improved since 2002 (91.7% for living and 80.9% for deceased donor KT at 10 years post-transplantation). The number of elderly recipients (older than 60 years) and the percentage of grafts donated from spouses have increased. The rejection rate decreased and the cytomegalovirus antigenemia–positive rate increased during the 20-year period assessed. The percentage of pre-emptive KTs progressively increased, with graft survival in this group tending to be better than non-preemptive KTs. The causes of graft loss were chronic allograft dysfunction (54.7%), acute rejection (11.1%), and malignancies (9.4%). After living donor KT, the principal predictors of graft loss were if the recipient was younger than 30 years, if the donor was older than 50 years, and if the rejection episodes occurred after living donor KT. In contrast, the only risk factor in the case of deceased donor KT occurred after transplantation from donors who were older than 50 years.

Conclusions

A summary of the long-term outcome of KT over 20 years in a single center has been reported. Along with the changes in patient backgrounds, immunosuppressive drugs, and our knowledge of transplantation, patient and graft survival outcomes have also changed. Investigation into such outcomes during a different transplantation era is required to fully appreciate advances in KT.     

Impact of Age Difference,Sex Matching,and Body Mass Index Matching Between Donor and Recipient in Renal Transplant

BackgroundVarious factors influence kidney transplant (KT) outcome. The impact of age difference between donor and recipient on long- and short-term graft and patient survival in living donor KT remains unclear.ObjectiveWe aim to determine whether age difference, sex matching, and body mass index (BMI) matching between donor and recipient affect the 12-month patient and graft survival in KT.MethodWe studied a retrospective cohort of 804 patients 18 years or older with primary KT from January 2010 to December 2014. Patient renal function and patient survival were followed up for 12 months post KT. Repeated analysis of variance measurement determined if there was a significant difference in the mean creatinine levels when the sample was grouped according to the matching groups for sex, age difference, and BMI classification. Odds ratios were computed to ascertain graft loss and graft rejection. Results were considered statistically significant if P < .05.ResultsMale donor–female recipient had the lowest creatinine levels over time compared with male donor–male recipient (P < .001) and female donor–male recipient (P < .001). Older donor–younger recipient with age difference of ≥ 15 years had the highest overall creatinine (P < .001). For BMI matching, a normal donor and an underweight recipient combination resulted in the lowest mean creatinine levels over the course of 12 months (P < .001). In terms of graft rejection, odds ratio was highest for a female donor and a male recipient (P < .00a) compared with a male donor and a female recipient. For graft loss, older donors (≥ 15 years) had the highest risk (P < .001) vs those older by 11 to 15 years.ConclusionThere was significant difference in the 12-month graft function of patients when grouped according to their matching for age difference, sex, and BMI. The risk for graft rejection increases when the combination for donor-recipient is female donor–male recipient. For graft loss, this is most significant for donors who are older by ≥ 15 years than their recipients.     

The influence of acute rejection on long-term renal allograft survival: a comparison of living and cadaveric donor transplantation

BACKGROUND: We investigated whether recipients of living donor grafts who suffer an acute rejection progress to graft loss because of chronic rejection at a slower rate than recipients of cadaveric grafts. METHODS: A retrospective review was made of 296 renal transplantations performed at Mount Sinai Hospital. Only grafts functioning for at least 3 months were included in this analysis. Demographic variables of donor and recipient age, race, sex, and serum creatinine at 3 months after transplantation were compared between groups. RESULTS: Among the acute rejection-free cohort, the estimated 5-year graft survival was 90% for those receiving transplants from living relatives and 88% for those receiving cadaveric transplants (P=0.76). However, in grafts with early acute rejection, the 5-year survival was 40% for cadaveric recipients compared with 73% for living related graft recipients (P<0.014). Using the proportional hazards model, cadaveric donor source, older donor age, African American recipient race, and elevated 3-month serum creatinine were independent predictors of long-term graft loss caused by chronic rejection. The severity of acute rejection and recipient age had no impact on the risk of graft loss because of chronic rejection. CONCLUSION: These data indicate that the benefit of living related transplantation results from the fact that a living related graft progresses from acute to chronic rejection at a slower rate than a cadaveric graft. Furthermore, a cadaveric graft that is free of acute rejection 3 months after transplantation has an equal likelihood of functioning at 5 years as that of a graft from a living related donor.     

Impact of donor kidney function and donor age on poor outcome of living‐unrelated kidney transplantation (KT) in comparison with living‐related KT

Living‐unrelated donors (LURD) have been widely used for kidney transplantation (KT). We retrospectively reviewed 779 patients who underwent living‐donor KT from 2000 to 2012, to compare outcomes of 264 KT from LURD and 515 from living‐related donors (LRD), and to identify risk factors for living KT. Median follow‐up was 67 months. Mean donor age, total human leukocyte antigen (HLA) mismatches, and HLA–DR mismatches were higher, and mean estimated glomerular filtration rate (eGFR) was lower in LURD. Acute rejection (AR)‐free survival (p = 0.018) and graft survival (p = 0.025) were lower for LURD than LRD, whereas patient survival rate was comparable. Cox regression analysis showed HLA–DR mismatches (OR 1.75 for one mismatch; OR 2.19 for two mismatches), recipient age ≤ 42 yr, and donor age > 50 yr were significant risk factors for acute rejection. For graft survival, AR and donor eGFR (OR 1.90, p = 0.035) were significant. We also identified significant impact of recipient age > 50 yr and diabetes for patient survival. However, KT from LURD was not a significant risk factor for AR (p = 0.368), graft survival (p = 0.205), and patient survival (p = 0.836). Our data suggest that donor eGFR and donor age are independent risk factors for clinical outcomes of living KT, which can be related with poor outcome of KT from LURD.     

Outcomes of Renal Transplantation Following Bone Marrow Transplantation

This single center retrospective study was undertaken to determine the outcome of kidney transplantation (KT) after bone marrow transplantation (BMT) and also to determine the need for immunosuppressive therapy after KT when the BMT marrow donor is the KT donor. Kidney transplantation was performed in 10 patients with BMT nephropathy (BMTN). In six patients, the KT donor was the BMT donor; these individuals were given no long-term immunosuppression. Four other patients received KT from donors who were not the marrow donor (two living donors, two cadaveric donors). After median follow up of 34 months, no patient had an episode of acute rejection. All graft losses (n = 4) resulted from patient death. Three were because of infectious processes, including two infectious deaths in patients not on immunosuppression. Median estimated actuarial patient and graft survival (Kaplan-Meier) was 105 months. We conclude that patients with BMTN who receive KT from their marrow donor do not require immunosuppression. Whether immunosuppressive therapy is given or not, outcome appears to be determined largely by BMT-related immune dysfunction.     

The impact of gender and age matching for long-term graft survival in living donor renal transplantation

In renal transplantation, donor age and allograft size are known to have an important influence on the outcome of the graft reflecting functional renal mass. Women tend to have smaller kidneys with 17% fewer nephrons than male kidneys. The number of glomeruli per kidney as well as the mean glomerular volume closely correlate with kidney weight and negatively correlate with subject age. We evaluated the impact of gender and age matching in living-donor renal transplantation on long-term graft survival. MATERIALS AND METHODS: Four groups were discerned among 614 renal transplants, according to donor and recipient gender: Group 1 was male donor to male recipient; Group 2 was male donor to female recipient; Group 3 was female donor to male recipient; and Group 4 was female donor to female recipient. We analyzed long-term graft survival and risk factors between the four groups as well as according to age matching. Statistical significance was determined by the Kaplan-Meier method and log rank test (P < .05). RESULT: The graft survival rates at 1, 3, 5, and 10 years were 92.62%, 88.13%, 82.37%, and 76.07%, respectively. The risk factors affecting long-term graft survival were donor age, donor gender, acute rejection rate, and HLA-DR matching. Among the four groups, the graft survival rates of Group 3 (female donor to male recipient) were significantly different from the other groups (P = .0165). Also, the long-term graft survival rates according to age differences were significantly different between older donors than recipients and younger donors than recipients in each group (P = .0213). CONCLUSION: The importance of inadequate renal mass is magnified in high-risk recipients. Age matching could perhaps improve the results of transplantation, particularly when kidneys from older donors are used. Consideration of age and gender as criteria for the choice of donors and recipients may be considered in organ allocation.     

Living donor kidney transplantation: the effects of donor age and gender on short- and long-term outcomes

BACKGROUND: The influence of donor age and sex on acute rejection episodes and short- and long-term graft survival in living donor (LD) kidney transplantation has not been well characterized. METHODS: This prospective cohort study includes 739 first time LD transplantations with median follow-up time of 55.1 months. Death censored graft survival according to donor age and sex was compared with Kaplan-Meier plots. Cox regression was performed to estimate the association between different risk factors and graft survival and acute rejection episodes. RESULTS: Graft survival was not affected by donor age above 50 years as long as these recipients did not experience an early acute rejection episode. Acute rejection episodes increased in recipients of grafts from donors > or =65 years (P=0.009). Donor age > or =65, recipient age less than 50 years, human leukocyte antigen (HLA)-DR matching, and female donor gender were risk factors for early acute rejection episodes. In multivariate analysis donor age > or =65 years was a risk factor for graft loss in all time periods after transplantation. During the first 5 years after transplantation a steroid resistant rejection episode was an additional risk factor. More than 5 years after transplantation male donor gender was the only additional risk factor for graft loss. CONCLUSION: These results support the continued use of older male and female living donors who meet carefully constructed medical criteria and who are highly motivated to donate. Furthermore, donor age seems to be a more important predictor of graft loss than donor sex.     

Progress in renal transplantation. A single center study of 3359 patients over 25 years.

OBJECTIVE: The study analyzed 3359 consecutive renal transplant operations for patient and graft survival, including living related, cadaveric, and living unrelated patients. The analysis was separated into three groups according to immunosuppression and date of transplant. SUMMARY BACKGROUND DATA: Improvements in renal transplantation in the past 25 years have been the result of better immunosuppression, organ preservation, and patient selection. METHODS: A single transplant center's experience over a 25-year period was analyzed regarding patient and graft survival. Potential risk factors included patient demographics, tissue typing, donor characteristics, number of transplants, acute and chronic rejection, acute tubular necrosis, primary disease, and malignancy. RESULTS: The primary cause of graft loss was rejection. Improvement in cadaveric graft survival since 1987 with quadruple therapy was not apparent in living donor patients. Race continued to be a negative factor in graft survival. Avoiding previous mismatched antigens and the use of flow cytometry improved allograft survival. The leading cause of death in the past 7 years in cadaveric recipients was cardiac (52%). CONCLUSIONS: Improved graft survival in the past 25 years was related to 1) advances in immunosuppression, 2) better methods of cytotoxic antibody detection, and 3) human lymphocyte antigen match.     

亲属活体供肾移植与尸体供肾移植的临床疗效比较

目的比较HLA配型和免疫抑制方案相同情况下亲属活体供肾移植与尸体供。肾移植的临床效果。方法对12例亲属活体供肾移植供、受者的临床资料进行回顾性分析，并与22例同期进行的、HLA配型情况相近的尸体供肾移植的临床资料进行对比，分析各组术后人／肾1年及3年存活率、1年内急性排斥反应发生率及3年内的。肾功能。结果12例供者均无手术并发症，术后肾功能正常，生活及工作未受明显影响。术后1年内的急性排斥反应发生率，亲属活体供。肾组和尸体供。肾组分别为16．7％和22．7％（P〈0．05）；人／肾1年和3年存活率，亲属活体供肾组分别为100％（12／12）／91．7％（11／12）和91．7％（11／12）／83．3％（10／12），尸体供。肾组分别为100％（22／22）／90．9％（20／22）和95．4％（21／22）／86．4％（19／22），两组比较，差异无统计学意义（P〉0．05）；3年内的。肾功能，亲属活体供肾移植组明显优于尸体供肾移植组（P〈0．05）。结论在HLA配型和免疫抑制方案相同的情况下，亲属活体供。肾移植的临床效果优于尸体供。肾移植。     

Role of donor age and acute rejection episodes on long-term graft survival in cadaveric kidney transplantations

Cadaveric donors can provide an effective solution to the problem of organ shortage, and many factors that may affect the functioning and survival of cadaveric kidneys have been studied. We aimed to clarify the impact of donor age and acute rejection episodes on long-term graft and patient survival in patients receiving cadaveric renal transplants. We retrospectively evaluated the long-term outcomes of 207 patients who had received cadaveric renal transplants between 1985 and 2004. Mean recipient age, HLA mismatch, mean donor age, delayed graft function (DGF), mean cold ischemia time, acute rejection episodes in the first 6 months after transplantation, and 1-, 3-, and 5-year graft survivals were evaluated. Two study groups were created according to donor age: group 1 (n = 126) was composed of patients receiving kidneys from donors younger than 50 years, and group 2 (n = 81) was composed of patients receiving kidneys from donors 50 years of age or older. Mean recipient age, HLA mismatch, and mean cold ischemia time between groups were not different. The DGF rate in group 1 was 40% (n = 50) and in group 2 was 46% (n = 37) (P > .05). The 1-, 3-, and 5-year survival rates of patients without acute rejection within the first 6 months after transplantation in group 1 (58/126; 46%) versus those in group 2 (46/81; 57%) were 95% versus 90%, 65% versus 60%, and 40% versus 35%, respectively (P > .05). The 1-, 3-, and 5-year graft survival rates of patients with acute rejection within the first 6 months in group 1 (n = 68) versus those in group 2 (n = 35) were 93% versus 89%, 71% versus 55%, and 44% versus 28%, respectively (P = .005). There was no significant difference in 1-, 3-, and 5-year survival rates between patients with DGF in both groups. Acute rejection episodes within the first 6 months after cadaveric transplantation, especially in patients receiving kidneys from donors older than 50 years, were shown to affect 5-year survival of the kidney graft. However, cadaver age alone had no negative effect on 5-year graft survival rates. Cadaveric donors older than 50 years may be a solution to the organ shortage in the treatment of end-stage renal disease.     

Use of elderly donors (> 60 years) for liver transplantation

BACKGROUND: As the demand for liver transplantation has become greater than the availability of donor livers, the criteria for donor selection or rejection are more important than ever before. In view of an increasing number of patients on the waiting list, some centres are expanding their donor pool by relaxing the criteria, such as by using organs from elderly (> 60 years) brainstem-dead donors. In this study, we reviewed our experience of using elderly brain-dead donor livers, investigating the potential prognostic factors of the donor, and analysing the influence of donor age on early graft function and graft survival. METHODS: We retrospectively evaluated 106 cadaveric donor liver transplantations in 98 patients. Seven patients (6.6%, 7 vs 106) received livers from donors older than 60 years. Pre-transplantation characteristics of donors and the outcome of recipients were evaluated. Donor prognostic factors were analysed using Cox univariate analysis and confirmed by a multivariate forward stepwise Cox model. Early graft function was compared between recipients of grafts from donors older and younger than 60 years. RESULTS: There were no primary non-functions or re-transplants in the group receiving elderly grafts. Early graft function was similar in patients with grafts from elderly and younger donors. Univariate analysis demonstrated that prognostic factors had no relationship with long-term recipient survival. The 3-month and 1-year cumulative graft survival rates were 100% and 82% in the elderly graft group and 84% and 83% in the younger graft group, respectively. Kaplan-Meier curves and the log-rank test indicated that there was no difference in graft and patient survival rates between the two groups. CONCLUSIONS: Old age is not a contraindication for liver donation. Liver grafts from donors older than 60 years can be used safely.     

Clinical studies on 228 renal transplants

We studied patient survival and graft survival rates by dividing 228 renal transplants into seven groups according to their immunosuppressive regimen and the degree of histocompatibility. Both patient survival and graft survival rates of HLA identical sibling (Id Sib), living related transplantation with cyclosporin (CYA), transplantation with donor-specific transfusion and anti-lymphocyte globulin (DST.ALG) and cadaveric transplantation with cyclosporin (CYA.Cad) groups were better than those of living related transplantation with ALG, without DST (ALG), living related transplantation with azathioprine and steroid (Non-DST.Non-ALG) and cadaveric transplantation without cyclosporin (Conv.Cad) groups. The incidence and severity of acute rejection were lower in Id Sib, CYA, DST.ALG and CYA.Cad groups than in other groups. The incidence of infections was the highest in Conv.Cad group and that of fatal infections was higher in ALG, Non-DST.Non-ALG and Conv.Cad groups than in other groups. These results indicated that acute rejection and infection were two important factor that influenced the survival rates of these patients. Up to now, the graft survival rate of CYA.Cad group has been much improved as compared to that of Conv.Cad group and was better than those of ALG and Non-DST.Non-ALG groups. The fact urges us to promote more cadaveric renal transplantation in our country by virtue of ciclosporin.     

Survival of cadaveric renal allografts in Hispanic as compared with Caucasian recipients

Evaluation of allograft survival rates revealed a significantly better overall graft survival in Hispanic (n = 66) as compared with Caucasian (n = 38) recipients of primary cadaveric renal transplants. There were no significant differences between the Hispanic and Caucasian cadaveric recipient groups in terms of patient survival, pretransplant transfusion status, immunosuppressive protocols, rejection therapy, mean age, or frequency of diabetes mellitus. Cadaveric donor ethnic origin (i.e., Caucasian or Hispanic) did not significantly alter graft survival rates in either recipient ethnic group. Although Caucasian patients with splenectomies had better cadaveric graft survival than Caucasian graft recipients without splenectomies (P = .02), splenectomy had no significant effect on the renal allograft survival rate in Hispanics. Other factors that were evaluated and found not to correlate significantly with cadaveric graft survival rates were donor recipient HLA matching (A, B, or DR), and panel reactivities of recipient pregraft serum samples. In contrast to the superior cadaveric renal allograft survival in Hispanic as compared with Caucasian recipients, 1-haplotype-matched or 2-haplotype-matched living-related renal allografts had comparable graft survival rates in Caucasian and Hispanic recipients. These results indicate that Hispanics without splenectomy enjoy a cadaveric renal allograft survival rate superior to nonsegregated populations (treated with conventional immunosuppression) reported elsewhere.     

Factors Having Effect on Graft Survival in Cadaveric Renal Transplantation

Background

One of the problems of cadaveric renal transplantation is that its graft survival rate is less than that for living renal transplantation. We aim to study relationships between the graft survival of cadaveric renal transplantation patients and various factors.

Materials and Methods

We retrospectively analyzed 350 cadaveric renal transplantation patients from our institutions from 1983 to 2011. Kaplan-Meier analysis was performed to evaluate graft survival ratios. Using a multivariable Cox regression model, we evaluated the relationship between graft survival and the factors such as age and gender of donor and recipient, body mass index of recipient, duration of hemodialysis, warm ischemic time, and acute rejection (AR), etc.

Results

Among 235 males and 115 females, the overall mean age was 41 years. Median follow-up was 15 years (2 to 28 years). The graft survival ratio was 97% at 1 year, 85% at 5 years, and 71% at 10 years. Using the Cox regression model, graft survival was affected by donor age (younger than 60 years; hazard ratio [HR] 1.5; 95% confidence interval (CI) 1.0–2.0; P = .027) and early acute rejection (within 3 months; HR 2.1; CI 1.6–2.8; P < .001).

Conclusions

The graft survival of cadaveric renal transplantation patients is affected by factors of donor age and early AR.     

Right lobe living donor liver transplantation.

BACKGROUND: The shortage of livers for transplantation has prompted transplant centers to seek alternatives to conventional cadaveric liver transplantation. Left lateral segmentectomy from living donors has proven to be a safe operation for the donor with excellent results in the pediatric population. Left lobectomy, conceived to supply more tissue, still provides insufficient liver mass for an average size adult patient. Right lobectomy could supply a graft of adequate size. METHODS: Donors were considered only after recipients were listed according to United Network for Organ Sharing (UNOS) criteria. Donor evaluation included liver biopsy, magnetic resonance imaging, and celiac and mesenteric angiography. The donor operation consisted of a right lobectomy uniformly performed throughout the series as described herein. RESULTS: Twenty-five right lobe living donor liver transplants were performed between adults, with no significant complications in donors. Recipient and graft survival was 88%, with three recipient deaths secondary to uncontrolled sepsis in patients at high risk for liver transplant; all three had functioning grafts. CONCLUSIONS: Right lobe living donor liver transplantation poses challenges that require a meticulous surgical technique to minimize morbidity in the recipient. Right lobectomies for living donation can be performed safely with minimal risk to both donor and recipient although providing adequate liver mass for an average size adult patient.     

Risk factors on graft survival of living donor kidney transplantation

Living donors have always been the basic resources of transplantation in our country, where cadaveric harvesting is still hampered for various reasons. OBJECTIVE: The aim of this study was to compare graft survival rates between living unrelated donor (LURD) and living related donor (LRD), to assess the potential risk factors for the graft survival, and to discuss the role of LURD. METHOD: From October 1991 to February 2003, 77 living donor renal transplants were performed: 41 were LURD and 36 were LRD transplants. The analyzed variables were donor relationship, recipient age and sex, donor age and sex, HLA-DR mismatching, nonspecific blood transfusion history of donor, acute rejection episodes, repeated rejection episode (more than 3 times), delayed graft function, recurred primary disease, and immunosuppressive regimen. Graft survival rate was assessed with the Kaplan-Meier method and the significance of possible variables with the Cox proportional hazard model. RESULTS: Eleven recipients lost their grafts (6 from LURD and 5 from LRD), most of them are due to chronic rejection (n = 7). Overall 3-, 5- and 10-year graft survival in live donors were 92.8%, 86.6%, and 76.9%, respectively. Graft survival at 3, 5, and 10 years being 91.9%, 88.5%, and 74.7% for the LURD versus 94%, 84%, and 78.8% for LRD transplants (P > .05). Acute rejection episodes, especially more than 3 times (risk ratio [RR] = 11.1) and preoperative multiple transfusion history (RR = 4.2) were significant factors on graft survival in our series. CONCLUSION: Acute rejection episodes markedly decreased the long-term graft survival in live donor renal transplants. The use of LURD transplants provides graft survival comparable with LRD transplants and proper management to acute rejection is essential for long-term graft survival.     

Outcomes of renal transplantation for recipients with lupus nephritis: analysis of the Organ Procurement and Transplantation Network database

Prior analyses of transplant outcomes in lupus transplant recipients have not consisted of multivariate analyses in the modern immunosuppressive era. Here, we compared patient and graft outcomes in lupus and non-lupus recipients transplanted between 1996 to 2000 using the United Network of Organ Sharing/Organ Procurement Transplant Network database. We evaluated the impact of recipient and donor demographic factors, time on dialysis and the initial immunosuppression regimen on rejection rates and transplant outcomes. Univariate analysis showed similar graft but better patient survival rates for primary lupus and non-lupus transplant recipients (5-year patient survival rates for lupus cohort 85.2% for deceased donor transplants and 92.1% for living donor transplants as opposed to 82.1% and 89.8% respectively for the non-lupus cohort; P=0.05 and 0.03) but similar patient survival rates for deceased donor retransplant patients. After controlling for confounding factors, no differences in patient or graft survival were seen between the two groups. No difference in acute rejection rates were observed in deceased donor transplants, but there was a small but significant increase in the risk of acute rejection in living donor lupus transplant recipients (hazard ratio=1.19, P=0.05). Risk of graft failure was lower for deceased donor recipients receiving MMF (five-year graft loss rate=29.6% for MMF vs. 40.2% for those not receiving MMF, P<0.0001), but no differences were seen among living donor recipients. Outcomes were similar regardless of type of calcineurin inhibitor, induction therapy, and time on dialysis. We conclude that lupus transplant recipients have outcomes generally equivalent to non-lupus transplant recipients.     

Transplantation from a living related donor: Results

The results of transplantation from a living donor (LDT) are constantly better than those of cadaveric transplantation (2004 Report of the French Agency of Biomedicine: graft survival 80 versus 63% at 10 years). Transplantation from an HLA-identical sibling is in any case the best combination, but there is no significant difference in graft survival when the donor is a parent, a child, a non HLA-identical sibling, a spouse or an unrelated person. The reasons for these better results are several: the quality of the kidney transplant, the absence of brain death, the advantage of a programmed surgery and of preemptive transplantation. It is admitted now that HLA compatibility plays a minor role. As in cadaveric transplantation, acute rejection, delayed graft function, pretransplant HLA immunisation, age of the donor and the recipient and possibly the discrepancy between the weight of the donor and the recipient are determinants of transplant outcome.     

Survival among pediatric liver transplant recipients: impact of segmental grafts.

Segmental liver transplantation with living donor (LD), reduced cadaveric (Reduced), and split cadaveric (Split) allografts has expanded the availability of size-appropriate organs for pediatric recipients. The relevance of recipient age to the selection of graft type has not been fully explored, but could offer the potential to maximize recipient outcome and donor utilization. We conducted a retrospective cohort study among children 12 years of age or less utilizing the United Network of Organ Sharing (UNOS) database. Cox proportional-hazards analysis was used to explore the association of recipient age and graft type to graft and patient survival. Among children <1 year of age and those 1 to 2 years of age, 3-year LD graft survival was superior to whole cadaveric (CAD) organs, Split grafts, and Reduced grafts (for children <1 year of age: 79.4 vs. 61.5, 66.0, and 61.1%, respectively, P = .0003; and for children 1-2 years of age: 79.2 vs 66.9, 57.1, and 63.9%, respectively, P = .02). However, in children 3 to 12 years of age, after controlling for multiple donor and recipient factors, LD grafts failed to offer a survival advantage (hazard ratio = .61; 95% confidence interval = .37-1.02) compared to CAD organs. In an adjusted analysis examining patient survival, there appeared to be minimal association between recipient age and graft type. Much of the difference in graft survival could be attributed to events in the perioperative period. In conclusion, LD liver transplantation provides improved graft survival in children 2 years of age or less.     

Simultaneous pancreas-kidney transplant from living related donor: a single-center experience

BACKGROUND: Simultaneous pancreas and kidney transplantation (SPK) from cadaveric donors has become a widely accepted therapeutic option for insulin-dependent uremic patients. In 1996 the first SPK from a live donor was performed. This procedure offers the advantage of a better immunologic match, reduced cold ischemia injury, and decreased waiting time. As such, it is an attractive alternative treatment for diabetic patients with end-stage nephropathy with an available living donor. METHODS: We performed six SPKs from living-related donors. There were four men and two women among the recipients; median age was 34 (range, 29-39) years. All donors were recipients' siblings with excellent HLA matching. Donors underwent standardized metabolic workup, anti-insulin and anti-islet antibody assays, and computed tomography of the abdomen. Both donors and recipients were treated with octreotide for 5 days perioperatively. After transplantation, the patients were maintained on tacrolimus-based immunosuppression, with the exception of one recipient of SPK from an identical twin, who received cyclosporine monotherapy. RESULTS: All the donors are doing well and have normal renal function and blood glucose levels. One-year patient, renal, and pancreatic graft survival rates were 100%, 100%, and 83%, respectively. Acute kidney rejection was documented in two patients, and both recovered completely after OKT3 therapy. No rejection of pancreatic graft has been documented. Except for one patient who lost the graft because of hemorrhagic pancreatitis, all recipients maintained serum glucose levels at less than 130 mg/dL without insulin therapy. No major surgical complications such as graft thrombosis, intra-abdominal infection, or abscess were reported. CONCLUSIONS: Living donor SPK can represent a successful alternative to cadaveric donor SPK. The procedure can be performed safely in the donor and with low morbidity in the recipient.