Living or Deceased Donor Kidney Transplantation: A Comparison of Results and Survival Rates Among Iranian Patients

Objective

Kidney transplantation is the selective treatment of end-stage renal disease. Although most previous studies have concluded that living kidney donation achieves better graft survival, some factors may limit this type of donation. This study investigated the survival rates of living and deceased donor kidney transplantations among Iranian patients.

Materials and Methods

The records of kidney transplantations up to year 2005 were used to compare 50 deceased (group I) with 50 living donor transplants (group II). The recipients were matched by transplantation time. We used SPSS version 15 software to analyze the data.

Results

Group I patients included 28 males and 22 females of mean age of 38 ± 13 years, while 26 males and 24 females in group II had a mean age of 34.6 ± 14 years. The rejection and graft nephrectomy rates were significantly higher among group I than group II (P = .01, P = .02). The first-year graft survival was higher in group II (P = .001). The graft survival was significantly lower in recipients who needed a biopsy or dialysis (P = .006 and P = .02, respectively) and higher among those who had a urine volume >4200 mL within the first 24 hours after transplantation (P = .003). Patient survivals were not significantly different between the groups.

Conclusion

Living donor kidney transplantations showed higher graft survival and lower acute rejection rates compared with those from deceased donors.     

Delayed Graft Function in Renal Transplant Recipients: Risk Factors and Impact on 1-Year Graft Function: A Single Center Analysis

Delayed graft function (DGF), a frequent complication after kidney transplantation, occurs among about 60% of recipients of kidneys from deceased donors. DGF has a multifactorial etiology. It is characterized by acute tubular necrosis (ATN) upon biopsy. In this study we sought to identify among a group of recipients of kidneys from deceased donors, the incidence, risk factors, and impacts on patient and graft survivals of DGF.

Materials and Methods

We retrospectively analyzed medical records from renal transplant recipients aged >18 years who received a deceased donor kidney graft between January 2003 and December 2006. Kidneys lost during the first week posttransplantation were excluded from this series.

Results

Among 165 transplants, 111 (67%) displayed DGF, defined as the need for dialysis during the first week posttransplantation. The incidence of DGF was higher among patients with a cold ischemia time (CIT) > 24 hours: 85% vs 60%, DGF vs no DGF (P < .05), as well as for grafts from older donors. After 1-year follow-up, the DGF group showed worse graft function (serum creatinine 1.6 ± 0.7 vs 1.3 ± 0.4 mg/dL; P < .05) as well as a greater incidence of graft loss.

Conclusion

Prolonged cold ischemia and older donor age were associated with a greater incidence of DGF in this series, leading to prolonged hospitalization, increased risk for an acute rejection episode, and reduced graft function and survival after 1 year.     

Impact of early lymph node procurement to facilitate histocompatibility testing on long-term cadaveric kidney graft survival

Background

Prolonged cold ischemia time (CIT) is a clinically important causes of delayed graft function (DGF) after kidney transplantation. As DGF has been previously shown to have a deleterious influence on long-term graft survival, in the present study we analyzed the impact of early lymph node (LN) procurement on CIT, HLA mismatches, and long-term kidney graft outcome.

Materials and Methods

We evaluated 394 consecutive cadaveric procedures performed from 2001 to 2006, including 289 recipients, in whom LN were obtained before kidney procurement seeking to shorten the total time for HLA typing and crossmatch procedures.

Results

During 58 ± 6 months, 24 patients died (918 [8.3%] in the early and 6 [5.7%] in late procurement group, P = ns) and 52 lost their kidney grafts (31 [10.7%] vs 21 [20%]; P = .025). Early procurement of LN performed in 73.4% of all kidney graft recipients shortened CIT by almost 7 hours (22.9 vs 16.1 hours; P < .001), with a nonsignificantly lower incidence of DGF (32.2% vs 41.0%; P = .13). However, a Cox proportional hazards regression model revealed that early procurement reduced the risk of death-censored kidney graft loss by roughly 40% (log-rank, P = .013).

Conclusion

Early LN procurement in significantly shorten CIT and subsequently reduced the risk of long-term kidney graft loss.     

Creatinine clearance and proteinuria as early markers of kidney graft survival

Introduction

In patients who receive a kidney transplant from expanded criteria donors (ECDs), few studies are available concerning the relation between the clinical characteristics, pretransplant biopsies, and graft outcomes.

Aim

To identify early clinical markers predicting worse graft survival in recipients of kidneys from ECDs.

Materials and methods

Between 1999 and 2006, we performed a prospective, observational study in 180 recipients of kidney grafts from ECDs that had undergone a preoperative biopsy to evaluate viability. The patients received immunosuppression with basiliximab, late introduction of tacrolimus, mycophenolate mofetil, and steroids. Data were gathered on demographic and posttransplantation clinical characteristics at 1, 3, 6, and 9 months, including estimates of proteinuria and of the glomerular filtration rate using the Modification of Diet in Renal Disease (MDRD) formula.

Results

The mean age of the donors was 63.54 years and of the recipients, 58.38 years. A creatinine clearance below the median (40 mL/min, interquartile range 32-50 mL/min) in the first posttransplant year was significantly associated with worse death-censored graft survival (log-rank 14.22, P < .0001). A proteinuria value above the median (100 mg/24 h, interquartile range 40-275 mg/24 h) at 1 year posttransplant significantly reduced the death-censored graft survival (log-rank 14.3, P < .0001). Multivariate Cox analysis showed that a creatinine clearance < 40 mL/min in the first year (hazardsratio [HR] 5.7, 95% Confidence Interval [CI] 1.62-20.37; P = .007) and proteinuria at 1 year greater tan 100 mg/24 h (HR 8.3, 95% CI 2.15-32.06; P = .002) were independent risk factors for death-censored graft loss after adjusting for donor age and acute rejection episodes.

Conclusions

Limited renal function and/or low proteinuria at 1 year posttransplant were associated with worse kidney graft survival among recipients of kidneys from ECDS.     

Renal transplantation in old recipients from expanded criteria donors selected by kidney biopsy

Background

In Spain, the number of ideal kidney transplant donors has fallen, with at the same time an increase in the number of older recipients on the waiting list.

Aim

To analyze the results of expanded criteria cadaveric donor kidney transplants into older recipients using grafts selected by kidney biopsy.

Patients and methods

We studied 360 kidney transplant recipients who had been followed to December 2009: 180 in the study group and 180 in a control group composed of younger patients who received grafts from non-expanded criteria donors between 1999 and 2006. A paraffin-embedded kidney biopsy was evaluated by the percentages of sclerosed glomeruli, arteriolar hyalinosis, intimal wall thickening, interstitial fibrosis, and tubular atrophy.

Results

Significant differences were observed in donor age (63.50 ± 5.46 vs 31.90 ± 13.29 years; P < .001) and recipient age (58.40 ± 8.80 vs 40.71 ± 13.23 years; P < .001). Donor renal function was significantly worse among the expanded criteria group (90.80 vs 108.11 mL/min/1.73 m²; P = .006), remaining so over time in the recipient (at 1 year: 42.08 vs 63.71 [P < .001]; at 3 years: 41.25 vs 62.31 [P < .001], and at 7 years: 38.17 vs 64.18 [P < .001]). Censored 7-year graft survivals were 73% versus 87% (P < .001) with similar patient survivals (90.5% vs 95%; P = .39).

Conclusions

Selection of expanded criteria donors by kidney biopsy resulted in good renal function as well as graft and patient survivals at 7 years in older recipients.     

One-year follow-up of en bloc renal transplants from pediatric donors in adult recipients

Objectives

The optimal use of kidneys from small pediatric cadaveric donors remains controversial. The aim of this study was to analyze short-term graft and patient survivals of en bloc kidney transplantations compared with single cadaveric adult donor kidney transplantations.

Patients and methods

We compared the 1-year evolution of 14 adult recipients of en bloc pediatric kidney donors (EBKT) of median age 13.5 ± 14.5 months (range = 3 days to 48 months) with 182 recipients of ideal adult cadaveric donors (ADT) showing a median age of 30 ± 21 years (range = 14-45 years).

Results

Besides the different age and weight of the donors, EBKT recipients were more commonly women (P = .05) and received thymoglobulin induction treatment (P = .00). Delayed graft function was higher in EBKT (46.2% vs 22.2%, P = .05), with no differences in the incidences of acute rejection episodes. Mean serum creatinine values at 3, 6, and 12 months after transplantation were 1.1 ± 0.3, 1.1 ± 0.2, and 1.0 ± 0.2 mg/dL in the EBKT group, compared with 1.3 ± 0.5 (P = .16), 1.3 ± 0.5 (P = .02), and 1.3 ± 0.6 (P < .01) in the ADT group. Vascular allograft complications were more frequent among EBKT. Graft survival rate at 1 year was 92% in both groups, with no differences in patient survival (100% in EBKT vs 92% in ADT; P = .49).

Conclusions

EBKT from small pediatric donors show excellent graft function and 1-year survival and should be considered for transplantation into adults.     

Elevated serum gamma-glutamyltransferase and hypomagnesemia are not related with new-onset diabetes after transplantation

Background

New-onset diabetes mellitus after transplantation (NODAT) contributes to the risk of cardiovascular disease (CVD) and infection, reducing graft and patient survival in kidney transplant recipients. To reduce CVD and improve outcomes of kidney transplant recipients, it is of great interest to more precisely elucidate the risk factors that contribute to the development of NODAT. A previous study reported that hypomagnesemia is an independent predictor of NODAT. Elevated gamma-glutamyltransferase (GGT) activity increases the risk of incident type 2 diabetes in the general population. The objective of this study was to determine whether magnesium (Mg) and GGT were risk factors for NODAT among our population of kidney transplant recipients.

Methods

We retrospectively analyzed 205 non-previously diabetic kidney transplant recipients. GGT was measured before transplantation as well as at months 1, 2, and 12. Mg was measured at months 1, 2, and 12. NODAT was defined at month 12 and at the end of follow-up according to the “2003 international consensus guidelines.”

Results

Although 36 patients (17.5%) developed NODAT at month 12, 55 patients (26.8%) displayed it at the end of follow-up. We did not observe any significant difference, either in mean Mg (month 1, 1.73 ± 0.24 vs 1.75 ± 0.30 [P = .824]; month 2, 1.71 ± 0.22 vs 1.68 ± 0.26 [P = .565]; month 12, 1.77 ± 0.27 vs 1.80 ± 0.24 [P = .596]) or GGT values (pretransplantation, 32 ± 27 vs 33 ± 85 [P = .866]; month 1:39 ± 24 vs 48 ± 70 [P = .452]; month 2, 53 ± 96 vs 48 ± 83 [P = .739]; month 12, 40 ± 37 vs 38 ± 53 [P = .830]) between NODAT and non-NODAT patients at month 12 or at the end of follow-up.

Conclusion

Hypomagnesemia and high GGT activity were not risk factors for NODAT development in kidney transplant recipients.     

Imaging evaluation of kidney using multidetector computerized tomography in living-related renal transplantation

Background

Multidetector computerized tomography (MDCT) is lesser invasive than conventional angiography and has the advantage of assessment of vessels and surrounding anatomic variants before laparoscopic nephrectomy.

Methods

From May 2005 to March 2011, 62 consecutive living kidney donors of mean age 45.3 ± 12.7 years (range 24-70 y, male:female 26:36) underwent laparoscopic nephrectomy to paired recipients of mean age 44.8 ± 14.0 years (range 17-74 y, male:female 38:24). The clinical characteristics and laboratory data of donors and recipients were collected for analysis. Graft function as indicated by estimated glomerular filtration rate (eGFR) was obtained from the last stable visit of the donors and the best value displayed by the recipients.

Results

There was no significant correlation between CT kidney volume and and eGFR. By univariate analysis, donor age was associated with worse graft function (−0.51 mL/min lower eGFR per 1 year of donor age; P < .0001). Female sex and higher effective renal plasma flow/body mass index ratio were associated with better graft function; conversely, body weight and BMI were associated with poor graft function upon univariate and multivariate analysis. An ERPF of <220 mL/min and a donor age >45 y showed significantly lower eGFR. There was no effect of CT kidney volume <100 mL.

Conclusions

Our preliminary data suggest that CT kidney volume does not predict posttransplantation graft function, but MDCT is still important for analysis of anatomy before laparoscopic nephrectomy among living donors.     

Autosomal-Dominant Polycystic Kidney Disease and Kidney Transplantation: Experience of a Single Center

Background

Autosomal dominant polycystic kidney disease (ADPKD) is a hereditary disease that frequently leads to end-stage renal disease and is a common indication for kidney transplantation. We sought to evaluate the demographic characteristics, graft and patient survival, and some posttransplantation complications among ADPKD recipients.

Methods

This retrospective study included 445 renal transplant recipients, among whom 48 had ADPKD. We excluded patients with pretransplantation diabetes mellitus. We evaluated patient and graft survivals as well as posttransplantation complications.

Results

There was no difference between the 2 groups with respect to demographic or transplant characteristics, except for older age among the ADPKD group (51.2 ± 8.6 years vs 44 ± 13.1 years; P < .001). We also observed no significant difference with regard to immediate graft function, immunological graft, or patient survival. Although not significant, there was a lower incidence of proteinuria and a greater number of acute rejections among ADPKD patients. As for posttransplantation complications, there was no difference regarding the prevalence of hypertension, but there was more erythrocytosis among the ADPKD group. The incidence of posttransplantation diabetes mellitus was significantly greater in ADPKD patients (33.3% vs 17.1%; P = .009), and remained significant after adjusting for confounding variables by multivariate analysis with an adjusted odds ratio of 2.3 (95% confidence interval, 1.008-5.136; P = .048).

Conclusion

Our results suggested that ADPKD patients display a greater incidence of diabetes mellitus posttransplantation; ADPKD emerged as an independent predictor for this complication.     

Early steroid withdrawal in adult kidney transplantation at a single center

Background

Beneficial effects of protocols using minimal steroid exposure have been recently reported. The purpose of this study was to evaluate the outcomes of kidney transplantation recipients who received immunosuppression protocols with early steroid withdrawal (ESW) at our center.

Methods

We retrospectively studied 84 kidney transplant recipients who had received ESW immunosuppressive protocols at our center from March 2005 to December 2010. The immunosuppressive regimen was a combination of calcineurin inhibitors (tacrolimus/cyclosporine), methylprednisolone, which was tapered and discontinued within 2 months, mycophenolate mofetil, and basiliximab (postoperative days 0 and 4). We compared the outcomes of our ESW recipients with those of a historical control group (February 2003 to January 2005; n = 18).

Results

Clinical acute rejection episodes were observed in 15 (17.9%) and 5 (27.8%) cases in the ESW and control groups, respectively. Cytomegalovirus infection occurred in 12 (14.3%) and 5 (27.8%) cases in the ESW and control groups, respectively. The creatinine levels at 1 year after transplantation were 1.3 ± 0.4 mg/dL and 1.3 ± 0.5 mg/dL in the ESW and control groups, respectively. In the ESW group of 84 recipients, actuarial patient survival at 1 year was 94.0%. In the historical group of 18 recipients, the actuarial patient survival at 1 year was 100% (P = .76). In the ESW group the graft survival rate at 1 year was 95.2%. In the historical group, graft survival rate at 1 year was 100% (P = .65). There were no significant differences in the parameters between the groups.

Conclusions

The outcomes from this study were considered to be acceptable; however, the possibility of improving the protocols exists.     

Comparison between thymoglobulin and ATGAM as an induction agent in adult kidney transplantation: a single-center experience

Objective

The best antithymocyte globulin (ATG) preparation for induction suppression in kidney transplant recipients is still not clear. The aim of this study was to identify short- and long-term outcomes in kidney transplant recipients who received Thymoglobulin or ATGAM as an induction agent.

Methods

We retrospectively reviewed patients who underwent kidney transplantation from 1996 to 2010. Recipients were classified according to the ATG preparation.

Results

One hundred fifty-two patients (64.4%) received thymoglobulin and 84 (35.6%) received ATGAM. The occurrence of delayed graft function in patients receiving Thymoglobulin was higher than in patients receiving ATGAM (P = .005), but serum creatinine levels and acute rejection after kidney transplantation were not different between the two groups. The death-censored graft survival curve in Thymoglobulin recipients was higher than in ATGAM recipients (P = .027). Bacterial infection was a predisposing factor for graft survival (P = .008).

Conclusion

The efficacy of Thymoglobulin induction is generally better than that of ATGAM induction, and prevention of bacterial infections was just as important as the use of ATG because bacterial infection was an important risk factor for graft failure.     

The role of obesity in kidney transplantation outcome

Background

The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation.

Methods

We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable.

Results

Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035).

Conclusions

Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.     

Increasing levels of hemoglobin improve renal transplantation outcomes

Introduction

Several studies have reported various data on prevalence of posttransplant anemia (PTA). We have little information about its impact on long-term graft outcomes and few studies of the optimal hemoglobin (Hb) target in kidney transplantation.

Methods

We examined retrospectively 144 kidney transplant recipients of mean age 44.4 ± 12.3 years and follow-up of 40.5 ± 4.6 months. Exclusion criteria were age below 18 years, multiorgan transplantation, and graft failure in the first year. Using simple and multiple linear regression models, we evaluated the potential prediction of a serum concentration of Hb at 1 year after renal transplantation on allograft outcome as measured by Δ% estimated glomerular filtration rate (eGFR), the difference between eGFR, measured with the Modification of Diet in Renal Disease (MDRD) formula, at the end of follow-up, and at 1 year. Multiple models were adjusted for recipient sex, recipient age, donor age, ESA therapy, acute rejection episodes (ARE), days of delayed graft function, human leukocyte antigen mismatches and cold ischemia time.

Results

At 1 year after transplantation, the mean Hb level was 13.77 ± 1.87 g/dL in males and 12.52 ± 1.53 g/dL in females. The average eGFR at 1 year was 63.07 ± 25.88 mL/min. At the end of follow-up, the mean Δ% eGFR was −5.73% ± 27.30%. Blood concentration of Hb correlated with donor, recipient sex, ARE, and eGFR at 1 year. There was a close correlation between the Δ% Hb and eGFR upon univariate analysis and the multiple linear regression model. Hb was the only predictor of transplant outcome.

Conclusions

Many factors are involved in kidney allograft function. Among these, Hb is important. In this work we demonstrated that increasing levels of Hb at 1 year after transplantation seemed to predict better preservation of graft function, representing a marker of a good quality graft.     

Prevalence of the Metabolic Syndrome in Kidney Transplantation

Objectives

We investigated the prevalence of the metabolic syndrome (MS) in kidney transplantation patients and assessed its development based on plasma adiponectin levels and the results of an oral glucose tolerance test (OGTT).

Methods

We performed a cross-sectional study of 94 recipients with stable graft function who underwent kidney transplantation between January 1999 and October 2008. The presence of MS was determined using National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) criteria with body mass index (BMI) used in place of waist circumference. In addition, we measured plasma adiponectin level and performed a 75-g oral GTT.

Results

Fourteen (14.9 %) recipients suffered from MS for a mean period of 46.7 months (range, 1-106) after transplantation. BMI at the time of transplantation was significantly greater in the MS group (23.4 ± 3.24 vs 20.1 ± 2.50; P < .0001), whereas plasma adiponectin level was significantly lower (11.95 ± 5.13 vs 17.71 ± 8.47; P = .0158). The insulinogenic index values were similar, whereas the homeostatic model assessment of insulin resistance was greater in the MS group (2.598 ± 1.918 vs 1.340 ± 0.934; P = .0002).

Conclusion

The level of adiponectin, which was lower in kidney transplant recipients who developed MS, was negatively correlated with insulin sensitivity. We concluded that a low adiponectin level may correlate with the prevalence of MS in kidney transplantation in association with impaired insulin sensitivity.     

Does simultaneously transplanted pancreas improve long-term outcome of kidney transplantation in type 1 diabetic recipients?

Introduction

Simultaneous pancreas-kidney transplantation (SPK) is an alternative to kidney transplantation (KTx) for type 1 diabetic patients with end-stage kidney disease. However, a fair comparison of SPK and KTx is difficult because of significant differences in donor, recipient, and transplantation procedure parameters. The aim of this study was to compare the early and long-term outcomes of SPK versus KTx in southwest Poland.

Material and Methods

Thirty-five diabetic dialysis patients who had SPK and 64 patients who had KTx were included in the analysis.

Results

SPK recipients were younger (38 ± 6 years versus 42 ± 9 years) and received organs from younger donors (25 ± 7 versus 43 ± 12 years) compared to the KTx group. They had shorter kidney cold ischemia time (9 ± 2 hours versus 22 ± 7 hours) but worse HLA class II mismatches (1.4 ± 0.6 versus 1.0 ± 0.5). In the early postoperative period, three patients died from the SPK group and one patient died from the KTx group. Additionally, two SPK patients lost their pancreatic grafts, and five KTx patients lost their kidney grafts. One-year patient survival rates for the SPK and KTx groups were 88% and 98%, respectively, and 5-year, 81% and 93%, respectively. One-year kidney graft survivals rates for the SPK and KTx groups were 100% and 89%, respectively, and 5-years, 89% and 81%, respectively. One-year insulin-free survival among SPK patients was 90% and the 5-year survival rate was 76%. Excretory function of the transplanted kidneys was better among SPK group; however, the difference reached statistical significance only in posttransplant years 2 and 3: 63.5 ± 20.1 versus 50.3 ± 19.7 and 64.9 ± 12.9 versus 51.6 ± 21.8 mL/min/1.73 m² for SPK and KTx, respectively.

Conclusions

Normoglycemia in SPK recipients did not improve patient survival at 5 years. The worse HLA compatibility in the SPK group did not lead to impaired kidney graft survival compared to KTx. Better kidney graft function among SPK recipients probably resulted from a more restrictive donor selection.     

Selection of live-related liver transplantation candidates

Purpose

Living donor liver transplantation (LR) is an important alternative for children. We compared our outcomes of LR and cadaveric (CAD) graft recipients, with attention to the pediatric end-stage liver disease (PELD) score and perioperative morbidity and mortality to identify appropriate candidates for LR.

Methods

Our transplant database and electronic medical records were searched for demographics and outcome measures.

Results

From 2000 to 2008, 81 children underwent liver transplantation from 37 LR and 44 CAD donors. There were no significant differences in graft or overall survival at 3 months or 1 year. The LR group was significantly younger (4.46 ± 5.2 years vs 7.41 ± 6.6 years; P = .03) and had a significantly lower PELD score (12.7 ± 13 vs 22 ± 12; P = .001) at the time of transplantation. Ten patients were transplanted for unresectable tumor in the LR group vs 4 CAD (P = .03). Significantly fewer LR recipients required return to the operating room in the first 30 days posttransplant (13.9% vs 34.1%; P = .03). The LR recipients had a higher rate of biliary stricture requiring reoperation (22.2% vs 2.3%; P = .005).

Conclusions

The LR liver transplantation is highly selected for patients with a parent donor who will need transplant but do not yet have a high PELD score. A lower PELD score at operation may have contributed to the lower incidence of postoperative complications requiring reoperation.     

Outcome of renal transplantation in Alport's syndrome: a single-center experience

Background

Anti-glomerular basement membrane (anti-GBM) nephritis post-renal transplantation (RTx) is known to cause graft loss in Alport's syndrome (AS). We evaluated the results of RTx in AS patients vis à vis patient and graft survivals, incidence of anti-GBM nephritis, and causes of graft failure.

Materials and methods

Between 1993 and 2009 we performed 31 RTx on AS patients (28 males and three females) of overall mean age of 22 ± 7.9 years from six deceased and 27 living donors. Two patients underwent second RTx.

Results

Over a follow-up of 1, 3, 5, and 10 years, the mean serum creatinines (mg/dL) were 1.51 ± 0.52, 1.59 ± 0.26, 1.61 ± 0.30, and 1.63 ± 0.32, respectively. Patient survivals at 1, 5, and 10 years were 89.71%, 81.32% and 81.32% with graft survival for all periods of 81.2%. Twenty-one percent experienced biopsy-proven acute rejection episodes. Graft failures were due to anti-GBM nephritis in 12.2% (n = 4), chronic allograft nephropathy in 3.2% (n = 1), and acute rejection or cyclosporine toxicity 3.2% (n = 1 each). The mean duration to graft loss was 4.9 ± 2.4 months.

Conclusion

Graft and patient survivals were acceptable among transplant recipients with AS despite the risk of anti-GBM nephritis.     

Systemic vascular hemodynamics and transplanted kidney survival

Introduction

High blood pressure and arterial stiffness contribute independently to cardiovascular mortality in uremic patients. High blood pressure is an established risk factor for chronic allograft nephropathy, recently named interstitial fibrosis/tubular atrophy (IF/TA). We sought to assess whether heart afterload determinants: arterial stiffness and vascular resistance or impedance accelerate kidney graft failure upon long-term observation.

Methods

Using a noninvasive method of blood pressure waveform analysis, (HDI/PulseWave/CR-2000), we studied 160 consecutive kidney transplant recipients, who were at least 3 months after transplantation, for systolic (SBP), diastolic, and mean blood pressure; pulse rate; systemic vascular resistance and impedance as well as large and small artery compliance. The associations of the hemodynamic parameters with relative increases in serum creatinine for every year of graft survival (ΔCreat) were assessed using multiple linear regression analysis. Relationships between systemic hemodynamics and kidney graft loss due to IF/TA were evaluated by Cox regression analysis, including serum creatinine, time after transplantation, delayed graft function, human leukocyte antigen mismatch, panel-reactive antibodies, cold ischemia time, donor age glomerular filtration rate as well as prescribed cardiovascular and immunosuppressive drugs.

Results

Over 6.6 ± 0.4 years of follow-up, excluding four noncompliant patients, 11 patients died and 32 lost their kidney grafts, including 25 due to IF/TA. ΔCreat (10.3% ± 22.0%/y) was independently and positively associated with the initial SBP (β = 0.26; P = .001) and serum creatinine values (β = 0.16; P = .04). The risk of graft loss due to IF/TA was greater among patients with an increased serum creatinine (relative risk [RR] = 59.5 per nlog-unit increase; P < .001) or higher SBP (RR = 51.1 per nlog-unit increase; P = .04). Besides SBP, no other hemodynamic parameter was associated with graft failure.

Conclusions

The rate of kidney graft function deterioration and risk of transplant loss due to IF/TA are not independently influenced by systemic arterial compliance, resistance, or impedance. SBP appears to be the key circulatory parameter independently affecting the progression of IF/TA, and should be a therapeutic target.     

Risk Factors for Urinary Tract Infections During the First Year After Kidney Transplantation

Introduction

Urinary tract infections (UTI) have been reported to occur with frequencies ranging from 30% to 60% in kidney transplant recipients during the first year posttransplantation. UTI is the main cause of infectious complications in this period. The objective of this study was to evaluate the incidence of UTI, during the first year posttransplantation and to identify the risk factors associated with its development, as well as its impact on graft function.

Patients and Methods

This retrospective cohort study had as a primary outcome the development of UTI, defined as the presence of more than 100,000 colony-forming units (CFU) of a pathogenic organism by mL of urine. The univariate analysis was performed with chi-square test for categorical variables and Student t test for continuous ones metrics. We performed multivariate analysis with logistic regression. P < .05 was considered statistically significant.

Results

We studied 176 kidney transplant recipients, including 54.5% of male gender and with an overall average age of 37 ± 12 years. The UTI incidence was of 35.8% (n = 63). The bacterium most frequently found in urine cultures was Escherichia coli (n = 46). In this study, the risk factors that were independently associated with UTI development were age, female gender, days of bladder catheterization, genitourinary anatomic alterations, and UTI during 1 month prior to kidney transplantation.

Conclusion

This type of study makes it possible to identify risk factors and to formulate strategies focused on particular risk factors.     

Increased incidence of acute graft rejection on calcineurin inhibitor-free immunosuppression after heart transplantation

Background

Calcineurin inhibitor (CNI)-free immunosuppression is used increasingly after heart transplantation to avoid CNI toxicity, but in the absence of a randomized trial, concerns remain over an increased rejection risk.

Methods

We studied the incidence of graft rejection episodes among all cardiac graft recipients, beginning with the first introduction of CNI-free protocols. We compared events during CNI-free and CNI-containing immunosuppression among 231 transplant recipients of overall mean age 55.2 ± 11.8 years, from a mean 5.2 ± 5.4 years after transplantation through a mean follow-up of 3.1 ± 1.4 years. We considered as acute rejection episodes requiring treatment those of International Society for Heart and Lung Transplantation.

Results

During the total follow-up of 685 patient years (CNI-containing, 563; CNI-free, 122), we performed 1,374 biopsies which diagnosed 78 rejection episodes. More biopsies were performed in CNI-free patients: biopsies/patient-month of CNI-containing, 0.13 versus CNI-free, 0.22 (P < .05). The incidence of rejection episodes per patient-month was significantly higher on CNI-free compared with CNI therapy, among patients switched both early and later after heart transplantation, namely, within 1 year, 0.119 versus 0.035 (P = .02); beyond 1 year, 0.011 versus 0.004 (P = .007); beyond 2 years, 0.007 versus 0.003 (P = .04); and beyond 5 years: 0.00578 versus 0.00173 (P = .04).

Conclusions

Rejection incidence during CNI-free immunosuppression protocols after heart transplantation was significantly increased in both early and later postoperative periods. Given the potentially long delay to rejection occurrence, patients should be monitored closely for several months after a switch to CNI-free immunosuppressive protocols.