Spontaneous kidney allograft rupture

Spontaneous renal allograft rupture is one of the most dangerous complications of kidney transplantation, which can result in graft loss. This condition needs immediate surgical intervention. Conservative management has dismal results. Its prevalence varies from 0.3% to 3%. Rupture occurs in first few weeks after transplantation. Predisposing factors for graft rupture are acute rejection, acute tubular necrosis, and renal vein thrombosis. There are growing reports about successful results of repairing these ruptured kidneys. In this study, we reviewed the medical records of 1682 patients who received kidney allografts from living donors from 1986 through 2003. There were six (0.35%) cases of renal allograft rupture. All were preceded by acute graft rejection. They were treated with antirejection medications. In first three cases, the kidney allografts were removed because the procedure of choice in this situation is graft nephrectomy; but in three next cases we repaired the ruptured grafts with good results in two of them. In conclusion, the procedure of choice for kidney allograft rupture is graft repair.     

Higher graft salvage rate in renal allograft rupture associated with acute tubular necrosis

BACKGROUND: Renal allograft rupture is an early postoperative complication threatening graft and patient survival. We reviewed the etiology and prognostic factors for renal allograft rupture. MATERIAL AND METHODS: Among 657 renal transplants performed between 1990 and 2001, renal allograft rupture was diagnosed in 10 cases. Statistical analysis by Student t test, ANOVA, and chi-square was performed to assess donor and recipient characteristics. Multivariate logistic regression to predict renal allograft rupture used variables with P <.15 in the univariate analysis. RESULTS: Patients with renal allograft rupture were mainly men and young. Renal allograft rupture incidence was higher among allografts from non-heart-beating donors, kidneys with delayed graft function, or patients with a high antibody titer. Histopathological findings revealed that six renal allograft ruptures were secondary to acute rejection, three to acute tubular rejection and one to allograft infarction. Only one of six renal allograft ruptures (17.7%) secondary to rejection was resolved by surgery; two of the three patients (66.7%) with acute tubular necrosis were successfully operated and a nephrectomy was performed for the patient with allograft infarction. By multivariate logistic regression analysis, factors shown to be predictive for renal allograft rupture were: delayed graft function, age of recipient, peak panel-reactive antibody >25%, and initial immunosuppressive treatment without antithymocyte globulin. CONCLUSIONS: Higher graft salvage rates are possible in cases of graft rupture associated with acute tubular necrosis.     

Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis

BACKGROUND: Waiting time on dialysis has been shown to be associated with worse outcomes after living and cadaveric transplantation. To validate and quantify end-stage renal disease (ESRD) time as an independent risk factor for kidney transplantation, we compared the outcome of paired donor kidneys, destined to patients who had ESRD more than 2 years compared to patients who had ESRD less than 6 months. METHODS: We analyzed data available from the U.S. Renal Data System database between 1988 and 1998 by Kaplan-Meier estimates and Cox proportional hazards models to quantify the effect of ESRD time on paired cadaveric kidneys and on all cadaveric kidneys compared to living-donated kidneys. RESULTS: Five- and 10-year unadjusted graft survival rates were significantly worse in paired kidney recipients who had undergone more than 24 months of dialysis (58% and 29%, respectively) compared to paired kidney recipients who had undergone less than 6 months of dialysis (78% and 63%, respectively; P<0.001 each). Ten-year overall adjusted graft survival for cadaveric transplants was 69% for preemptive transplants versus 39% for transplants after 24 months on dialysis. For living transplants, 10-year overall adjusted graft survival was 75% for preemptive transplants versus 49% for transplants after 24 month on dialysis. CONCLUSIONS: ESRD time is arguably the strongest independent modifiable risk factor for renal transplant outcomes. Part of the advantage of living-donor versus cadaveric-donor transplantation may be explained by waiting time. This effect is dominant enough that a cadaveric renal transplant recipient with an ESRD time less than 6 months has the equivalent graft survival of living donor transplant recipients who wait on dialysis for more than 2 years.     

Cholesterol embolization in renal allografts

Renal cholesterol embolization (RCE) in native kidneys has a dismal outcome and frequently leads to irreversible renal failure. RCE may rarely occur in renal allografts as well, particularly if the recipient or the donor has prominent atherosclerosis. The natural history of RCE in renal transplants is unknown. We have reviewed the surgical pathology files of The Johns Hopkins Hospital in the 14-year period between 1984 and early 1999 and found 7 RCE cases among 1500 renal transplant biopsies (0.47%). One of the seven cases had three biopsies showing cholesterol emboli, the first of which was a postreperfusion (immediate posttransplant) biopsy. The probable source of the cholesterol emboli was the recipient in six cases and the donor in one case. Five donors were cadaveric and two were living donors. Six biopsies were taken within the first 4 months posttransplant (four were postreperfusion biopsies). One recent patient had the inciting event of arteriography and stent placement 2 years posttransplant and is currently doing well. One kidney failed due to posttransplant lymphoproliferative disorder (PTLD), another kidney failed with complicating opportunistic infections, and the other five were functioning 2 to 6 years posttransplant. A literature review revealed additional 14 RCE cases in renal transplants. Combining our cases with those in the literature (21 cases), reveals that the origin of the RCE was probably the recipient in 11 cases (seven cadaveric, two living-related, and two unknown), and the donor in 10 cases (eight cadaveric and two unknown). Graft failure occurred in two of the 11 cases, where RCE was of probable recipient origin. Seven of the 10 kidneys, where the RCE was probably of donor origin, failed due to allograft dysfunction; one of them also developed superimposed rejection and cytomegalovirus infection. We conclude that if RCE is originating in the recipient, graft survival is usually good. In contrast, if RCE is of donor origin, graft dysfunction and subsequent graft loss are common. The reason for this difference may be the more extensive RCE developing in an atherosclerotic cadaveric donor during organ procurement or severe trauma leading to death.     

The contribution of adhesion molecule expression in donor kidney biopsies to early allograft dysfunction.

BACKGROUND: Renal allograft rejection is associated with the expression of adhesion molecules on vascular endothelial and tubular epithelial cells. METHODS: To assess whether the number of cell adhesion molecules expressed in donor kidneys can predict early rejection or delayed graft function, kidney biopsies from 20 living and 53 cadaveric kidney donors were obtained before engraftment into the recipients and the expression of the cell adhesion molecules intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), and endothelial leukocyte adhesion molecule (E-selectin) were determined by immunohistochemistry. RESULTS: All biopsies from living donors showed significantly lower expression of ICAM-1 and VCAM-1 compared to biopsies from cadaveric donors. There was no difference in the expression of adhesion molecules on tubular cells between transplants with primary function compared to allografts with early rejection in living donated kidneys (ICAM-1: 2+/-8 vs. 3+/-8%; VCAM-1: 9+/-7 vs. 1+/-1%), as well as in cadaveric kidneys (ICAM-1: 38+/-29 vs. 39+/-38%; VCAM-1: 55+/-27 vs. 48+/-29%). The expression of ICAM-1 molecules on tubular cells was determined to be a predictor for the occurrence of delayed graft function in cadaveric kidneys (ICAM-1: 65+/-24* vs. 38+/-29% delayed graft versus primary graft function). No delayed graft function occurred in recipients of living donated kidneys. CONCLUSIONS: These data suggest that adhesion molecule expression in donor biopsies is not a predictor for early allograft rejection, but can be used as a marker for the development of postischemic acute renal allograft failure.     

Causes of long-term graft failure in renal transplantation

Summary A single-center experience of 980 consecutive renal transplant recipients treated with cyclosporine (CyA) was reviewed to analyze the causes of renal allograft loss and the factors affecting long-term renal survival in CyA-treated kidney transplants. In all, 217 grafts were lost during the observation period, with the most common causes of graft loss being chronic rejection (96 cases, 44%), death with a functioning graft (52 cases, 24%), glomerulonephritis (28 cases, 13%), and acute rejection (20 cases, 8%). The actuarial 10-year survival of patients with living and cadaveric grafts was 93% and 91%, respectively. The actuarial 10-year survival of living and cadaveric grafts was 70% and 63%, respectively. Patients were divided into two groups, namely a graft-survival group (n=763) and a graft-loss group (n=217). There was no significant difference between the two groups in terms of sex, donor source, donor age, recipient age, duration of hemodialysis, retransplants, transfusions, presensitization, of HLA match. There was no difference between the graft-survival group and the graft-loss group in the mean CyA dose given or the mean CyA trough level measured at any time following transplantation. Acute rejection episodes occurred in patients from the graft-survival group (55%) as compared with those from the graft-loss group (83%; P<0.00001). These data suggest that long-term graft survival in CyA-treated kidney transplant patients is primarily influenced by the occurrence of rejection episodes rather than by the drug dose or the duration of CyA administration. CyA nephrotoxicity was not the major risk factor for long-term graft survival in CyA-treated renal transplants.     

A decade of experience with renal transplantation in African-Americans

OBJECTIVE To evaluate the strategies instituted by the authors' center to decrease the time to transplantation and increase the rate of transplantation for African-Americans, consisting of a formal education program concerning the benefits of living organ donation that is oriented to minorities; a laparoscopic living donation program; use of hepatitis C-positive donors in documented positive recipients; and encouraging vaccination for hepatitis B, allowing the use of hepatitis B core Ab-positive donors.SUMMARY BACKGROUND DATA The national shortage of suitable kidney donor organs has disproportional and adverse effects on African-Americans for several reasons. Type II diabetes mellitus and hypertension, major etiologic factors for end-stage renal disease, are more prevalent in African-Americans than in the general population. Once kidney failure has developed, African-Americans are disadvantaged for the following reasons: this patient cohort has longer median waiting times on the renal transplant list; African-Americans have higher rates of acute rejection, which affects long-term allograft survival; and once they are transplanted, the long-term graft survival rates are lower in this population than in other groups.METHODS From March 1990 to November 2001 the authors' center performed 2,167 renal transplants; 944 were in African-Americans (663 primary cadaver renal transplants and 253 primary Living donor renal transplants). The retransplants consisted of 83 cadaver transplants and 17 living donor transplants. Outcome measures of this retrospective analysis included median waiting time, graft and patient survival rates, and the rate of living donation in African-Americans and comparable non-African-Americans. Where applicable, data are compared to United Network for Organ Sharing national statistics. Statistical analysis employed appropriate SPSS applications.RESULTS One- and 5-year patient survival rates for living donor kidneys were 97.1% and 91.3% for non-African-Americans and 96.8% and 90.4% for African-Americans. One- and 5-year graft survival rates were 95.1% and 89.1% for non-African-Americans and 93.1% and 82.9% for African-Americans. One- and 4-year patient survival rates for cadaver donor kidneys were 91.4% and 78.7% for non-African-Americans and 92.4% and 80.2% for African-Americans. One- and 5-year graft survival rates for cadaver kidneys were 84.6% and 73.7% for non-African-Americans and 84.6% and 68.9% for African-Americans. One- and 5-year graft and patient survival rates were identical for recipients of hepatitis C virus-positive and anti-HBc positive donors, with the exception of a trend to late graft loss in the African-American hepatitis C virus group due to higher rates of noncompliance, an effect that disappears with censoring of graft loss from that cause. The cadaveric renal transplant median waiting time for non-African-Americans was 391 days compared to 734 days nationally; the waiting time for African-Americans was 647 days compared to 1,335 days nationally. When looking at all patients, living and cadaver donor, the median waiting times are 220 days for non-African-Americans and 462 days for African-Americans.CONCLUSIONS Programs specifically oriented to improve volunteerism in African-Americans have led to a marked improvement in overall waiting time and in rates of living donation in this patient group. The median waiting times to cadaveric renal transplantation were also significantly shorter in the authors' center, especially for African-American patients, by taking advantage of the higher rates of hepatitis C infection and encouraging hepatitis B vaccination. These policies can markedly improve end-stage renal disease care for African-Americans by halving the overall waiting time while still achieving comparable graft and patient survival rates.     

ABO-incompatible kidney transplantation using both A2 and non-A2 living donors

BACKGROUND: Given the scarcity of cadaveric organs, efforts are intensifying to increase the availability of living donors. The current study assessed the feasibility of using ABO-incompatible living-donor kidneys to expand the donor pool. METHODS: The authors performed 18 ABO-incompatible living-donor kidney transplants between May 1999 and April 2001. Ten patients received living-donor kidneys from A2 and eight patients received kidneys from non-A2 blood group donors. Immunosuppression consisted of Thymoglobulin antibody induction, tacrolimus, mycophenolate mofetil, and prednisone. Eight non-A2 and two A2 kidney recipients also received a pretransplant conditioning regimen of four plasmapheresis treatments followed by intravenous immunoglobulin and splenectomy at the time of transplantation. Antidonor blood group antibody titer was measured at baseline, pretransplant, at 1- to 3-month and 1-year follow-up, and at the time of diagnosis of antibody-mediated rejection. RESULTS: No hyperacute rejection episodes occurred. One-year graft and patient survival rates in the 18 ABO-incompatible recipients were only slightly lower than those of 81 patients who received ABO-compatible kidney transplants during the same period (89% vs. 96% and 94% vs. 99%, respectively). Glomerular filtration rate and serum creatinine levels did not differ between the groups. Antibody-mediated rejection occurred in 28% of ABO-incompatible recipients, and was reversible with plasmapheresis, intravenous immunoglobulin, and increasing immunosuppression in all patients except one. CONCLUSIONS: ABO-incompatible living donor kidney transplants can achieve an acceptable 1-year graft survival rate using an immunosuppressive regimen consisting of Thymoglobulin induction, tacrolimus, mycophenolate mofetil, and prednisone combined with pretransplant plasmapheresis, intravenous immunoglobulin, and splenectomy.     

Successful Renal Transplantation in Children With Posterior Urethral Valves

PurposeThe treatment of children with posterior urethral valve (PUV) and end-stage renal disease can be challenging. Some series have had poor outcomes after renal transplantation with an increased risk of graft dysfunction and urinary tract infections. We present our experience with a pediatric population and compare it to all the other pediatric renal transplants done at our institution.Materials and MethodsWe identified 10 patients with PUV who underwent a total of 13 renal transplants between 1990 and 2000. The comparison group included 120 transplants done in 95 patients during the same period. Cumulative allograft survival and function were recorded.ResultsOverall patient survival in the PUV group was 100%. Mean age at transplant in the PUV group was 10.0 years and mean followup was 3.9 years. Six patients underwent high proximal urinary tract diversion, while the remainder had primary transurethral valve ablation. Three patients had bladder augmentation before transplantation. Cumulative allograft survival in the PUV group at 1 and 5 years was 85% and 64%, respectively. Of the 10 patients 9 currently have functioning living related donor transplants. One patient lost 3 cadaveric donor transplants to chronic rejection. No patients lost grafts due to infection or bladder dysfunction. Mean serum creatinine of the functioning grafts was 1.1 mg/dl.ConclusionsRenal transplantation can be performed safely and effectively in patients with PUV, including those who have undergone previous proximal urinary tract diversion. Preoperative bladder management and continued monitoring of bladder and kidney function postoperatively are paramount in the preservation of allograft function.     

Kidney transplantation from donors with viral B and C hepatitis

INTRODUCTION: The success of renal transplantation as a treatment for end-stage renal disease has created a chronic shortage of donor organs. We present our experience in transplanting kidneys from donors with hepatitis B virus (HBV) or hepatitis C virus (HCV) among matched serology-positive recipients. MATERIALS AND METHODS: From January 2002 to November 2005, 44 patients with end-stage renal disease and HCV seropositivity underwent kidney transplantation. In 28 transplants in HCV+ recipients, the donor was HCV+ (DC+/RC+) and in 16 of these cases the donor (one living donor) was HCV- (DC-/RC+). In the same period 14 patients with HBV infection and HbsAg seropositivity underwent kidney transplantation: eight received their graft from a cadaveric HbsAg-positive donor (DB+/RB+), while six patients received their graft from an HbsAg-negative donor. RESULTS: Viral reactivation was higher among DC+/RC+ (21.4%) than DC-/RC+ patients (6%). Graft survivals were 90% and 88% for DC+/RC+ and DC-/RC+, respectively; patient survivals were 100% for DC+/RC+ and 94% for DC-/RC+. Among the group of DB+/RB+, all the patients developed an HBV-DNA positivity in the early postoperative period. Patient and graft survivals were 100% in both groups. CONCLUSIONS: Our results suggest that HBV- and HCV-positive donors can be considered as an alternative donor source, because their kidneys are allocated to the matched serology-positive recipients, shortening their time on the waiting list.     

Kidney and Pancreas Transplantation in the United States, 1998–2007: Access for Patients with Diabetes and End-Stage Renal Disease

Although the number of candidates on the kidney transplant waiting list at year-end rose from 40 825 to 76 070 (86%) between 1998 and 2007, recent growth principally reflects increases in the number of patients in inactive status. The number of active patients increased by 'only' 4510 between 2002 and 2007, from 44 263 to 48 773. There were 6037 living donor and 10 082 deceased donor kidney transplants in 2007. Patient and allograft survival was best for recipients of living donor kidneys, least for expanded criteria donor (ECD) deceased donor kidneys, and intermediate for non-ECD deceased donor kidneys. The total number of pancreas transplants peaked at 1484 in 2004 and has since declined to 1331. Among pancreas recipients, those with simultaneous pancreas-kidney (SPK) transplants experienced the best pancreas graft survival rates: 86% at 1 year and 53% at 10 years. Between 1998 and 2006, among diabetic patients with end-stage renal disease (ESRD) who were under the age of 50 years, 23% of all and 62% of those waitlisted received a kidney-alone or SPK transplant. In contrast, 6% of diabetic patients aged 50–75 years with ESRD were transplanted, representing 46% of those waitlisted from this cohort. Access to kidney-alone or SPK transplantation varies widely by state.     

Excellent Long-term Outcome of ABO-Incompatible Living Donor Kidney Transplantation in Japan

Owing to the severe shortage of cadaveric grafts in Japan, we have performed ABO-incompatible living donor kidney transplantation since 1989. This study assessed short- and long-term outcomes in 441 patients who received ABO-incompatible living donor kidney transplants between January 1989 and December 2001. We compared our results with historical data from 1055 recipients of living kidney transplantation. Overall patient survival rates 1, 3, 5, 7, and 9 years after ABO-incompatible transplantation were 93%, 89%, 87%, 85%, and 84%, respectively. Corresponding overall graft survival rates were 84%, 80%, 71%, 65%, and 59%. After ABO-incompatible transplantation, graft survival rates were significantly higher in patients 29 years or younger than in those 30 years or older and in patients who received anticoagulation therapy than in those who did not receive such therapy. There were no significant differences between A-incompatible and B-incompatible recipients with respect to clinical outcomes. The graft survival rate at 1 year in the historical controls was slightly but not significantly higher than that in our recipients of ABO-incompatible transplants. We conclude that long-term outcome in recipients of ABO-incompatible living kidneys is excellent. Transplantation of ABO-incompatible kidneys from living donors is a radical, but effective treatment for end-stage renal disease.     

移植肾自发性破裂的诊治

目的：探讨移植肾自发性破裂的原因及防治措施。方法：回顾分析本院３９２例同种肾移植术后发生移植肾自发性破裂２０例临床资料。结果：发生率为５．１％。１４例保留肾脏功能，其中２例经保守治疗痊愈。６例肾切除者中有４例为急性排斥反应引起。结论：肾破裂的发生与排斥反应、肾缺血性损害、肾静脉引流不畅及尿路梗阻有关。对于出血量少、肾功能好者，可采用保守治疗。预防要从肾脏摘取与灌洗、植肾手术、合理应用免疫抑制剂、及     

Why should we implement living donation in renal transplantation?

BACKGROUND: Renal transplantation started with living donor transplants. However, after the introduction of cyclosporine, the improved results of kidney transplants from cadaveric donors have raised controversy regarding the use of living donors. There are various reasons as to why some transplant centers tend to refuse living donation: first of all, the possibility that unilateral nephrectomy can be harmful to a healthy individual. SUBJECTS AND METHODS: By reviewing the medical literature on the various aspects of living donation, postoperative mortality in connection with living donation has been calculated to be 1:3,000. RESULTS: Long-term follow-up investigations of donors demonstrated that the risk of progressive renal failure, hypertension, and proteinuria was not increased by nephrectomy per se, but other causes were responsible for that in occasional patients. From these studies, one can conclude that unilateral nephrectomy is not harmful to a healthy individual. In addition, there are other valid reasons to expand living donation: 1) the need for cadaveric donor kidneys for transplantation far exceeding the supply; 2) the better kidney quality from living donors due to the shorter ischemia time, the lack ofagonal phase and cytokines release that follows brain death; 3) the continuing improved results of kidney transplants from living donors in comparison with those from cadaveric donors in the cyclosporine era also. This appears to be true also for kidney transplants from unrelated living donors in spite of complete incompatibility with recipients. 4) Pre-emptive transplantation, based on living donors, not only avoids the risks, cost, and inconvenience of dialysis, but is also associated with better graft survival than transplantation after a period of dialysis, particularly within the live donor cohort. CONCLUSIONS: In conclusion, living donor transplants should be part of any transplant center's activity. To encourage living donation, every center should have a formal recipient family education program in conjunction with national organ donation campaigns.     

Renal allograft implantation in respect of atypical vascular procedures

In minority of renal transplants it is unevitable to perform atypical vascular procedures of renal allograft implantation, which increases the risk of vascular complications, graft loss and lethality. In the presenting study, we retrospectively evaluated kinds of atypical vascular procedures in renal allograft implantation by donor type and the transplants outcome related to these procedures. From 1980 to 1998, a total of 463 patients (mean age 36.2+/-10.3), underwent renal transplantation (319 from living donor and 144 from cadaveric donor) at the Institute of Urology & Nephrology in Belgrade. Atypical vascular procedures of renal allograft implantation were representative for the some of the following cohorts: bypass grafting, endarterectomy, end to side both arterial and venous anastomotic site. A total of 45 patients (9.72%) underwent some of atypical vascular procedures (41 from living donor and 4 from cadaveric donor) (p<0.01). Among analyzed procedures, bypass grafting was performed in majority of cases (n=38). A total of 101 patients underwent endarterectomy. End to side both arterial and venous anastomotic site was done in two patients. Severe direct postoperative vascular complications following by lethal outcome appeared in 2 patients. Related to standardized, atypical vascular procedures had been of increased risk for appearance of severe vascular complication.     

Operative management of spontaneous kidney transplant rupture. Personal experiences and literature review

Spontaneous rupture of the cadaver kidney is not rare in the early post-transplant period. In the literature the rupture complication rate varies between 0.3% and 8.5%. in our series 4.2% (12 of 285) of transplanted kidneys ruptured spontaneously. All transplant ruptures occurred as an early complication within 6 weeks postoperatively in the clinical setting of oliguria. In 8 of 12 patients we tried to preserve the graft by covering it with dehydrated solvent-dried human dura that is then sutured in place. In these cases surgical repair resulted in diuresis and restoration of normal graft function with long-term survival. This study emphasizes the possibility and necessity of conservation and repair of the ruptured allograft.     

Transplantation of pediatric kidneys to adult recipients: an analysis of 13 cases

INTRODUCTION: The shortage of cadaveric donors for kidney transplantation has prompted many centers to expand the criteria used for donor selection to increase the organ supply. The use of cadaveric pediatric kidneys has been suggested as a means to overcome the shortage. However, some studies indicate that kidneys from pediatric donors show inferior results to those from adult donors. In this retrospective study we examined the outcome of kidney transplantation using cadaveric pediatric donors. MATERIALS AND METHODS: From October 1990 to May 2002, 13 adult patients received pediatric renal transplants including two that were transplanted en bloc. The patients were divided into two groups based upon donor age: group I donors were 18 months to 6 years old; the seven recipients were of mean age 47.3 years. Group II donors were 7 to 15 years old; the six recipients were of mean age 43.6 years old. Cyclosporine-based immunosuppressive regimens were used in both groups. RESULTS: The patient survival rate was 85.7% in group I and 100% in group II. The graft survival rates at the first and third posttransplant year in group I were 71.4% (5/7) and 57.1% (4/7) and in group II, 66.7% and 50%, respectively. The frequency of urinary complications in group I was 28.5% (2/7) and in group II 33.3% (2/6). There was one case of venous thrombosis in group II. CONCLUSION: Pediatric renal grafts may be used with reasonable safety. However, surgical complications remain a significant problem especially with younger pediatric grafts.     

Live donor renal transplants using kidneys with arteriographic evidence of mild renovascular disease

The objective of the study was to determine whether using a living donor kidney with arteriographic evidence of renovascular disease affects the outcome of the recipient's transplanted graft. Twenty-eight patients who had unilateral renovascular abnormalities on conventional angiography underwent donor nephrectomy of the ipsilateral kidney. Results in the recipients who received these kidneys were reviewed. Comparison was made to a control group of living donor renal transplant recipients who were matched for donor, recipient age. Graft survival, patient survival, serum creatinine for all 28 recipients were evaluated. All 28 donors underwent a successful donor nephrectomy. Recipient graft survival was 96% at 1 yr, 92% at 3 yr, 71% at 5 yr, 62% at 10 yr. Mean serum creatinine values at 1 month, 1 yr, 3 yr were 1.5, 1.5, 1.6, respectively. Similar results were observed in the control group. We conclude that renal transplantation utilizing kidneys with arteriographic evidence of renovascular disease results in excellent short, long-term renal allograft survival.     

The impact of the UNOS mandatory sharing policy on recipients of the black and white races--experience at a single renal transplant center.

The impact of the United Network for Organ Sharing mandatory sharing policy on a large transplant center procuring kidneys primarily from caucasians while serving a pool of prospective recipients composed mainly of blacks is described. This policy requires that all 6-antigen-matched and phenotypically identical donor kidneys be shipped to the appropriately matched recipients. The study consisted of 49 kidneys from 25 cadaveric donors; one kidney was unusable. In general, the 33 recipients of the mandatorily shared kidneys were caucasian (94%), unsensitized (70%), and first-time transplants (73%). Allograft survival for the 24 first-time recipients was 100% (mean graft survival = 11.3 months). Of the 9 regraft kidneys, 2 have failed (mean graft survival = 11.9 months) due to chronic rejection. In comparison, the 16 paired kidneys transplanted into non-6-antigen-matched recipients exhibited a 1-year graft survival of 80% versus 92% for the 33 recipients of mandatorily shared kidneys (P = 0.01). These 16 recipients were composed of more blacks (38%), fewer regrafts (6%), and most were unsensitized (75%). All 25 cadaveric donors were caucasians with very common HLA types. Thus, kidneys provided by the UNOS mandatory sharing policy had excellent allograft survival, and the recipients were largely unsensitized caucasians receiving their first kidney. The low number of blacks receiving allografts under this policy may be due to two factors. First, the histocompatibility differences between black recipients and the primarily caucasian cadaveric donor pool limit the number of kidneys available to blacks. Secondly, blacks do not have access to the best-matched kidneys, in part due to few black donors, their best source for well-matched kidneys. Thus, the mandatory sharing program is of clear benefit to the recipients of these well-matched kidneys; however, for a local program servicing a waiting list composed of 64% blacks the policy has been of limited value. In contrast, over 50% of local cadaveric transplants are into black recipients in a waiting time of 197 days, one third the national average for blacks. In conclusion, this study supports efforts to improve graft survival through matching but emphasizes the need to broaden our efforts in all areas of research and organ procurement to serve the entire recipient population, regardless of race.     

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.