Survival benefits of kidney transplantation with expanded criteria deceased donors in patients aged 60 years and over

BACKGROUND: The proportion of transplant candidates aged 60 years and over listed on the kidney transplant waiting list is increasing, as is the proportion of potential organ donors of this age. We compared in elderly recipients: kidney graft survival of expanded criteria deceased donor (ECD) to nonexpanded criteria deceased donor (NECD), and survival of patients receiving these grafts to those remaining on the waiting list. METHODS: Between 1996 and 2004, a total of 3001 patients aged 60 years and over were registered on the French kidney transplant waiting list, of which 2099 were transplanted. The data were analyzed using Kaplan-Meier methods and Cox models. RESULTS: ECD was defined as presenting at least one of the following factors: age over 60 years than less (relative risk [RR]=1.26; P=0.02), history of arterial hypertension vs. absence (RR=1.34; P=0.01), history of diabetes mellitus vs. absence (RR=1.6; P=0.01), and death due to cerebrovascular accident vs. other cause (RR=1.3; P=0.01). Patients who did not undergo transplantation had an adjusted risk of death 2.54 times higher than that of transplanted patients of the same age (P<0.0001), regardless of the type of graft. The risk was 3.78 times higher than that for patients receiving NECD grafts (P<0.0001) and 2.31 for patients receiving ECD grafts (P<0.0001). CONCLUSION: In elderly patients, transplantation with an ECD kidney was associated with higher survival rates than remaining on the waiting list. This result suggests that the identification and use of ECD kidney grafts should be optimized, given changes in the characteristics of potential donors and recipients.     

Access to, and outcome of, renal transplantation according to treatment modality of end-stage renal disease in France

BACKGROUND: Although peritoneal dialysis (PD) is recognized as one of the methods of treatment of end-stage renal disease (ESRD), there have been recurrent concerns about the access of patients treated by this modality to kidney transplantation (KTx), as well as reports showing increased complications of KTx in such patients, such as graft thrombosis and infections. METHODS: The aim of this study was to provide a comprehensive view of the impact on transplantation of pretransplant modality of treatment of ESRD using a multivariate analysis of the French database. From 1997 to 2000, after exclusion of pediatric patients, multiple transplantations, and living donors, 6420 were patients registered on the waiting list, and 3464 were transplanted. RESULTS: Using a Cox proportional hazard analysis, we found a shorter waiting time for PD patients (RR 0.71, P < 0.0001), which became equivalent to hemodialysis (HD) patients when taking into account the transplant center as a variable (RR 1.0, P= 0.95). Concerning graft survival, only preemptive transplantation had a significant impact, being associated to a decreased risk of graft failure (RR 0.46, P= 0.005). Conclusion. Our study supports the concept that the choice of any pretransplant dialysis modality does not influence waiting time for transplant or the results of transplantation.     

Peripheral arterial disease and renal transplantation

It was hypothesized that peripheral arterial disease (PAD) is less frequent after kidney transplantation than among comparable patients who are on the deceased-donor waiting list. The cumulative incidences and risk factors for PAD were compared among 43,427 adult transplant recipients and 53,309 adults who were placed on the renal transplant waiting list between 1995 and 2003. All patients had Medicare primary insurance coverage, and Medicare claims were used to identify PAD. For patients with diabetes, the 3-yr cumulative incidence of de novo PAD was 24% on the waiting list versus 20% after transplantation. For patients without diabetes, the 3-yr cumulative incidence was 9% on the waiting list versus 5% after transplantation. The adjusted relative risk (RR) for PAD among patients without diabetes was 0.73 (95% confidence interval [CI] 0.66 to 0.80; P < 0.0001) in the transplant population versus the waiting list population, whereas among patients with diabetes, it was 0.88 (95% CI 0.82 to 0.96; P = 0.0024). A diagnosis of PAD on the waiting list was associated with an almost three-fold increase in the RR for death for patients without diabetes (2.98; 95% CI 2.71 to 3.27; P < 0.0001) and with diabetes (2.92; 95% CI 2.71 to 3.15; P < 0.0001). After transplantation, de novo PAD increased the RR for death almost two-fold in patients without diabetes (1.92; 95% CI 1.63 to 2.26; P < 0.0001) and with diabetes (1.83; 95% CI 1.58 to 2.12; P < 0.0001). The incidence of PAD is higher on the waiting list than after transplantation and is associated with an increased risk for death among patients with and without diabetes.     

Outcome‐dependent geographic and individual variations in the access to renal transplantation in incident dialysed patients: a French nationwide cohort study

This study investigated geographical variations of access to renal transplantation using three outcomes (access to the transplant waiting list, access to renal transplantation after waitlisting and access to renal transplantation after dialysis start). Associations of patient‐related and regional variables with the studied outcomes were assessed using a Cox shared frailty model and a Fine and Gray model. At the study endpoint (December 31, 2015), 26.3% of all 18–90‐year‐old patients who started dialysis in the 22 mainland and four overseas French regions in 2012 (n = 9312) were waitlisted and 15.1% received a kidney transplant. The geographical disparities of access to renal transplantation varied according to the studied outcome. Patients from the Ile‐de‐France region had the highest probability of being waitlisted, but were less likely to receive a kidney transplant. Two regional factors were associated with the access to the waiting list and to renal transplantation from dialysis start: the incidence of preemptive kidney transplantation and of ESRD. The use of different outcomes to evaluate access to kidney transplantation could help healthcare policy‐makers to select the most appropriate interventions for each region in order to reduce treatment disparities.     

How great is the survival advantage of transplantation over dialysis in elderly patients?

BACKGROUND: Patients >60 years old represent 66% of all new patients starting renal replacement therapy in Scotland. The aim of this study was to investigate whether or not transplantation provides any survival benefit in this group of patients. METHODS: 325 patients >60 years old listed for transplantation in Scotland between 1 January 1989 and 31 December 1999 were followed up until 31 December 2000. Sociodemographic, comorbidity, listing and transplant data were obtained from the national renal and transplant databases and case-notes review. Survival was compared between those who received a transplant and those who were listed but did not receive a transplant by the end of the follow-up period. Mann-Whitney, chi(2), Fisher's exact and log-rank tests were used where appropriate. RESULTS: Of the 325 patients listed, 128 (39.4%) received a first transplant within the study period and the remaining 197 (60.6%) continued to undergo dialysis. The transplant recipients were younger at listing (P<0.0001), lived closer to the transplant centre (P = 0.043) and spent less time on the active waiting list (P<0.0001) than patients who remained on dialysis. They had less ischaemic heart disease (P = 0.024), cerebrovascular disease (P = 0.03) and arrhythmias (P = 0.016). The overall mortality rate was 0.16 per patient-year for dialysis and 0.10 for transplantation. There was a significantly lower risk of death (RR = 0.35, 95% CI 0.22--0.54; P<0.0001, log-rank) and a longer life expectancy after listing with a transplant (8.17 vs 4.32 years). CONCLUSIONS: Renal transplantation offers a significant survival advantage over dialysis in elderly patients with end-stage renal failure who are considered suitable for transplantation.     

Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients

BACKGROUND: Elderly patients (ages 70 yr and older) are among the fastest-growing group starting renal-replacement therapy in the United States. The outcomes of elderly patients who receive a kidney transplant have not been well studied compared with those of their peers on the waiting list. METHODS: Using the Scientific Registry of Transplant Recipients, we analyzed data from 5667 elderly renal transplant candidates who initially were wait-listed from January 1, 1990 to December 31, 2004. Of these candidates, 2078 received a deceased donor transplant, and 360 received a living donor transplant by 31 December 2005. Time-to-death was studied using Cox regression models with transplant as a time-dependent covariate. Mortality hazard ratios (RRs) of transplant versus waiting list were adjusted for recipient age, sex, race, ethnicity, blood type, panel reactive antibody, year of placement on the waiting list, dialysis modality, comorbidities, donation service area, and time from first dialysis to first placement on the waiting list. RESULTS: Elderly transplant recipients had a 41% lower overall risk of death compared with wait-listed candidates (RR=0.59; P<0.0001). Recipients of nonstandard, that is, expanded criteria donor, kidneys also had a significantly lower mortality risk (RR=0.75; P<0.0001). Elderly patients with diabetes and those with hypertension as a cause of end-stage renal disease also experienced a large benefit. CONCLUSIONS: Transplantation offers a significant reduction in mortality compared with dialysis in the wait-listed elderly population with end-stage renal disease.     

Cross sectional survey on the concerns and anxiety of patients waiting for organ transplants

Aim: We aimed to gain an understanding of patient concerns while on a transplantation waiting list in areas with long transplant waiting time. Methods: The study population comprised patients with organ failure on the transplant waiting list in Hong Kong. They were invited to complete a questionnaire survey. Demographic data and waiting time were collected. Respondents rated their chance of getting transplanted, their subjective concerns and feelings, level of happiness and support received. Results: A total of 442 patients on the waiting list for kidney, liver, lung and heart‐lung transplants completed the questionnaire survey. The majority of patients (93.0%) were waiting for kidney transplantation. More than half of the respondents (63.3%) had been waiting for more than 3 years. Patients with longer transplant waiting times had lower self‐estimated chance of receiving a transplant (P = 0.004). Self‐estimated chance of getting transplanted was positively associated with the happiness score (P < 0.0001). Issues of most concerns to the patients waiting for organ transplants were: inconvenience of therapy (48.2%), disease progression (47.9%), burden to family (59.5%) and financial difficulties (52.3%). More female patients on the waiting list (50.0% vs 25.7% in male) reported concerns about suffering associated with the illnesses. 21.7% of patients considered the level of support received inadequate. Conclusions: Our patients had long waiting time for transplantation, which is associated with a lower perceived chance of getting a transplant. Attention to more psychosocial support to these patients waiting for organ transplant is important. Promoting and improving organ donation would be the ultimate way to help these patients.     

Multicenter analysis of kidney preservation

BACKGROUND: Kidney preservation is an integral part of clinical kidney transplantation. Changes in the use of preservation methods and storage solutions, ischemic preservation times, and the relationship between ischemia time and human leukocyte antigen (HLA) match have not been extensively studied in recent years. METHODS: The Collaborative Transplant Study database was used to analyze effects of kidney preservation methods and times. Graft survival and death-censored functional survival were used as endpoints. In all, 91,674 transplants from deceased donors were analyzed using univariate and multivariate methods. RESULTS: Cold storage accounted for more than 95% of kidney preservations from 1990-2005. Increasing ischemia up to 18 hr was not detrimental for graft outcome, whereas the risk of graft failure rose with ischemia 19-24 hr to relative risk (RR) 1.09, 25-36 hr to RR 1.16, and >36 hr to RR 1.30 (P<0.001). As compared to other preservation solutions, University of Wisconsin (UW) solution was associated with significantly better outcome when ischemia exceeded 24 hr. Short ischemia did not eliminate the effect of HLA matching. Kidneys from young or old donors were affected by prolonged ischemia to similar degrees. Pulsatile machine perfusion was not superior to cold storage. CONCLUSION: Kidneys from deceased donors should ideally be transplanted within 18 hr. Within the 18-hr window, the time of ischemia has no significant influence on graft survival. UW solution should be used if preservation for longer periods is envisioned. HLA matching improves graft survival regardless of length of ischemia.     

Comparison of blood group versus HLA-dependent transplantation and its influence on donor kidney survival.

BACKGROUND: The advantages of organ allocation based on human leukocyte antigen (HLA) typing are controversial. This evaluation compares the results of HLA-dependent and non-HLA-dependent allocation in the transplantation of donor kidneys. METHODS: Seventy-seven donor kidney pairs explanted locally between 1984 and 1994 were examined. One half of each pair was transplanted locally in Bonn on the basis of criteria including blood group, waiting time and currently negative cross-match. The other half of these pairs was allocated in accordance with the Eurotransplant (ET) criteria. RESULTS: Cold ischaemia time was an average of 14.02 h in Bonn vs. 24.18 h in the ET group (P<0.0001). The number of HLA mismatches was calculated and, for example, for locus A it was 1.13 in Bonn vs. 0.73 in the ET group (P=0.0003). One-year graft survival for the locally transplanted kidneys was 92.2% and, for the ET kidneys, 90.9%. Five-year survival was 79.5% vs. 81.7%, respectively. Patient survival after 1 year was 100% vs. 97.4%, and after 5 years, 93.4% vs. 93.1%. CONCLUSION: The results show that it is possible to provide patients with a locally allocated kidney graft that enables good function after a short waiting period. This procedure avoids long cold ischaemia time and long waiting periods.     

Logistics and transplant coordination activity in the GRAGIL Swiss-French multicenter network of islet transplantation

BACKGROUND: Since the Edmonton trial in 2000, increasing numbers of transplant centers have been implementing islet transplantation programs. Some institutions have elected to associate in multicenter networks, such as the Swiss-French GRAGIL (Groupe Rhin-Rh?ne-Alpes-Genève pour la Transplantation d'Ilots de Langerhans) consortium. METHODS: All pancreata offers to the University of Geneva Cell Isolation and Transplantation Center from within the network in 2002 and 2003 were reviewed. Islet preparations were attributed to the most suitable recipient on a centrally managed waiting list. All shipments were performed by ambulance in less than 5 hr. RESULTS: Over the period of study, 260 pancreata were offered, from a total of 1,304 cadaveric donors in the four allocation regions (20%). Fifty-two patients were on the waiting list at any time during this 2-year period. The percentage of organs offered varied in the range of 0.5% to 42%, depending on region of origin, with a correlation with number of patients on the waiting list in each region. Of these, 104 (40%) were accepted for processing. Ninety-two pancreata were actually processed, resulting in 42 islet preparations being transplanted. The number of international equivalents of transplanted preparations was 378,500+/-16,000 versus 165,400+/-15,400 (P<0.0001) for nontransplanted preparations. Total cold ischemia time was 6+/-0.3 hr for transplanted preparations versus 6.7+/-0.4 hr for nontransplanted preparations (not significant). CONCLUSIONS.: A high rate of pancreas offers, successful isolation, and islet transplantation can be achieved in multicenter networks such as GRAGIL. Such an approach can expand both the donor pool and the recipient population.     

Preemptive Cadaveric Renal Transplantation: Fairness and Utility in the Case of High Donation Rate—Pilot Experience of Tuscany Region

Preemptive kidney transplantation is performed before the initiation of chronic dialysis. Preemptive transplantation is the best treatment modality for patients reaching end-stage renal disease. The Tuscany region has experienced, in the last years, a marked increase in donation rate. Starting from 2006, the first Italian cadaveric preemptive transplant program was activated. The aim of our study was to investigate the characteristics and preliminary results of this program. Among 163 patients entered on to the waiting list for renal transplantation from October 2006 to October 2008, 120 (73.6%) were on dialysis for 21.3 ± 17.8 months, whereas 43 patients (26.4%) had not yet been on dialysis (preemptive). Eighty two patients (50.3%) resided in Tuscany and 81 (49.7) outside Tuscany; 36.6% of Tuscany patients and 16% of extraregional patients (P = .003) were listed as preemptive. Fifty-eight of 163 (35.6%) patients were transplanted during the period after a mean waiting time of 10.3 ± 6.4 months. The estimated overall man waiting time was 17.5 months (confidence interval (CI) = 15.8-19.2). Upon Cox multivariate analysis, the probability of transplantation was similar for preemptive and dialysed patients (relative risk [RR] 1.02, P = NS). According to local allocation policy, only residents of Tuscany showed a significant advantage in both groups (RR = 0.43, CI = 0.24-0.75, P = .003). Two-year graft and patients survivals were similar, but delayed graft function was lower in the preemptive group (13% vs 42%, P = .007). The 1-year serum creatinine was 1.56 ± 0.43 in the preemptive group and 1.68 ± 0.92 in the dialysis group (P = NS). No differences were observed concerning rejection rate. The preemptive listing rate for cadaveric renal transplantation was more than 35% for Tuscany patients.     

Living kidney donors requiring transplantation: focus on African Americans

Risks of kidney donation include a poorly characterized risk of late kidney failure. We hypothesized that African Americans (AA) kidney donors were at greater risk for kidney failure. The United Network for Organ Sharing/Organ Procurement Transplantation Network database was searched for patients who previously donated a kidney and were subsequently placed on the kidney transplant waiting list. We then compared the race of donors listed for kidney transplant to the race of all living donors during the same time period. Between 1993 and 2005, 8889 donors (14.3%) were AA and 42,419 (68.1%) were Caucasian. During this same time period, 102 previous kidney donors developed kidney failure and were listed for kidney transplantation. Although AAs comprised 14.3% of all living kidney donors, they constituted 44% of donors reaching the waiting list (P<0.001). These data provide indirect evidence that the risk of kidney failure may be exaggerated in AA donors.     

Impact of renal transplantation on survival in end-stage renal disease patients with elevated body mass index

BACKGROUND: Cadaveric renal transplantation is associated with a survival advantage compared with dialysis patients remaining on the renal transplantation waiting list, but this advantage has not been confirmed in obese end-stage renal disease (ESRD) patients. METHODS: Using data from the USRDS, we studied 7521 patients who presented with ESRD from 1 April 1995 to 29 June 1999 and later enrolled on the renal transplantation waiting list with body mass indices (BMI) >or=30 kg/m(2) at the time of presentation to ESRD, and followed until 6 November 2000. Recipients of preemptive renal transplantation or organs other than kidneys were excluded. Cox non-proportional hazards regression models were used to calculate adjusted, time-dependent hazard ratios (HR) for time to death in a given patient during the study period, controlling for renal transplantation, demographics and comorbidities (Form 2728). RESULTS: The incidence of mortality was 3.3 episodes per 100 patient-years (PY) in cadaveric renal transplantation and 1.9/100 PY in living donor renal transplantation compared with 6.6 episodes/100 PY in all patients on the transplant waiting list. In comparison to maintenance dialysis, both recipients of solitary cadaveric kidneys (HR 0.39, 95% CI 0.33 to 0.47), and recipients of living donor kidneys (HR 0.23, 95% CI 0.16 to 0.34) had statistically significant improved survival. A benefit of cadaveric renal transplantation did not apply to patients with BMI >or=41 kg/m(2) (HR 0.47, 95% CI, 0.17 to 1.25, P = 0.13). CONCLUSIONS: Obese patients on the renal transplant waiting list had a significantly lower risk of mortality after renal transplantation compared with those remaining on dialysis.     

Kidney transplant outcomes in the indigenous population in the Northern Territory of Australia

BACKGROUND: Indigenous Australians develop end-stage renal disease (ESRD) at a significantly higher rate than nonindigenous Australians. Renal transplantation is the preferred treatment modality; however, they are underrepresented in the transplanted population. In addition, despite the morbidity and mortality gains demonstrated in other patient groups, it is unclear whether such an advantage is replicated for indigenous Australians. We have sought to identify some of the factors that lead to poorer outcomes within this group of recipients. METHODS: We performed a retrospective analysis of a cohort of renal transplant recipients (indigenous and nonindigenous) from the Northern Territory of Australia. RESULTS: Indigenous patients waited longer on dialysis, were more sensitized at the time of transplantation, and the number of human leukocyte antigen mismatches was greater. Overall renal allograft survival is poorer among indigenous Australians (HR 4.13, 2.0-8.5, P<0.0001) with the majority of grafts lost due to recipient death. The most common cause of death was septicemia. Graft loss due to any cause has not been influenced by the absence of full-time specialist staff at major treatment centers. Infection rates are greatly increased in indigenous patients (RR 4.1, 95% CI 3.5-4.7, P<0.0001), in addition to the incidence of rejection (RR 2.5 95% CI 1.8-3.5, P<0.001) and hospitalization (RR 3.9, 95% CI 3.2-4.9, P<0.0001). There is increased steroid exposure among indigenous recipients. CONCLUSIONS: Indigenous recipients of cadaveric kidney transplants have worse outcomes than nonindigenous recipients, mostly due to increased mortality and morbidity from infective causes.     

Survival improvement among patients with end-stage renal disease: trends over time for transplant recipients and wait-listed patients

Both transplant and dialysis outcomes have improved over recent years. In addition, transplantation has been shown to confer a survival benefit over maintenance dialysis. The study presented here addresses the question of whether the survival benefit of transplantation over maintenance dialysis has changed in the most recent eras. This study was based on data collected by the United States Renal Transplant Scientific Registry and the United States Renal Data System. The study sample consisted of 104,000 patients placed on the renal transplant waiting list between 1988 and 1996, of which 73,707 subsequently received renal transplants. The annualized adjusted mortality rates per 1000 patient-years were calculated by calendar year of placement on the renal transplant waiting list and for kidney transplant recipients. The resulting data were plotted, and linear curve fitting was used to estimate the slope of the change of the adjusted mortality rates by year during the period studied, 1988 to 1996. Overall annual adjusted death rates in the wait-listed patients and transplant recipients per 1000 patient-years decreased for both groups throughout the study period. From 1989 to 1996, the relative risk (RR) for patient death had decreased by 30% for transplant recipients and 23% for wait-listed patients (RR = 0.70 and 0.77; P < 0.0001 each). Slope analysis of the cause-specific mortality rates for cardiovascular disease and infection showed nearly equivalent, linear decreases for both groups. Mortality rates have improved overall and by categories of major cause of death for both renal transplant recipients and patients on the renal transplant waiting list. These favorable trends most likely represent equal advances in transplantation, dialysis, and general medical care.     

Does cadaveric donor renal transplantation ever provide better outcomes than live-donor renal transplantation?

BACKGROUND: Live donor renal transplantation (LRT) now comprises more than 40% of all kidney transplants performed in the United States. Many patients on the cadaveric waiting list have a prospective live kidney donor. This study determines whether cadaveric donor renal transplantation (CRT) can demonstrate better outcomes than LRT. METHODS: From the United States Renal Data System registry, 31,909 adult recipients of a first-time kidney transplant from 1995 to 1998 were analyzed. Recipients were followed until December 31, 2000. RESULTS: CRT, more human leukocyte antigen (HLA) mismatches, increased donor age, cold ischemia time greater than 24 hr, African American recipient, and a history of diabetic nephropathy all increased the risk of graft failure, return to dialysis, and death. Nevertheless, in specific circumstances, CRT could provide better outcomes than LRT. For example, in recipients aged 18 to 59 years with a hypothetical live kidney donor aged 50 years and four HLA mismatches, the relative risk of graft loss with LRT is comparable or increased compared with CRT if the cadaveric kidney donor is much younger or with fewer HLA mismatches. On the other hand, for recipients aged 60 years or older, CRT never provides better outcomes than LRT. All analyses were adjusted for recipient race, gender, and history of diabetic nephropathy. There were no significant interactions among donor type, HLA mismatches, donor age, and cold ischemia time. CONCLUSIONS: The elderly recipient with an imminent LRT should never be offered CRT. A combination of recipient and donor factors can make CRT preferable to LRT in younger patients.     

Comparison of time on the deceased donor kidney waitlist versus time on the kidney paired donation registry in the Australian program

In the Australian kidney paired donation (KPD) program matching is based on acceptable mismatches, whereas deceased donor waitlist (DDWL) patients are allocated kidneys based on HLA antigen matching rules. Herein, we compared waiting time for a KPD match to the waiting time on the DDWL and the occurrence of matching in the DDWL for patients who were registered in both programs. Data on first dialysis, matches on the DDWL, KPD program entry, matches and transplant dates were assessed in 26 KPD recipients of the Australian program. There were 22 recipients who were listed in the DDWL and received kidney transplants by KPD. Time on dialysis until KPD transplantation was 808 ± 646 days. Eleven patients had never been matched with a deceased donor (waiting time 345 ± 237 days) and 11 had been matched on average 3 ± 5 times (waiting time 1227 ± 615 days, P < 0.0001 vs. never matched), but did not progress to transplantation because of positive crossmatch or class II donor‐specific antibody. Mean time from registration in the KPD program until kidney transplantation was 153 ± 92 days (P < 0.0001 vs. DDWL). KPD allocation using the acceptable mismatch approach is effective in identifying suitable live donors for some recipients within a relatively short time‐frame.     

The impact of changing practice on improved outcomes of paediatric renal transplantation in the United Kingdom: a 25 years review

This review reports the outcomes of paediatric renal transplantation in the United Kingdom over the last 25 years. UK Transplant Registry data on 3236 paediatric renal transplants performed between 1 January 1992 and 31 December 2016 were analysed. Significant improvements in human leucocyte antigen (HLA) matching have been achieved; 84% of recipients received 000 or favourable (0 DR and 0 or 1 B) mismatched kidneys in 2016 compared with 27% in 1992. The median waiting time has increased from 126 days in 1999 to 351 days in 2016. Tacrolimus replaced ciclosporin in most immunosuppressive regimens after 2002. Renal transplant outcome has improved significantly, mainly because of a reduction in early graft loss. One‐year donation after brain death renal allograft survival for those transplanted from 2012 to 2016 was 98%, compared with 72% for those transplanted from 1987 to 1991. Renal allograft survival for first kidney only transplants at 1, 5, 10, 20 and 25 years were 89%, 79%, 65%, 42% and 33% respectively. Superior survival with living donor was maintained throughout the study period with 25‐year graft survival at 33% compared with 31% from deceased donor (P < 0.0001). Changes in immunosuppression regimens, improvements in HLA matching and a reduction of cold ischaemia time may in part explain the improvements in graft survival.     

Liver Transplant Waiting Time Does Not Correlate With Waiting List Mortality: Implications for Liver Allocation Policy

Factors associated with the risk for mortality once placed on the liver transplant waiting list and how this risk relates to center-specific waiting time and transplant activity have not been adequately evaluated. We performed this study to determine the association between center-specific waiting time and waiting list mortality among liver transplant candidates stratified by medical urgency at the time of registration. A Cox proportional hazards model was used to calculate 2-year mortality risk for a cohort of 16,414 registrants added to the United Network for Organ Sharing liver transplant waiting list between January 1, 1997, and December 31, 1997. After controlling for confounding variables, we calculated the mortality risk for centers, organ procurement organizations (OPOs), and states. The relation between center-specific waiting list mortality risk and median waiting time or transplant activity was determined by linear regression. In multivariate analyses, higher initial medical urgency status (relative risk [RR] = 12.8;P < .001), increasing age (P < .001), black ethnicity (RR = 1.29; P < .001), history of previous transplant (RR = 1.2; P = .009), certain liver diagnoses, and smaller center size (RR = 1.39; P = .008) were associated with significantly increased waiting list mortality. Candidates with blood type A (RR = 0.87; P < .001) and those with cholestatic cirrhosis as the primary diagnosis (RR = 0.73; P < 0.001) had a reduced risk for dying. There were significant variations in 2-year waiting list mortality risk among centers, OPOs, and states. However, when stratified by medical urgency status at waiting list entry, center-specific waiting time and transplantation rates accounted for almost none of the center-specific waiting list mortality. Although there are variations in waiting list mortality risk among centers, OPOs, and states, there is very little relation between center-specific waiting list mortality and center-specific median waiting time or center-specific transplantation rates when stratified by medical urgency. Waiting time and center transplant rates should not influence liver allocation policy. (Liver Transpl 2000;6:543-552.)