First‐line choice for severe aplastic anemia in children: Transplantation from a haploidentical donor vs immunosuppressive therapy

We retrospectively compared the outcomes of children with severe aplastic anemia (SAA) who received immunosuppressive therapy (IST) or who underwent hematopoietic stem cell transplantation (HSCT) from a haploidentical donor (HID), between 2007 and 2016. A total of 52 children with SAA under the age of 17 years were initially treated with IST (n = 24) or haploidentical HSCT (n = 28) as first‐line treatment. The estimated 10‐year overall survival was 73.4 ± 12.6% and 89.3 ± 5.8% in patients treated with IST or HID‐HSCT (P = .806). The failure‐free survival was significantly inferior in patients receiving IST than in those undergoing transplantation from an HID (52.6 ± 10.5% vs 89.3 ± 5.8, P = .008). In univariate and multivariate analysis, the choice of first‐line immunosuppressive therapy was the only adverse predictor for failure‐free survival. At the last follow‐up, completely normal blood count was observed in 11 of 20 (55.0%) and 24 of 25 (96.0%) live cases in IST and HID‐HSCT cohort (P = .003). These suggest that HSCT from a haploidentical donor could be considered as first‐line treatment in children who lack a matched related donor, especially in experienced transplantation centers.     

Changing demographics of heart donors: The impact of donor drug intoxication on posttransplant survival

Recent reports have shown an increase in the number of organ donors from drug intoxication. The impact of donor drug use on survival after cardiac transplant remains unclear. The aim of our study was to illustrate changes in donor death mechanisms and assess the impact on posttransplant survival. We queried United Network of Organ Sharing thoracic transplant and deceased donor databases to identify patients undergoing heart transplantation between 2005 and 2015. We evaluated annual trends in donor death mechanisms. Recipients were propensity matched (drug‐intoxicated—non‐drug‐intoxicated = 1:2) and posttransplant survival was compared using Kaplan‐Meier curves. In total, 19 384 donor hearts were used for transplant during the period (donor age 31.6 ± 11.8 years, 72% male). Use of drug‐intoxicated donors increased from 2% (2005) to 13% (2015) and decreased from blunt injury (40%‐30%) and intracranial hemorrhage (29%‐25%). After propensity matching, posttransplant survival of drug‐intoxicated donor hearts was 90%, 82%, and 76% at 1, 3, and 5 years, which was similar to non‐drug‐intoxicated. Heart transplants using drug‐intoxicated donors have significantly increased; however, they have not adversely affected posttransplant survival. Hearts from drug‐intoxicated donors should be carefully evaluated and considered for transplant.     

First-Line Unrelated Double-Unit Umbilical Cord Blood Transplantation for Acquired Severe Aplastic Anemia

We analyzed the outcomes of 14 patients with severe aplastic anemia (SAA) who received first-line double-unit cord blood transplantation (dUCBT). Patients’ median age was 24.5 years (range, 10-44 years). The median numbers of infused nucleated and CD34⁺ cells were 5.48 × 10⁷/kg (range, 3.33-7.96 × 10⁷/kg) and 2.30 × 10⁵/kg (range, 0.86-3.97 × 10⁵/kg), respectively. One patient died 5 days after transplantation. Three of the 13 patients acquired autologous myeloid recovery. Neutrophil engraftment was observed in 10 patients (76.29%), and the median time of neutrophil recovery was 19 days (range, 15-40 days). Platelet engraftment was observed in 7 cases (53.8%), and 3 patients experienced platelet graft failure. The median time of platelet recovery was 32 days (range, 22-80 days). The cumulative incidence of grade II-IV acute graft-vs-host disease (GVHD) was 38.5%. One patient demonstrated mild chronic GVHD. After a median follow-up of 61 months (range, 18-102 months), 6 patients were alive. The predicted 5-year overall survival and GVHD-free, failure-free survival rates were 42.9% ± 13.2% and 14.3% ± 9.4%, respectively. The first-line dUCBT for SAA is still primarily evaluated through multicenter prospective clinical trials by an optimal conditioning regimen, cell dose, and other graft and transplantation-related factors.     

Men With Breast Cancer Have Same Disease-Specific and Event-Free Survival as Women

Background  Breast carcinoma in men is an uncommon disease. The aim of this study is to compare overall survival (OS) and disease-specific survival (DSS) in a group of matched men and women with breast cancer. Methods  Each man with breast cancer recorded in the database was matched with two women. Matching was done based on age, year of diagnosis, and stage. To compare breast cancer characteristics between men and women, the chi-square test was used for qualitative data and the t-test for quantitative data. Overall survival and DSS were calculated using Kaplan-Meier methods. Cox proportional hazards models have been used to compare survival rates between men and women. Results  The 58 male breast cancer patients were matched with 116 female patients. The mean age at diagnosis was 63.9 ± 11.9 years for men and 65.7 ± 11.5 years for women (P = .72). The median follow-up was 9.7 years for men and 10.7 years for women. The 5- and 10-year OS for men were, respectively, 58.9% and 33.9%. The 5- and 10-year OS for women were 68.2% and 52.1%. Men with breast cancer had a significant risk of dying compared with women (hazard ratio [HR] = 1.59; 95% confidence interval (95% CI), 1.04–2.42, P = .03). The 5- and 10-year DSS were 73.0% and 55.1% for men, and 72.8 and 61.2% for women, respectively. There was no difference in DSS between the two matched groups (HR = 1.26; 95% CI, 0.76–2.10, P = .37). Conclusions  The prognosis for men with breast carcinoma is similar to that for women with similar-stage disease.     

Patient and Graft Survival After Dual Kidney Transplantation With Marginal Donors in Comparison to Matched Control Groups

BackgroundPostmortal organ donor rates remain low in Germany, whereas donor age has been increasing considerably in the last decades. As a consequence of low donation rates older and more marginal donor kidneys are accepted for transplantation. However, procured kidneys from very old a/o marginal donors may be considered as not suitable for transplantation as a single organ and subsequently be discarded. However, dual transplantation of both kidneys from such donors may provide an opportunity to nevertheless use these organs for renal transplantation, thereby providing the twofold nephron mass as a single kidney transplantation.MethodsWe compared in this retrospective analysis the outcome of 10 recipients of a dual kidney transplantation (DKT) with 40 matched recipients of a single kidney transplantation (SKT). Recipients were matched for donor and recipient age (ie, a maximum age difference of ±10 years in a ratio of 1:4 for DKT vs SKT recipients). In addition, a second SKT control group of 10 SKT recipients being transplanted immediately before each DKT recipient with a kidney from a donor aged ≥65 years was used for comparison. All renal transplant recipients were observed for up to 3 years or until July 31, 2020.ResultsMean donor and recipient age was 77.2 ± 4.6/75.1 ± 6.6/82.1 ± 7.9 and 66.4 ± 5.8/66.1 ± 6.0/64.8 ± 8.4 for SKT group 1/SKT group 2/DKT, respectively. Procurement serum creatinine concentrations were significantly higher in the DKT group in comparison to the SKT control group 1 (P = .019) as was the rate of transplant artery atherosclerosis (P = .021). Furthermore, Kidney Donor Profile Index, and Kidney Donor Risk Index were significantly higher (P = .0138/P = .064, and P < .001/P = .038) in the DKT group than in SKT group 1 and 2. Rates of acute rejection and delayed graft function were not significantly different between groups, though biopsy-proven acute rejection was numerically higher in the SKT groups. Patient survival and overall and death-censored graft survival rates were also not significantly different between groups, although they tended to be higher after DKT.ConclusionsDKT provides an opportunity to successfully use postmortal kidneys even from donors aged >80 years and a Kidney Donor Profile Index ≥95% for renal transplantation. DKT may thereby increase the available pool of donors to better serve patients with end-stage renal disease on the waiting list.     

Long‐term outcome of renal transplantation from octogenarian donors: A multicenter controlled study

To assess whether biopsy‐guided selection of kidneys from very old brain‐dead donors enables more successful transplantations, the authors of this multicenter, observational study compared graft survival between 37 recipients of 1 or 2 histologically evaluated kidneys from donors older than 80 years and 198 reference‐recipients of non–histologically evaluated single grafts from donors aged 60 years and younger (transplantation period: 2006‐2013 at 3 Italian centers). During a median (interquartile range) of 25 (13‐42) months, 2 recipients (5.4%) and 10 reference‐recipients (5.1%) required dialysis (crude and donor age‐ and sex‐adjusted hazard ratio [95% confidence interval] 1.55 [0.34‐7.12], P = .576 and 1.41 [0.10‐19.54], P = .798, respectively). Shared frailty analyses confirmed similar outcomes in a 1:2 propensity score study comparing recipients with 74 reference‐recipients matched by center, year, donor, and recipient sex and age. Serum creatinine was similar across groups during 84‐month follow‐up. Recipients had remarkably shorter waiting times than did reference‐recipients and matched reference‐recipients (7.5 [4.0‐19.5] vs 36 [19‐56] and 40 [24‐56] months, respectively, P < .0001 for both comparisons). Mean (± SD) kidney donor risk index was 2.57 ± 0.32 in recipients vs 1.09 ± 0.24 and 1.14 ± 0.24 in reference‐recipients and matched reference‐recipients (P < .0001 for both comparisons). Adverse events were similar across groups. Biopsy‐guided allocation of kidneys from octogenarian donors permits further expansion of the donor organ pool and faster access to a kidney transplant, without increasing the risk of premature graft failure.     

Outcomes of shipped live donor kidney transplants compared with traditional living donor kidney transplants

The disparity between kidney transplant candidates and donors necessitates innovations to increase organ availability. Transporting kidneys allows for living donors and recipients to undergo surgery with a familiar transplant team, city, friends, and family. The effect of shipping kidneys and prolonged cold ischemia time (CIT) with living donor transplantation outcomes is not clearly known. This retrospective matched (age, gender, race, and year of procedure) cohort study compared allograft outcomes for shipped live donor kidney transplants and nonshipped living donor kidney transplants. Fifty‐seven shipped live donor kidneys were transplanted from 31 institutions in 26 cities. The mean shipping distance was 1634 miles (range 123–2811) with mean CIT of 12.1 ± 2.8 h. The incidence of delayed graft function in the shipped cohort was 1.8% (1/57) compared to 0% (0/57) in the nonshipped cohort. The 1‐year allograft survival was 98% in both cohorts. There were no significant differences between the mean serum creatinine values or the rates of serum creatinine decline in the immediate postoperative period even after adjusted for gender and differences in recipient and donor BMI. Despite prolonged CITs, outcomes for shipped live donor kidney transplants were similar when compared to matched nonshipped living donor kidney transplants.     

Ex vivo lung perfusion to improve donor lung function and increase the number of organs available for transplantation

This paper describes the initial clinical experience of ex vivo lung perfusion (EVLP) at the Fondazione Ca’ Granda in Milan between January 2011 and May 2013. EVLP was considered if donor PaO₂/FiO₂ was below 300 mmHg or if lung function was doubtful. Donors with massive lung contusion, aspiration, purulent secretions, pneumonia, or sepsis were excluded. EVLP was run with a low‐flow, open atrium and low hematocrit technique. Thirty‐five lung transplants from brain death donors were performed, seven of which after EVLP. EVLP donors were older (54 ± 9 years vs. 40 ± 15 years, EVLP versus Standard, P < 0.05), had lower PaO₂/FiO₂ (264 ± 78 mmHg vs. 453 ± 119 mmHg, P < 0.05), and more chest X‐ray abnormalities (P < 0.05). EVLP recipients were more often admitted to intensive care unit as urgent cases (57% vs. 18%, P = 0.05); lung allocation score at transplantation was higher (79 [40–84] vs. 39 [36–46], P < 0.05). After transplantation, primary graft dysfunction (PGD₇₂ grade 3, 32% vs. 28%, EVLP versus Standard, P = 1), mortality at 30 days (0% vs. 0%, P = 1), and overall survival (71% vs. 86%, EVLP versus Standard P = 0.27) were not different between groups. EVLP enabled a 20% increase in available donor organs and resulted in successful transplants with lungs that would have otherwise been rejected (ClinicalTrials.gov number: NCT01967953).     

Hematopoietic cell transplant outcomes after myeloablative conditioning with fludarabine,busulfan, low-dose total body irradiation,and rabbit antithymocyte globulin

Optimal conditioning and graft-vs-host disease (GVHD) prophylaxis for hematopoietic cell transplantation (HCT) are unknown. Here, we report on outcomes after low toxicity, myeloablative conditioning consisting of fludarabine, busulfan, and 4 Gy total body irradiation, in combination with thymoglobulin and post-transplant methotrexate and cyclosporine. We retrospectively studied 700 patients with hematologic malignancies who received blood stem cells from 7 to 8/8 HLA-matched unrelated or related donors. Median follow-up of surviving patients was 5 years. At 5 years, overall survival (OS), relapse-free survival (RFS), and chronic GVHD/relapse-free survival (cGRFS) were 58%, 55%, and 40%. Risk factors for poor OS, RFS, and cGRFS were (1). high to very high disease risk index (DRI), (2). high recipient age, and (3). cytomegalovirus (CMV)-seropositive recipient with seronegative donor (D−R+). The latter risk factor applied particularly to patients with lymphoid malignancies. Neither donor other than HLA-matched sibling (7-8/8 unrelated) nor one HLA allele mismatch was risk factors for poor OS, RFS, or cGRFS. In conclusion, the above regimen results in excellent long-term outcomes. The outcomes are negatively impacted by older age, high or very high DRI, and CMV D−R+ serostatus, but not by donor unrelatedness or one HLA allele mismatch.     

Impact of donor age on living related donor kidney transplantation

Two comparable groups of kidney transplant recipients were identified according to the age of their kidney donors. The first group (A) comprised 42 recipients of donors aged < 40 years, and the second group (B) comprised 48 recipients of donors aged > 50 years. The patients were followed for a mean period of 26 months (range 13–50 months). Post-transplant renal function and graft survival were assessed together with the frequency of post-transplant proteinuria and hypertension. More-over, the functional reserve of the grafts was determined by comparing the clearance values, obtained by both isotope and chemical means, before and after a combined infusion of dopamine and an amino acids preparation. The graft function was significantly better in group A according to the serum creatinine levels (µmol/l) at 1 month (107 ± 4.5 vs. 134 ± 10.7, P < 0.01), 12 months (119 ± 5.3 vs. 181 ± 88, P < 0.05) and at last follow-up visit (118 ± 6.2 vs. 223 ± 63, P < 0.03) for groups A and B, respectively. The graft survival in group A was significantly higher than that in group B (100 % vs. 87 % at 1 year, P < 0.05). The graft functional reserve was significantly better in group A than in group B. Post-transplant proteinuria was significantly more frequent in group B recipients (70 % vs. 40 %, P < 0.03). The age of the donors had no impact on the incidence of post-transplant hypertension. These observations suggest that the transplantation of a kidney from an older live kidney donor is associated with an inferior post-transplant outcome.     

Effect of donor age and parent-to-child transplant on living-related donor kidney transplantation: a single center's experience of 236 cases

Abstract

To study the impact of parent-to-child transplant and older donor age on recipients' post-transplant creatinine levels, a total of 236 patients who received living donor kidney transplantation were evaluated for kidney viability based on creatinine (Cr) level. Of the 236 pairings, 113 (48%) were parent-to-child followed by sibling transplants (66, 30%). Recipient Cr levels were significantly higher at 6 months and 3 years post-transplant in the parent-to-child transplants compared to other donor–recipient relationships. In addition, donor age (average age: 44.1?±?11.5; range: 19–66) contributed to higher recipient post-transplant Cr levels (p?<?0.01). Pre-transplant donor and recipient Cr levels tended to result in higher post-transplant Cr levels in recipients (p?<?0.05). Multivariate logistic regression analysis revealed that the presence of both parent-to-child transplant and older donor significantly increased the risk of elevated post-transplant Cr levels in recipients with an estimated odds ratios ranging from 3.46 (95% CI: 1.71–6.98) at 6 months to 8.04 (3.14–20.56) at 3 years post-transplant. Donor age significantly affected transplant survival as measured by higher recipient post-transplant Cr levels. In addition, parent-to-child transplant pairings, along with older donor age, significantly increased the risk of elevated post-transplant Cr levels in recipients.     

Rethinking the advantage of zero‐HLA mismatches in unrelated living donor kidney transplantation: implications on kidney paired donation

The OPTN/UNOS Kidney Paired Donation (KPD) Pilot Program allocates priority to zero‐HLA mismatches. However, in unrelated living donor kidney transplants (LDKT)—the same donor source in KPD—no study has shown whether zero‐HLA mismatches provide any advantage over >0 HLA mismatches. We hypothesize that zero‐HLA mismatches among unrelated LDKT do not benefit graft survival. This retrospective SRTR database study analyzed LDKT recipients from 1987 to 2012. Among unrelated LDKT, subjects with zero‐HLA mismatches were compared to a 1:1–5 matched (by donor age ±1 year and year of transplantation) control cohort with >0 HLA mismatches. The primary endpoint was death‐censored graft survival. Among 32,654 unrelated LDKT recipients, 83 had zero‐HLA mismatches and were matched to 407 controls with >0 HLA mismatches. Kaplan–Meier analyses for death‐censored graft and patient survival showed no difference between study and control cohorts. In multivariate marginal Cox models, zero‐HLA mismatches saw no benefit with death‐censored graft survival (HR = 1.46, 95% CI 0.78–2.73) or patient survival (HR = 1.43, 95% CI 0.68–3.01). Our data suggest that in unrelated LDKT, zero‐HLA mismatches may not offer any survival advantage. Therefore, particular study of zero‐HLA mismatching is needed to validate its place in the OPTN/UNOS KPD Pilot Program allocation algorithm.     

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.     

Comparative survival of elderly renal transplant recipients with a living donor versus a deceased donor: A retrospective single center observational study

Increasing numbers of elderly (≥65 years) patients are listed for kidney transplantation. This study compares the survival outcome between living (LDK), regularly allocated (ETKAS), and Eurotransplant Senior Program (ESP) donor kidneys in elderly recipients. This is a single-center retrospective cohort study of elderly kidney transplant recipients transplanted between 2005 and 2017. Primary outcome measures were nondeath-censored graft, death-censored graft, and patient survival. In total, 348 patients were transplanted, 109 recipients (31.3%) received an LDK, 100 (28.7%) an ETKAS, and 139 (40%) an ESP kidney. 62.5% were male, and median age was 68 years. LDK recipients had significantly better 5-year nondeath-censored graft survival compared with ETKAS and ESP (resp. 71.0% vs. 66.1% vs. 55.6%, P = 0.047). Death-censored graft survival after 1 year was significantly better in LDK recipients (99.1%) (ETKAS 90.8%; ESP 87.7%, P < 0.001). After 5 years, the difference remained significant (P < 0.001) with little additional graft loss (97.7% vs. 88.1% vs. 85.6). There was no significant difference in patient survival after 5 years (71.7% vs. 67.4% vs 61.9%, P = 0.480). In elderly recipients, the patient survival benefits of an LDK are limited, but there is decreased death-censored graft loss for LDK recipients. Nevertheless, graft survival in ETKAS and ESP remains satisfactory.     

Gender mismatch between donor and recipient is a factor of morbidity but does not condition survival after cardiac transplantation

We intended to evaluate the influence of sex mismatch between donor and recipient, which is still under much debate, on survival and comorbidities after cardiac transplantation. From November 2003 to December 2013, a total of 258 patients were transplanted in our center. From these, 200 receptors were male (77.5%) and constituted our study population, further divided into those who received the heart from a female donor (Group A) – 44 patients (22%) and those who received it from a male donor (Group B) – 156 (78%). Median follow‐up was 4.2 ± 3.0 years (1–10 years). The two groups were quite comparable with each other, except for body mass index, systolic pulmonary artery pressure, and transpulmonary gradient, which were significantly lower in Group A. A low donor/recipient weigh ratio (<0.8) was avoided whenever possible. Hospital mortality was not different in the two groups. During follow‐up, global survival was similar, as was survival free from acute cellular rejection and cardiac allograft vasculopathy. However, patients in Group A had decreased survival free from serious infections and malignant tumors. Allocation of female donors to male receptors can be done safely, at least in receptors without pulmonary hypertension and when an adequate donor/recipient weigh ratio is ensured.     

ABO-incompatible kidney transplantation in perspective of deceased donor transplantation and induction strategies: a propensity-matched analysis

Kidney transplant candidates are blood group incompatible with roughly one out of three potential living donors. We compared outcomes after ABO-incompatible (ABOi) kidney transplantation with matched ABO-compatible (ABOc) living and deceased donor transplantation and analyzed different induction regimens. We performed a retrospective study with propensity matching and compared patient and death-censored graft survival after ABOi versus ABOc living donor and deceased donor kidney transplantation in a nationwide registry from 2006 till 2019. 296 ABOi were compared with 1184 center and propensity-matched ABOc living donor and 1184 deceased donor recipients (matching: recipient age, sex, blood group, and PRA). Patient survival was better compared with deceased donor [hazard ratio (HR) for death of HR 0.69 (0.49–0.96)] and non-significantly different from ABOc living donor recipients [HR 1.28 (0.90–1.81)]. Rate of graft failure was higher compared with ABOc living donor transplantation [HR 2.63 (1.72–4.01)]. Rejection occurred in 47% of 140 rituximab versus 22% of 50 rituximab/basiliximab, and 4% of 92 alemtuzumab-treated recipients (P < 0.001). ABOi kidney transplantation is superior to deceased donor transplantation. Rejection rate and graft failure are higher compared with matched ABOc living donor transplantation, underscoring the need for further studies into risk stratification and induction therapy [NTR7587, www.trialregister.nl ].     

Dual‐graft adult living donor liver transplantation with ABO‐incompatible graft: short‐term and long‐term outcomes

ABO‐incompatible (ABOi) dual‐graft (DG) adult living donor liver transplantation (ALDLT) is not commonly performed due to its inherently intricate surgical technique and immunological complexity. Therefore, data are lacking on the short‐ and long‐term clinical outcomes of ABOi DG ALDLT. We performed a retrospective study by reviewing the medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. Additionally, computed tomography volumetric analysis was conducted to assess the graft regeneration rate. The mean age of a total of 28 recipients was 50.2 ± 8.5 years, and the mean model for end‐stage liver disease score was 12.2 ± 4.6. The 1‐, 3‐, and 5‐year patient survival rate was 96.4% during the mean follow‐up period of 57.0 ± 22.4 months. The 1‐, 3‐, and 5‐year graft survival rate was 96.4%, 94.2%, and 92.0%, respectively, and no significant differences were observed between ABO‐compatible (ABOc) and ABOi grafts (P = .145). The biliary complication rate showed no significant difference (P = .195) between ABOc and ABOi grafts. Regeneration rates of ABOi grafts were not significantly different from those of ABOc grafts. DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks.     

Factors Influencing Short-Term Patient Survival in Elderly Kidney Transplant Recipients

BackgroundFor the average patient with end-stage renal disease, kidney transplantation improves quality of life and prolongs survival compared with patients on the transplant waiting list who remain on dialysis. Patients ≥65 years of age represent an increasing proportion of adults with end-stage renal disease, and kidney transplantation outcomes remain controversial in this population. The aim of this study was to evaluate factors that may increase 1-year mortality after renal transplantation in older recipients.MethodsA retrospective study that included 147 patients (75.5% men) ≥65 years old (mean age 67.5 ± 2 years) who were transplanted between January 2011 and December 2020. The mean follow-up was 52.6 ± 27.2 months.ResultsRehospitalization (<1 year) occurred in 39.5% of patients. Infectious complications were present in 18.4% of patients. The overall mortality rate was 23.1%, and 1-year mortality was 6.8%. As 1-year mortality predictors, we found a positive correlation with factors related to kidney transplant, such as cold ischemia time (P = .003), increasing donor age (P = .001); and factors related to the receptor such as pretransplantation dialysis modality as peritoneal dialysis (P = .04), cardiovascular disease (P = .004), delayed graft function (P = .002), early cardiovascular complications after kidney transplant (P < .001), and early rehospitalizations (P < .001). No correlation was found between 1-year mortality and age, sex, race, body mass index, and type of kidney transplant.ConclusionA more rigorous pretransplant evaluation, focusing on cardiovascular disease and strict exclusion criteria, is recommended for patients ≥65 years old.     

Renal transplantation in the elderly: South Indian experience

In developing countries, renal transplantation is offered to young end-stage renal disease (ESRD) patients, while the older ones face limitations due to higher mortality risk. We retrospectively analyzed 225 patients who underwent renal transplantation from living donors, aged 40–60 years (Group A) and >60 years (Group B), focusing on their survival outcome. Group A (n = 181) had mean creatinine (mg/dL) 1.41 ± 0.84, 1.30 ± 0.65 and 1.40 ± 0.60 and mean eGFR (mL/min/1.73 m²) of 65.32 ± 23.03, 69.14 ± 32.65 and 59.21 ± 22.79 at 0, 3 and 6 months post-transplantation. Death-censored graft survival was 93.1% in first year followed by 91.2% in subsequent 4 years. Patient survival was 92.5% in first year, 90.7% in the next 2 years, and 89.2% in 4th year. Highest cumulative graft survival was 86.7% in the first year with 83.4%, 82.7% and 82.4% during the subsequent 3 years. Group B (n = 44) had mean creatinine (mg/dL) of 1.46 ± 1.02, 1.29 ± 0.23 and 1.2 ± 0.29 with a mean eGFR (mL/min/1.73 m²) of 67.90 ± 23.48, 67.02 ± 12.76 and 75.23 ± 15.19 at 0, 3 and 6 months. Highest death-censored graft survival was 97.4% in the first year with 94.7% in next 3 years. Patient survival was 88.1% throughout 4 years post-transplantation. Cumulative graft survival was 84.1% during 4 years. Biopsy-proven acute rejection rate was 28.7% in group A and 15.9% in group B (P = 0.058). There was higher mortality rate in group B with death mainly due to infections and cardiovascular complication. Cardiovascular risk assessment, pre-transplant cancer screening and judicious use of immunosuppressive agents should help minimize adverse events, balanced with an inherently reduced risk of acute rejection, hence the graft survival advantage and is the way forward to maximize patient and renal allograft survival in elderly patients.     

The impact of donor and recipient diabetes on renal transplant outcomes

The use of diabetic kidneys is increasing worldwide with better outcome than being on waitlist and possible reversal of diabetic changes in transplanted kidneys. But particular caution is warranted in diabetic donor-recipient combination. Total 1223 deceased donor kidney transplants were performed at our center between 2008 and 2018. 689 from non-diabetic donor (NDD) to non-diabetic recipient, 400 from non-diabetic donor to diabetic recipient, 97 from diabetic to non-diabetic recipient, and 32 from diabetic donor (DD) to diabetic recipient. The DD was older than NDDs (median age 48 vs 39 years, P < 0.0001). DD had higher BMI (35.6 vs 26.9, P < 0.0001), higher KDPI (74% vs 37%, P < 0.0001), and higher terminal creatinine (1.10 mg/dl vs 0.95 mg/dl, p 0.0046) than the NDD. Diabetes recipients were comparatively older (57 vs 54, P < 0.001). DD recipients had higher serum creatinine at 6 months (1.70 vs 1.50 mg/dl, p 0.00304) and 2 years post-transplant (1.70 vs 1.50 mg/dl P < 0.0002). DD recipients had more favorable end CPRA than NDD recipients (77.5% at 0% vs 67.4% at 0, P = 0.0074). Ten-year patient and graft survival was best in NDD-recipient pair and worse in DD-recipient pair. Diabetic donor kidneys to diabetic recipients have lower 1-, 3-, and 5-year graft survival.