再次肾移植受者和移植肾长期预后影响因素分析

目的探究再次肾移植受者和移植肾存活情况及长期预后影响因素。 方法回顾性分析1991年1月1日至2017年12月31日于浙江大学医学院附属第一医院肾脏病中心接受肾移植受者临床资料。共纳入再次肾移植受者37例,首次肾移植受者5 374例。根据再次肾移植受者移植肾存活时间长短,将其分为长期存活组(19例,>5年)和短期存活组(18例,≤5年)。采用成组t检验比较长期和短期存活组供受者年龄、首次与再次肾移植间隔时间、HLA错配数和再次移植供肾冷/热缺血时间。采用卡方检验比较长期和短期存活组受者性别、再次移植供肾类型、再次移植前后群体反应性抗体阳性比例、首次移植失功移植肾切除比例、再次移植前免疫诱导比例及再次移植后移植肾功能延迟恢复(DGF)和急性排斥反应发生比例。采用Kaplan-Meier法分析再次和首次肾移植受者/移植肾1、5和10年存活率。采用Cox比例风险模型分析影响再次肾移植术后移植肾长期存活影响因素。P<0.05为差异有统计学意义。 结果截至2018年3月1日,37例再次肾移植受者中位随访时间为152个月(11～323个月),2例死亡,18例发生移植肾失功,17例移植肾功能稳定。5 374例首次肾移植受者中位随访时间为108.9个月(0.1～350.0个月),459例死亡,1 343例发生移植肾失功。再次移植组受者/移植肾1、5和10年存活率分别为86%/81%、86%/62%和82%/36%,首次移植组受者/移植肾1、5和10年存活率分别为99%/98%、93%/89%和88%/80%。再次移植组移植肾1、5和10年存活率均低于首次移植组(χ²＝60.816、25.110和43.900,P均<0.05);再次移植组受者1年存活率低于首次移植组,差异有统计学意义(χ²＝40.409,P<0.05)。长期和短期存活组受者再次移植后移植肾DGF和急性排斥反应发生比例差异均有统计学意义(χ²＝4.039和4.748,P均<0.05)。Cox回归分析结果示DGF和急性排斥反应是影响再次肾移植受者移植肾长期存活的独立危险因素,差异有统计学意义(RR＝4.317和4.571,P均<0.05)。 结论再次肾移植受者移植肾存活率低于首次肾移植受者,DGF和急性排斥反应是影响再次移植受者移植肾存活的独立危险因素。     

Outcome of transplantation using kidneys from controlled (Maastricht category 3) non-heart-beating donors

BACKGROUND: Many renal transplant centres are reluctant to use kidneys from non-heart-beating (NHB) donors because of the high incidence of primary non-function and delayed graft function reported in the literature. Here, we report our favourable experience of using kidneys from Maastricht category 3 donors (controlled NHB donors). MATERIALS AND METHODS: From January 1996 to June 2002, 42 renal transplants using kidneys from 25 controlled NHB donors were undertaken at our centre. The rates of primary non-function, delayed graft function (DGF), rejection and long-term graft and patient survival were compared with those of 84 recipients of grafts from heart-beating (HB donors) transplanted contemporaneously. RESULTS: Primary non-function did not occur in recipients of grafts from NHB donors but was seen in two grafts from HB donors. DGF occurred in 21 of 42 (50%) kidneys from NHB donors and 14 of 84 (17%) kidneys from HBD donars (p < 0.001). The acute rejection rates in the two groups were similar (33% for grafts from NHB donors vs. 40% from HB donors). By 1 month after transplantation, there was no significant difference in serum creatinine concentration between the two groups. Over a median follow-up period of 32 months (range 2-75 months), the actuarial graft survival rates at 1, 3 and 5 yr after transplantation were 84, 80 and 74% for recipients of kidneys from NHB donors, compared with 89, 85 and 80% for kidneys from HB donors. CONCLUSION: Controlled NHB donors are a valuable and under-used source of kidneys for renal transplantation. The outcome for recipients of kidney allografts from category 3 NHB donors is similar to that seen in recipients of grafts from conventional HB cadaveric donors.     

Acute kidney injury in donors of donation after brain plus cardiac death does not affect recipients' short-term prognosis in transplantation

Objective To investigate the clinical efficacy of renal transplantation from donors of donation after brain and cardiac death(DBCD) complicated with acute kidney injury (AKI), and summarize the clinical experience of evaluation and application. Methods The clinical data of the 45 DBCD donors and 80 recipients in the First People's Hospital of Foshan from September 2011 to September 2015 were retrospectively analyzed. DBCD donors were classified into the AKI group (n=26)and non-AKI group (n=19) according to the serum creatinine level and urine output when the donors were admitted to the intensive care unit (ICU) in this hospital. A total of 80 recipients were divided into the AKI group (n=46) and non-AKI group (n=34) correspondingly. The condition of the donors before organ procurement between the two groups was compared, and the incidence of various complications, the 1 years survival rates of recipients and graft after renal transplantation were compared between the two groups. Results Among 45 donors, 26 cases(57.8%) suffered from AKI. The serum creatinine of donors was significantly higher in the AKI group than that in the non-AKI group (P＜0.01). The incidence of delayed graft function (DGF) in AKI group and non-AKI group was 21.7% and 8.8% respectively (P＞0.05). After 1 years, the serum creatinine of the recipients in AKI group was significantly higher than that in non-AKI group [(134.9±63.4) μmol/L vs (106.6±28.2) μmol/L, P＜0.05], but the survival rates of recipients and grafts did no differ between the two groups (both P＞0.05). Conclusions The donors combined with AKI do not have a worse effect on the incidence of DGF, the 1-year survival rates of recipients and grafts after transplantation. So, the donors with AKI for transplantation can widen the origin of kidney grafts.     

Non-Heart Beating Donor Kidneys with Delayed Graft Function Have Superior Graft Survival Compared with Conventional Heart-Beating Donor Kidneys That Develop Delayed Graft Function

Delayed graft function may have an association with reduced graft survival, and nonheart-beating donor (NHBD) kidneys have higher rates of delayed graft function (DGF) than heart-beating donor (HBD) kidneys. This study compared outcome of renal transplants from HBDs who developed DGF, with NHBDs who developed DGF. All recipients of HBD and NHBD kidneys who developed DGF were identified during a 10-year period. All patients with graft primary nonfunction were excluded from analysis. Four hundred and fifty-six functioning transplants were performed. Delayed graft function occurred in 69 (17%) HBD and 55 (93%) NHBD kidneys. The grafts developing DGF were well matched for donor and recipient age. The rate of acute rejection was similar; [n = 16/69 (23%) HBD vs. n = 13/55 (24%) NHBD]. Cold ischaemia was 21 h in the HBD group and 17 h in NHBD group (p > 0.05). Serum creatinine was similar for both groups at 1.3 and 6 years (p > 0.05 for all time points). Graft survival in the NHBD recipients with DGF was significantly better at 3 years (84%) compared with recipients of a HBD renal transplant that developed DGF (73%) (p < 0.05), and at 6 years (62% survival for HBDs and 84% survival for NHBDs). This study shows that graft survival was better for NHBD kidneys up to 6 years after transplantation.     

Inferior Early Posttransplant Outcomes for Recipients of Right Versus Left Deceased Donor Kidneys: An ANZDATA Registry Analysis

Anatomical differences between right and left kidneys could influence transplant outcome. We compared graft function and survival for left and right kidney recipients transplanted from the same deceased organ donor. Adult recipients of 4900 single kidneys procured from 2450 heart beating deceased donors in Australia and New Zealand from 1995 to 2009 were included in a paired analysis. Right kidneys were associated with more delayed graft function (DGF) (25 vs. 21% for left kidneys, p < 0.001) and, if not affected by DGF, a slower fall in serum creatinine. One‐year graft survival was lower for right kidneys (89.1 vs. 91.1% for left kidneys, p = 0.001), primarily attributed to surgical complications (66 versus 35 failures for left kidneys). Beyond the first posttransplant year, kidney side was not associated with eGFR, graft or patient survival. Receipt of a right kidney is a risk factor for inferior outcomes in the first year after transplantation. A higher incidence of surgical complications suggests the shorter right renal vein may be contributory. The higher susceptibility of right kidneys to injury should be considered in organ allocation.     

Simultaneous cadaver pancreas living-donor kidney transplantation: a new approach for the type 1 diabetic uremic patient

OBJECTIVE: To review the authors' experience with a new approach for type I diabetic uremic patients: simultaneous cadaver-donor pancreas and living-donor kidney transplant (SPLK). SUMMARY BACKGROUND DATA: Simultaneous cadaver kidney and pancreas transplantation (SPK) and living-donor kidney transplantation alone followed by a solitary cadaver-donor pancreas transplant (PAK) have been the transplant options for type I diabetic uremic patients. SPK pancreas graft survival has historically exceeded that of solitary pancreas transplantation. Recent improvement in solitary pancreas transplant survival rates has narrowed the advantage seen with SPK. PAK, however, requires sequential transplant operations. In contrast to PAK and SPK, SPLK is a single operation that offers the potential benefits of living kidney donation: shorter waiting time, expansion of the organ donor pool, and improved short-term and long-term renal graft function. METHODS: Between May 1998 and September 1999, the authors performed 30 SPLK procedures, coordinating the cadaver pancreas transplant with simultaneous transplantation of a laparoscopically removed living-donor kidney. Of the 30 SPLKs, 28 (93%) were portally and enterically drained. During the same period, the authors also performed 19 primary SPK and 17 primary PAK transplants. RESULTS: One-year pancreas, kidney, and patient survival rates were 88%, 95%, and 95% for SPLK recipients. One-year pancreas graft survival rates in SPK and PAK recipients were 84% and 71%. Of 30 SPLK transplants, 29 (97%) had immediate renal graft function, whereas 79% of SPK kidneys had immediate function. Reoperative rates, early readmission to the hospital, and initial length of stay were similar between SPLK and SPK recipients. SPLK recipients had a shorter wait time for transplantation. CONCLUSIONS: Early pancreas, kidney, and patient survival rates after SPLK are similar to those for SPK. Waiting time was significantly shortened. SPLK recipients had lower rates of delayed renal graft function than SPK recipients. Combining cadaver pancreas transplantation with living-donor kidney transplantation does not harm renal graft outcome. Given the advantages of living-donor kidney transplant, SPLK should be considered for all uremic type I diabetic patients with living donors.     

High terminal creatinine donors should not preclude simultaneous kidney and pancreas transplantation

BackgroundSimultaneous pancreas and kidney transplantation (SPK) in the setting of end-stage renal disease offers unmatched outcomes in insulin dependent diabetic patients. Donor pool expansion through the transplantation of kidneys with acute kidney injury (AKI) is controversial.Methods59 SPK transplants were classified by presence of donor AKI, defined as donor terminal creatinine ≥ 1.5x the initial creatinine or donor terminal creatinine > 4.0 mg/dL. Endpoints included graft and patient survival, delayed graft function (DGF), serum creatinine, glomerular filtration rate (GFR), Hemoglobin A1c (HbA1c) and acute rejection.ResultsThe donor AKI group (n = 35) had significantly higher rates of DGF (38 v. 9%, p = 0.01). There was no difference in creatinine or GFR at 1, 3, 6 and 12 months. HbA1c was comparable at 3, 6 and 12 months. There was no significant difference in the percentage of patients that required anti-diabetic agents after transplant (14 v. 4%, p = 0.56).ConclusionsWe observed increased rates of DGF in SPK recipients with donor AKI. However, equivalent outcomes of pancreas and kidney function in both groups were observed.     

供肾零点活检病理结果与移植肾功能延迟恢复的相关研究

目的探讨供肾零点活检病理结果与肾移植术后并发移植肾功能延迟恢复(DGF)的关系。 方法回顾性分析西安交通大学第一附属医院肾移植科2018年5月至2019年4月实施的心脏死亡器官捐献(DCD)肾移植供、受者临床资料。采用零点活检病理结果评估供肾质量，并按照Banff 2013标准、Remuzzi评分及马里兰病理指数(MAPI)对供肾进行病理分级和评分。肾小球数量≥7个，小动脉数量≥2支为合格标本。根据受者肾移植术后是否发生DGF，将其分为DGF组和非DGF组。采用Mann-Whitney U检验比较两组供肾肾小球硬化率、小动脉玻璃样变率、Banff 2013标准评分、Remuzzi评分和MAPI评分。采用卡方检验比较两组供肾肾间质纤维化、肾小管萎缩、小动脉内膜纤维化增厚、小动脉管壁透明样变、肾小管损伤/坏死及肾小球内微血栓发生情况。采用logistic回归分析供肾零点活检病理结果与DCD肾移植术后并发DGF的关系。P<0.05为差异有统计学意义。 结果最终纳入133例受者，其中DGF组26例，DGF发生率为19.5%，非DGF组107例。133例合格肾穿刺标本中，平均获得肾小球数量(13±5)个，中位肾小球硬化率5.8%(0～13.3%)，中位小动脉数量5支(3～6支)，中位小动脉玻璃样变率0(0～11%)，肾间质纤维化占47.4%(63/133)，肾小管萎缩占48.1%(64/133)，小动脉内膜纤维化增厚占58.6%(78/133)，小动脉管壁透明样变占36.8%(49/133)，未见肾小球内微血栓，所有供肾均合并不同程度肾小管损伤/坏死。两组受者供肾肾间质纤维化、肾小管萎缩、肾小管损伤/坏死以及Remuzzi评分差异有统计学意义(χ²＝7.65、7.92和16.81，Z＝-2.02，P均<0.05)。多因素分析结果显示肾小管损伤/坏死是肾移植术后并发DGF的独立危险因素。 结论供肾零点活检病理学评估对于预测肾移植短期预后具有一定价值，在供者维护和器官保存过程中应尽可能避免造成肾小管缺血/坏死，以降低DGF发生风险。     

Reduced graft function (with or without dialysis) vs immediate graft function--a comparison of long-term renal allograft survival.

BACKGROUND: Delayed graft function (DGF) is a common complication in cadaveric kidney transplants affecting graft outcome. However, the incidence of DGF differs widely between centres as its definition is very variable. The purpose of this study was to define a parameter for DGF and immediate graft function (IGF) and to compare the graft outcome between these groups at our centre. METHODS: The renal allograft function of 972 first cadaveric transplants performed between 1990 and 2001 in the Republic of Ireland was examined. The DGF and IGF were defined by a creatinine reduction ratio (CRR) between time 0 of transplantation and day 7 post-transplantation of <70 and >70%, respectively. Recipients with reduced graft function (DGF) not requiring dialysis were defined as slow graft function (SGF) patients. The serum creatinine at 3 months, 6 months, 1, 2 and 5 years after transplantation was compared between these groups of recipients. The graft survival rates at 1, 3 and 5 years and the graft half-life for DGF, SGF and IGF recipients were also assessed. RESULTS: Of the 972 renal transplant recipients, DGF was seen in 102 (10.5%) patients, SGF in 202 (20.8%) recipients and IGF in 668 (68.7%) patients. Serum creatinine levels were significantly different between the three groups at 3 and 6 months, 1, 2 and 5 years. Graft survival at 5 years for the DGF patients was 48.5%, 60.5% for SGF recipients and 75% for IGF patients with graft half-life of 4.9, 8.7 and 10.5 years, respectively. CONCLUSION: This study has shown that the CRR at day 7 correlates with renal function up to 5 years post-transplantation and with long-term graft survival. We have also demonstrated that amongst patients with reduced graft function after transplantation, two groups with significantly different outcomes exist.     

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.     

Economic impact of delayed graft function and suboptimal kidneys

Renal transplantation remains the cost-effective treatment of choice for end-stage renal disease. However, the gap between supply and demand for cadaveric kidneys only continues to widen. To expand the donor pool, many transplant centers now accept organs from donors that only a few years ago would have been rejected. The use of kidneys from ECDs and those with a high likelihood of DGF can have a significant impact on graft survival and cost. The average cost of initial hospitalization for patients undergoing cadaveric renal transplant in which there is DGF is approximately $25,000 higher per patient than when there is no DGF. Moreover, the use of an ECD kidney increases the average cost by $12,000 per patient. When the clinical manifestations of DGF and ECD kidneys, such as increased rate of acute rejection and worse graft survival, are taken into account the economic impact is expanded. In the past decade, pharmaceutical companies have focused their resources far more on new immunosuppressive agents rather than treatments to improve early graft function or reduce alloantigen independent injury and inflammation. As the negative economic and clinical impacts of DGF and ECD kidney become clearer, there may be more incentive for scientific and clinical research in this area to improve long-term and short-term graft survival.     

Kidney transplantation from donation after cardiac death donors in China--a single-center experience

Objective

To report clinical outcomes of kidney transplantation from cardiac death donors (DCD) in China, and to investigate its feasibility to expand the organ donor pool.

Patients and methods

We retrospectively studied clinical data of 46 DCD kidneys from 31 donors from February 2007 to August 2011. Recipients were followed for patient and graft survival.

Results

We discarded the organs from 3 of 29 (10.3%) DCD donors and 7 of 42 (16.7%) kidneys that displayed renal thrombosis. Of the 39 recipients engrafted with DCD kidneys successfully, the mean follow-up was 16 months, (range = 50 days to 43 months). Delayed graft function (DGF) occurred in 15 (38.5%) recipients, who except one recovered within 3 months. Three biopsy-proven acute rejection episodes were observed in two recipients (5.1%). All patients survived through the follow-up. The graft survival rate was 97.4% at 12 months and 94.9% at 24 months. A 45-year-old male recipient who received a pair of grafts from a 6-year-old child survived with good renal function.

Conclusion

Although kidney transplantations from DCD donors showed a higher rate of DGF with a longer duration of graft recovery, we achieved favorable short-term clinical outcome in terms of graft survival and function. Donation after cardiac death can expand the organ donor pool in China.     

Use of marginal organs from non-heart-beating cadaveric kidney donors.

BACKGROUND: The severe shortage of cadaver donor kidneys for transplantation has prompted many centers to utilize older donor kidneys, which have been associated with lower graft survival rates. The aim of the present study was to examine the availability and feasibility of considering kidneys from donors over the age of 60. METHOD: We studied 252 cadaveric renal transplant recipients (156 males, 96 females) who received kidneys from uncontrolled non-heart-beating donors between 1987 and 1997. We performed in situ cooling with especially designed double-balloon catheters to minimize warm ischemic kidney damage. Recipients were classified according to donor age (age 60), and we examined graft survival rates. All patients were followed for a minimum of 1 year after transplantation. RESULTS: Graft survival rates for recipients of kidneys from the older donor group at 1, 5, and 10 years after transplantation were 77%, 37%, and 30%, respectively. Corresponding values for the younger donor kidney recipients were 87%, 64%, and 47%, respectively (P=0.0011). Improved survival rates were noted when older kidneys were used for lighter weight recipients (<54 kg). No other significant factors impacted on older donor graft survival rates. CONCLUSION: Older donor kidneys are associated with poorer graft survival rates. However, kidney transplants from older donors can be quite effective in lighter weight recipients (<54 kg).     

Significance of delayed graft function in cyclosporine-treated recipients of cadaver kidney transplants

Many transplant teams are reluctant to initiate cyclosporine immunosuppression in recipients of cadaver kidney grafts with delayed graft function (DGF). The renal function of cadaver kidney grafts in cyclosporine-treated recipients was compared in 47 recipients with DGF and 57 without DGF. Regardless of initial renal function, all recipients received prednisone, azathioprine, and oral cyclosporine 5 mg/kg/day or its intravenous equivalent. All kidneys were flushed with ice-cold intracellular electrolyte solution and cold-stored for 15-54 hr (mean of 31 hr) prior to transplantation at our hospital between April 10, 1985 and November 30, 1986. Rejection crises were treated with high-dose steroids or OKT3. Cyclosporine was discontinued during courses of OKT3. Recipients with DGF had significantly higher one-month serum creatinine nadirs (2.6 +/- 1.8 mg/dl vs. 1.5 +/- 0.5 mg/dl). Actuarial graft survivals were not significantly different at one year (82.2 +/- 5.5% vs. 82.6 +/- 6.4%, all graft losses included). Mean serum creatinine levels at six months and twelve months after grafting were not significantly different (1.7 +/- 0.4 mg/dl vs. 1.8 +/- 1.2 mg/dl and 2.0 +/- 0.5 vs. 1.7 +/- 0.7 mg/dl, respectively). Delayed graft function following cadaver kidney transplantation does not adversely affect intermediate term function of kidney grafts flushed with intracellular electrolyte solution and cold-stored until transplantation when a low-dose cyclosporine induction protocol is used and cyclosporine is discontinued during OKT3 administration.     

扩大标准公民逝世后器官捐献肾移植术后一年内临床效果分析

目的观察并比较扩大标准供者(ECD)和标准供者(SCD)供肾移植受者术后1年内临床效果。 方法回顾性分析2014年3月至2017年3月空军军医大学西京医院接受公民逝世后器官捐献90例肾移植受者临床资料,按供肾来源分为ECD组(31例)和SCD组(59例)。所有受者均应用免疫诱导及三联免疫抑制方案治疗(吗替麦考酚酯或麦考酚钠肠溶片＋他克莫司或环孢素＋甲泼尼龙)。采用t检验或Mann-Whitney U检验比较两组受者肾移植术后1年内血清肌酐(Scr)水平,采用χ²检验和Fisher确切概率法比较两组受者性别比例、受者/移植肾存活率及急性排斥反应(AR)、移植肾功能延迟恢复(DGF)和肺部感染等并发症发生率。P<0.05为差异有统计学意义。 结果ECD组和SCD组肾移植受者术后Scr水平逐步下降。术后1个月内(术后1、3、7、14和21 d)两组受者Scr水平差异均无统计学意义(t＝0.076、0.905、0.670、0.893和0.048,P均>0.05);术后1～12个月,除术后9个月两组受者Scr水平差异无统计学意义(t＝1.727,P>0.05),其余各时间点ECD组受者Scr水平均高于SCD组,差异均有统计学意义(P均<0.05)。两组受者术后1年受者/移植肾存活率分别为93.1%/80.6%和91.5/84.7%,差异均无统计学意义(P＝0.734; χ²＝0.246,P>0.05)。ECD组和SCD组AR发生率分别为12.9%(4/31)和18.6%(11/59),DGF发生率分别为22.6%(7/31)和22.0%(13/59),肺部感染发生率分别为25.8%(8/31)和11.9%(7/59),其他并发症发生率分别为41.9%(13/31)和28.8%(17/59),差异均无统计学意义(P均>0.05)。 结论与SCD相比,ECD供肾移植仍可获得相当的临床效果。在目前供器官来源严重缺乏的情况下,ECD的合理选择可以扩大供肾来源。     

Dual-kidney transplants: long-term results

BACKGROUND: Dual-kidney transplantation, where two usually aged adult kidneys are placed into an adult recipient, is one way to help alleviate the continuing disparity between the number of patients on the kidney transplant waiting list and those who receive kidney transplants each year. The Dual Kidney Registry was developed to analyze donor and recipient data and outcomes at several centers. METHODS: Two hundred eighty-seven patients who have undergone transplantation since 1994 have been entered into the relational database. The patients were followed yearly after initial entry into the database. RESULTS: The mean donor age was 58+/-13 years and the mean terminal creatinine clearance was 77+/-40 mL/min. The mean glomerular sclerosis on procurement biopsy was 16+/-13%. Delayed graft function (DGF), defined as dialysis in the first 7 days after transplantation, was a predictor of poor outcome, and increased cold storage time was a predictor of DGF. The overall incidence of DGF was 27%. In recipients with prompt graft function (PGF), the mean cold storage time was 22+/-9 hr versus 29+/-10 hr in recipients with DGF (P<0.001). The overall 1- and 5-year graft survival was 86% and 69%, respectively. The 1- and 5-year graft survival rates were significantly better in recipients with PGF (90% and 74%) versus DGF (79% and 54%) (P<0.002). CONCLUSIONS: Cold storage time and DGF have a significant impact on the 1- and 5-year graft survival in recipients of dual-kidney transplants. The 5-year graft survival in recipients of dual-kidney transplants is excellent.     

供肾Remuzzi评分对肾移植受者预后的指导作用

目的分析不同Remuzzi评分供肾移植后受者/移植肾预后情况。 方法回顾性分析武汉大学人民医院2018年11月至2020年8月接受单肾移植的81例受者临床资料。根据供肾Remuzzi评分将81例受者分为低分组(Remuzzi评分0~3分,n＝38)及高分组(43例)(Remuzzi评分4~6分,n＝43)。正态分布计量资料采用两独立样本t检验比较;非正态分布计量资料采用Mann-Whitney U检验比较。计数资料采用χ²检验或Fisher确切概率法比较。采用Graphpad 8.0.2绘制受者/移植肾生存曲线,并采用log-rank检验比较。P<0.05为差异有统计学意义。 结果低分组38例受者供肾Remuzzi评分为(2.23±0.87)分,高分组43例受者供肾Remuzzi评分为(4.56±0.66)分,差异有统计学意义(t＝-13.449,P<0.05)。低分组术后1、3个月血清肌酐分别为(143±92)和(136±75) μmol/L,高分组分别为(138±80)和(123±39) μmol/L,差异均无统计学意义(t＝0.237和1.031,P均>0.05)。低分组术后6个月血清肌酐[107.5(60,821) μmol/L]低于高分组[113.0 (67,224) μmol/L],差异有统计学意义(U＝-0.371,P<0.05)。低分组术后1、3和6个月估算肾小球滤过率分别为(60±24)、(59±26)和(61±27)mL/min,高分组分别为(64±25)、(64±21)和(66±20)mL/min,差异均无统计学意义(t＝-0.823、-0.903和-0.756,P均>0.05)。截至2022年2月14日,受者随访时间(29±6)个月(1~36个月)。低分组16例受者(42.1%)移植术后发生移植肾功能延迟恢复(DGF),高分组12例受者(27.9%)移植术后发生DGF,差异无统计学意义(χ²＝0.180,P>0.05)。两组受者术后生存率差异无统计学意义(χ²＝0.668,P>0.05)。两组受者移植肾存活率差异有统计学意义(χ²＝4.078,P<0.05)。低分组发生DGF、低分组未发生DGF、高分组发生DGF和高分组未发生DGF受者术后生存率及移植肾存活率差异均无统计学意义(P均>0.05)。 结论Remuzzi评分作为供肾病理学评估的重要部分,为肾移植受者术后治疗提供一定指导,评分较高供肾移植后受者也能获得良好预后。     

Predictors and outcomes of delayed graft function after living‐donor kidney transplantation

Delayed graft function (DGF) following deceased donor kidney transplantation is associated with inferior outcomes. Delayed graft function following living‐donor kidney transplantation is less common, but its impact on graft survival unknown. We therefore sought to determine risk factors for DGF following living‐donor kidney transplantation and DGF's effect on living‐donor kidney graft survival. We analyzed living‐donor kidney transplants performed between 2000 and 2014 in the UNOS dataset. A total of 64 024 living‐donor kidney transplant recipients were identified, 3.6% developed DGF. Cold ischemic time, human leukocyte antigen mismatch, donor age, panel reactive antibody, recipient diabetes, donor and recipient body mass index, recipient race and gender, right nephrectomy, open nephrectomy, dialysis status, ABO incompatibility, and previous transplants were independent predictors of DGF in living‐donor kidney transplants. Five‐year graft survival among living‐donor kidney transplant recipients with DGF was significantly lower compared with graft survival in those without DGF (65% and 85%, respectively, P < 0.001). DGF more than doubled the risk of subsequent graft failure (hazard ratio = 2.3, 95% confidence interval: 2.1–2.6; P < 0.001). DGF after living‐donor kidney transplantation is associated with inferior allograft outcomes. Minimizing modifiable risk factors may improve outcomes in living‐donor kidney transplantation.     

Clinical research and social status investigation for donor and recipient of living-related kidney transplant

Objective

Renal transplantation is the best options for treating end-stage renal disease. Better patient and allograft survival rates are provided by living donation, which has been safe, with minimal immediate and long-term risk for the donor. This study aims to investigate the life status and summarize the clinical experience in living-related kidney transplant (LRKT) before and after renal transplantation.

Methods

A total of 310 cases of LRKT have been performed in our center since 1998. Tissue matching and risk factors assessment in donors and recipients were performed before donation. Small lumbar incision was used in all cases for unilateral nephrectomy. Donors and recipients were followed up regularly after renal transplantation.

Results

All living donors were healthy, with normal renal function after unilateral nephrectomy. The 1- and 5-year patient/graft survival rates of LRKT were 98.3 %/97.6 % and 91.3 %/86.9 %, respectively. The cumulative incidence of delayed graft function (DGF) and acute rejection (AR) was 2.9 % (9 cases). Thirteen cases developed pulmonary infection (4.2 %) and eight cases were cured. The graft function in most cases returned to normal range soon after kidney transplant. Moreover, the creatinine and BUN levels of grafts donated by children or siblings of recipients were markedly lower than those donated by parents, at 1 month after transplant.

Conclusion

Adequate pretransplant assessment, better tissue matching, and reduced ischemia time may result in lower incidence of DGF, AR and higher patient/graft survival rates for LRKT. It is important to improve selection criteria and health assessment of donors. Long-term follow-up is essential to ensure a healthy life for donors and recipients after kidney transplant.     

Increased kidney transplantation utilizing expanded criteria deceased organ donors with results comparable to standard criteria donor transplant

OBJECTIVE: To compare outcomes in recipients of expanded criteria donor (ECD) versus standard criteria donor (SCD) kidneys at a single center using a standardized approach with similar immunosuppression. SUMMARY BACKGROUND DATA: Expanded criteria deceased organ donors (ECD) are a source of kidneys that permit more patients to benefit from transplantation. ECD is defined as all deceased donors older than 60 years and donors older than 50 years with 2 of the following: hypertension, stroke as the cause of death, or pre-retrieval serum creatinine (SCr) greater than 1.5 mg/dl. METHODS: We retrospectively studied 90 recipients of adult deceased donor kidneys transplanted from October 1, 2001 to February 17, 2003, including 37 (41%) from ECDs and 53 (59%) from SCDs. ECD kidneys were used by matching estimated renal functional mass to recipient need, including the use of dual kidney transplants (n = 7). ECD kidney recipients were further selected on the basis of older age, HLA-matching, low allosensitization, and low body mass index. All patients received a similar immunosuppressive regimen. Minimum follow up was 9 months. RESULTS: There were significant differences in donor and recipient characteristics between ECD and SCD transplants. Patient (99%) and kidney graft survival (88%) rates and morbidity were similar between the 2 groups, with a mean follow-up of 16 months. Initial graft function and the mean 1-week and 1-, 3-, 6-, 12-, and 18-month SCr levels were similar among groups. CONCLUSIONS: The use of ECD kidneys at our center effectively doubled our transplant volume within 1 year. A systematic approach to ECD kidneys based on nephron mass matching and nephron sparing measures may provide optimal utilization with short-term outcomes and renal function comparable to SCD kidneys.