Transplantation of pediatric cadaveric kidneys into adult or pediatric recipients

In Japan, nationwide cadaveric organ sharing for kidney transplantation by the Japan Organ Transplant Network (JOTN) has operated since April 1995. This study retrospectively analyzed the long-term results of single pediatric donor kidneys transplanted into adult or pediatric recipients at a single center. From March 1983 to December 2002, 281 cadaveric renal allografts were transplanted at our center, including, 17 recipients of cadaveric kidneys from donors aged less than 16 years. We divided these 17 recipients into two groups: 10 adult recipients (group 1; G1) and seven pediatric recipients (group 2; G2). HLA-AB, -DR mismatches were 1.3 +/- 1.3, 0.7 +/- 0.5 in G1 and 2.6 +/- 1.3, 1.4 +/- 0.8 in G2, respectively (P < .05 for both). The end of the observation of this study was March 2003. Among G1, two recipients died with functioning grafts and one died after graft loss. Among G2, no recipients died. Patient survival rates at 1 and 5 years were 90% and 80% in G1 and 100% and 100% in G2, respectively. At the end of the observation in this study, five recipients among G1 and six recipients among G2 had functioning grafts. Graft survival rates at 1 and 5 years were 90% and 80% in G1 and 85.7% and 85.7% in G2, respectively. Our results demonstrate that transplantation of pediatric cadaveric kidneys into pediatric recipients was excellent compared to adult recipients in terms of survival. Priority to pediatric patients should be given especially in cases of pediatric donors.     

Transplantation of single and paired pediatric kidneys into adult recipients

Background:The transplantation of kidneys from cadaveric donors ≤ 5 years of age into adult recipients is controversial. The large disparity between donor renal mass and recipient body mass is feared to be problematic. Controversy also exists whether to transplant kidneys from these young donors individually or as a pair into a single recipient.Study Design:We retrospectively reviewed our experience from January 1991 to January 1995 with 22 adulrenal transplantations using kidneys from cadaveric donors ≤ 5 years of age. Ten patients received single allografts. Twelve received organs paired en bloc. Fiftytwo adult recipients from cadaveric donors aged 18–55 years served as controls. All patients received cyclosporine-based immunosuppression. Recipient characteristics did not differ significantly between the groups.Results:Actuarial patient and graft survival rates were similar for the two groups. The incidence of urinary complications was higher in the recipients of pediatric kidneys than in the adult-donor group (18.2% versus 3.8%, respectively, p = not significant). No grafts were lost from urinary complications. Renal function, as determined by the calculated creatinine clearance, was significantly greater in the pediatric group (76.1 ± 4.0 versus 61.4 ± 23.2 mL/min, p = 0.035) by 6 months after transplantation. Recipients of paired pediatric kidneys initially had better renal function (63.9 ± 21.4 mL/min) than those receiving single pediatric kidneys (38.2 ± 11.6 mL/min) (p = 0.004), but by 6 months, no significant difference existed. At 2 years, renal function in the pediatric-donor group remained significantly better than in the adult-donor group. Hematocrit levels as a measure of erythropoiesis were similar for single pediatric, paired pediatric, and adult-donor recipients.Conclusions:Kidneys from cadaveric donors ≤ 5 years of age are suitable for transplantation into adults. Pediatric kidneys provide excellent renal function despite an initially tremendous disparity between renal mass and recipient body mass. Rapid true renal growth probably occurs. No appreciable advantage is achieved by using two pediatric kidneys for a single recipient.     

Pediatric cadaver kidneys for transplantation.

A group of 24 kidneys from donors ranging in age from 1 1/2 to 10 years were transplanted singly into adults and were compared to a group of 44 adult cadaveric kidneys transplanted into adults. There were no vascular complications in either group. There were two urological complications in the 24 pediatric donor cases and none with the adult donor cases. During the first month after transplantation, the mean creatinine clearance was lower in the pediatric donor group; later the function of the pediatric donor kidneys was at least as good as the function of the adult donor grafts. In the group of pediatric donor kidneys, the outcome using kidneys from donors younger than 3 years of age was less satisfactory than for donors 3 to 10 years of age. These data suggest that transplantation of a single pediatric kidney into an adult, particularly if the pediatric donor is at least 3 years of age, will provide satisfactory renal function.     

Renal transplantation of the infant and young child and the use of pediatric cadaver kidneys for transplantation in pediatric and adult recipients

Transplantation of infants less than 1 year of age with kidneys from live-related parental donors has recently led to good results, whereas cadaver donor renal transplantation in this recipient age group has led to a high mortality rate (11/13). Similarly, the results of cadaver donor renal transplantation in infants and young children less than 5 years of age has been suboptimal in the past, although recent data are more encouraging. With recent availability of long-term peritoneal dialysis for the infant and young child with end-stage renal disease (ESRD), it is possible to defer transplantation until an optimal donor becomes available. Because of the possible immunologic hyperactivity of such recipients, the immunosuppressive regimen may need to be modified if improved cadaver donor survival rates are to be obtained. The use of anencephalic kidneys for transplantation has been associated with a high incidence of primary nonfunction and few recipients with long-term functioning grafts. Harvesting of kidneys from anencephalic donors declared "brain-dead" at birth may reduce the incidence of primary nonfunction and increase the availability of anencephalic kidneys for transplantation. Reports of the use of pediatric cadaver kidneys for transplantation into pediatric and adult recipients yields discrepant results. Analysis of the data indicates that if pediatric cadaver kidneys from donors less than 6 years of age are used, the potential for decreased graft survival rates and an increased incidence of technical complications exists. However, the use of pediatric cadaver kidneys can provide adequate graft function in both pediatric and adult recipients and the use of such kidneys should increase the number of kidneys available for transplantation.     

Factors contributing to long graft survival in non-heart-beating cadaveric renal transplantation in Japan: a single-center study at Kitasato University

A total of 107 cadaveric kidneys from non-heart-beating donors (NHBDs) have been transplanted between 1974 and 2000 at Kitasato University Hospital, Sagamihara, Japan. The patient survival of the 107 recipients of cadaveric renal transplants at 1, 5 and 10 yr was 0.857, 0.770 and 0.746, respectively. The 50% graft survival was 3.8 yr. The 5 and 10-yr graft survival was 0.457 and 0.337, respectively. Twenty of the 107 recipients of non-heart-beating cadaveric renal transplantation had graft survival longer than 10 yr. Of these 20 patients, 14 survivors still maintain functioning renal grafts and two died with functioning graft, although the remaining four reverted to dialysis because of chronic rejection and nephropathy. The average graft survival of these 20 patients at the time of study was 13.3 yr and the longest was 21.4 yr. The average serum creatinine level at 10 yr after transplantation was 1.63 mg/dL, almost identical to that at 5 yr post-transplant. The donors aged on average 40.2 yr; 13 were male and seven were female. The youngest donor was 9-yr-old and the oldest was 66. The graft survival was significantly better in the group with donor age younger than 55 yr (Log-rank: p=0.007). The average weight of the renal graft was not different between the long and shorter graft survival groups. The average warm ischemic time and total ischemic time were 9.7 and 539.7 min, respectively. The duration of post-transplant acute tubular necrosis averaged 9.2 days. These parameters tended to be shorter than those in recipients with graft survival >10 yr, but with no statistical significance. The mean numbers of acute rejection (AR) episode within 3 months after transplantation were 0.25 +/- 0.66 and 0.92 +/- 0.90 (p=0.020) in long survival and shorter survival groups, respectively. Long survivors had a significantly lower incidence of AR. Two of 20 cases received conventional immunosuppression with prednisolone, azathioprine and mizoribin, and 18 had prednisolone and calcineurin inhibitor (CNI). Kaplan-Meier analysis showed a significant contribution of CNI to graft survival (p=0.036). However, the graft survival reduction rate after 1 yr post-transplant did not differ between conventional and CNI immunosuppression. These data suggest that renal grafts retrieved with proper organ procurement procedures from NHBDs may survive long-term and help to overcome donor shortage.     

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

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

Hypothermic pulsatile perfusion and transplantation of pediatric cadaveric kidneys into adults.

Twenty-seven adults received en block or single renal allografts from pediatric donors less than 12 years of age. Hypothermic pulsatile perfusion of these small kidneys presented no technical difficulties. Flow rates ranged between 0.8-1.2 ml/min/gm. Single pediatric kidneys from donors as young as three years were able to produce a creatinine clearance of 50 ml/min in adults by one month posttransplant. No differences in renal function were noted between en bloc or single kidneys. En bloc transplants were associated with an increased incidence of renal arterial thromboses (3/8 cases). Because of this, pediatric cadaver kidneys were transplanted as single units, and an additional advantage was that they could provide donor kidneys for two recipients. In our series, one year pediatric graft survival is less than a comparable group of adult cadaveric kidney recipients.     

When is it reasonable to split pediatric en bloc kidneys for transplantation into two adults?

Background

Traditionally, kidneys from donors ≥60 years old and pediatric kidneys are considered marginal organs for transplantation. Pediatric donor kidneys are underutilized for transplantation into adult recipients due to concern for poor outcomes.

Methods

Using data from the Organ Procurement and Transplant Network, we analyzed patterns of pediatric kidney use (single vs en bloc) in the United States from 1987 to 2007. Using the Cox proportional hazards model, graft outcomes of pediatric donor kidneys transplanted as single vs en bloc grafts from different donor weight groups were compared with renal transplantation from donors ≥60 years old in an attempt to define a pediatric donor weight at which kidneys can be justifiably split to expand the donor pool.

Results

Compared with older donor kidneys, graft failure risk of pediatric single kidneys was consistently lower when the donor weight exceeded 10 kg. On the other hand, graft survival benefit for pediatric en bloc kidneys was evident starting at donor weight ≤10 kg in comparison to older donor kidneys. Pediatric en bloc kidneys performed consistently better than pediatric single kidneys for all donor weight groups.

Conclusions

Splitting of pediatric donor en bloc kidneys for transplantation into 2 adults when the donor weight exceeds 10 kg was associated with acceptable graft outcomes. This practice, along with increased use of small pediatric donor kidneys, may help to alleviate the waiting list burden in renal transplantation.     

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).     

Outcome of 3 years of immunosuppression with tacrolimus in more than 1,000 renal transplant recipients in japan

BACKGROUND: In Japan, the new macrolide immunosuppressant, tacrolimus, was approved for the prevention and treatment of allograft rejection in renal transplant recipients in April 1996. This article summarizes efficacy and safety data for tacrolimus gathered since its approval. METHOD: Data from 1,007 patients who received tacrolimus-based treatment after kidney transplantation at 35 leading Japanese transplant centers between April 1996 and December 2000 were retrospectively analyzed. RESULTS: The renal transplants consisted of 856 living (756 ABO compatible, 100 ABO incompatible) and 151 cadaveric (146 non-heart-beating, 5 brain dead) donor grafts. Mean follow-up duration was 24.4 months. Overall patient and graft survival rates were 98.4% and 94.8% at 1 year, 98.0% and 92.6% at 2 years, and 97.6% and 90.4% at 3 years, respectively. Graft survival rates in living and non-heart-beating donor graft transplantations were 95.9% and 88.8% at 1 year, 94.0% and 85.0% at 2 years, and 92.2% and 80.0% at 3 years, respectively. Graft survival rates in living ABO-compatible donor graft transplantation ranged from 93.4% to 97.5%, and in ABO-incompatible cases, rates were stable at 83.2% throughout the 3-year assessment period. Median serum creatinine levels ranged from 1.30 to 1.37 mg/dL during this time. Percentages of patients receiving antihyperlipidemics, antihypertensives, and insulin were 12.6%, 41.1%, and 6.5% at 1 year, respectively, and remained low at 3 years after transplantation. CONCLUSION: Three years of tacrolimus therapy demonstrated excellent efficacy and safety in more than 1,000 renal transplant recipients, including recipients of living ABO-incompatible and non-heart-beating donor grafts, with favorable graft function maintained.     

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.     

Renal allograft function in matched pediatric and adult recipient pairs of the same donor

BACKGROUND: To study the effect of donor age on kidney function, the authors investigated matched pairs from the same kidney donor given to a pediatric or an adult recipient. METHODS: Fifteen matched pairs of an adult and a pediatric patient, selected from the Eurotransplant registry, receiving the renal graft from the same cadaveric donor were selected for analysis of graft function over 7 years. Nine matched pairs were from adult donors (mean age, 40 years; range, 23-60 years) and six from pediatric donors (mean age, 11 years; range, 4-15 years). All recipients had comparable immunosuppression with cyclosporine A, prednisolone, and azathioprine and comparable numbers of acute rejection, cytomegalovirus reactivation, and antihypertensive therapy. Mean age of pediatric and adult recipients at transplantation was 5 years (range, 1-9 years) and 38 years (range, 25-60 years), respectively. RESULTS: The calculated glomerular filtration rate (GFR) corrected to body surface area was not different in adult and pediatric recipients. Initial absolute GFR was significantly lower in pediatric recipients (27 mL/ min; range, 17-38 mL/min) than in adult recipients (54 mL/min; range, 25-74 mL/min) (P <0.05) and remained lower in the following years. Initially, pediatric donor kidneys transplanted into pediatric recipients showed a lower absolute GFR than those transplanted into adults, however, approaching the GFR in adult recipients later. Adult donor kidneys transplanted into pediatric recipients showed a persistently lower absolute GFR in children compared with those transplanted into adult recipients. CONCLUSIONS: The authors conclude that adult donor kidneys in pediatric recipients decrease GFR in the early stages and lack an increase in GFR with growth of the child.     

Renal transplantation with aged donors

Research indicates that aged heart-beating cadaveric donors cause greater risk factors in kidney transplantation. The influence of age on the outcome of non-heart-beating (NHB) cadaveric renal transplantations has not yet been clarified. From July 1986 to May 1999, 63 patients who received cadaveric renal transplantation at Osaka City University Hospital and Osaka City General Hospital were divided into two groups according to their age. Renal function and graft-survival rates of the two groups were compared. The mean values of nadir donor serum creatinine were significantly worse (P < 0.05) in the aged donor group. In the aged donor group the percentage of immediately functioning grafts was lower and the percentage of non-functioning grafts was higher. During the first 10 years post-transplant, graft survival in the aged donor group was significantly lower than that in the younger donor group. We conclude that cadaveric renal transplantation from NHB aged donors can be to the detriment of renal function and graft survival rates compared to transplantation from younger donors.     

Outcome of renal transplantation in children less than two years of age.

Twenty-two renal transplants were performed in 21 children less than two years of age at Children's Hospital. Fourteen were from living related donors and eight were from cadaveric donors. The five year patient and graft survivals of these recipients were compared to all other pediatric recipients between two and 18 years of age who received renal transplants over the same time period. Five year graft survival for recipients less than two years of age was 86% following living-related donor transplantation and 38% following cadaver donor transplantation. Older pediatric recipients aged between two and 18 years had a five year graft survival of 73% following living-related donor renal transplantation, which was similar to that for recipients less than two years of age. Although older cadaveric recipients had a comparable five year graft survival to younger recipients, at 42%, the patterns of graft loss were different. Graft failures in young recipients occurred within the first seven months post-transplant, whereas the older recipient's grafts failed more gradually. Actuarial five-year patient survival in recipients less than two years of age was 86% following living-related donor renal transplantation and 70% following cadaver-donor renal transplantation. Recipients less than two years of age had a poorer patient survival than older recipients following both living-related donor renal transplantation (P = 0.06) and cadaver-donor renal transplantation (P less than 0.05). These findings suggest that the graft survival of living-related donor renal transplantation in recipients less than two years of age is better than that of cadaver-donor renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diffuse glomerular basement membrane lamellation in renal allografts from pediatric donors to adult recipients

The transplantation of kidneys from pediatric cadaveric donors into adult recipients is performed in many centers. However, some studies indicate that the outcome of such renal transplants may be inferior compared with that of adult donors, particularly if the donor is an infant. Morphologic studies of failed pediatric donor kidneys in adult recipients describe various degrees of segmental or global glomerular sclerosis. The authors have performed ultrastructural examinations on such transplants and have identified six cases with diffuse irregular lamellation of the glomerular basement membrane (GBM), a change that may develop as early as 10 weeks after transplantation. The age of all donors was < or =6 years; three were infants. The incidence of the lesion was 9% at our institution in renal transplant patients who received a graft from donors <10 years old. Diffuse GBM lamellation has not been found in renal transplants from adult donors. Light microscopy showed various degrees of diffuse mesangial expansion, usually with segmental glomerular sclerosis. The patients had severe proteinuria. While recurrent focal segmental glomerular sclerosis (FSGS) has to be excluded, such diffuse GBM lamellation is generally not seen in recurrent FSGS cases. The pathogenesis of the lesion is most likely related to hyperperfusion injury of small pediatric donor kidneys grafted into adult recipients.     

Survival of cadaveric renal transplant grafts from young donors and in young recipients

Evidence from multicenter registries has suggested that cadaveric renal graft survival is poorer when either the recipient or the donor is very young. We therefore analyzed our results from a single pediatric center. There was a significant correlation between greater recipient age and improved cadaveric graft (P=0.002) and patient (P=0.0009) survival. The age of the donor also appeared important, particularly in very young children, but became less so as donor age rose. Forty-four percent of recipients under 3 years old who received cadaveric kidneys from donors less than 4 years old lost their grafts as a result of renal thrombosis, ischemia, or technical problems, compared with only 3% of recipients over 9 years of age, whose grafts came from donors who were also over 9 years. The 1-year first cadaveric graft survival rates for these two age groups were 33% and 82% respectively. Our experience confirms the poor findings reported in very young recipients and with very young donors.     

The influence of acute rejection on long-term renal allograft survival: a comparison of living and cadaveric donor transplantation

BACKGROUND: We investigated whether recipients of living donor grafts who suffer an acute rejection progress to graft loss because of chronic rejection at a slower rate than recipients of cadaveric grafts. METHODS: A retrospective review was made of 296 renal transplantations performed at Mount Sinai Hospital. Only grafts functioning for at least 3 months were included in this analysis. Demographic variables of donor and recipient age, race, sex, and serum creatinine at 3 months after transplantation were compared between groups. RESULTS: Among the acute rejection-free cohort, the estimated 5-year graft survival was 90% for those receiving transplants from living relatives and 88% for those receiving cadaveric transplants (P=0.76). However, in grafts with early acute rejection, the 5-year survival was 40% for cadaveric recipients compared with 73% for living related graft recipients (P<0.014). Using the proportional hazards model, cadaveric donor source, older donor age, African American recipient race, and elevated 3-month serum creatinine were independent predictors of long-term graft loss caused by chronic rejection. The severity of acute rejection and recipient age had no impact on the risk of graft loss because of chronic rejection. CONCLUSION: These data indicate that the benefit of living related transplantation results from the fact that a living related graft progresses from acute to chronic rejection at a slower rate than a cadaveric graft. Furthermore, a cadaveric graft that is free of acute rejection 3 months after transplantation has an equal likelihood of functioning at 5 years as that of a graft from a living related donor.     

Evaluation of pediatric cadaver kidneys transplanted into adult recipients receiving cyclosporine

The major problem in clinical transplantation is the imbalance between the need for cadaveric organs and the available numbers of donors. If pediatric kidneys were transplanted into adult recipients when no pediatric recipient was available, the potential number of renal donors would be increased by 15 to 20%. Some centers are reluctant to use pediatric kidneys for adult recipients because of recent reports indicating poorer patient and allograft survival, increased delayed graft function, increased post-transplant hypertension and increased technical complication. (There also has been concern that the nephrotoxic effect of cyclosporine A would retard the organ growth that is necessary to provide normal renal function in adults.) A retrospective analysis was performed on 18 adult recipients who received kidneys from cadaver donors 14 months to 12 years old (group 1). These patients were compared to 106 adult recipients who received kidneys from donors greater than 12 years old (group 2). Actuarial patient survival at 1 year was 85% for group 1 and 95.8% for group 2 (p equals 0.13), while 1-year actuarial allograft survival was 83.1% for group 1 and 81.1% for group 2 (p equals 0.87). There was no significant difference between groups 1 and 2 in the frequency of delayed graft function, serum creatinine at 1, 3 and 6 months after transplantation, incidence of post-transplant hypertension or frequency of surgical complications. It is of interest that the pediatric kidneys had significant growth during the initial post-transplant month. Sonographic examination at postoperative days 1 and 30 demonstrated a mean increase in size from 80.7 to 143.5 cm. (p less than 0.001). In this series pediatric kidneys were safe and effective donor organs in adult recipients, and increased the available number of organs by 15%.     

Intermediate outcomes of dual renal allografts: the University of Washington experience

PURPOSE: The increased survival advantage of renal transplantation with end stage renal disease combined with an increasing incidence of renal disease fuel an increasing disparity between supply and demand for transplantable kidneys. Despite efforts to increase cadaveric organ donation through education and publicity, the number of cadaveric kidneys transplanted has not increased and in the last year was surpassed by kidneys transplanted from living donors. In an effort to maximize cadaver organ donors use of kidneys from expanded criteria donors has been investigated. In select cases both donor kidneys have been transplanted into a single recipient, which is called dual renal transplant. We report on the 4-year dual renal transplant graft and patient outcomes and compare these to age matched single cadaver kidney transplants. MATERIALS AND METHODS: A retrospective review of 10 dual renal transplant recipients and 10 age matched single cadaver kidney recipients was performed. All patients underwent transplantation at our university between January 1996 and February 1998. Mean followup was 4.1 years (range 2.5 to 5.1) for the dual kidney recipients and 3.6 (0.0 to 5.5) years for the control group. RESULTS: Of the 10 dual renal transplant recipients 7 remain alive and 3 died of nontransplant related causes. Of the 10 single recipients 8 are alive, 1 died of postoperative complications and 1 died of nontransplant related causes. When censored for death with a functioning graft, 7 of 10 dual grafts are functioning at followup with a mean creatinine clearance of 39.4 ml. per minute (range 16.1 to 65.9) and mean serum creatinine of 2.0 mg./dl. (1.1 to 3.9). If not censored for death with a functioning graft, 50% of dual grafts are functioning. Of the 3 graft losses 2 were due to recurrent disease and 1 was attributed to chronic rejection. In the control group 8 of 10 grafts are functioning at current followup (regardless of censoring for death with a functioning graft) with a mean creatinine clearance of 48.7 ml. per minute (range 23.4 to 66.5) and mean serum creatinine of 1.6 mg./dl. (1.2 to 2.4). Of the 2 graft losses 1 resulted from postoperative complications and 1 was due to chronic rejection. CONCLUSIONS At the 4-year followup patients undergoing dual renal transplant have comparable graft function, incidence of graft loss and survival compared to the control group. However, because of our small sample size, differences in the 2 groups may be significant in a larger study. Additional studies need to be conducted to determine if this practice represents an acceptable use of kidneys from expanded criteria donors.     

Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool

The terms extended donor or expanded donor mean changes in donor acceptability criteria. In almost all cases, the negative connotations of these terms cannot be justified. Factors considered to affect donor or organ acceptability have changed with time, after showing that they did not negatively affect graft or patient survival per se or when the adequate measures had been adopted. There is no age limit to be an organ donor. Kidney and liver transplantation from donors older than 65 years can have excellent graft and patient actuarial survival and graft function. Using these donors can be from an epidemiological point of view the most important factor to esablish the final number of cadaveric liver and kidney transplantations. Organs with broad structural parenchyma lesion with preserved functional reserve and organs with reversible functional impairment can be safely transplanted. Bacterial and fungal donor infection with the adequate antibiotic treatment of donor and/or recipient prevents infection in the latter. The organs, including the liver, from donors with infection by the hepatitis B and C viruses can be safely transplanted to recipients with infection by the same viruses, respectively. Poisoned donors and non-heart-beating donors, grafts from transplant recipients, reuse of grafts, domino transplant and splitting of one liver for two recipients can be an important and safe source of organs for transplantation.