Delayed Graft Function in Renal Transplant Recipients: Risk Factors and Impact on 1-Year Graft Function: A Single Center Analysis

Delayed graft function (DGF), a frequent complication after kidney transplantation, occurs among about 60% of recipients of kidneys from deceased donors. DGF has a multifactorial etiology. It is characterized by acute tubular necrosis (ATN) upon biopsy. In this study we sought to identify among a group of recipients of kidneys from deceased donors, the incidence, risk factors, and impacts on patient and graft survivals of DGF.

Materials and Methods

We retrospectively analyzed medical records from renal transplant recipients aged >18 years who received a deceased donor kidney graft between January 2003 and December 2006. Kidneys lost during the first week posttransplantation were excluded from this series.

Results

Among 165 transplants, 111 (67%) displayed DGF, defined as the need for dialysis during the first week posttransplantation. The incidence of DGF was higher among patients with a cold ischemia time (CIT) > 24 hours: 85% vs 60%, DGF vs no DGF (P < .05), as well as for grafts from older donors. After 1-year follow-up, the DGF group showed worse graft function (serum creatinine 1.6 ± 0.7 vs 1.3 ± 0.4 mg/dL; P < .05) as well as a greater incidence of graft loss.

Conclusion

Prolonged cold ischemia and older donor age were associated with a greater incidence of DGF in this series, leading to prolonged hospitalization, increased risk for an acute rejection episode, and reduced graft function and survival after 1 year.     

Risk Factors for Delayed Graft Function After Hand-Assisted Laparoscopic Donor Nephrectomy

Background

Delayed graft function (DGF) has a negative effect on the results of living-donor kidney transplantation.

Objective

To investigate potential risk factors for DGF.

Methods

This prospective study included 200 consecutive living donors and their recipients between January 2002 and July 2007. Delayed graft function was defined as need for dialysis within the first postoperative week.

Results

Delayed graft function was diagnosed in 12 patients (6%). Intraoperative complications occurred in 10 donors (5%), and postoperative complications in 24 donors (13.5%). One-year kidney graft survival with vs without DGF was 52% and 98%, respectively (P < .002). In donors, 2 univariate risk factors for DGF identified were lower counts per second at peak activity during scintigraphy, and multiple renal veins. In recipients, only 2 or more kidney transplantations and occurrence of an acute rejection episode were important factors. At multivariate analysis, increased risk of DGF was associated with the presence of multiple renal veins (odds ratio, 151.57; 95% confidence interval, 2.53-9093.86) and an acute rejection episode (odds ratio, 78.87; 95% confidence interval, 3.17-1959.62).

Conclusion

Hand-assisted laparoscopic donor nephrectomy is a safe procedure. The presence of multiple renal veins and occurrence of an acute rejection episode are independent risk factors for DGF.     

Complications of Transplantation of Kidneys From Expanded-Criteria Donors

Background

Organ shortage is the primary barrier to kidney transplantation. To maximize organ use, organs from expanded-criteria donors (ECDs) have been used increasingly. Expanded-criteria donors are defined as individuals older than 60 years or older than 50 years with at least 2 of the following risk factors: hypertension, stroke as the cause of death, or serum creatinine concentration greater than 1.5 mg/dL.

Objective

To assess the incidence of complications posttransplantation in ECD kidneys compared with kidneys from standard-criteria cadaveric donors (SCDs).

Patients and Methods

One hundred seventy-two patients received cadaveric renal transplants between January 1, 2006, and August 31, 2008. Donor and recipient data were collected, as well as patient and graft survival and immediate, delayed, or slow graft function. Complication rates for lymphocele, urinary leak, thrombosis, hematoma, urinary tract infection, and cytomegalovirus infection were recorded. Follow-up was for 3 to 35 months, ending on November 30, 2008.

Results

Overall, mean 1-year graft survival was 86.9%, and mean creatinine concentration was 1.58 mg/dL. One incidence of primary nonfunction (0.6%) was observed. More than 25% of transplanted kidneys were from ECDs. No significant differences were noted in postoperative complications between recipients of ECD or SCD organs.

Conclusion

The rate of complications in recipients of ECD and SCD kidneys is comparable.     

Delayed Graft Function Has an Equally Bad Impact on Deceased Donor Renal Graft Survival in Both Standard Criteria Donors and Expanded Criteria Donors

Introduction

The use of expanded criteria donors (ECDs) is still limited because of inferior graft survival compared to standard criteria donors (SCDs). We assessed the impact of immediate graft function (IGF) on renal graft survival among recipients of SCD and ECD grafts to determine whether these kidneys performed equally well under “ideal” conditions favoring IGF.

Methods

We included all cadaveric renal transplants performed from 1990 to 2002 (n = 335). Delayed graft function (DGF) was defined as the need for dialysis in the first 7 days posttransplant. Slow graft function (SGF) and IGF were defined as a serum creatinine fall by <20% versus >20% in the first 24 hours posttransplant, respectively. Non-death censored actual graft survivals are reported herein.

Results

Seventy-two of the 335 subjects (21.5%) received organs from ECDs and displayed IGF in 54.7%, SGF 16.2%, and DGF 29.1%. Among SCDs, the SGF and DGF rates were 15.3% and 23.4%, respectively. In ECD, the SGF and DGF rates were 19.4% and 50% (P < .02). Actual graft survivals at 1 and 5 years was 86.3% and 70.4%, respectively. Patients with IGF had higher actual graft survival at 5 years compared to SGF and DGF (83.5% vs 74.1% vs 45.4%). DGF had an equally bad impact on actual 5-year graft survival in SCDs and ECDs (42.6% vs 50%).

Conclusion

DGF has a strong detrimental impact on 5-year graft survival. There is a higher rate of DGF in ECD versus SCD kidneys. The detrimental impact on 5-year actual graft survival is equal in SCD and ECD kidneys. Minimizing DGF should be our goal.     

Impact of Slow and Delayed Graft Function on Kidney Graft Survival Between Various Subgroups Among Renal Transplant Patients

Objective

Renal allografts with excellent graft function show good long-term outcomes, while grafts with delayed function have been associated with poor long-term survivals, although few reports have analyzed outcomes among these groups. We compared first-week postoperative graft function among renal transplant patients to analyze the impact of slow graft function (SGF) and delayed graft function (DGF) on graft survival.

Materials and Methods

Renal transplantations were performed from 362 unrelated, 46 related, and 163 deceased donors. Kidney transplant patients were divided into 3 groups according to their initial graft function. First-week dialyzed patients formed the DGF group. Nondialyzed patients were divided into a SGF or an excellent graft function (EGF) cohort according to whether the serum creatinine at day 7 was higher vs lower than 2.5 mg/dL, respectively.

Results

Of the 570 renal transplant recipients, DGF was observed in 39 patients (6.8%), SGF in 64 (11.2%), and EGF in 467 (81.8%). There was no significant difference in SGF vs DGF between patients who received kidneys from unrelated vs related living or deceased donors. Graft survival was worse among the DGF than the SGF or EGF patients, with no significant difference between the last 2 groups. The 6-month graft survivals were 74%, 93%, and 96%; the 3-year graft survivals were 70%, 88%, and 90%, respectively (P < .001).

Conclusions

We observed a similar impact of EGF and SGF on kidney graft survival. Kidney transplant recipients who developed DGF showed worse graft survival than those with EGF or SGF.     

Impact of early lymph node procurement to facilitate histocompatibility testing on long-term cadaveric kidney graft survival

Background

Prolonged cold ischemia time (CIT) is a clinically important causes of delayed graft function (DGF) after kidney transplantation. As DGF has been previously shown to have a deleterious influence on long-term graft survival, in the present study we analyzed the impact of early lymph node (LN) procurement on CIT, HLA mismatches, and long-term kidney graft outcome.

Materials and Methods

We evaluated 394 consecutive cadaveric procedures performed from 2001 to 2006, including 289 recipients, in whom LN were obtained before kidney procurement seeking to shorten the total time for HLA typing and crossmatch procedures.

Results

During 58 ± 6 months, 24 patients died (918 [8.3%] in the early and 6 [5.7%] in late procurement group, P = ns) and 52 lost their kidney grafts (31 [10.7%] vs 21 [20%]; P = .025). Early procurement of LN performed in 73.4% of all kidney graft recipients shortened CIT by almost 7 hours (22.9 vs 16.1 hours; P < .001), with a nonsignificantly lower incidence of DGF (32.2% vs 41.0%; P = .13). However, a Cox proportional hazards regression model revealed that early procurement reduced the risk of death-censored kidney graft loss by roughly 40% (log-rank, P = .013).

Conclusion

Early LN procurement in significantly shorten CIT and subsequently reduced the risk of long-term kidney graft loss.     

Delayed graft function and long-term outcome in kidney transplantation

Background

There are still many controversies about the impact of delayed graft function (DGF) on kidney transplantation outcome. The aims of this study were to define factors associated with DGF and to ascertain the relative impact of DGF on kidney transplantation outcome, both in the early postoperative period and in long-term follow-up.

Patients and Methods

Four hundred kidney transplant recipients were reviewed to assess the clinical impact of DGF on long-term outcome.

Results

The overall prevalence of DGF was 24.3%. DGF was significantly associated with increasing recipient and donor age, duration of dialysis, and cold ischemia time. Patients with DGF displayed a significantly worse graft (P = .005) and patient (P < .001) survival compared with recipients with immediate function.

Conclusion

DGF is a frequent complication of renal transplantation and may be associated with a reduced graft and even patient survival. Strategies to prevent graft injury and, more specifically, DGF may be an important clue to provide a better long-term outcome in kidney transplantation.     

Multivariate Analysis of Risk Factors for Early Loss of Pancreas Grafts Among Simultaneous Pancreas-Kidney Transplants

To evaluate the risk factors for pancreas graft loss within 3 months postoperatively among 170 simultaneous pancreas-kidney transplantation (SPKT) we examined 38 variables.

Methods

Twenty-two variables were related to recipients; 12 to donors and 4 to the surgical procedure. In addition the latest follow-up dates as well as the transplant and/or death dates. Independent variables were examined with reference to the dependent pancreatic loss variable, excluding losses owing to deaths. Variables with statistical significance were analyzed to predict early graft loss.

Results

Univariate analyses determined the following significant variables: kidney cold ischemia time, older donors, non-white donors, death cause related to vascular disease, wound infection, and length of extended hospitalization. However, multivariate analysis showed that only donor age and kidney cold ischemia time were significant predictors for early pancreastic graft loss.

Conclusion

Donor age and kidney cold ischemia time were independently related to pancreatic loss after SPKT within 3 months posttransplantation.     

Size does matter-donor-to-recipient body mass index difference may affect renal graft outcome

Background

Obesity, in the either kidney donor or the recipient, has been related to worse graft function. The aim of this study was to compare long-term graft outcomes of living-related kidney recipients regarding the donor-to-recipient body mass index (BMI) ratio.

Methods

From November 2002 to November 2010, 62 consecutive living-related kidney transplantations were performed at our center. Donor and recipient BMIs were categorized by Taiwan's national standard using dividing values of 18.5, 24, and 27 kg/m² to divide subjects into donor-to-recipient BMI categories. These with the same BMI category as their donors were defined as the same-BMI group (group 0); recipients with a lower BMI category than their donors were defined as the large-to-small group (group 1); and those with a higher BMI category than their donors were defined as the small-to-large group (group 2). Baseline parameters and posttransplantation follow-up data were analyzed according to this grouping.

Results

Of the 57 recipients followed regularly at our hospital (mean follow-up 48.9 months), 21 (36.8.1%) were in group 0; 26 (45.6%) in group 1, and 10 (17.6%) in group 2. The baseline parameters were similar among these groups. The overall graft survival rates were 81.0% in group 0, 76.9% in group 1, and 90.0% in group 2. The rejection-free graft survival rates were 81.0%, 65.4%, and 90.0%, respectively. By Kaplan-Meier analysis, group 1 showed worse rejection-free graft survival than group 0 or group 2 (log-rank P = .046).

Conclusions

Living-related recipients of kidneys from donors with a higher BMI showed lower long-term graft survival, which might suggest that petite recipients may need time to compensate adequate blood flow for the relative large graft, thus carrying a higher chance of rejection and worse graft outcomes.     

Renal Transplantation With Expanded Criteria Donors: The Experience of One Portuguese Center

Background

The shortage of kidneys available for transplantation has led to enlarged criteria donors (ECD): namely, donors older than 60 years or aged between 50 and 59 years with 2 of the following characteristics-hypertension, predonation serum creatinine level higher than 1.5 mg/dL or cerebrovascular disease as the cause of death. The aim of this study was to analyze renal transplants using ECD compared with standard criteria donors (SCD) concerning the incidences of delayed graft function (DGF), acute rejection episodes (ARE), and patient and graft survivals.

Materials and Methods

This retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD.

Results

Of the transplants, 24.4% used ECD. The baseline characteristics of recipients of ECD versus SCD kidneys were similar, except for age and cold ischemia time. Comparing ECD and SCD, we observed an higher incidence of DGF (35% vs 18%), occurrence of ARE (34.4% vs 16.6%), average serum creatinine levels at 6 (1.87 vs 1.4 mg/dL), and 12 months (1.88 vs 1.43 mg/dL) as well as lower graft survival at 1 (82% vs 91%) and 3 years (75% vs 84%) after transplantation. Recipient survival at 1 year was not different. Multivariate analysis identified recipient age, cold ischemia time, ARE, and DGF as risk factors for graft failure.

Conclusions

Renal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.     

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.     

Pairs of kidneys transplanted from the same donor: is there any difference?

Objectives

The aim of this study was to compare the evolution of the first kidney in relation to the second kidney transplanted from the same donor, focusing on the impact that a longer cold ischemia time may have as an independent variable.

Material and Methods

The study included 44 pairs of kidneys transplanted from the same donor between February 2008 and October 2010, divided into Groups 1 and 2 according to the graft placement order. The variables analyzed were age, sex, comorbidities, number of transfusions, length of hospital stay, maximum peak PRA, immunologic incompatibility, ischemia time, delayed graft function (DGF), presence of rejection, creatinine clearance at first week, at 3 months and at 1 year, and vascular and tract complications in each group.

Results

The mean cold ischemia time was 15.6 hours in Group 1 and 20.1 hours in Group 2 (P < .001). The average recipient age was 52.79 years in Group 1 and 54.52 years in Group 2, with an equal sex ratio in the two groups; an average of 2.06 PRC were transfused prior to transplantation in Group 1 and 0.93 PRC in Group 2; the average length of stay was similar in the two groups. Major DR incompatibility was only found in Group 2 (P < .03). Creatinine clearance at first week, DGF and acute rejection showed worse results in Group 2, but these differences were not significant. Vascular complications were present in 4.5% and 2.3% of Groups 1 and 2, respectively, and tract complications were 6.8% and 11.4%.

Conclusions

A greater tendency to DGF, early rejection and tract complications were found in the group with longer ischemia time, although the difference was not statistically significant. Larger series will be necessary to confirm our results.     

Delayed renal graft function: risk factors and impact on the outcome of transplantation

Objectives

The objectives of this study were to determine whether delayed graft function (DGF) implied a higher incidence of poor prognostic markers and to determine its impact on renal transplantation outcomes, particularly graft and patient survivals.

Methods

This retrospective study included 997 cadaveric kidney transplantations between January 1, 1996 and December 31, 2007. Two groups were created: immediate diuresis (ID; n = 803; 80.5%) and DGF (n = 194; 19.5%).

Results

These donor related variables showed significant differences (P < .05): age (ID, 35.20 ± 15.681; DGF, 42.49 ± 16.316), weight (ID, 70.54 ± 12.896; DGF, 74.86 ± 14.402), death cause (stroke: ID, 24.9%; DGF, 42.6%), hourly urinary output (ID, 225.55 ± 168.107; DGF, 187.29 ± 125.623), and creatinine (ID, 1.004 ± 0.3737; DGF, 1.075 ± 0. 4148). The significant recipient-related age (ID, 42.95 ± 13.095; DGF, 45.57 ± 13.138), dialysis time ID, 39.41 ± 38.172; DGF, factors were as follows 56.14 ± 44.243), dialysis type, and comorbidities. The significant transplant-related variables were follows: cold ischemia time (ID, 19.489 ± 4.841; DGF, 21.469 ± 5.297) and surgery duration (ID, 2.549 ± 1.105; DGF, 3.028 ± 1.738). Acute rejection and chronic allograft nephropathy (CAN) were greater among the DGF group (ID, 27.3% and 15.0% and DGF, 55.2% and 34.0%, respectively). Average graft (ID, 127.8 months; DGF, 93.9 months) and patient survival (ID, 143.2 months; DGF, 125.6 months) were higher in patients with ID. Multivariate analysis identified these independent risk factors for graft loss: CAN (hazard ratio [HR], 3.30) and DGF (HR, 2.30) but neither had an influence on patient survival.

Conclusions

DGF was associated with multiple risk factors and contributed to worse graft outcomes. It is an independent risk factor for graft loss and an important marker of other factors that affect decisively the outcome of renal transplantation.     

Machine Perfusion Preservation for Kidney Grafts With a High Creatinine From Uncontrolled Donation After Cardiac Death

Background

This study evaluated the usefulness of machine perfusion preservation parameters as selection criteria for donation after cardiac arrest (DCD) with high creatinine level. The aim of this study is to evaluate to whether DCD donor >50 years old and with high creatinine are acceptable.

Methods

We examined 17 kidneys from uncontrolled DCD who showed creatinine levels >3.0 mg/dL before procurement. The study included the following two groups: group 1 (n = 9), donor age <50 years old versus group 2 (n = 8), donor age >50 years old.

Results

There were no significant differences in donors or preservation conditions among the 2 groups, including age, terminal creatinine, warm ischemic time, cold perfusion time, and total ischemic time. A greater resistance of 47.9 mmHg/mL per min/g was observed among group 2, compared with 42.5 mmHg/mL per min/g in group 1. A shorter ATN period (8.2 days) was noted in group 1, compared with 21.2 days for group 2. The flow rate (mL/g/min) was not significantly different between the two groups. The best-Cr level was 1.22 mg/dL in group 1 and 1.94 mg/dL in group 2.

Conclusion

Machine perfusion flow was a reliable indicator of graft viability in uncontrolled DCD, particularly kidneys with high creatinine level. Even older donors were acceptable if the machine perfusion preservation parameters such as flow rate and pressure were acceptable; however, they may show severe delayed graft function.     

Assessment of Kidneys Procured From Expanded Criteria Donors Before Transplantation

Background

Using expanded criteria donor (ECD) organs is 1 strategy to make more organs available for transplant. To reduce the number of posttransplant complications and failures, there is a need to create a comprehensive system of evaluation before transplantation, especially for kidneys harvested from ECD. The aim of this study was to assess the results of kidneys procured from ECD seeking to discover the most useful factors for kidney evaluation before transplantation.

Patients and Methods

One hundred seventy-two patients received cadaveric renal transplants between January 1, 2006, and August 31, 2008. We collected data on donors, recipients, and perfusion parameters. We analyzed patient and graft survivals, as well as immediate, delayed, and slow graft function. Kidney recipient function was assessed by serum creatinine concentrations and by creatinine clearance calculated according to the Cockroft-Gault formula. Renal biopsy specimens were obtained in the perioperative periods 147 cases.

Results

The overall 1-year graft survival was 86.9%. More than 25% of transplanted kidneys were harvested from ECD. There were no significant differences in patient survival between recipients of standard criteria donor kidneys (RSCDK) versus of expanded criteria donor kidneys (RECDK). One-year graft survival was higher among the RSCDK group than the RECDK group, namely, 94.4% versus 62.5%, (P = .004). There were no differences in the incidence of primary nonfunction or in delayed graft function between the groups. RECDK were more likely to show slow graft function (69.2% vs 37.8%; P = .033). A lower graft survival at 6 months after transplantation was observed among organs harvested from ECD compared with standard criteria donor (SCD) kidneys who showed histologic lesions or a flow at the fourth hour of machine perfusion below 0.4 mL/g. Using a logistic regression model, chronic histologic changes were shown to influence kidney survival at 6 months after transplantation.

Conclusion

There was no significant difference in patient survival between recipients of kidneys harvested from expanded versus standard criteria donors. ECD kidneys displayed lower graft survival rates. There was no significant difference in the incidence of delayed graft function between recipients of kidneys harvested from expanded versus standard criteria donors. Pretransplant evaluation of ECD kidneys should include 3 variables: donor parameters, histologic findings, and machine perfusion parameters.     

Kidney Transplantation From Cardiac Death Donors With Terminal Acute Renal Failure

Objectives

Kidney transplantation from donation after cardiac death (DCD) donors with terminal acute renal failure (ARF) is not widely accepted due to concern about the organ quality. Here we report our initial clinical outcomes of kidney transplantation from DCD donors with ARF.

Materials and Methods

The results of 29 kidney transplants from ARF DCD donors were compared with those of 60 kidney transplants from non-ARF DCD donors performed at our center from August 2011 to March 2013.

Results

There was no difference in the incidence of delayed graft function and acute rejection between ARF and non-ARF kidneys (27.6% vs 16.7%, 10.3% vs 8.3%, respectively). Estimated glomerular filtration rate at 12 months was similar between ARF and non-ARF kidneys. With a mean follow-up of 18 months (range 7 to 26 months), actual patient and graft survival rates for ARF DCD recipients were 100% and 96.6%, respectively, which were similar to those of the control group of kidney transplants from non-ARF kidneys (98.3% and 95.0%).

Conclusions

Kidneys from DCD donors with terminal ARF have excellent short-term outcomes and may represent another potential method to safely expand the donor pool.     

Liver Transplant Donation After Cardiac Death: Experience at the University of Liege

Objective

Donation after cardiac death (DCD) has been proposed to overcome in part the organ donor shortage. In liver transplantation, the additional warm ischemia time associated with DCD procurement may promote higher rates of primary nonfunction and ischemic biliary lesions. We reviewed the results of liver transplantation from DCD.

Patients and Methods

From 2003 to 2007, we consecutively performed 13 controlled DCD liver transplantations. The medical records of all donors and recipients were retrospectively reviewed, evaluating in particular the outcome and occurrence of biliary complications. Mean follow-up was 25 months.

Results

Mean donor age was 51 years, and mean intensive care unit stay was 5.4 days. Mean time between ventilation arrest and cardiac arrest was 9.3 minutes. Mean time between cardiac arrest and arterial flushing was 7.7 minutes. No-touch period was 2 to 5 minutes. Mean graft cold ischemia time was 295 minutes, and mean suture warm ischemia time was 38 minutes. Postoperatively, there was no primary nonfunction. Mean peak transaminase level was 2546 UI/mL. Patient and graft survival was 100% at 1 year. Two of 13 patients (15%) developed main bile duct stenosis and underwent endoscopic management of the graft. No patient developed symptomatic intrahepatic bile duct strictures or needed a second transplantation.

Conclusions

Our experience confirms that controlled DCD donors may be a valuable source of transplantable liver grafts in cases of short warm ischemia at procurement and minimal cold ischemia time.     

Donor kidneys with small renal cell cancers: can they be transplanted?

Introduction

The purpose of this study was to determine whether incidentally discovered, small renal cell cancers (RCC) in donor kidneys can be excised and safely transplanted.

Methods

The Israel Penn International Transplant Tumor Registry database was searched and all small RCC that were identified and resected prior to transplantation of deceased and living donor kidneys were reviewed. Patient demographics, tumor characteristics, recurrence, and survival were examined.

Results

Fourteen kidneys were identified in which small RCC were noted at the time of procurement and where the tumors were excised ex vivo and then transplanted. Eleven kidneys were obtained from living related donors and three were from deceased donors. Median tumor size was 2 cm (range 0.5 to 4 cm). All 14 tumors were of histological Furhman grade II/VI (n = 8) or Furhman grade I/VI (n = 6). All kidneys had pathologically confirmed negative margins. The mean age of the recipients was 40.8 ± 9.2 years, with the majority being men (11 men; 3 women). Median follow-up for this group was 69 months (range 14 to 200 months). There have been no recurrences of tumor in these recipients and the 1-, 3-, and 5-year patient and graft survivals are 100%, 100%, and 93%.

Conclusions

These data represent the only data available (to our knowledge) on this issue. This experience indicates that donor kidneys with small, incidental RCC and low histological grade (Furhman grade I and II/IV) can be managed with excision and transplantation, with a low risk of tumor recurrence in the recipient.     

Kidney transplantation from older donors

Background

The use of kidneys from older donors has become generally accepted and increasingly common, despite the knowledge that donor age is a well-known risk factor for graft failure.

Aim

To review our experience with the utilization of kidneys from donors older than 60 years.

Patients and methods

Among two hundred eight patients, 32 (group A) received an organ obtained from a donor older than 60 years. The organs were age-matched with a maximum gap of 20 years between donors and recipients. Organs from older donors were assigned to recipients presenting a body mass index lower than that of the donor. The Primary end point was patient and graft survival. Secondary endpoints were incidences of delayed graft function and of acute rejection episodes as well as renal function at 3 months and yearly.

Results

The two groups were comparable in terms of demographic features, indications for transplantation, comorbidities, as well as cold and warm ischemia times. The Mean lengths of follow up were 31.4 ± 20.3 months and 30.3 ± 20.1 months, respectively. Graft and patient survivals were comparable. Mean creatinine values at the study intervals were significantly lower among group B who received grafts from younger donors. The incidence of delayed graft function and acute rejection episodes were similar: 15.6% (5/32) versus 20.5% (36/176; P = 0.35) and 15.6% (5/32) and 12.1% (21/167; P = 0.136) in groups A and B, respectively.

Conclusions

Donor age older than 60 years showed a negative impact on kidney function. Though, given the escalating disparity between organ supply and demand, this precious source of organs cannot be neglected. We need better ways to use the available organs.     

Impact of Recipient and Donor Nonimmunologic Factors on the Outcome of Deceased Donor Kidney Transplantation

Objective

To study the influence of nonimmunologic factors on the outcome of extended criteria deceased donor (DD) kidney transplants.

Method

This is a retrospective study of DD transplantation carried out from January 1, 2003 to December 31, 2007, to investigate the impact on graft survival and function of donor renal function at retrieval, cold ischemia time (CIT), delayed graft function (DGF), acute rejection episodes (ARE), age, and weight of donors and recipients, transplant center activities, cause of donor death, donor-recipient gender pairing and size of the donating intensive care unit (ICU).

Results

At retrieval, the frequency of donors with a creatinine clearance <60 mL/min, using the Cockcroft-Gault formula, and age >40 years were 31.7% and 32%, respectively. CIT > 24 hours, DGF, and ARE occurred in 27.1%, 33.4%, and 16.5% of cases, respectively. The overall 1- and 5-year graft and patient survival rates were 88% and 79.8% and 96.6% and 92.3%, respectively. The graft function was inferior with occurrences of ARE (P = .0001), DGF (P = .0001), CIT > 20 hours (P = .005), nontraumatic the donor death (P = .022), and donor ICUs bed capacity <20 (P = .03). The odds ratio (OR) for graft loss with DGF, ARE, and donors right kidneys were 7.74 (95% confidence interval [CI] 6-13.4; P = .0001), 4.47 (95% CI, 2.6-7.6; P = .0001) and 1.7 (95% CI, 1-2.8; P = .045), respectively. Graft function was not influenced by donor renal function at retrieval, donor weight, or donor- recipient gender pairings.

Conclusion

CIT and ARE had an impact on both graft survival and function. DGF and cerebrovascular accidents as the cause of donor death negatively affected graft function during follow-up. ICU center experience had a positive impact on graft survival. Patient survival was affected by recipient age >50 years and female to male donation versus other gender pairings. Neither donor age nor acute terminal rise in the donor serum creatinine affected graft function or survival, or patient mortality.