A single-center experience with six-antigen-matched kidney transplants

Effect on graft and patient survival between shipped and locally transplanted well-matched cadaveric renal allografts in Australia over a 10-year period

BACKGROUND

The national sharing of well-matched cadaveric renal allografts has been established since 1992 in Australia. It remains uncertain whether the shipment of renal allografts interstate has a detrimental effect on graft and patient survival.

METHODS

Using data collected by the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), graft and patient survival were compared between shipped (n = 623) and locally transplanted allografts (n = 894) in Australia between January 1992 and December 2001.

RESULTS

Shipped renal allografts were from younger donors and had a longer ischaemic time, and were transplanted into higher risk recipients. Shipping of allografts had no effect on graft or patient survival, acute rejection at 6 months, presence of delayed graft function and serum creatinine at 6 and 12 months. In addition, human leucocyte antigen-matching and allograft ischaemic time had no effect on graft or patient survival.

CONCLUSION

Recipients of either shipped or locally transplanted well-matched renal allografts have similar graft and patient survivals.

The national impact of the 1995 changes to the UNOS renal allocation system. United Network for Organ Sharing

In 1995, changes in the United Network for Organ Sharing (UNOS) renal allocation policies expanded the mandatory share (MS) category to include zero antigen mismatches (0 mm), increased points for waiting time and for pediatric status, and eliminated points for certain HLA match grades. Data from the national scientific registry on 11344 and 11652 renal allograft recipients were analyzed for periods prior to and following the policy changes to assess the impact on organ allocation. The overall frequency of transplants going to non-Caucasians increased between the study periods, but the increase was significant only in the MS category. The proportion of MS transplants nearly doubled for African-Americans, increasing from 5.5% to 10.5%, while Hispanic/Latino recipients experienced a smaller increase, from 7.2% to 8.9%. The increased numbers of MS transplants clearly resulted from the inclusion of the 0 mm in the MS category. Among the NMS transplants, the average number of mismatched HLA antigens increased slightly. No effect of the additional points for waiting time was observed among recipients of non-mandatory share (NMS) transplants. The increase in mean waiting time until transplant for NMS recipients was attributable to the growth in the size of the waiting list. In contrast, there was a significant increase in mean waiting time for MS recipients. There were no significant changes in the proportions of sensitized or pediatric recipients between the study periods. In conclusion, only the changes in the MS policies appeared to have any significant effect on renal allocation. Further efforts will be required to address increasing allocation to patients disadvantaged by sensitization and/or prolonged waiting times.

Local impact of 1995 changes in the renal transplant allocation system

In 1995, changes to the United Network for Organ Sharing renal allocation system eliminated points for certain HLA matches, increased points for waiting time and for pediatric patients, and extended the mandatory share rule to include the zero-antigen mismatch. We analyzed data, from the period December 1993 to August 1996, on 393 donors, 348 kidney-only cadaveric transplants, and 615 patients ranked first or second on the allocation lists generated for each donor, to assess the effect of the changes in the point system. There was an appreciable (46%) but not significant increase in the frequency of transplants occurring under the mandatory share rule, with a greater relative increase seen in African-Americans than in Caucasians. Recipients of transplants not falling under the mandatory share rule had an increased average waiting time but no increase in sensitization or HLA mismatch, whereas patients ranked at the top of the allocation list had higher levels of sensitization but no increase in waiting time. There was an appreciable increase in the percentage of transplants occurring in African-Americans. Of the various changes we observed, only those involving the mandatory share rule could be attributed to changes in the allocation system, whereas others paralleled changes in the composition of our local waiting list.

The results of 1009 kidney transplantations performed in Hungary

Kidney transplantation is a widely used method throughout the world for the treatment of end-stage renal disease. Following the pioneering work of Szeged Medical University Hospital and Miskolc District General Hospital, the first successful kidney transplantation in Hungary was performed at the Department of Transplantation and Surgery at Semmelweis Medical University on November 16, 1973. This patient is still alive with a functioning kidney graft after 21 years. We report herein our review of the global results of Hungarian kidney transplantation. Hungary is a medium-developed country with a population of over 10 million where the gross national product is about 4000 U.S. dollars per person per year. In Hungary there are 49 dialysis centers, 4 immunological laboratories, and 4 transplantation centers.

Is kidney transplantation in sensitized recipients justified?

The objective of the study was to determine if it is justified to use the scarce resources of cadaveric kidneys on HLA-sensitized patients, by reviewing the initial and long-term outcome of cadaveric renal transplantation at Uppsala University Hospital, Sweden. Between January 1988 and December 1994, 402 renal transplantations were performed. The patients were divided into one group of sensitized recipients (peak panel antibody reactivity > or = 25%; n = 84) and a second of non-sensitized recipients (panel reactive antibodies < 25%; n = 318). The groups were comparable in terms of recipient and donor age, gender, HLA-A, -B and -DR mismatches and numbers of diabetics. None of the sensitized patients received a six-antigen-matched kidney. For the non-sensitized group, life table analysis showed a 1-year actuarial graft survival (GS) of 91.8% and a 4-year GS of 84.4%. The corresponding GSs for the sensitized group were 79.9% and 68.7%, respectively (P < 0.01). The statistical significance vanished if patients with primary non-function were excluded. When excluding donors above 55 years of age, kidneys with cold ischemia time above 20 h, and two-antigen (HLA-DR) mismatches, there was no detectable difference between the non-sensitized and sensitized groups at 1-year or 4-year GS. Although there is a statistical significance in GS between non-sensitized and sensitized recipients of a kidney transplant, this does not differ from other risk groups such as diabetics, rheumatoid disease sufferers or elderly recipients. We therefore conclude that the sensitized patient should be accepted on the waiting list for a kidney transplant and that it is worthwhile to do the utmost to transplant this category of patients. Our data indicate that kidney GS in sensitized recipients is more affected by negative risk factors such as older donors, long cold ischemia time and two-antigen HLA-DR mismatch, than the non-sensitized recipient. To improve the outcome, those negative factors should be avoided or reduced.