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Grosso G, Corona D, Mistretta A, Zerbo D, Sinagra N, Giaquinta A, Cimino S, Ekser B, Giuffrida G, Leonardi A, Gula R, Veroux P, Veroux M. Delayed graft function and long-term outcome in kidney transplantation. Transplant Proc 2013; 44:1879-83. [PMID: 22974861 DOI: 10.1016/j.transproceed.2012.06.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- G Grosso
- Department G.F. Ingrassia, section of Hygiene and Public Health, University Hospital of Catania, Catania, Italy
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2
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Nel D, Vogel J, Muller E, Barday Z, Kahn D. Slow early graft function: a neglected entity after renal transplantation. Nephron Clin Pract 2012; 120:c200-4. [PMID: 22922445 DOI: 10.1159/000340032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 05/30/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND After renal transplantation, early graft function (EGF) can be divided into delayed graft function (DGF), slow graft function (SGF) and immediate graft function (IGF). DGF is well documented. However, when evaluating the long-term significance of early function, the literature shows conflicting definitions and inconsistent results. In addition, SGF, a new entity separate to DGF and IGF, is a recent and poorly understood development. AIM To investigate the risk factors for and the impact of poor EGF (PEGF) on long-term outcome. METHODS This retrospective study reviewed the records of local adult patients who underwent renal transplantation at the Groote Schuur Hospital (Cape Town, South Africa) between 2004 and 2008. EGF was divided according to day 5 serum creatinine into IGF (serum creatinine <150 µmol/l), SGF (serum creatinine >150 but <450 µmol/l) and DGF (serum creatinine >450 µmol/l or dialysis in the first week). DGF and SGF together comprised PEGF, with IGF alone representing good EGF (GEGF). RESULTS A total of 121 patients (77 men, 44 women; mean age 39 years, range 14-67) were included in the study. Eighteen were excluded due to nephrectomy (n = 8), death (n = 6) or loss to follow-up (n = 4) within the first year. Analysis of cadaveric donors showed no significant risk factors for PEGF with the exception of cold ischaemic time, which differed significantly between the GEGF and PEGF groups, with means of 12 and 16 h, respectively (p = 0.013). Considering both living and cadaveric grafts, the 1-year estimated glomerular filtration rate (eGFR) was significantly different between IGF and DGF (p = 0.038) as well as between IGF and SGF (p = 0.028), with no significant difference between SGF and DGF (p > 0.05). A comparison of the PEGF and GEGF groups yielded significantly different 1-year eGFR values (60 and 50 ml/min, respectively; p = 0.07), with PEGF also associated with a longer hospital stay (20 vs. 14 days; p = 0.00005). Acute rejection was independently associated with a lower 1-year eGFR (p = 0.028), but in the absence of rejection, GEGF and PEGF remained significantly different with regards to 1-year eGFR (p = 0.024). CONCLUSIONS SGF is not related to IGF but rather to DGF and should thus be regarded as a form of PEGF as opposed to GEGF. PEGF has a worse long-term outcome, and this indicates the need for increased efforts in its prevention and greater attention to its management.
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Affiliation(s)
- D Nel
- Renal Transplant Unit, Department of Surgery, University of Cape Town, and Groote Schuur Hospital, Cape Town, South Africa
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3
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Tyson M, Castle E, Andrews P, Heilman R, Mekeel K, Moss A, Mulligan D, Reddy K. Early graft function after laparoscopically procured living donor kidney transplantation. J Urol 2010; 184:1434-9. [PMID: 20727548 DOI: 10.1016/j.juro.2010.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Indexed: 12/12/2022]
Abstract
PURPOSE We determined predictors of poor early graft function after laparoscopic living donor kidney transplantation. MATERIALS AND METHODS We performed an institutional review board approved review of the living donor kidney transplantation database at our institution. RESULTS Seven of the 510 transplants (1%) were excluded from study due to immediate graft nephrectomy for vascular complications. Of the remaining 503 transplants 48 (9.5%) and 18 (3.6%) had slow and delayed graft function, respectively. Recipient male gender (OR 2.03, 95% CI 1.05-3.91, p = 0.035), black ethnicity (OR 1.59, 95% CI 1.08-2.34, p = 0.020) and donor age (OR 1.03, 95% CI 1.00-1.05, p = 0.021) emerged as independent predictors of poor early graft function in multivariate logistic regression models. Poor early graft function strongly redisposed patients to acute rejection during year 1 (HR 3.43, 95% CI 2.04-5.77, p <0.0001) while grafts from genetically related donors conferred a protective effect (HR 0.40, 95% CI 0.24-0.66, p <0.0001). Three-year death censored allograft survival was lower in the delayed and slow graft function groups than in the immediate function group (89% and 87% vs 98%, p = 0.0068 and 0.0002, respectively). Overall 3-year patient survival was lower in the delayed than in the immediate function group (81% vs 94%, p <0.0001). CONCLUSIONS Male black recipients of laparoscopically procured living donor kidney transplants from donors older than 50 years are at higher risk for poor early graft function, which in turn strongly predicts acute rejection during year 1. This is significant since excellent early graft function confers specific recipient and allograft survival advantages, and may assist physicians in better understanding the various recipient, donor and perioperative parameters that influence clinical outcomes.
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Affiliation(s)
- Mark Tyson
- Dartmouth Medical School, Hanover, New Hampshire, USA.
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4
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Otukesh H, Hosein R, Fereshtehnejad SM, Riahifard A, Basiri A, Simforoosh N, Chalian M, Jazayeri S, Chalian H, Safarzadeh AE, Sharifian M, Hoseini S. Short-term and long-term effects of slow graft function on graft survival in pediatric live donor renal transplantation. Pediatr Transplant 2010; 14:196-202. [PMID: 19496981 DOI: 10.1111/j.1399-3046.2009.01191.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
SGF generally has early and long-term consequences for allograft survival. Limited studies have been performed on SGF and its complications in pediatric renal transplantation. Therefore, 230 children who received transplants between 1985 and 2005 in Labafi Nejad hospital were included in this study. SGF was defined if the serum creatinine level increased, remained unchanged, or decreased by <10% per day immediately after surgery during three consecutive days in the first week after transplantation. The children were divided into two groups: 183 children in group A (non-SGF) and 47 patients in group B (SGF). The impact of SGF on renal function within the first year, long-term graft survival and post-transplantation complications were analyzed and compared using logistic regression model and Kaplan-Meier survival analysis. The incidence of graft failure at the end of follow-up period was significantly more common in SGF group (53.2% vs. 22.4%, p < 0.001). The median survival time was 140.25 (s.e.m. = 19.35) months in group A (non-SGF) and 60 (s.e.m. = 17.90) months in group B (SGF) (p < 0.001). The graft survival rate was 94.9%, 91.9%, 83.9%, 79.2%, and 72% at one, three, five, seven, and twelve yr after transplantation in children without SGF vs. 75.6%, 53.2%, 47.2%, 40% at one, three, five, and seven yr after transplantation in patients with SGF. The results of our study showed that slow graft function could remarkably affect graft survival and worsen both short-term and long-term transplantation outcomes. Thus, the prevention of SGF is one of the most important issues in graft survival improvement.
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Affiliation(s)
- Hasan Otukesh
- Urology and Nephrology Research Center, Labbafi Nejad Hospital, Tehran, Iran.
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5
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Barakat N, Hussein AAM, Abdel-Maboud M, El-shair MA, Mostafa A, Abol-Enein H. Ischaemia-reperfusion injury in renal transplantation: the role of nitric oxide in an experimental rat model. BJU Int 2010; 106:1230-6. [DOI: 10.1111/j.1464-410x.2010.09225.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Liu M, Agreda P, Crow M, Racusen L, Rabb H. Effects of Delayed Rapamycin Treatment on Renal Fibrosis and Inflammation in Experimental Ischemia Reperfusion Injury. Transplant Proc 2009; 41:4065-71. [DOI: 10.1016/j.transproceed.2009.08.083] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 06/27/2009] [Accepted: 08/17/2009] [Indexed: 11/30/2022]
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Messa P, Brezzi B, Cresseri D, Berardinelli L, Poli F, Scalamogna M, Tripepi G, Ponticelli C. Immediate graft function positively affects long-term outcome of renal allografts from older but not from younger donors. Transplant Proc 2007; 38:3377-81. [PMID: 17175276 DOI: 10.1016/j.transproceed.2006.10.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Indexed: 11/17/2022]
Abstract
There is disagreement about the impact of delayed graft function (DGF) on renal allograft outcome. This may depend on several variables including the age of the donor. We evaluated whether DGF could have different effects in recipients of kidneys from donors aged more than 60 years versus well-matched recipients of younger kidney donors. Patients were retrospectively subdivided into 3 groups. Immediate graft function (IGF), DGF without dialysis (DGF-ND), DGF requiring dialysis (DGF-D). DGF-ND and DGF-D occurred more frequently among 198 older than 198 younger donors (P = .016 and P = .044, respectively). The 5-year patient (96% vs 93%) and pure graft (96% vs 89%) survivals were significantly better in younger recipients, while the incidence of acute rejection was similar. After a mean follow-up of 66 +/- 44 months in older donor recipients, the graft survival was significantly better among IGF than patients in the DGF-ND (P = .046) or DGF-D (P = .003) groups. Instead, in younger recipients there was no difference in graft survival between IGD and DGF-ND. Only patients with DGF-D showed a significantly worse outcome. Upon multivariate analysis of older donors, their recipients, showed the pattern of graft function recovery to be the only variable associated with allograft outcome. Instead in younger donor recipients, acute rejection and time on dialysis were the main variables associated with a poor outcome. In older donor recipients, DGF was an independent variable associated with a poor graft outcome. In younger donor recipients, duration of dialysis and rejection were the most important predictors of poor graft outcomes.
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Affiliation(s)
- P Messa
- Nephrology and Dialysis Unit, Ospedale Maggiore-Policlinico-Milan ITA, Milan, Italy
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8
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Azevedo LS, Castro MCR, Monteiro de Carvalho DB, d'Avila DO, Contieri F, Gonçalves RT, Manfro R, Ianhez LE. Incidence of delayed graft function in cadaveric kidney transplants in Brazil: a multicenter analysis. Transplant Proc 2006; 37:2746-7. [PMID: 16182798 DOI: 10.1016/j.transproceed.2005.05.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To evaluate the frequency of delayed graft function (DGF) in kidney transplant centers in Brazil, we sent a questionnaire requesting information on the number of cadaveric donor kidney transplants performed during the years 2000, 2001, and 2002, the number of early nonfunctioning grafts, and the number of patients on dialysis during the first posttransplant week with subsequent recovery. Among all centers performing more than 50 kidney transplants during the last year of evaluation, 6, performing 612 cadaveric kidney transplants during the study period, replied to the questionnaire. Sixty procedures (9.7%) resulted in nonfunctioning grafts, while 312 (55.6%) patients required dialysis during the first Ptx week: 216 (53.9%) in 2000, 189 (62.3%) in 2001, and 216 (51.6%) in 2002. The frequency of DGF during the study period was higher than that noted by several previous foreign studies. To better evaluate the possible causes of this finding, a more extensive and focused study is warranted.
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Affiliation(s)
- L S Azevedo
- Hospital das Clinicas da Faculdade de Medicina da USP
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9
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Renkens JJM, Rouflart MMJ, Christiaans MHL, van den Berg-Loonen EM, van Hooff JP, van Heurn LWE. Outcome of nonheart-beating donor kidneys with prolonged delayed graft function after transplantation. Am J Transplant 2005; 5:2704-9. [PMID: 16212630 DOI: 10.1111/j.1600-6143.2005.01072.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nonheart-beating donor (NHBD) kidneys are frequently associated with delayed graft function (DGF), with a deleterious effect on kidney function and allograft survival. The influence and the duration of DGF on the outcome of NHBD kidneys are assessed. All recipients of an NHBD kidney in the period 1993-2003 were reviewed. Excluded from analysis were patients with primary nonfunction (PNF). One hundred and five patients with a functioning NHBD graft were reviewed: 23 (22%) had immediate function (group 1), 40 (38%) had DGF < or = 2 weeks (group 2), 31 (30%) had DGF 15 days to 4 weeks (group 3) and 11 (10%) had DGF for > 4 weeks (group 4). Creatinine clearance at 3 months was higher in groups 1 and 2 versus group 4 (p = 0.015 and p = 0.006, respectively) and was higher in group 2 versus group 4, at 1 year (p = 0.01). Graft survival was 95%, 98%, 97% and 89%, respectively, at 1 year and 95%, 85%, 77% and 89%, respectively, at 5 years, which was not significantly different. The duration of DGF in NHB kidneys has a negative effect on creatinine clearance, but no effect on graft survival.
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Affiliation(s)
- Jeroen J M Renkens
- Department of Surgery, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
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10
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Weiss-Salz I, Mandel M, Galai N, Nave I, Boner G, Mor E, Nakache R, Simchen E. Factors associated with primary and secondary graft failure following cadaveric kidney transplant*. Clin Transplant 2004; 18:571-5. [PMID: 15344962 DOI: 10.1111/j.1399-0012.2004.00228.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The risk profile for primary renal graft failure is largely unknown because of its inclusion with secondary failures or its exclusion from analysis. This study compares characteristics of the cadaveric transplant recipients who experienced primary failure, secondary failures or survived with a functioning graft for at least 6 months. Medical records of all cadaveric kidney-transplant patients performed in Israel over a 3-yr period 1997-2000 were reviewed. Fisher's exact test and multinomial regression models were used to assess the association of demographic, pre-operative and operative risk factors with the two types of failure outcomes. Of 325 grafts, 54 (16.6%) failed of which half were primary failures. Univariate analysis demonstrated a significant trend of increasing proportion of patients with specific risk factors from the functioning grafts group to the secondary and to the primary graft failure groups. Independent risk factors for primary graft failure included 'surgical complications', 'donor's age > or =60 yr', 'waiting for transplant > or =6 yr', and 'human leukocyte antigen-DR (HLA-DR) mismatch', based on the multivariate model. These factors may reflect the scarcity of organ donations in Israel, which leads to a prolonged waiting time, higher tolerance for HLA-DR mismatches, and utilization of kidneys from elderly donors.
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Affiliation(s)
- Inbal Weiss-Salz
- The Department of Health Services Research, Ministry of Health, Jerusalem, Israel
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11
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Rodrigo E, Ruiz JC, Piñera C, Fernández-Fresnedo G, Escallada R, Palomar R, Cotorruelo JG, Zubimendi JA, Martín de Francisco AL, Arias M. Creatinine reduction ratio on post-transplant day two as criterion in defining delayed graft function. Am J Transplant 2004; 4:1163-9. [PMID: 15196076 DOI: 10.1111/j.1600-6143.2004.00488.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Delayed graft function (DGF) is a common complication after renal transplant, affecting its outcome. A common definition of DGF is the need for dialysis within the first week of transplantation, but this criterion has its drawbacks. We tried to validate an earlier and better defined parameter of DGF based on the creatinine reduction ratio on post-transplant day 2 (CRR2). We analyzed the clinical charts of 291 cadaver kidney recipients to compare the outcome of patients with immediate graft function (IGF), dialyzed patients (D-DGF) and nondialyzed CRR2-defined DGF patients (ND-DGF) and to identify risk factors for D-DGF and ND-DGF. Creatinine reduction ratio on post-transplant day 2 correlates significantly with renal function during the first year. Patients with IGF have significantly better renal function throughout the first year and better graft survival than patients with D-DGF and ND-DGF, while we found no differences either in renal function from days 30-365 or in graft survival between D-DGF and ND-DGF patients. Defining DGF by CRR2 allows an objective and quantitative diagnosis after transplantation and can help to improve post-transplant management. Creatinine reduction ratio on post-transplant day 2 correlates with renal function throughout the first year. The worse survival in the ND-DGF group is an important finding and a major advantage of the CRR2 criterion.
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Affiliation(s)
- Emilio Rodrigo
- Service of Nephrology, Hospital Valdecilla, University of Cantabria, Santander, Spain.
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12
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13
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Delles C, Schlüter C, Wittmann M, Renders L, Riess R, Rösch W, Schott GE, Rupprecht HD, Kunzendorf U. “Very delayed” graft function in a patient after living related kidney transplantation: a case report. Transplant Proc 2004; 36:1377-9. [PMID: 15251336 DOI: 10.1016/j.transproceed.2004.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We report the case of a patient who experienced anuric renal transplant failure for 44 days after living related kidney transplantation. Immunosuppressive and other therapies were carefully adapted to the findings of frequent renal transplant biopsies, which ultimately led to excellent graft function.
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Affiliation(s)
- C Delles
- Department of Medicine IV, University of Erlangen-Nürnberg, Erlangen, Germany.
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14
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Schnuelle P, Yard BA, Braun C, Dominguez-Fernandez E, Schaub M, Birck R, Sturm J, Post S, van der Woude FJ. Impact of donor dopamine on immediate graft function after kidney transplantation. Am J Transplant 2004; 4:419-26. [PMID: 14961996 DOI: 10.1111/j.1600-6143.2004.00331.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Optimizing medical donor management may have a considerable impact on transplantation outcome. This study investigated the effect of donor dopamine on initial graft function in renal allograft recipients, involving 254 consecutive recipients of a cadaver kidney, aged 18-74 years, transplanted between 1990 and 2003. Immunosuppression was based on cyclosporine. Patients were grouped according to donor use of dopamine during intensive care. Delayed graft function (DGF), and serial creatinine concentrations were compared between the groups. Dopamine-treated and -untreated donors were very similar regarding hemodynamics and renal function. Delayed graft function occurred in 47/158 treated and 48/96 untreated kidneys (p = 0.001). Donor dopamine was associated with a more rapid decrease of s-creatinine, which became obvious on the first postoperative day. Of patients in the treated and untreated group, respectively, 81.9% and 65.8% reached a s-creatinine level less than 2 mg/dL during the first month (p = 0.005). Donor dopamine remained predictive of a normalized s-creatinine level [HR 1.71; 95% CI 1.22-2.41] after controlling for confounding factors by multivariate Cox regression. Donor dopamine is associated with improvements of initial graft function after kidney transplantation. The beneficial effect of dopamine is achievable without side-effects for the recipients, and correlates with superior long-term graft survival.
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Affiliation(s)
- P Schnuelle
- Vth Medical Clinic (Department of Nephrology and Endocrinology), University Hospital Mannheim, Mannheim, Germany.
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15
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Barrero Candau R, Pérez Espejo MP, Gentil Govantes MA, Torrubia Romero FJ, Cruz Navarro N, Leal Arenas J, Montañés Medina P. [Analysis of the reasons for non graft initial function in our series of the last eleven years]. Actas Urol Esp 2003; 27:524-9. [PMID: 12938582 DOI: 10.1016/s0210-4806(03)72966-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
UNLABELLED FUNDAMENTAL: [corrected] To know which risk factor of delayed graft function in our patients. MATERIAL AND METHODS We analyzed 469 transplants, 270 had good initial function and 199 had delayed function graft. Variables studies in booth groups were: age, sex and dead cause of donant, type of extraction and place were it was done, implantation side, vases multiple, isquemia times, age and receptor sex, HLA compatibility, retransplant, Ac Anti-VHC, PTH pretransplant, years in waiting list, hiperinmunization, number of transfusion, and type of inmunosupretion. RESULTS Univariant study: significant differences were found in age and dead cause of donant, isquemia times, years in waiting list, hiperinmunization, number of transfusions, and HLA-B incompatibility. Multivariate study: we have significant differences in age of donant, could isquemia time, years in waiting list, cuadruple? Inmunosupretion. CONCLUSIONS Results suggest to short could and revascularization isquemia time as possible, and use less nefrotoxic inmunosupretion pautes in high-risk patients.
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Affiliation(s)
- R Barrero Candau
- Unidad de Trasplante Renal, Servicio de Urología, Servicio de Nefrología H. U. Virgen del Rocío, Sevilla.
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16
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El-Agroudy AE, Bakr MA, Hassan NA, Ismail AM, Ali-El-Dein B, Shehab El-Dein AB, Ghoneim MA. Characteristics of long-term live-donor renal allograft survivors. Am J Nephrol 2003; 23:165-71. [PMID: 12690226 DOI: 10.1159/000070333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2002] [Accepted: 01/30/2003] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Despite the high rate of rejection, allograft failure and patient mortality in the early years of renal allotransplantation, some patients have done-remarkably well. We report here on 62 renal transplant recipients out of 144 patients (43%) who had functioning grafts for more than 15 years (range 15-24 years). MATERIALS Demographic and follow-up data for patients fulfilling the criteria were reviewed. These patients include 43 males and 19 females, with a mean age at transplantation of 27.5 +/- 6.6 years (range 9-43 years), and mean donor age of 30 +/- 8.6 years. The donor source was 8 parents, 49 siblings and 5 unrelated. The main causes of end-stage renal disease were chronic pyelonephritis and chronic glomerulonephritis. Twenty-nine patients were treated with cyclosporine (CsA) while 33 patients were primarily immunosuppressed by steroids and azathioprine. RESULTS Acute rejection episodes occurred in 40 patients (64.3%), out of them 19 patients experienced two or more acute rejection episodes. Univariate analysis showed that recipient and donor age, HLA-DR matching, pre- and post-transplant hypertension, ATN, delayed diuresis and chronic allograft nephropathy are significant risk factors; while recipient age, delayed diuresis and post-transplant hypertension were still significant by multivariate analysis. CONCLUSIONS We concluded that renal transplantation, even in its earliest years and despite the numerous complications, has provided 15 or more years of near-normal life to patients with end-stage renal disease. Certain characteristics of long-term renal allograft survivors include young donor/recipient pairs, good DR matching with less pre- and post-transplantation prevalence of hypertension.
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17
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McTaggart RA, Gottlieb D, Brooks J, Bacchetti P, Roberts JP, Tomlanovich S, Feng S. Sirolimus prolongs recovery from delayed graft function after cadaveric renal transplantation. Am J Transplant 2003; 3:416-23. [PMID: 12694063 DOI: 10.1034/j.1600-6143.2003.00078.x] [Citation(s) in RCA: 154] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Sirolimus, lacking known nephrotoxicity, appeared to be an ideal immunosuppressive agent in the setting of delayed graft function (DGF) after renal transplantation. Coincident with our use of sirolimus however, we noticed prolongation of DGF. To investigate possible causes of prolonged DGF, extensive donor, recipient, transplant, and post-transplant data were collected on 132 consecutive cases of DGF at the University of California, San Francisco between 1/1/97 and 6/30/01. Cox proportional hazards analysis of time to graft function was used in univariate and multivariate models to identify factors that prolong DGF. Sirolimus had a large and highly significant effect on time to graft function (hazard ratio 0.48, p = 0.0007). The hazard ratio indicates that a recipient on sirolimus is half as likely to resolve DGF or twice as likely to remain on dialysis as a recipient without sirolimus. Two other factors had less potent but still significant association with DGF duration: recipient sensitization (hazard ratio 0.66, p = 0.037), and Novartis score (hazard ratio 0.93 per 1.0 increase; p = 0.034). Sirolimus retained its profound negative association with time to graft function in all multivariate models. Because sirolimus appears to prolong DGF, it may not be the optimal immunosuppressive choice in the DGF setting.
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Affiliation(s)
- Ryan A McTaggart
- Department of Surgery, Division of Transplantation, University of California-San Francisco, San Francisco, CA, USA
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18
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Gentil MA, Alcaide MP, Algarra GR, Pereira P, Toro J, González-Roncero F, López M, Bernal G, Mateos J. Impact of delayed graft function on cadaveric kidney transplant outcome. Transplant Proc 2003; 35:689-91. [PMID: 12644095 DOI: 10.1016/s0041-1345(03)00048-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- M A Gentil
- Department of Nephrology, Hospital Universitario Virgen del Rocio, Sevilla, Spain
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Smits JMA, Persijn GG, van Houwelingen HC, Claas FHJ, Frei U. Evaluation of the Eurotransplant Senior Program. The results of the first year. Am J Transplant 2002; 2:664-70. [PMID: 12201369 DOI: 10.1034/j.1600-6143.2002.20713.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED On 4 January 1999, the Eurotransplant Senior Program (ESP) was implemented within the Eurotransplant kidney allocation scheme. PATIENTS AND METHODS Kidneys obtained from donors aged over 65 years of age (65+) were allocated to a selected group of nonimmunized 65+ patients undergoing their first transplant. All transplants were performed locally to minimize cold-ischemic time. All transplants performed with kidneys from elderly donors that were allocated via ESP (ESP group) were compared to transplants performed with similar kidneys allocated via the standard renal allocation system (control group). Initial kidney function and 1-year graft outcome were assessed. RESULTS In 1999, 227 ESP and 102 control transplants were performed. The duration of cold-ischemic time was 12 and 19 h for the ESP and control groups, respectively. No rejection episodes occurred in 60% and 67% of the ESP patients and controls, respectively, while a direct kidney function was observed in 59% of ESP and 49% of control patients. The 1-year graft survival rates, censoring for graft losses due to deaths in patients with functioning grafts, were 86% and 79%, respectively. CONCLUSION An old-for-old renal allocation algorithm can be successful provided that risk factors, such as cold-ischemic time, are reduced.
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Fernández-Juarez G, Marcén R, Pascual J, Teruel JL, Rivera ME, Villafruela JJ, Mampaso F, Burgos FJ, Ortuño J. Prolonged delayed graft function decreases graft survival in transplant patients taking cyclosporine. Transplant Proc 2002; 34:338-9. [PMID: 11959314 DOI: 10.1016/s0041-1345(01)02789-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Grinyo JM. Role of ischemia-reperfusion injury in the development of chronic renal allograft damage. Transplant Proc 2001; 33:3741-2. [PMID: 11750594 DOI: 10.1016/s0041-1345(01)02527-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- J M Grinyo
- Servei de Nefrología, Hospital de Bellvitge, University of Barcelona, Barcelona, Spain.
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Schnuelle P, Berger S, de Boer J, Persijn G, van der Woude FJ. Effects of catecholamine application to brain-dead donors on graft survival in solid organ transplantation. Transplantation 2001; 72:455-63. [PMID: 11502976 DOI: 10.1097/00007890-200108150-00017] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In a recent single-center study, donor use of catecholamines was identified to reduce kidney allograft rejection. This study investigates the effects of donor employment of adrenergic agents on graft survival in a large data base, including liver and heart transplants. METHODS The study was based on the registry of the Eurotransplant International Foundation including 2415 kidney, 755 liver, and 720 heart transplants performed between January 1 and December 31, 1993. A total of 1742 donor record forms referring to the cadaveric donor activities in 1993 were systematically reviewed with regard to employment of adrenergic agents. Catecholamine use was simply coded dichotomously and divided into three strata according to zero, single, and combined application. Multivariate Cox regression including age, gender, cause of brain death, cold ischemia, HLA-mismatching, number of previous transplants, and urgency in liver transplants was applied for statistical analysis. RESULTS Donor employment of catecholamines was associated with increased 4-year graft survival after kidney transplantation (hazard ratio [HR], 0.85; 95% confidence interval [95% CI], 0.74-0.98). The benefit is conferred in a dose-dependent manner and compares in quantitative terms with prospective HLA matching on class I and class II antigens (HR, 0.90; 95% CI, 0.84-0.97). Use of norepinephrine was predictive of initial nonfunction after heart transplantation (HR, 1.66; 95% CI, 1.14-2.43), but did not compromise liver grafts (HR, 0.94; 95% CI, 0.67-1.32). CONCLUSIONS Optimizing the management of brain-dead organ donors, including the possibility of selective administration of adrenergic agents, may provide a major benefit on graft survival without adverse side effects for the recipients. Further investigation on best use of adrenergic drugs, optimum dosage, and duration is warranted.
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Affiliation(s)
- P Schnuelle
- University Hospital Mannheim, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany.
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Hong JC, Kahan BD. A calcineurin antagonist-free induction strategy for immunosuppression in cadaveric kidney transplant recipients at risk for delayed graft function. Transplantation 2001; 71:1320-8. [PMID: 11397971 DOI: 10.1097/00007890-200105150-00025] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Avoidance of calcineurin antagonists for a prolonged period de novo after cadaver donor renal transplantation may facilitate recovery from delayed graft function. The present study examined the benefit of prolonging the calcineurin antagonist-free interval by administering sirolimus (SRL) in combination with chimeric (c-) anti-interleukin-2 receptor (IL-2R) monoclonal antibodies (mAb). METHODS Three contemporaneous but nonrandomized cohorts were compared for acute rejection episodes, patient and graft survival rates, renal function, and adverse reaction profiles for 12 months. Patients with delayed graft function were treated with either SRL/c-IL-2R mAb/prednisone (Pred) with inception of cyclosporine (CsA) once the serum creatinine value was < or =2.5 mg/dl (n=43; group 1) or anti-lymphocyte preparations/Pred/delayed CsA for 7 to 14 days (n=18; group 3). A third cohort displayed immediate function and was treated de novo with CsA/c-IL-2R mAb/Pred (n=21; group 2). RESULTS The incidence of acute rejection episodes was significantly lower among group 1 (16%) compared with groups 2 (52%, P=0.004) or 3 (39%, P=0.05). Among the seven rejection episodes in group 1, six of seven occurred among African-American or retransplant recipients, and a separate cluster of six of seven occurred among patients who displayed SRL trough concentrations < or =9 ng/ml. Furthermore, additional antilymphocyte antibody treatment was required to reverse either steroid-resistant or Banff grades II or III acute rejection episodes among 14%, 55% (P=0.08), and 71% (P=0.03) of patients in each group, respectively. Patient and graft survival rates, as well as mean serum creatinine values, were similar at 12 months among the three groups. However, group 1 patients displayed higher serum cholesterol and triglyceride values, as well as lower hemoglobin, platelet, and leukocyte values compared with the other two groups. CONCLUSION This pilot study suggests that a SRL/c-IL-2R mAb/Pred induction regimen provides excellent acute rejection prophylaxis.
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Affiliation(s)
- J C Hong
- Department of Surgery, The University of Texas Medical School at Houston, 77030, USA
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Michael Cecka J, Shoskes DA, Gjertson DW. Clinical impact of delayed graft function for kidney transplantation. Transplant Rev (Orlando) 2001. [DOI: 10.1016/s0955-470x(05)80001-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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D.H. Koo D, Fuggle SV. Impact of ischemia/reperfusion injury and early inflammatory responses in kidney transplantation. Transplant Rev (Orlando) 2000. [DOI: 10.1053/trre.2000.16754] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mauskopf JA, Richter A, Annemans L, Maclaine G. Cost-effectiveness model of cytomegalovirus management strategies in renal transplantation. Comparing valaciclovir prophylaxis with current practice. PHARMACOECONOMICS 2000; 18:239-251. [PMID: 11147391 DOI: 10.2165/00019053-200018030-00004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) disease may occur following renal transplantation and has been shown to have health and cost consequences in this setting. OBJECTIVE To compare the cost effectiveness of different CMV management strategies for renal transplant patients: prophylaxis with (i) oral valaciclovir or (ii) intravenous ganciclovir; viral testing for CMV followed by (iii) pre-emptive therapy with intravenous ganciclovir or (iv) adjustment of immunosuppression and intensive monitoring; or (v) waiting to treat when CMV disease develops. METHODS A decision-tree model was constructed that included the different management strategies for the donor seropositive/recipient seronegative (D+R-) population. Clinical outcomes for the D+R- population came from clinical trials. Treatment algorithms and costs for CMV syndrome and tissue invasive disease were developed from published literature and UK physician interviews. One- and 2-way sensitivity analyses were performed. STUDY PERSPECTIVE UK National Health Service. RESULTS Prophylaxis with either oral valaciclovir or intravenous ganciclovir dominated (lower costs and fewer cases of CMV disease) the pre-emptive treatment and wait-and-treat strategies. The cost per patient was from 157 Pounds to 438 Pounds higher with oral valaciclovir prophylaxis compared with intravenous ganciclovir prophylaxis and the incremental cost per case of CMV disease avoided with valaciclovir prophylaxis ranged from 2243 Pounds to 8111 Pounds (1996 values). These results are sensitive to the efficacy of intravenous ganciclovir prophylaxis and CMV management costs. CONCLUSIONS For D+R- renal transplant patients, prophylaxis is the dominant (more effective and less costly) management strategy compared with pre-emptive and wait-and-treat strategies. The cost per patient with oral valaciclovir prophylaxis compared with intravenous ganciclovir prophylaxis is slightly higher in our base case scenario, but may be lower under reasonable alternative assumptions.
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Affiliation(s)
- J A Mauskopf
- Research Triangle Institute, Research Triangle Park, North Carolina, USA.
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Madden RL, Mulhern JG, Benedetto BJ, O'Shea MH, Germain MJ, Braden GL, O'Shaughnessy J, Lipkowitz GS. Completely reversed acute rejection is not a significant risk factor for the development of chronic rejection in renal allograft recipients. Transpl Int 2000. [DOI: 10.1111/j.1432-2277.2000.tb01008.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Boom H, Mallat MJ, de Fijter JW, Zwinderman AH, Paul LC. Delayed graft function influences renal function, but not survival. Kidney Int 2000; 58:859-66. [PMID: 10916111 DOI: 10.1046/j.1523-1755.2000.00235.x] [Citation(s) in RCA: 238] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In renal transplantation, the impact of delayed graft function (DGF) on prognosis is controversial. We analyzed the risk factors of DGF and its impact on graft function and prognosis. METHODS Seven hundred thirty-four cadaveric renal transplants performed between 1983 and 1997 were analyzed. DGF was diagnosed when serum creatinine levels increased, remained unchanged, or decreased less than 10% per day in three consecutive days in the first week after transplantation. Creatinine clearances of more or less than 50 or 30 mL/min at one year were used as cut-off points for optimal and suboptimal graft function, respectively. The logistic regression model was used to identify independent risk factor related to DGF and renal function one year after transplantation. The Cox regression model was used to examine the influence of DGF on long-term graft survival. RESULTS Multivariate analysis revealed the following risk factors for DGF: recipient pretransplantation mean arterial blood pressure of less than 100 mm Hg (OR = 2.08, 95% CI, 1.43 to 3.03), female donor to male recipient combination (OR = 1.55, 95% CI, 1.02 to 2.35), donor age of more than 50 years (OR = 2.21, 95% CI, 1.49 to 3.26), cold ischemia time of more than 28 hours (OR = 1.78, 95% CI, 1.19 to 2.63), and peak panel reactive antibodies of more than 50% (OR = 1.7, 95% CI, 1.15 to 2.55). The incidence of DGF was one of the independent risk factors for suboptimal graft function at one year (OR = 1.68, 95% CI, 1.14 to 2.48), together with donor age of more than 50 years (OR = 2.39, 95% CI, 1.61 to 3.57), female donor gender (OR = 1.99, 95% CI, 1.42 to 2.78), the occurrence of acute rejection episodes (OR = 2.66, 95% CI, 1.87 to 3.78), peak panel-reactive antibodies of more than 50% (OR = 1.67, 95% CI, 1.15 to 2.47), and sharing of 1 to 3 versus 4 to 8 cross-reactive antigens groups (OR = 1.65, 95% CI, 1.09 to 2. 49). Moreover, DGF was one of the two independent risk factors for acute rejection episodes, but it had no independent effect on graft survival. CONCLUSION Several risk factors for DGF were identified, of which a low recipient pretransplant mean arterial blood pressure, the transplantation of kidneys from female donors to male recipients, and a prolonged cold ischemia time are potentially avoidable. Although DGF is one of the several risk factors of acute rejection and suboptimal function at one year, it is not independently associated with an increased rate of graft loss.
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Affiliation(s)
- H Boom
- Departments of Nephrology and Medical Statistics, Leiden University Medical Center, The Netherlands.
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McLaren AJ, Fuggle SV, Welsh KI, Gray DW, Morris PJ. Chronic allograft failure in human renal transplantation: a multivariate risk factor analysis. Ann Surg 2000; 232:98-103. [PMID: 10862201 PMCID: PMC1421113 DOI: 10.1097/00000658-200007000-00014] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To identify potential risk factors for the development of chronic renal allograft failure. SUMMARY BACKGROUND DATA Chronic allograft failure (CAF) is the leading cause of late graft loss in renal transplantation. The authors studied the risk factors for the development of CAF in a single center during a period in which a consistent baseline immunosuppression regimen (cyclosporine, azathioprine, and prednisolone) was used. METHODS Data from the Oxford Transplant Center Database were assessed on 862 renal allografts during a 10-year period. Risk factors were identified using multivariate logistic regression analysis. RESULTS Biopsy-proven CAF occurred in 77 patients (9.2%) in the entire group. Multivariate risk factor analysis revealed that early and late acute rejection episodes, proteinuria, and serum triglycerides were significant factors. Acute rejection after 3 months was more important than early acute rejection. Serum triglyceride level and proteinuria at 1 year were both elevated in the CAF group. Male sex provided a protective effect. Serum creatinine levels at 6 months after the transplant were not predictive of the risk of developing CAF. CONCLUSIONS These results from the largest single-center review to date suggest that both antigen-dependent and -independent factors are involved in the pathogenesis of CAF. Acute rejection at all time points has a significant impact on the development of CAF.
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Affiliation(s)
- A J McLaren
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
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31
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Kyllönen LEJ, Salmela KT, Eklund BH, Halme LEH, Höckerstedt KAV, Isoniemi HM, Mäkisalo HJ, Ahonen J. Long-term results of 1047 cadaveric kidney transplantations with special emphasis on initial graft function and rejection. Transpl Int 2000. [DOI: 10.1111/j.1432-2277.2000.tb01051.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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32
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Kyllönen LEJ, Salmela KT, Koskimies SA. The clinical significance of conversion of complement-dependent cytotoxic T cell crossmatch test after renal transplantation. Transpl Int 1999. [DOI: 10.1111/j.1432-2277.1999.tb00769.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schnuelle P, Lorenz D, Mueller A, Trede M, Van Der Woude FJ. Donor catecholamine use reduces acute allograft rejection and improves graft survival after cadaveric renal transplantation. Kidney Int 1999; 56:738-46. [PMID: 10432416 DOI: 10.1046/j.1523-1755.1999.00567.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Epidemiological data implicate that renal transplants from living unrelated donors result in superior survival rates as compared with cadaveric grafts, despite a higher degree of human lymphocyte antigen (HLA) mismatching. We undertook a center-based case control study to identify donor-specific determinants affecting early outcome in cadaveric transplantation. METHODS The study database consisted of 152 consecutive cadaveric renal transplants performed at our center between June 1989 and September 1998. Of these, 24 patients received a retransplant. Donor kidneys were allocated on the basis of prospective HLA matching according to the Eurotransplant rules of organ sharing. Immunosuppressive therapy consisted of a cyclosporine-based triple-drug regimen. In 67 recipients, at least one acute rejection episode occurred during the first month after transplantation. They were taken as cases, and the remaining 85 patients were the controls. Stepwise logistic regression was done on donor-specific explanatory variables obtained from standardized Eurotransplant Necrokidney reports. In a secondary evaluation, the impact on graft survival in long-term follow-up was further measured by applying a Cox regression model. The mean follow-up of all transplant recipients was 3.8 years (SD 2.7 years). RESULTS Donor age [odds ratio (OR) 1.05; 95% CI, 1.02 to 1.08], traumatic brain injury as cause of death (OR 2.75; 95% CI, 1.16 to 6. 52), and mismatch on HLA-DR (OR 3.0; 95% CI, 1.47 to 6.12) were associated with an increased risk of acute rejection, whereas donor use of dopamine (OR 0.22; 95% CI, 0.09 to 0.51) and/or noradrenaline (OR 0.24; 95% CI, 0.10 to 0.60) independently resulted in a significant beneficial effect. In the multivariate Cox regression analysis, both donor treatment with dopamine (HR 0.44; 95% CI, 0.22 to 0.84) and noradrenaline (HR 0.30; 95% CI, 0.10 to 0.87) remained a significant predictor of superior graft survival in long-term follow-up. CONCLUSIONS Our data strongly suggest that the use of catecholamines in postmortal organ donors during intensive care results in immunomodulating effects and improves graft survival in long-term follow-up. These findings may at least partially be explained by down-regulating effects of adrenergic substances on the expression of adhesion molecules (VCAM, E-selectin) in the vessel walls of the graft.
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Affiliation(s)
- P Schnuelle
- Fifth Medical Clinic (Nephrology, Endocrinology), University Hospital Mannheim, Germany.
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Lu CY, Penfield JG, Kielar ML, Vazquez MA, Jeyarajah DR. Hypothesis: is renal allograft rejection initiated by the response to injury sustained during the transplant process? Kidney Int 1999; 55:2157-68. [PMID: 10354265 DOI: 10.1046/j.1523-1755.1999.00491.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Allograft rejection can be caused by numerous factors such as damage to the donor kidney during surgical removal or implantation, injury sustained during the transport process between the donor and recipient, and suboptimal allograft perfusion during the intra- and post-operative period. In cadaveric allografts, damage can occur during cold storage, during the transit stage between donor and recipient, and hemodynamic instability due to the initial damage that caused its removal from the donor (such as brain death or trauma). We hypothesize that rejection requires recognition of this injury in addition to recognition of alloantigens. If indeed injury proves to be one factor in acute rejection episodes, then therapeutic efforts can be made to reduce injury during the transplantation process.
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Affiliation(s)
- C Y Lu
- Division of Nephrology, Department of Internal Medicine, Dallas, Texas, USA.
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Abstract
Factors which influence graft function can be divided into donor factors that affect both kidneys from the same donor equally and postdonor factors that affect each kidney individually. This study assessed the influence of donor factors on graft function early after transplantation. Sixty-one donors who provided kidneys that were transplanted locally into two separate recipients were identified. Recipient creatinine clearance values were estimated from serum creatinine concentrations using a computer model. Pairwise ANOVA showed that donor factors accounted for 35 to 45% of the variation in recipient creatinine clearance from 2 d to 2 wk posttransplantation. Although donor factors had a large aggregate effect during this period, individual factors that influenced graft function could not be identified from analysis of donor medical records. At 6 mo after transplantation, the effect of donor factors on graft function was no longer discernible. These results show that the condition of the donor exerts an important influence on graft function early after transplantation. More detailed study is required to identify individual factors that contribute to this effect.
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Affiliation(s)
- D Suri
- Department of Medicine, Palo Alto Veterans Administration Health Care Service and Stanford University, California 94304, USA
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36
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McLaren AJ, Jassem W, Gray DW, Fuggle SV, Welsh KI, Morris PJ. Delayed graft function: risk factors and the relative effects of early function and acute rejection on long-term survival in cadaveric renal transplantation. Clin Transplant 1999; 13:266-72. [PMID: 10383108 DOI: 10.1034/j.1399-0012.1999.130308.x] [Citation(s) in RCA: 166] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Delayed graft function (DGF) and acute rejection have both been associated with reduced renal allograft survival. In some studies, they have been shown to have an interactive effect. We studied the risk factors for DGF and the relative impact of DGF and rejection on both short- and long-term survival in recipients of cadaveric renal transplants. Data from the Oxford Transplant Centre Database were assessed on 710 cadaver allografts over a 10-yr period, during which time all recipients received cyclosporin-based immunosuppressive protocols. The interaction between DGF and acute rejection was examined using logistic and Cox multivariate regression. Long cold ischaemia time (CIT), sensitisation and older donor age were found to be independent predictors of DGF. The occurrence of DGF resulted in a reduced 5-yr survival (56 vs. 75%). However, the effect of DGF was confined to the first year post-transplant, as there was no significant difference in survival, as measured by half-life (t1/2) of grafts functioning at 1 yr, with DGF alone and a group with good early function (t1/2 = 21.3 vs. 20.0 yr). There was no increase in acute rejection in grafts with DGF. However, the combination of DGF and acute rejection resulted in the worst short-term graft survival (68% at 1 yr, compared to 92.3% in those grafts with no DGF or acute rejection) and this continued over the long term (t1/2 = 10.5 yr). These data suggest that early function is critical to the success of renal transplantation. The effects of DGF are limited to the first year post-transplant. Long-term graft survival may be improved by efforts to limit CITs, particularly for grafts from older donors and sensitised recipients.
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Affiliation(s)
- A J McLaren
- Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK.
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37
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Woo YM, Jardine AG, Clark AF, MacGregor MS, Bowman AW, Macpherson SG, Briggs JD, Junor BJ, McMillan MA, Rodger RS. Early graft function and patient survival following cadaveric renal transplantation. Kidney Int 1999; 55:692-9. [PMID: 9987094 DOI: 10.1046/j.1523-1755.1999.00294.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The influence of events that occur early following renal transplantation such as delayed graft function (DGF) and acute rejection on long-term graft survival has been widely reported, but its association with patient survival has received less attention. METHODS We studied 589 patients who received their first cadaveric transplants between 1984 and 1993, all of whom received cyclosporine-based immunosuppression and who had a median follow-up of seven years. The following factors were identified, and both univariate and multivariate analyses were used to determine their association with long-term patient and graft survival: age, sex, duration of pretransplant dialysis, primary renal disease, immediate graft function (IGF), DGF, primary nonfunction (PNF), acute rejection, and serum creatinine at 3, 6, and 12 months. RESULTS Patients with PNF had a poorer survival than those with DGF and IGF (P = 0.01), but there was no difference in survival between DGF and IGF (P = 0.54). Good graft function (serum creatinine of less than 200 mumol/liter) at three months was predictive of better long-term patient survival (P = 0.03). Other factors associated with poor patient outcome were older age, diabetes, adult polycystic kidney disease, male gender, and acute rejection. Cardiovascular disease was the most common cause of death (51.8%). Good graft function at three months (P < 0.001) and an absence of rejection episodes (P = 0.01) were associated with better graft survival. CONCLUSION Patients with poor levels of early graft function (but not DGF) and those with either acute rejection episodes or early graft loss are at an increased risk of early death. These high-risk groups should be targeted for interventional studies in an attempt to improve patient survival.
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Affiliation(s)
- Y M Woo
- Renal Unit, University of Glasgow, United Kingdom
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Koo DD, Welsh KI, Roake JA, Morris PJ, Fuggle SV. Ischemia/reperfusion injury in human kidney transplantation: an immunohistochemical analysis of changes after reperfusion. THE AMERICAN JOURNAL OF PATHOLOGY 1998; 153:557-66. [PMID: 9708815 PMCID: PMC1852972 DOI: 10.1016/s0002-9440(10)65598-8] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Organs used for transplantation undergo varying degrees of cold ischemia and reperfusion injury after transplantation. In renal transplantation, prolonged cold ischemia is strongly associated with delayed graft function, an event that contributes to inferior graft survival. At present, the pathophysiological changes associated with ischemia/reperfusion injury in clinical renal transplantation are poorly understood. We have performed an immunohistochemical analysis of pre- and postreperfusion biopsies obtained from cadaver (n = 55) and living/related donor (LRD) (n = 11) renal allografts using antibodies to adhesion molecules and leukocyte markers to investigate the intragraft changes after cold preservation and reperfusion. Neutrophil infiltration and P-selectin expression were detected after reperfusion in 29 of 55 (53%) and 24 of 55 (44%) cadaver renal allografts, respectively. In marked contrast, neutrophil infiltration was not observed in LRD allografts, and only 1 of 11 (9%) had an increased level of P-selectin after reperfusion. Immunofluorescent double-staining demonstrated that P-selectin expression resulted from platelet deposition and not from endothelial activation. No statistically significant association was observed between neutrophil infiltration and P-selectin expression in the glomeruli or intertubular capillaries despite the large number of cadaver renal allografts with postreperfusion changes. Neutrophil infiltration into the glomeruli was significantly associated with long cold ischemia times and delayed graft function. Elevated serum creatinine levels at 3 and 6 months after transplantation were also associated with the presence of neutrophils and platelets after reperfusion. Our results suggest that graft function may be influenced by early inflammatory events after reperfusion, which can be targeted for future therapeutic intervention.
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Affiliation(s)
- D D Koo
- Nuffield Department of Surgery and Oxford Transplant Centre, University of Oxford, John Radcliffe Hospital, Headington, United Kingdom
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39
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Abstract
Despite the fact that kidney transplants have routinely been successfully performed for over 30 years there continues to be challenges for the transplant surgeon. These include a static donor pool, growing recipient list, declining number of ideal donors and greater reliance on marginal donors. Innovative methods to deal with these problems continue to be sought.
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Affiliation(s)
- R J Taylor
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
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