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Symptomatic atherosclerotic vascular disease and graft survival in primary kidney transplant recipients – Observational analysis of the united network of organ sharing database. Transpl Immunol 2022; 75:101734. [DOI: 10.1016/j.trim.2022.101734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
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Axelrod DA, Cheungpasitporn W, Bunnapradist S, Schnitzler MA, Xiao H, McAdams-DeMarco M, Caliskan Y, Bae S, Ahn JB, Segev DL, Lam NN, Hess GP, Lentine KL. Posttransplant Diabetes Mellitus and Immunosuppression Selection in Older and Obese Kidney Recipients. Kidney Med 2022; 4:100377. [PMID: 35072042 PMCID: PMC8767140 DOI: 10.1016/j.xkme.2021.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rationale & Objective Posttransplant diabetes mellitus (DM) after kidney transplantation increases morbidity and mortality, particularly in older and obese recipients. We aimed to examine the impact of immunosuppression selection on the risk of posttransplant DM among both older and obese kidney transplant recipients. Study Design Retrospective database study. Setting & Participants Kidney-only transplant recipients aged ≥18 years from 2005 to 2016 in the United States from US Renal Data System records, which integrate Organ Procurement and Transplantation Network/United Network for Organ Sharing records with Medicare billing claims. Exposures Various immunosuppression regimens in the first 3 months after transplant. Outcomes Development of DM >3 months-to-1 year posttransplant. Analytical Approach We used multivariable Cox regression to compare the incidence of posttransplant DM by immunosuppression regimen with the reference regimen of thymoglobulin (TMG) or alemtuzumab (ALEM) with tacrolimus + mycophenolic acid + prednisone using inverse propensity weighting. Results 12.7% of kidney transplant recipients developed posttransplant DM with higher incidences in older (≥55 years vs <55 years: 16.7% vs 10.1%) and obese (body mass index [BMI] ≥ 30 kg/m2 vs BMI < 30 kg/m2: 17.1% vs 10.9%) patients. The incidence of posttransplant DM was lower with steroid avoidance [TMG/ALEM + no prednisone (8.4%) and IL2rAb + no prednisone (9.7%)] than TMG/ALEM with triple therapy (13.1%). After adjustment for donor and recipient characteristics, TMG/ALEM with steroid avoidance was beneficial for all groups [age < 55 years: adjusted HR (aHR), 0.63 (95% confidence interval [CI], 0.54-0.72); age ≥ 55 years: aHR, 0.69 (95% CI, 0.60-0.79); BMI < 30 kg/m2: aHR, 0.69 (95% CI, 0.60-0.78); BMI ≥ 30 kg/m2: aHR, 0.67 (95% CI, 0.57-0.79)]. However, IL2rAb with steroid avoidance was beneficial only for older patients (aHR, 0.76; 95% CI, 0.58-0.99) and for those with BMI < 30 kg/m2 (aHR, 0.63; 95% CI, 0.46-0.87). Limitations Retrospective study and lacked data on immunosuppression levels. Conclusions The beneficial impact of steroid avoidance using tacrolimus on posttransplant DM appears to differ by patient age and induction regimen.
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Affiliation(s)
| | | | | | - Mark A. Schnitzler
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Huiling Xiao
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Sunjae Bae
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - JiYoon B. Ahn
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | | | - Krista L. Lentine
- University of Iowa, Iowa City, Iowa
- Address for Correspondence: Krista L. Lentine, MD, PhD, Saint Louis University Center for Abdominal Transplantation, 1402 S. Grand Blvd., St. Louis, MO, 63104.
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Lentine KL, Cheungpasitporn W, Xiao H, McAdams-DeMarco M, Lam NN, Segev DL, Bae S, Ahn JB, Hess GP, Caliskan Y, Randall HB, Kasiske BL, Schnitzler MA, Axelrod DA. Immunosuppression Regimen Use and Outcomes in Older and Younger Adult Kidney Transplant Recipients: A National Registry Analysis. Transplantation 2021; 105:1840-1849. [PMID: 33214534 PMCID: PMC10576532 DOI: 10.1097/tp.0000000000003547] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although the population of older transplant recipients has increased dramatically, there are limited data describing the impact of immunosuppression regimen choice on outcomes in this recipient group. METHODS National data for US Medicare-insured adult kidney recipients (N = 67 362; 2005-2016) were examined to determine early immunosuppression regimen and associations with acute rejection, death-censored graft failure, and mortality using multivariable regression analysis in younger (18-64 y) and older (>65 y) adults. RESULTS The use of antithymocyte globulin (TMG) or alemtuzumab (ALEM) induction with triple maintenance immunosuppression (reference) was less common in older compared with younger (36.9% versus 47.0%) recipients, as was TMG/ALEM + steroid avoidance (19.2% versus 20.1%) and mammalian target of rapamycin inhibitor (mTORi)-based (6.7% versus 7.7%) treatments. Conversely, older patients were more likely to receive interleukin (IL)-2-receptor antibody (IL2rAb) + triple maintenance (21.1% versus 14.7%), IL2rAb + steroid avoidance (4.1% versus 1.8%), and cyclosporine-based (8.3% versus 6.6%) immunosuppression. Compared with older recipients treated with TMG/ALEM + triple maintenance (reference regimen), those managed with TMG/ALEM + steroid avoidance (adjusted odds ratio [aOR], 0.440.520.61) and IL2rAb + steroid avoidance (aOR, 0.390.550.79) had lower risk of acute rejection. Older patients experienced more death-censored graft failure when managed with Tac + antimetabolite avoidance (adjusted hazard [aHR], 1.411.782.25), mTORi-based (aHR, 1.702.142.71), and cyclosporine-based (aHR, 1.411.782.25) regimens, versus the reference regimen. mTORi-based and cyclosporine-based regimens were associated with increased mortality in both older and younger patients. CONCLUSIONS Lower-intensity immunosuppression regimens (eg, steroid-sparing) appear beneficial for older kidney transplant recipients, while mTORi and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Sunjae Bae
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - JiYoon B. Ahn
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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Cheungpasitporn W, Lentine KL, Tan JC, Kaufmann M, Caliskan Y, Bunnapradist S, Lam NN, Schnitzler M, Axelrod DA. Immunosuppression Considerations for Older Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2021; 8:100-110. [PMID: 34211822 PMCID: PMC8244945 DOI: 10.1007/s40472-021-00321-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW While kidney transplantation improves the long-term survival of the majority of patients with end-stage kidney disease (ESKD), age-related immune dysfunction and associated comorbidities make older transplant recipients more susceptible to complications related to immunosuppression. In this review, we discuss appropriate management of immunosuppressive agents in older adults to minimize adverse events, avoid acute rejection, and maximize patient and graft survival. RECENT FINDINGS Physiological changes associated with senescence can impact drug metabolism and increase the risk of posttransplant infection and malignancy. Clinical trials assessing the safety and efficacy of immunosuppressive agents in older adults are lacking. Recent findings from U.S. transplant registry-based studies suggest that risk-adjusted death-censored graft failure is higher among older patients who received antimetabolite avoidance, mammalian target of rapamycin inhibitor (mTORi)-based, and cyclosporine-based regimens. Observational data suggest that risk-adjusted mortality may be increased in older patients who receive mTORi-based and cyclosporine-based regimens but lower in those managed with T-cell induction and maintenance steroid avoidance/withdrawal. SUMMARY Tailored immunosuppression management to improve patient and graft survival in older transplant recipients is an important goal of personalized medicine. Lower intensity immunosuppression, such as steroid-sparing regimens, appear beneficial whereas mTORi- and cyclosporine-based maintenance are associated with greater potential for adverse effects. Prospective clinical trials to assess the safety and efficacy of immunosuppression agents in older recipients are urgently needed.
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von Moos S, Schalk G, Mueller TF, Laube G. Age-associated decrease in de novo donor-specific antibodies in renal transplant recipients reflects changing humoral immunity. IMMUNITY & AGEING 2019; 16:9. [PMID: 31168309 PMCID: PMC6509825 DOI: 10.1186/s12979-019-0149-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 04/25/2019] [Indexed: 01/09/2023]
Abstract
Background Older age at organ transplantation is associated with increased risk of infection and malignancy but reduced risk of cellular rejection. De novo donor-specific anti-HLA antibodies (dnDSA), are key biomarkers associated with reduced long-term allograft survival, yet there is a lack of data focusing on age-associated changes. Methods Development of dnDSA was restrospectively analyzed in all subjects who received a kidney transplant at the University Hospital Zurich between 01/2006 and 02/2015. Follow up continued until 03/2016. The incidence of dnDSA in different age categories was compared with special focus on the extremes of age: children < 10 years (n = 19) and adults ≥60 years of age (n = 110). Results Incidence of dnDSA gradually decreased with age, with older recipients having a significantly lower risk (HR 0.21, p = 0.0224) compared to pediatric recipients. Cumulative incidence of dnDSA at 2, 5 and 10 years was 6.2, 9.1 and 36% in the older recipients versus 5.3, 29.5 and 47.1% in pediatric recipients. Median time to development of dnDSA was similar (older 720 days, min 356, max 3646 days; children 1086 days, min 42, max 2474 days). Annual incidence was highest within the first two years after transplantation in the older recipients and peaked in years two to four in pediatric recipients. DnDSA were predominantly class II. More dnDSA were observed with cyclosporine as compared to tacrolimus. Conclusion Older kidney transplant recipients have a lower risk of developing dnDSA than pediatric recipients, pointing towards reduced humoral immune reactivity with increasing age. This observation raises the question of adjustment in immunosuppression.
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Affiliation(s)
- Seraina von Moos
- 1Department of Nephrology, University of Zurich and University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Gesa Schalk
- 2Department of Nephrology, University of Zurich and University Children's Hospital, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Thomas F Mueller
- 1Department of Nephrology, University of Zurich and University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Guido Laube
- 2Department of Nephrology, University of Zurich and University Children's Hospital, Steinwiesstrasse 75, 8032 Zurich, Switzerland
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DeLeonibus A, Mitro G, Brooks J, Rees M, Ortiz J. Alemtuzumab Induction Is Associated With Equalization of Graft Outcomes Between Elderly and Nonelderly Kidney Transplant Recipients: A Single-Center Report. EXP CLIN TRANSPLANT 2019; 18:284-291. [PMID: 31050614 DOI: 10.6002/ect.2018.0296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Alemtuzumab (monoclonal anti-CD52 antibody) provides profound lymphocyte depletion and offers numerous advantages as an induction agent. Elderly recipients (> 65 years old) traditionally have inferior posttransplant outcomes versus younger recipients. We investigated short-term and long-term patient and graft survival rates following alemtuzumab induction in elderly recipients. MATERIALS AND METHODS This retrospective analysis, which included 676 renal allograft transplant recipients with alemtuzumab induction, was conducted at the University of Toledo Medical Center between March 2006 and November 2015. We used 2-sided t test, Pearson chi-square test, Fisher exact test, and Cox proportional hazard regressions with 95% confidence interval for analyses. P < .05 was significant. RESULTS Elderly recipients were more likely to receive a kidney from an inferior donor (deceased donor: 82% vs 72.4%; P = .030) and have higher mean kidney donor profile index (46.2 vs 38.4; P = .024) than nonelderly recipients. Elderly recipients were more likely to experience delayed graft function (15.1% vs 8.5%; P = .038). Elderly recipients demonstrated death-censored graft survival (1 year: 95.4% vs 93.1%; 3 years: 88.5% vs 93.3%; 5 years: 83.1% vs 86.4%) and rejection rates (1 year: 19.8% vs 21.2%; 3 years: 22.1% vs 25.3%; 5 years: 23.8% vs 26.9%) similar to nonelderly recipients. Elderly recipients had significantly higher overall mortality rates than recipients under 65 years old (29.8% vs. 13.2%; P = .001). Although 1-year patient survival was similar to younger recipients (94.8% vs 96.3%; P = .431), 3-year (80.0% vs 91.5%; P = .006) and 5-year (72.9% vs 86.2%; P = .19) rates were significantly decreased in elderly recipients. CONCLUSIONS Elderly age is not a predictor of rejection or death-censored graft loss in individuals who receive alemtuzumab induction. Despite elevated overall mortality, elderly recipients induced with alemtuzumab demonstrated rejection, graft, and short-term patient survival rates similar to younger recipients.
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Affiliation(s)
- Anthony DeLeonibus
- From the College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio, USA
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Sayin B, Ozdemir A, Ayvazoglu Soy EH, Kirnap M, Akdur A, Moray G, Haberal M. Over 5 Years of Excellent Graft Kidney Function Determinants: Baskent University Experience. EXP CLIN TRANSPLANT 2019; 17:75-77. [PMID: 30777527 DOI: 10.6002/ect.mesot2018.o12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Kidney graft survival may be evaluated according to the duration of time with a functioning graft. Survival alone may not satisfy expectations of a successful kidney transplant if the graft kidney does not show excellent function. In our study, we analyzed the characteristics of kidney transplant recipients who showed excellent graft function after 5 to 10 years of follow-up in an aim to improve graft survival and to ensure the best kidney function in the long term. MATERIALS AND METHODS We retrospectively evaluated graft function and demographic characteristics of 288 patients who underwent kidney transplant between January 2008 and December 2012. RESULTS We found that 149 patients (51.7%) had excellent graft function, 88 patients (30.5%) had a functioning graft with a glomerular filtration rate lower than 60 mL/min and/or had signs of graft kidney dysfunction, and 45 patients (15.6%) experienced graft loss. Of 288 kidney transplant recipients enrolled in the study, most were male (56%), and mean age was 30.47 ± 14.36 years at time of transplant. Median time on dialysis was 39.09 ± 59.30 months. The overall graft survival rate in the patient group was 82.2% after 5 to 10 years of follow-up. Multivariate analysis showed that excellent graft survival predictors beyond 5 years were negative panel reactive antibody levels, lower donor age, shorter duration on dialysis, absence of acute rejection episodes, 3 or less HLA mismatches, lower immunosuppressive levels, and lower recipient age at transplant. CONCLUSIONS Lower panel reactive antibody levels, lower donor age, shorter duration on dialysis, absence of acute rejection episodes, 3 or less HLA mismatches, and lower recipient age at transplant are major determinants of excellent graft survival in our kidney transplant recipients.
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Affiliation(s)
- Burak Sayin
- From the Department of Nephrology, Baskent University Ankara Hospital, Ankara, Turkey
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Lemoine M, Titeca Beauport D, Lobbedez T, Choukroun G, Hurault de Ligny B, Hazzan M, Guerrot D, Bertrand D. Risk Factors for Early Graft Failure and Death After Kidney Transplantation in Recipients Older Than 70 Years. Kidney Int Rep 2019; 4:656-666. [PMID: 31080920 PMCID: PMC6506713 DOI: 10.1016/j.ekir.2019.01.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 01/23/2023] Open
Abstract
Introduction Although kidney transplantation carries a survival benefit compared with dialysis, mortality, especially the first year after transplantation, is high in recipients older than 70. The aim of this study was to evaluate early death and graft failure, and to determine the risk factors associated with these events in this specific population. Methods All patients older than 70 years who received a kidney transplant between January 2000 and December 2014 in the North-West of France were included (n = 171). Baseline characteristics and outcomes after transplantation were studied. Kaplan-Meier analysis was performed to assess patient and graft survival, and Cox regression analysis to evaluate risk factors for graft failure and patient death. Results The mean recipient age was 73.3 ± 2.5 years. Death-censored graft survival at 1, 3, and 5 years were 82.6%, 78.7%, and 75.4%, respectively. Patient survival at 1, 3, and 5 years was 90.1%, 82.5%, and 68.1%, respectively. One year after transplantation, 17 patients (9.9%) were dead, mainly from infectious (58.5%) or cardiovascular disease (29.4%). According to the Cox multivariate analysis, the independent risk factors for death or graft failure during the first year were arrhythmia (odds ratio [OR] 2.26; 95% confidence interval [CI] 1.08–4.8), left-ventricular ejection fraction (LVEF) under 56% (OR 2.38; 95% CI 1.18–4.83), human leucocyte antigen (HLA) antibodies (OR 2.1; 95% CI 1.04–4.2), deceased donor from cardiovascular cause (OR 5.18; 95% CI 1.22–6.3), and acute rejection (OR 2.77; 95% CI 1.2–6.3). Conclusion In kidney transplant recipients older than 70 years, cardiac evaluation and immunosuppression optimization seem to be crucial to improve short-term patient and graft survival.
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Affiliation(s)
- Mathilde Lemoine
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
| | | | - Thierry Lobbedez
- Department of Nephrology, Centre Hospitalo-Universitaire de Caen, Caen, France
| | - Gabriel Choukroun
- Department of Nephrology, Centre Hospitalo-Universitaire d'Amiens, Amiens, France
| | | | - Marc Hazzan
- Department of Nephrology, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Dominique Guerrot
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France.,INSERM U1096, Rouen, France
| | - Dominique Bertrand
- Department of Nephrology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
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9
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[Focusing on kidney transplantation in the elderly]. Nephrol Ther 2017; 14:71-80. [PMID: 29173815 DOI: 10.1016/j.nephro.2017.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/14/2017] [Accepted: 06/25/2017] [Indexed: 02/06/2023]
Abstract
Due to the increase in life expectancy and the ageing of end-stage renal disease patients, the number of patients older than 65 years receiving a kidney transplant has been continuously growing over the last fifteen years. The benefits of renal transplantation compared to dialysis in terms of survival and quality of life have been shown in selected recipients over 65, or 70 years. However, the age remains the main limiting factor for the access to the waiting list, and the reluctance of the clinicians can be explained by the multiple comorbidities of these candidates, their limited life expectancy or the shortage of grafts. The challenge is to select the candidates who can benefit from renal transplantation, thanks to rigorous cardiovascular and neoplastic evaluation before enrolment and by taking into account the specific characteristics of elderly patients. The living donor appears to be the ideal option for elderly recipients, the alternative being the extended criteria donor, allowing waiting times to be limited. The choice of immunosuppressive therapy is also crucial in these patients at high risk of infectious and cardiovascular complications in whom the occurrence of acute rejection can have severe consequences. There are currently no specific recommendations for immunosuppression in elderly recipients, and we would need large-scale randomized studies to improve the prognosis of renal transplantation in this population.
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Vimal M, Chacko MP, Basu G, Daniel D. Correlation of Pretransplant Donor-specific Antibody Assay Using Luminex Crossmatch with Graft Outcome in Renal Transplant Patients. Indian J Nephrol 2017; 27:347-352. [PMID: 28904429 PMCID: PMC5590410 DOI: 10.4103/ijn.ijn_132_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The significance of pretransplant anti-human leukocyte antigen antibody levels that are detectable by more sensitive platforms (including the Luminex platform) yet undetected by complement-dependent cytotoxicity (CDC) assay remains unclear. The aim of this study was to determine the clinical significance of the donor-specific antibody (DSA) assay Luminex crossmatch and its impact on short-term renal graft outcome such as acute rejections, graft survival, and graft function. The results of pretransplant DSA-lymphocyte crossmatching (LCXM) assay in 126 renal allograft recipients whose CDCs crossmatches were negative were retrospectively analyzed for correlation with posttransplant outcomes. Of the 126 recipients, 32 (25.4%) had pretransplant DSA positive. Statistically significant association was found between DSA-LCXM positivity with 14th day estimated glomerular filtration rate (eGFR) (P = 0.05), DSA Class I with 3rd (P = 0.014) and 6th month (P = 0.02) eGFR, DSA Class II with 14th day (P = 0.06) and 1st month (P = 0.10) eGFR, mean fluorescent intensity (MFI) DSA with 7th day (P = 0.08) and 14th day (P = 0.09) eGFR, and maximum MFI DSA with 7th day eGFR (P = 0.09). The posttransplant eGFR was higher at various time intervals in DSA-LCXM-negative patients as compared to DSA-positive patients. However, pretransplant DSA-LCXM results did not predict the rejection episodes, graft loss, and 1-year posttransplant 24 h urine protein. Pretransplant DSA detected by LCXM in patients with a negative CDC does not predict adverse short-term outcomes. However, the difference in posttransplant eGFR supports further investigation in long-term effects.
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Affiliation(s)
- M Vimal
- Department of Pathology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, Tamil Nadu, India
| | - M P Chacko
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - G Basu
- Central Northern Adelaide Renal and Transplant Service, Royal Adelaide Hospital, Australia
| | - D Daniel
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
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Selvey LA, Lim WH, Boan P, Swaminathan R, Slimings C, Harrison AE, Chakera A. Cytomegalovirus viraemia and mortality in renal transplant recipients in the era of antiviral prophylaxis. Lessons from the western Australian experience. BMC Infect Dis 2017; 17:501. [PMID: 28716027 PMCID: PMC5514475 DOI: 10.1186/s12879-017-2599-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 07/11/2017] [Indexed: 12/12/2022] Open
Abstract
Background Cytomegalovirus (CMV) establishes a lifelong infection that is efficiently controlled by the immune system; this infection can be reactivated in case of immunosuppression such as following solid organ transplantation. CMV viraemia has been associated with CMV disease, as well as increased mortality and allograft failure. Prophylactic antiviral medication is routinely given to renal transplant recipients, but reactivation during and following cessation of antiviral prophylaxis is known to occur. The aims of this study were to assess the incidence, timing and impact of CMV viraemia in renal transplant recipients and to determine the level of viraemia associated with adverse clinical outcomes. Methods Data from all adult (18 years and over) Western Australian renal transplant recipients transplanted between 1 January 2007 and 31 December 2012 were obtained from the Australia and New Zealand Dialysis and Transplant registry and were supplemented with data obtained from clinical records. Potential risk factors for detectable CMV viraemia (≥600 copies/ml) and all-cause mortality were assessed using univariable analysis and Cox Proportional Hazards Regression. Results There were 438 transplants performed on 435 recipients. The following factors increased the risk of CMV viraemia with viral loads ≥600 copies/ml: Donor positive/Recipient negative status; receiving a graft from a deceased donor; and receiving a graft from a donor aged 60 years and over. CMV viraemia with viral loads ≥656 copies/ml was a risk factor for death following renal transplantation, as was being aged 65 years and above at transplant, being Aboriginal and having vascular disease. Importantly 37% of the episodes of CMV viraemia with viral loads ≥656 copies/ml occurred while the patients were expected to be on CMV prophylaxis. Conclusions CMV viraemia (≥656 copies/ml) was associated with all-cause mortality in multivariable analysis, and CMV viraemia at ≥656 copies/ml commonly occurred during the period when renal transplant recipients were expected to be on antiviral prophylaxis. A greater vigilance in monitoring CMV levels if antiviral prophylaxis is stopped prematurely or poor patient compliance is suspected could protect some renal transplant recipients from adverse outcomes such as premature mortality.
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Affiliation(s)
- Linda A Selvey
- School of Public Health, Curtin University, Bentley, WA, Australia.
| | - Wai H Lim
- ANZDATA Registry, Adelaide, Australia.,Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, WA, Australia
| | - Ramyasuda Swaminathan
- Department of Nephrology and Renal Transplantation, Fiona Stanley Hospital, Murdoch, WA, Australia
| | | | - Amy E Harrison
- School of Public Health, Curtin University, Bentley, WA, Australia
| | - Aron Chakera
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Translational Renal Research Group, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, WA, Australia
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Abstract
CD8+ T cells play a cardinal feature in response to alloantigens and are able to generate effector/memory T cells independently from CD4+ T cells. To investigate the impact of aging on CD8 T cells, we used a fully mismatched mouse skin transplant model. Our findings showed a prolonged allograft survival in older recipients associated with a significant increase of CD4+ and CD8+ CD44high CD62Llow effector/memory T cells and a reduced systemic IFNγ production. When reconstituting young CBA Rag-1 mice that lack mature T and B cells with old CD8+ T cells expressing clonal anti-H2K T cell receptor (TCR) alloreactive for MHC I, graft survival was significantly prolonged and comparable to those receiving young CD8+ T cells. Moreover, our data showed that reduced systemic IFNγ levels observed in old recipients had been linked to a compromised expression of the IL-2R β subunit (CD122) by old CD8+ T cells. In addition, we observed an impaired IFNγ production on IL-2 receptor activation. At the same time, gene profiling analysis of old CD8 T cells demonstrated reduced chemokine ligand-3 and CD40L expression that resulted in compromised CD8+ T cell/dendritic cell communication, leading to impaired migratory and phagocytic activity of CD11c cells.Collectively, our study demonstrated that aging delays allograft rejection. CD8 T cells play a critical role in this process linked to a compromised production of IFNγ, in addition to a defective IL-2 receptor signaling machinery and a defective communication between CD8 T cells and dendritic cells.
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13
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Pinter J, Hanson CS, Craig JC, Chapman JR, Budde K, Halleck F, Tong A. 'I feel stronger and younger all the time'-perspectives of elderly kidney transplant recipients: thematic synthesis of qualitative research. Nephrol Dial Transplant 2016; 31:1531-40. [PMID: 27333617 DOI: 10.1093/ndt/gfv463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 12/29/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Kidney transplantation offers improved survival and quality of life to an increasing number of elderly patients with end-stage kidney disease. However, elderly kidney transplant recipients may face unique challenges due to a higher burden of comorbidity, greater cumulative risk of immunosuppression-related complications and increasing frailty. We aimed to describe the perspectives of elderly kidney transplant recipients. METHODS Electronic databases were searched to April 2015. Qualitative studies were eligible if they reported views from elderly kidney transplant recipients (≥60 years). Thematic synthesis was used to analyse the findings. RESULTS Twenty-one studies involving >116 recipients were included. We identified seven themes. 'Regaining strength and vitality' meant valuing the physical and psychosocial improvements in daily functioning and life participation. 'Extending life' was the willingness to accept any organ, including extended criteria kidneys, to prolong survival. 'Debt of gratitude' entailed conscious appreciation toward their donor while knowing they were unable to repay their sacrifice. 'Moral responsibility to maintain health' motivated adherence to medication and lifestyle recommendations out of an ethical duty to protect their gift for graft survival. 'Unabating and worsening forgetfulness' hindered self-management. 'Disillusionment with side effects and complications' reflected disappointment and exasperation with the unintended consequences of medications. 'Finality of treatment option' was an acute awareness that the current transplant may be their last. CONCLUSIONS Kidney transplantation was perceived to slow and even reverse the experience of aging among elderly recipients, especially compared with dialysis. However, some were frustrated over persistent limitations after transplant, struggled with the burden of medication side effects and worried about a possible return to dialysis if the transplant failed. Clarifying patient expectations of transplantation, providing support to alleviate the debilitating impacts of immunosuppression and addressing fears about deteriorating health and graft failure may improve satisfaction and outcomes in elderly kidney transplant recipients.
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Affiliation(s)
- Jule Pinter
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Klemens Budde
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
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14
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Roller-Wirnsberger RE, Wirnsberger GH. [Management of older patients following solid organ transplantation]. Z Gerontol Geriatr 2015; 49:59-68. [PMID: 26650035 DOI: 10.1007/s00391-015-0993-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
Abstract
Due to a continuous expansion of transplantation registers, such as the old-for-old program in Europe, the number of older patients treated with transplantation is increasing. At the same time the perioperative survival rates show a clear increase even in this patient collective (older than 65 years); therefore, the probability that the care of older patients after organ transplantation will be undertaken in the routine practice increases. This article describes the medical characteristics of older patients following organ transplantation. Special emphasis is placed on the management of accompanying diseases as well as possible side effects and interactions of immunosuppressive therapy.
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Affiliation(s)
| | - Gerhard Hubert Wirnsberger
- Universitätsklinik für Innere Medizin/Geriatrie, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
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15
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Mazanowska O, Zabińska M, Kościelska-Kasprzak K, Kamińska D, Banasik M, Krajewska M, Madziarska K, Zmonarski SC, Chudoba P, Biecek P, Boratyńska M, Klinger M. Advanced age of renal transplant recipients correlates with increased plasma concentrations of interleukin-6, chemokine ligand 2 (CCL2), and matrix metalloproteinase 2, and urine concentrations of CCL2 and tissue inhibitor of metalloproteinase 1. Transplant Proc 2015; 46:2640-3. [PMID: 25380884 DOI: 10.1016/j.transproceed.2014.08.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Advanced age of renal transplant recipients (RTRs) has a negative impact on kidney allograft survival through impaired extracellular matrix degradation by the matrix metalloproteinases/tissue inhibitors of metalloproteinases (MMPs/TIMPs) system. Moreover, older RTRs are at risk of smoldering inflammation, known as inflammaging. AIM The aim of the study was to assess the impact of a RTR's age on plasma and urine concentrations of interleukin 6 (IL-6), chemokine ligand 2 (CCL2), and the MMPs/TIMPs system. MATERIAL AND METHODS One hundred fifty adult RTRs (8.7% ≥ 65 years) and 37 adult healthy volunteers (10.8% ≥ 65 years) were enrolled in the study. The studied factors (IL-6, CCL2, MMP-2, MMP-9, TIMP-1 and TIMP-2) were quantified in plasma and urine with enzyme-linked immunosorbent assay. The Mann-Whitney U test and Spearman's (rs) rank correlation were applied, and differences with a P < .05 were considered statistically significant. RESULTS There was a weak but significant positive correlation between increasing RTR's age and plasma IL-6 (rs = 0.18, P = .028), CCL2 (rs = 0.27, P = .001), and MMP-2 (rs = 0.20, P = .017), as well as urine CCL2 (rs = 0.16, P = 0.050) and TIMP-1 (rs = 0.20, P = .014) concentrations. CONCLUSIONS Advancing age of RTRs correlates with increasing plasma IL-6 and CCL2 concentrations, reflecting smoldering inflammation (known as inflammaging) and alterations in MMPs/TIMPs profiles, especially with increased plasma MMP-2 and urine TIMP-1 concentrations.
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Affiliation(s)
- O Mazanowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland.
| | - M Zabińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - K Kościelska-Kasprzak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - D Kamińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - M Banasik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - M Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - K Madziarska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - S C Zmonarski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - P Chudoba
- Department of Vascular, General and Transplant Surgery, Wroclaw Medical University, Poland
| | - P Biecek
- Interdisciplinary Centre for Mathematical and Computational Modelling, University of Warsaw, (ICM UW), Poland
| | - M Boratyńska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - M Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
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16
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Dreyer GJ, Hemke AC, Reinders MEJ, de Fijter JW. Transplanting the elderly: Balancing aging with histocompatibility. Transplant Rev (Orlando) 2015; 29:205-11. [PMID: 26411382 DOI: 10.1016/j.trre.2015.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/30/2015] [Accepted: 08/30/2015] [Indexed: 01/10/2023]
Abstract
Across the world, the proportions of senior citizens (i.e. those ≥65years) increase rapidly and are predicted to constitute over 25% of the general population by 2050. In 2012 already 48% of the population with end stage renal disease (ESRD) was aged 65years or older. Transplantation is considered the preferred treatment option for ESRD offering survival advantage over long-term dialysis in the majority of patients. Indeed, acceptable outcomes have been documented for selected patients over the age of 70years or even cases over 80years. The reality of organ scarcity and prolonged waiting times for a deceased donor kidney transplantation, however, indicate that at best 50% of the selected elderly may have realistic expectations to receive a timely transplant offer. By choice or medical selection, access to transplantation also decreases with increasing age. In order to expedite the chance for elderly to receive a kidney transplant dedicated allocation systems have been developed. These allocation systems, like the Eurotransplant Senior Program (ESP), support preferential local allocation of kidneys from older donors to older patients in order to match recipient and graft life while disregarding histocompatibility for HLA antigens. The consequence has been more acute rejection episodes and an increase in immunosuppressive load. In the elderly, the most common cause of graft loss is death with functioning graft and death from infectious diseases is one of the dominant causes. The Eurotransplant Senior DR-compatible Program (ESDP) was designed to further improve the perspective of successful transplantation in the elderly in terms of life and quality of life by re-introducing matching criteria for HLA-DR in the old-for-old algorithm.
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Affiliation(s)
- G J Dreyer
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - A C Hemke
- Nefrovision/Renine, Dutch Transplant Foundation, Leiden, The Netherlands
| | - M E J Reinders
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - J W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.
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17
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Shi YY, Hesselink DA, van Gelder T. Pharmacokinetics and pharmacodynamics of immunosuppressive drugs in elderly kidney transplant recipients. Transplant Rev (Orlando) 2015; 29:224-30. [PMID: 26048322 DOI: 10.1016/j.trre.2015.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 02/05/2023]
Abstract
Elderly patients are a fast growing population among transplant recipients over the past decades. Both the innate and adaptive immune reactivity decrease with age, which is believed to contribute to the decreased incidence of acute rejection and increased infectious death rate in elderly transplant recipients. In contrast to recipient age, donor age is associated with a higher incidence of acute rejection. Pharmacokinetic studies in renal transplant recipients show that CNI troughs are >5% higher in elderly compared to younger patients given the same dose normalized by body weight. This may impact the starting dose of tacrolimus and cyclosporine. Possibly in elderly patients the intracellular (in lymphocyte) concentrations are relatively high in relation to the whole blood concentration, resulting in a stronger pharmacodynamic effect at the same whole blood trough concentration. For cyclosporine this has been shown, but it is not clear if the same is true for other immunosuppressive drugs. Pharmacodynamic studies have compared the inhibition of target enzymes, or more downstream effects of immunosuppressive drugs, in younger and older patients. Measurement of nuclear factor of activated T-cell (NFAT)-regulated gene expression (RGE), a pharmacodynamic read-out of CNI, is a promising biomarker of immunosuppression. Low levels of NFAT RGE are associated with increased risk of infection and non-melanoma skin cancer in elderly patients. Clinical trials to evaluate the safety and efficacy of immunosuppression regimens in this specific patient population, which is underrepresented in published trials, are lacking. More studies in elderly patients are needed to investigate the impact of age on the pharmacokinetics or pharmacodynamics of immunosuppressive drugs, and to decide on the optimal regimen and target levels for elderly transplant recipients.
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Affiliation(s)
- Yun-Ying Shi
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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18
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Pieloch D, Dombrovskiy V, Osband AJ, DebRoy M, Mann RA, Fernandez S, Mondal Z, Laskow DA. The Kidney Transplant Morbidity Index (KTMI): A Simple Prognostic Tool to Help Determine Outcome Risk in Kidney Transplant Candidates. Prog Transplant 2015; 25:70-6. [DOI: 10.7182/pit2015462] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background The Kidney Transplant Morbidity Index (KTMI) is a novel prognostic morbidity index to help determine the impact that pretransplant comorbid conditions have on transplant outcome. Objective To use national data to validate the KTMI. Design Retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. Setting and Participants The study sample consisted of 100 261 adult patients who received a kidney transplant between 2000 and 2008. Main Outcome Measure Kaplan-Meier survival curves were used to demonstrate 3-year graft and patient survival for each KTMI score. Cox proportional hazards regression models were created to determine hazards for 3-year graft failure and patient mortality for each KTMI score. Results A sequential decrease in graft survival (0 = 91.2%, 1 = 88.2%, 2 = 85.4%, 3 = 81.7%, 4 = 77.8%, 5 = 74.0%, 6 = 69.8%, and ≥7 = 68.7) and patient survival (0 = 98.2%, 1 = 96.6%, 2 = 93.7%, 3 = 89.7%, 4 = 84.8%, 5 = 80.8%, 6 = 76.0%, and ≥7 = 74.7%) is seen as KTMI scores increase. The differences in graft and patient survival between KTMI scores are all significant ( P < .001) except between 6 and ≥7. Multivariate regression analysis reveals that KTMI is an independent predictor of higher graft failure and patient mortality rates and that risk increases as KTMI scores increase. Conclusion The KTMI strongly predicts graft and patient survival by using pretransplant comorbid conditions; therefore, this easy-to-use tool can aid in determining outcome risk and transplant candidacy before listing, particularly in candidates with multiple comorbid conditions.
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Affiliation(s)
- Daniel Pieloch
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
| | - Viktor Dombrovskiy
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
| | - Adena J. Osband
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
| | - Meelie DebRoy
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
| | - Richard A. Mann
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
| | - Sonalis Fernandez
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
| | - Zahidul Mondal
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
| | - David A. Laskow
- Robert Wood Johnson University Hospital (DP, AJO, MD, RAM, SF, ZM, DAL) and Medical School (VD, AJO, MD, RAM, SF, ZM, DAL) New Brunswick, New Jersey
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19
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Fujiwara T, Tanaka S, Okada K, Namba K, Yamamoto H, Teruta S, Matsuda H. Impact of recipient aging on kidney allograft in living donor transplantation. Transplant Proc 2014; 46:454-6. [PMID: 24655986 DOI: 10.1016/j.transproceed.2013.10.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 10/02/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aging of recipients is becoming increasingly important in organ transplantation. PATIENTS AND METHODS We analyzed outcomes in 215 consecutive adult kidney transplant recipients from living donors who underwent transplantation at our center between November 1988 and March 2012. The list of recipients was divided by age at transplantation into those aged 16 to 29 years (n = 61), 30 to 39 years (n = 69), 40 to 49 years (n = 33), 50 to 59 years (n = 29), and those 60 years or older (elderly group, n = 23). Cox proportional hazards analysis was used to calculate the relative risk (RR) of patient death and graft failure, with recipient age included as a continuous variable. RESULTS Univariate analysis showed that recipient age did not significantly affect the risk of graft failure, either uncensored (RR = 1.01, P = .312) or censored for death (RR = 0.993, P = .587). Multivariate analysis, however, showed that recipient age was an independent risk factor for patient death (RR = 1.053, P = .024). The patient survival rate was the poorest in elderly group (87.0%, P = .036), whereas the both death uncensored and censored graft survival rates of this group were 78.1% and 91.3%, respectively, comparable to those of other age groups (P = .567 and P = .696). Mean estimated glomerular filtration rate (eGFR) 1 year after transplantation was lower in elderly groups than in other groups (46.1 ± 13.0 mL/min/1.73 m(2), P = .014). However, mean δeGFR, defined as the difference between pretransplantation eGFR of the donor and eGFR of the recipient 1 year post-transplantation, did not differ significantly among age groups. CONCLUSION Recipient age did not affect allograft deterioration in living donor kidney transplantation, although it was an independent risk factor of recipient death.
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Affiliation(s)
- T Fujiwara
- Department of Surgery, National Hospital Organization Okayama Medical Center.), Okayama, Japan.
| | - S Tanaka
- Department of Surgery, National Hospital Organization Okayama Medical Center.), Okayama, Japan
| | - K Okada
- Department of Surgery, National Hospital Organization Okayama Medical Center.), Okayama, Japan
| | - K Namba
- Department of Surgery, National Hospital Organization Okayama Medical Center.), Okayama, Japan
| | - H Yamamoto
- Department of Surgery, National Hospital Organization Okayama Medical Center.), Okayama, Japan
| | - S Teruta
- Department of Surgery, National Hospital Organization Okayama Medical Center.), Okayama, Japan
| | - H Matsuda
- Department of Surgery, Saiwaicho Memorial Hospital, Okayama, Japan
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20
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Kim JI, Stott RT, Soohoo J, Lee KM, Zhao G, Yeh H, Deng S, Markmann JF. Elevated levels of interferon-γ production by memory T cells do not promote transplant tolerance resistance in aged recipients. PLoS One 2013; 8:e82856. [PMID: 24340063 PMCID: PMC3858330 DOI: 10.1371/journal.pone.0082856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/28/2013] [Indexed: 11/18/2022] Open
Abstract
Immunosenescence predisposes the elderly to infectious and autoimmune diseases and impairs the response to vaccination. We recently demonstrated that ageing also impedes development of transplantation tolerance. Unlike their young counterparts (8-12 weeks of age) aged male recipients (greater than 12 months of age) transplanted with a full MHC-mismatched heart are resistant to tolerance mediated by anti-CD45RB antibody. Surprisingly, either chemical or surgical castration restored tolerance induction to levels observed using young recipients. Based on the strong impact of endocrine modulation on transplant tolerance, we explored the impact of ageing and castration on the immune system. Here we report a significant increase in the percentage of T cells that produce interferon-γ (IFN-γ) in aged male versus young male animals and that the overall increase in IFN-γ production was due to an expansion of IFN-γ-producing memory T cells in aged animals. In contrast to IFN-γ production, we did not observe differences in IL-10 expression in young versus old male mice. We hypothesized that endocrine modulation would diminish the elevated levels of IFN-γ production in aged recipients, however, we observed no significant reduction in the percentage of IFN-γ+ T cells upon castration. Furthermore, we neutralized interferon-γ by antibody and did not observe an effect on graft survival. We conclude that while elevated levels of interferon-γ serves as a marker of tolerance resistance in aged mice, other as yet to be identified factors are responsible for its cause. Defining these factors may be relevant to design of tolerogenic strategies for aged recipients.
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Affiliation(s)
- James I. Kim
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ryan T. Stott
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Julie Soohoo
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kang Mi Lee
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Gaoping Zhao
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, Sichuan Provincial People’s Hospital and Sichuan Academy of Medical Sciences, Chengdu, Sichuan Province, China
| | - Heidi Yeh
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Shaoping Deng
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, Sichuan Provincial People’s Hospital and Sichuan Academy of Medical Sciences, Chengdu, Sichuan Province, China
| | - James F. Markmann
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Martins PNA, Tullius SG, Markmann JF. Immunosenescence and immune response in organ transplantation. Int Rev Immunol 2013; 33:162-73. [PMID: 24127845 DOI: 10.3109/08830185.2013.829469] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The immune system undergoes a complex and continuous remodeling with aging. Immunosenescence results into both quantitative and qualitative changes of specific cellular subpopulations that have major impact on allorecognition and alloresponse, and consequently on graft rejection and tolerance. Here, we are going to review the immunological changes associated with the aging process relevant for transplantation. Interventions to selectively target changes associated with the senescence process seem promising therapeutic strategies to improve transplantation outcome.
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Affiliation(s)
- Paulo Ney Aguiar Martins
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
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22
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Shin M, Moon H, Kim J, Park J, Kwon C, Joh JW, Kim SJ. Implication of Donor–Recipient Age Gradient in the Prognosis of Graft Outcome After Deceased-Donor Kidney Transplantation. Transplant Proc 2013; 45:2907-13. [DOI: 10.1016/j.transproceed.2013.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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23
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Pieloch D, Dombrovskiy V, Osband AJ, Lebowitz J, Laskow DA. Morbid obesity is not an independent predictor of graft failure or patient mortality after kidney transplantation. J Ren Nutr 2013; 24:50-7. [PMID: 24070588 DOI: 10.1053/j.jrn.2013.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Obesity is often an absolute contraindication to kidney transplant, but an internal analysis of our center's recipients suggests that not all obese populations exhibit poor outcomes. We used national data to compare outcomes in select groups of morbidly obese and normal-weight recipients after kidney transplant. DESIGN This study was a retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SUBJECTS The study sample consisted of 30,132 morbidly obese (body mass index [BMI] 35-40 kg/m(2)) and normal-weight (BMI 18.5-24.9 kg/m(2)) patients who underwent primary kidney-only transplantation between 2001 and 2006. MAIN OUTCOME MEASURE Crude 3-year graft and patient survival rates of morbidly obese and normal-weight subgroups were evaluated. Logistic regression modeling compared 3-year graft failure and patient mortality in morbidly obese and normal-weight subgroups with opposite characteristics. Kaplan-Meier survival curves were created for 3-year graft and patient survival. Cox proportional hazard regression modeling was used to determine hazards for patient and graft mortality. RESULTS No differences in crude graft and patient survival rates were seen between normal weight and morbidly obese recipients who were African American, diabetic, and 50 to 80 years of age. Morbidly obese recipients who were nondialysis dependent, nondiabetic, had good functional status, and received living-donor transplants had significantly lower 3-year graft failure and patient mortality risk compared with normal-weight recipients who were dialysis dependent, diabetic, had poor functional status, and received a deceased-donor transplant, respectively (P < .01). Morbidly obese recipients have significantly lower graft and patient survival curves compared with normal-weight recipients; however, multivariate regression analysis reveals that morbid obesity is not an independent predictor of graft failure or patient mortality. CONCLUSIONS Morbid obesity is not independently associated with graft failure or patient mortality; therefore, it should not be used as a contraindication to kidney transplantation.
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Affiliation(s)
- Daniel Pieloch
- The Transplant Center, Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
| | - Viktor Dombrovskiy
- Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Adena J Osband
- The Transplant Center, Robert Wood Johnson University Hospital, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jonathan Lebowitz
- The Transplant Center, Robert Wood Johnson University Hospital, New Brunswick, New Jersey; Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - David A Laskow
- The Transplant Center, Robert Wood Johnson University Hospital, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey
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24
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Kostakis ID, Moris DN, Barlas A, Bokos I, Darema M, Theodoropoulou E, Karaolanis G, Kostakis A, Boletis I, Zavos G. Impact of donor and recipient age difference on long-term allograft survival after living donor renal transplantation: analysis of 478 cases. Clin Transplant 2013; 27:838-43. [PMID: 23991890 DOI: 10.1111/ctr.12219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Either deceased or living-related renal transplantation constitutes the best therapeutic option for patients with end-stage renal disease. In this retrospective study, an attempt to identify parameters that affect allograft survival in living donor renal transplantation was made. METHODS Between January 2000 and July 2012, 478 adult patients received a renal transplant from a living-related donor in our center and their records were retrospectively reviewed in November 2012. Data concerning donor age, recipient age, donor/recipient age difference, donor/recipient gender, and ABO compatibility/incompatibility were recorded and associated with renal allograft survival rate. RESULTS Renal allograft survival rate was 96%, 89.5%, and 77.7% in the first, fifth, and 10th yr after transplantation, respectively. Only the difference between donor and recipient age was statistically significant in relation to graft survival. In cases with age difference >13 yr, graft survival rate was lower from the third yr onward. CONCLUSIONS Only the age difference between donor and recipient exerts an adverse impact on graft outcome after living donor renal transplantation, whereas donor age, recipient age, donor/recipient gender, and ABO incompatibility do not significantly influence renal allograft survival.
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25
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De Rosa P, Muscogiuri G, Sarno G. Expanded Criteria Donors in Kidney Transplantation: The Role of Older Donors in a Setting of Older Recipients. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/301025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Kidney transplantation (KT) is the therapy of choice for end-stage renal disease (ESRD). The ESRD population is aging and so are patients waiting for KT. New strategies have been made for increasing the donor and recipient pools, and as a consequence kidneys from older donors or donors with significant comorbidities, the so-called “expanded criteria donor” (ECD) kidneys, are used for transplantation. Although good outcomes have been achieved from ECD, several issues are still waiting for clarification and need to be discussed. The concept of age matching is accepted as a method to ameliorate utilization of these allografts, but an optimal and widely accepted strategy is still not defined. The development of machine perfusion and the dual kidney transplantation are techniques which further improve the outcome of transplants from ECD, but the described experiences are scarce or coming from small single institutional reports. Also due to age-related immune dysfunction and associated comorbidities, the elderly recipients are more susceptible to immunosuppression related complications (e.g., infections and malignancy), although a widely accepted and validated immunosuppressive regimen is still lacking. In this paper, we review the issues related to KT employing allografts from marginal donors with a particular interest for the elderly patients.
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Affiliation(s)
- Paride De Rosa
- Department of General Surgery and Transplantation Unit, “San Giovanni di Dio e Ruggi D’Aragona” University Hospital, Scuola Medica Salernitana, Largo Città di Ippocrate, 84131 Salerno, Italy
| | - Giovanna Muscogiuri
- Division of Endocrinology and Metabolic Diseases, Catholic University of the Sacred Heart “Agostino Gemelli” University Hospital, Rome, Italy
| | - Gerardo Sarno
- Department of General Surgery and Transplantation Unit, “San Giovanni di Dio e Ruggi D’Aragona” University Hospital, Scuola Medica Salernitana, Largo Città di Ippocrate, 84131 Salerno, Italy
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Heinbokel T, Elkhal A, Liu G, Edtinger K, Tullius SG. Immunosenescence and organ transplantation. Transplant Rev (Orlando) 2013; 27:65-75. [PMID: 23639337 DOI: 10.1016/j.trre.2013.03.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/17/2012] [Accepted: 03/19/2013] [Indexed: 12/22/2022]
Abstract
Increasing numbers of elderly transplant recipients and a growing demand for organs from older donors impose pressing challenges on transplantation medicine. Continuous and complex modifications of the immune system in parallel to aging have a major impact on transplant outcome and organ quality. Both, altered alloimmune responses and increased immunogenicity of organs present risk factors for inferior patient and graft survival. Moreover, a growing body of knowledge on age-dependent modifications of allorecognition and alloimmune responses may require age-adapted immunosuppression and organ allocation. Here, we summarize relevant aspects of immunosenescence and their possible clinical impact on organ transplantation.
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Affiliation(s)
- Timm Heinbokel
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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27
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Shin M, Park JB, Kwon CHD, Joh JW, Lee SK, Kim SJ. Enhanced Significance of Donor–Recipient Age Gradient as a Prognostic Factor of Graft Outcome in Living Donor Kidney Transplantation. World J Surg 2013; 37:1718-26. [DOI: 10.1007/s00268-013-2038-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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28
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Knoll GA. Kidney transplantation in the older adult. Am J Kidney Dis 2012; 61:790-7. [PMID: 23261121 DOI: 10.1053/j.ajkd.2012.08.049] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 08/21/2012] [Indexed: 01/23/2023]
Abstract
The end-stage renal disease population is aging. Nearly half of all new patients are older than 65 years and one third are older than 70 years. Assessing the possibility of transplantation for older patients with end-stage renal disease often involves contemplating more complex issues, including cognitive impairment, decreased functional status, and frailty, which makes selecting appropriate candidates more difficult. Older transplant recipients have decreased patient and transplant survival compared with younger recipients. For example, 75% of deceased donor transplant recipients aged 30-49 years are alive after 5 years compared to only 61% for those older than 65 years. Despite poorer outcomes compared with younger recipients, older transplant recipients have a significant improvement in survival compared with similar patients who remain on the wait list, with decreases in mortality of 41%-61% depending on the study. Use of living donors, even older living donors, provides significantly better outcomes for elderly recipients compared with the use of deceased donors. However, in the absence of a living donor, survival is improved significantly by accepting an expanded criteria donor organ rather than waiting for a standard criteria deceased donor. Older transplant recipients experience more infectious complications and less acute rejection, but the risk of transplant loss from rejection is increased compared with younger patients. These immunologic issues, along with the fact that older patients often are excluded from transplant trials, have made selecting an ideal immunosuppressive regimen challenging. Prospective comparative trials of different agents in the elderly population are warranted to better define the risk-benefit profile. This review discusses transplantation outcomes, including patient and transplant survival, different donor types, quality of life, and immunosuppression for older dialysis patients.
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Affiliation(s)
- Greg A Knoll
- Division of Nephrology, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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29
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Heinbokel T, Hock K, Liu G, Edtinger K, Elkhal A, Tullius SG. Impact of immunosenescence on transplant outcome. Transpl Int 2012. [DOI: 10.1111/tri.12013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Guangxiang Liu
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
| | - Karoline Edtinger
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
| | - Abdallah Elkhal
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
| | - Stefan G. Tullius
- Transplant Surgery Research Laboratory and Division of Transplant Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston; MA; USA
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Grubbs V, Plantinga LC, Vittinghoff E, O'Hare AM, Dudley RA. Medicare immunosuppressant coverage and access to kidney transplantation: a retrospective national cohort study. BMC Health Serv Res 2012; 12:254. [PMID: 22894737 PMCID: PMC3470983 DOI: 10.1186/1472-6963-12-254] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 08/12/2012] [Indexed: 11/10/2022] Open
Abstract
Background In December 2000, Medicare eliminated time limitations in immunosuppressant coverage after kidney transplant for beneficiaries age ≥65 and those who were disabled. This change did not apply to younger non-disabled beneficiaries who qualified for Medicare only because of their end-stage renal disease (ESRD). We sought to examine access to waitlisting for kidney transplantation in a cohort spanning this policy change. Methods This was a retrospective cohort analysis of 241,150 Medicare beneficiaries in the United States Renal Data System who initiated chronic dialysis between 1/1/96 and 11/30/03. We fit interrupted time series Cox proportional hazard models to compare access to kidney transplant waitlist within 12 months of initiating chronic dialysis by age/disability status, accounting for secular trends. Results Beneficiaries age <65 who were not disabled were less likely to be waitlisted after the policy change (hazard ratio (HR) for the later vs. earlier period, 0.93, p = 0.002), after adjusting for sociodemographic factors, co-morbid conditions, income, and ESRD network. There was no evidence of secular trend in this group (HR per year, 1.00, p = 0.989). Likelihood of being waitlisted among those age ≥65 or disabled increased steadily throughout the study period (HR per year, 1.04, p < 0.001), but was not clearly affected by the policy change (HR for the immediate effect of policy change, 0.93, p = 0.135). Conclusions The most recent extension in Medicare immunosuppressant coverage appears to have had little impact on the already increasing access to waitlisting among ≥65/ disabled beneficiaries eligible for the benefit but may have decreased access for younger, non-disabled beneficiaries who were not. The potential ramifications of policies on candidacy appeal for access to kidney transplantation should be considered.
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Affiliation(s)
- Vanessa Grubbs
- Division of Nephrology, University of California San Francisco, San Francisco General Hospital, San Francisco, CA, USA.
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31
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Lim WH, Dogra G, Chadban SJ, Campbell SB, Clayton P, Cohney S, Russ GR, McDonald SP. Lack of impact of donor age on patient survival for renal transplant recipients ≥60years. Transpl Int 2012; 25:401-8. [PMID: 22340432 DOI: 10.1111/j.1432-2277.2012.01429.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There has been an increase in the number of older patients on the transplant waiting list and acceptance of older donor kidneys. Although kidneys from older donors have been associated with poorer graft outcomes, whether there is a differential impact of donor age on outcomes in older recipients remains unclear. The aim of this study was to evaluate the effect of donor age on graft and patient survival in renal transplant (RT) recipients ≥60years. Using the Australia and New Zealand Dialysis and Transplant Registry, outcomes of 1,037 RT recipients ≥60years between 1995 and 2009 were analyzed. Donor age groups were categorized into 0-20, >20-40, >40-60, and >60years. Compared with recipients receiving donor kidneys >60years, those receiving donor kidneys >20-40years had lower risk of acute rejection (odds ratio 0.46, 95% CI 0.27, 0.79; P<0.01) and death-censored graft failure (HR 0.37, 95% CI 0.19, 0.72; P<0.01). There was no association between donor age groups and death. With a corresponding growth in the availability of older donor kidneys and the observed lack of association between donor age and patient survival in RT recipients ≥60years, preferential allocation of older donor kidneys to RT recipients ≥60years may not disadvantage the life expectancy of these patients.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.
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Lin J, McGovern ME, Brunelli SM, Gaccione P, Malek S, Tullius SG, Chandraker AK, Milford EL. Longitudinal trends and influence of BMI mismatch in living kidney donors and their recipients. Int Urol Nephrol 2011; 43:891-7. [PMID: 21384099 DOI: 10.1007/s11255-011-9921-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 02/15/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Age and body mass index (BMI) of kidney donors and recipients affect kidney allograft outcomes. Moreover, while deceased donor and recipient body size mismatch have been reported to influence allograft outcomes, how BMI mismatch in living kidney donor-recipient pairs affect graft survival is not well defined. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We investigated trends in characteristics of 90,815 US. living kidney donors and their recipients between 1987 and 2008. RESULTS Median ages of donors and their recipients have risen over time, and the proportion of living donors age ≥ 50 years increased from 11 to 25%. Median BMI of recipients increased from 22.6 to 26.6 kg/m(2); median BMI of kidney donors for the past 5 years has been 26.4 kg/m(2). Only 35% of living donor-recipient pairs were in the same BMI category (<25, 25-29.9, 30-34.9, or ≥ 35 kg/m(2)). BMI mismatch where the living donor was three categories heavier than the recipient was associated with a significant adjusted risk for death-censored allograft loss (HR 2.31, 95% CI 1.05-5.08). CONCLUSIONS Living kidney donors are donating at more advanced ages, and the majority are overweight or obese in recent years. In summary: (1) previous longitudinal studies of living kidney donor outcomes may not be generalizable to recent donors, and studies of contemporary living kidney donor cohorts may be informative, (2) the majority of living donor-recipient pairs have BMI mismatch, and (3) extreme BMI mismatch where the living donor is heavier may confer an independent risk for allograft loss.
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Affiliation(s)
- Julie Lin
- Renal Division and Division of Transplantation Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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33
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Lim WH, Chang S, Chadban S, Campbell S, Dent H, Russ GR, McDonald SP. Donor-recipient age matching improves years of graft function in deceased-donor kidney transplantation. Nephrol Dial Transplant 2010; 25:3082-9. [PMID: 20736266 DOI: 10.1093/ndt/gfq127] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Donor and recipient age in kidney transplantation are known to affect graft and patient survival. In deceased-donor (DD) transplantation, donor and recipient age matching are being increasingly accepted as part of the kidney allocation programme. The aims of this study are to evaluate the effect of donor and recipient age on transplant outcomes and to determine the effect of changing existing allocation criteria to allocation based on age matching of donors and recipients on total graft years of function. METHODS Using the Australia and New Zealand Dialysis and Transplant Registry, all DD kidney transplant recipients in Australia and New Zealand between 1991 and 2006 were analysed (n = 4616). Outcomes analysed were overall graft failure, death with functioning graft and serum creatinine. We calculated the mean time to graft loss ('years of graft function') for donor and recipient age cut-offs as 60 and 55 years, respectively, over up to 16 years follow-up. We then examined the gain in graft years if all older kidneys were allocated to older recipients. RESULTS Older donors were associated with higher risk of overall graft failure [adjusted hazard ratio (HR) = 1.79, 95% confidence interval (95% CI) = 1.45, 2.21 and HR = 1.29, 95% CI = 1.09, 1.53, respectively] at 1-8 years post-transplant and higher serum creatinine at 1 and 5 years post-transplant (mean differences 32.74 micromol/L, 95% CI 27.60, 37.89 and 38.17 micromol/L, 95% CI 27.58, 48.77, respectively). Overall, young and old recipients with young donor kidneys have an additional two to three mean graft years compared to those receiving older donor kidneys. CONCLUSION Donor and recipient age matching is an effective method of organ allocation to improve total graft years.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.
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34
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Favorable outcomes with machine perfusion and longer pump times in kidney transplantation: a single-center, observational study. Transplantation 2010; 90:882-90. [PMID: 20703178 DOI: 10.1097/tp.0b013e3181f2c962] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Hypothermic machine perfusion (MP) preservation is used for all deceased donor kidney transplants at our center. Kidneys are placed in cold storage at retrieval, then transferred to MP on arrival. Because a lack of consensus regarding optimal use of MP still exists, we evaluated the overall impact of using MP at our center and the prognostic value of MP (Pump) time. METHODS We retrospectively analyzed 339 adult, primary deceased donor kidney transplant recipients who were pooled across three prospective, randomized immunosuppression trials (since 2000) at our center. In addition to providing overall results for delayed graft function (DGF) (requirement for dialysis in the first week), slow graft function (SGF), first biopsy-proven acute rejection (BPAR), and graft failure, stepwise logistic and Cox regression analyses were used to determine the prognostic value of pump time, particularly after controlling for other significant prognosticators. RESULTS Mean cold storage and pump times were 6.6 and 26.7 hr, consistent across immunosuppression protocols. Overall DGF and SGF rates were 4.4% (15/339) and 12.1% (41/339). DGF was equally low for pump time less than 24 vs. more than or equal to 24 hr, 5.2% (6/116) vs. 4.0% (9/223) (P=0.63), with similar results after adjusting for known DGF predictors. A significantly lower first BPAR rate was observed for longer pump time (as a continuous variable) among more immunologically active recipients (those having more risk factors: DGF, age <50 yr, and non-white) (univariable P=0.005; multivariable P=0.009), with an estimated hazard ratio of 0.43 (P=0.006) favoring pump time more than or equal to 24 hr among those with more than or equal to two risk factors. CONCLUSIONS.: In this single-center, observational study, MP with prolonged pump times was associated with low DGF/SGF and first BPAR rates, supporting continued use of MP.
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Foucher Y, Daguin P, Akl A, Kessler M, Ladrière M, Legendre C, Kreis H, Rostaing L, Kamar N, Mourad G, Garrigue V, Bayle F, H de Ligny B, Büchler M, Meier C, Daurès JP, Soulillou JP, Giral M. A clinical scoring system highly predictive of long-term kidney graft survival. Kidney Int 2010; 78:1288-94. [PMID: 20861817 DOI: 10.1038/ki.2010.232] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Determining early surrogate markers of long-term graft outcome is important for optimal medical management. In order to identify such markers, we used clinical information from a cross-validated French database (Données Informatisées et VAlidées en Transplantation) of 2169 kidney transplant recipients to construct a composite score 1 year after transplantation. This Kidney Transplant Failure Score took into account a series of eight accepted pre- and post-transplant risk factors of graft loss, and was subsequently evaluated for its ability to predict graft failure at 8 years. This algorithm outperformed the traditional surrogates of serum creatinine and the estimated graft filtration rate, with an area under the receiver-operator characteristic curve of 0.78. Validation on an independent database of 317 graft recipients had the same predictive capacity. Our algorithm was also able to stratify patients into two groups according to their risk: a high-risk group of 81 patients with 25% graft failure and a low-risk group of 236 patients with an 8% failure rate. Thus, although this clinical composite score predicts long-term graft survival, it needs validation in different patient groups throughout the world.
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Affiliation(s)
- Yohann Foucher
- Institut de Transplantation et de Recherche en Transplantation-Urologie-Néphrologie, CHU Nantes, IUN and INSERM U643, Nantes, France
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Abstract
There is an increase in the older incident end-stage renal disease population that is associated with an increasing prevalence of end-stage renal disease in the United States. This trend is paralleled by an increasing rate of kidney transplantation in the elderly. Although patient survival is lower in older versus younger kidney recipients, the elderly benefit from a reduction in mortality rate and improved quality of life with transplantation compared with dialysis. Immunologic, physiologic, and psychosocial factors influence transplant outcomes and should be recognized in the care of the elderly transplant patient. In this review, we discuss transplantation in the elderly patient, particularly the topics of access to transplantation, patient and graft survival, the impact of donor quality on transplant outcomes, immunology and immunosuppression of aging, and ethical considerations in the development of an equitable organ allocation scheme.
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Affiliation(s)
- Edmund Huang
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
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37
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Denecke C, Bedi DS, Ge X, Kim IKE, Jurisch A, Weiland A, Habicht A, Li XC, Tullius SG. Prolonged graft survival in older recipient mice is determined by impaired effector T-cell but intact regulatory T-cell responses. PLoS One 2010; 5:e9232. [PMID: 20169060 PMCID: PMC2821908 DOI: 10.1371/journal.pone.0009232] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 01/16/2010] [Indexed: 12/02/2022] Open
Abstract
Elderly organ transplant recipients represent a fast growing segment of patients on the waiting list. We examined age-dependent CD4+ T-cell functions in a wild-type (WT) and a transgenic mouse transplant model and analyzed the suppressive function of old regulatory T-cells. We found that splenocytes of naïve old B6 mice contained significantly higher frequencies of T-cells with an effector/memory phenotype (CD4+CD44highCD62Llow). However, in-vitro proliferation (MLR) and IFNγ-production (ELISPOT) were markedly reduced with increasing age. Likewise, skin graft rejection was significantly delayed in older recipients and fewer graft infiltrating CD4+T-cells were observed. Old CD4+ T-cells demonstrated a significant impaired responsiveness as indicated by diminished proliferation and activation. In contrast, old alloantigen-specific CD4+CD25+FoxP3+ T-cells demonstrated a dose-dependent well-preserved suppressor function. Next, we examined characteristics of 18-month old alloreactive T-cells in a transgenic adoptive transfer model. Adoptively transferred old T-cells proliferated significantly less in response to antigen. Skin graft rejection was significantly delayed in older recipients, and graft infiltrating cells were reduced. In summary, advanced recipient age was associated with delayed acute rejection and impaired CD4+ T-cell function and proliferation while CD4+CD25+FoxP3+ T-cells (Tregs) showed a well-preserved function.
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MESH Headings
- Adoptive Transfer
- Age Factors
- Animals
- CD4-Positive T-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/metabolism
- CD4-Positive T-Lymphocytes/transplantation
- Cell Proliferation
- Cytokines/metabolism
- Female
- Flow Cytometry
- Graft Rejection/immunology
- Graft Survival/immunology
- Humans
- Immunohistochemistry
- Interferon-gamma/metabolism
- Mice
- Mice, Inbred C57BL
- Mice, Nude
- Mice, Transgenic
- Receptors, Antigen, T-Cell/genetics
- Receptors, Antigen, T-Cell/metabolism
- Receptors, Chemokine/metabolism
- Skin Transplantation/immunology
- Skin Transplantation/methods
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/metabolism
- Time Factors
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Affiliation(s)
- Christian Denecke
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Damanpreet Singh Bedi
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Xupeng Ge
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Irene Kyung-eun Kim
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anke Jurisch
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anne Weiland
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Antje Habicht
- Transplantation Research Center, Brigham and Women's Hospital and Children's Hospital of Boston, Boston, Massachusetts, United States of America
| | - Xian C. Li
- Transplant Research Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stefan G. Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Demirbas A, Hugo C, Grinyó J, Frei U, Gürkan A, Marcén R, Bernasconi C, Ekberg H. Low toxicity regimens in renal transplantation: a country subset analysis of the Symphony study. Transpl Int 2010; 22:1172-81. [PMID: 19891046 DOI: 10.1111/j.1432-2277.2009.00937.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Regional transplant practices may affect clinical outcomes within multinational studies. This study evaluated whether the overall results from the Symphony study can be generalized to the participating countries. De novo adult renal transplant recipients (n = 1645) were randomized to receive standard-dose cyclosporine, or daclizumab induction plus low-dose cyclosporine, low-dose tacrolimus,or low-dose sirolimus, all in addition to mycophenolate mofetil and steroids. Data for the highest patient-recruiting countries, Spain (n = 275),Germany (n = 316) and Turkey (n = 258), were compared. Patient transplant characteristics were different among the country subsets; only deceased donors in Spain, more expanded criteria donors in Germany, and mainly living donors in Turkey. Efficacy results for the three countries were consistent with that of the overall study - renal function and biopsy-proven acute rejection (BPAR)rates were superior with low-dose tacrolimus. Turkey had higher mean calculated glomerular filtration rate across all treatment groups (60.6-72.2 ml/min)compared with that of Spain (51.1-57.5 ml/min) and Germany (51.3-62.9 ml/min). Spain and Turkey had lower BPAR rates across the four treatment groups compared with the overall study; Germany had much higher rates(21.0-54.2%). These findings confirm the general applicability of the Symphony study results and highlight the importance of inclusion of patients from different geographic origins in randomized clinical trials.
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A randomized trial comparing renal function in older kidney transplant patients following delayed versus immediate tacrolimus administration. Transplantation 2010; 88:1101-8. [PMID: 19898206 DOI: 10.1097/tp.0b013e3181ba06ee] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This large, randomized, multicenter trial evaluated if basiliximab induction and delayed tacrolimus can preserve renal function in older kidney transplant patients. METHODS Patients aged 60 years and older received delayed tacrolimus with basiliximab and mycophenolate mofetil with early steroid discontinuation (Tac-d, n=132) or standard tacrolimus with mycophenolate mofetil and steroids until day 91 (Tac-s, n=122). Tacrolimus trough levels were 5 to 10 ng/mL after day 43 in both groups. Renal function at month 6 was measured by calculated creatinine clearance (Cockcroft-Gault formula). RESULTS In both groups, mean recipient age was 66 years, mean donor age was 63 years with 73% of donors aged 60 years and older. Steroid discontinuation was slower than protocol specified. In the Tac-d group, 56.1% were steroid free at day 14 and 81.8% at month 6. In the Tac-s group, 37.7% were steroid free at month 4 and 63.9% at month 6. Mean (+/-SD) calculated creatinine clearance was 45.7+/-16.1 mL/min (Tac-d) and 45.0+/-18.2 mL/min (Tac-s) (P=ns), mean glomerular filtration rate (modified diet in renal disease formula) was 44.9+/-16.2 mL/min and 41.6+/-16.8 mL/min, respectively. Incidences of biopsy-proven acute rejection were 18.9% (Tac-d) and 18.0% (Tac-s). Delayed graft function was 30.3% (Tac-d) and 23.8% (Tac-s). Estimated patient survival rates (Kaplan-Meier) in the Tac-d and Tac-s groups were 96.1% vs. 99.2% and estimated graft survival rates were 90% vs. 87.6%, respectively. Safety results were similar with both regimens. CONCLUSION Delayed tacrolimus with basiliximab induction did not provide an advantage in preserving renal function or reducing delayed graft function in older kidney transplant patients.
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40
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Badowski M, Gurk-Turner C, Cangro C, Weir M, Philosophe B, Klassen D, Haririan A. The impact of reduced immunosuppression on graft outcomes in elderly renal transplant recipients. Clin Transplant 2009; 23:930-7. [DOI: 10.1111/j.1399-0012.2009.01028.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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41
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Potent early immune response after kidney transplantation in patients of the European senior transplant program. Transplantation 2009; 87:992-1000. [PMID: 19352117 DOI: 10.1097/tp.0b013e31819ca0d7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The increasing age of organ donors and the transplantation of older recipients have become clinical practice. Age-adapted immunosuppressive protocols considering these changes are currently not established. This study analyzed the age-dependent immune response after human kidney transplantation. METHODS One hundred renal allograft recipients were prospectively evaluated from 2004 to 2005. Patients older than 65 years of the European Senior Program receiving kidneys from donors older than 65 years were compared with recipients younger than 65 years receiving kidneys from donors younger than 65 years. Age-dependent modifications of the immune response were evaluated before transplantation and 7 days and 6 months after grafting by flow cytometry analysis of lymphocyte surface markers in peripheral blood. The cytokine pattern was determined by Cytometric Bead Array, T-cell alloreactivity by enzyme-linked immunospot analysis. RESULTS There were no differences between the groups regarding patient survival, graft survival, and function at 6 months after transplantation. Before transplantation, 7 days and 6 months thereafter recipients older than 65 years demonstrated significantly elevated numbers of memory T-cells while counts for naive T-cells were significantly reduced. Numbers of activated cytotoxic cells were elevated with increasing age before and 7 days after transplantation. T-cell alloreactivity was more pronounced in older recipients at all time points. Seven days after transplantation tumor necrosis factor-alpha (TNF-alpha) levels were significantly higher, whereas TNF-alpha and interleukin-10 (IL-10) concentrations were significantly reduced after 6 months in older recipients. CONCLUSIONS Our data demonstrate an initially pronounced immune response in elderly recipients receiving grafts from elderly donors. This observation supports the concept of a donor and recipient age-adapted immunosuppression.
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Helal I, Abderrahim E, Ben Hamida F, Ounissi M, Essine S, Hedri H, Bardi R, Elgorgi Y, El Younsi F, Ben Maiz H, Ben Abdallah T, Kheder A. The First Year Renal Function as a Predictor of Long-Term Graft Survival After Kidney Transplantation. Transplant Proc 2009; 41:648-50. [DOI: 10.1016/j.transproceed.2009.02.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tesar BM, Du W, Shirali A, Walker WE, Shen H, Goldstein DR. Aging augments IL-17 T-cell alloimmune responses. Am J Transplant 2009; 9:54-63. [PMID: 18976294 PMCID: PMC2626154 DOI: 10.1111/j.1600-6143.2008.02458.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
As increasing numbers of elderly patients require solid organ transplantation, the need to better understand how aging modifies alloimmune responses increases. Here, we examined whether aged mice exhibit augmented, donor-specific memory responses prior to transplantation. We found that elevated donor-specific IL-17, but not IFN-gamma, responses were observed in aged mice compared to young mice prior to transplantation. Further characterization of the heightened IL-17 alloimmune response with aging demonstrated that memory CD4(+) T cells were required. Reduced IL-2 alloimmune responses with age contributed to the elevated IL-17 phenotype in vitro, and treatment with an anti-IL-17 antibody delayed the onset of acute allograft rejection. In conclusion, aging leads to augmented, donor-specific IL-17 immune responses that are important for the timing of acute allograft rejection in aged recipients. IL-17 targeting therapies may be useful for averting transplant rejection responses in older transplant recipients.
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Affiliation(s)
- Bethany M. Tesar
- Department of Internal Medicine, Yale University School of Medicine, Yale University School of Medicine, New Haven CT, 333 Cedar St, CT, 06520, USA
| | - Wei Du
- Department of Internal Medicine, Yale University School of Medicine, Yale University School of Medicine, New Haven CT, 333 Cedar St, CT, 06520, USA
| | - Anushree Shirali
- Department of Internal Medicine, Yale University School of Medicine, Yale University School of Medicine, New Haven CT, 333 Cedar St, CT, 06520, USA
| | - Wendy E Walker
- Department of Internal Medicine, Yale University School of Medicine, Yale University School of Medicine, New Haven CT, 333 Cedar St, CT, 06520, USA
| | - Hua Shen
- Department of Internal Medicine, Yale University School of Medicine, Yale University School of Medicine, New Haven CT, 333 Cedar St, CT, 06520, USA
| | - Daniel R. Goldstein
- Department of Internal Medicine, Yale University School of Medicine, Yale University School of Medicine, New Haven CT, 333 Cedar St, CT, 06520, USA,Address for correspondence: Daniel R. Goldstein, 333 Cedar Street, 3 FMP, P.O. BOX 208017, New Haven, CT, USA, 06520-8018. Fax: 203 785 7567, tel: 203 785 3271,
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Abou-Jaoude MM, Khoury M, Nawfal N, Shaheen J, Almawi WY. Effect of recipient age on the outcome of kidney transplantation. Transpl Immunol 2009; 20:118-20. [DOI: 10.1016/j.trim.2008.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 09/04/2008] [Indexed: 11/29/2022]
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Basic-Jukic N, Furic-Cunko V, Kes P, Bubic-Filipi L, Pasini J, Hudolin T, Juric I. Outcome After Renal Transplantation in a “Senior” Program: The Croatian Experience. Transplant Proc 2008; 40:3418-21. [DOI: 10.1016/j.transproceed.2008.06.109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 06/13/2008] [Accepted: 06/18/2008] [Indexed: 11/30/2022]
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Courtney AE, McNamee PT, Maxwell AP. The evolution of renal transplantation in clinical practice: for better, for worse? QJM 2008; 101:967-78. [PMID: 18927195 DOI: 10.1093/qjmed/hcn136] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Kidney transplantation is the optimal form of renal replacement therapy for most patients with end-stage renal disease. Attempting to improve graft and recipient survival remains challenging in clinical practice. AIM To identify the factors that have significantly changed over the past four decades and assess their impact on renal transplant outcomes. DESIGN Retrospective review of all renal transplant procedures in a single UK region. METHODS All 1346 renal transplant procedures performed between 1 January 1967 and 31 December 2006 were reviewed. Clinical data, histological reports and outcomes were available from a prospectively recorded database. The study period was divided into four decades to assess the changes in renal transplantation over time. RESULTS Significant changes that have occurred include an increase in donor and recipient ages, a greater proportion of recipients with diabetic nephropathy, a longer wait before the first transplant procedure, a fall in the incidence and impact of acute rejection, a smaller proportion of deaths due to cardiovascular disease, (P < 0.001 for all) and a trend to increased deaths from malignancy (P = 0.06) over time. In multivariate analysis, death censored graft survival was significantly influenced by the era of transplantation, donor and recipient ages, living vs. deceased donor status, and histological evidence of acute rejection, chronic allograft nephropathy, or disease recurrence. Significant factors in recipient survival were the era of transplantation, recipient age, a primary renal diagnosis of diabetic nephropathy or unspecified chronic renal failure, and biopsy proven acute rejection. CONCLUSION There have been major changes in the clinical practice related to renal transplantation over the past four decades; some have been beneficial and others detrimental to survival. Regular review of outcomes is essential to guide renal services development and maximize graft and recipient survival.
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Affiliation(s)
- A E Courtney
- Regional Nephrology Unit, Belfast City Hospital-Level 11, Lisburn Road, Belfast, BT9 7AB, UK.
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Renal transplantation in the elderly. Int Urol Nephrol 2008; 41:195-210. [PMID: 18989746 DOI: 10.1007/s11255-008-9489-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 10/06/2008] [Indexed: 12/31/2022]
Abstract
Elderly patients are increasingly being considered for kidney transplantation due to a global explosion of the aging population with end-stage renal disease (ESRD). However, mounting scarcity of available organs for transplant has led to a wider disparity between organ supply and demand. Consequently, the criteria for accepting kidneys for transplantation have been extended in an attempt to allow the use of organs from elderly donors or those with significant co-morbidities, so-called "expanded criteria donor" (ECD) kidneys. Excellent outcomes have been achieved from ECD kidneys with appropriate donor and recipient profiling and selection. With increasing recovery efforts directed at older donors, the concept of age-matching is becoming more accepted as a method of optimizing utilization of organs in elderly donors and recipients. Utilization of pulsatile perfusion has further improved ECD outcomes and helped the decision-making process for the UNOS (United Network for Organ Sharing) offer. However, age-related immune dysfunction and associated co-morbidities make the elderly transplant recipients ever more susceptible to complications associated with immunosuppressive agents. Consequently, the elderly population is at a higher risk to develop infections and malignancy in the post-transplant period notwithstanding improved transplant outcomes. Appropriate immunosuppressive agents and dosages should be selected to minimize adverse events while reducing the risk of acute rejections and maximizing patient and renal allograft survival.
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Mendonça HM, Dos Reis MA, de Castro de Cintra Sesso R, Câmara NOS, Pacheco-Silva A. Renal transplantation outcomes: a comparative analysis between elderly and younger recipients. Clin Transplant 2008; 21:755-60. [PMID: 17988270 DOI: 10.1111/j.1399-0012.2007.00734.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Renal transplantation is presently the best treatment for end-stage renal disease, although considered contraindicated for elderly patients. However, more investigation is needed due to higher life expectancy rates of the general population and the increasing number of over 60-yr-old patients with chronic renal failure dependent upon dialysis. This study aims to determine graft and patient survival rates of renal transplant patients 60 yr and older compared to a younger group (50-59 yr old). Relevant pre- and post-transplant clinical data related to graft and patient survival in both groups were also investigated. Three-hundred and twenty consecutive renal transplant patients were enrolled in this study and grouped based on age at the time of the transplantation: one-hundred and ten patients at or over 60 yr old (elderly group) and 210 patients ranging from 50 to 59 yr old (younger group). There were no statistical differences in either group regarding clinical characteristics and immunological risk factors. The incidence of acute rejection was higher in the younger group (37.6%) than in the elderly (22.7%) (p = 0.01). Censored to death graft survivals at five yr were respectively 86.7% for patients > or = 60 yr and 82.1% for patients 50-59 yr old (p = 0.49). Patient survival rates at five yr were respectively 76.2% for patients > or = 60 yr and 81.6% for patients 50-59 yr old (p = 0.33). Our data show that renal transplantation for elderly patients has similar results to those found in younger individuals, which does not make age, in and of itself, a contraindication for transplantation.
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Proliferation Signal Inhibitors in Transplantation: Questions at the Cutting Edge of Everolimus Therapy. Transplant Proc 2007; 39:2937-50. [DOI: 10.1016/j.transproceed.2007.09.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 09/02/2007] [Indexed: 12/23/2022]
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