Outcomes of single kidney transplantation from pediatric donors: A single-center experience

Predictors and one-year outcomes of patients with delayed graft function after deceased donor kidney transplantation

BACKGROUND

Delayed graft function (DGF) is closely associated with the use of marginal donated kidneys due to deficits during transplantation and in recipients. We aimed to predict the incidence of DGF and evaluate its effect on graft survival.

METHODS

This retrospective study on kidney transplantation was conducted from January 1, 2018, to December 31, 2019, at the Second Xiangya Hospital of Central South University. We classified recipients whose operations were performed in different years into training and validation cohorts and used data from the training cohort to analyze predictors of DGF. A nomogram was then constructed to predict the likelihood of DGF based on these predictors.

RESULTS

The incidence rate of DGF was 16.92%. Binary logistic regression analysis showed correlations between the incidence of DGF and cold ischemic time (CIT), warm ischemic time (WIT), terminal serum creatine (Scr) concentration, duration of pretransplant dialysis, primary cause of donor death, and usage of LifePort. The internal accuracy of the nomogram was 83.12%. One-year graft survival rates were 93.59 and 99.74%, respectively, for the groups with and without DGF (P < 0.05).

CONCLUSION

The nomogram established in this study showed good accuracy in predicting DGF after deceased donor kidney transplantation; additionally, DGF decreased one-year graft survival.

Kidney transplantation from small pediatric donors may be feasible to those who developed chronic refractory dialysis hypotension: a single-center experience

Background

Chronic refractory dialysis hypotension (CRDH) is a serious issue in dialysis patients waiting for transplants. It leads to fatal clinical outcomes and disqualification from kidney transplantation. Kidney transplantation from pediatric donor to adult patient with lower blood pressure (BP) may be an option. No related study has been reported and we conducted this study to first evaluate the effect of pediatric donor kidney transplantation in CRDH recipients.

Methods

Ten single-kidney transplantations from small pediatric donors after cardiac death in our center between August 2016 and April 2018 were described. Half were CRDH recipients (group A) with intradialytic and interdialytic systolic blood pressure (SBP) below 100 mmHg. Each was paired with no-CRDH recipient (control, group B) from the same donor. The operation method of vascular anastomosis and ureterocystoneostomy was the same as that of adult donors. Clinical characteristics, post-operative treatment and outcomes of all recipients were retrieved. Postoperative BP, graft function and size were compared between two groups. The follow-up time was up to April 2019.

Results

There was no acute rejection (AR), graft loss or death in all recipients after transplantation. Their renal function was recovered despite three transient delayed graft function (DGF). There was no significant difference in serum creatinine (SCr) or graft size (P=0.84, 0.94) after transplantation between two groups. For all CRDH recipients, the postoperative SBP was above 100 mmHg (except one, 90–130 mmHg). The BP one year after transplantation was maintained at 110–125/70–85 mmHg.

Conclusions

kidney transplantation from small pediatric donors may be feasible to CRDH recipients and their BP may return to normal after transplantation.

Non-linear Relationship between Tacrolimus Blood Concentration and Acute Rejection After Kidney Transplantation: A Systematic Review and Dose-Response Meta-Analysis of Cohort Studies

BACKGROUND

Maintaining the exposure of tacrolimus (Tac) after kidney transplantation (KT) must be necessary to prevent acute rejection (AR) and improve graft survival，but there is still no clear consensus on the optimal Tac target blood concentration and concentration-effect relationship is poorly defined.

METHODS

We conducted a dose-response meta-analysis to quantitatively assess the association between Tac blood concentration and (AR) or adverse effects after KT. A comprehensive search of PubMed, Embase and Cochrane library databases was conducted to find eligible studies up to 10th September 2018. Unpublished data from patients receiving KT in West China Hospital (Sichuan University, China) were also collected. Both twostage dose-response and one-stage dose-response meta-analysis models were used to improve the statistical power.

RESULTS

A total of 4967 individuals from 10 original studies and 1453 individuals from West China Hospital were eligible for the ultimate analysis. In the two-stage dose-response meta-analysis model, we observed a significant non-linear relationship between Tac blood concentration and AR (P < 0.001) with moderate heterogeneity (I2 = 46.0%, P = 0.08). Tac blood concentration at 8ng/ml was associated with the lowest risk of AR (RR: 0.26, 95%CI: 0.13 - 0.54) by reference to 2ng/ml. Tac concentration at 7.0 - 11.0 ng/ml reduced the risk of AR by at least 70%, 5-14 ng/ml by at least 60%, and 4.5 - 14 ng/ml at least 50%. In the one-stage dose-response model, we also found a strong non-linear relationship between Tac and AR (P < 0.001) with moderate heterogeneity (I2 = 41.2%, P = 0.10). Tac concentration of 7.5 ng/ml was associated with the lowest risk of AR (RR: 0.35, 95%CI: 0.16 - 0.77). The blood concentration at 5.5 - 9.5 ng/ml was associated with the reduced AR by at least 60% and 4.5 - 10.5 ng/ml by at least 50% by reference to 2 ng/ml.

CONCLUSION

Maintaining Tac blood concentration at 5 - 9.5 ng/ml within the first year may prevent AR most effectively.

Tacrolimus Trough Level at the First Month May Predict Renal Transplantation Outcomes Among Living Chinese Kidney Transplant Patients: A Propensity Score-Matched Analysis

Supplemental Digital Content is Available in the Text.

Background:

Monitoring and maintaining a stable tacrolimus trough level is essential because of its narrow therapeutic window and considerable fluctuation in the early phase after kidney transplantation. However, optimal tacrolimus exposure early after transplantation remains unclear among Chinese patients.

Methods:

In this propensity score–matched cohort study, we thoroughly investigated the association between tacrolimus trough level at the first month and acute rejection (AR) as well as infection within the first year after kidney transplantation.

Results:

In a first step, a total of 1415 patients were divided into 3 groups according to the receiver operating characteristic curve: low-level group (410 patients with a tacrolimus trough level <5.35 ng/mL at the first month), median-level group (466 patients with a tacrolimus trough level from 5.35 to 7.15 ng/mL), and high-level group (539 patients with a tacrolimus trough level >7.15 ng/mL). Ultimately, 363 and 459 pairs of cases were enrolled by using 2 propensity score matches between low- and median-level groups and between high- and median-level groups, respectively. Compared with patients in the low-level group, patients in the median-level group had lower risk of AR without increased incidence of infection (AR, 12.4% versus 5.7%, P = 0.02; infection, 13.2% versus 13.2%, P = 1.00 for low- and median-level groups, respectively) within the first year. Compared with patients in the high-level group, patients in the median-level group had lower incidence of infection without the growing risk of AR (infection, 17.6% versus 12.2%, P = 0.021; AR, 4.6% versus 5.4%, P = 0.545 for high- and median-level groups, respectively) within the first year. Multilogistic analysis showed that tacrolimus trough levels were an independent factor for AR (odds ratio, 0.749, 95% confidence interval, 0.632–0.888, P = 0.001). Tacrolimus trough levels were also associated with infection (odds ratio 1.110, 95% confidence interval, 1.013–1.218, P = 0.001). Serum creatinine levels were similar among groups. No difference was found in 1-, 3-, and 5-year graft survival and patient survival among groups.

Conclusions:

The tacrolimus trough level maintained between 5.35 and 7.15 ng/mL at the first posttransplant month may prevent AR without increasing the incidence of infection within the first year after living kidney transplantation among Chinese patients.

Single kidney transplantation from donors with acute kidney injury: A single-center experience

INTRODUCTION

Despite a severe shortage of organ supply, patients are reluctant to accept organs from deceased donors with AKI, let alone from pediatric AKI donors.

METHODS

We assessed 70 patients who received kidneys from donors with AKI (10 with pediatric and 60 with adult donors) and 176 contemporaneous patients who received kidneys from non-AKI donors (41 with pediatric and 135 with adult donors) between March 2012 and February 2017 for retrospectively evaluating the clinical outcomes.

RESULTS

AKI was defined and staging by the RIFLE criteria and pediatric-modified RIFLE criteria. Median age was 11.00 years IQR (4.50-14.00 years), and median weight was 25.00 kg (IQR, 17.00-45.00 kg) for all pediatric donors. Median follow-up was 8 months (range, 1-49 months). Adult AKI group had the highest incidence of DGF (35.0% vs 10%, 9.8%, and 19.3%, P = 0.011). There was a significant increase in DGF in higher AKI stages (Risk: 20.7%, Injury: 46.7%, Failure: 50.0%; P = 0.014) among patients with adult donors. No significant differences were noted in 1-year (100.0%, 95.1%, 98.3%, and 97.8%; P = 0.751) and 3-year (100.0%, 95.1%, 98.3%, and 97.8%; P = 0.751) patient survival, and 1-year (90.0%, 97.6%, 98.3%, and 95.6%; P = 0.535) and 3-year (90.0%, 97.6%, 98.3%, and 95.6%; P = 0.535) graft survival.

CONCLUSION

Transplants procured from donors with AKI, particularly pediatric ones, could achieve excellent intermediate-term clinical outcomes and thus potentially expand the donor pool.