First Asian Kidney Donor Profile Index (KDPI) and Estimated Post-Transplant Survival (EPTS) Models, With Validation Against US Models in Thai Population

INTRODUCTION

Differences in transplant characteristics limit the application of kidney donor profile index (KDPI) and estimated post-transplant survival (EPTS) models developed in Western countries to Asian populations.

METHODS

We analyzed data of the Thai Transplant Registry and the Thai Red Cross Society on 2,558 DDKTs performed between 2001 and 2014. Thai KDPI and EPTS models were developed using Cox regression, and validation against the US models.

RESULTS

Thai KDPI was developed based on 7 donor factors: age, height, best estimated glomerular filtration rate, diabetes mellitus, hypertension, cerebrovascular accident, and adrenaline infusion. The Thai and US donor risk index had comparable predictive abilities for transplant survival (C-statistics 0.5871 vs 0.5548; P = 0.429). KTs from donors with a US KDPI > 70% demonstrated significantly worse 5-year transplant survival. The Thai EPTS model was developed from 4 recipient factors: age, body weight, diabetes mellitus, and hepatitis C infection. The C-statistics of the Thai and US EPTS models were comparable (0.5924 vs 0.6039; P = 0.360). A US EPTS > 70% was revealed in only 2.5% of our cohort.

CONCLUSIONS

The first simplified KDPI and EPTS models for an Asian population were developed. Our models are available at www.thai-kdpi-epts.org. This article is protected by copyright. All rights reserved.

[Rehabilitation after kidney transplantation]

Hintergrund

Durch strukturierte (Langzeit‑)Nachsorge nach Nierentransplantation und Nierenlebendspende können Risikofaktoren für Transplantatüberleben und Nierenfunktion und für die physische wie psychische Morbidität unterschiedlichster Genese detektiert und gebessert werden. Neben den klassischen kardiovaskulären Risikofaktoren zählen hierzu eine mangelnde Adhärenz des Patienten, Wissensdefizite im Hinblick auf Verhaltensregeln nach Transplantation und Lebendspende, Bewegungsmangel, mangelnde Coping-Strategien oder auch arbeitsmedizinische und sozialrechtliche Belange.

Ziel der Arbeit

Es soll dargestellt werden, wie Rehabilitationsmaßnahmen die Nachsorge nach Nierentransplantation und Lebendspende optimieren können, worauf sich der Rehabilitationsbedarf begründet, welche Ziele verfolgt werden und welche multidisziplinären Therapiemodule sich etabliert haben.

Material und Methoden

Hierfür dienen neben einer Literaturrecherche die Erfahrungen einer Rehabilitationsklinik, die seit dem Jahr 2000 Rehabilitationen nach Nierentransplantation und nach Lebendspende anbietet und etwa 600 Patienten pro Jahr behandelt.

Ergebnisse

Spezialisierte Rehamaßnahmen mit nephrologischem und transplantationsmedizinischem Schwerpunkt können die ambulante Nachsorge nach Nierentransplantation und Nierenlebendspende sinnvoll ergänzen, wenn die Rehabilitationsklinik konzeptionelle, personelle und strukturelle Qualitätsanforderungen erfüllt. Eine enge Kooperation der Rehaklinik mit dem Transplantationszentrum und den behandelnden Nephrologen ist essenziell.

Diskussion

Kontrollierte Studien zur Langzeitnachsorge unter Einbeziehung der stationären Rehabilitation sind anzustreben. Auch Prärehabilitation sollte in diesen Kontext einbezogen werden.

[Influence of the donor age on graft survival : Is the demographic change also important for corneal tissue donation?]

The success of corneal transplantation highly depends on the quality of the used graft. Various factors play a crucial role such as a perfect stroma without optically relevant, centrally located cloudiness or changes (e. g. scars) or an adherent Descemet membrane. One of the most important parameters is the quality of the endothelial cell layer with a sufficiently large endothelial cell count. An open question is so far whether the donor age affects corneal quality and therefore has an impact on the success of transplantation. A comprehensive review of the available literature revealed that a large amount of scientific data on the influence of donor age exist to answer this question. In a variety of studies, no significant dependence of graft quality of donor age could be detected. Rather the studies prove that graft survival depends primarily on the state of the endothelial cell layer, and postoperative endothelial cell loss must be considered as a major cause of graft failure. Extensive quality assurance procedures in tissue preparation and cornea processing in the eye banks in Germany (Europe) ensures that only corneas with tested high quality are allocated for transplantation regardless of the donor age. Against the background of an aging population, the use of grafts from older donors should not be waived.

[Immunosuppression and its use in kidney transplantation]

BACKGROUND

Current immunosuppressive protocols effectively prevent acute rejection of renal allografts. Extensive drug toxicity and the deleterious effects of long-term immunosuppression are associated with significant morbidity and mortality.

OBJECTIVES

The purpose of this article is to provide an overview over modern immunosuppressants and their unwanted side effects and to discuss strategies for improved long-term transplant survival.

METHODS

Review of the current topic-related literature and discussion of our own experience.

RESULTS

The use of antibody induction together with an initial combination therapy of calcineurin inhibitors, mycophenolate and steroids is recommended and results in excellent early outcomes. Detrimental effects include an increased incidence of infections, malignomas, and cardiovascular diseases. Long-term transplant survival is impaired by extensive drug toxicity and the frequent development of donor specific antibodies. Reduction of overall cumulative exposure to immunosuppressants or the reduction of specific toxic drugs such as calcineurin inhibitors and steroids may improve long-term results. Alternative immunosuppressants like mTOR inhibitors and belatacept appear to be effective and safe but their long-term effects on patient and allograft survival needs to be established in clinical trials.

CONCLUSIONS

Current immunosuppressants provide effective protection from renal allograft rejection. However, their use is complicated by serious side effects. In the future, development of novel immunosuppressants and optimization of minimization strategies may help to improve long-term success after kidney transplantation.

Pros and Cons: Usage of organs from donors infected with hepatitis C virus - Revision in the direct-acting antiviral era

Should organs from hepatitis C antibody positive donors (HCVD+) be used for transplantation? Organ shortage forces transplant teams to use donors with extended criteria. The decision to transplant a HCVD+ graft is a balance between the risk of transmission of a virus that could lead to end-stage liver diseases and the benefit of access to transplantation, specifically in patients with life-threatening disease. The other issue is the impact of HCV-related liver fibrosis in the donor graft on the long-term outcome in the recipient. Thus, the use of HCVD+ demonstrated a shorter meantime on the waiting list in kidney transplantation. When a HCVD+ graft is transplanted, the risk of HCV transmission depends on; 1) the quality of screening of the donor; 2) the presence of viral replication in the donor at the time of transplantation and the ability to detect it; and 3) the HCV status of the recipient but also the type of transplanted organ. In liver transplantation, the use of HCVD+ graft is usually restricted to recipients with a chronic HCV infection. Several reports showed some competition between HCV donor and recipient strain without deleterious impact on graft and patient survival. Controversies are still pending regarding the quality of the graft and the progression of fibrosis. The recent approval of direct-acting antiviral agents (DAA) dramatically changes the landscape of HCV infection treatment. After transplantation, combinations of DAA show high efficacy and good safety profile. In the near future, extensive use of DAA should reduce the number of HCVD+ with a positive HCV RNA, limiting the risk of transmission but also the number of patients on waiting lists for a disease related to HCV.

Relationship between nitrogen concentration, light, and Zostera marina habitat quality and survival in southeastern Massachusetts estuaries

The relationship of eelgrass survival and habitat quality to water column nitrogen level, phytoplankton biomass, particulate matter, bottom light intensity, and light attenuation was quantified at 70 sites within 19 Massachusetts estuaries through 4 growing seasons (2007-2009, 2011). Sites included a range of eelgrass habitat quality, from stable productive eelgrass beds, to degraded beds, to areas that have lost all eelgrass coverage. Survival of transplanted eelgrass culms was used as a bio-indicator of habitat quality. Habitat quality based upon both changes in stability of eelgrass coverage and transplant survival was positively related to light intensity and percent transmittance. Transplant survival was consistent with habitat designations based upon long-term changes in eelgrass coverage, with lowest light coinciding with areas that lost eelgrass in earlier decades. Bottom light declined in proportion to increases in total nitrogen levels, phytoplankton biomass, and water column particulates determined from long-term water quality data. Field surveys indicated that eelgrass survival required bottom light ≥100 μE/m(2)/s and healthy eelgrass existed where tidally-averaged total nitrogen was less than 0.34 mg/L, equivalent to a mid-ebb tide water-column total nitrogen of <0.37 mg/L. Traditional sampling of water column nitrogen at mid-ebb tide was found to slightly overestimate the average nitrogen level over a complete tidal cycle. However, since long-term, ebb-tide and tidally-averaged total nitrogen are correlated, it is possible to use the monitoring average to guide management until tidally-averaged TN becomes available. Nitrogen thresholds that support eelgrass communities provide a fundamental tool for managing this habitat and for selection of transplant sites aimed at accelerating restoration of this resource under increasing nitrogen loading of the coastal zone.