• Aged
• Humans
• Graft Rejection/epidemiology
• Graft Survival
• Kidney
• Kidney Transplantation
• Prospective Studies
• Retrospective Studies
• Tissue Donors
• Treatment Outcome
• Middle Aged

• Aged, 70 and over
• Donor selection
• Graft survival
• Kidney transplantation

To evaluate the outcomes of kidney transplantations (KTs) in the Eurotransplant Senior Program (ESP) with a focus on the very old, defined as recipients ≥75 years. This retrospective clinical study included 85 patients, who under the ESP protocol underwent deceased donor kidney transplantation from January 2010 to July 2018 at the Charité–Universitätsmedizin Berlin in Germany. Recipients were divided in three age groups, i.e., Group 65–69, Group 70–74, Group ≥75, and compared. Prognostic risk factors for short and long-term outcomes of kidney transplantations were investigated. Graft survival at 1 and 5 years were respectively 90.7% and 68.0% for group 65–69, 88.9% and 76.2% for Group 70–74, and 100% and 71.4% for Group ≥75. Patient survival at 1 and 5 years were respectively 92.9% and 68.0% for Group 65–69, 85.7% and 61.5% for Group 70–74 and 100% and 62.5% for Group ≥75. Serum creatinine did not significantly differ between the three groups, with the exception of serum creatinine at 1 year. Increased recipient age and prolonged time on dialysis correlated with increased occurrence of postoperative complication. An increase in BMI, pretransplant diabetes mellitus and prolonged time on dialysis correlated with the occurrence of delayed graft function (DGF). History of smoking was identified as an independent risk factor for events of rejection. Increased human leukocyte antigen mismatches (HLA-MM) and prolonged cold ischemia time (CIT) correlated with higher rates of intensive care unit (ICU) treatment. This study supports kidney transplantations for the very old. End-stage renal disease (ESRD) patients ≥75 years of age who underwent kidney transplantation experienced comparable results to their younger counterparts. A comprehensive evaluation of ESRD patients with consideration of prognostic risk factor is the most suitable mean of identifying adequate kidney transplant candidates.

• Eurotransplant Senior Program
• cold ischemia time
• delayed graft function
• end-stage renal disease
• intensive care unit
• kidney transplantation

• deceased donor transplantation
• kidney transplantation
• marginal donor

The 5-year graft survival rate of donor kidneys transplanted in the Eurotransplant Senior Program (ESP) is only 47 per cent. Normothermic machine perfusion (NMP) may be a new preservation technique that improves graft outcome. This pilot study aimed to assess safety and feasibility of this technique within the ESP.

Recipients were eligible for inclusion if they received a donor kidney within the ESP. Donor kidneys underwent 2 h of oxygenated NMP with a red cell-based solution at 37°C, additional to standard-of-care preservation (non-oxygenated hypothermic machine perfusion). The primary outcome was the safety and feasibility of NMP. As a secondary outcome, graft outcome was investigated and compared with that in a historical group of patients in the ESP and the contralateral kidneys.

Eleven patients were included in the NMP group; the function of eight kidneys could be compared with that of the contralateral kidney. Fifty-three patients in the ESP, transplanted consecutively between 2016 and 2018, were included as controls. No adverse events were noted, especially no arterial thrombosis or primary non-function of the transplants. After 120 min of oxygenated NMP, median flow increased from 117 (i.q.r. 80–126) to 215 (170–276) ml/min (P = 0.001). The incidence of immediate function was 64 per cent in the NMP group and 40 per cent in historical controls (P = 0.144). A significant difference in graft outcome was not observed.

This pilot study showed NMP to be safe and feasible in kidneys transplanted in the ESP. A well powered study is warranted to confirm these results and investigate the potential advantages of NMP on graft outcome.

• donation
• expanded donor pool
• kidney clinical
• outcome

• Age Factors
• Aged
• Allografts
• Europe
• Graft Survival
• Humans
• Kidney
• Kidney Transplantation
• Middle Aged
• Tissue Donors
• Tissue and Organ Procurement

• Clinical Decision-Making
• Consensus
• Decision Support Techniques
• Humans
• Kidney Failure, Chronic/diagnosis
• Kidney Failure, Chronic/surgery
• Kidney Transplantation/adverse effects
• Kidney Transplantation/standards
• Patient Selection
• Predictive Value of Tests
• Risk Assessment
• Risk Factors

Prognostic models for 3-year mortality after kidney transplantation based on pre-transplant donor and recipient variables may avoid futility and thus improve donor organ allocation.

There were 1546 consecutive deceased-donor kidney transplants in adults (January 1, 2000 to December 31, 2012) used to identify pre-transplant donor and recipient variables with significant independent influence on long-term survival (Cox regression modelling). Detected factors were used to develop a prognostic model for 3-year mortality in 1289 patients with follow-up of >3 years (multivariable logistic regression). The sensitivity and specificity of this model’s prognostic ability was assessed with the area under the receiver operating characteristic curve (AUROC).

Highly immunized recipients [hazard ratio (HR: 2.579, 95% CI: 1.272–4.631], high urgency recipients (HR: 3.062, 95% CI: 1.294–6.082), recipients with diabetic nephropathy (HR: 3.471, 95% CI: 2.476–4.751), as well as 0, 1, or 2 HLA DR mismatches (HR: 1.349, 95% CI: 1.160–1.569) were independent and significant risk factors for patient survival. Younger recipient age ≤42.1 years (HR: 0.137, 95% CI: 0.090–0.203), recipient age 42.2–52.8 years (HR: 0.374, 95% CI: 0.278–0.498), recipient age 52.9–62.8 years (HR: 0.553, 95% CI: 0.421–0.723), short cold ischemic times ≤11.8 hours (HR: 0.602, 95% CI: 0.438–0.814) and cold ischemic times 11.9–15.3 hours (HR: 0.736, 95% CI: 0.557–0.962) reduced this risk independently and significantly. The AUROC of the derived model for 3-year post-transplant mortality with these variables was 0.748 (95% CI: 0.689–0.788).

Older, highly immunized or high urgency transplant candidates with anticipated longer cold ischemic times, who were transplanted with the indication of diabetic nephropathy should receive donor organs with no HLA DR mismatches to improve their mortality risk.

• Brain dead
• Coordinador de trasplantes
• Donación de órganos
• Intensive care unit
• Muerte cerebral
• Organ donation
• Transplant coordinator
• Unidad de cuidados intensivos

The widening gap between demand and supply of organs for transplantation provides extraordinary challenges for ethical donor organ allocation rules. The transplant community is forced to define favorable recipient/donor combinations for simultaneous kidney-pancreas transplantation. The aim of this study is the development of a prognostic model for the prediction of kidney function 1 year after simultaneous pancreas and kidney transplantation using pre-transplant donor and recipient variables with subsequent internal and external validation.

Included were patients with end-stage renal failure due to diabetic nephropathy. Multivariable logistic regression modeling was applied for prognostic model design with retrospective data from Hannover Medical School, Germany (01.01.2000–31.12.2011) followed by prospective internal validation (01 Jan. 2012–31 Dec. 2015). Retrospective data from another German transplant center in Kiel was retrieved for external model validation via the initially derived logit link function.

The developed prognostic model is able to predict kidney graft function 1 year after transplantation ≥ KDIGO stage III with high areas under the receiver operating characteristic curve in the development cohort (0.943) as well as the internal (0.807) and external validation cohorts (0.784).

The proposed validated model is a valuable tool to optimize present allocation rules with the goal to prevent transplant futility. It might be used to support donor organ acceptance decisions for individual recipients.

The online version of this article (10.1007/s00423-018-1712-z) contains supplementary material, which is available to authorized users.

• Diabetic nephropathy
• Donor variables
• Post-transplant graft function
• Prognostic scores
• Recipient variables
• Simultaneous pancreas kidney transplantation

• donation after brain death
• donation after cardiac death
• expanded criteria donor
• graft survival
• kidney transplantation
• patient survival

• NKG2D
• kidney
• senescence
• zero-hour biopsy

• calcineurin inhibitor: cyclosporine A (CsA)
• clinical research/practice
• donors and donation: deceased
• donors and donation: donation after circulatory death (DCD)
• donors and donation: extended criteria
• immunosuppressant
• kidney transplantation/nephrology

Demand for deceased donor kidneys has exceeded supply in Australia over the past 2 decades. With a desire to use as many donor organs as possible, the health characteristics of accepted donors may have changed over time.

All deceased kidney donors actually transplanted in Australia between January 1, 1994, and December 31, 2013, were retrospectively analyzed, using data from the Australian and New Zealand Organ Donor Registry.

Of 4172 deceased donors, 57% were men. Mean donor age increased from 37.2 ± 16.8 years to 46.1 ± 17.7 years over time, and donor numbers increased from 162 in 1994 to 334 in 2013. As the primary cause of death, motor vehicle accidents decreased from 27% to 12%, whereas cerebral pathology persisted at 50%. There was an increase in the proportion of donors with hypertension (12% to 24%), diabetes (2% to 7%), and an increase in mean body mass index (24.4 ± 4.4 kg/m² to 27.5 ± 6.3 kg/m²) between 1994 and 2013. These changes were reflected by an increase in the median kidney donor risk index from 1.08 (interquartile range, 0.85-1.25) to 1.32 (interquartile range, 0.95-1.53). The proportion of medically higher risk donors increased over time.

Because deceased kidney donor numbers have increased, the range of donor quality has broadened, with an increase in both the proportion and number of high-risk donors, as well as a decline in donor quality. These data highlight the need for kidney allocation algorithms to evolve to ensure appropriate allocation of deceased donor kidneys.

The growing gap between demand and supply for kidney transplants has led to renewed interest in the use of expanded criteria donor (ECD) kidneys in an effort to increase the donor pool. Although most studies of ECD kidney transplantation confirm lower allograft survival rates and, generally, worse outcomes than standard criteria donor kidneys, recipients of ECD kidneys generally have improved survival compared with wait-listed dialysis patients, thus encouraging the pursuit of this type of kidney transplantation. The relative benefits of transplantation using kidneys from ECDs are dependent on patient characteristics and the waiting time on dialysis. Because of the increased risk of poor graft function, calcineurin inhibitor (CNI)-induced nephrotoxicity, increased incidence of infections, cardiovascular risk, and malignancies, elderly recipients of an ECD kidney transplant are a special population that requires a tailored immunosuppressive regimen. Recipients of ECD kidneys often are excluded from transplant trials and, therefore, the optimal induction and maintenance immunosuppressive regimen for them is not known. Approaches are largely center specific and based upon expert opinion. Some data suggest that antithymocyte globulin might be the preferred induction agent for elderly recipients of ECD kidneys. Maintenance regimens that spare CNIs have been advocated, especially for older recipients of ECD kidneys. CNI-free regimens are not universally accepted due to occasionally high rejection rates. However, reduced CNI exposure and CNI-free regimens based on mammalian target of rapamycin inhibitors have shown acceptable outcomes in appropriately selected ECD transplant recipients.

• Expanded-criteria donors
• Outcomes
• Kidney transplantation
• Immunosuppression
• Survival

• diabetes
• obesity
• organ donor
• donation after cardiac death
• forecast

Acute kidney injury (AKI) affects roughly 25% of all recipients of deceased donor organs. The prevention of post-transplant AKI is still an unmet clinical need. We prospectively collected zero-hour, indication as well as protocol kidney biopsies from 166 allografts between 2011 and 2013. In this cohort eight cases with AKI and ten matched allografts without pathology serving as control group were identified with a follow-up biopsy within the first twelve days after engraftment. For this set the zero-hour and follow-up biopsies were subjected to genome wide microRNA and mRNA profiling and analysis, followed by validation in independent expression profiles of 42 AKI and 21 protocol biopsies for strictly controlling the false discovery rate. Follow-up biopsies of AKI allografts compared to time-matched protocol biopsies, further baseline adjustment for zero-hour biopsy expression level and validation in independent datasets, revealed a molecular AKI signature holding 20 mRNAs and two miRNAs (miR-182-5p and miR-21-3p). Next to several established biomarkers such as lipocalin-2 also novel candidates of interest were identified in the signature. In further experimental evaluation the elevated transcript expression level of the secretory leukocyte peptidase inhibitor (SLPI) in AKI allografts was confirmed in plasma and urine on the protein level (p<0.001 and p = 0.003, respectively). miR-182-5p was identified as a molecular regulator of post-transplant AKI, strongly correlated with global gene expression changes during AKI. In summary, we identified an AKI-specific molecular signature providing the ground for novel biomarkers and target candidates such as SLPI and miR-182-5p in addressing AKI.

• Age Factors
• Aged
• Aged, 80 and over
• Aging
• Geriatric Assessment
• Humans
• Middle Aged
• Predictive Value of Tests
• Prevalence
• Renal Dialysis
• Renal Insufficiency, Chronic/diagnosis
• Renal Insufficiency, Chronic/epidemiology
• Renal Insufficiency, Chronic/therapy
• Risk Assessment
• Risk Factors
• Treatment Outcome

With a growing shortage of organs for transplantation, finding ways of increasing the donor organ pool remains of utmost importance. Perfusion machines (PM) have been proven to enhance the potential for kidney transplants to function sooner, last longer, giving patients the opportunity for a better life quality.

The aim of this study is to evaluate the relation between the resistance index provided by the PM, the postoperative resistance index measured by Doppler ultrasound and the initial graft outcome.

Between January 2012-December 2012, clinical data obtained from 82 consecutive renal transplants from brain death donors (BDD) which underwent PM maintenance were analyzed in a transversal study. Prior transplantation we recorded the solution temperature, filtration rate and the resistance index provided by PM. After the surgical intervention, each patient had standard follow-up. Doppler ultrasound resistivity index (RI) was recorded on the first postoperative day.

Out of 115 renal transplants, 98 (85.21%) were performed with grafts from BDD. The PM was used for 82 renal grafts. The Doppler resistance index in relation to the resistance index shows a highly statistical correlation by linear regression (R=0.813, p<0.0001). Primary graft function was recorded in 74 patients (90.24%) and it was highly statistically significant correlated with the resistance index measured by PM. Out of 8 patients with primary non-function, 6 patients recovered with normal graft function at one year.

The resistivity index recorded by the life-port machine is correlated with the vascular resistivity index measured by Doppler ultrasound and thus it may predicts the primary graft outcome.

• Graft quality
• perfusion machine
• post-transplant Doppler ultrasound
• renal transplantation