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Patil VD, Yensani PR, Prasad V, Nuthalapati M, Agrawal S, Menon AR, Kumar PG. Partial nephrectomy for a completely endophytic tumor in an allograft kidney, 14 years after transplantation. Indian J Urol 2025; 41:145-147. [PMID: 40292375 PMCID: PMC12021362 DOI: 10.4103/iju.iju_135_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 08/31/2024] [Accepted: 09/01/2024] [Indexed: 04/30/2025] Open
Abstract
We report our experience with nephron-sparing surgery for a completely endophytic small renal mass in an allograft kidney. A 37-year-old female, 14 years post live-related renal transplant for end-stage renal disease due to crescentic glomerulonephritis, presented with a 3.6 cm renal mass. She underwent open allograft partial nephrectomy and was discharged on the 5th postoperative day. Six months postsurgery, she showed excellent graft function with no tumor recurrence. Nephron-sparing surgery of the allograft kidney presents challenges regarding vascular anatomy, hilar, and parenchymal adhesions making the surgery difficult, but is feasible and oncologically safe for transplant recipients with tumors in the allograft kidney.
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Affiliation(s)
- Vivek Dadasaheb Patil
- Department of Urooncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | | | - Vishnu Prasad
- Department of Urooncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Mounish Nuthalapati
- Department of Urooncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Shashank Agrawal
- Department of Urooncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Arun Ramdas Menon
- Department of Urooncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - P. Ginil Kumar
- Department of Urooncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Khairallah P, Lorenz EC, Waterman A, Aggarwal N, Pai A, Winkelmayer WC, Niu J. Trends in Kidney Allograft Failure Among First-Time Transplant Recipients in the United States. Am J Kidney Dis 2025; 85:273-283.e1. [PMID: 39521400 DOI: 10.1053/j.ajkd.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 08/28/2024] [Accepted: 09/17/2024] [Indexed: 11/16/2024]
Abstract
RATIONALE & OBJECTIVE The management and outcomes of kidney transplant recipients have evolved over the past 3 decades. This study of US patients whose first kidney allograft failed examined long-term trends in subsequent waitlisting, retransplantation, and all-cause mortality. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Patients recorded in the US Renal Data System (USRDS) whose first kidney allograft failed between 1990 and 2019. EXPOSURE The 5-year period in which the allograft failure occurred: 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014, or 2015-2019. OUTCOME (1) Waitlisting for retransplantation, (2) retransplantation, and (3) all-cause mortality following first allograft failure. ANALYTICAL APPROACH Competing risk survival analyses with the approach described by Fine and Gray used for the outcomes of waitlisting and retransplantation, and Cox proportional hazards models used for the outcome of all-cause mortality. RESULTS The absolute number of patients whose allograft failed and who started dialysis increased from 3,197 in 1990 to 5,821 in 2019. Compared with 1990-1994, the rate of waitlisting for a second transplant increased with each subsequent 5-year period, peaking between 2005 and 2009 before decreasing again subsequently. The rate of retransplantation following allograft failure decreased by 9%, 14%, 18%, 7%, and 11% in the sequential 5-year eras; and the mortality rate was 25% lower in 2015-2019 (HR, 0.75 [95% CI, 0.72-0.77]) compared with 1990-1994. Women had a reduced rate of waitlisting (HR, 0.93 [95% CI, 0.91-0.95]) and lower rate of retransplantation (HR, 0.93 [95% CI, 0.91-0.95]) compared with men. Compared with White patients, African American and Hispanic patients had significantly lower rates of waitlisting, retransplantation, and mortality. LIMITATIONS Retrospective data that lacks granular clinical information. CONCLUSIONS During the past 3 decades, among patients whose first kidney allograft failed and subsequently initiated dialysis, the rates of waitlisting for retransplantation increased while the rates of retransplantation and mortality decreased. Disparities based on race, ethnicity, and sex in waitlisting and retransplantation were observed and warrant further investigation. PLAIN-LANGUAGE SUMMARY Kidney allograft failure constitutes the fourth most common cause of dialysis initiation in the United States, and it accounts for 4% to 10% of yearly new dialysis starts globally. Little is known about the trends in the outcomes of patients whose kidney allograft failed. We studied US patients whose first kidney allograft failed between 1990 and 2019 to understand trends in waitlisting for retransplantation, retransplantation, and all-cause mortality after kidney allograft failure. Among patients whose first kidney allograft failed and started dialysis, rates of waitlisting increased and rates of retransplantation and mortality decreased over the past 3 decades. We found racial, ethnic, and sex-based disparities in outcomes. Compared with White patients, African American and Hispanic patients had significantly lower rates of waitlisting, retransplantation, and mortality. Women also had lower rates of waitlisting and retransplantation compared with men.
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Affiliation(s)
| | | | - Amy Waterman
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Nidhi Aggarwal
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Akshta Pai
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | | | - Jingbo Niu
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
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Slominska A, Loban K, Kinsella EA, Ho J, Sandal S. Supportive care in transplantation: A patient-centered care model to better support kidney transplant candidates and recipients. World J Transplant 2024; 14:97474. [PMID: 39697448 PMCID: PMC11438939 DOI: 10.5500/wjt.v14.i4.97474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/31/2024] [Accepted: 08/06/2024] [Indexed: 09/20/2024] Open
Abstract
Kidney transplantation (KT), although the best treatment option for eligible patients, entails maintaining and adhering to a life-long treatment regimen of medications, lifestyle changes, self-care, and appointments. Many patients experience uncertain outcome trajectories increasing their vulnerability and symptom burden and generating complex care needs. Even when transplants are successful, for some patients the adjustment to life post-transplant can be challenging and psychological difficulties, economic challenges and social isolation have been reported. About 50% of patients lose their transplant within 10 years and must return to dialysis or pursue another transplant or conservative care. This paper documents the complicated journey patients undertake before and after KT and outlines some initiatives aimed at improving patient-centered care in transplantation. A more cohesive approach to care that borrows its philosophical approach from the established field of supportive oncology may improve patient experiences and outcomes. We propose the "supportive care in transplantation" care model to operationalize a patient-centered approach in transplantation. This model can build on other ongoing initiatives of other scholars and researchers and can help advance patient-centered care through the entire care continuum of kidney transplant recipients and candidates. Multi-dimensionality, multi-disciplinarity and evidence-based approaches are proposed as other key tenets of this care model. We conclude by proposing the potential advantages of this approach to patients and healthcare systems.
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Affiliation(s)
- Anita Slominska
- MEDIC Program, Research Institute of the McGill University Health Centre, Montreal H4A3J1, QC, Canada
| | - Katya Loban
- MEDIC Program, Research Institute of the McGill University Health Centre, Montreal H4A3J1, QC, Canada
| | - Elizabeth Anne Kinsella
- Institute of Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal H4A3J1, QC, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg R3A1R9, MB, Canada
| | - Shaifali Sandal
- Department of Medicine, McGill University Health Centre, Montreal H4A3J1, QC, Canada
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Tessmer P, Weigle CA, Meyer A, Wiemann BA, Gwinner W, Einecke G, Klempnauer J, Vondran FWR, Richter N, Oldhafer F, Beetz O. Kidney re-transplantation in the ipsilateral iliac fossa: a surgeon's perspective on perioperative outcome. Clin Kidney J 2024; 17:sfae271. [PMID: 39323730 PMCID: PMC11422716 DOI: 10.1093/ckj/sfae271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Indexed: 09/27/2024] Open
Abstract
Background Compared with primary transplantation, ipsilateral renal re-transplantation is associated with an increased risk of surgical complications and inferior graft outcomes. This study investigates whether an ipsilateral re-transplantation approach per se is an independent risk factor for surgical complications and early graft loss. Methods In this retrospective, single-centre analysis, surgical complications and early graft outcomes of ipsilateral kidney re-transplantations from January 2007 to December 2017 were compared with primary transplantations and contralateral re-transplantations. Univariate and multivariate binary logistic regression analyses were performed to identify risk factors for surgical complications requiring surgical revision and graft loss within the first year after transplantation. Results Of the 1489 kidney transplantations, 51 were ipsilateral, 159 were contralateral re-transplantations and 1279 were primary transplantations. Baseline characteristics did not differ between the ipsilateral and contralateral re-transplant recipients except for current and highest panel reactive antibody levels. Major complications requiring surgical revision were significantly more frequent in ipsilateral re-transplantations (P = .010) than in primary transplantations but did not differ between ipsilateral and contralateral re-transplantations (P = .217). Graft loss within the first year after transplant was 15.7% in the ipsilateral versus 8.8% in the contralateral re-transplant group (P = .163) versus 6.4% in the primary transplantation group (P = .009). In a multivariate regression model, ipsilateral re-transplantation was not identified as an independent risk factor for complications requiring surgical revision or first-year graft loss. Conclusions Ipsilateral renal re-transplantation is not a risk factor for inferior outcomes. Graft implantation into a pre-transplanted iliac fossa is a feasible and valid therapeutic option.
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Affiliation(s)
- Philipp Tessmer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Clara A Weigle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Anna Meyer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Bengt A Wiemann
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Wilfried Gwinner
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Gunilla Einecke
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
- Department of Nephrology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Department of General, Visceral, Pediatric and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Oldhafer
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Department of General, Visceral, Pediatric and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Oliver Beetz
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Department of General, Visceral, Pediatric and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
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Tran J, Alrajhi I, Chang D, Sherwood KR, Keown P, Gill J, Kadatz M, Gill J, Lan JH. Clinical relevance of HLA-DQ eplet mismatch and maintenance immunosuppression with risk of allosensitization after kidney transplant failure. Front Genet 2024; 15:1383220. [PMID: 38638120 PMCID: PMC11024336 DOI: 10.3389/fgene.2024.1383220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/21/2024] [Indexed: 04/20/2024] Open
Abstract
The optimal immunosuppression management in patients with a failed kidney transplant remains uncertain. This study analyzed the association of class II HLA eplet mismatches and maintenance immunosuppression with allosensitization after graft failure in a well characterized cohort of 21 patients who failed a first kidney transplant. A clinically meaningful increase in cPRA in this study was defined as the cPRA that resulted in 50% reduction in the compatible donor pool measured from the time of transplant failure until the time of repeat transplantation, death, or end of study. The median cPRA at the time of failure was 12.13% (interquartile ranges = 0.00%, 83.72%) which increased to 62.76% (IQR = 4.34%, 99.18%) during the median follow-up of 27 (IQR = 18, 39) months. High HLA-DQ eplet mismatches were significantly associated with an increased risk of developing a clinically meaningful increase in cPRA (p = 0.02) and de novo DQ donor-specific antibody against the failed allograft (p = 0.02). We did not observe these associations in patients with high HLA-DR eplet mismatches. Most of the patients (88%) with a clinically meaningful increase in cPRA had both a high DQ eplet mismatch and a reduction in their immunosuppression, suggesting the association is modified by immunosuppression. The findings suggest HLA-DQ eplet mismatch analysis may serve as a useful tool to guide future clinical studies and trials which assess the management of immunosuppression in transplant failure patients who are repeat transplant candidates.
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Affiliation(s)
- Jenny Tran
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ibrahim Alrajhi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Doris Chang
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Karen R. Sherwood
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul Keown
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jagbir Gill
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Providence Health Care Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Matthew Kadatz
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Gill
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Providence Health Care Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James H. Lan
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Noguchi H, Miyamoto K, Matsukuma Y, Ueki K, Tsuchimoto A, Nakano T, Kaba A, Sato Y, Kubo S, Kaku K, Okabe Y, Nakamura M. A Single-Center Retrospective Study of Re-Transplantation After Allograft Failure in Kidney Transplant Recipients. Transplant Proc 2024; 56:488-493. [PMID: 38326204 DOI: 10.1016/j.transproceed.2024.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/23/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND This study aimed to examine the outcomes of kidney retransplantation in patients with allograft failure at Kyushu University. METHODS We reviewed data from 1043 consecutive patients (including 1001 in a first kidney transplantation [KT] group and 42 in a second KT group) who had undergone KT alone at our institution between January 2008 and September 2022. We also studied immunologic risks and outcomes of patients who had undergone preoperative testing for KT at Kyushu University during the same period. RESULTS No patient received more than 2 transplants. Donor-specific anti-HLA antibody (DSA) had been detected in a greater percentage of patients in the second KT group than in the first (31% vs 11%, respectively; P < .001). There were no significant differences in 5-year death-censored/overall graft survival rates, rates of surgical complications, or incidence of delayed graft function between the groups. During the study period, significantly more candidates for second than first KT were rejected for this procedure because of their high immunologic risk (20% vs 2%, P < 001). Seven of the 42 patients in the second KT group required the removal of the primary graft during the second transplantation. CONCLUSION There is a higher percentage of patients whose DSA has been detected among patients undergoing retransplantation after allograft failure than among those receiving first KTs, which often leads to remaining on the waiting list in the former group. However, if the immunologic risk is within acceptable limits, the graft survival for retransplantation is not inferior to that of a first KT.
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Affiliation(s)
- Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kyoko Miyamoto
- Center for Cellular and Molecular Medicine, Kyushu University, Fukuoka, Japan
| | - Yuta Matsukuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akari Kaba
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yu Sato
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinsuke Kubo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Sandal S, Ahn JB, Chen Y, Massie AB, Clark-Cutaia MN, Wu W, Cantarovich M, Segev DL, McAdams-DeMarco MA. Trends in the survival benefit of repeat kidney transplantation over the past 3 decades. Am J Transplant 2023; 23:666-672. [PMID: 36731783 PMCID: PMC10269548 DOI: 10.1016/j.ajt.2023.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/19/2023] [Indexed: 02/01/2023]
Abstract
Repeat kidney transplantation (re-KT) is the preferred treatment for patients with graft failure. Changing allocation policies, widening the risk profile of recipients, and improving dialysis care may have altered the survival benefit of a re-KT. We characterized trends in re-KT survival benefit over 3 decades and tested whether it differed by age, race/ethnicity, sex, and panel reactive assay (PRA). By using the Scientific Registry of Transplant Recipient data, we identified 25 419 patients who underwent a re-KT from 1990 to 2019 and 25 419 waitlisted counterfactuals from the same year with the same waitlisted time following graft failure. In the adjusted analysis, a re-KT was associated with a lower risk of death (adjusted hazard ratio [aHR] = 0.63; 95% confidence interval [CI], 0.61-0.65). By using the 1990-1994 era as a reference (aHR = 0.77; 95% CI, 0.69-0.85), incremental improvements in the survival benefit were noted (1995-1999: aHR = 0.72; 95% CI, 0.67-0.78: 2000-2004: aHR = 0.59; 95% CI, 0.55-0.63: 2005-2009: aHR = 0.59; 95% CI, 0.56-0.63: 2010-2014: aHR = 0.57; 95% CI, 0.53-0.62: 2015-2019: aHR = 0.64; 95% CI, 0.57-0.73). The survival benefit of a re-KT was noted in both younger (age = 18-64 years: aHR = 0.63; 95% CI, 0.61-0.65) and older patients (age ≥65 years: aHR = 0.66; 95% CI, 0.58-0.74; Pinteraction = .45). Patients of all races/ethnicities demonstrated similar benefits with a re-KT. However, it varied by the sex of the recipient (female patients: aHR = 0.60; 95% CI, 0.56-0.63: male patients: aHR = 0.66; 95% CI, 0.63-0.68; Pinteraction = .004) and PRA (0-20: aHR = 0.69; 95% CI, 0.65-0.74: 21-80: aHR = 0.61; 95% CI, 0.57-0.66; Pinteraction = .02; >80: aHR = 0.57; 95% CI, 0.53-0.61; Pinteraction< .001). Our findings support the continued practice of a re-KT and efforts to overcome the medical, immunologic, and surgical challenges of a re-KT.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | - JiYoon B Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yusi Chen
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Allan B Massie
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Maya N Clark-Cutaia
- Department of Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Wenbo Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York, USA; Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
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8
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Thongprayoon C, Vaitla P, Jadlowiec CC, Mao SA, Mao MA, Acharya PC, Leeaphorn N, Kaewput W, Pattharanitima P, Tangpanithandee S, Krisanapan P, Nissaisorakarn P, Cooper M, Cheungpasitporn W. Differences between kidney retransplant recipients as identified by machine learning consensus clustering. Clin Transplant 2023; 37:e14943. [PMID: 36799718 DOI: 10.1111/ctr.14943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/13/2022] [Accepted: 02/11/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Our study aimed to characterize kidney retransplant recipients using an unsupervised machine-learning approach. METHODS We performed consensus cluster analysis based on the recipient-, donor-, and transplant-related characteristics in 17 443 kidney retransplant recipients in the OPTN/UNOS database from 2010 to 2019. We identified each cluster's key characteristics using the standardized mean difference of >.3. We compared the posttransplant outcomes, including death-censored graft failure and patient death among the assigned clusters RESULTS: Consensus cluster analysis identified three distinct clusters of kidney retransplant recipients. Cluster 1 recipients were predominantly white and were less sensitized. They were most likely to receive a living donor kidney transplant and more likely to be preemptive (30%) or need ≤1 year of dialysis (32%). In contrast, cluster 2 recipients were the most sensitized (median PRA 95%). They were more likely to have been on dialysis >1 year, and receive a nationally allocated, low HLA mismatch, standard KDPI deceased donor kidney. Recipients in cluster 3 were more likely to be minorities (37% Black; 15% Hispanic). They were moderately sensitized with a median PRA of 87% and were also most likely to have been on dialysis >1 year. They received locally allocated high HLA mismatch kidneys from standard KDPI deceased donors. Thymoglobulin was the most commonly used induction agent for all three clusters. Cluster 1 had the most favorable patient and graft survival, while cluster 3 had the worst patient and graft survival. CONCLUSION The use of an unsupervised machine learning approach characterized kidney retransplant recipients into three clinically distinct clusters with differing posttransplant outcomes. Recipients with moderate allosensitization, such as those represented in cluster 3, are perhaps more disadvantaged in the kidney retransplantation process. Potential opportunities for improvement specific to these re-transplant recipients include working to improve opportunities to improve access to living donor kidney transplantation, living donor paired exchange and identifying strategies for better HLA matching.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Pradeep Vaitla
- Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Shennen A Mao
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Prakrati C Acharya
- Division of Nephrology, Texas Tech Health Sciences Center El Paso, El Paso, Texas, USA
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke's Health System, Kansas City, Missouri, USA
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Pitchaphon Nissaisorakarn
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Cooper
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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9
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Loban K, Horton A, Robert JT, Hales L, Parajuli S, McAdams-DeMarco M, Sandal S. Perspectives and experiences of kidney transplant recipients with graft failure: A systematic review and meta-synthesis. Transplant Rev (Orlando) 2023; 37:100761. [PMID: 37120965 DOI: 10.1016/j.trre.2023.100761] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Kidney transplant recipients with graft failure are a rapidly rising cohort of patients who experience high morbidity, mortality, and fragmented transitions of care between transplant and dialysis teams. Current approaches to improving care focus on medical and surgical interventions, increasing re-transplantation, and improving coordination between treating teams with little understanding of patient needs and perspectives. METHODS We undertook a systematic literature review of personal experiences of patients with graft failure. Six electronic and five grey literature databases were searched systematically. Of 4664 records screened 43 met the inclusion criteria. Six empirical qualitative studies and case studies were included in the final analysis. Thematic synthesis was used to combine data that included the perspectives of 31 patients with graft failure and 9 caregivers. RESULTS Using the Transition Model, we isolated three interconnected phases as patients transition through graft failure: shattering of lifestyle and plans associated with a successful transplant; physical and psychological turbulence; and re-alignment by learning adaptive strategies to move forward. Critical factors affecting coping included multi-disciplinary healthcare approaches, social support, and individual-level factors. While clinical transplant care was evaluated positively, participants identified gaps in the provision of information and psychosocial support related to graft failure. Graft failure had a profound impact on caregivers especially when they were living donors. CONCLUSIONS Our review reports patient-identified priorities for improving care and can help inform research and guideline development that strives to improve the care of patients with graft failure.
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Affiliation(s)
- Katya Loban
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Anna Horton
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jorane-Tiana Robert
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Lindsay Hales
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Shaifali Sandal
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
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10
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Elgenidy A, Shemies RS, Atef M, Awad AK, El-Leithy HH, Helmy M, Aly MG. Revisiting maintenance immunosuppression in patients with renal transplant failure: early weaning of immunosuppression versus prolonged maintenance-systematic review and meta-analysis. J Nephrol 2023; 36:537-550. [PMID: 36109426 DOI: 10.1007/s40620-022-01458-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/28/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Prolonged immunosuppression after dialysis start has been assumed to reduce sensitization, need for graft nephrectomy, and to favor re-transplantation. In contrast, immunosuppression is considered to increase the risk of mortality, infection, and malignancy. We aimed to assess the evidence regarding superiority of early or late withdrawal of maintenance immunosuppression post renal transplant failure. METHODS A literature search of the PubMed, WOS, Ovid, and Scopus databases was conducted. Combined relative risks, (RRs), mean differences, and 95% confidence intervals (CIs) were calculated by using a random-effect model. RESULTS Ten studies involving 1187 patients with kidney transplant failure were included. No difference could be detected between patients with early withdrawal of immunosuppressive drugs (≤ 3 months) or prolonged immunosuppressive treatment (> 3 months) regarding mortality (95% CI 0.91-2.28), panel reactive antibodies (PRAs) (95% CI - 0.75-30.10), re-transplantation rate (95% CI 0.55-1.35), infectious episodes (95% CI 0.67, 1.17), cancer (95% CI 0.26-1.54), and graft nephrectomy (95% CI 0.82-1.63). Similarly, no difference was found between immunosuppressive drug withdrawal over < 6 or ≥ 6 months regarding mortality (95% CI 0.16, 2.89), re-transplantation rate (95% CI 0.85-1.55), cancer (95% CI 0.37-1.63), and allograft nephrectomy (95% CI 0.87-4.33). CONCLUSION Prolonged maintenance immunosuppression post kidney transplant failure is not associated with increased risk of mortality, infection, or malignancy, or reduced risk of sensitization or allograft nephrectomy compared with early withdrawal.
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Affiliation(s)
| | - Rasha Samir Shemies
- Mansoura and Nephrology Dialysis Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mostafa Atef
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | | | | | - Mostafa G Aly
- Nephrology Unit, Internal Medicine Department, Assiut University, Assiut, Egypt.
- Transplantation Immunology, Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany.
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany.
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11
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Murakami N, Reich AJ, Pavlakis M, Lakin JR. Conservative Kidney Management in Kidney Transplant Populations. Semin Nephrol 2023; 43:151401. [PMID: 37499572 PMCID: PMC10543459 DOI: 10.1016/j.semnephrol.2023.151401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.
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Affiliation(s)
- Naoka Murakami
- Harvard Medical School, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Amanda J Reich
- Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Martha Pavlakis
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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12
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Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review. J Clin Med 2022; 11:6108. [PMID: 36294429 PMCID: PMC9605319 DOI: 10.3390/jcm11206108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Patients with a failed kidney allograft have steadily increase in recent years and returning to dialysis after graft loss is one of the most difficult transitions for chronic kidney disease patients and their assistant physicians. The management of these patients is complex and encompasses the treatment of chronic kidney disease complications, dialysis restart and access planning, immunosuppression withdrawal, graft nephrectomy, and evaluation for a potential retransplant. In recent years, several groups have focused on the management of the patient with a failing renal graft and expert recommendations are arising. A review of Pubmed, ScienceDirect and the Cochrane Library was performed focusing on the specific care of these patients, from the management of low clearance complications to concerns with a subsequent kidney transplant. Conclusion: There is a growing interest in the failing renal graft and new approaches to improve these patients' outcomes are being defined including specific multidisciplinary programs, individualized immunosuppression withdrawal schemes, and strategies to prevent HLA sensitization and increase retransplant rates.
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Affiliation(s)
- Rita Leal
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Clara Pardinhas
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - António Martinho
- Coimbra Histocompatibility Center, Portuguese Institute of Blood and Transplantation, 3041-861 Coimbra, Portugal
| | - Helena Oliveira Sá
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Urology and Kidney Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
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13
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Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:5753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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Affiliation(s)
- Rita Leal
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Clara Pardinhas
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - António Martinho
- Coimbra Histocompatibility Center, Portuguese Institute of Blood and Transplantation, 3041-861 Coimbra, Portugal
| | - Helena Oliveira Sá
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Urology and Kidney Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
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14
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Girerd S, Duarte K, Couchoud C, Laurain E, Courivaud C, Bauwens M, Kessler M, Frimat L, Girerd N. Association between kidney retransplantation and survival according to age in the French national cohort of dialysis patients. Am J Transplant 2022; 22:2028-2040. [PMID: 35510748 PMCID: PMC9542860 DOI: 10.1111/ajt.17081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/05/2022] [Accepted: 04/28/2022] [Indexed: 01/25/2023]
Abstract
The mean age of patients returning to dialysis after a first kidney transplantation (KT) has increased in the past decades. We aimed to assess the association between second KT (2KT) and survival according to age at the time of return to dialysis. Data of 5334 patients registered in the French Renal Epidemiology and Information Network (REIN) (mean age 56.6 ± 13.6 years) who returned to dialysis after a first KT were collected. The association of 2KT with death was assessed using a propensity score-based analysis taking into account baseline and follow-up variables. In relisted patients (3272 patients, 61.3%), retransplantation was associated with better overall survival in comparison with patients who remained in dialysis (adjusted HR 0.75 [0.63-0.89], p = .0009). The survival advantage conferred by retransplantation gradually declined with increasing age (adjusted HR 0.41 [0.24-0.70] in patients <50, HR 0.94 (0.69-1.27) in patients aged 70 or older, p for interaction 0.034 for age considered as a continuous variable). 2KT is associated with better survival as opposed to remaining on dialysis after a first kidney graft failure. Nevertheless, this survival benefit is age dependent and diminishes with increasing age. The risk/benefit ratio should be comprehensively assessed in the oldest patients when relisting is considered.
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Affiliation(s)
- Sophie Girerd
- Université de LorraineInsermCentre d’Investigations Cliniques‐ 1433, and Inserm U1116CHRU NancyF‐CRIN INI‐CRCTNancyFrance,Nephrology DepartmentUniversity Hospital of NancyVandoeuvre les NancyFrance
| | - Kevin Duarte
- Université de LorraineInsermCentre d’Investigations Cliniques‐ 1433, and Inserm U1116CHRU NancyF‐CRIN INI‐CRCTNancyFrance
| | | | - Emmanuelle Laurain
- Nephrology DepartmentUniversity Hospital of NancyVandoeuvre les NancyFrance
| | - Cécile Courivaud
- Department of Nephrology, Dialysis, and Renal TransplantationUniversity Hospital of BesançonBesançonFrance
| | - Marc Bauwens
- Department of Nephrology, Dialysis, and Renal TransplantationUniversity Hospital of PoitiersPoitiersFrance
| | - Michèle Kessler
- Nephrology DepartmentUniversity Hospital of NancyVandoeuvre les NancyFrance
| | - Luc Frimat
- Nephrology DepartmentUniversity Hospital of NancyVandoeuvre les NancyFrance
| | - Nicolas Girerd
- Université de LorraineInsermCentre d’Investigations Cliniques‐ 1433, and Inserm U1116CHRU NancyF‐CRIN INI‐CRCTNancyFrance
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15
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Kidney Retransplantation after Graft Failure: Variables Influencing Long-Term Survival. J Transplant 2022; 2022:3397751. [PMID: 35782455 PMCID: PMC9242806 DOI: 10.1155/2022/3397751] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background There is an increasing demand for kidney retransplantation. Most studies report inferior outcomes compared to primary transplantation, consequently feeding an ethical dilemma in the context of chronic organ shortage. Objective To assess variables influencing long-term graft survival after kidney retransplantation. Material and Methods. All patients transplanted at our center between 2000 and 2016 were analyzed retrospectively. Survival was estimated with the Kaplan–Meier method, and risk factors were identified using multiple Cox regression. Results We performed 1,376 primary kidney transplantations and 222 retransplantations. The rate of retransplantation was 67.8% after the first graft loss, with a comparable 10-year graft survival compared to primary transplantation (67% vs. 64%, p=0.104) but an inferior graft survival thereafter (log-rank p=0.026). Independent risk factors for graft survival in retransplantation were age ≥ 50 years, time on dialysis ≥1 year, previous graft survival <2 years, ≥1 mild comorbidity in the Charlson–Deyo index, active smoking, and life-threatening complications (Clavien–Dindo grade IV) at first transplantation. Conclusion Graft survival is comparable for first and second kidney transplantation within the first 10 years. Risk factors for poor outcomes after retransplantation are previous graft survival, dialysis time after graft failure, recipient age, comorbidities, and smoking. Patients with transplant failure should have access to retransplantation as early as possible.
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16
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Marra G, Agnello M, Giordano A, Soria F, Oderda M, Dariane C, Timsit MO, Brancherau J, Hedli O, Mesnard B, Tilki D, Olsburgh J, Kulkarni M, Kasivisvanathan V, Breda A, Biancone L, Gontero P. Robotic Radical Prostatectomy for Prostate Cancer in Renal Transplant Recipients: Results from a Multicenter Series. Eur Urol 2022; 82:639-645. [PMID: 35750583 DOI: 10.1016/j.eururo.2022.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/19/2022] [Accepted: 05/26/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite an expected increase in prostate cancer (PCa) incidence in the renal transplant recipient (RTR) population in the near future, robot-assisted radical prostatectomy (RARP) in these patients has been poorly detailed. It is not well understood whether results are comparable to RARP in the non-RTR setting. OBJECTIVE To describe the surgical technique for RARP in RTR and report results from our multi-institutional experience. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective review of the experience of four referral centers. SURGICAL PROCEDURE Transperitoneal RARP with pelvic lymph node dissection in selected patients. MEASUREMENTS We measured patient, PCa, and graft baseline features; intraoperative and postoperative parameters; complications, (Clavien classification); and oncological and functional outcomes. RESULTS AND LIMITATIONS We included 41 men. The median age, American Society of Anesthesiologists score, preoperative renal function, and prostate-specific antigen were 60 yr (interquartile range [IQR] 57-64), 2 points (IQR 2-3), 45 ml/min (IQR 30-62), and 6.5 ng/ml (IQR 5.2-10.2), respectively. Four men (9.8%) had a biopsy Gleason score >7. The majority of the patients (70.7%) did not undergo lymphadenectomy. The median operating time, hospital stay, and catheterization time were 201 min (IQR 170-250), 4 d (IQR 2-6), and 10 d (IQR 7-13), respectively. At final pathology, 11 men had extraprostatic extension and seven had positive surgical margins. At median follow-up of 42 mo (IQR 24-65), four men had biochemical recurrence, including one case of local PCa persistence and one local recurrence. No metastases were recorded while two patients died from non-PCa-related causes. Continence was preserved in 86.1% (p not applicable) and erections in 64.7% (p = 0.0633) of those who were continent/potent before the procedure. Renal function remained unchanged (p = 0.08). No intraoperative complications and one major (Clavien 3a) complication were recorded. CONCLUSIONS RARP in RTR is safe and feasible. Overall, operative, oncological, and functional outcomes are comparable to those described for the non-RTR setting, with graft injury remaining undescribed. Further research is needed to confirm our findings. PATIENT SUMMARY Robot-assisted removal of the prostate is safe and feasible in patients who have a kidney transplant. Cancer control, urinary and sexual function results, and surgical complications seem to be similar to those for patients without a transplant, but further research is needed.
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Affiliation(s)
- Giancarlo Marra
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin, Italy; Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France; Department of Urology, Hôpital Tenon, Paris, France.
| | - Marco Agnello
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Andrea Giordano
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Francesco Soria
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Marco Oderda
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Charles Dariane
- Department of Urology, Hôpital Européen Georges Pompidou and Necker Hospital, Paris, France
| | - Marc-Olivier Timsit
- Department of Urology, Hôpital Européen Georges Pompidou and Necker Hospital, Paris, France
| | - Julien Brancherau
- Institut de Transplantation Urologie Néphrologie, CHU Nantes, Nantes, France
| | - Oussama Hedli
- Institut de Transplantation Urologie Néphrologie, CHU Nantes, Nantes, France
| | - Benoit Mesnard
- Institut de Transplantation Urologie Néphrologie, CHU Nantes, Nantes, France
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
| | | | | | - Veeru Kasivisvanathan
- Department of Urology, Guy's Hospital, London, UK; Division of Surgery, University College London, London, UK
| | - Alberto Breda
- Department of Urology, Fundacio Puigvert, Barcelona, Spain
| | - Luigi Biancone
- Department of Nephrology, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Paolo Gontero
- Department of Surgical Sciences, University of Turin and Città della Salute e della Scienza, Turin, Italy
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17
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Sandal S, Ahn JB, Cantarovich M, Chu NM, Segev DL, McAdams-DeMarco MA. Evolving Trends in Risk Profiles and Outcomes in Older Adults Undergoing Kidney Retransplantation. Transplantation 2022; 106:1051-1060. [PMID: 34115459 PMCID: PMC8636546 DOI: 10.1097/tp.0000000000003842] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In older adults (≥65), access to and outcomes following kidney transplantation (KT) have improved over the past 3 decades. It is unknown if there were parallel trends in re-KT. We characterized the trends, changing landscape, and outcomes of re-KT in older adults. METHODS Among the 44,149 older kidney-only recipients (1995-2016) in the Scientific Registry of Transplant Recipients, we identified 1743 who underwent re-KT. We analyzed trends and outcomes (mortality, death-censored graft failure [DCGF]) by eras (1995-2002, 2003-2014, and 2015-2016) that were defined by changes to the expanded criteria donors and Kidney Donor Profile Index policies. RESULTS Among all older kidney-only recipients during 1995-2002, 2003-2014, 2015-2016 the proportion that were re-KTs increased from 2.7% to 4.2% to 5.7%, P < 0.001, respectively. Median age at re-KT (67-68-68, P = 0.04), years on dialysis after graft failure (1.4-1.5-2.2, P = 0.003), donor age (40.0-43.0-43.5, P = 0.04), proportion with panel reactive antibody 80-100 (22.0%-32.7%-48.7%, P < 0.001), and donation after circulatory death (1.1%-13.4%-19.5%, P < 0.001) have increased. Despite this, the 3-y cumulative incidence for mortality (22.3%-19.1%-11.5%, P = 0.002) and DCGF (13.3%-10.0%-5.1%, P = 0.01) decreased over time. Compared with deceased donor retransplant recipients during 1995-2002, those during 2003-2014 and 2015-2016 had lower mortality hazard (aHR = 0.78, 95% confidence interval, 0.63-0.86 and aHR = 0.55, 95% confidence interval, 0.35-0.86, respectively). These declines were noted but not significant for DCGF and in living donor re-KTs. CONCLUSIONS In older retransplant recipients, outcomes have improved significantly over time despite higher risk profiles; yet they represent a fraction of the KTs performed. Our results support increasing access to re-KT in older adults; however, approaches to guide the selection and management in those with graft failure need to be explored.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec
- Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec
- Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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18
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Pardinhas C, Leal R, Figueiredo C, Fernandes M, Rodrigues L, Guedes M, Santos L, Romãozinho C, Escada L, Martinho A, Sá HO, Alves R, Figueiredo A. Kidney Retransplantation Outcomes: A Paired Recipient Control Study. Transplant Proc 2022; 54:1236-1241. [DOI: 10.1016/j.transproceed.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/21/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
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19
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Sageshima J, Chandar J, Chen LJ, Shah R, Al Nuss A, Vincenzi P, Morsi M, Figueiro J, Vianna R, Ciancio G, Burke GW. How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond. Transplantation 2022; 106:709-721. [PMID: 34310100 DOI: 10.1097/tp.0000000000003888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.
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Affiliation(s)
- Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rushi Shah
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ammar Al Nuss
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Paolo Vincenzi
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
- Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - George W Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
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20
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Davis S, Mohan S. Managing Patients with Failing Kidney Allograft: Many Questions Remain. Clin J Am Soc Nephrol 2022; 17:444-451. [PMID: 33692118 PMCID: PMC8975040 DOI: 10.2215/cjn.14620920] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Patients who receive a kidney transplant commonly experience failure of their allograft. Transplant failure often comes with complex management decisions, such as when and how to wean immunosuppression and start the transition to a second transplant or to dialysis. These decisions are made in the context of important concerns about competing risks, including sensitization and infection. Unfortunately, the management of the failed allograft is, at present, guided by relatively poor-quality data and, as a result, practice patterns are variable and suboptimal given that patients with failed allografts experience excess morbidity and mortality compared with their transplant-naive counterparts. In this review, we summarize the management strategies through the often-precarious transition from transplant to dialysis, highlighting the paucity of data and the critical gaps in our knowledge that are necessary to inform the optimal care of the patient with a failing kidney transplant.
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Affiliation(s)
- Scott Davis
- Department of Medicine, University of Colorado, Aurora, Colorado,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Sumit Mohan
- Department of Medicine, University of Colorado, Aurora, Colorado .,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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21
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Yahyazadeh SR, Naderi G, Zadeh SST, Saatchi M, Khatami F, Aghamir SMK. Comparative study of the outcomes of the second kidney transplantation from the young deceased donors versus living-unrelated donors. Transpl Immunol 2022; 71:101527. [PMID: 34998989 DOI: 10.1016/j.trim.2022.101527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/01/2022] [Accepted: 01/01/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To compare the kidney graft function and survival in patients who had second kidney transplantation from living donors versus those who had a second transplant from young deceased donors. METHODS In this retrospective cohort study, a total of 86 patients who underwent second kidney transplantation in Shariati hospital from 2001 until 2017 were enrolled. Baseline clinical data on the age, sex, type of kidney donor (living unrelated or deceased), duration of pretransplant dialysis, and the length of hospitalization were recorded. As the indicators of the graft function, we used the serum creatinine level and estimated glomerular filtration rate (eGFR) at time intervals during the study. The 1, 5, and 10-year graft survival rates were reported using life tables and the relative hazard ratios of the graft failure were calculated using the forward stepwise Cox proportional hazard model. RESULTS Forty-six of our patients were men (53.5%), with a mean ± SD age of 44.3 ± 12.3 years at the time of transplantation. The majority of the enrolled patients received the kidney from living unrelated donors (50 vs. 36 patients). In terms of serum creatinine and eGFR, at time intervals, no significant difference was found between the two recipient groups. In the living donor group, the 1, 5, and 10-year graft survival rates of the second transplant were 91% (95%CI: 73-96%), 87% (95%CI: 69-95%), and 82% (95%CI: 59-92%), and for the deceased donor group were 95% (95% CI: 69-99%), 95% (95%CI: 69-99%), and 79% (95%CI: 31-95%), respectively. CONCLUSION Considering the long-term outcomes of the second kidney transplantation, in our experience, the graft function and survival, either from the living or deceased donors, were favorable; and the type of organ donation had no significant effect on the risk of graft failure.
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Affiliation(s)
- Seyed Reza Yahyazadeh
- Shariati Hospital, Department of Urology, Tehran University of Medical Sciences, Tehran, Iran
| | - Gholamhossein Naderi
- Shariati Hospital, Department of Urology, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Saatchi
- Department of Epidemiology and Biostatistics, School of Public Health(,) Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Khatami
- Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran
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22
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Kainz A, Kammer M, Reindl-Schwaighofer R, Strohmaier S, Petr V, Viklicky O, Abramowicz D, Naik M, Mayer G, Oberbauer R. Waiting Time for Second Kidney Transplantation and Mortality. Clin J Am Soc Nephrol 2022; 17:90-97. [PMID: 34965955 PMCID: PMC8763155 DOI: 10.2215/cjn.07620621] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/11/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES The median kidney transplant half-life is 10-15 years. Because of the scarcity of donor organs and immunologic sensitization of candidates for retransplantation, there is a need for quantitative information on if and when a second transplantation is no longer associated with a lower risk of mortality compared with waitlisted patients treated by dialysis. Therefore, we investigated the association of time on waiting list with patient survival in patients who received a second transplantation versus remaining on the waiting list. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this retrospective study using target trial emulation, we analyzed data of 2346 patients from the Austrian Dialysis and Transplant Registry and Eurotransplant with a failed first graft, aged over 18 years, and waitlisted for a second kidney transplantation in Austria during the years 1980-2019. The differences in restricted mean survival time and hazard ratios for all-cause mortality comparing the treatment strategies "retransplant" versus "remain waitlisted with maintenance dialysis" are reported for different waiting times after first graft loss. RESULTS Second kidney transplantation showed a longer restricted mean survival time at 10 years of follow-up compared with remaining on the waiting list (5.8 life months gained; 95% confidence interval, 0.9 to 11.1). This survival difference was diminished in patients with longer waiting time after loss of the first allograft; restricted mean survival time differences at 10 years were 8.0 (95% confidence interval, 1.9 to 14.0) and 0.1 life months gained (95% confidence interval, -14.3 to 15.2) for patients with waiting time for retransplantation of <1 and 8 years, respectively. CONCLUSIONS Second kidney transplant is associated with patient survival compared with remaining waitlisted and treatment by dialysis, but the survival difference diminishes with longer waiting time.
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Affiliation(s)
- Alexander Kainz
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Michael Kammer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria,Institute of Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | | | - Susanne Strohmaier
- Department of Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Vojtěch Petr
- Department of Nephrology, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
| | - Marcel Naik
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin, Berlin, Germany,Berlin Institute of Health, Berlin, Germany
| | - Gert Mayer
- Department of Internal Medicine IV–Nephrology and Hypertension, Medical University of Innsbruck, Innsbruck, Austria,Austrian Dialysis and Transplant Registry, Innsbruck, Austria
| | - Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
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23
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Fallahzadeh MK, Birdwell KA. Waitlist Mortality for Second Kidney Transplants. Clin J Am Soc Nephrol 2022; 17:6-7. [PMID: 34965956 PMCID: PMC8763152 DOI: 10.2215/cjn.15021121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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24
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Sandal S, Ahn JB, Segev DL, Cantarovich M, McAdams-DeMarco MA. Comparing outcomes of third and fourth kidney transplantation in older and younger patients. Am J Transplant 2021; 21:4023-4031. [PMID: 34355512 PMCID: PMC8639643 DOI: 10.1111/ajt.16786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 01/25/2023]
Abstract
Performing third or fourth kidney transplantation (3KT and 4KT) in older patients is rare due to surgical and immunologic challenges. We aimed to analyze and compare the outcomes of younger (18-64 years) and older (≥65 years) recipients of 3KT and 4KT. Between 1990 and 2016, we identified 5816 recipients of 3KTs (153 were older) and 886 recipients of 4KTs (18 were older). The incidences of delayed graft function (24.3% vs. 24.8%, p = .89), primary non-function (3.2% vs. 1.3%, p = .21), 1-year acute rejection (18.6% vs. 14.8%, p = .24), and 5-year death censored graft failure (DCGF) (24.8% vs. 17.9%, p = .06) were not different between younger and older recipients of 3KT. However, 5-year mortality was higher in older recipients (14.0% vs. 33.8%, p < .001) which remained significant after adjustment (aHR = 3.21, 95% CI: 2.59-3.99). Similar patterns were noted in the 4KT cohort. When compared with waitlisted patients, 3KT and 4KT are associated with a lower risk of mortality; aHR = 0.37, 95% CI: 0.33-0.41 and aHR = 0.31, 95% CI: 0.24-0.41, respectively. This survival benefit did not differ by recipient age (younger vs. older, p for interaction = 3KT: .49 and 4KT: .58). In the largest cohort described to date, we report that there is a survival benefit of 3KT and 4KT even among older patients. Although a highly selected cohort, our results support improving access to 3KT and 4KT.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec,Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec,Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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25
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Harris TN, Szempruch KR, Dupuis RE, Serrano Rodriguez P, Toledo AH. Alemtuzumab in Renal Retransplantation - Transplant Outcomes and Associated Infections. Transplant Proc 2021; 53:2888-2894. [PMID: 34774310 DOI: 10.1016/j.transproceed.2021.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/30/2021] [Indexed: 10/19/2022]
Abstract
Renal retransplant patients have decreased graft survival compared with primary renal transplant patients. Alemtuzumab induction is often used at the time of retransplant; however, the literature surrounding alemtuzumab induction in renal retransplant patients is limited. In this single-center, retrospective, observational study, we aimed to determine the 1-year incidence of infections and transplant outcomes in renal retransplant patients who received alemtuzumab induction. Thirty-four patients who received alemtuzumab met inclusion criteria and were included in the final analysis. Twenty-two (64.7%) of these patients acquired infections. Of these, 7 patients (31.8%) acquired infections that resulted in hospitalization or intravenous antibiotics. The most common infections were urinary tract infections (n = 10; 29.4%), cytomegalovirus DNAemia (n = 7; 20.6%), and BK virus (n = 6; 17.6%). The use of steroid maintenance therapy after alemtuzumab induction did not increase the number of infections compared with patients with a steroid-free interval after alemtuzumab induction. The number of patients who developed de novo donor-specific antibodies (DSA) was 11 (32.4%) with only 1 of these patients having DSA before retransplantation. The incidence of acute cellular rejection was 2.9% (n = 1). There was no graft loss, and patient survival was 97% (n = 33). There were no significant differences in infection rate or DSA development between alemtuzumab and the other induction agents, antithymocyte globulin and basiliximab, among retransplanted patients. Alemtuzumab induction in renal retransplant patients resulted in similar bacterial and viral infection rates as previously reported in the literature and did not negatively impact graft and patient survival.
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Affiliation(s)
- Taylor N Harris
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Kristen R Szempruch
- Pharmacy Department, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Robert E Dupuis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Pablo Serrano Rodriguez
- Surgery Department - Abdominal Transplant, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Alexander H Toledo
- Surgery Department - Abdominal Transplant, University of North Carolina Medical Center, Chapel Hill, North Carolina.
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26
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De Souza LM, Ghahramani N, Abendroth C, Kaur G. Evaluating a Living Donor With Rheumatoid Arthritis for a Recipient With End-Stage Renal Disease From Antineutrophil Cytoplasmic Antibodies Associated Vasculitis. Cureus 2021; 13:e18117. [PMID: 34692328 PMCID: PMC8527875 DOI: 10.7759/cureus.18117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/30/2022] Open
Abstract
A 60-year-old Caucasian female with sero-positive rheumatoid arthritis (RA) was evaluated as a potential kidney donor for her brother-in-law with end-stage kidney disease (ESKD) secondary to c-antineutrophil cytoplasmic antibody (c-ANCA) associated vasculitis (AAV) and membranous nephropathy (MN). With little to no data supporting or contradicting this unique scenario, in addition to the varying viewpoints expressed by the different specialists, our multidisciplinary transplant committee encountered a difficult decision of whether to approve a candidate with RA for a living kidney donation or not. As a result, we carried out a careful literature review addressing aspects of recipients' outcomes following kidney transplants from a living donor with RA, especially when the recipient has AAV, living donor's short- and long-term outcomes post kidney donation, renal disease in AAV and RA, and maintenance of disease remission.
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Affiliation(s)
- Luisa M De Souza
- Medicine, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, USA
| | | | | | - Gurwant Kaur
- Nephrology, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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27
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Wong YHS, Wong G, Johnson DW, McDonald S, Clayton P, Boudville N, Viecelli AK, Lok C, Pilmore H, Hawley C, Roberts MA, Walker R, Ooi E, Polkinghorne KR, Lim WH. Socioeconomic disparity, access to care and patient relevant outcomes after kidney allograft failure. Transpl Int 2021; 34:2329-2340. [PMID: 34339557 DOI: 10.1111/tri.14002] [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: 11/17/2020] [Revised: 06/16/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022]
Abstract
Social disparity is a major impediment to optimal health outcomes after kidney transplantation. In this study, we aimed to define the association between socioeconomic status (SES) disparities and patient-relevant outcomes after kidney allograft failure. Using data from the Australia and New Zealand Dialysis and Transplant registry, we included patients with failed first kidney allografts in Australia between 2005-2017. The association between residential postcode-derived SES in quintiles (quintile 1-most disadvantaged areas, quintile 5-most advantaged areas) with uptake of home dialysis (peritoneal or home haemodialysis) within the first 12-months post-allograft failure, repeat transplantation and death on dialysis were examined using competing-risk analysis. Of 2175 patients who had experienced first allograft failure, 417(19%) and 505(23%) patients were of SES quintiles 1 and 5, respectively. Compared to patients of quintile 5, quintile 1 patients were less likely to receive repeat transplants (adjusted subdistributional hazard ratio [SHR] 0.70,95%CI 0.55-0.89) and were more likely to die on dialysis (1.37[1.04-1.81]), but there was no association with the uptake of home dialysis (1.02[0.77-1.35]). Low SES may have a negative effect on outcomes post-allograft failure and further research is required into how best to mitigate this. However, small-scale variation within SES cannot be accounted for in this study.
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Affiliation(s)
- Yun Hui Sheryl Wong
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Germaine Wong
- University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.,Department of Renal Medicine and National Pancreas Transplant Unit, Westmead Hospital, Sydney, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia.,University of Queensland, Queensland, Australia.,Translational Research Institute, Brisbane, Australia
| | - Stephen McDonald
- South Australian Health and Medical Research Institute, ANZDATA Registry, Adelaide, Australia.,University of Adelaide, Adelaide, Australia.,Royal Adelaide Hospital, Adelaide, Australia
| | - Philip Clayton
- South Australian Health and Medical Research Institute, ANZDATA Registry, Adelaide, Australia.,University of Adelaide, Adelaide, Australia.,Royal Adelaide Hospital, Adelaide, Australia
| | - Neil Boudville
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia.,University of Queensland, Queensland, Australia
| | - Charmaine Lok
- Division of Nephrology, Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Canada.,The University of Toronto, Toronto, Canada
| | - Helen Pilmore
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand.,Department of Medicine, Auckland University, Auckland, New Zealand
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia.,University of Queensland, Queensland, Australia.,Translational Research Institute, Brisbane, Australia
| | - Matthew A Roberts
- Eastern Health Clinical School, Monash University, Victoria, Australia
| | | | - Esther Ooi
- Medical School, University of Western Australia, Perth, Australia.,School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Victoria, Australia.,Department of Medicine, Monash University, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
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28
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Repeated kidney re-transplantation in times of organ shortage - a critical review. Curr Opin Organ Transplant 2021; 26:106-111. [PMID: 33332921 DOI: 10.1097/mot.0000000000000831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Organ shortage forces those responsible to streamline allocation rules to provide a maximum of candidates with a graft and to optimize transplant outcome. Recently, repeated kidney re-transplantation was investigated in several studies with different analytic settings concerning the control group, the donors, parameters influencing outcome, and demographic characteristics. This review gives an overview on the candidates awaiting a repeated re-transplantation, summarizes the outcome, and comments on the relevance of these findings in the context of sustained organ shortage. RECENT FINDINGS Repeated kidney re-transplantation is technically and immunologically feasible and the recipients' survival is better compared to candidates remaining on dialysis or on the waiting-list. However, the outcome is mainly reported to be worse as compared to first or second kidney transplantation. Kidneys from living donors seem to have a favorable impact on outcome in this setting. SUMMARY The survival benefit of repeated re-transplantation recipients over patients on dialysis demands for continuation of this procedure. Comprehensive registries are essential to continuously optimize allocation. Governmental authorities are obliged to set the course to increase organ donation rather than forcing transplant decision makers to withhold a third or fourth graft from any candidate.
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29
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Schwarz A, Schäfer F, Framke T, Linnenweber-Held S, Richter N, Haller H. Risk Factors Influencing the Outcomes of Kidney Re-Transplantation. Ann Transplant 2021; 26:e928922. [PMID: 34267171 PMCID: PMC8290903 DOI: 10.12659/aot.928922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Our kidney transplant waitlist includes 20% re-transplantations (TX2). Knowing what to expect is a clinical obligation. MATERIAL AND METHODS We compared graft and patient survival of all 162 TX2 patients, transplanted 2000 to 2009, with 162 patients after first transplantation (TX1) matched for age, sex, living/non-living donation, and transplantation date. Patient follow-up was 10 years. RESULTS TX2 graft and patient survivals were inferior to TX1 (p<0.001 and p=0.047). TX2 patients had a longer cumulative dialysis vintage, more human leucocyte antigen (HLA) mismatches, more panel-reactive HLA antibodies, more often received induction therapy with rabbit-antithymocyte globulin (rATG), and had a lower body mass index (all p<0.05). Death from infection and graft failure by rejection was more frequent after TX2 (both p<0.05) but not after TX1. Multivariable Cox regression analysis revealed that both cohorts had graft failure and death risk associated with infection and cardiovascular disease, and graft failure by humoral rejection. However, only TX2 patients had an additional risk of graft failure with early inferior graft function and of patient death with ≥2 comorbidities. Moreover, Kaplan-Meier analysis showed that TX2 and not TX1 patients had a lower graft and patient survival associated with infection and with ≥2 comorbidities (all p<0.05). CONCLUSIONS Re-transplantation is associated with worse graft outcomes mainly because of immunologic and graft-quality reasons, although the high number of comorbidities and infection severities aside from cardiovascular disease drive mortality. The more frequent rATG induction of TX2 patients could promote infection by enhancing immunosuppression. By addressing comorbidities, outcomes could possibly be improved.
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Affiliation(s)
- Anke Schwarz
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Frank Schäfer
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Theodor Framke
- Institute for Biostatistics, Hannover Medical School, Hannover, Germany
| | | | - Nicolas Richter
- Department of Visceral Surgery and Transplantation, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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30
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Wongpraparut N, Chaipruckmalakarn T, Tongdee T, Jaspttananon A, Vongwiwatana A, Premasathian N, Anusonadisai K, Pongakasira R. Long-term outcome of percutaneous transluminal renal angioplasty (PTRA) versus PTRA with stenting (PTRAS) in transplant renal artery stenosis. BMC Cardiovasc Disord 2021; 21:212. [PMID: 33902459 PMCID: PMC8077892 DOI: 10.1186/s12872-021-02015-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 04/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Endovascular treatment is standard of care for transplant renal artery stenosis (TRAS). No study has evaluated long-term outcomes compared between percutaneous transluminal renal angioplasty (PTRA) and PTRA with stenting (PTRAS). Accordingly, this study aimed to investigate the 1-year clinical success, and short- and long-term event-free survival between PTRA and PTRAS in patients diagnosed with TRAS at Thailand’s largest national tertiary referral center. Methods This single-center retrospective study included kidney transplant patients treated for TRAS during January 2001 to June 2019. Clinical success was defined as (1) increase in estimated glomerular filtration rate (eGFR) > 15%, or (2) reduction in mean arterial pressure (MAP) > 15% with no decrease in antihypertensive medication, or no reduction in MAP or reduction in MAP < 15% with decrease in antihypertensive medication. Incidence of kidney transplant graft failure and transplant renal artery stenosis were also collected. Results Sixty-five cases of TRAS were identified from 1072 patients who underwent kidney transplantation. The majority (98.5%) had end-to-side anastomosis technique. Thirty-four patients had PTRA, while 31 patients had PTRAS. One-year clinical success according to renal outcome and BP reduction was 78.5% and 49.2%, respectively. Both renal outcome (79.4% vs. 77.4%, p = 0.845) and BP reduction (40.6% vs. 58.1%, p = 0.166) at 1 year were similar between the PTRA and PTRAS groups. Compared between PTRA and PTRAS, event-free survival for composite of kidney transplant graft failure or transplant renal artery restenosis was significantly higher for PTRAS at 1 year (82.4% vs. 100%, p = 0.025), but not significantly different at 10 years (73.5% vs. 71%, p = 0.818). Conclusions We demonstrated the 1-year clinical success, and short- and long-term event-free survival between PTRA and PTRAS in TRAS patients. One-year clinical success was found to be similar between groups. Event-free survival for composite of kidney transplant graft failure or transplant renal artery restenosis was significantly higher in PTRAS at 1 year, but similar between groups at 10 years. Trial registration Thai Clinical Trials Registry, TCTR20200626002. Registered 26 June 2020—Retrospectively registered, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trial search&smenu = fulltext&task = search&task2 = view1&id = 6441
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Affiliation(s)
- Nattawut Wongpraparut
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Thunyarat Chaipruckmalakarn
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Thongtum Tongdee
- Interventional Radiology Unit, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Archan Jaspttananon
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Attapong Vongwiwatana
- Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nalinee Premasathian
- Division of Nephrology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kawin Anusonadisai
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Rungtiwa Pongakasira
- Her Majesty's Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Beltrán Catalán S, Sancho Calabuig A, Molina P, Vizcaíno Castillo B, Gavela Martínez E, Kanter Berga J, González Moya M, Pallardó Mateu LM. Impact of dialysis modality on morbimortality of kidney transplant recipients after allograft failure. Analysis in the presence of competing events. Nefrologia 2021; 41:200-209. [PMID: 36165381 DOI: 10.1016/j.nefroe.2020.12.005] [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: 07/08/2020] [Accepted: 12/10/2020] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The number of patients who start dialysis due to graft failure increases every day. The best dialysis modality for this type of patient is not well defined and most patients are referred to HD. The objective of our study is to evaluate the impact of the dialysis modality on morbidity and mortality in transplant patients who start dialysis after graft failure. MATERIAL AND METHODS A multicentre retrospective observation and cohort study was performed to compare the evolution of patients who started dialysis after graft failure from January 2000 to December 2013. One group started on PD and the other on HD. The patients were followed until the change of dialysis technique, retransplantation or death. Anthropometric data, comorbidity, estimated glomerular filtration rate (eGFR) at start of dialysis, the presence of an optimal access for dialysis, the appearance of graft intolerance and retransplantation were analyzed. We studied the causes for the first 10 hospital admissions after starting dialysis. For the statistical analysis, the presence of competitive events that hindered the observation of the event of interest, death or hospital admission was analyzed. RESULTS 175 patients were included, 86 in DP and 89 in HD. The patients who started PD were younger, had less comorbidity and started dialysis with lower eGFR than those on HD. The mean follow-up was 34 ± 33 months, with a median of 24 months (IQR 7-50 months), Patients on HD had longer follow-up than patients on PD (35 vs. 18 months, p = < 0.001). The mortality risk factors were age sHR 1.06 (95% CI: 1.03-1.106, p = 0.000), non-optimal use of access for dialysis sHR 3.00 (95% CI: 1.507-5.982, p = 0.028) and the dialysis modality sHR (PD/HD) 0.36 (95% CI: 0.148-0.890, p = 0.028). Patients on PD had a lower risk of hospital admission sHR [DP/HD] 0.52 (95% CI: 0.369-0.743, p = < 0.001) and less probability of developing graft intolerance HR 0.307 (95% CI 0.142-0.758, p = 0.009). CONCLUSIONS With the limitations of a retrospective and non-randomized study, it is the first time nationwide that PD shows in terms of survival to be better than HD during the first year and a half after the kidney graft failure. The presence of a non-optimal access for dialysis was an independent and modifiable risk factor for mortality. Early referral of patients to advanced chronic kidney disease units is essential for the patient to choose the technique that best suits their circumstances and to prepare an optimal access for the start of dialysis.
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Affiliation(s)
- Sandra Beltrán Catalán
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain.
| | - Asunción Sancho Calabuig
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Pablo Molina
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Belén Vizcaíno Castillo
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Eva Gavela Martínez
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Julia Kanter Berga
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Mercedes González Moya
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Luis Manuel Pallardó Mateu
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
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Requião-Moura LR, Albino CRM, Bicalho PR, Ferraz ÉDA, Pires LMDMB, da Silva MFR, Pacheco-Silva A. Long-term outcomes after kidney transplant failure and variables related to risk of death and probability of retransplant: Results from a single-center cohort study in Brazil. PLoS One 2021; 16:e0245628. [PMID: 33471845 PMCID: PMC7816974 DOI: 10.1371/journal.pone.0245628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
Background Returning to dialysis after kidney graft loss (GL) is associated with a high risk of mortality, mainly in the first 3–6 months. The follow-up of patients with GL should be extended to better understand crude patient outcomes, mainly in emerging countries, where the transplantation activity has increased. Methods This is a historical single-center cohort study conducted in an emerging country (Brazil) that included 115 transplant patients with kidney allograft failure who were followed for 44.1 (21.4; 72.6) months after GL. The outcomes were death or retransplantation after GL calculated by Kaplan-Meier and log-rank tests. Proportional hazard ratios for death and retransplantation were assessed by Cox regression. Results The 5-year probability of retransplantation was 38.7% (95% CI: 26.1%-51.2%) and that of death was 37.7% (95% CI: 24.9%-50.5%); OR = 1.03 (95% CI: 0.71–1.70) and P = 0.66. The likelihood of retransplantation was higher in patients who resumed dialysis with higher levels of hemoglobin (HR = 1.22; 95% CI = 1.04–1.43; P = 0.01) and lower in blood type O patients (HR = 0.48; 95% CI = 0.25–0.93; P = 0.03), which was associated with a lower frequency of retransplantation with a subsequent living-donor kidney. On the other hand, the risk of death was significantly associated with Charlson comorbidity index (HR for each point = 1.37; 95% CI 1.19–1.50; P<0.001), and residual eGFR at the time when patients had resumed to dialysis (HR for each mL = 1.14; 95% CI = 1.05–1.25; P = 0.002). The trend toward a lower risk of death when patients had resumed to dialysis using AV fistula access was observed (HR = 0.50; 95% CI 0.25–1.02; P = 0.06), while a higher risk seems to be associated with the number of previous engraftment (HR = 2.01; 95% CI 0.99–4.07; P = 0.05). Conclusions The 5-year probability of retransplantation was not less than that of death. Variables related to the probability of retransplantation were hemoglobin level before resuming dialysis and ABO blood type, while the risk of death was associated with comorbidities and residual eGFR.
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Affiliation(s)
- Lúcio R. Requião-Moura
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
- * E-mail:
| | | | | | | | | | | | - Alvaro Pacheco-Silva
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
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Telkes G, Piros L, Szabó J, Huszty G, Eitler K, Kóbori L. Outcomes of first versus third kidney transplantations: propensity score matching and paired subgroup analysis-a single-centre experience. Langenbecks Arch Surg 2021; 406:863-871. [PMID: 33454840 PMCID: PMC8106582 DOI: 10.1007/s00423-020-02063-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022]
Abstract
Background In the Eurotransplant, 12.6% of kidney transplantations are a repeat procedure. Third transplants are significantly more complex than first and second ones. We compared the results of first (PRT) versus third (TRT) transplantations. Methods Between 2011 and 2016, we performed 779 deceased donor adult kidney transplantations, 14.2% out of them were second, 2.6% (20) third, and 0.3% fourth. We compared the pre-, intra-, and postoperative data, kidney function, and survival rate. Results Recipients of TRT were younger (53.4 vs. 47.3 p = 0.02). HCV infection rate (20%, p = 0.00) is ten times higher. The operation time is longer (132 vs. 152 min, p = 0.02), and delayed graft function is much more frequent (22.4% vs. 60%, p = 0.00). Induction therapy was given to every TRT (7.9% vs.100%), but as a result, the rejection rate was the same (~ 15%). Hospital stay is a week longer. Patient’s survival at 1, 3, and 5 years for PRT is 96.4%, 93.9%, and 91.2% and for TRT is 90%, 85%, and 78.4%, respectively (p = 0.023). TRT’s odds ratio of fatal outcome is 4.35 (1.5–12.5). Graft survival at 1, 3, and 5 years for PRT is 93.1%, 91.4%, and 90.3% and for TRT is 75%, 75%, and 75%, respectively (p = 0.020). TRT’s odds ratio of graft loss is 3.14 (1.1–8.9). Of PRT 85.76%, out of PRT 85.76%, while out of TRT 60% live with a functioning graft, p=0.00149. Conclusion In a third transplant, both graft and patient survival are significantly inferior to primer ones. Careful selection is required to minimize the patient risk and graft loss.
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Affiliation(s)
- Gábor Telkes
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary.
| | - László Piros
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - József Szabó
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - Gergely Huszty
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - Katalin Eitler
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, VIII. Baross u. 23, Budapest, H-1082, Hungary
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Freist M, Bertrand D, Bailly E, Lambert C, Rouzaire PO, Lemal R, Aniort J, Büchler M, Heng AE, Garrouste C. Management of Immunosuppression After Kidney Transplant Failure: Effect on Patient Sensitization. Transplant Proc 2020; 53:962-969. [PMID: 33288310 DOI: 10.1016/j.transproceed.2020.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/03/2020] [Accepted: 10/20/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immunosuppressive treatment is often interrupted in the first months following kidney transplant failure (KTF) to limit side effects. The aim of this study was to assess the effect of prolonged treatment (PT) of more than 3 months' duration after KTF on HLA sensitization and treatment tolerance. METHODS We performed a retrospective observational study involving 119 patients with KTF in 3 French kidney transplant centers between June 2007 and June 2017. Sensitization was defined as the development of HLA donor-specific antibodies (DSA). RESULTS In the PT group receiving calcineurin inhibitor (CNI) treatment, 30 of 52 patients (57.7%) were sensitized vs 52 of 67 patients (77.6%) who had early cessation of treatment (P = .02). The results were confirmed by multivariate analysis (odds ratio [OR] = 0.39, 95% confidence interval [CI] [0.16; 0.98], P = .04). The development of de novo DSAs after CNI treatment (n = 63/90 [70.0%]) was significantly more frequent than during CNI treatment, (n = 18/52 [34.6%], P = .01). Panel-reactive antibody ≥85% was lower in the PT group in multivariate analysis (OR = 0.28, 95% CI [0.10; 0.78], P = .02). No differences in the rates of infection, cardiovascular complications, neoplasia, and deaths were observed between the 2 groups. In multivariate analysis, continuation of corticosteroid treatment had no influence on sensitization but was associated with a higher rate of infection (OR = 2.66, 95% CI [1.09; 6.46], P = .03). CONCLUSION Maintenance of CNI treatment after return to dialysis in patients requesting a repeat transplant could avoid the development of anti-HLA sensitization with a good tolerance.
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Affiliation(s)
- Marine Freist
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Dominique Bertrand
- Service de Néphrologie, Centre Hospitalier Régional Universitaire, Rouen, France
| | - Elodie Bailly
- Department of Nephrology and Clinical Immunology, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Céline Lambert
- Biostatistics Unit, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Paul Olivier Rouzaire
- Department of Human Leucocyte Antigen, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Richard Lemal
- Department of Human Leucocyte Antigen, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Julien Aniort
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Matthias Büchler
- Department of Nephrology and Clinical Immunology, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Anne Elisabeth Heng
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Cyril Garrouste
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France.
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Tomonari M, Kobayashi A, Yamamoto I, Hatanaka S, Kawabe M, Yamakawa T, Katsumata H, Katsuma A, Mafune A, Nakada Y, Koike Y, Miki J, Kimura T, Tanno Y, Yamamoto H, Yokoo T. A Case of Transplant Nephrectomy due to Chronic Graft Intolerance Syndrome. Nephron Clin Pract 2020; 144 Suppl 1:102-107. [PMID: 33242860 DOI: 10.1159/000511558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/09/2020] [Indexed: 11/19/2022] Open
Abstract
We report a case of graft intolerance syndrome in which transplant nephrectomy was performed 11 years after kidney transplantation. A 46-year-old man was admitted to our hospital in February 2018 with a mild fever, left lower abdominal pain, and gross hematuria with enlargement of the transplanted kidney. Urinary tract infection was ruled out. Because the symptoms developed after the immunosuppressants had been stopped after kidney graft loss, graft intolerance syndrome was suspected. He had lost his graft in 2016 and had stopped all immunosuppressants since January of 2017. Immunosuppressive therapy was intensified, and steroid half-pulse therapy was added for 3 days. After the steroid pulse therapy, the C-reactive protein (CRP) decreased from 6.47 mg/dL to 0.76 mg/dL, but there was little improvement in the symptoms, and the CRP then increased to 4.44 mg/dL. Transplant nephrectomy was performed in March 2018. Postoperatively, the symptoms disappeared without the administration of immunosuppressants, and the CRP decreased. Pathologically, the resected kidney graft showed persistent active allograft rejection with severe endarteritis, transplant glomerulopathy, and diffuse interstitial fibrosis. Massive thrombi occluded the large arteries, and there was extensive hemorrhagic cortical necrosis. Transplant nephrectomy is uncommon in patients >6 months after transplantation. However, even if more time has passed since transplantation, as in this case, transplant nephrectomy may be a valid option in some cases of severe graft intolerance syndrome.
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Affiliation(s)
- Masahiro Tomonari
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akimitsu Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan,
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Saeko Hatanaka
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Mayuko Kawabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takafumi Yamakawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruki Katsumata
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Ai Katsuma
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Aki Mafune
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasuyuki Nakada
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yusuke Koike
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yudo Tanno
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyasu Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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36
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Phonphok K, Homkrailas P, Duong T, Panombualert S, Cho YW, Sampaio M, Lum EL, Bunnapradist S. Time to second kidney transplantation in young adults after failed pediatric kidney transplant. Pediatr Transplant 2020; 24:e13800. [PMID: 32722896 DOI: 10.1111/petr.13800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/16/2020] [Accepted: 06/30/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Under the current kidney allocation system, pediatric candidates listed prior to age 18 receive priority for high-quality deceased donor organs. This has resulted in a decline in living donor transplantation in pediatrics, despite superior outcomes of living donor transplantation. Due to a young age at transplantation, most pediatric kidney transplant recipients require re-transplantation. The effects of a previously failed deceased donor vs a previously failed living donor on re-transplant candidates are unknown. METHODS Using the United Network for Organ Sharing database, we examined 2772 re-transplant recipients aged 18-30 years at time of relisting for second KT from 2000 to 2018 with history of prior pediatric KT (age ≤ 18 years). RESULTS PFLDKT recipients compared to those with PFDDKT had shorter median waiting times and dialysis time regardless of their second donor type (14.0 vs 20.3 months, and 19.1 vs 34.5 months, respectively). PFLDKT recipients had higher re-transplant rates (adjusted HR 1.17, 95% CI 1.09-1.27, and adjusted HR 1.05, 95% CI 0.95-1.15 when calculating from time of relisting and time of returning to dialysis, respectively). PFDDKT recipients were more likely to have higher median PRA levels (90% vs 73%). CONCLUSIONS Re-transplant candidates who received a previous deceased donor as a child had a higher level of sensitization, longer waiting time, and dialysis exposure compared to those with PFLDKT. Among primary pediatric kidney transplant candidates, consideration should be considered for living donor transplantation, despite the priority for deceased donor organs, to avoid increased sensitization and longer waiting times for with re-transplantation.
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Affiliation(s)
- Korntip Phonphok
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, Rajavithi Hospital, Bangkok, Thailand
| | - Piyavadee Homkrailas
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Tin Duong
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sunee Panombualert
- Division of Pediatric Nephrology, Department of Pediatrics, Khon Kaen University, Khon Kaen, Thailand
| | - Yong W Cho
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Marcelo Sampaio
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Erik L Lum
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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de Kok MJ, Schaapherder AF, Mensink JW, de Vries AP, Reinders ME, Konijn C, Bemelman FJ, van de Wetering J, van Zuilen AD, Christiaans MH, Baas MC, Nurmohamed AS, Berger SP, Ploeg RJ, Alwayn IP, Lindeman JH. A nationwide evaluation of deceased donor kidney transplantation indicates detrimental consequences of early graft loss. Kidney Int 2020; 97:1243-1252. [DOI: 10.1016/j.kint.2020.01.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/10/2020] [Accepted: 01/31/2020] [Indexed: 11/28/2022]
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O'Kelly JA, Davis NF, Ferede AA, Breen KJ, O'Kelly P, MacCraith E, Forde J, Mohan P, Power R, Smyth G, Little DM. Predictors of long-term renal allograft survival after second kidney transplantation. Clin Transplant 2020; 34:e13907. [PMID: 32416641 DOI: 10.1111/ctr.13907] [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: 12/31/2019] [Revised: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Few studies investigate significant perioperative predictors for long-term renal allograft survival after second kidney transplant (SKT). We compared long-term survival following SKT with primary kidney transplant and determined predictors of renal allograft failure after SKT. METHODS Outcomes of all primary or second kidney transplant recipients at a national kidney transplant center between 1993 and 2017 were reviewed. The primary outcomes measurements were renal allograft survival for both first and second kidney transplants. Secondary outcome measurements were incidence of delayed graft function (DGF), incidence of acute rejection (AR), and predictors for renal allograft survival in SKT recipients. RESULTS In total, there were 392 SKTs and 2748 primary kidney transplants performed between 1993 and 2017. The 1-, 5-, and 10-year death-censored graft survival for deceased-donor recipients was 95.3%, 88.7%, and 78.2% for primary kidney transplant and 94.9%, 87.1%, and 74.9% for SKT (P = .0288). Survival of primary renal allograft <6 years (HR 0.6, P = .017), AR episodes (HR 1.6, P = .031), DGF (HR 2.0, P = .005), and HLA-DR MM (HR 1.7, P = .018) was independent predictors of long-term renal allograft failure after SKT. CONCLUSION These findings may provide important information on long-term survival outcomes after SKT and for identifying patients at risk for long-term renal allograft failure after SKT.
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Affiliation(s)
- John A O'Kelly
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Niall F Davis
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Atakelet A Ferede
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Kieran J Breen
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Eoin MacCraith
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - James Forde
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Ponnusamy Mohan
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Richard Power
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Gordon Smyth
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
| | - Dilly M Little
- Department of Transplant, Urology and Nephrology (TUN), National Kidney Transplant Service (NKTS), Beaumont Hospital, Dublin, Ireland
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Weaning Immunosuppressant in Patients with Failing Kidney Grafts and The Outcomes: A Single-Center Retrospective Cohort Study. Sci Rep 2020; 10:6425. [PMID: 32286398 PMCID: PMC7156393 DOI: 10.1038/s41598-020-63266-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/19/2020] [Indexed: 11/14/2022] Open
Abstract
An immunosuppressant weaning protocol in failing allografts has not yet been established. Maintaining immunosuppressants would preserve residual renal function (RRF) and prevent graft intolerance syndrome and sensitization but would increase the risks of infection and malignancy. In this study, graft failure cases after kidney transplantation in a single center were reviewed retrospectively. The outcome differences in all-cause mortality, infection-related hospitalization, cancer, graft intolerance syndrome, re-transplantation, and RRF duration between the immunosuppressant maintaining and weaning groups 6 months after graft failure were compared. Among the weaning group, the outcome differences according to low-dose steroid use were also compared at 6 and 12 months. In a total of 131 graft failure cases, 18 mortalities, 42 infection-related hospitalizations, 22 cancer cases, 11 graft intolerance syndrome cases, and 28 re-transplantations occurred during the 94-month follow-up. Immunosuppressant maintenance significantly decreased the patient survival rate 6 months after graft failure compared with weaning (log-rank P = 0.008) and was an independent risk factor for mortality, even after adjustments (hazard ratio, 3.01; P = 0.025). Infection-related hospitalization, graft intolerance syndrome development, and re-transplantation were not affected by the immunosuppressant weaning protocol. Among the immunosuppressant weaning group, low-dose steroid maintenance at 6 and 12 months helped preserved RRF (P = 0.008 and P = 0.003, respectively).
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Immunosuppression with Calcineurin Inhibitor after Renal Transplant Failure Inhibits Allosensitization. Biomedicines 2020; 8:biomedicines8040072. [PMID: 32231087 PMCID: PMC7235765 DOI: 10.3390/biomedicines8040072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/16/2020] [Accepted: 03/26/2020] [Indexed: 01/12/2023] Open
Abstract
Immunosuppression withdrawal after graft failure seems to favor sensitization. A high percentage of calculated panel-reactive antibody (cPRA) and the development of de novo donor specific antibodies (dnDSA) indicate human leukocyte antigen (HLA) sensitization and may hinder the option of retransplantation. There are no established protocols on the immunosuppressive treatment that should be maintained after transplant failure. A retrospective analysis including 77 patients who lost their first renal graft between 1 January 2006–31 December 2015 was performed. Two sera were selected per patient, one immediately prior to graft loss and another one after graft failure. cPRA was calculated by Single Antigen in all patients. It was possible to analyze the development of dnDSA in 73 patients. By multivariate logistic regression analysis, the absence of calcineurin inhibitor (CNI) at 6 months after graft failure was related to cPRA > 75% (OR 4.8, CI 95% 1.5–15.0, p = 0.006). The absence of calcineurin inhibitor (CNI) at 6 months after graft loss was significantly associated with dnDSA development (OR 23.2, CI 95% 5.3–100.6, p < 0.001). Our results suggest that the absence of CNI at the sixth month after graft loss is a risk factor for sensitization. Therefore, maintenance of an immunosuppressive regimen based on CNI after transplant failure should be considered when a new transplant is planned, since it seems to prevent HLA allosensitization.
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Sasal J, Naimark D, Klassen J, Shea J, Bargman JM. Late Renal Transplant Failure: An Adverse Prognostic Factor at Initiation of Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080102100413] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis. Objective To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant. Setting Peritoneal dialysis (PD) unit in a teaching hospital. Patients and Design All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998. Results There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group ( p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease. Conclusions W e conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.
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Affiliation(s)
- Joanna Sasal
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Judy Klassen
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
| | - Judy Shea
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
| | - Joanne M. Bargman
- Division of Nephrology, The University Health Network, Toronto, Ontario, Canada
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Assfalg V, Selig K, Tolksdorf J, Meel M, Vries E, Ramsoebhag A, Rahmel A, Renders L, Novotny A, Matevossian E, Schneeberger S, Rosenkranz AR, Berlakovich G, Ysebaert D, Knops N, Kuypers D, Weekers L, Muehlfeld A, Rump L, Hauser I, Pisarski P, Weimer R, Fornara P, Fischer L, Kliem V, Sester U, Stippel D, Arns W, Hau H, Nitschke M, Hoyer J, Thorban S, Weinmann‐Menke J, Heller K, Banas B, Schwenger V, Nadalin S, Lopau K, Hüser N, Heemann U. Repeated kidney re‐transplantation—the Eurotransplant experience: a retrospective multicenter outcome analysis. Transpl Int 2020; 33:617-631. [DOI: 10.1111/tri.13569] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/09/2019] [Accepted: 12/27/2019] [Indexed: 12/18/2022]
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Atallah DM, Badawy M, El-Sayed A. Intelligent feature selection with modified K-nearest neighbor for kidney transplantation prediction. SN APPLIED SCIENCES 2019. [DOI: 10.1007/s42452-019-1329-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Lucisano G, Brookes P, Santos-Nunez E, Firmin N, Gunby N, Hassan S, Gueret-Wardle A, Herbert P, Papalois V, Willicombe M, Taube D. Allosensitization after transplant failure: the role of graft nephrectomy and immunosuppression - a retrospective study. Transpl Int 2019; 32:949-959. [PMID: 30980556 DOI: 10.1111/tri.13442] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/07/2019] [Accepted: 04/09/2019] [Indexed: 01/30/2023]
Abstract
There are conflicting data about the role of transplant nephrectomy and immunosuppression withdrawal on the development of allosensitization and the impact on re-transplantation. We divided 109 first graft recipients into two groups according to whether they underwent nephrectomy (NX+, n = 61) or their graft was left in situ (NX-, n = 48). Sera were assessed for HLA-A/B/Cw/DR/DQ antibodies at the time of NX/transplant failure and after 3, 6, 12, 24 months. The NX+ group showed a higher rate of donor specific antibody (DSA) and non-DSA human leukocyte antigen (HLA) antibody production at all the time points. Multivariable analysis showed that nephrectomy was a strong, independent risk factor for the development of DSAs after 12 and 24 months (P = 0.005 and 0.008). In the NX- group, low tacrolimus levels correlated with DSA formation (AUC 0.817, P = 0.002; best cut-off level 2.9 ng/ml). Analysis with a standardized pool of UK donors showed a more difficult grade of HLA matchability following nephrectomy compared with the NX- group. Nephrectomy is followed by the long-term production of DSA and non-DSA HLA antibodies and negatively impacts on the chances of finding a HLA-compatible kidney. Tacrolimus levels ≥3 ng/ml are protective against the development of allosensitization and could facilitate re-transplantation in the NX- group.
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Affiliation(s)
- Gaetano Lucisano
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Paul Brookes
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Eva Santos-Nunez
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Firmin
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Gunby
- Histocompatibility and Immunogenetics, Imperial College Healthcare NHS Trust, London, UK
| | - Sevda Hassan
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Alexander Gueret-Wardle
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Paul Herbert
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Vassilios Papalois
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - David Taube
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
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Caring for the patient with a failing allograft: challenges and opportunities. Curr Opin Organ Transplant 2019; 24:416-423. [DOI: 10.1097/mot.0000000000000655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Clark S, Kadatz M, Gill J, Gill JS. Access to Kidney Transplantation after a Failed First Kidney Transplant and Associations with Patient and Allograft Survival: An Analysis of National Data to Inform Allocation Policy. Clin J Am Soc Nephrol 2019; 14:1228-1237. [PMID: 31337621 PMCID: PMC6682813 DOI: 10.2215/cjn.01530219] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients who have failed a transplant are at increased risk of repeat transplant failure. We determined access to transplantation and transplant outcomes in patients with and without a history of transplant failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this observational study of national data, the proportion of waitlisted patients and deceased donor transplant recipients with transplant failure was determined before and after the new kidney allocation system. Among patients initiating maintenance dialysis between May 1995 and December 2014, the likelihood of deceased donor transplantation was determined in patients with (n=27,459) and without (n=1,426,677) a history of transplant failure. Among transplant recipients, allograft survival, the duration of additional kidney replacement therapy required within 10 years of transplantation, and the association of transplantation versus dialysis with mortality was determined in patients with and without a history of transplant failure. RESULTS The proportion of waitlist candidates (mean 14%) and transplant recipients (mean 12%) with transplant failure did not increase after the new kidney allocation system. Among patients initiating maintenance dialysis, transplant-failure patients had a higher likelihood of transplantation (hazard ratio [HR], 1.16; 95% confidence interval [95% CI], 1.12 to 1.20; P<0.001). Among transplant recipients, transplant-failure patients had a higher likelihood of death-censored transplant failure (HR, 1.44; 95% CI, 1.34 to 1.54; P<0.001) and a greater need for additional kidney replacement therapy required within 10 years after transplantation (mean, 9.0; 95% CI, 5.4 to 12.6 versus mean, 2.1; 95% CI, 1.5 to 2.7 months). The association of transplantation versus dialysis with mortality was clinically similar in waitlisted patients with (HR, 0.32; 95% CI, 0.29 to 0.35; P<0.001) and without transplant failure (HR, 0.40; 95% CI, 0.39 to 0.41; P<0.001). CONCLUSIONS Transplant-failure patients initiating maintenance dialysis have a higher likelihood of transplantation than transplant-naïve patients. Despite inferior death-censored transplant survival, transplantation was associated with a similar reduction in the risk of death compared with treatment with dialysis in patients with and without a prior history of transplant failure.
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Affiliation(s)
- Stephanie Clark
- Kidney Division, Providence Health Research Institute, Vancouver, Canada
| | | | - Jagbir Gill
- Division of Nephrology and.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada; and
| | - John S Gill
- Division of Nephrology and .,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada; and.,Division of Nephrology, Tufts New England Medical Center, Boston, Massachusetts
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Dabare D, Kassimatis T, Hodson J, Khurram MA, Papadakis G, Rompianesi G, Shaw O, Karydis N, Callaghan C, Olsburgh J, Mamode N, Kessaris N, Loukopoulos I. Outcomes in Third and Fourth Kidney Transplants Based on the Type of Donor. Transplantation 2019; 103:1494-1503. [PMID: 30130325 DOI: 10.1097/tp.0000000000002428] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND An increasing number of patients are requiring multiple retransplants. We assessed outcomes of third and fourth kidney transplants, to aid decision making on the most suitable donor type. METHODS Data were collected retrospectively for 2561 transplants, including 69 third and 8 fourth, performed from 2000 to 2017. Demographics and outcomes for the combined third/fourth group were compared to first and second transplants. Within the third/fourth kidney transplant group, comparisons were made between deceased donors (n = 39), live donor HLA-compatible (n = 23) and -incompatible (n = 13) transplants, as well as between standard (n = 25) and extended-criteria (n = 14) deceased donor transplants. RESULTS Patient survival did not differ significantly by transplant number (P = 0.532), whereas death-censored graft survival declined progressively, from 89% at 5 years in first, 85% in second and 74% in the third/fourth transplant group (P < 0.001). Within the combined third/fourth transplant subgroup, 5-year graft survival was found to be 100% in recipients of HLA-compatible live donors, compared to 75% in deceased donors and 53% in HLA-incompatible live donors, although this difference did not reach statistical significance (P = 0.083). No significant difference in patient survival (P = 0.356) or complication rates (P = 0.757) were detected between these groups. For recipients of deceased donors in the third/fourth transplant group, there were no significant differences between standard versus extended-criteria donors for any of the outcomes considered. CONCLUSIONS Despite variable functional outcomes, third and fourth kidney transplant recipients experience comparable patient survival rates to first and second transplants, regardless of the donor type. In selected patients, HLA-incompatible live donors and extended-criteria deceased donors should be considered.
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Affiliation(s)
- Dilan Dabare
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Theodoros Kassimatis
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Muhammad Arslan Khurram
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Georgios Papadakis
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Gianluca Rompianesi
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Olivia Shaw
- Clinical Transplantation Laboratory, Viapath, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Nikolaos Karydis
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Jonathon Olsburgh
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Nizam Mamode
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Nicos Kessaris
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
| | - Ioannis Loukopoulos
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, United Kingdom
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Mehta SG, Chang JH, Alhamad T, Bromberg JS, Hiller DJ, Grskovic M, Yee JP, Mannon RB. Repeat kidney transplant recipients with active rejection have elevated donor-derived cell-free DNA. Am J Transplant 2019; 19:1597-1598. [PMID: 30468563 PMCID: PMC6587949 DOI: 10.1111/ajt.15192] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Shikha G. Mehta
- Division of NephrologyDepartment of MedicineUniversity of Alabama School of MedicineBirminghamAlabama
| | - Jae H. Chang
- Columbia University Medical CenterNew YorkNew York
| | | | - Jonathan S. Bromberg
- Division of NephrologyDepartment of MedicineUniversity of Maryland School of MedicineBaltimoreMaryland
| | | | | | | | - Roslyn B. Mannon
- Division of NephrologyDepartment of MedicineUniversity of Alabama School of MedicineBirminghamAlabama
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Song T, Jiang Y, Liu J, Wang Z, Zeng J, Huang Z, Fan Y, Wang X, Lin T. Steroid withdrawal or avoidance is safe in high‐risk kidney transplants: A systematic review and meta‐analysis. Kaohsiung J Med Sci 2019; 35:350-357. [PMID: 30942560 DOI: 10.1002/kjm2.12064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/03/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Tu‐Run Song
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Ya‐Mei Jiang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Jin‐Peng Liu
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Zhi‐Ling Wang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Jun Zeng
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Zhong‐Li Huang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Yu Fan
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Xian‐Ding Wang
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
| | - Tao Lin
- Department of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Institute of UrologyWest China Hospital, Sichuan University Chengdu Sichuan China
- Organ Transplantation CenterWest China Hospital, Sichuan University Chengdu Sichuan China
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Long-Term Outcomes among Kidney Transplant Recipients and after Graft Failure: A Single-Center Cohort Study in Brazil. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7105084. [PMID: 31061825 PMCID: PMC6466891 DOI: 10.1155/2019/7105084] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 12/29/2022]
Abstract
Background The results of kidney transplantation are impacted by the categories of events responsible for patient death and graft failure. The objective of this study was to evaluate the causes of death and graft failure and outcomes after graft failure among kidney transplant recipients. Methodology A retrospective cohort study was conducted with 944 patients who underwent kidney transplantation. Outcomes were categorized in a managed and hierarchical manner. Results The crude mortality rate was 10.8% (n=102): in 35.3% cause of death was infection, in 30.4% cardiovascular disease, and in 15.7% neoplasia and in 6.8%, it was not possible to determine the cause of death. The rate of graft loss was 10.6%. The main causes of graft failure were chronic rejection (40%), acute rejection (18.3%), thrombosis (17.3%), and recurrence of primary disease (16.5%). Failures due to an acute rejection occurred earlier than those due to chronic rejection and recurrence (p<0.0001). As late causes of graft loss, death with the functioning kidney occurred earlier than recurrence and chronic rejection (p=0.008). The outcomes after graft failure were retransplantation in 26.1% and death in 21.4%, at a mean of 25.5 and 21.4 months, respectively. Conclusion It was possible to identify more than 90% of the events responsible for the deaths of transplanted patients, predominantly infectious and cardiovascular diseases. Among the causes of graft failure, chronic and acute rejections and recurrence were the main causes of graft failure which were followed more frequently by retransplantation than by death on dialysis.
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