Lower donated kidney volume is associated with increased risk of lower graft function and acute rejection at 1 year after living donor kidney-a retrospective study.

Kidney volume has been proven to be a surrogate marker of nephron mass and renal function. We studied 190 donor and recipient pairs undergoing living donor kidney transplantation at our institution during 9 years. Different metrics of donor kidney volume (DKV) were explored: alone or indexed to recipient's anthropometry, as body surface area (BSA). DKV/BSA (min. 49.7; P33rd 77.7; P67th 95.3; max. 176 cm3 /m2 ) was chosen given its higher correlation with eGFR at 1 year, and recipients were divided according to its tertiles (T). The eGFR at 1 year was lower in T1, when compared with T2 (P = 0.015) and T3 (P < 0.001). In a multivariable model, a regression spline revealed that a DKV/BSA lower than 80 was significantly associated with an eGFR at 1 year <60. In the first 6 years, the overall annual eGFR slope was -0.90 ml/min/year. Acute rejection occurred in 19%, 11%, and 0% of patients in T1, T2, and T3, respectively (P < 0.001). DKV/BSA increased stepwise from cellular- (n = 12) to antibody-mediated (n = 7) AR cases and to those without AR (n = 171; P = 0.002; no AR versus cellular AR). Lower DKV/BSA ratio was associated with significantly worse graft function and higher incidence of AR. Hence, it can be a tool for better selection of donors in order to improve graft outcomes, particularly in the setting of multiple potential living donors or kidney paired exchange programs.

Increase of allosensitization after a kidney graft failure: Predictors and effect on retransplantation outcomes / Aumento de la alosensibilización después de un fallo del injerto renal: predictores y efecto en los resultados del retrasplante

Patients who are candidates for a second kidney transplant (SKT) frequently have a higher level of panel reactive antibodies (PRA). We assessed the allosensitisation change after a first graft failure (GF), its predictors and impact on retransplantat outcomes. We retrospectively selected 140 adult patients who received a SKT. Recipient and donor characteristics were analyzed. We defined the delta PRA (dPRA) as the difference between peak PRA before the SKT and first one (cohort median value=+10%). Logistic regression analysis was used to determine risk factors for dPRA≥10% and acute rejection (AR) in the SKT. Univariable and multivariable Cox analysis was applied to assess independent predictors of second GF. Risk factors for dPRA≥10% at SKT were AR (OR=2.57; P=0.022), first graft survival <1 year (OR=2.47; P=0.030) and ABDR HLA mismatch (OR=1.38 per each mismatch; P=0.038). AR in the SKT was associated with dPRA≥10% (OR=2.79; P=0.047). Induction with a lymphocyte-depleting agent had a protective effect (OR=0.23; P=0.010). SKT survival was lower (P=0.008) in patients with a dPRA≥10% (75.6%, 60.5% in dPRA≥10%; 88.6%, 88.6% in dPRA<10% patients at 5 and 10 years, post-transplant respectively). Multivariable Cox regression showed that dPRA≥10% (HR=2.38, P=0.042), delayed graft function (HR=2.82, P=0.006) and AR (HR=3.30, P=0.001) in the SKT were independent predictors of retransplant failure. This study shows that an increased allosensitisation at retransplant was associated with the degree of HLA mismatch and led to poorer outcomes. De-emphasis of HLA matching in current allocation policies may be undesirable, particularly in patients with a higher chance of needing a SKT (AU)

Los pacientes candidatos a un segundo trasplante de riñón (STR) tienen a menudo un nivel superior de panel reactivo de anticuerpos (PRA). Evaluamos el cambio de alosensibilización después de un primer fracaso del injerto, sus predictores y repercusión en los resultados del retrasplante. Elegimos retrospectivamente a 140 pacientes adultos que recibieron un STR. Analizamos las características de los receptores y de los donantes. Definimos el delta PRA (dPRA) como la diferencia entre el pico de PRA antes del STR y el primero (cohorte mediana=+10%). Se aplicó análisis de regresión logística para determinar los factores de riesgo para dPRA≥10% y rechazo agudo (RA) en STR y análisis univariado y multivariado de Cox para evaluar predictores independientes de fallo del retrasplante. Los factores de riesgo para dPRA≥10% fueron: RA (OR=2,57; p=0,022), supervivencia del primero injerto menor a un año (OR=2,47; p=0,030) e incompatibilidad HLA ABDR (OR=1,38 por cada mismatch; p=0,038). El RA en el STR fue asociado con dPRA≥10% (OR=2,79; p=0,047). La inducción con un agente depletor de linfocitos tuvo un efecto protector (OR=0,23; p=0,010). La supervivencia del STR fue menor en pacientes con dPRA≥10% (75,6; 60,5% en dPRA≥10%; y 88,6; 88,6% en dPRA<10%; a los 5 y 10 años). La regresión multivariada de Cox mostró que dPRA≥10% (HR=2,38; p=0,042), función retardada de injerto(HR=2,82; p=0.006) y RA (HR=3,30; p=0,001) en STR fueron factores predictores independientes de fracaso en el retrasplante. Este estudio muestra que un incremento en la alosensibilización de retrasplante se ha asociado con el grado de incompatibilidad HLA y puede conducir a resultados más pobres en STR. La falta de énfasis en la compatibilidad de HLA en las políticas actuales de asignación puede no ser deseable, especialmente en pacientes con una mayor probabilidad de necesitar un STR (AU)

Increase of allosensitization after a kidney graft failure: Predictors and effect on retransplantation outcomes.

Patients who are candidates for a second kidney transplant (SKT) frequently have a higher level of panel reactive antibodies (PRA). We assessed the allosensitisation change after a first graft failure (GF), its predictors and impact on retransplantat outcomes. We retrospectively selected 140 adult patients who received a SKT. Recipient and donor characteristics were analyzed. We defined the delta PRA (dPRA) as the difference between peak PRA before the SKT and first one (cohort median value=+10%). Logistic regression analysis was used to determine risk factors for dPRA≥10% and acute rejection (AR) in the SKT. Univariable and multivariable Cox analysis was applied to assess independent predictors of second GF. Risk factors for dPRA≥10% at SKT were AR (OR=2.57; P=0.022), first graft survival <1 year (OR=2.47; P=0.030) and ABDR HLA mismatch (OR=1.38 per each mismatch; P=0.038). AR in the SKT was associated with dPRA≥10% (OR=2.79; P=0.047). Induction with a lymphocyte-depleting agent had a protective effect (OR=0.23; P=0.010). SKT survival was lower (P=0.008) in patients with a dPRA≥10% (75.6%, 60.5% in dPRA≥10%; 88.6%, 88.6% in dPRA<10% patients at 5 and 10 years, post-transplant respectively). Multivariable Cox regression showed that dPRA≥10% (HR=2.38, P=0.042), delayed graft function (HR=2.82, P=0.006) and AR (HR=3.30, P=0.001) in the SKT were independent predictors of retransplant failure. This study shows that an increased allosensitisation at retransplant was associated with the degree of HLA mismatch and led to poorer outcomes. De-emphasis of HLA matching in current allocation policies may be undesirable, particularly in patients with a higher chance of needing a SKT.

An uncommon cause of linfadenopathy in a kidney transplant patient: Cat-scratch disease

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Cost analysis of renal replacement therapy by transplant in a system of bundled payment of dialysis.

Renal replacement therapies (RRT) for patients with end-stage renal failure represent a high burden on European countries' healthcare budget. Our purpose was to report and compare the costs of RRT by hemodialysis (HD) or peritoneal dialysis (PD) and renal transplantation (RT) after introduction of a bundled payment system of dialysis. We analyzed average annual cost of RT in a public national health system hospital - surgical/anesthesiologist team and material, induction and maintenance immunosuppression therapy, hospital stay, diagnostic examinations (DE), and post-transplant office visits (including DE). Incentives paid to hospitals performing RT were included. Annual cost of HD or PD was estimated by bundled payment established in a recently revised law - 537.25 €/wk. Total first year cost or RT is 61 658.14 € and from the second year forth 543.86 €/month. Dialysis costs 28 033.71 €/yr. Break-even point for cost is at 32 months, and from there on, RT is less expensive. Strategies aimed at increasing RT are needed as it confers better survival than RRT by dialysis with lower costs to Portuguese health system.