Pediatric Renal Transplantation: Evaluation of Long-Term Outcomes and Comparison to Adult Population.

BACKGROUND: In Europe, pediatric transplantation accounts for only about 4% of all kidney transplantations performed. The aim of our work is to evaluate the evolution of pediatric renal transplantation in our department over time, but also to compare this special population with the adult one. METHODS: We evaluated all pediatric renal transplantations performed in our department between January 1981 and December 2016. We performed the analysis of clinical, analytical, and surgical factors to look for predictive factors of graft loss or decrease of survival. In addition, we performed a comparative study of pediatric and adult populations and an evaluation of the evolution of pediatric renal transplantation in our department over time. RESULTS: We evaluated 101 renal transplantations performed in patients younger than 18 years. Pediatric transplantations corresponded to 3.4% of all renal transplantations performed in our department. The rate of living donors was 12%. Donors of grafts for the pediatric population were significantly younger than in the adult population. The increase in donor age was associated with lower renal graft survival rates. Acute rejections were more frequent in the pediatric population. Eleven pediatric recipients (10.9%) died in the follow-up period. Renal graft survival in the pediatric population was 94.8%, 77.4%, and 66.5% at 1, 5, and 10 years, respectively. There was no significant difference in graft survival in the pediatric and adult population. The pediatric overall survival rate at 1, 5 and 10 years was 97.9%, 96.8%, and 91.9%, respectively. CONCLUSION: Pediatric renal transplantation presents results identical to those identified in adults.

Prostate Cancer in Renal Transplant Recipients: Diagnosis and Treatment.

BACKGROUND: We currently know that prostate cancer (Pca) risk is reduced in patients undergoing kidney transplantation. However, its impact and treatment are not widely studied. METHODS: This was a retrospective study of male patients submitted to kidney transplantation in our center from 1980 to 2016 evaluating incidence, treatment, and follow-up of Pca in our population. RESULTS: In 1805 patients undergoing kidney transplantation, 20 men were diagnosed with Pca, leading to an incidence of 1.1%. Median age at renal transplantation was 53.4 years with a median age at diagnosis of Pca of 61.2 years. Initial median prostate-specific antigen (PSA) was 6 ng/mL and Gleason score was 7 (3 + 4) in about 50% of cases. Bone metastasis developed in 10% and no visceral metastases were diagnosed. The majority of patients were submitted to radical prostatectomy and bilateral pelvic lymph node dissection. Some other cancers occurred in these patients such as skin and pulmonary cancers. In 35% of the cases, the graft was lost. The main cause of patient death was cardiovascular. The mean graft survival was about 14 years. The majority of patients are alive with functioning grafts (65%). CONCLUSION: In our center the clinical incidence of Pca in patients undergoing kidney transplantation is 1.1% and surgical treatment seems to be a good initial option.

Surgical Complications in Early Post-transplant Kidney Recipients.

BACKGROUND: The purpose of this study was to determine the incidence of early surgical complications of kidney transplantation in our institution and its association with donor and recipient factors, as well as patient and transplant outcome. METHODS: A retrospective cohort study of all kidney transplants performed during 2015 was made. We evaluated the incidence of surgical complications and the outcome of patients and grafts at a 3-month follow-up interval. RESULTS: During the study period, 141 kidney transplants occurred. Seventeen patients had surgical complications (6 urologic, 6 vascular, and 5 other complications). Five patients lost the graft during the follow-up. Older age was associated with other surgical complications (P = .023), and graft loss was associated with the existence of surgical complications, namely, vascular complications (P <.001). For both surgical complications in general and urologic complications, a statistically significant relationship was found with patient weight (P = .003 and P = .034, respectively). The correlation between body mass index (BMI) and surgical complications was not statistically significant. CONCLUSIONS: Our study reveals that older and heavier patients have a higher risk of surgical complications and that vascular complications are associated with graft loss. A statistically significant relationship was not found between BMI and surgical complications, which could indicate that BMI is not the ideal obesity marker. The incidence of surgical complications found in our study is similar to the literature. The selection of transplant recipients is a difficult task, and the possibility of additional surgical complications in older and overweight patients should be taken into account.

Small kidneys for large recipients: does size matter in renal transplantation?

BACKGROUND: Imbalance between transplanted renal mass and the metabolic demands of the recipient has been identified as a predictor of renal graft function. Multiple factors have been used to test this influence, but none of them is consensually accepted. The aim of this study is to evaluate the influence of the imbalance between transplanted renal mass and the metabolic needs of the recipient by analyzing the relationship between the ratio of the weight of the renal graft and the body weight of the recipient (Kw/Rw) on transplantation outcomes. METHODS: Prospective observational study of 236 first and single cadaveric renal transplants in non-hyperimmunized recipients was conducted. Grafts were orthogonally measured and weighed immediately before implantation, and these measures were correlated with donor and recipient data. According to the Kw/Rw ratio, patients were divided into three groups: Kw/Rw < 2.8 (P25), Kw/Rw = 2.8-4.2, and Kw/Rw > 4.2 (P75). After a mean follow-up of 5.2 years, transplant outcomes (delayed graft function; acute rejections; and estimated 1-, 6-, 12-, 36-, and 60-month renal function, graft, and patient survivals) were evaluated and correlated in uni- and multivariate analyses with the Kw/Rw ratio. RESULTS: Mean values for graft dimensions were 109.47 × 61.77 × 40.07 mm and the mean weight was 234.63 g. Mean calculated volume was 145.64 mL. The mean Kw/Rw ratio was 3.65 g/kg. These values were significantly lower for female grafts (3.91 vs 3.24, P < .001). According to the Kw/Rw ratio groups, there were no differences on delayed graft function, acute rejection episodes, and estimated graft function at the defined times. The increase in estimated glomerular filtration rate by a mean of 3.6 mL/min between 1 and 6 months for patients with Kw/Rw < 2.8 was not statistically relevant when compared to the higher ratio group with a mean variation of -0.91 mL/min (P = .222). Graft survival rate at 5 years after transplantation was 79% in the Kw/Rw < 2.8 group and 82% in the Kw/Rw > 4.2 group (P = .538). Patient survival rate at 5 years after transplantation was 85% in the Kw/Rw < 2.8 group and 92% in the high ratio group (P = .381). Kw/Rw ratio was not an independent risk factor for transplant failure at 5.2 years in a multivariate logistic regression analysis. Irrespective of recipient weight, graft survival was significantly higher for grafts with volume or weight above the 50 percentile (vol > 134 mL, P = .011 or weight > 226 g, P = .016). CONCLUSION: The imbalance between implanted renal mass and recipient metabolic demands does not seem to influence the functional outcomes and graft survival up to 60 months post-transplantation. Nevertheless, irrespective of recipient weight, graft survival is significantly higher for grafts with volume or weight above the 50 percentile.

Kidney retransplantation: removal or persistence of the previous failed allograft?

A significant percentage of patients with failed renal graft are candidates for retransplantation. The outcomes of retransplantation are poorer than those of primary transplantation and sensitization is documented to be a major reason. The management of a failed allograft that is not immediately symptomatic is still very controversial. The aim of this study was to determine the impact of the failed allograft nephrectomy on a subsequent transplantation and its importance in the sensitization. We performed a retrospective analysis of the local prospective transplantation registry of the outcome of 126 second kidney transplantations among 2438 transplantations performed in our unit between June 1980 and March 2013, comparing those who underwent allograft nephrectomy prior to retransplantation with those who retained the failed graft. Primary endpoints were graft and patient survival. The levels of panel-reactive antibodies (PRA) and rate of acute rejections on retransplantation outcomes were also studied. Among the 126 patients who underwent a second renal transplantation, 76 (60.3%) had a prior graft nephrectomy (Group A), whereas 50 (39.7%) kept their failed graft (Group B). Group A showed significantly more positive PRA levels when compared with the other group (38% vs 10%; P < .001), as measured before the most recent transplantation, and a higher rate of acute rejection (19% vs 5.6%; P = .016). There were 28 (36%) renal allograft losses for Group A and 18 (36%) for those who had not had transplantectomy (P = not significant [NS]). One-, 3-, and 5-year graft survival rates were 96.6%, 90.7%, and 83.4%, respectively, in Group A and 95%, 82%, and 68.4%, respectively, in Group B, with no statistical differences (P = .19). Five-year actuarial patient survival rates in the 2 groups was 89.3% and 82.8%, respectively (P = .55). Multivariate analysis showed that PRA level and delayed graft function (DGF) had a statistically significant influence on graft survival (P = .028; odds ratio [OR] = 1.029; and P = .024; OR = 8.6), irrespective of whether the patient had graft nephrectomy or not. The allosensitization indicated by PRA increases after transplantectomy and leads to a higher incidence of acute rejection after retransplantation. Nephrectomy of failed allograft does not seem to significantly influence the survival of a subsequent graft. The decision to remove or retain a failed graft in the context of retransplantation should thus be based on known clinical indications for the procedure.

Ureteric stent in renal transplantation.

INTRODUCTION: Several techniques can be used to accomplish the ureteroneocystostomy in kidney transplantation. A ureteral catheter is a prophylactic measure to avoid urological complications (UC) of stenosis and/or fistula. In this study we evaluate the influence of using a ureteral stent upon the rate of UC in renal transplantation. PATIENTS AND METHODS: Retrospective review of 2061 kidney transplants (75 living and 1986 cadaveric donors) for 1360 male and 684 female recipients, from July 14, 1991, to January 13, 2012, with a minimum follow-up of 6 months A double J stent (JJ) was used in 1890 an external tumor (ET) catheter in 52 and no catheter (NC) in 119 cases. RESULTS: Mean recipient age was 44.66 ± 13.66 years. UC occurred in 5.9% among which ET showed 17.3%, 8.4% for NC, and 5.4% for JJ (P < .0005). Urological complications were more frequent when surgery duration exceeded 3 hours (8.8% vs 5.3% ≤ 3 hours; P = .003), using older donors organs (P = .048) and with higher donor weight (P = .009). No differences were observed related to recipient age, gender, or weight; donor gender; pretransplant dialysis time; cold ischemia time; type of donor (living vs cadaveric); number of HLA matches; or initial immunosuppression (mammalian target of rapamycin inhibitor vs other). On multivariate analysis, donor weight (odds ratio [OR]: 1.023; P = .015), use of a JJ vs ET (OR: 0.280; P = .005), and surgery time exceeding 3 hours (OR: 3.270; P < .0005) were independently associated with UC. CONCLUSIONS: Catheterization of the urinary anastomosis with a JJ was associated with fewer UC. This is especially important for grafts from heavier donors. The use of an external catheter which was associated with an high rate of UC, should be avoided.

Renal transplantation with donors older than 70 years: does age matter?

PURPOSE: The need for organs for renal transplantation has encouraged the use of grafts from increasingly older donors. Studies of transplantation results with donors older than 70 years are sparse. The main purpose of this study is to compare the results of transplantation with donors older and younger than 70 years old. METHODS: This retrospective study included 1233 consecutive deceased-donor renal transplantations performed between January 1, 2001, and December 31, 2011. We compared outcomes of grafts from donors older than 70 years (group ≥ 70; n = 82) versus donors younger than 70 years (group < 70; n = 1151). RESULTS: Univariate analysis of pretransplantation data showed statistically significant differences (P < .05) among the following variables for the group < 70 and group ≥ 70, respectively: recipient age (46 ± 13 versus 61 ± 5 years), donor age (44 ± 16 versus 73 ± 3 years), donor male gender (69.4% versus 47.6%), use of antibody induction immunosuppression (51.7% versus 70.7%), and HLA compatibilities (2.4 versus 2). The group ≥ 70 showed increased postoperative minor complications: bleeding (8.5% versus 3.4%; P = .017), lymphocele formation (3.7% versus 0.5%; P = .011), and incisional hernia (2.4% versus 0.2%; P < .001). Regarding transplantation results, we observed that mean serum creatinine was significantly lower among group < 70, at 1, 3, 6, 12, 24, and 60 months after transplantation (P < .05). Cumulative graft survival at 1, 3, and 4 years was 90%, 85%, and 83% in the group < 70 versus 87%, 79%, and 72% in the group ≥ 70. In the subgroup of recipients younger than 60 years, we did not verify statistically significant differences in allograft survival between group ≥ 70 and group < 70. Using Cox regression for survival analysis, we verified that donor age was not an independent risk factor for graft failure. CONCLUSIONS: The group of patients who received kidneys from donors younger than 70 years achieved better transplantation outcomes. Nevertheless, kidneys from older donors represent an excellent alternative for older recipients.

Donor cause of brain death in renal transplantation: a predictive factor for graft function?

PURPOSE: Our aim was to evaluate the influence of donor cause of brain death on the results of kidney transplantation. METHODS: This retrospective study included 896 consecutive deceased-donor renal transplantations performed between January 1, 2000, and December 31, 2009. We compared outcomes of grafts from donors after cerebrovascular accident (CVA; n = 371) versus head trauma (HT; n = 525). RESULTS: Univariate analysis of pretransplantation data showed statistically significant differences (P < .05): among the following variables for the HT versus CVA groups respectively: recipient age (43.63 ± 13.2 y vs 49.80 ± 12.5 y); donor age (36.06 ± 16.6 y vs 52.57 ± 13.2 y) and time on dialysis (50.67 ± 45.034 mo vs 59.39 ± 46.3 mo). Regarding transplantation results, we observed that mean serum creatinine was significantly lower among HT recipient, at 1, 3, 6, 12, and 24 months after transplantation (P < .05). Chronic allograft nephropathy (CAN) and delayed graft function were higher among the CVA group. HT group kidneys showed significantly longer mean survival times than CVA group kidneys (102.7 ± 3.9 mo vs 94.8 ± 5.6 mo; log rank: P = .04). Upon multivariate analysis donor cause of death was not identified as an independent risk factor for graft survival or occurrence of chronic allograft nephropathy. CONCLUSIONS: Transplantation results were better among the HT group. However multivariate regression analysis indicated that donor cause of death was not an independent risk factor for graft survival or occurrence of chronic allograft nephropathy.

Induction with basiliximab in renal transplantation.

INTRODUCTION: The use of monoclonal antibodies in renal transplantation for induction therapy has been associated with a marked reduction in acute rejection rates with an impact on graft and patient survivals. OBJECTIVE: We sought to evaluate the efficacy of renal transplant induction protocols using Basiliximab based on the rates of acute rejection episodes (ARE) and delayed graft function (DGF) of infectious complications in the first 6 months posttransplant, as well as patient and graft survivals. METHODS: We retrospectively evaluated all renal transplants performed between 2000 and 2008 that were primary grafts from cadaveric heart-beating donors, into recipients with a panel reactive antibody titer <5% and who were treated with an immunosuppression scheme based on cyclosporine, mycophenolate mofetil/mycophenolic acid plus corticosteroids, with (group 1) or without basiliximab (group 2). RESULTS: We enrolled 52 recipients in group 1 (induction with basiliximab) and 189 in group 2 (without basiliximab). The baseline characteristics were similar among the groups, except for time on dialysis which was longer in group 1 and the number of HLA matches, which was lower in group 1. The ARE rate was lower among group 1 (7.8% vs 27.8%; P = .001); rates of DGF and infectious complications were similar. There was no significant difference in graft and patient survivals. CONCLUSION: In this study, induction with basiliximab was associated with a reduced rate rate of ARE, despite a lower number of HLA matches and a longer previous time on dialysis. The use of this induction modality was not associated with a greater rate of infectious complications.

Renal transplantation with expanded criteria donors: the experience of one Portuguese center.

BACKGROUND: The shortage of kidneys available for transplantation has led to enlarged criteria donors (ECD): namely, donors older than 60 years or aged between 50 and 59 years with 2 of the following characteristics-hypertension, predonation serum creatinine level higher than 1.5 mg/dL or cerebrovascular disease as the cause of death. The aim of this study was to analyze renal transplants using ECD compared with standard criteria donors (SCD) concerning the incidences of delayed graft function (DGF), acute rejection episodes (ARE), and patient and graft survivals. MATERIALS AND METHODS: This retrospective study of 409 cadaveric renal transplants over the last 4 years identified ECD in contrast with SCD. RESULTS: Of the transplants, 24.4% used ECD. The baseline characteristics of recipients of ECD versus SCD kidneys were similar, except for age and cold ischemia time. Comparing ECD and SCD, we observed an higher incidence of DGF (35% vs 18%), occurrence of ARE (34.4% vs 16.6%), average serum creatinine levels at 6 (1.87 vs 1.4 mg/dL), and 12 months (1.88 vs 1.43 mg/dL) as well as lower graft survival at 1 (82% vs 91%) and 3 years (75% vs 84%) after transplantation. Recipient survival at 1 year was not different. Multivariate analysis identified recipient age, cold ischemia time, ARE, and DGF as risk factors for graft failure. CONCLUSIONS: Renal transplantation with grafts from ECD shows significantly worse outcomes with higher rates of DGF and ARE, worse graft function, and lower graft survival.

Kidney transplantation with corticosteroid-free maintenance immunosuppression: a single center analysis of graft and patient survivals.

The purpose of this study was to assess the impact of a corticosteroid-free maintenance immunosuppression on graft survival in kidney transplantation. We analyzed 79 patients who were transplanted between June 1, 2006 and May 31, 2007. We excluded hyperimmunized patients, second transplantations, living donors, and black recipients. Patients underwent induction with thymoglobulin or basiliximab, followed by treatment with mycophenolate mofetil (MMF), tacrolimus, and methylprednisolone. On the 5th day, the patients were divided into 2 groups: group A (n = 45) discontinued steroid therapy; group B (n = 34) continued prednisone therapy. We performed a comparative analysis of incidence of delayed graft function (DGF), acute rejection episodes (ARE), renal function at 6 and 12 months, graft and patient survivals, causes of graft loss, and mortality. The 2 groups were similar for donor, recipient, and graft characteristics. The incidences of DGF were 8.9% in group A and 14.7% in group B; those for ARE were 2.3% in group A and 13.8% in group B (P = .077). The mean serum creatinine levels at 6 and 12 months were similar. There were 8 graft losses: 3 in group A (3 deaths with functioning grafts) and 5 in group B (1 death, 3 vascular causes, 1 kidney nonfunction). The 4 deaths were due to infection (n = 3) or neoplasia (n = 1). Graft survivals at 1 year were 98% in group A and 85% in group B, and patient survivals were 98% and 97%, respectively. An immunosuppressive regimen using antibody induction and steroid-free treatment proved to be effective in low-risk patients.

Cadaveric donor factor variations during a 12-year period: influence on kidney transplant outcomes.

UNLABELLED: Our purpose was to evaluate changes in cadaveric donor factors between 1993 and 2004 and their impact on the short- and long-term outcomes of renal transplants in a single center. PATIENTS AND METHODS: Cadaveric renal transplants performed in our unit between 1993 and 2004 were divided in two groups of identical length: A (n = 455; 1993-1998) and B (n = 465; 1999-2004). Major differences related to donor, graft, and recipient factors were analyzed between groups and correlated with main outcome parameters. Recipient age, gender, weight, etiology of end-stage renal disease, average length of dialysis, and cold ischemia were not different in the two periods. RESULTS: Grafts harvested in our hospital were more frequent in group A (92.3 vs 78.2%; P < .005). Traumatic causes of death were more frequent before 1999: 90.9 vs 70.9% (P < .001). Mean donor age was higher after 1999: 31.37 vs 35.94 years (P < .005). Female donors were more frequent in the second period: 20.5 vs 26.6% (P < .05). Mean donor weight was also higher: 52.36 vs 67.86 kg (P < .05). All of these differences were unfavourable characteristics regarding graft outcomes. Delayed graft function (A = 13%, B = 24.2%), acute rejection episodes (A = 41.2%, B = 28%), and chronic allograft dysfunction (A = 23.5%, B = 14.4%) were also significantly different between the two cohorts (P < .005). Graft function (serum creatinine at 1 and 2 years), patient and graft survivals, causes of graft loss, and of patient death were similar across time. CONCLUSION: The unfavorable tendency in the quality of cadaveric donors during the last 12 years had no negative impact on graft function and patient outcome.

Pediatric renal transplantation: comparative study with renal transplantation in the adult population.

PURPOSE: To retrospectively review our experience with pediatric renal transplantation and to compare the results with the adult population. PATIENTS AND METHODS: Between January 1981 and August 2003, 74 renal transplants were performed in patients < or =18 years at the time of the transplant--the pediatric group versus 1153 patients in the adult group. We analyzed various risk factors for actuarial kidney graft and patient survivals using the Kaplan-Meier method. RESULTS: Median ages were 13.8 +/- 3.5 and 42.6 +/- 2.4 years, respectively. There was no statistically significant difference in the human leukocyte antigen matching or immunosuppression. There was, however, a younger donor age and shorter ischemia time in the pediatric group. Overall, kidney transplant survival rates for patients < or =18 years at 1, 2, 5, and 10 years were 94.4%, 91.3%, 70.6%, and 58.2%, respectively, with no significant difference for patients older than 18 (91.2%, 89.3%, 78.8%, 60.5%, P = .4325). There was a significantly decreased graft survival in the adult group at 10 years when the donor age was over 60 years and when the ischemia time was > or =20 hours. The incidence of delayed graft function and the creatinine levels of functioning grafts did not differ between the two groups. During the follow-up, acute rejections were more frequent in the younger group. Patient survival in the pediatric group at 1, 2, 5, and 10 years was 98.6%, 98.8%, 98.6%, and 90.3%, respectively, significantly lower in the adult group (95.3%, 94.0%, 87.9%, 76.8%, P < .02). CONCLUSIONS: Renal transplantation may be successfully performed in the pediatric patients with end-stage renal disease. Overall graft survival at 10 years did not differ significantly between the two groups. There is a higher incidence of acute rejections but longer patient survival in the pediatric population.

[Kidney transplantation in patients with type I and type II diabetes mellitus]. / Transplantação renal em doentes com diabetes mellitus tipo I e tipo II.

A total of 618 patients with end-stage renal disease received kidney transplants between 1980 and September 1996. Twenty eight of them were diabetics. Better results were achieved for type 1 diabetic patients than for type 2 (mortality: 5.9% vs 27.3%; functioning graft: 88.2% vs 72.7%). The morbility was also higher in those patients (infections: 81.8% vs 29.4%; vascular complications: 45.5% vs 17.6%). Actuarial patient and graft survival were lower for type 2 than for non diabetic patients. For type 1 diabetics the results are similar to those for non diabetics. Better results can probably be achieved by restricting the selection criteria. The decision to transplant or maintain on dialysis should be made on a case by case basis.

[Pancreatic transplantation]. / Transplantação pancreática.

The AA. report on their very limited experience with whole pancreatic transplantation. For the moment this is the only experience in Portugal, the detailed report of the 3 cases may be of some help to other Portuguese groups interested in starting this therapeutical approach for insulin-dependent end-stage renal failure patients. The main comments focus on the third simultaneous pancreas-kidney transplantation, which failed for technical reasons, mainly related to less than good selection of both donor and recipient. In all the three cases the technique preferred was the duodenocystostomy. The 2 first cases are doing very well, free of insulin and with normal glucose metabolism, at 15 and 7 months after grafting. The AA. also make some considerations on the indications, complications and follow-up of patients with pancreas-kidney transplantation.