Factors affecting graft survival among patients receiving kidneys from live donors: a single-center experience.

INTRODUCTION: The aim of this report is to study the graft and patient survival in a large cohort of recipients with an analysis of factors that may affect the final outcomes. METHODS: Between March 1976 and March 2008, 1967 consecutive live-donor renal transplants were carried out. Various variables that may have an impact on patients and/or graft survival were studied in two steps. Initially, a univariate analysis was carried out. Thereafter, significant variables were embedded in a stepwise regression analysis. RESULTS: The overall graft survival was 86.7% and 65.5%, at 5 and 10 years, respectively. The projected half-life for grafts was 17.5 years and for patients was 22 years. Five factors had an independent negative impact on graft survival: donor's age, genetic considerations, the type of primary immunosuppression, number of acute rejection episodes, and total steroid dose during the first 3 months after transplantation. CONCLUSIONS: Despite refinements in tissue matching techniques and improvements in immunosuppression protocols, an important proportion of grafts is still lost following living donor kidney transplantation, presumably due to chronic allograft nephropathy.

Long-term outcome of grafts with multiple arteries in live-donor renal allotransplantation: Analysis of 2100 consecutive patients.

PURPOSE: To analyse the long-term outcome in relation to multiple graft arteries (MGA) in live-donor renal transplantation, and assess its effect on graft and patient survival. PATIENTS AND METHODS: Between March 1976 and November 2009, a total of 2100 live-donor renal transplants were carried out at our centre. Patients were stratified according to the number of graft arteries into two groups, i.e. MGA (two or more arteries; 237 patients) and single-graft artery (SGA; 1863 patients). Variables assessed included patient demographics, site of vascular anastomosis, ischaemia time, onset of diuresis, delayed graft function, acute tubular necrosis (ATN), acute rejection, vascular and urological complications. Moreover, long-term patient and graft survival were compared among both groups. Patients were followed up for a mean (SD) of 112 (63) months. RESULTS: Grafts with MGA were associated with a prolonged ischaemia time (P = 0.001) and ATN (P = 0.005). Vascular thrombosis (arterial and venous) had a higher incidence in MGA (2.5%) than SGA (0.6%) (P = 0.01). Both groups were not significantly different for the onset of diuresis, acute rejection and urological complications (P = 0.16, 0.23 and 0.85, respectively). Graft and patient survival were comparable in both groups. The mean (SD) 1-, 5-, 10- and 20-year graft survival rates (%) for MGA were 96.1 (1.26), 86.6 (2.39), 61.3 (4.42) and 33.8 (7.23), and 97.5 (0.36), 86.8 (0.84), 66.0 (1.35) and 37.3 (2.76) for SGA (P = 0.54). CONCLUSIONS: Although there was a higher incidence of prolonged ischaemia time, ATN and vascular thrombosis in live-donor renal transplants with MGA, it did not adversely affect patient or graft survival. The early, intermediate- and long-term follow-up showed an outcome comparable to that in patients with SGA.

Necessity of routine postoperative heparinization in non-risky live-donor renal transplantation: results of a prospective randomized trial.

OBJECTIVES: To determine the exact value of postoperative heparinization in preventing thrombotic sequelae in non-risky renal transplants and to assess the possible hazards of this therapy through a prospective randomized trial. METHODS: Of 120 consecutive live-donor renal transplants, 45 patients were excluded because of young age, multiple or atheromatous graft arteries, a history of thromboembolic disease, or intraoperative technical difficulties. The remaining patients were prospectively randomized into three groups, with 25 patients each. Group 1 did not undergo heparinization. Groups 2 and 3 received a prophylactic dose of low-molecular-weight heparin and conventional heparin, respectively, for 1 week. RESULTS: None of our patients in any group developed graft vascular thrombosis, deep venous thrombosis, or pulmonary embolism, and the rate of spontaneous closure of arteriovenous fistulas was comparable among the three groups (P = 0.79). No statistically significant difference was found among the three groups in terms of the development of significant perirenal hematomas, rate of blood transfusions, or mean number of transfused units (P = 0.37, P = 0.56, and P = 0.69, respectively). In contrast, a significant decrease in the hemoglobin level occurred in group 3 compared with group 1 among nontransfused patients (1.6 +/- 0.8 g% and 0.7 +/- 0.9 g%, respectively; P = 0.01). Moreover, a significant shortening of lymph drainage time and a reduction of the total amount of lymphorrhea were found in group 1 compared with groups 2 and 3 (P = 0.01, P = 0.03, respectively). CONCLUSIONS: Postoperative heparinization should not be routinely indicated in non-risky live-donor renal transplantation.

Rotoresection versus transurethral resection of the prostate: short-term evaluation of a prospective randomized study.

PURPOSE: We compared in a prospective fashion the short-term outcome of rotoresection to transurethral resection of the prostate. MATERIALS AND METHODS: A total of 50 patients with bladder outlet obstruction secondary to benign prostatic hyperplasia were randomized into 2 groups, rotoresection and transurethral resection of the prostate. Mean+/-SD patient age was 60.76+/-5.85 years in the rotoresection and 64.24+/-6.84 in the transurethral resection groups. All patients had an International Prostate Symptom Score of 8 or more, maximum free flow rate less than 15 ml per second, prostate volume 20 to 100 ml and prostate specific antigen 1 to 4 ng/ml. Pressure flow study revealed bladder outlet obstruction (Schafer's grade 3 or more). Patients were assessed at 1, 3 and 6 months by International Prostate Symptom Score, maximum free flow rate, transrectal ultrasound, pressure flow study, hemoglobin and urinalysis. RESULTS: At 6 months International Prostate Symptom Score decreased from 26.2+/-4.06 to 5.32+/-1.52 in the rotoresection group and from 22.84+/-4.56 to 7+/-1.4 in the transurethral resection group. Maximum free flow rate increased from 7.87+/-2.24 to 25.29+/-10.39 ml per second in the rotoresection group and from 9.44+/-2.29 to 25.2+/-5.8 ml per second in the transurethral group. Prostate volume decreased from 41.2+/-16.58 to 17.24+/-7.61 ml in the rotoresection group and from 40.6+/-16.93 to 18.28+/-8.75 ml in the transurethral group. Detrusor pressure at maximum flow and Schafer grade decreased from 79.84+/-26.8 cm H2O and 4.24+/-0.97 to 38.8+/-18.8 cm H2O and 1.24+/-0.93 in the rotoresection group, and from 63.04+/-21.08 cm H2O and 3.48+/-0.65 to 34.16+/-12.7 cm H2O and 1+/-0.7 in the transurethral group. Dilutional hyponatremia was higher with transurethral resection of the prostate (p=0.005) but no patient showed manifestations of the transurethral syndrome. Mild stress urinary incontinence was noted in 4 patients in the rotoresection group and in 3 in the transurethral group. CONCLUSIONS: Rotoresection is a safe and effective method of treating bladder outlet obstruction resulting from benign prostatic hyperplasia, and its efficacy is comparable to transurethral resection of the prostate.

Histologic and clinical findings in living donor allografts with long-term stable function.

BACKGROUND/AIMS: Protocol biopsy is an important strategy which assesses the histological changes that can occur in the renal allograft and adversely affect its outcome. We aimed to evaluate histological changes in long-term living donor transplants. METHODS: Elective biopsies were done for 120 live donor renal transplant recipients with well-functioning grafts and no rejection history at least 1 year or more after transplant. All patients had serum creatinine levels <2 mg/dl. The histopathological findings using the chronic allograft damage index score were correlated with different clinical and immunological parameters. RESULTS: Chronic tubulointerstitial fibrosis was the most prevalent finding (85% of cases), mostly of mild degree. Normal biopsies were reported in only 7.5% of cases, whereas chronic cyclosporine nephrotoxicity was detected in 5.8% of biopsies. Posttransplant hypertension was significantly correlated with glomerulosclerosis, and posttransplant diabetes with glomerulosclerosis, mesangial matrix increase, tubular atrophy and interstitial fibrosis. The main risk factors associated with a high chronic allograft damage index score were DR mismatching, posttransplant diabetes and time of biopsy. All histopathological changes increased with advancing donor age and declining graft function. CONCLUSION: Elective biopsies showed that histopathological findings do exist even with stable renal function that may pave the way for predicting long-term graft outcome.

A 2-year follow-up after rotoresection of the prostate: a prospective study.

OBJECTIVE: To evaluate the success of rotoresection of the prostate for benign prostatic hyperplasia (BPH), after a follow-up of 24 months. PATIENTS AND METHODS: The 24 patients who were the subject of a previous report were followed for up to 24 months; only one patient was lost to follow-up. RESULTS: The mean (sd) American Urologic Association-7 score decreased from 20.5 (3.8) before surgery to 1.12 (1.56) at 24 months; the mean maximum urinary flow rate increased from 8.7 (2.1) to 21.8 (8.5) mL/s, and the mean total prostate volume decreased from 36.5 (12.9) to 21 (7.9) mL. Early complications were urinary tract infection in 10 patients and mild stress urinary incontinence in 11. One patient had a urethral stricture and another had a posterior urethral stone at 6 months; both were treated successfully with good urinary flow rates thereafter. At 24 months, 23 patients had sterile urine and were continent. CONCLUSION: Thus far, rotoresection of the prostate is a safe and effective method for treating BPH. The hospital stay was short and the functional results excellent at up to 24 months.

Living-donor kidney retransplantation: risk factors and outcome.

OBJECTIVE: To review the results of kidney retransplantation at our centre. PATIENTS AND METHODS: Between March 1976 and January 2002, 1406 kidneys were transplanted; among these, 54 patients received a second graft (39 men, mean age 32.1 years, sd 8.6). The donors were 48 relatives (mean age 35.4 years, sd 10.1). RESULTS: The mean (sd, range) duration of the first graft was 49.1 (45.9, 1-192) months and the main cause of these grafts failing was immunological. The mean duration of graft failure was 17.3 (10.5, 5-62) months. The rate of histocompatibility leukocyte antigen (HLA)-A, -B >3 was 16.7% and of haplotype DR matching was 11%. The immunosuppression regimen was mainly based on cyclosporin (75%). There were 33 episodes of acute rejection in 23 patients. The major complications were hypertension (70%), infections (30%) and hepatitis (11%). The overall graft and patient survival was good; 15 grafts (27%) were lost during the follow-up of 1-17 years. Ten patients died, five with a functioning graft. Multivariate analysis showed that donor relationship, primary immunosuppression, duration of first graft and serum creatinine level at 1 year were predictors of graft survival. CONCLUSION: Renal retransplantation is the treatment of choice in patients who have lost their graft. The use of related living-donors and potent immunosuppression could help to improve the outcome.

Weight gain after renal transplantation is a risk factor for patient and graft outcome.

BACKGROUND: The present study aimed to evaluate the effect of weight gain after transplantation on patient and graft outcome. METHODS: Patients receiving kidney transplants between April 1986 and April 2001 were divided according to their body mass index (BMI) at 6 months after transplantation into group I, BMI less than 25 (normal weight); group II, BMI greater than or equal to 25 and less than 30 (overweight); and group III, BMI greater than or equal to 30 (obese) after exclusion of pediatric patients (aged < or =18 years), second transplant recipients, those with a history of cardiovascular disease, and those with a BMI less than 25 and greater than 18.5 kg/m2. Six hundred fifty kidney transplant recipients were selected for this retrospective study. RESULTS: There was a statistically significant increase in the incidence of posttransplant hypertension, diabetes mellitus, and ischemic heart disease in the obese group. The incidence and frequency of acute rejection episodes were similar in the three groups. A trend toward decreased graft and patient survival, which reached significance at 5 years and 10 years, was observed in the obese group. CONCLUSIONS: BMI has a strong association with outcomes after renal transplantation independent of most of the known risk factors for patient and graft survival.

Effect of donor/recipient body weight mismatch on patient and graft outcome in living-donor kidney transplantation.

BACKGROUND/AIMS: There have been conflicting reports showing that kidneys from small donors may be at risk for graft loss if they are transplanted into large recipients. The aim of this work was to examine the donor/recipient body weight ratio (D/RBWR) on patient and graft outcome. METHODS: During the period from January 1990 to January 2002, 856 kidney transplants were performed. Of these, 776 kidney transplant recipients were selected after exclusion of pediatric, second transplant patients and those with a body mass index of 35. All patients achieved a minimum follow-up of 1-year. According to D/RBWR, patients were divided into 3 groups: low (0.9), medium (0.91-1.2) and high (1.2). Data were collected on graft function, acute and chronic rejection, post-transplant complications, and 1- and 5-year graft and patient survival. RESULTS: There was a statistically significant increase in the incidence of chronic rejection, post-transplant hypertension and diabetes mellitus in the low group. The incidence and frequency of acute rejection episodes were nearly the same in the 3 groups. Graft function, estimated by serum creatinine at 1 year, was significantly lower in the low group. The 5-year graft and patient survival was 71, 80, 88 and 81, 85 and 92%, in the low, medium and high groups, respectively. CONCLUSIONS: We conclude that a low D/RBWR may contribute to inferior long-term renal allograft survival. The hyperfiltration hypothesis due to low nephron mass in the low D/RBWR group may explain these findings.

Multiple arteries in live donor renal transplantation: surgical aspects and outcomes.

PURPOSE: This retrospective study describes the surgical techniques and outcomes of live donor renal allografts with multiple arteries. MATERIALS AND METHODS: Between 1976 and 2000, 1,200 consecutive live donor renal transplants were done, including 1,087 with single (group 1) and 113 with multiple (group 2) arteries. Intracorporeal in situ anastomotic techniques were used for 94 grafts with multiple arteries, while ex vivo techniques were used for 19. During in situ surgery each one of the multiple arteries was anastomosed separately to an individual artery. In ex vivo surgery 2 or more arteries were joined together on the bench to form a common stem, which was then anastomosed to an iliac artery or the aorta. RESULTS: Patient and graft survival were comparable in groups 1 and 2. The 2 groups were comparable regarding complications, including arterial bleeding, hematoma, renal artery stenosis, acute rejection, new onset hypertension, acute tubular necrosis and urological complications. Mean serum creatinine +/- SD at 1 year was 1.4 +/- 0.5 and 1.5 +/- 0.6 mg./dl., and at 5 years it was 1.8 +/- 1 and 2.1 +/- 1.4 mg./dl. for the 2 groups, respectively. The difference was only significant at 1 year (p = 0.02). Graft and patient survival, and the incidence of the described complications were comparable for the ex vivo bench anastomotic techniques and intracorporeal in situ techniques in the group with multiple renal arteries. CONCLUSIONS: The use of multiple arteries in renal allografts does not adversely affect patient or graft survival. It is not associated with an increased rate of complications except for significantly higher mean serum creatinine at 1 year. Extracorporeal bench surgery was as effective as intracorporeal surgery for the anastomosis of multiple renal arteries with no increase in the incidence of relevant complications.

Characteristics of long-term live-donor renal allograft survivors.

BACKGROUND/AIMS: Despite the high rate of rejection, allograft failure and patient mortality in the early years of renal allotransplantation, some patients have done-remarkably well. We report here on 62 renal transplant recipients out of 144 patients (43%) who had functioning grafts for more than 15 years (range 15-24 years). MATERIALS: Demographic and follow-up data for patients fulfilling the criteria were reviewed. These patients include 43 males and 19 females, with a mean age at transplantation of 27.5 +/- 6.6 years (range 9-43 years), and mean donor age of 30 +/- 8.6 years. The donor source was 8 parents, 49 siblings and 5 unrelated. The main causes of end-stage renal disease were chronic pyelonephritis and chronic glomerulonephritis. Twenty-nine patients were treated with cyclosporine (CsA) while 33 patients were primarily immunosuppressed by steroids and azathioprine. RESULTS: Acute rejection episodes occurred in 40 patients (64.3%), out of them 19 patients experienced two or more acute rejection episodes. Univariate analysis showed that recipient and donor age, HLA-DR matching, pre- and post-transplant hypertension, ATN, delayed diuresis and chronic allograft nephropathy are significant risk factors; while recipient age, delayed diuresis and post-transplant hypertension were still significant by multivariate analysis. CONCLUSIONS: We concluded that renal transplantation, even in its earliest years and despite the numerous complications, has provided 15 or more years of near-normal life to patients with end-stage renal disease. Certain characteristics of long-term renal allograft survivors include young donor/recipient pairs, good DR matching with less pre- and post-transplantation prevalence of hypertension.

Death with functioning graft in living donor kidney transplantation: analysis of risk factors.

BACKGROUND: Death with a functioning graft (DWF) has been reported as a major cause of graft loss after renal transplantation. It has been reported to occur in 9-30%. METHODS: From March 1976 to January 2002, a total of 1400 living donor renal transplants were performed in our center. Out of 257 reported deaths among our patients, 131 recipients died with functioning grafts after a mean period of 53.4 +/- 53.2 months. RESULTS: DWF patients account for 27% of all graft losses in our series. The mean age was 34.9 + 10.6 (range 8-62 years), 98 of them were male and 33 were female. The original kidney disease was GN in 9, PN in 24, PCK in 5 and nephrosclerosis in 8 patients. Acute rejection episodes were diagnosed in 84 patients (63.1). The post-transplant complications encountered were hypertension in 78 patients (59.5%), diabetes mellitus in 30 patients (22.9%), medical infections in 68 (51.5%), hepatic complications in 30 (22.9%) and malignancy in 17 patients (13%). The main causes of death in these patients were infections in 46 (35.6%), cardiovascular in 23 (17.6%), liver cell failure in 15 patients (11.4%) and malignancy in 8 (6.1%). The mean serum creatinine was 2 +/- 0.6 mg/dl at last follow-up before death. CONCLUSION: We conclude that the relatively higher mortality in renal transplantation is, in part, due to co-morbid medical illness, pre-transplant dialysis treatment, and factors uniquely related to transplantation, including immunosuppression and other drug effects. DWF must be in consideration when calculating graft survival.