Long-term outcome of renal transplantation from older donors.

BACKGROUND: Long-term survival of kidney grafts from older donors is inferior to that of grafts from younger donors. We sought to determine whether selecting older kidneys according to their histologic characteristics before implantation would positively influence long-term outcome. METHODS: In a prospective cohort study, we assessed outcomes among 62 patients who received one or two histologically evaluated kidneys from donors older than 60 years of age. These outcomes were compared with outcomes among 248 matched recipients of single kidney grafts that had not been histologically evaluated and were either from donors 60 years of age or younger (124 positive-reference recipients who, according to available data, were expected to have an optimal outcome) or from those older than 60 years (124 negative-reference recipients, expected to have a worse outcome). The primary end point was graft survival. RESULTS: During a median period of 23 months, 4 recipients (6 percent) of histologically evaluated kidneys progressed to dialysis, as compared with 7 positive-reference recipients (6 percent) and 29 negative-reference recipients (23 percent). Graft survival in recipients of histologically evaluated kidneys did not differ significantly from that of grafts in positive-reference recipients but was superior to that of grafts in negative-reference recipients (hazard ratio for graft failure in the negative-reference recipients relative to the recipients of histologically evaluated kidneys, 3.68; 95 percent confidence interval, 1.29 to 10.52; P=0.02). The performance of preimplantation histologic evaluation predicted better survival both in the whole study group (P=0.02) and among recipients of kidneys from older donors (P=0.01). CONCLUSIONS: The long-term survival of single or dual kidney grafts from donors older than 60 years of age is excellent, provided that the grafts are evaluated histologically before implantation. This approach may help to expand the donor-organ pool for kidney transplantation.

Cyclosporine prolongs delayed graft function in kidney transplantation: are rabbit anti-human thymocyte globulins the answer?

BACKGROUND: Cyclosporine (CsA) nephrotoxicity may prolong duration of anuria in renal transplant patients with delayed graft function (DGF). Thus, many Transplant Centers tend to delay CsA treatment in order to accelerate renal function recovery. METHODS: In this single-center, retrospective analysis we compared the outcomes of 40 renal transplant patients with DGF given a CsA-based (n = 17) regimen since the day of transplant or a CsA-sparing regimen (n = 23) based on early treatment with rabbit anti-human thymocyte globulin (RATG) and delayed CsA administration. We studied all patients with DGF who received a first or second graft at the Bergamo Transplant Center from January 1992 to March 2000. RESULTS: Patients given RATG as compared to those on CsA had significantly shorter duration of anuria (11.0 +/- 5.6 vs. 19.6 +/- 8.9 days; p < 0.005) and of initial hospitalization (17.4 +/- 4.3 vs. 27.4 +/- 10.4 days; p < 0.001). Throughout the whole study period, 4 patients on RATG as compared to 6 on CsA had an acute rejection episode (p > 0.05). However, no patient on RATG as compared to 4 on CsA had an acute rejection during the anuria period (p < 0.05). Costs including hospitalization, dialysis treatment and study drugs were significantly lower in RATG than in CsA patients (EUR 29,944 +/- 7,281 vs. 36,795 +/- 13,656; p < 0.05). CONCLUSIONS: In renal transplant patients with DGF, early RATG treatment with delayed CsA administration accelerated renal function recovery and patient discharge, prevented occult rejections throughout the anuria period and significantly decreased the treatment costs.

Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial.

BACKGROUND: In chronic nephropathies, inhibition of angiotensin-converting enzyme (ACE) is renoprotective, but can further renoprotection be achieved by reduction of blood pressure to lower than usual targets? We aimed to assess the effect of intensified versus conventional blood-pressure control on progression to end-stage renal disease. METHODS: We undertook a multicentre, randomised controlled trial of patients with non-diabetic proteinuric nephropathies receiving background treatment with the ACE inhibitor ramipril (2.5-5 mg/day). We randomly assigned participants either conventional (diastolic <90 mm Hg; n=169) or intensified (systolic/diastolic <130/80 mm Hg; n=169) blood-pressure control. To achieve the intensified blood-pressure level, patients received add-on therapy with the dihydropyridine calcium-channel blocker felodipine (5-10 mg/day). The primary outcome measure was time to end-stage renal disease over 36 months' follow-up, and analysis was by intention to treat. FINDINGS: Of 338 patients who were randomised, three (two assigned intensified and one allocated conventional blood-pressure control) never took study drugs and they were excluded. Over a median follow-up of 19 months (IQR 12-35), 38/167 (23%) patients assigned to intensified blood-pressure control and 34/168 (20%) allocated conventional control progressed to end-stage renal disease (hazard ratio 1.00 [95% CI 0.61-1.64]; p=0.99). INTERPRETATION: In patients with non-diabetic proteinuric nephropathies receiving background ACE-inhibitor therapy, no additional benefit from further blood-pressure reduction by felodipine could be shown.