One-year results of a prospective, randomized, trial comparing two machine perfusion devices used for kidney preservation

Transplant International One-year results of a prospective, randomized, trial comparing two machine perfusion devices used for kidney preservation

Studies have shown beneficial effects of machine perfusion (MP) on early kidney function and long-term graft survival. The aim of this study was to investigate whether the type of perfusion device could affect outcome of transplantation of deceased donor kidneys. A total of 50 kidneys retrieved from 25 donors were randomized to machine perfusion using a flow driven (FD) device (RM3; Waters Medical Inc) or a pressure driven (PD) device (LifePort; Organ Recovery Systems), 24 of these kidneys (n=12 pairs; 48%) were procured from expanded criteria donors (ECD). The primary endpoints were kidney function after transplantation defined using the incidence of delayed graft function (DGF), the number of hemodialysis sessions required, graft function at 12 months, and analyses of biopsy. DGF was similar in both groups (32%; 8/25). Patients with DGF in the FD group required a mean of 4.66 hemodialysis sessions versus 2.65 in the PD group (p=0.005). Overall 1-year graft survival was 80% (20/25) versus 96% (24/25) in the FD and PD groups. One-year graft survival of ECD kidneys was 66% (8/12) in the FD group versus 92% (11/12) in the PD group. Interstitial fibrosis and tubular atrophy were significantly more common in the FD group – 45% (5/11) versus 0% (0/9) (p=0.03) in PD group. There were no differences in creatinine levels between the groups.Machine perfusion using a pressure driven device generating lower pulse stress is superior to a flow driven device with higher pulse stress for preserving kidney function. This article is protected by copyright. All rights reserved.


http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Ftri.12169

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The Survival Benefit of Kidney Transplantation in Obese Patients

AJT - Early The Survival Benefit of Kidney Transplantation in Obese Patients

Obese patients have a decreased risk of death on dialysis but an increased risk of death after transplantation, and may derive a lower survival benefit from transplantation. Using data from the United States between 1995 and 2007 and multivariate non-proportional hazards analyses we determined the relative risk of death in transplant recipients grouped by body mass index (BMI) compared to wait-listed candidates with the same BMI (n = 208 498). One year after transplantation the survival benefit of transplantation varied by BMI: Standard criteria donor transplantation was associated with a 48% reduction in the risk of death in patients with BMI ≥ 40 kg/m2 but a ≥66% reduction in patients with BMI < 40 kg/m2. Living donor transplantation was associated with ≥66% reduction in the risk of death in all BMI groups. In sub-group analyses, transplantation from any donor source was associated with a survival benefit in obese patients ≥50 years, and diabetic patients, but a survival benefit was not demonstrated in Black patients with BMI ≥ 40 kg/m2. Although most obese patients selected for transplantation derive a survival benefit, the benefit is lower when BMI is ≥40 kg/m2, and uncertain in Black patients with BMI ≥ 40 kg/m2.


http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.12331

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The effect of donor-recipient gender mismatch on short- and long-term graft survival in kidney transplantation: a systematic review and meta-analysis

Clinical Transplantation The effect of donor-recipient gender mismatch on short- and long-term graft survival in kidney transplantation: a systematic review and meta-analysis

Background There is no limitation of gender matching in renal transplantation. This study was intended to evaluate its effect on short- and long-term graft survival. Methods PubMed, the Web of Knowledge, Medline, the Cochrane Library, and two additional Chinese databases were searched. The data were then abstracted and meta-analyzed. Results 14 studies involving 445 279 patients were included. Each study reported data on the four gender matches (male donor-male recipient, MDMR; male donor-female recipient, MDFR; female donor-male recipient, FDMR; female donor-female recipient, FDFR). The pooled risk ratios (RRs) for 0.5-, 1-, 2-, 3-, 5-, and 10-yr graft survival rates showed that the FDMR group had the worst outcomes, and when recipients were female, short-term graft survival was worse, but long-term graft survival was better. The differences between groups changed with time. Conclusions FDMR patients showed poor graft survival. The female recipients had worse short-term graft survival but the best long-term graft survival. This study introduces an important consideration into donor-recipient matching in renal transplantation.


http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fctr.12191

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Analysis of Anti-HLA Antibodies in Sensitized Kidney Transplant Candidates Subjected to Desensitization with Intravenous Immunoglobulin and Rituximab

Transplantation - Most Popular Articles Analysis of Anti-HLA Antibodies in Sensitized Kidney Transplant Candidates Subjected to Desensitization with Intravenous Immunoglobulin and Rituximab

Background: Preexisting donor-specific antibodies against human leukocyte antigens are major risk factors for acute antibody-mediated and chronic rejection of kidney transplant grafts. Immunomodulation (desensitization) protocols may reduce antibody concentration and improve the success of transplant. We investigated the effect of desensitization with intravenous immunoglobulin and rituximab on the antibody profile in highly sensitized kidney transplant candidates.

Methods: In 31 transplant candidates (calculated panel-reactive antibody [cPRA], 34%–99%), desensitization included intravenous immunoglobulin on days 0 and 30 and a single dose of rituximab on day 15. Anti–human leukocyte antigen antibodies were analyzed before and after desensitization.

Results: Reduction of cPRA from 25% to 50% was noted for anti–class I (5 patients, within 20–60 days) and anti–class II (3 patients, within 10–20 days) antibodies. After initial reduction of cPRA, the cPRA increased within 120 days. In 24 patients, decrease in mean fluorescence intensity of antibodies by more than 50% was noted at follow-up, but there was no reduction of cPRA. Rebound occurred in 65% patients for anti–class I antibodies at 350 days and anti–class II antibodies at 101 to 200 days. Probability of rebound effect was higher in patients with mean fluorescence intensity of more than 10,700 before desensitization, anti–class II antibodies, and history of previous transplant.

Conclusions: The desensitization protocol had limited efficacy in highly sensitized kidney transplant candidate because of the short period with antibody reduction and high frequency of rebound effect.

http://journals.lww.com/transplantjournal/Fulltext/2013/07270/Analysis_of_Anti_HLA_Antibodies_in_Sensitized.12.aspx

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Donor-Derived Trypanosoma cruzi Infection in Solid Organ Recipients in the United States, 2001-2011.

AJT Donor-Derived Trypanosoma cruzi Infection in Solid Organ Recipients in the United States, 2001-2011.

• Huprikar S, Bosserman E, Patel G, et al. 
• Donor-Derived Trypanosoma cruzi Infection in Solid Organ Recipients in the United States, 2001-2011. [JOURNAL ARTICLE]
• Am J Transplant 2013 Jul 9.

Although Trypanosoma cruzi, the parasite that causes Chagas disease, can be transmitted via organ transplantation, liver and kidney transplantation from infected donors may be feasible. We describe the outcomes of 32 transplant recipients who received organs from 14 T. cruzi seropositive donors in the United States from 2001 to 2011. Transmission was confirmed in 9 recipients from 6 donors, including 3 of 4 (75%) heart transplant recipients, 2 of 10 (20%) liver recipients and 2 of 15 (13%) kidney recipients. Recommended monitoring posttransplant consisted of regular testing by PCR, hemoculture, and serology. Thirteen recipients had no or incomplete monitoring; transmission was confirmed in five of these recipients. Four of the five recipients had symptomatic disease and all four died although death was directly related to Chagas disease in only one. Nineteen recipients had partial or complete monitoring for T. cruzi infection with weekly testing by PCR, hemoculture and serology; transmission was confirmed in 4 of 19 recipients with no cases of symptomatic disease. Our results suggest that liver and kidney transplantation from T. cruzi seropositive donors may be feasible when the recommended monitoring schedule for T. cruzi infection is followed and prompt therapy with benznidazole can be administered.

http://www.unboundmedicine.com/medline/citation/23837488/Donor_Derived_Trypanosoma_cruzi_Infection_in_Solid_Organ_Recipients_in_the_United_States_2001_2011_

Kidney Allograft Survival After Acute Rejection, the Value of Follow-Up Biopsies

AJT - Early Kidney Allograft Survival After Acute Rejection, the Value of Follow-Up Biopsies

Kidney allografts are frequently lost due to alloimmunity. Still, the impact of early acute rejection (AR) on long-term graft survival is debated. We examined this relationship focusing on graft histology post-AR and assessing specific causes of graft loss. Included are 797 recipients without anti-donor antibodies (DSA) at transplant who had 1 year protocol biopsies. 15.2% of recipients had AR diagnosed by protocol or clinical biopsies. Compared to no-AR, all histologic types of AR led to abnormal histology in 1 and 2 years protocol biopsies, including more fibrosis + inflammation (6.3% vs. 21.9%), moderate/severe fibrosis (7.7% vs. 13.5%) and transplant glomerulopathy (1.4% vs. 8.3%, all p < 0.0001). AR were associated with reduced graft survival (HR = 3.07 (1.92–4.94), p < 0.0001). However, only those AR episodes followed by abnormal histology led to reduced graft survival. Early AR related to more late alloimmune-mediated graft losses, particularly transplant glomerulopathy (31% of losses). Related to this outcome, recipients with AR were more likely to have new DSA class II 1 year posttransplant (no-AR, 11.1%; AR, 21.2%, p = 0.039). In DSA negative recipients, early AR often leads to persistent graft inflammation and increases the risk of new DSA II production. Both of these post-AR events are associated with increased risk of graft loss.


http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2Fajt.12370