Donor factors.

1. Although left kidneys had a 2% higher graft survival rate at one-year posttransplant, the survival rates for left and right kidneys were comparable at 2, 3, and 4 years after transplantation. Kidneys transplanted en bloc were shown to have a 6% lower graft survival rate than either left or right kidneys. 2. Male donor kidney had a 4% higher rate of graft survival than female donor kidneys at both one and 4 years posttransplant. 3. Kidneys obtained from Black donors had a 4% lower graft survival rate at one-year posttransplant, and a 7% lower graft survival rate at 4 years after transplantation than White donor kidneys. White, Hispanic, and Asian donors all had comparable rates of graft survival at one, 2, and 3 years posttransplant. Black donor kidneys also had a significantly shorter half-life; 6.7 years, compared with 7.1 years for kidneys from Asian donors, 9.7 years for Hispanic donors, and 8.6 years for White donors. Blacks continued to make up a small fragment of the total donor pool, accounting for less than 10% of all cadaveric donor kidneys. 4. Kidneys from type O donors had a 5% higher graft survival rate at 4 years posttransplant when compared to AB kidneys and had a 2% higher 4-year graft survival rate than either type A or B kidneys. 5. Pediatric (younger than 5 years of age) donor kidneys had a 10% lower graft survival rate than kidneys from donors between 6 and 45 years of age. Kidneys from donors over 60 years of age had an 11% lower one-year graft survival rate than donors between 6 and 45 years of age, and a 19% lower survival rate at 4 years posttransplant. Survival rates decreased with increasing donor age; kidneys from donors between 46 and 60 years of age had a 5% lower graft survival rate at one year, and a 9% lower rate of graft survival at 4 years posttransplant when compared to "middle aged" donors. The poorest graft survival was observed for kidneys from donors over 60 years of age; 10% and 19% lower graft survival at one and 4 years posttransplant, respectively, compared to donors between 6 and 45 years of age. 6. Kidneys from trauma donors had a 4% higher survival rate at one-year posttransplant, and a 6% higher survival rate at 4 years posttransplant when compared to kidneys from nontrauma donors. Kidneys obtained from victims of motor vehicle accidents, traumatic suicides, and assaults (gunshot wounds and stabbings) had the highest rate of graft survival.(ABSTRACT TRUNCATED AT 400 WORDS)

Donor factors in cadaveric renal transplantation.

1. Donor kidney side (left/right) had no significant effect on cadaveric renal allograft survival. 2. Kidneys from male donors had an 83% one-year graft survival rate, compared with 78% for those from female donors. 3. Donor race did not have an effect on renal allograft survival. 4. One-year survival rates for kidneys from very young (< 5 years old) donors and older (> 50 years old) cadaver donors (74%) were significantly poorer than those for kidneys from donors age 6-50 (84%). 5. Donor ABO blood type and Rh factor had no significant effect on renal allograft survival. 6. Cause of death (trauma/nontrauma) had a pronounced effect on cadaveric renal allograft survival. Kidneys from trauma donors (motor vehicle accident, gunshot wound, head injury, etc.) had a significantly higher one-year graft survival rate (84%) than that of kidneys from nontrauma donors (77%). This effect was found to be independent of donor age. 7. Donor past medical history had a significant effect on renal allograft survival. Kidneys from donors with histories of hypertension had slightly poorer graft survival (75%) than those from "normal" donors (80%). Donors with histories of diabetes had significantly lower graft survival; 54.8% at one-year posttransplant. 8. Donor lifestyle factors, including smoking, drinking, drug use, and sexual history, had no significant effect on renal allograft survival. 9. The duration of donor hospitalization (from admission to the time of procurement) had no effect on renal allograft survival. 10. Donor cardiac arrest (in either the field, hospital, or operating room) had no significant effect on renal allograft survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Methods for comparing cumulative hazard functions in a semi-proportional hazard model.

Graphical methods based on the analysis of differences between log cumulative hazard functions are considered for a two-group semi-proportional hazard model which allows for interaction between treatments and covariates. Confidence procedures and test statistics that can be used to test for interaction and for main effects are developed. Their use is illustrated by applying them to the analysis of kidney transplant data from the University of California, San Francisco.

Are blood transfusions beneficial in the cyclosporine era?

In patients treated with conventional immunosuppression (azathioprine and prednisone) after renal transplantation, there is a beneficial effect of pre-transplant blood transfusions on graft survival; in patients treated with cyclosporine, this effect may be lost. In 66 children who received living-related donor transplants after donor-specific transfusions (DST) and were treated with azathioprine-prednisone in our center, 1- and 5-year graft survival rates were 99% and 77% respectively. These rates were similar to those reported for children who did not receive DST but were treated with cyclosporine in other centers. There were 634 adult and pediatric recipients of cadaver transplants in our center who were treated with cyclosporine and prednisone (non-sequential therapy, n = 89) or antilymphoblast globulin, azathioprine preduisone, and cyclosporin (sequential therapy, n = 545). When all patients were considered, graft survival rates were higher in transfused than in non-transfused patients at 3-5 years, but in the sequential therapy group, there were no differences in graft survival rates between transfused and non-transfused patients. The results suggest that transfusions do not improve cadaver graft survival in patients receiving optimal cyclosporine therapy and that equally good related donor graft survival can be achieved with DST and conventional immunosuppression or no DST and cyclosporine.

Donor-specific blood transfusions versus cyclosporine--the DST story.

DST provides excellent graft survival in one- and zero-haplotype-matched donor-recipient pairs as well as a trend towards improving graft survival in HLA-identical matches; serum creatinine levels are good in functioning grafts; Imuran coverage does appear to decrease DST sensitization to the blood donor in nonsensitized patients undergoing a first transplant, which encourages early DST and transplantation in this group; flow cytometry has been extremely helpful in excluding subliminal anti-class 1 antigen activity in patients with positive B warm crossmatches alone; DST, in itself, does not appear to preclude subsequent cadaveric transplantation in patients sensitized to their blood donor; and the family history of the blood donor is known, with essentially no risk to the recipients of hepatitis, AIDS, etc. In regards to the issue of whether DST or Cs is better, both have merits, and one must be aware of the circumstances that relate to the optimum application of each therapy. Only a prospective study of DST- and Cs-treated patients with a long-term follow-up will probably resolve the issue of the optimum regimen for one-haplotype-matched living related donor-recipient pairs. The ultimate strategy may involve the selective use of each regimen for the most appropriate circumstances.

The beneficial effect of pretransplant blood transfusions in cyclosporine-treated cadaver renal allograft recipients.

212 cyclosporine-treated recipients of mismatched first cadaveric renal allografts are evaluated with respect to the effect of pretransplant random blood transfusions. It is determined that transfusions do not effect patient survival or morbidity. Pretransplant random blood transfusions correlate with significantly improved allograft success. There is also a trend, although not statistically significant, for further improvement of allograft survival with increasing numbers of transfusions. The transfusion effect is not related to the time at which the transfusions are given up to 2 years prior to transplantation. Transfused patients have a higher percent reactive antibody (PRA) than untransfused patients, but this does not cause them to wait for a cadaveric allograft significantly longer than the untransfused patients. Rejections are less severe in transfused patients. It is concluded that cyclosporine-treated recipients of first cadaveric renal allografts benefit from pretransplant blood transfusions.