Preemptive living donor kidney transplantation: do the benefits extend to all recipients?

BACKGROUND: Preemptive kidney transplantation (prior to the institution of dialysis) avoids the morbidity and mortality of dialysis; however, detailed studies of high-risk patients are lacking. The aim of the current study was to compare recent outcomes of preemptive (P) versus nonpreemptive (NP) living donor kidney transplantation with an emphasis on high-risk recipients. METHODS: We retrospectively analyzed 438 sequential solitary living donor kidney transplants at our institution between January 2000 and December 2002. In all, 44% were preemptive. NP recipients were dialyzed for 21+/-36 months (range 1-312 months). RESULTS: Overall, three-year patient survival was similar in the NP and P groups. When stratified by diabetes and age >65 years, P and NP recipients again showed similar survival. Death-censored three-year graft survival was better in the P group (97% vs. 90%, P=0.01), but was not significant by multivariate analysis. Delayed graft function was more frequent in NP vs. P (10% vs. 4%; P=0.01), but other early complications were similar including: acute rejection, 16% vs. 11% (P=0.11); primary nonfunction, 3% vs. 2% (P=0.38); and wound complications, 19% vs. 17% (P=0.54). Glomerular filtration rate at three years was similar in the two groups (53+/-23 preemptive vs. 52+/-20 ml/min nonpreemptive; P=0.37). CONCLUSION: With prompt referral and workup, preemptive kidney transplantation can be performed successfully in a large percentage of renal allograft recipients. Preemptive transplantation avoids unnecessary dialysis and should be emphasized as initial therapy for many patients with end-stage renal disease.

Overcoming a positive crossmatch in living-donor kidney transplantation.

Many patients who have an otherwise acceptable living-kidney donor do not undergo transplantation because of the presence of antibodies against the donor cells resulting in a positive crossmatch. In the current study, 14 patients with a positive cytotoxic crossmatch (titer

Living-donor kidney transplantation at Mayo Clinic--Rochester.

With the established benefits of living-donor kidney transplantation, our primary emphasis at Mayo Clinic, Rochester has been to develop protocols that allow living donation to occur even in the presence of relatively unusual or generally contraindicated situations. This approach has significantly increased the number of patients receiving kidney transplants in the past few years. Our protocols for extended criteria donors and recipients along with the exclusive use of laparoscopic donor nephrectomy have been major contributors to the increase in volume. ABO-incompatible and positive-crossmatch living-donor kidney transplant protocols also have increased the availability of transplants for our patients. Protocol biopsies have aided in the diagnosis of subclinical rejection, polyoma virus and chronic allograft nephropathy. Innovative immunosuppressive protocols such as calcineurin inhibitor-free immunosuppression have decreased rejection and improved both short and long-term renal allograft survival.