Long-Term Outcomes of Kidney Transplants from Older/Marginal Donors: A Cohort Study.

INTRODUCTION: To safely expand the donor pool, we introduced a strategy of biopsy-guided selection and allocation to single or dual transplantation of kidneys from donors >60 years old or with hypertension, diabetes, and/or proteinuria (older/marginal donors). Here, we evaluated the long-term performance of this approach in everyday clinical practice. METHODS: In this single-center cohort study, we compared outcomes of 98 patients who received one or two biopsy-evaluated grafts from older/marginal donors ("recipients") and 198 patients who received nonhistologically assessed single graft from ideal donors ("reference-recipients") from October 2004 to December 2015 at the Bergamo Transplant Center (Italy). RESULTS: Older/marginal donors and their recipients were 27.9 and 19.3 years older than ideal donors and their reference-recipients, respectively. KDPI/KDRI and donor serum creatinine were higher and cold ischemia time longer in the recipient group. During a median follow-up of 51.9 (interquartile range 23.1-88.6) months, 11.2% of recipients died, 7.1% lost their graft, and 16.3% had biopsy-proven acute rejection (BPAR) versus 3.5, 7.6, and 17.7%, respectively, of reference-recipients. Overall death-censored graft failure (rate ratio 0.78 [95% CI 0.33-2.08]), 5-year death-censored graft survival (94.3% [87.8-100.0] vs. 94.2% [90.5-98.0]), BPAR incidence (rate ratio 0.87 [0.49-1.62]), and yearly measured glomerular filtration rate decline (1.18 ± 3.27 vs. 0.68 ± 2.42 mL/min/1.73 m2, p = 0.37) were similar between recipients and reference-recipients, respectively. CONCLUSIONS: Biopsy-guided selection and allocation of kidneys from older/marginal donors can safely increase transplant activity in clinical practice without affecting long-term outcomes. This may help manage the growing gap between organ demand and supply without affecting long-term recipient and graft outcomes.

Role of remission clinics in the longitudinal treatment of CKD.

Heavy proteinuria is a major determinant of progression to ESRD for patients with chronic nephropathies and reducing proteinuria should be a key target for renoprotective therapy. In the Remission Clinic, we applied a multimodal intervention to target urinary proteins in 56 consecutive patients who had >3 g proteinuria/d despite angiotensin-converting enzyme inhibitor therapy. We compared the rate of GFR decline and incidence of ESRD in this cohort with 56 matched historical reference subjects who had received conventional therapy titrated to a target BP. During a median follow-up of 4 yr, the monthly rate of GFR decline was significantly lower in the Remission Clinic cohort (median -0.17 versus -0.56 ml/min per 1.73 m2; P < 0.0001), and ESRD events were significantly reduced (3.6 versus 30.4% reached ESRD). Follow-up BP, cholesterol, and proteinuria were lower in Remission Clinic patients than in reference subjects, such that disease remission or regression was achieved in up to 50% of patients who would have been otherwise expected to progress rapidly to ESRD on conventional therapy. Proteinuria reduction independently predicted a slower rate of GFR decline and ESRD incidence, but response to treatment differed depending on the underlying disease. Regarding safety, no patient was with drawn because of hyperkalemia. In summary, multidrug treatment titrated to urinary protein level can be safely and effectively applied to normalize proteinuria and to slow the loss of renal function significantly,especially among patients without type 2 diabetes and with otherwise rapidly progressing chronic nephropathies.

The Bergamo Kidney Transplant Program.

Since the beginning of transplant activities in 1989, the Kidney Transplant Center at the Ospedali Riuniti Bergamo has based its clinical program on the most recent achievements of transplant medicine, in order to optimize the outcome of kidney grafts and improve the quality of life of kidney transplant recipients. Although the transplantation community attempts to keep up with increasing demand for transplantable organs, the supply continues to fall far short of the need. This observation prompted us to focus on the expansion of the available pool of deceased donor organs. In 1997, we established a dual kidney transplant program for donors older than 60 years based on a pretransplant histology protocol with a scoring system ranging from low-dose RATG and delayed CsA administration has been successfully adopted in this population of kidney transplant recipients in our routine clinic practice. In kidney transplantation, chronic deterioration of renal function and death with a functioning graft, mainly due to side effects of the medications, represents a major limitation for long-term success of many transplant programs. We recently documented that per-protocol biopsy more than one year after kidney transplantation is a safe procedure to guide change of conventional immunosuppressive regimens and to lower the risk of major drug-related side effects. In particular, substantial reduction of the CsA dose, leading to extremely low CsA trough level, has no major detrimental effect on renal function and histology during 3 years follow-up, while patients remain free of rejection episodes with concomitant steroid and azathioprine therapy. Novel induction therapies with Campath-1H or Simulect and low-RATG have also helped to minimize maintenance immunosuppression in most patients largely avoiding the use of corticosteroids, Monitoring a patient's exposure to immunosuppressive agents is a critical issue in a minimum of 0 (no renal lesions) to a maximum of 12 (marked changes in renal parenchyma). The assumptions of the proposed algorithm to guide acceptance of single suboptimal or dual marginal kidneys for transplantation were validated in a prospective pilot study involving centers in Europe and North America. Whether the encouraging short-term data translate into improved graft survival is currently a matter of investigation in a prospective, multicenter, matched-cohort trial. As kidneys from marginal donors have an increased risk of delayed graft function, we also studied strategies to manage and prevent this complication. A dual immunosuppressive regimen of basiliximab and transplantation. By pharmacokinetics studies, we documented that a fixed dose regimen of MMF--adopted in the majority of transplant units worldwide--might no longer be the best approach for the management of transplant patients, and MPA pharmacokinetic monitoring is advised. Similarly, we reported pharmacokinetic interaction of concomitant immunosuppression on blood levels of the new immunosuppressant sirolimus. We have a special multiorgan transplant program at our center for patients affected by rare diseases, such as the recurrent hemolytic uremic syndrome (HUS). Based on genotyping for complement factor H-1, membrane co-factor protein or factor I gene mutations, we are exploring the possibility of combining liver and renal transplant or performing renal transplant alone in patients with recurrent HUS who have end-stage renal disease. The achievements of our clinical center are the result of the continuous support by an intense clinical and basic research program. This has allowed us to create a unique model to address the major challenges of transplant medicine.