Influence of Donor and Recipient Ages in Survival of Simultaneous Pancreas-Kidney Transplantation.

INTRODUCTION: Simultaneous pancreas-kidney transplantation (SPKT) is a well treatment for patients with insulin-dependent diabetes and end-stage renal disease. Donor age is a barrier to the acceptance of organs. Age matching has been extensively studied in kidney transplantation; however, there are no studies in graft survival after SPKT. We aimed to study the combined influence of the ages of the donors and recipients in graft survival after SPKT. MATERIAL AND METHODS: Donors and recipients are classified as younger (age <40 years) or older (age ≥40 years). There were four study groups (young-young, young-old, old-young, and old-old). They were evaluated retrospectively for demographic and clinical characteristics of donors and recipients and the long-term survival between 2001 and 2012 of kidney pancreas transplantation patients at our center. RESULTS: A total of 115 transplantations were performed. The four groups had 55 young-young, 40 young-old, 10 old-young, and 10 old-old patients. Serious complications occurred in 32%, 42%, 30%, and 40%, respectively, and deaths were 2%, 5%, 0%, and 20%, respectively, in the groups. Pancreas graft survival at 3 years for each group was 80%, 87, 5%, 90%, and 60%, respectively, and kidney graft survival was 92.7%, 90%, 90%, and 70%, respectively. Panel-reactive antibodies (PRAs) >30% were associated with poor graft survival, and serious postoperative complications associated with poor pancreas-kidney graft survival. CONCLUSIONS: In conclusion, both younger and older recipients show excellent long-term graft and patient survival after SPKTs from younger donors. We recommended that older-recipient SPKT be transplanted from younger donors because older recipients who have been transplanted from older donors had decreased survival.

Incidence and Long-Term Prognosis of Cancer After Kidney Transplantation.

BACKGROUND: Malignancy is an important cause of mortality in renal transplants recipients. The incidence of cancer is increased by immunosuppressive treatment and longer kidney graft survival. The aim of this study was to evaluate the incidence, prognosis and survival of posttransplant malignancies: solid organ cancer (SOC), posttransplant lymphoproliferative disorder (PTLD), and nonmelanoma skin cancer (NMSC). METHODS: We retrospectively studied the development of cancers among kidney transplants patients in our hospital from January 1979 to January 2015. We analyzed demographic and clinical characteristics, risk factors, and patient survival after tumor diagnosis. RESULTS: We included 1450 kidney transplants recipients with a mean follow-up was 10 years; among them, 194 developed malignancies. The mean age at presentation was 59 ± 10 years. The SOC, PTLD, and NMSC incidences were 6.2%, 1.2%, and 6%, respectively. The most common tumors were kidney (16.6%), colon (11%), bladder (10%), breast (10%), prostate (10%), and lung (8.8%). The median times to development of a SOC, PTLD, and NMSC were 6.86 (range, 3.7-12), 4.43 (range, 1.8-5.7), and 8.19 (range, 3.8-12.2) years, respectively. Risk factors associated with developing SOC and PTLD were patient age (odds ratio [OR], 1.03; P < .001) and time posttransplant (OR, 1.05; P = .02), whereas for NMSC were to be male (OR, 3.61; P < .001), to take calcineurin inhibitors (OR, 2.17; P = .034), patient age (OR, 1.05; P < .001) and time posttransplant (OR, 1.15; P < .01). The mean survival time from the diagnosis of SOC, PTLD, and NMSC were 2.09 (range, 0.1-5.3), 0.22 (range, 0.05-1.9), and 7.68 (range, 3.9-10.5) years, respectively (P < .001). CONCLUSIONS: SOC occurs more frequently than other malignancies among renal transplant patients. NMSC has better survival and prognosis. Older patients and prolonged graft function have a greater risk of developing malignancies.

Passenger Lymphocyte Syndrome After Simultaneous Pancreas-Kidney Transplantation: A Case Report of an Unusual Cause of Alloimmune Hemolytic Anemia.

BACKGROUND: Passenger lymphocyte syndrome (PLS) is a disease in which the donor's lymphocytes produce antibodies to the red blood cell antigens of the recipient, causing alloimmune hemolysis. CASE REPORT: We report the case of a 39-year-old woman with stage V chronic kidney disease on hemodialysis secondary to poorly controlled diabetes mellitus type 1. She received a simultaneous pancreas-kidney transplant from a cadaver donor. The donor was A- and the recipient was A+ without initial complications with normal renal and pancreatic function, and her hemoglobin (Hb) level was 10.2 g/dL at discharge. Four weeks later she was admitted with acute pyelonephritis of the renal graft, with a Hb level of 7.5 g/dL, creatinine level of 0.7 mg/dL, and glucose level of 80 mg/dL. The study of anemia showed direct polyspecific direct Coombs weakly positive (w/+), presenting 2 alloantibodies against the Rh system: anti-D, anti-E. We increased Prednisone dose to 1 mg/kg/d and then decreased it in a pattern. Eight days after discharge, without transfusion, her Hb level was 9.9 g/dL and then it normalized. CONCLUSIONS: PLS is a very rare condition and should be suspected in the first few weeks after transplantation. In our case anemia was probably due to a residual population of Rh-negative donor cells in the transplanted pancreas-kidney received. It is usually a sudden onset of hemolytic anemia in patients with a solid organ transplant and different Rh or ABO lower incompatibility.

Short-term evolution of renal transplant with grafts from donation after cardiac death: Type III Maastricht category.

BACKGROUND: Kidney transplantation from donors after cardiac death (Type III Maastricht category) is a therapeutic option for patients with terminal renal failure. MATERIALS AND METHODS: We present a cohort of 8 patients who received a kidney transplant from donors after cardiac death (DCD). We analyzed the analytical results for the first 6 months after transplantation. RESULTS: We included 8 cases of kidney transplants with organs from DCD (Type III Maastricht category). The mean age of donors was 58.40 ± 4.39 years and 3 (60%) were male. The mean creatinine (Cr) level prior to death was 1.10 ± 0.36 mg/dL. The mean age of recipients was 59.88 ± 10.58 years and 7 (87.5%) were male. Seven patients (87.5%) were on hemodialysis, whereas only 1 (12.5%) was on peritoneal dialysis. The median time on renal replacement therapy was 18 months (range, 2-76). Mean total warm ischemia time (WIT) was 24.88 ± 6.72 minutes, whereas the mean real WIT was 20.13 ± 4.51 minutes. The mean cold ischemia time (CIT) was 6 hours and 12 minutes ± 2 hours. Preimplantation biopsy showed acute tubular necrosis (extensive 40%). Tubular atrophy was mild in 100% of cases. After transplantation, 6 patients (75%) had delayed graft function requiring dialysis sessions whereas 2 patients (25%) did not require renal replacement therapy. Mean Cr level at 1, 3, and 6 months after transplantation was 2.37, 1.75, and 1.17 mg/dL, respectively. CONCLUSION: Kidney transplantation with grafts from donors after cardiac arrest Maastricht Type III evolves favorably in the short term. According to preliminary results, controlled asystole donation could be an effective alternative to transplantation.

Index high insulin resistance in pancreas-kidney transplantation contributes to poor long-term survival of the pancreas graft.

BACKGROUND: Pancreas-kidney transplantation (PKT) is the best therapeutic option for diabetic patients with end-stage renal failure. Peripheral insulin resistance and the percentage of remaining ß-cells in the PKT have been little studied in medical literature. METHODS: We analyzed PKT performed in our hospital from January 1992 to January 2014, with follow-up for 5 years. Metabolic values related to glycemic were studied, namely, proteinuria, peptide C, glucose, insulin, and glycosylated hemoglobin. We analyzed insulin resistance (homeostatic model assessment [HOMA]-IR), the percentage of remaining ß-cells (HOMA-ß), and the influence of these variables on the glycemic profile and graft survival. RESULTS: In the study period, 156 simultaneous PKT were performed in our center. At 2 years posttransplantation, the median value of HOMA-IR kidney-pancreas was 4. We compared transplantation with lower HOMA-IR (<4) and higher HOMA-IR (>4). HOMA-ß (36 [26-67] vs 29 [14-42]; P = .04), glucose (86 [80-90] vs 81 [74-89]; P = .018), and body mass index (BMI; 24 [21-27] vs 21 [19-24]; P = .013) were greater in the group HOMA-IR>4 versus HOMA-IR<4 group, respectively, after 3 months. These differences in glycemic profile were maintained until the first year after transplantation. At 2 and 5 years of follow-up, the HOMA-IR>4 group showed higher glucose levels and greater BMI, but not differences in HOMA-ß. At 1 and 5 years posttransplantation, pancreatic graft survival in the HOMA-IR>4 group (82.9% vs 92.5%) was lower compared with the HOMA-IR<4 group (67% vs 87.5%; P = .016). CONCLUSIONS: PKT exhibit an altered glycemic profile in the posttransplantation follow-up associated with the percentage of remaining ß-cells and peripheral insulin resistance. PKT patients with peripheral insulin resistance showed decreased pancreatic graft survival.

Outcomes in renal transplantation with expanded-criteria donors.

BACKGROUND: Kidney transplantation is the treatment of choice for patients with end-stage renal disease. In recent years donor criteria have changed to increase the percentage of expanded-criteria donors (ECDs). The aim of this study was to analyze transplants from ECDs obtained at our institution from. 2010 to 2012. We studied the comorbidity of ECD, preimplantation histologic study, renal function, and survival of transplanted grafts. PATIENTS AND METHODS: Eighty ECDs (160 kidneys) were analyzed. Forty-nine grafts were not implanted owing to macroscopic lesions (37 kidneys) or histologic findings on preimplantation biopsy (12 kidneys). Finally, 60 grafts from ECDs were implanted in our center. We analyzed the characteristics of the grafts (kidney function, creatinine clearance) and compared the data with a control group of allografts from standard-criteria donors (n = 14). RESULTS: The median age of the ECD group was 72 years (range 65-77). No differences were found in certain characteristics between the ECDs whose kidneys were or were not implanted (hypertension, diabetes, creatinine at the time of the donation or proteinuria). However, there were differences in donor age (75 vs 67; P = .043), increased preimplantation biopsy score (6.8 ± 1.3 vs 4.8 ± 1.1; P = .041), and a higher percentage of cardiovascular disease (62.5% vs 43%; P = .038). Comparison of ECD and non-ECD grafts showed a lower creatinine clearance at 1 year (50 ± 05 mL/min vs 69 ± 96 mL/min, respectively; P < .001) and 2 years (50 ± 07 mL/min vs 67 ± 74 mL/min; P < .001) after transplantation. There were no differences in delayed graft function or graft survival between the 2 groups at 2 years after transplantation (95% vs 100%; P = .38). CONCLUSIONS: We found no differences in graft survival from ECD compared with the control group of standard-criteria donors. The evaluation of grafts from ECD may be a strategy to increase the number of kidney transplants.

Combined liver-kidney transplantation: survey of a single center in Spain.

BACKGROUND: Renal dysfunction is a common complication of advanced liver failure and liver transplantation. Since the introduction of the MELD criteria the proportion of patients with advanced chronic kidney disease and need for liver transplantation has increased. One alternative is the combined liver-kidney transplant (CLKT). The aim of this study was to evaluate the outcome of this type of transplant in our center. METHODS: We retrospectively analyzed all combined simultaneous or sequential transplants from 1989 to 2012. We studied demographic and clinical variables. Survival analysis was performed by Kaplan-Meier method. RESULTS: In the study period, 1,265 kidney and 1,050 liver transplantations were performed; 34 were CLKT (to 29 adults and 5 children); 13 of these were simultaneous and 12 sequential liver-kidney. We also carried out 4 triple liver-pancreas-kidney transplantations, 3 simultaneous and 1 sequential. The mean age was 44.1 ± 15 years, and 27 were male (93.1%); 9 (37.5%) were diabetic. The main causes of liver disease were viral (n = 11 [41.3%; hepatitis virus B, C, or both] and alcoholism (9 [31%]). The renal disease etiology was unknown in 16 (55.1%), IgA nephropathy in 2 (6.8%), membranoproliferative glomerulonephritis in 2 (6.8%), and calcineurin inhibitor toxicity in 4 (13.6%). Transjugular renal biopsy was performed in 6 sequential transplants. Survival of patients who received a CLKT was excellent: 91%, 51%, and 40%, at 1, 5, and 10 years, respectively. No significant difference was found between sequential and simultaneous transplants (log rank 0.5). CONCLUSIONS: Our results of CLKT show results similar or superior to those of other series and are an alternative to consider in candidates for liver transplantation with chronic kidney disease. Transjugular biopsy is an alternative to study the etiology of renal disease in patients with hepatic dysfunction before or after liver transplantation.