Intermediate-term outcomes associated with kidney transplantation in recipients 80 years and older: an analysis of the OPTN/UNOS database.

BACKGROUND: An increasing number of patients 80 years and older have received a kidney transplant in the United States, but their outcomes are not well described. Using Organ Procurement and Transplantation Network/United Network of Organ Sharing data, outcomes of recipients 80 years and older were evaluated. METHODS: Thirty-one thousand one hundred seventy-nine elderly recipients defined by age 60 years and older receiving kidney transplants from 2000 to 2008 were stratified: ages 60 to 69 years (n=24,877), 70 to 79 years (n=6,103), and 80 years and older (n=199). Cox regression models were used to compare patient, graft, and death-censored graft survival. RESULTS: The majority of recipients 80 years and older was male (82.9%), white (87.9%), and less likely to have diabetes or coronary artery disease. More expanded criteria donor (ECD) but fewer living donor transplants were performed among 80 years and older compared with those younger than 80 years. Perioperative mortality, defined as death within 30 days posttransplant, was rare (60-69 years: 1.4%; 70-79 years: 1.5%; and ≥80 years: 2.5%) but tended to be higher among those 80 years and older compared with recipients 60 to 69 years (hazard ratio [HR] 1.67; 95% confidence interval [CI] 0.69-4.05). At 2 years, survival was lower for 80 years and older (73%; HR 2.42; 95% CI 1.91-3.06) and 70 to 79 years (86%; HR: 1.42; 95% CI: 1.34-1.51) compared with recipients 60 to 69 years (89%). There was a greater risk of graft loss among recipients 80 years and older compared with those 60 to 69 years (HR 1.78; 95% CI 1.42-2.23); however, no difference in death-censored graft survival was observed (0.89; 0.57-1.39). Among recipients 80 years and older, no difference in survival was observed between standard criteria donor and ECD recipients. CONCLUSION: Although perioperative mortality was uncommon among elderly recipients (1.5%), a trend toward higher perioperative mortality was observed in recipients 80 years and older. There was no difference in survival among standard criteria donor and ECD recipients.

Induction therapy in pediatric kidney transplant recipients discharged with a triple drug immunosuppressive regimen.

We evaluated the effectiveness of induction therapy on transplant outcomes during 2004-2007 in the United States. We retrospectively reviewed OPTN/UNOS registry and selected kidney pediatric (<21-yr) recipients that received no induction (NoIND), IL-2RA, or rabbit anti-THY and were discharged with a triple drug immunosuppressive maintenance regimen, including steroids. Of 2932 recipients, 20%, 36%, and 43% were in NoIND, THY, and IL-2RA groups, respectively. The majority received tacrolimus (88%) and MMF (89%) at discharge. There was no association of induction with the risk of acute rejection even after adjusting for known cofounders. Compared to NoIND, IL2-RA, but not THY, had a modest decrease (3%) in absolute rate of graft loss and was associated with a risk reduction ratio of 0.51 (95% CI, 0.31-0.84) in one-yr graft loss. At three yr, no induction agent was associated with decreased graft loss. In conclusion, induction agents were used in 80% of pediatric kidney recipients discharged with a triple drug immunosuppressive maintenance regimen between 2004-2007 in the United States. Neither THY nor IL-2RA was associated with reduced rejection episodes. The use of induction therapy was not associated with improvement in three-yr graft survival.

Influence of preexisting hepatitis C virus antibody positivity in simultaneous pancreas-kidney transplant recipients.

BACKGROUND: Preexisting hepatitis C virus (HCV) infection is implicated in diminished patient and graft survivals in renal transplant recipients. The impact of HCV infection on patient and graft survival in simultaneous pancreas-kidney transplantations is unclear. We evaluated the effect of preexisting HCV infection on patient and graft survival in simultaneous pancreas-kidney transplant (SPKT) recipients in the United States. METHODS: Using the Organ Procurement and Transplant Network/United Network for Organ Sharing database as of March 2009, adult primary SPKT recipients transplanted from 1995 to 2008 were studied. We stratified recipients based on pretransplant HCV status as HCV positive (HCV+) or HCV negative (HCV-). Overall kidney graft, pancreas graft, and patient survival were compared. RESULTS: A total of 10,809 adults received primary SPKT, of which 350 (3.2%) were HCV+. Less than 2% of the HCV+ recipients received organs from HCV+ donors. There were no significant differences in baseline donor and recipient characteristics between groups. Rates of acute kidney rejection at 1 year were similar: 22.9% for HCV+ and 23.0% for HCV- recipients (P=0.49). There was no difference in serum creatinine between groups up to 3 years. After controlling for confounding factors, HCV positivity was not associated with worsened overall kidney graft (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.61-1.03), pancreas graft (HR 0.80, 95% CI 0.63-1.00), or patient survival (HR 0.78, 95% CI 0.56-1.08). CONCLUSIONS: Only 3.2% of SPKT recipients had preexisting HCV infection. Preexisting HCV infection had no significant impact on kidney graft, pancreas graft, or patient survival.

Pancreas after living donor kidney versus simultaneous pancreas-kidney transplant: an analysis of the organ procurement transplant network/united network of organ sharing database.

BACKGROUND: One of the alternative options to simultaneous pancreas-kidney transplantation (SPKT) for type I diabetics with renal failure is sequential transplant of a living donor kidney followed by a deceased donor pancreas transplant (pancreas after living donor kidney transplant [PALK]). We retrospectively compared the outcomes of SPKT versus PALK. METHODS: Adults (age 18-59 years) with type I diabetes who were waitlisted for kidney-pancreas and received a SPKT or PALK between 2000 and 2007 were studied. We compared patient, kidney graft, and pancreas graft survival. Multivariate analysis was performed, and the results were expressed as hazard ratios (HRs) of graft loss and death of PALK, with SPKT as a reference. RESULTS: Of 11,966 patients who received a kidney transplant, 807 received a PALK and 5580 received a SPKT. Median time to pancreas from kidney transplant was 336 (25%-75%: 185-602 days) days. Average hospital stay for SPKT recipients was 13.2+/-15 days, whereas for PALK recipients was 5.7+/-4 days and 9.5+/-8 days for kidney and pancreas transplants, respectively. After controlling for confounding factors, patients receiving PALK had better patient survival (HR 0.52; 95% confidence interval [CI] 0.39-0.70) and kidney survival (HR 0.48; 95% CI 0.39-0.60) but worse pancreas survival (HR 1.37; 95% CI 1.16-1.62) compared with SPKT. CONCLUSION: Among those who were waitlisted for a kidney-pancreas transplant, 53% received a kidney-pancreas transplant. Of those who received a kidney-pancreas transplant, 87% patients underwent SPKT and 13% underwent PALK. PALK was associated with better kidney graft and patient survival compared with SPKT. We found an inferior pancreas graft survival and longer total transplant hospitalization in PALK.

Risk factors for development of new-onset diabetes mellitus in pediatric renal transplant recipients: an analysis of the OPTN/UNOS database.

BACKGROUND: The objective of this study was to identify the risk factors for new-onset diabetes mellitus (NODM) after kidney transplant in pediatric renal transplant recipients using Organ Procurement Transplant Network/United Network of Organ Sharing database. METHODS: A total of 2726 nondiabetic primary kidney transplant recipients (age 2-20 years, transplanted between July 2004 and December 2007) in the Organ Procurement Transplant Network/United Network of Organ Sharing database as of August 2008 with at least one follow-up report were included. We examined the risk factors for NODM using multivariate Cox regression analysis using the time to NODM reported as a time-varying endpoint. In recipients with functional graft at 1 year after transplant, the graft survivals during subsequent 24 months were compared according to the presence of NODM within first year of transplant. RESULTS: NODM was reported in 4.6% (median follow-up time: 693 days). Independent risk factors for NODM included increased age (>10 years vs. <10 years, hazard ratio [HR]=2.143, P=0.015), abnormal body mass index percentile (<5% or >85% vs. 5%-85%, HR=1.697, P=0.01), and steroid use at discharge (yes vs. no, HR=3.573, P=0.03). Living donor transplant was associated with a decreased risk of NODM (living vs. deceased, HR=0.629, P=0.05). NODM within first year of transplant was not associated with inferior graft survival during subsequent 24 months. DISCUSSION: Some of the identified risk factors for NODM are potentially modifiable, including abnormal body mass index percentile and the use of steroid. Prospective clinical trials are needed to assess whether modifying these risk factors will prevent NODM.

Obesity was associated with inferior outcomes in simultaneous pancreas kidney transplant.

BACKGROUND.: In kidney transplant, obesity was reported to be associated with increased posttransplant complications and worse survival outcomes. The impact of obesity in simultaneous pancreas-kidney (SPK) transplant is less known. METHODS.: Using Organ Procurement Transplantation Network/United Network for Organ Sharing data as of August 2008, we included all adults (>18 years) type 1 diabetic SPK recipients between years 2000 and 2007 with a pretransplant body mass index (BMI) of 18.5 to 40 kg/m. The cohort was divided in three groups: normal (BMI 18.5-24.9 kg/m, reference group), overweight (BMI 25-29.9 kg/m), and obese (BMI 30-40 kg/m). Covariate-adjusted relative risk of a combination of posttransplant complications and patient, pancreas and kidney allograft outcomes were evaluated. RESULTS.: Of 5725 recipients, 56%, 33%, and 11% were in normal, overweight, and obese groups, respectively. Overweight and obese recipients were older, had a higher percent of coronary artery disease, and private health insurance coverage. Overall posttransplant complications were higher in obese group (35.7% vs. 28.6%) when compared with normal BMI group. They were mainly due to increased delayed kidney graft function (11.8% vs. 7.4%), 1-year kidney acute rejection (17.0% vs. 12.1%), and pancreas graft thrombosis (2.6% vs. 1.3%). After adjusting for possible confounders, the odds ratios for overall transplant complications were 1.03 (95% confidence interval [CI]: 0.90-1.17) for overweight and 1.38 (95% CI: 1.15-1.68) for obese. Obesity, but not overweight, was associated with patient death (hazard ratio [HR]: 1.35; 95% CI: 1.00-1.81), pancreas graft loss (HR: 1.41; 95% CI: 1.17-1.69), and kidney graft loss (HR: 1.33; 95% CI: 1.05-1.67) at 3 years. The higher rates of death and graft failure in the first 30 days posttransplant mostly accounted for the 3-year survival differences. CONCLUSION.: Obesity in SPK recipients was associated with increased risk of posttransplant complications, pancreas and kidney graft loss, and patient death.

Transplantation with pancreas after living donor kidney vs. living donor kidney alone in type 1 diabetes mellitus recipients.

Living donor kidney transplantation (LDKT) in type 1 diabetic recipients (T1DM) may be followed by a pancreas after living donor kidney (PALK). The impact of the PALK is largely unknown. Adult T1DM living donor kidney recipients (1997-2007) listed for pancreas transplantation were divided into those who subsequently received pancreas transplantation and those who did not (living donor kidney transplant alone [LDKA]). Outcomes were compared. A sub-analysis was performed in recipients with at least one yr of kidney graft survival and limiting PALK to those who underwent pancreas transplantation in the first year. Of 4554 recipients, 23% received PALK. PALK had more favorable baseline characteristics. At the end of eight yr, we found significantly superior patient (85% vs. 75%) and kidney graft survival (75% vs. 62%) in PALK group. The adjusted hazard ratios of PALK (LDKA as reference) were 0.65 (95%CI: 0.52-0.81) for death and 0.63 (0.54-0.76) for renal graft loss. In sub-group analysis, there was a trend toward decreased death in PALK (HR = 0.78: 0.57-1.07). In conclusion, only 23% of those wait-listed received a pancreas with patient and kidney survival superior to LDKA. Pancreas transplant in the first year after kidney transplant was associated with a trend toward better long-term patient survival.