Delayed Graft Function in Kidney Retransplantation: United Network for Organ Sharing Data With Linked Primary and Retransplant.

INTRODUCTION: There are several articles exploring the risk factors for primary delayed graft function (DGF). However, current literature does not include many resources on the risk factors for DGF when it is a recipient's second kidney transplant or look at short-term graft and patient survival of DGF retransplants. METHODS: United Network for Organ Sharing data from January 2008 to June 2021 were analyzed. Pancreas transplants, multi-organ transplants, and lost to follow-up transplants were excluded. Second transplant patients with DGF were identified. Multivariate logistic regression models based on the primary and second transplant characteristics were created. Survival analysis was performed with Kaplan-Meier methodology and assessed with log-rank test. RESULTS: A total of 2964 second kidney transplants were identified. Rate of DGF in the second transplant was 28.4% (843/2964) and 49.2% of them had a prior DGF in their first transplant (P < 0.001). Multivariate analysis confirmed that occurrence of DGF (odds ratio [OR] 1.5, P < 0.001) and graft loss due to acute rejection (OR 1.2, P < 0.005) in the primary transplant were predictors of reappearing DGF in the second transplant. Dialysis at transplant was the greatest risk factor from the second transplant (OR 3.539, P < 0.001). There was a decreased graft survival after 12 mo (77% versus 49% with log t-test <0.001) in the second transplant. However, DGF was not significantly associated with patient survival. CONCLUSIONS: This study shows the interaction between primary and second transplant in developing DGF. Survival analysis shows lower graft survival for retransplants in the case of DGF. This study opens the possibility of identifying additional risk factors for patients undergoing retransplant surgeries.

Improved Medication Adherence with the Use of Extended-Release Tacrolimus in Liver Transplant Recipients: A Pilot Randomized Controlled Trial.

Background: Nonadherence to immunosuppression in liver transplant recipients (LTRs) leads to deterioration in health outcomes. Once-dailyextended-release tacrolimus (TAC-ER) may improve adherence when compared to twice-dailyimmediate-release tacrolimus (TAC-IR). Methods: We conducted a randomized controlled study to evaluate medication adherence, clinical efficacy, and safety of TAC-ER in stable LTR. All patients >18 years who underwent liver transplantation before 6 months were eligible. Patients were randomized 1 : 1 to continued TAC-IR or conversion to TAC-ER. The primary outcome was change in medication adherence from baseline to 9 months, assessed using BAASIS. Secondary outcomes were tacrolimus trough levels, safety, and quality of life. Results: Thirty-one patients were consented and randomized to either of the two groups: conversion to TAC-ER (n = 15) or continued TAC-IR (n = 16). Six patients in the TAC-ER group withdrew after randomization due to apprehension about switching medication (n = 2), unwillingness to travel (n = 2), and increased liver tests after conversion (n = 2, both were acute rejections despite therapeutic tacrolimus levels and were considered unrelated to TAC-ER). We compared the results of nine patients in the TAC-ER group that completed the study with those of sixteen in the TAC-IR group. At baseline, there was no difference in tacrolimus trough levels between groups. Improved adherence was observed in the TAC-ER group as 100% of patients reported at least one period of full adherence during the study period (100% vs. 62.6%, p = 0.035). Tacrolimus trough levels and liver tests were comparable between groups throughout the study. There were no differences in eGFR, HbA1c, or QoL between the groups. Conclusion: TAC-ER improved medication adherence while maintaining comparable trough levels, liver function, and QoL as TAC-IR in LTR.

A single dose of pre-operative pregabalin reduces post-operative opioid use after orthotopic liver transplantation.

Multimodal pain management strategies including pregabalin (PGB) have been shown to reduce pain and opioid use after many types of surgeries. This was a single-center, retrospective study aimed to determine whether a single pre-operative dose of PGB reduces opioid requirements and post-operative pain after orthotopic liver transplantation (OLT). Outcomes included the mean morphine milligram equivalents used; the proportion of patients with no pain documented; and the maximum level of pain documented within the first 24h and in the 24-72h following OLT. A total of 44 patients received PGB vs 57 who received standard of care. Baseline demographics were comparable between groups. Patients who received PGB required 70% and 54% less opioids within the first 24h and subsequent 24-72h post-OLT, respectively (p-values < .001). In the first 24h post-OLT, there were more patients with no documented pain, and fewer with severe pain in the PGB group, but these were not significant. A greater proportion in the PGB group reported a maximum of mild pain (p = .039). This study demonstrated that a single dose of pre-operative PGB significantly reduced opioid use in the first 72 h after OLT. Larger studies will help determine the safety and efficacy of PGB in this setting.

A Rare Case of Calciphylaxis in an Orthotopic Liver Transplant Recipient with Acute Kidney Injury.

Calciphylaxis is a rare disease characterized by calcification of small- to medium-sized blood vessels in the dermis and subcutaneous fat, resulting in cutaneous necrosis. Although most commonly shown in patients with end-stage kidney disease, it has also been reported in patients with other diseases, including alcoholic cirrhosis and malignancies. Here, we report an unusual case of calciphylaxis in an orthotopic liver transplant recipient with acute kidney injury. The patient, a 43-year-old white female with a history of type 2 diabetes mellitus, alcoholic cirrhosis, and normal kidney function, presented with decompensated liver disease and hepatorenal syndrome; she no longer responded to medical treatment and required treatment with dialysis. Ten days after admission, she underwent liver transplant, resulting in improved liver function tests. She had acute tubular necrosis (creatinine peak: 325 µmol/L) from sustained hypotension during and after surgery, which required 4 sessions of dialysis over 2weeks. Six weeks after her transplant, she developed painful, nonulcerating, erythematous plaques over her shins and thighs. Skin biopsy of the lesions showed calciphylaxis, calcium deposits, and thrombotic vasculopathy. She also developed severe hypercalcemia (calcium level of 2.75 mmol/L) from immobility, which required treatment with a bisphosphonate and hemodialysis. The lesions improved 6 weeks later, and her renal function returned to normal. Calciphylaxis diagnosed in an orthotopic liver transplant recipient with acute kidney injury has not been previously reported. We hypothesize that her chronic inflammatory state caused down-regulation and low levels of fetuin A and protein C. She also had other risk factors, including hypoalbuminemia, obesity, systemic glucocorticoids, and alcoholic liver disease. Calciphylaxis can occur in patients with alcoholic cirrhosis and acute renal failure even after liver transplant. Further studies into the pathogenesis of this disease may help us understand why it develops in these patients and not others with the same risk factors.

Urinary excretion after transcaval renal penetration of a fragmented Bird's Nest filter.

Permanent inferior vena cava (IVC) filters are used to prevent venous thromboembolic events in select populations of patients. The Bird's Nest filter (BNF; Cook Medical, Bloomington, Ind) is an IVC filter that has been associated with various complications including filter strut fractures, migration, caval wall perforation, visceral perforation, and vascular injury. We report a case of a BNF that eroded transmurally through the IVC into the right kidney parenchyma. The patient underwent operative intervention with removal of the BNF with an uncomplicated postoperative course. In patients with symptoms and local filter perforations, we advocate for safe filter removal when possible to avoid long-term damage.

Inadvertent Traumatic Fracture of Central Venous Catheter during Procurement, Transmitted Through Solid Organ Transplant.

Central venous catheters play a pivotal role in the perioperative support of critically ill patients. They are used for administration of fluids, vasopressors, blood products, and various medications; however, their use may be associated with serious complications, such as catheter fracture and embolization. While most data on catheter fracture embolization consist of isolated case reports, only a few studies have examined patients with central venous catheter embolism. We report a traumatic inadvertent transection of central venous catheter that migrated through a donor transplanted liver and was found to be lodged in the recipient's right ventricle. The catheter was retrieved under fluoroscopy using a trilobed snare device.

Endovascular Stenting of Portal Vein for Graft Rescue after a Pancreas Transplant Venous Graft Thrombosis: A Case Report.

Venous thrombosis of pancreas transplant allografts often leads to graft loss. It is an worrisome complication and difficult to treat, forming the most common nonimmunological cause of graft loss. Multiple risk factors have been implicated in the development of venous thrombosis of pancreas transplant. Color Doppler ultrasonography enables early diagnosis of venous thrombosis, thus increasing the possibility of graft-rescue treatments. Endovascular management of pancreatic transplant vascular complications is scant and in the form of case reports. We report a case of early detection of pancreatic graft venous thrombosis that was treated successfully by catheter-directed thrombolysis mechanical thrombectomy, percutaneous transluminal angioplasty, and stenting of portal vein.

Association Between Delayed Graft Function and Incisional Hernia after Renal Transplant.

OBJECTIVES: Incisional hernias can occur after any abdominal operation, including after renal transplant. Several risk factors have been identified in nonimmunosuppressed surgical patients. We aimed to identify whether specific risk factors correlated with the development of incisional hernias after renal transplant. The existence of associations between these risk factors and postoperative complications was also reviewed. MATERIALS AND METHODS: We reviewed 969 kidney transplants performed between February 2000 and January 2011. Thirty-nine kidney transplant recipients who were treated with rapamycin were excluded. The following potential risk factors were evaluated: recipient age, sex, body mass index at transplant, delayed graft function, diabetes, albumin, postoperative platelet count, drain placement, donor body mass index, donor type, warm ischemic time, and cold ischemic time. We performed univariate and multivariate logistic regression tests. RESULTS: In our patient group, a total of 52 (5.4%) transplants were complicated by incisional hernia. On univariate analysis, we found that delayed graft function (P = .001) and infection (P < .001) were statistically significant predictors for development of incisional hernia. Multivariate analyses revealed that delayed graft function and length of stay remained statistically significant predictors. CONCLUSIONS: Delayed graft function and length of stay are significant predictors of incisional hernia after kidney transplant.

De Novo Thrombotic Microangiopathy Immediately After Kidney Transplant in Patients Without Apparent Risk Factors.

Thrombotic microangiopathy refers to a spectrum of conditions that share a common underlying pathologic mechanism that result in endothelial damage and microangiopathic hemolytic anemia. De novo thrombotic microangiopathy after kidney transplant is often triggered by immunosuppressive drugs, and studies most often implicate calcineurin inhibitors and/or mammalian target of rapamycin inhibitors; however, muromonab and alemtuzumab also reportedly cause thrombotic microangiopathy. In addition, thrombotic microangiopathy may be triggered by acute antibody-mediated rejection and infections like cytomegalovirus and parvovirus. Here, we present a case series of 3 patients without any apparent risk factors (eg, acute antibody-mediated rejection) who developed de novo thrombotic microangiopathy immediately following kidney transplant, but before the introduction of calcineurin inhibitors. Two of these 3 patients were successfully managed with plasma exchange, and calcineurin inhibitors were successfully introduced without the recurrence of thrombotic microangiopathy.

Dialysis within 24 hours of transplant does not improve graft function.

OBJECTIVES: Grafts from extended criteria donors, donors after cardiac death, and elderly donors have an increased risk of delayed graft function, lower graft survival, longer hospital stay, higher costs, and increased medical sequelae. A modifiable risk factor for delayed graft function may be the performance of dialysis on the same day as renal transplant. We reviewed our institutional experience to determine whether dialysis performed within 24 hours of engraftment increased the incidence or length of delayed graft function. MATERIALS AND METHODS: We retrospectively reviewed our kidney transplants performed between 2008 and 2012. Preemptive transplants, transplants associated with peritoneal dialysis, potassium > 5 mmol/L, or living donors, and cases with insufficient information were excluded. Data collected included demographic, biochemical, donor, operative, and outcome variables (length of stay, length of delayed graft function, rejection, and a composite unfavorable outcome comprising cardiac and infectious events). Transplants that were associated with hemodialysis within 24 hours before transplant (study group) were compared with the remainder of the cohort (control group). RESULTS: A total of 205 renal transplants were reviewed. There were 144 of 205 transplants (70.24%) in the study group, and the others comprised the control group. The rate of delayed graft function was 31% for the study group and 29% for control groups (P = .4959). Mean length of delayed graft function was 5.8 days for the study group and 6.1 days for control group (P = .7323). Delayed graft function risk factors such as donor age, terminal creatinine, and machine perfusion rate were similarly distributed across both groups. CONCLUSIONS: Normokalemic patients who did or did not undergo dialysis within 24 hours before transplant had equivalent incidence and duration of delayed graft function, graft outcomes, and patient outcomes. Therefore, dialysis within 24 hours before transplant is unnecessary in the setting of normokalemia.

Severe Interferon/Ribavirin-Induced Hyperuricemia and Urate Nephropathy Requiring Rasburicase and Hemodialysis in a Liver Transplant Recipient.

INTRODUCTION: Hyperuricemia caused by pegylated-interferon-α2a and ribavirin therapy has been rarely reported. We report a case of severe hyperuricemia and urate nephropathy in a liver transplant recipient with recurrent hepatitis C, which required discontinuation of therapy, rasburicase, and hemo-dialysis. CASE REPORT: A 64-year-old female liver transplant recipient was begun on treatment of fibrosis cholestatic hepatitis with pegylated-interferon-α2a and ribavirin therapy. She received a one-time dose of pegylated-interferon-α2a 135 mcg subcutaneously, and ribavirin was initiated. Within 24 hours of treatment initiation, she developed an acute kidney injury with serum creatinine increased from a baseline 132.6 µmol/L (1.5 mg/dL) to 459.7 µmol/L (5.2 mg/dL) within 72 hours. Ultrasound and computed tomography of the kidneys were normal with no stones and urinalysis showed no crystals. Her ribavirin dosage was adjusted based on her changing renal function. Within 72 hours after treatment initiation, her serum uric acid level was 1392 µmol/L (23.4 mg/dL), for which she received rasburicase 3 mg intravenously. Ribavirin was discontinued at this time. The next day, her serum uric acid level and remained elevated at 1166 µmol/L (19.6 mg/dL) and she received a second dose of rasburicase 7.5 mg and hemodialysis. Her serum uric acid level decreased to 131 µmol/L (2.2 mg/dL) and remained within normal limits; however, she continued to require intermittent hemodialysis until she died from complications of sepsis 38 days after admission. After discontinuation, she was not rechallenged with pegylated-interferon-α2a /and ribavirin. CONCLUSIONS: A liver transplant recipient with recurrent hepatitis C developed severe hyperuricemia and urate nephropathy shortly after receiving pegylated-interferon-α2a and ribavirin therapy. The patient's hyperuricemia was managed with rasbu-ricase and hemodialysis. This rare but potentially serious adverse reaction can limit the use of these agents in patients with recurrence of life threatening hepatitis C after liver transplant.

Equal 3-Year Outcomes for Kidney Transplantation Alone in HCV-Positive Patients With Cirrhosis.

Kidney transplantation alone in clinically compensated patients with cirrhosis is not well documented. Current guidelines list cirrhosis as a contraindication for kidney transplantation alone. This is an Institutional Review Board-approved retrospective study. We report our experience with a retrospective comparison between transplants in hepatitis C virus-positive (HCV(+)) patients without cirrhosis and HCV(+) patients with cirrhosis. All of the patients were followed for at least a full 3-year period. All of the deaths and graft losses were recorded and analyzed using Kaplan-Meier methodology. One- and three-year cumulative patient survival rates for noncirrhotic patients were 91% and 82%, respectively. For cirrhotic patients, one- and three-year cumulative patient survival rates were 100% and 83%, respectively (P = NS). One- and three-year cumulative graft survival rates censored for death were 94% and 81%, and 95% and 82% for the noncirrhosis and cirrhosis groups, respectively (P = NS). Comparable patient and allograft survival rates were observed when standard kidney allograft recipients were analyzed separately. This study is the longest follow-up document in the literature showing that HCV(+) clinically ompensated patients with cirrhosis may undergo kidney transplantation alone as a safe and viable practice.

Risk factors for renal allograft compartment syndrome.

Renal allograft compartment syndrome (RACS) is graft dysfunction secondary to intracompartment hypertension. The purpose of this study was to identify risk factors for RACS. We reviewed 7 cases of established RACS and all intra-abdominal placements of the kidney in order to include potential RACS. We also studied early graft losses in order to rule out a missed RACS. We compared the allograft length and width, recipient height, weight, body mass index, aberrant vessels, site of incision, and side of kidney with the remainder of the cohort as potential predictors of RACS. Among 538 transplants, 40 met the criteria for actual RACS or potential RACS. We uncovered 7 cases of RACS. Only kidney length and width were statistically significant (P = 0.041 and 0.004, respectively). The width was associated with a higher odds ratio than was length (2.315 versus 1.61). Increased allograft length and width should be considered as a potential risk for RACS.

Elimination of warm ischemia using the Ice Bag Technique does not decrease delayed graft function.

BACKGROUND: Warm ischemic time (WIT) in kidney transplantation has significant effects on graft survival, function, and postoperative morbidity. We utilized the Ice Bag Technique (IBT) to determine if eliminating WIT would decrease the incidence and length of delayed graft function (DGF) in our cohort. METHODS: We conducted a prospective study of 150 kidney transplants. We compared the elimination of WIT with IBT to traditional methods. Data was analyzed using non-parametric statistical tests. RESULTS: 66 of the 134 patients underwent transplantation using IBT. 28 right kidneys, 34 left kidneys, and 4 dual kidneys were implanted successfully. Patients with a body mass index (BMI) as high as 41 were transplanted. Kidneys with up to three arteries and two veins, and kidneys up to 15.5 by 9 cm in size were safely transplanted into either iliac fossa. Despite the complete elimination of WIT, there was no difference in DGF, length of DGF, length of stay graft rejection, graft survival, patient survival, or wound or urologic complications between groups (p > 0.05). CONCLUSIONS: The elimination of warm ischemic time using the IBT does not appear to reduce the incidence or length of DGF in this cohort. The technique may be useful for cases with prolonged anastomosis time (AT), but further studies with larger cohorts are required to determine whether it decreases DGF.

No benefit when placing drains after kidney transplant: a complex statistical analysis.

OBJECTIVES: This paper sought to determine if there were an association between drain placement and the incidence of wound complications. MATERIALS AND METHODS: A single-center institutional review board-approved retrospective study between 2001 to 2008, comparing 680 kidney transplant patients who either had a drain placed or were left undrained. Linear regression modeling was used to adjust the risk factors between the groups. Patients received calcineurin inhibitors, steroids, and a mycophenolate formulation. The incidence of early major and minor wound complications were captured. Minor wound complications were defined as seroma, lymphocele, and perigraft fluid collection, and major wound complications were defined as wound dehiscence, hematomas, evisceration, infections, wound necrosis, and hernias. Patients with incomplete data or those taking sirolimus were excluded. RESULTS: Six hundred eighty kidney transplant cases were reviewed. Four hundred seventy-nine received drains; 201 did not. Demographic analyses revealed that the drain group had a higher average value in age and body mass index. The drain group had a lower albumin and a lower mean platelet count after surgery. The number of patients without diabetes in the drain group numbered nearly twice as many as did those without drains. An attempt was made to statistically account for demographic differences. Seventy-eight of 479 drained patients (16.28%) and 24 of 201 no-drain patients (11.94%) had a wound complication. Minor wound complications were observed in 9 patients (1.88%) in the drain group and 6 in no-drain group (2.99%) (P = .3702). Major wound complications were observed in 58 patients in the drain group (12.18%) and 17 in the no-drain group (8.46%) (P = .1655). Drain placement had no effect on major or minor wound complications. CONCLUSIONS: Drain placement is not associated with major or minor wound complications in kidney transplants.

Concomitant proton pump inhibitors with mycophenolate mofetil and the risk of rejection in kidney transplant recipients.

BACKGROUND: Recent pharmacokinetic studies have demonstrated that proton pump inhibitors (PPI) reduce exposure of mycophenolic acid. However, the clinical significance of this drug-drug interaction on transplantation outcomes has not been determined. METHODS: This was a retrospective cohort study in kidney transplant recipients who were prescribed rabbit antithymocyte globulin, calcineurin inhibitor, mycophenolate mofetil, and steroids. We evaluated the impact of PPI use on the 1-year rates of biopsy-proven acute rejection (BPAR). RESULTS: Two hundred thirteen patients who were prescribed PPI were compared with 384 patients who were on standard acid-suppressive therapy with ranitidine. BPAR occurred in similar rates in both groups (15% vs. 12%; P=0.31). In a multivariable analysis, black race was associated with a higher risk of rejection (risk ratio [RR], 2.38; 95% confidence interval [CI], 1.41-4.03). While controlling for rejection risk factors, PPI exposure was associated with an increased risk of rejection in black patients (RR, 1.93; 95% CI, 1.18-3.16) but not in non-black patients (RR, 0.54; 95% CI, 0.19-1.49). At 1 year, BPAR type, BPAR grade, patient and graft survival, graft function, and time to BPAR were not associated with PPI exposure. CONCLUSION: In this retrospective study, PPI use in the first transplant year was associated with an increased risk for BPAR in black patients but not in non-black patients. It is possible that a reduction in mycophenolic acid exposure contributed to the increased risk.

Immediate postoperative sonography of renal transplants: vascular findings and outcomes.

OBJECTIVE: The purpose of this study was to determine the frequency and types of significant vascular findings on bedside sonography immediately after renal transplantation and which abnormalities would suggest a benefit from early surgical revision. MATERIALS AND METHODS: Five hundred seventy-five renal transplant sonograms obtained within 4 hours of surgery were retrospectively reviewed for major vascular abnormalities: lack of renal artery (RA) or renal vein (RV) flow, elevated peak systolic velocity (PSV)>300 cm/s, parvus tardus waveforms, and markedly decreased or no color parenchymal flow. Clinical outcomes of abnormal cases were reviewed, including reoperations and percutaneous interventions. RESULTS: Thirty-two (5.6%) patients underwent repeat surgery within the first week, 16 for nonvascular causes. Forty-seven (8.2%) patients had positive sonography findings. In 16 patients, sonography impacted the decision for reoperation, with 14 confirmed vascular diagnoses: compartment syndrome (n=7), RV thrombosis (n=3), RA thrombosis (n=1), RA and RV thromboses (n=2), and vascular steal (n=1). All were salvaged except the three RV thromboses. Two patients had no vascular abnormality at surgery. All 16 had markedly decreased color flow and varying abnormalities of PSV and waveforms. Outcomes of the remaining 31 cases were infarct (n=1), renal or iliac artery stenoses eventually requiring stents (n=4), and normalized (n=26). These 26 had elevated PSV with normal or near-normal color flow. Unpaired Student t tests showed no significant difference in PSV between patients requiring surgery or stents and those who normalized (p=0.34). CONCLUSION: Immediate postoperative sonography has a spectrum of vascular findings, of which markedly decreased color flow is most likely to benefit from immediate reoperation.

Satisfactory outcomes with usage of extended criteria donor (ECD) kidneys in re-transplant recipients.

BACKGROUND: The use of extended criteria donor (ECD) kidneys have increased substantially and the benefit recognized in certain populations. Our institution has maintained a policy of aggressively utilizing ECD kidneys, even among those who have failed a previous transplant. Previous reports on the benefit of ECD in re-transplants have shown equivocal outcomes. We sought to determine if our experience would support or refute this finding. MATERIAL AND METHODS: This is a retrospective study of 19 ECD re-transplants between 2002 and 2010. We compared 1 and 3 year outcomes with 95 patients with standard criteria donor (SCD) re-transplant and 169 patients with first time transplant using ECD kidneys. Outcomes and demographics were evaluated including delayed graft function (DGF), HTN, DM, cold ischemia time (CIT), BMI, donor age and prior allograft nephrectomies using a Cox Proportional Hazard model. We compared patient and graft survival using the log rank test. RESULTS: Patient survival were similar among the first time ECD and ECD re-transplant groups at 1 year (p=0.9547) and at 3 years (p=0.8287). Graft survival was also similar between first time ECD and ECD re-transplant groups at 1 year (p=0.4781) and at 3 years (p=0.8519). As expected, SCD re-transplant had better outcomes than the other groups. CONCLUSIONS: 1 and 3 years graft and patient survival among first time ECD transplants and ECD re-transplants are similar. As the list of patients on dialysis is ever growing, it may be prudent to aggressively explore the utility of using ECD kidneys in re-transplant patients.

Evaluating safety and efficacy of rabbit antithymocyte globulin induction in elderly kidney transplant recipients.

OBJECTIVES: The optimal immunosuppression regimen for elderly kidney transplant recipients is poorly defined. We sought to evaluate the short-term efficacy and safety of thymoglobulin in geriatric recipients of deceased-donor kidneys. MATERIALS AND METHODS: A single-center, retrospective analysis was undertaken between elderly (≥ 65 years) (n=137) and nonelderly (n=276) kidney transplant recipients who received rabbit antithymocyte globulin induction and calcineurin inhibitor, mycophenolic acid, and prednisone maintenance. RESULTS: The mean age was 70 versus 52 years. Fewer elderly patients had an earlier transplant or panel reactive antibodies > 20%, but had more machine perfused, older, and extended criteria donor kidneys. Elderly patients received lower rabbit antithymocyte globulin (5.4 vs 5.6 mg/kg; P = .04) and initial mycophenolic acid doses (1620 vs 1774 mg; P = .002), and experienced less delayed graft function (31.1% vs 50.0%; P < .001). Death-censored graft survival and graft function at 3 years and biopsy-proven acute rejection at 1 year were comparable; however, there was lower 3-year patient survival in elderly patients. Donor age was the only factor associated with reduced patient survival. Rates of malignancy, infection, or thrombocytopenia were similar; however, leukopenia occurred less frequently in elderly patients (11.7% vs 19.9%; P = .038). CONCLUSIONS: Elderly kidney transplant recipients receiving rabbit antithymocyte globulin did not experience different short-term graft survival, graft function or rates of infection, malignancy or hematologic adverse reactions than did nonelderly patients; they experienced fewer episodes of delayed graft function, but had lower 3-year patient survival.