Deceased-donor kidney transplantation: improvement in long-term survival.

BACKGROUND: Despite marked improvement in short-term renal allograft survival rates (GSR) in recent years, improvement in long-term GSR remained elusive. METHODS: We analysed the kidney transplant experience at our centre accrued over four decades to evaluate how short-term and long-term GSR had changed and to identify risk factors affecting graft survival. The study included 1476 adult recipients of a deceased-donor kidney transplant who were transplanted between 1963 and 2006 and who had received one of five distinct immunosuppressive protocols. RESULTS: Five-year actual GSR steadily improved over the years as immunosuppressive therapy evolved (22-86%, P < 0.001) in spite of an increasing trend in the transplantation of higher-risk donor-recipient pairings. For those whose grafts functioned for the first year, subsequent 4-year GSR (5-year conditional GSR) also improved significantly (63-92%, P < 0.001). Acute rejection and delayed graft function (DGF) were the most significant risk factors for actual graft survival, while acute rejection was the only significant risk factor for conditional GSR. Use of kidneys from expanded-criteria donors (ECD) was not a risk factor, compared to the use of standard-criteria donor kidneys for either 5-year actual or conditional GSR. There was an impressive decline in the incidence of acute rejection events (77.4-5.8%, P < 0.001). While the DGF rate had decreased, it still remained high (68.7-38.5%, P < 0.001). CONCLUSIONS: We found a significant improvement in both short-term and long-term GSR of deceased-donor kidney transplants over the last four decades. These improvements are most likely related to the decreased incidence of acute rejection episodes. Minimizing acute rejection events and preventing DGF could result in further improvement in the GSR. Our experience in the judicious use of ECD kidneys suggests that this source of kidneys could be expanded further.

Excellent outcomes with expanded criteria donor kidneys: the role of the recipient's age.

At the present time, the number of deceased donor kidney transplants performed annually has remained unchanged for 4 years. Desire for standard criteria donor (SCD) kidneys by recipients, coupled with high discard rates of donor kidneys, contributes to a lack of procedures being performed. A subgroup of recipients, those under age 50, may fare as well with an expanded criteria donor (ECD) allograft as those who receive an SCD kidney. The use of ECD allografts in recipients over 50 years of age, while projected to have poorer allograft survival than that produced with an SCD graft, still results in better recipient survival than patients who have elected to remain on dialysis.