Living Donor Kidney Transplantation Improves Graft and Recipient Survival in Patients with Multiple Kidney Transplants

Abstract

<jats:p>Background: Failed kidney transplant recipients benefit from a new graft as the general incident dialysis population, although additional challenges in the management of these patients are often limiting the long-term outcomes. Previously failed grafts, a long history of comorbidities, side effects of long-term immunosuppression and previous surgical interventions are common characteristics in the repeated kidney transplantation population, leading to significant complex immunological and technical aspects and often compromising the short- and long-term results. Although recipients’ factors are acknowledged to represent one of the main determinants for graft and patient survival, there is increasing interest in expanding the donor’s pool safely, particularly for high-risk candidates. The role of living kidney donation in this peculiar context of repeated kidney transplantation has not been assessed thoroughly. The aim of the present study is to analyse the effects of a high-quality graft, such as the one retrieved from living kidney donors, in the repeated kidney transplant population context. Methods: Retrospective analysis of the outcomes of the repeated kidney transplant population at our institution from 1968 to 2019. Data were extracted from a prospectively maintained database and stratified according to the number of transplants: 1st, 2nd or 3rd+. The main outcomes were graft and patient survivals, recorded from time of transplant to graft failure (return to dialysis) and censored at patient death with a functioning graft. Duration of renal replacement therapy was expressed as cumulative time per month. A multivariate analysis considering death-censored graft survival, decade of transplantation, recipient age, donor age, living donor, transplant number, ischaemic time, time on renal replacement therapy prior to transplant and HLA mismatch at HLA-A, -B and -DR was conducted. In the multivariate analysis of recipient survival, diabetic nephropathy as primary renal disease was also included. Results: A total of 2395 kidney transplant recipients were analysed: 2062 (83.8%) with the 1st kidney transplant, 279 (11.3%) with the 2nd graft, 46 (2.2%) with the 3rd+. Mean age of 1st kidney transplant recipients was 43.6 ± 16.3 years, versus 39.9 ± 14.4 for 2nd and 41.4 ± 11.5 for 3rd+ (p &lt; 0.001). Aside from being younger, repeated kidney transplant patients were also more often males (p = 0.006), with a longer time spent on renal replacement therapy (p &lt; 0.0001) and a higher degree of sensitisation, expressed as calculated reaction frequency (p &lt; 0.001). There was also an association between multiple kidney transplants and better HLA match at transplantation (p &lt; 0.0001). A difference in death-censored graft survival by number of transplants was seen, with a median graft survival of 328 months for recipients of the 1st transplant, 209 months for the 2nd and 150 months for the 3rd+ (p = 0.038). The same difference was seen in deceased donor kidneys (p = 0.048), but not in grafts from living donors (p = 0.2). Patient survival was comparable between the three groups (p = 0.59). Conclusions: In the attempt to expand the organ donor pool, particular attention should be reserved to high complex recipients, such as the repeated kidney transplant population. In this peculiar context, the quality of the donor has been shown to represent a main determinant for graft survival—in fact, kidney retrieved from living donors provide comparable outcomes to those from single-graft recipients.</jats:p>

[Retracted] Prevalence, Mechanisms, Treatment, and Complications of Hypertension Postliving Kidney Donation

“…Kidney transplantation, for the majority of patients with end-stage renal failure, remains the treatment of choice of renal replacement therapy (RRT) [ 1 ] [ 2 ]. Despite the dawn of complex, patient- and evidence-directed immunosuppressive treatment, compared with deceased kidney donation, living kidney donation is significantly associated with sustainably improved long-term physical, biochemical, and psychological outcomes of the recipients [ 3 , 4 ]. Regardless however, deceased donation currently accounts for over 60 percent of kidney transplantation occurring in both the United Kingdom and United States, alluding somewhat to the complexities and challenges associated with appropriate donor selection [ 5 , 6 ].…”

Postoperative delirium in kidney transplant patients

“…Furthermore, in the KT scenario, delayed graft function requiring dialysis is a specific risk factor, explaining POD major incidence in recipients of deceased donor grafts compared with living donor kidneys: 9.07% versus 6.85%, respectively. These data are of interest and highlight the role of high-quality organs for frail older patients, to improve their short-and long-term outcomes [3].…”

Assessing Kidney Graft Viability and Its Cells Metabolism during Machine Perfusion

“…It also has a significant hospitalization cost, with a higher overall recipient morbidity [ 6 ]. Rates of DGF typically affect one third of the deceased donor kidney transplants [ 22 ] and are dependent from the intrinsic quality of the organ, with a general less incidence for high quality organs as for example those retrieved from living donors [ 23 ].…”