Search PubMed⌕ Search

Biomedical subjects

J M Cecka

Publications and source records attributed to J M Cecka.

At least 19 recordsLinked to original sources
PubMed2005

Prospective registry-based observational cohort study of the long-term risk of malignancies in renal transplant patients treated with mycophenolate mofetil.

This large prospectively conducted observational cohort study examined the risk of lymphoma and other malignancies with mycophenolate mofetil (MMF) in de novo renal transplant recipients. A total of 6751 patients receiving MMF, and an equal number of matched controls receiving non-MMF-based immunosuppression, were identified from two large registries (Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) and Collaborative Transplant Study (CTS)) and followed for 3 years. The primary endpoint was development of lymphoma. Secondary endpoints included development of any malignancy. There was no evidence of any increased risk of developing lymphoma or malignancy with MMF. The risk of developing lymphoma with MMF compared with the non-MMF cohort was not higher in either the CTS registry (relative risk (95% confidence interval); 0.4 (0.17-0.94)) or the OPTN/UNOS registry (1.04 (0.61-1.78)). In the MMF group, there was a trend toward a lower risk of malignancy in both registries (OPTN/UNOS 0.86 (0.69-1.07); CTS 0.79 (0.61-1.02)) and a significant increase in time to malignancy in the CTS dataset (p < 0.026). This study has demonstrated that MMF is not associated with an increased risk of lymphoma or other malignancies post-renal transplant, and may even be associated with a lower risk in some populations.

Adult↗
PubMed2001

Determinants of long-term survival of pediatric kidney grafts reported to the United Network for Organ Sharing kidney transplant registry.

Pediatric 1-yr kidney graft survival rates have steadily improved in the US so that, by 1998, over 90% of hospital-discharged young recipients had survived the first year post-transplantation (Tx). However, 25% of the early surviving kidney grafts failed at 5 yr, yielding a projected half-life of 10 yr. Given a median age at transplant of 13 yr (range 0-20 yr), 50% of all current pediatric kidney recipients will need a second graft before the age of 25 years. We examined 8,422 pediatric renal transplants reported to the United Network for Organ Sharing (UNOS) Kidney Transplant Registry and, by using a log-linear multifactorial analysis, determined the relative influence of 26 major transplant factors on long-term graft survival. Results are reported as percentages of assignable variation (totaling 100% for all 26 factors combined) in pediatric outcomes beyond 1 yr and as adjusted graft survival rates. Transplant center, recipient race and age, transplant year, and panel-reactive antibody (PRA) had assignable variation percentages of 25, 24, 16, 12, and 4, respectively. When combined, they accounted for 81% of changes in long-term survival. Besides center effects, Blacks, teenagers, and transplants performed before 1994 exhibited significantly (p <0.0001) lower adjusted 5-yr graft survival rates as did the few sensitized (PRA>40%) pediatric patients (p = 0.02). Patients transplanted with a living donor kidney demonstrated a 5% point advantage at 5 yr post-Tx over cadaver donor kidneys (p = 0.001). Although the survival rate of pediatric kidney transplants has improved steadily, the long-term outcomes for teenagers and for Black recipients lag significantly behind those of younger patients and non-Blacks.

Adolescent↗
PubMed2001

The UNOS renal transplant registry.

The shortage of cadaver kidneys relative to increasing demand for transplantation has lead to a remarkable rise in transplantation from living donors. Based upon data reported to UNOS, the number of living donor kidneys transplanted in 2000 (5,106) nearly equaled the number of cadaver kidneys from preferred donors aged 6-50. HLA-mismatched siblings, offspring, spouses and other genetically unrelated donors accounted for nearly 80% of increased living donor transplantation during 1994-2000. Despite the increased use of poorly HLA-matched living donor kidneys, the actuarial 10-year graft survival rates for transplants between 1988-2000 were clustered between 53-57% for HLA-mismatched living donor grafts, except for offspring-to-parent transplants (49%) when the recipients were generally older. The 10-year survival rate for 96,053 cadaver grafts was 38% during the same period. The 5-year graft survival rates for more recent (1996-2000) cadaver donor transplants were 66%, 62% and 56% for recipients of first, second and multiple grafts, respectively (p < 0.001). The comparable results among recipients of living donor kidneys were 67%, 66% and 59% (p = ns). The 5-year graft survival rates for HLA-matched first grafts were 7% higher than those for HLA-mismatched transplants when the kidney was from a living or cadaver donor. HLA-identical sibling transplants provided the best long-term graft survival (85% at 5 years and a 32 year half-life). Even with improved crossmatch tests and stronger immunosuppression, sensitization was associated with 8% lower graft survival at 5 years and with a higher rate of late graft loss among first cadaver kidney recipients. Sensitization also was associated with an increase in delayed graft function from 22% of unsensitized first transplant recipients to as much as 36% among multiply retransplanted patients. Recipient race was a key factor in long-term graft survival of both living and cadaver donor kidneys. The rate of late graft loss was double among blacks compared with recipients with other racial origins whether the kidney was from a living or cadaver donor. Black recipients accounted for 29% of first cadaver transplants during 1996-2000, but only 14% of living donor grafts. Thus an important component of long-term differences in graft survival comparing living and cadaver donor transplants is the disparate racial demographics. Both the recipient and donor populations are aging. The proportion of cadaver kidney recipients over age 50 increased from 26% to 45% and the proportion of living donor kidney recipients over age 50 rose from 10% to 35% between 1988 and 2000. The aging population affects the transplant outcome as 65% of graft losses among young recipients (ages 10-15) were attributed to acute or chronic rejection compared with only 25% of grafts lost among patients over age 60. More than half of graft losses among older recipients were due to death with a functioning graft. Kidneys from donors over age 60 comprised 9% of first cadaver transplants and yielded a 50% 5-year graft survival rate compared with 70% when the donor was aged 19-45. Kidneys from donors over age 60 accounted for only 3% of first living donor transplants and their 84% 5-year graft survival rate was comparable to that for younger donor kidneys. Despite declining immunological graft losses with advancing recipient age, the effect of HLA matching was similar among recipients of first cadaver transplants aged 50 or under and those over age 50. Completely HLA-mismatched grafts had a 10% lower 5-year graft survival rate than HLA-matched grafts when the recipient was over 50 compared with a 14% lower survival rate in younger recipients. The graft half-lives were shorter by 5-7 years for HLA-mismatched kidneys transplanted to older or younger recipients, respectively.

Aging↗
PubMed2001

Crossmatch tests--an analysis of UNOS data from 1991-2000.

Based on more than 20,000 cadaver donor transplants reported to UNOS between 1991-2000 with crossmatch results, the following observations were made: 1. One-hundred sixty-nine transplants performed despite a positive T-cell NIH crossmatch (usually with an historical serum sample) were reported to UNOS and had 5%, 6%, 7%, and 11% lower graft survival at one, 6, 12, and 24 months after transplantation compared with negative crossmatch transplants, respectively. 2. Transplants with a positive T-cell FCXM (n = 714) yielded 4%, 7%, and 9% lower graft survival at one, 6, and 12 months after transplantation compared with negative crossmatch transplants, respectively. 3. Transplants with a positive B-cell crossmatch using NIH, Wash, AHG or flow cytometry XM yielded statistically significantly lower (4-6%) graft survival rates compared with B-cell negative crossmatch transplants. 4. The differences in graft survival rates comparing recipients with a positive versus a negative T-cell crossmatch test (NIH, AHG, and FCXM) were significant in univariate analyses; however, only the NIH and FCXM showed a significant effect on graft survival after adjustment of other factors in a multivariate analysis. 5. Regrafted patients with a positive T- and B-cell FCXM experienced a higher incidence of primary nonfunction (12%) compared with those who had a negative T- and B-cell FCXM (1%; P < 0.001). Flow cytometric or ELISA screening of patient sera in addition to conventional cytotoxic crossmatch tests can provide additional information to aid in the final decision of renal transplantation.

Adolescent↗
PubMed2000

Adult-size kidneys without acute tubular necrosis provide exceedingly superior long-term graft outcomes for infants and small children: a single center and UNOS analysis. United Network for Organ Sharing.

BACKGROUND: Infants with end-stage renal disease are at highest risk for early graft loss and mortality of any subgroup undergoing renal transplantation. This study evaluates the influence of donor tissue mass and acute tubular necrosis (ATN) on graft survival and incidence of acute rejection episodes in infant and small child recipients of living donor (LD) and cadaver (CAD) adult-size kidneys (ASKs), pediatric CAD kidneys and combined kidney-liver transplants. Methods. Kidney transplants in infants and small children at a single center and those reported to the UNOS Scientific Renal Transplant Registry were analyzed. At Stanford, multi-variate analysis was conducted on 45 consecutive renal allograft recipients weighing < or = 15 kg, mean weight 11.2 +/- 2.6 kg. The UNOS Registry results in age groups 0-2.5 (n=548) and 2.5-5 years (n=743) were compared with age groups 6-12, 13-18, and the lowest risk adult group of 19-45 years. STANFORD RESULTS. Graft survival was 97.8 +/- 0.0 at 2 years and 84.6 +/- 0.1% at 8 years. The incidence of biopsy proven rejection was 8.8% in the first 3 months and 15.5% over the 8-year follow-up. None of the pediatric CAD kidneys had ATN. Rejection episodes were restricted to the pediatric CAD kidneys alone (3/3), with no kidney rejections in the combined pediatric CAD kidney-liver transplants (0/6; P=0.003). Four ASK transplants had ATN (1 postoperative and 3 late), and all predisposed to subsequent acute rejection episodes (4/4), whereas there were no rejection episodes in ASK transplants without ATN (0/32; P<0.001). At 3 years posttransplantation, mean serum creatinines were worse in ASKs with ATN (1.5 vs. 0.9 mg/dL; P<0.001) and in all grafts with rejection episodes (1.2 vs. 0.9 mg/dL; P<0.05). UNOS RESULTS: Among the 5 age groups studied, significantly better (P<0.001) long-term graft survival rates were observed in allograft recipients in the 2 youngest age groups with ASKs without ATN: 82 +/- 3% and 81 +/- 3% for LD and 70 +/- 7% and 78 +/- 4% for CAD recipients in the 0-2.5 and 2.5- to 5-year age groups, respectively, at 6 years after transplantation. Moreover, the projected graft half-lives after the 1st year in the LD groups without ATN were at least equivalent to those of HLA-identical sibling recipients ages 19-45 years: 26.3 +/- 5 and 29.3 +/- 6 years for the 0- to 2.5- and 2.5- to 5-year age groups, respectively, and 23.3 +/- 1 years for HLA-identical transplants. The graft half-lives for CAD recipients without ATN ages 0-2.5 and 2.5-5 yearswere equivalent or better than those for LD transplants without ATN in recipients aged 19-45 years: 15.4+/- 7 and 23.7 +/- 8 years versus 15.0 +/- 0.3 years. Mean serum creatinines were superior in the 2 younger recipient age groups compared with older age groups. CONCLUSIONS: Increased donor tissue mass of the ASK or kidney-liver transplants, in the absence of ATN, seems to confer a protective effect to infant and small child recipients of these allografts. This is manifested by a prolonged rejection-free state in the single center experience and enhanced graft survival and function in the UNOS analysis, comparable to HLA identical sibling transplants for LD infant and small child recipients and to LD adult results for CAD infant and small child recipients. To optimize this protective effect by whatever mechanism, absolute avoidance of ATN is essential in infant recipients of ASK or combined kidney-liver transplants.

Adolescent↗
PubMed2000

Flow cytometric detection of HLA-specific antibodies as a predictor of heart allograft rejection.

BACKGROUND: Historically, panel reactive antibody (PRA) analysis to detect HLA antibodies has been performed using cell-based complement-dependent cytotoxicity (CDC) techniques. Recently, a flow cytometric procedure (FlowPRA) was introduced as an alternative approach to detect HLA antibodies. The flow methodology, using a solid phase matrix to which soluble HLA class I or class II antigens are attached is significantly more sensitive than CDC assays. However, the clinical relevance of antibodies detected exclusively by FlowPRAhas not been established. In this study of cardiac allograft recipients, FlowPRA was performed on pretransplant sera with no detectable PRA activity as assessed by CDC assays. FlowPRA antibody activity was then correlated with clinical outcome. METHODS: PRA analysis by anti-human globulin enhanced (AHG) CDC and FlowPRA was performed on sera corresponding to final cross-match specimens from 219 cardiac allograft recipients. In addition, sera collected 3-6 months posttransplant from 91 patients were evaluated. The presence or absence of antibodies was correlated with episodes of rejection and patient survival. A rejection episode was considered to have occurred based on treatment with antirejection medication and/or histology. RESULTS: By CDC, 12 patients (5.5%) had pretransplant PRA >10%. In contrast, 72 patients (32.9%) had pretransplant anti-HLA antibodies detectable by FlowPRA (34 patients with only class I antibodies; 7 patients with only class II antibodies; 31 patients with both class I and class II antibodies). A highly significant association (P<0.001) was observed between pretransplant HLA antibodies detected by FlowPRA and episodes of rejection that occurred during the first posttransplant year. Fifteen patients died within the first year posttransplant. Of nine retrospective flow cytometric cross-matches that were performed, two were in recipients who had no pretransplant antibodies detectable by FlowPRA. Both of these cross-matches were negative. In contrast, five of seven cross-matches were positive among recipients who had FlowPRA detectable pretransplant antibodies. Posttransplant serum specimens from 91 patients were also assessed for antibodies by FlowPRA. Among this group, 58 patients had FlowPRA antibodies and there was a trend (although not statistically significant) for a biopsy documented episode of rejection to have occurred among patients with these antibodies. CONCLUSIONS: Collectively, our data suggest that pre- and posttransplant HLA antibodies detectable by FlowPRA and not AHG-CDC identify cardiac allograft recipients at risk for rejection. Furthermore, a positive donor reactive flow cytometric cross-match is significantly associated with graft loss. Thus, we believe that detection and identification of HLA-specific antibodies can be used to stratify patients into high and low risk categories. An important observation of this study is that in the majority of donor:recipient pairs, pretransplant HLA antibodies were not directed against donor antigens. We speculate that these non-donor-directed antibodies are surrogate markers that correspond to previous T cell activation. Thus, the rejection episodes that occur in these patients are in response to donor-derived MHC peptides that share cryptic determinants with the HLA antigens that initially sensitized the patient.

Antibodies↗
PubMed2000

Twelve years' experience with national sharing of HLA-matched cadaveric kidneys for transplantation.

BACKGROUND: In October 1987, the United Network for Organ Sharing (UNOS) established a national kidney-sharing program to increase the number of HLA-matched transplantations. Since then, over 7500 cadaveric kidneys have been shipped to centers in 48 states for transplantation to HLA-matched patients. We evaluated the efficacy of the program during its first 12 years of operation. METHODS: We compared the rates of rejection and actuarial graft survival for 7614 HLA-matched and 81,364 HLA-mismatched cadaveric kidney transplantations reported to the UNOS Scientific Registry between October 1987 and September 1999. To assess the effects of the extended period of ischemia associated with shipping HLA-matched kidneys, we identified 3562 pairs of cadaveric kidneys in which one kidney went to an HLA-matched recipient and the other went to an HLA-mismatched recipient. RESULTS: The estimated 10-year rate of graft survival was 52 percent for HLA-matched transplants, as compared with 37 percent for HLA-mismatched transplants. The estimated half-lives of the transplants were 12.5 years and 8.6 years, respectively, and the mean duration of cold ischemia was 23 hours and 22 hours, respectively. After adjustment for the effects of demographic characteristics, at 10 years the overall rates of graft survival and the rates of functional-graft survival (with data censored on patients who died with a functioning graft) were 10 percent and 11 percent higher, respectively, for HLA-matched transplants than for HLA-mismatched transplants. Among 3562 pairs of kidneys, HLA-matched transplants had higher rates of survival, a lower incidence of episodes of rejection, and a lower risk of loss as a result of rejection. CONCLUSIONS: A superior graft outcome with little increase in the duration of cold ischemia justifies national sharing of HLA-matched kidney transplants.

Actuarial Analysis↗
PubMed2000

Living unrelated donor kidney transplantation.

BACKGROUND: Living unrelated donors remain an underutilized resource, despite their high graft survival rates. In this article, we updated the long-term results of more than 2500 living unrelated donor transplants performed in the United States. METHODS: Between 1987 and 1998, 1765 spouse, 986 living unrelated, 27,535 living related, and 86,953 cadaver donor grafts were reported to the United Network for Organ Sharing Kidney Registry. Kaplan-Meier curves compared graft survival rates in stratified analyses, and a log-linear analysis adjusted donor-specific outcomes for the effects of 24 other transplant factors. RESULTS: The long-term survival rates for both spouse and living unrelated transplants were essentially the same (5-year graft survivals of 75 and 72% and half-lives of 14 and 13 years, respectively). The results were similar to that for parent donor grafts (5-year graft survival = 74% and half-life = 12 years) and were significantly (P = 0.003) better than cadaver donor grafts (5-year graft survival = 62% and half-life = 9 years). After adjusting for the presence of transplant factors known to influence survival rates, recipients of living unrelated donor kidney transplants still had superior outcomes compared with cadaver transplants. CONCLUSIONS: Living unrelated kidney donors represent the fastest growing donor source in the United States and provide excellent long-term results. Encouraging spouses to donate could remove nearly 15% of the patients from the UNOS waiting list, effectively increasing the number of available cadaveric organs.

Adult↗
PubMed2000

Selecting donors of platelets for refractory patients on the basis of HLA antibody specificity.

BACKGROUND: Patients who are refractory to platelet transfusion as a result of HLA alloimmunization are generally given HLA-matched or crossmatched platelets. However, HLA-matched platelets that are matched at HLA-A and -B loci (A-matched) or those without any mismatched or cross-reactive antigens (BU-matched) are frequently unavailable. A disadvantage of crossmatching is that crossmatched platelets have a shelf life of only 5 days, so that crossmatch tests must be performed frequently for patients requiring long-term platelet transfusions. An alternative method is the selection of platelets according to the patient's HLA antibody specificity, called the antibody specificity prediction (ASP) method. STUDY DESIGN AND METHODS: An anti-human globulin-enhanced microlymphocytotoxicity test modified by a double addition of serum and a computer program were used to determine the specificity of patients' HLA antibodies. Platelet crossmatching was performed with a solid-phase adherence assay. The percentage of platelet recovery (PPR) was determined in 1621 platelet transfusions in an observational study in 114 patients, and the PPR of platelets selected by the ASP method was compared with the PPR of those that were HLA-matched, crossmatched, or randomly selected. The numbers of potential donors in files of HLA-typed donors as identified by HLA matching vs. the ASP method were determined. RESULTS: After adjustments for covariates, the mean +/- SEM PPR was similar for HLA-matched (21 +/-4%), cross-matched (23+/-4%), and ASP-selected (24+/-3%) platelets and was significantly lower for randomly selected (15+/-1.4%) platelets. For 29 alloimmunized HLA-typed patients, the mean number of potential donors found in a file of 7247 HLA-typed donors was 6 who were an HLA-A match (median = 1), 33 who were an HLA-BU match (median = 20), and 1426 who were identified by the ASP method (median = 1365). CONCLUSION: The ASP method of donor selection for refractory alloimmunized patients appears as effective as HLA matching or crossmatching. Far more donors are identified in a file of HLA-typed donors by the ASP method than by HLA matching, and this indicates that the ASP method provides important advantages regarding the availability of compatible platelet components.

Analysis of Variance↗
PubMed2000

Kidney transplantation from living unrelated donors.

Kidney transplant candidates increasingly are looking to their relatives, spouses, and even friends for a better chance at transplantation. The wait for a cadaver kidney might be 2-5 years. Although kidneys from well-matched family members have been transplanted with excellent results for many years, accepting living donors who are genetically unrelated to the patient has not been encouraged until recently. Results show that, among 1700 patients who received kidney transplants from living unrelated donors in the United States from 1995 through 1998, the one- and projected ten-year graft survival rates were 92% and 67%, respectively. These results are superior to the 87% and 50% rates for more than 26,000 cadaver kidney transplants during the same period. Risks to the donor are low (< 0.005% mortality and < 0.3% serious complications) but not absent. Thus, motivated spouses, friends, and adopted or step-family members can play an important role in the rehabilitation of patients who need a kidney transplant.

Attitude↗
PubMed2000

The UNOS Scientific Renal Transplant Registry--2000.

During the 46 years since the first successful kidney was performed, more than 200,000 kidney transplants at United States transplant centers have been reported to the UCLA and UNOS Transplant Registries. After more than 25 years of follow-up, only 4% of cadaver donor transplants and 22% of living donor transplants performed before 1975 are still functioning. When compared with the 30% and 58% 5-year cadaveric and living donor graft survival rates, respectively, reported for kidney transplants 25 years ago, today's results of 66% and 78% are remarkably improved. Between 1995-1999, the 5-year graft survival rates for living donor transplant recipients were 80% for whites, 64% for American blacks and 84% for Asians and others. Among recipients of cadaver kidneys the results for the same racial groups were 70%, 55% and 76%, respectively. HLA-identical sibling transplants provided the best results in whites and blacks with 5-year graft survival rates of 90% and 88% respectively, and superior graft half-lives of 42 and 27 years. No substantial survival differences were noted among whites who received an HLA-mismatched living donor graft (5-year graft survival ranged from 76-81%). Among blacks who received HLA-mismatched living donor kidneys, 69% of sibling grafts survived 5 years compared with 60-62% of all others (p = 0.035). The racial distribution at the 25 largest US transplant centers varied from 6-64% black recipients. Graft survival rates for both blacks and whites were comparable at centers that transplanted more than 33% blacks or less than 20% blacks, suggesting that a larger experience with minority patients does not confer an advantage manifested in graft survival. Blacks consistently had higher rates of early rejection (34% vs. 28% in the first year) and delayed graft function (31% vs. 23%) than whites. Rejection prior to discharge resulted in a decreased one-year graft survival rate from 89% to 76% for both racial groups. DGF also reduced one-year graft survival from 82% to 76% for both racial groups. However, long-term graft survival rates were 15% lower for blacks than whites when there was no rejection or when there was no DGF. Sensitization patterns were similar comparing blacks and whites stratified according to sex, pregnancies, pretransplant transfusions, and previous transplants. There was no indication among patients transplanted between 1995-1999 for higher rates of sensitization among blacks. Recipients over age 60 had the lowest graft survival rate among whites (60% vs. 71% for those aged 19-45; p < 0.001). Among blacks, older recipients had the highest graft survival rate (57% vs. 55% for those aged 19-45; p = ns). Blacks aged 6-18 had the poorest 5-year survival rate (44%). The donor's age was an important determinant of long-term survival in both whites and blacks. The 5-year graft survival rates fell from 74-57% when the donor age was over 60 among whites. However, the difference was more pronounced among blacks, with a 5-year survival rate of 64% when the donor was aged 19-30, 47% when the donor was aged 46-60 and 35% when the donor was over 60 (p < 0.001). Increasing numbers of HLA mismatches resulted in a significantly increased incidence of rejection episodes in both blacks and whites. More than 19% of whites received an HLA-matched graft during 1995-1999 compared with 6% of blacks. HLA matching improved 3-year graft survival by 7-8% for both whites and blacks. Causes of graft failure were similar for blacks and whites during the first posttransplant year, however, after one year, blacks were more likely than whites to have an immunological graft loss whereas whites more often died with a functioning graft. The causes of patient death were also similar between blacks and whites during the first year, but after one year, blacks were more likely than whites to die from infection whereas whites more often died from cardiovascular disease and from malignancies. The racial disparity in renal allograft survival rates has diminished. The graft survival difference between whites and blacks at one year is now less than 2%. The long-term survival rates have also improved for blacks but the rate of late graft loss remains nearly double that for whites.

Adolescent↗
PubMed1999

The UNOS Scientific Renal Transplant Registry.

Based upon data reported to the UNOS Scientific Renal Transplant Registry regarding transplants performed between 1994-1998, the one- and 3-year graft survival rates for 16,288 recipients of living donor kidneys were 93% and 86%, respectively, with a half-life of 17 years. Among those were 2,129 transplants from HLA-identical siblings with one- and 3-year graft survival rates of 96% and 93% and a 39-year half-life, 3,140 sibling donor grafts matched for one HLA haplotype with 94% and 87% one- and 3-year survival rates and a 16-year half-life and 2,071 transplants from living unrelated donors with 92% and 86% one- and 3-year graft survival rates and a 17-year half-life. The overall results of 35,289 cadaver donor kidney transplants were 87% and 76% graft survival at one- and 3-years with a 10-year half-life. There was a 13% difference in 3-year graft survival rates when recipients of kidneys from donors over or under age 55 were considered separately and the half-life was 11 years for younger donors and 6 years when the donor was older (p < 0.001). A total of 4,688 (14%) of cadaver kidney recipients received an HLA-matched transplant. Their graft survival rates were 89% and 83% at one and 3 years and their graft half-life was 16 years compared with 86% and 76% one- and 3-year graft survival and a 10-year half-life for recipients of HLA-mismatched kidneys (p < 0.001). The recipient's age affected both graft survival and the cause of graft loss. Recipients aged 19-45 had a 78% 3-year graft survival rate compared with 72% for recipients over age 60 or under 18 (p < 0.001). However, 65% of graft losses after the first year among older recipients were due to death with a functioning graft compared with 18% among 19-45-year olds. Acute rejections accounted for 16% of graft failures after the first year when the recipient was aged 6-18. Immune failures decreased with increasing recipient age. The recipient's race also influenced graft survival rates. Asian recipients of cadaver kidneys had the highest graft survival rates of 91% and 85% at one and 3 years with a half-life of 18 years. The result for Whites and Blacks were significantly lower (87-86% at one year and 78% and 70% at 3 years, respectively; p < 0.001). The graft half-life was 12 years for Whites and 7 years for Blacks. DGF and acute rejection episodes during the early posttransplant period reduced 3-year survival of cadaveric transplants by 20% and reduced graft half-lives by 2 years (rejections) or 4 years (DGF). When rejections occurred in recipients with DGF, 3-year graft survival was 64%. Induction therapy with anti-T-cell reagents did not affect graft survival rates among patients with DGF, but reduced the incidence of early rejections from 27-14%. Rejections that occurred within the first 6 months had a more pronounced effect on subsequent graft half-lives (11.6 years without and 7.6 years with; p < 0.01) and increased the proportion of kidneys that failed because of chronic rejection from 31-43% between 1-3 years. More than 50% of diabetics received a simultaneous pancreas kidney transplant during this period and the graft and patient survival rates were significantly higher for recipients of the SPK transplants. When deaths with a functioning graft were censored, however, the graft failure rates were not significantly different. The major causes of death among cadaver kidney transplant recipients were cardiovascular (26%) and infections (24%) during the first posttransplant year. Between 1-3 years, the percentage of deaths due to infection fell to 15% and malignancies accounted for 13% of patient deaths.

Adolescent↗
PubMed1999

The center effect: is bigger better?

Grouping US kidney transplant centers according to the number of transplants performed during the past 10 years into those that reported more than 1,000 transplants and all others showed: 1. Ten-year graft survival rates at larger centers were no more than 5% higher than those at other centers. 2. Graft survival rates were most similar between the 2 center groups when the donor was an HLA-identical sibling or when the recipient had chronic glomerulonephritis. 3. Larger centers had a slightly but noticeably higher graft survival rate when the patient had juvenile onset diabetes, when the donor was older than age 60 and when the donor was a spouse. 4. Most differences in graft survival rates between larger and all other centers were apparent only 2-3 years after transplantation, suggesting that the differences reflect long-term management of the patients or that an historical difference existed that has disappeared in recent years.

Black or African American↗
PubMed1998

Deleterious effects of delayed graft function in cadaveric renal transplant recipients independent of acute rejection.

BACKGROUND: In cadaveric renal transplantation, delayed graft function (DGF) correlates with poor long-term graft survival; however, whether its effects are independent of acute rejection is controversial. We wished to study the effect of DGF on graft survival, controlling for acute rejection, discharge creatinine, and human leukocyte antigen match. METHODS: We analyzed 27,096 first cadaveric donor renal transplants reported to the UNOS Scientific Renal Transplant Registry between January 1994 and November 1997. DGF was defined as dialysis need in the first week. Acute rejection was recorded for initial hospitalization and within 6 months. Kaplan Meier survival curves were analyzed with the log rank test. RESULTS: DGF increased the incidence of acute rejection before discharge (8% without DGF; 25% with DGF, P<0.01) and any acute rejections by 6 months (25% without DGF, 42% with DGF, P<0.01). Without early rejection, DGF reduced 1-year graft survival from 91 to 75% (P<0.0001) and graft half-life from 12.9 to 8.0 years. In kidneys with acute rejection within 6 months, DGF decreased 3-year graft survival from 77 to 60% and graft half-life from 9.4 to 6.2 years (P<0.001). With a discharge creatinine of less than 2.5 mg/dl, the difference in graft half-life between no DGF and no rejection (13.4 years) and DGF with rejection (9.8 years) was significant (P<0.001). Increased donor age and cold ischemia time additionally decreased graft survival, whereas a good human leukocyte antigen match could not overcome the deleterious effects of DGF or acute rejection. CONCLUSIONS: DGF is an important independent predictor of poor graft survival. Newer immunosuppressive strategies must minimize nonimmune and immune renal injury if long-term graft survival is to improve.

Acute Disease↗
PubMed1998

Effects of changes in the criteria for nationally shared kidney transplants for HLA-matched patients.

BACKGROUND: Nine years ago, a prospective trial began in all U.S. transplant centers to determine whether the results of renal transplantation would improve with the nationwide shipment of kidneys from cadaveric donors to HLA-matched patients. Since then, the stringency of criteria for HLA matching have been liberalized twice, from sharing only those kidneys that matched at all six HLA-A, -B, -DR antigens, to sharing phenotypically HLA-matched kidneys, and most recently to sharing zero HLA-mismatched kidneys. METHODS: Data reported to the United Network for Organ Sharing Scientific Renal Transplant Registry from October 1987 to December 1996 were analyzed to examine the transplant results of nationally shared HLA-matched kidneys and the effects of changes to the HLA matching criteria on graft survival and the distribution of HLA-matched kidneys. RESULTS: The overall 1-year graft survival rate of 5102 HLA-matched transplants was 88% compared with 81% for 58,207 recipients of kidneys with at least one HLA mismatch (P < 0.001). HLA-matched kidneys had a projected 12-year graft half-life, 50% higher than the 8-year half-life of mismatched grafts (P < 0.01). After the first change in the match criteria in August 1990, 1365 phenotypically matched kidneys with fewer than six HLA antigens identified had an 89% 1-year graft survival rate compared with 84% for 466 six antigen-matched kidneys transplanted before the change. After March 1995, 1067 zero HLA-mismatched kidneys that were not phenotypically identical nor six antigen matched, had a 1-year graft survival rate of 88%. Graft survival has not decreased as a result of these changes in the criteria for national sharing, despite an increase in the percentage of matched transplants from 2.5% during the six antigen-match era to 15.5% during the zero antigen-mismatch era. CONCLUSIONS: Changes to the United Network for Organ Sharing policy for national sharing of HLA-matched kidneys have increased the number of patients, and especially minority patients, who can benefit by receiving a well-matched graft without compromising the high graft survival rates provided by an HLA-matched kidney.

Cadaver↗