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J M Cecka

Publications and source records attributed to J M Cecka.

At least 55 records · Page 3Linked to original sources
PubMed1996

Patient death after renal transplantation--an analysis of its role in graft outcome.

Whether patient deaths among renal transplant recipients should be counted as transplant failures when they occur while the transplant is still functioning is a controversial issue. Analyses of more than 45,000 first cadaver transplants reported to the UNOS Scientific Renal Transplant Registry between October 1987 and March 1995 showed that deaths among transplant recipients were strongly associated with the patient's age and presence of insulin-dependent diabetes. Other factors associated with poor early graft function were also associated with a significantly increased risk of death. Deaths within the first 5 years increased from 9% of recipients aged 2-15 to 30% of those over age 45 (P < 0.001). Deaths with a functioning graft occurred in 2% of the youngest patients and 13% in the older age group (P < 0.001). Among diabetics, 32% died within 5 years (12% with a functioning graft) compared with 10% (6% with graft function) of patients with glomerulonephritis (P < 0.001). When the transplanted kidney failed to function immediately or the patient required dialysis during the first week after transplant, 30% of patients died within 5 years compared with 20% when the graft functioned (P < 0.001). There was no difference in the percentage of deaths with a functioning graft. We conclude that deaths among renal transplant recipients follow an expected pattern in which the likelihood of death increases with age and diabetes.

Adolescent↗
PubMed1996

The liver neither protects the kidney from rejection nor improves kidney graft survival after combined liver and kidney transplantation from the same donor.

It has been proposed that the liver protects a simultaneously transplanted kidney from acute rejection. Using the United Network for Organ Sharing database, we compared the kidney allograft data from 248 combined liver and kidney transplants (LKT) with a control group comprising 206 contralateral kidney alone transplants (KAT) from the same donor. The LKT and KAT groups were identical with respect to most baseline parameters, save a greater degree of HLA matching in the KAT group. The overall 3-year graft survival rate was higher in the KAT group compared with the LKT group (80% vs 68%, P < 0.01). When these data were censored to remove death as a cause of graft loss and to minimize the matching effect, the 3-year survival rates were not statistically different (78% for KAT and 81% for LKT, P = NS). We conclude that the liver neither protects the kidney from rejection nor improves kidney allograft function or survival after LKT.

Adult↗
PubMed1996

The UNOS Scientific Renal Transplant Registry.

1. One-year graft survival rates for recipients of cadaver kidney transplants improved from 75% in 1988 to 83% in 1991 (p < 0.001). The one-, 5-, and projected 10-year graft survival rates for cadaver donor transplants performed in 1991-1995 were 84%, 60%, and 43% respectively. 2. One-year graft survival rates for recipients of living donor transplants also improved from 89% in 1988 to 93% in 1991 (p < 0.001). The one-, 5-, and projected 10-year graft survival rates for living donor kidney transplants performed in 1991-1995 were 92%, 75%, and 62% respectively. 3. Diabetic patients received one-quarter of the cadaver kidneys transplanted from 1991-1995 and one third of diabetic patients received a simultaneous pancreas (SPK) transplant. One- and 5-year graft survival rates were 81% and 54% for diabetics receiving a kidney transplant and 85% and 67% for SPK recipients, respectively. Patient survival was 10% lower for recipients of a kidney only transplant. 4. Sensitization to alloantigens, whether by pregnancy, transfusion, or graft failure resulted in about a 5% increased risk of early graft failure. Patients who developed broadly reactive anti-HLA antibodies before their first transplant had the same 5-year graft survival rate (60%) as unsensitized patients. Retransplanted patients who had not developed broadly reactive antibodies also had a 60% 5-year graft survival rate, compared with 50% for those with > 50% PRA. 5. Blacks received one-quarter of cadaver kidneys transplanted in 1991-1995. The one-year graft survival rate for Black first transplant recipients was 83% compared with 84% for Whites. After the first year, the graft loss rate among Blacks was almost double that for other racial groups (5.8 year half-life vs 11.3 years for Whites, p < 0.01). The 5-year graft survival rate was 49% among Blacks and 63% for Whites. Asian recipients had the highest one- and 5-year graft survival rates (89% and 70%, respectively). 6. Shared kidneys had a longer average cold ischemia time (30 hr) than kidneys transplanted locally (21 hr). Fewer than half of shared kidneys were transplanted to HLA-matched recipients. The 5-year graft survival rate for shared kidneys with zero or one HLA antigen mismatched was 68% compared with 59% for shared kidneys with more than 3 antigens mismatched and for locally transplanted kidneys (p < 0.001). 7. The distribution of living donor relationships has changed substantially. When comparing transplants performed in 1988-1989 with those performed in 1994-1995, the number of living donor transplants increased by 80%, the fraction of offspring-to-parent grafts increased from 9-15%, the fraction of genetically unrelated donors increased from 4-10%, and the fraction of distant relatives increased from 2-6% of the living donor transplants. 8. The results of living donor transplants generally followed the degree of HLA compatibility. The one-year survival rate for HLA-identical sibling grafts was 96%, followed by 92% for one-haplotype matched sibling, parent and offspring donor transplants, 90% for unmatched sibling donors and 88% for spousal donors. Other unrelated donor transplants had a slightly higher one-year graft survival rate of 92%, which was more similar to the one-haplotype matched grafts.

Black or African American↗
PubMed1996

Immunosuppressive regimens and their effects on renal allograft outcome.

The distribution and effectiveness of different immunosuppression protocols among recipients of first cadaver donor renal transplants reported to the UNOS Scientific Renal Transplant Registry whose graft survived at least 14 days after transplantation were analyzed. The results showed that between 1988-1993, 50-60% of recipients received triple therapy regimens including cyclosporine, azathioprine and prednisone (CAP). An additional 20% received CAP with antibody induction therapy (OKT3 or ALG). After 1993, there was an increase in the use of other drug combinations which include FK506 and, more recently, Neoral and mycophenylate mofetil. Patient survival was 90% at 3 years regardless of the immunosuppressive protocol. The 3-year graft survival rate was 75% under cyclosporine-based protocols, but was 79% for more recent recipients treated with FK506 (p = 0.015). Antibody induction protocols were not used more frequently for high-risk patients, including those with broadly reactive anti-HLA antibodies, pediatric recipients, transplants with delayed graft function and those with prolonged cold ischemia times. When induction therapies were reported for these higher risk transplants, there was no noticeable improvement in graft survival rates after excluding failures within the first 2 weeks. Any benefit of antibody induction must therefore be manifest with the first 2 weeks after transplantation. Induction protocols significantly reduced the incidence of rejection episodes (prior to hospital discharge) from 31% for those treated with CAP to 12% for those with antibody induction (p < 0.01), however, 24% of those given induction had at least one rejection between discharge and 6 months compared with only 18% of those treated with CAP without induction (p < 0.01). Although graft outcomes might be significantly influenced by the dosing and timing of immunosuppressive drugs, among the different combinations of drugs analyzed, only FK506 resulted in improved graft survival and half life. With the rapid proliferation of newer drugs and immunosuppressive strategies during 1996, it will be interesting to follow the course of these very recent transplants with regard to the effectiveness of changing immunosuppression.

Cadaver↗
PubMed1996

Immune responsiveness and renal transplantation.

Children and young adults produce lymphocytotoxic antibodies in response to blood transfusions more frequently than older patients. Young transplant recipients also have a higher incidence of rejection episodes, which lends support to the concept that young age is associated with a state of heightened immune responsiveness to alloantigens. Heightened immune responsiveness, however, does not explain the lower graft survival reported for Black transplant recipients. Black recipients have an increased rate of DGF, whose origin remains to be elucidated.

Adolescent↗
PubMed1996

HLA matching.

1. HLA matching exerts a profound influence on graft outcome. The difference in 3-year graft survival rates between best and worst matched cases was 17% for first grafts and 18% for retransplants. This HLA matching effect persists despite recent improvements in graft outcome. The matching effect at 3-years was 12% for transplants since 1991. 2. Surprisingly, HLA matching is especially important for recipients over age 60. The increase in the HLA matching effect to 20% in patients older than 60 can be attributed to the additive effects of HLA matching on both functional and patient survival. Consequently, graft survival for zero-MM recipients is similar for patients older and younger than age 60. 3. The difference in 3-year survival between zero and 0-MM kidneys was 10% for White and 15% for Black recipients. 4. Transplants with zero-broad but split A,B mismatches had graft outcomes similar to one-A,B,DR MM kidneys. Split DR MM did not affect the outcome of zero-MM kidneys. 5. HLA-matched transplants can be classified according to the degree of identity between the donor and recipient: 6-antigen match, phenotypic match, and zero-MM. Outcome for zero-MM was lower in transplants before 1990, but the 3 types have similar outcomes in recent transplants. The change in UNOS matching policy in 1995 to include zero-MM kidneys doubled the number of shared kidneys. 6. HLA typing from over 150 centers resulted in an error rate for shipped kidneys of less than 5%. Donor antigens retyped at the recipient center resulted in identical antigens for 70% of cases, a broad DR MM for 2.2%, and an A,B MM in 2.6% of the retyped cases. 7. Although increasing cold ischemia time (CIT) had a deleterious effect on survival of MM kidneys, no effect was seen for zero-MM kidneys. 8. An effect of a possible sex-linked minor histocompatibility antigen was demonstrated with improved outcome for male to male zero-MM cadaveric and parent-to-child transplants. 9. Zero-MM kidneys from pediatric donors and donors older than 60 years of age had poorer outcome than MM kidneys before 1991, but the recent experience shows a matching effect even with these marginal donors.

Adult↗
PubMed1996

Organ Procurement Organization and transplant center effects on cadaver renal transplant outcomes.

1. A majority of transplant centers had significant improvements in cadaver donor kidney graft survival rates since 1991. A 10% or greater increase in one-year graft survival rates was reported by 36 of 128 large transplant centers. 2. When transplants were grouped according to the organ procurement agency that procured the kidney, large variations in one-year graft survival rates among 65 OPOs were noted. The "OPO effect" was of a magnitude similar to that of the "center effect" when analyzed separately. 3. Fourteen OPOs with the lowest graft survival rates procured a significantly higher fraction of kidneys from older, hypertensive or Black donors and donors whose deaths were not from motor vehicle accidents. Transplants were more often given to Black recipients, and kidneys were less frequently shared compared with 15 OPOs with the highest graft survival rates. 4. Significantly higher proportions of non-Black donors and recipients, patients with no activity limitation at the time of listing, patients working fulltime at the time of transplantation, and patients on dialysis less than one year were more frequently transplanted at 21 centers with excellent one-year graft survival rates compared with centers in groups with poorer results. 5. Increased numbers of mismatched HLA-B,DR antigens were detrimental to graft survival at centers with good or fair one-year graft survival rates, but had a minimal effect at centers with excellent results. 6. The OPO effect on graft survival rates was significantly associated with the center effect. Kidneys procured by OPOs associated with low graft survival rates and transplanted at centers with low graft survival rates resulted in the worst graft outcome. Interestingly, kidneys procured by OPOs associated with high graft survival rates, but transplanted by centers with low graft survival rates had better outcomes than kidneys from OPOs with lower graft survival rates. 7. Based on univariate analyses, the center and OPO effects ranked third and fifth among 16 significant factors. However, after adjusting for these 16 potentially confounding variables using a multivariate Cox regression model, the differences between the best and worst center and OPO groups were the fourth and eleventh most detrimental risk factors on graft outcome, respectively.

Adolescent↗
PubMed1996

Risk rate and long-term kidney transplant survival.

The findings from the UNOS Scientific Renal Transplant Registry are summarized in the following table. We've also provided our opinions on ways to influence the risk factors in the Discussion section. [table: see text]

Adolescent↗
PubMed1995

The relative effects of FK506 and cyclosporine on short- and long-term kidney graft survival.

As reported to the UNOS Kidney Transplant Registry from 1988 through 1994, 544 first cadaveric kidney graft recipients have been discharged with maintenance tacrolimus (FK506) therapy. Total follow-up data was available on 38,057 first cadaveric kidney transplants from 224 centers reporting at least 10 grafts each to the Registry. We examined the effects of FK506 on short- and long-term renal graft outcomes and compared its effect with that of cyclosporine (CsA). Three drug categories (FK506, CsA, and Other) were defined using therapies through discharge (i.e., grafts surviving more than 15 days). The 1-year graft survival rate of 2366 recipients receiving Other therapies was 69.2 +/- 1.0%. By comparison, both FK506 and CsA recipients demonstrated significantly improved early graft function (1-yr survival rates of 91.1 +/- 1.3% and 86.6 +/- 0.2%, respectively). The long-term graft survival, as measured by half-lives, varied little (8-9 yr) between Other and CsA groups, but was significantly (P = 0.04) increased for FK506 patients (to approximately 14 yrs). CsA usage was reported by all 224 transplant centers, whereas FK506 was administered at only 24 (11%) centers. Using multivariate methods, a drug regimen's graft survival rate was adjusted for center effects and 19 covariates. The adjusted FK506 and CsA cadaveric graft survival rates at 1 and 3 years mirrored their unadjusted rates, indicating that demographic differences did not confound our results. Based on this study, FK506 appears to be the first therapeutic agent to significantly improve long-term kidney graft survival rates.

Adult↗
PubMed1995

High survival rates of kidney transplants from spousal and living unrelated donors.

BACKGROUND: In the United States, increasing numbers of persons are donating kidneys to their spouses. Despite greater histoincompatibility, the survival rates of these kidneys are higher than those of cadaveric kidneys. We examined the factors influencing the high survival rates of spousal-donor kidneys. METHODS: Kidney-transplant data from the United Network for Organ Sharing Renal Transplant Registry were used to calculate graft-survival rates with Kaplan-Meier analysis. RESULTS: The three-year survival rates were 85 percent for kidneys from 368 spouses, 81 percent for kidneys from 129 living unrelated donors who were not married to the recipients, 82 percent for kidneys from 3368 parents, and 70 percent for 43,341 cadaveric kidneys. The three-year survival rate for wife-to-husband grafts was 87 percent, which was the same as for husband-to-wife grafts if the wife had never been pregnant. If the wife had previously been pregnant, the three-year graft-survival rate was 76 percent (P = 0.40). The three-year graft-survival rate among recipients of spousal grafts who did not receive transfusions preoperatively was 81 percent, as compared with 90 percent for recipients who received 1 to 10 transfusions preoperatively (P = 0.008). The superior survival rate of grafts from unrelated donors could not be attributed to better HLA matching, white race, younger donor age, or shorter cold-ischemia times, but might be explained by damage due to shock before removal in 10 percent of the cadaveric kidneys. CONCLUSIONS: Spouses are an important source of living-donor kidney grafts because, despite poor HLA matching, the graft-survival rate is similar to that of parental-donor kidneys. This high rate of survival is attributed to the fact that the kidneys were uniformly healthy.

Adolescent↗
PubMed1995

The UNOS scientific renal transplant registry. United Network for Organ Sharing.

Overall one-, 5-, and projected 10-year graft survival rates were 81%, 58% and 39%, respectively for 51,442 cadaveric kidney transplants performed at 251 U.S. transplant centers from October 1987-December 1994. The comparable results for recipients of living donor kidneys were significantly higher, 91%, 75%, and 60% (p<0.001). One-year first cadaver graft survival rates improved from 77% for transplants performed in 1987-1988 to 84% for transplants performed in 1991-1992 (p<0.001). Recipients of second cadaveric transplants in 1987-1988 had a 69% one-year graft survival rate compared with 81% for those transplanted after 1990 (p<0.001). Graft survival rates have been stable since 1991. The percentage of broadly sensitized first transplant recipients decreased from 13% before 1991 to 7% after, and the one-year graft survival rates increased by 4-6% for both sensitized and nonsensitized recipients between the 2 periods (p<0.001). Among retransplanted patients, the percent of broadly sensitized recipients fell from 40-33% over the same periods (p<0.01). One-year graft survival rates increased by 7-8% for sensitized and nonsensitized patients (p<0.001). One-year graft survival rates improved from 74-83% for Blacks (p<0.001) and from 78-85% for non-Blacks (p<0.001) transplanted for the first time when comparing transplants performed in 1987-88 with those performed in 1993-94. The cause of donor death had a significant effect on graft survival. The 5-year graft survival rate was 61% for 28,923 recipients of trauma donor kidneys compared with 54% for 16,956 transplants from CVA donors (p<0.001). Kidneys from CVA donors increased from 28% of all cadaveric kidneys in 1988 to 38% in 1994. The donor's age was a more important determinant of long-term survival, however, and correlated strongly with the cause of donor death. Only 16% of CVA donors were reportedly age 30 or less, compared with 75% of trauma donors. First cadaver graft survival decreased by approximately 2% for each 12 hours of cold ischemia time. Although there was a significant increase in the incidence of delayed graft function from 19% when the CIT was less than 12 hours to 35% when the CIT was more than 36 hours, there was no significant long-term effect of cold ischemia time. The recent change in UNOS policy to share zero-HLA mismatched kidneys resulted in a 2-fold increase (from 8%-16%) in the number of HLA-matched transplants performed during the first 6 months following the change. The percentage of Blacks who have received matched kidneys following this change has increased from less than 2% to more than 5%, a 3-fold increase. The 163 Blacks who received an HLA-matched kidney prior to 1995 had a 65% 4-year graft survival rate compared with 53% for mismatched Blacks (p<0.001). The incidence of early rejections was also reduced by 25% among matched recipients and the graft half-life was 8 years compared with 5 years for mismatched Blacks. About 25% of HLA-matched kidneys were transplanted to ABO compatible but not identical recipients. Although the effect of the policy allowing compatible transplants did not result in a large number of type O kidneys transplanted to non-O recipients when only 8% of kidneys were shared, the recent change in allocation policy may be detrimental to type O waiting patients.

Adolescent↗
PubMed1995

Living donor transplants.

The number of living donor transplants reported to the UNOS Scientific Renal Transplant Registry has increased from 1,810 in 1988 to 2,861 in 1994. Nearly all 250 United States transplant centers have reported living donor transplants. Graft survival rates were uniformly high for recipients of living donor transplants. One- and 5-year survival ranged from 95% and 84% for 3,653 HLA-identical sibling transplants to 89% and 69% for 1,981 offspring-to-parent transplants. Transplant half-lives ranged from 10 years for 360 transplants from nonspouse unrelated donors to 22 years for 3,653 transplants between HLA-identical siblings. These half-lives were significantly better than the 9 year half-lives projected for cadaveric grafts (p<0.01). The 282 second transplants from HLA-identical sibling donors had one- and 5-year survival rates of 94% and 80%, respectively, which were not significantly different than those of first grafts. The 1,005 retransplants from HLA-mismatched living donors had one- and 5-year survival rates of 88% and 69%, respectively, 2% below the survival rate for first transplants (p=0.026). The one- and 5-year graft survival rates for 1,932 zero-HLA haplotype matched living donor transplants were 89% and 73%, respectively, and the half life was 13.6 years. These results were comparable to those for parent donor transplants. Although the graft survival rates were similar regardless of the donor's relationship to the recipient, the causes of graft failure differed. About 48% of graft failures among parents who received a kidney from their offspring were deaths with a functioning graft. Only 12% of failures among parent-to-offspring transplants were deaths. One- and 5-year graft survival rates were 85% and 57%, respectively, for Black recipients of parent donor kidneys, and were 95% and 68%, respectively, for Blacks with an HLA-identical sibling donor transplant. The results were higher for comparable Whites: 91% and 73% for parental, and 95% and 86% for HLA-identical sibling grafts, respectively. HLA-mismatched transplants to 656 broadly sensitized recipients resulted in 83% and 62% one- and 5-year graft survival rates, respectively. The comparable results for those with less than 50% PRA were 91% and 73% (p<0.001). Pretransplant blood transfusions did not result in improved graft survival, nor in a reduced incidence of early rejection episodes. Information was not available to distinguish between donor-specific and random donor transfusions. The oldest living donor was aged 76, and 404 donors were over age 60. The one- and 5-year survival rates were 86% and 61%, respectively, for donors over age 60. The comparable results for younger donors were 90% and 72% (p=0.005).

ABO Blood-Group System↗