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PubMed2004

Pushing the envelope in renal preservation; improved results with novel perfusate modifications for pulsatile machine perfusion of cadaver kidneys.

INTRODUCTION: Novel preservation techniques may diminish ischemia/reperfusion (I/R) injury. Our preservation laboratory has modified Belzer MPS for machine perfusion (MP) with prostaglandin E1 (PGE 1), nitroglycerin (NTG), and polyethylene glycol-superoxide dismutase (PEG-SOD) to attenuate I/R injury. We reviewed our recent experience using this novel formulation (NF) compared with standard perfusates. RESULTS: Between January 1998 and March 2000, 1060 consecutive kidneys were preserved in our laboratory. One hundred forty-eight kidneys (14%) were discarded. Fifty-eight percent of kidneys during this time period underwent MP (n = 532). En bloc kidney pairs were randomly assigned to pulsatile MP using Waters RM3 or MOX-100 perfusion systems using 1 of 3 perfusates; NF (NF; n = 119), Belzer MPS (MPS; n = 201), or Belzer II albumin gluconate (ALB; n = 212) Significant improvements in delayed graft function (DGF) rate were seen with NF versus other perfusates (8% vs 14% vs 19%, respectively; P =.03). At 6 months, graft survival was significantly improved with NF compared with MPS and ALB (96% vs 90% vs 87%, respectively; P =.03). NF also produced a significantly higher percentage of recipients with a serum creatinine level < or = 1.5 mg/dL. CONCLUSIONS: Novel modifications of standard MP perfusate improved outcomes after renal transplantation. Preservation-based interventions targeted to ameliorate I/R injury can improve outcomes and may allow expansion of the donor pool.

Adult↗
PubMed2004

Initial experience with laparoscopic donor nephrectomies.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) is being adopted rapidly by transplant centres around the world as it offers less postoperative pain, quicker convalescence, and better cosmetic result when compared with the open approach. There may, however, be a steep learning curve with this technique. METHOD: A retrospective review was performed to evaluate the donor morbidity and graft outcome of 21 consecutive LDN performed at one centre between May 2002 and August 2003. RESULTS: Eighteen LDN were performed on the left and three on the right side. All left and one right LDN were done transperitoneally while the remaining two right side kidneys were removed by a retroperitoneal approach. The mean (+/-SD) operating time and warm ischemic time were, respectively, 236 minutes (+/- 46) and 4 minutes (+/- 1). The mean time for resuming oral intake was 23 hours (SD +/- 22.7). The median length of hospital stay was 5 days (range 3 to 18). One patient was reoperated for bleeding and required four units of packed cell transfusion. One recipient displayed delayed graft function requiring dialysis for 14 days. There were no graft losses. The mean creatinine of the recipients at the time of discharge was 1.15 mg/dL (+/- 0.21). CONCLUSIONS: There is undoubtedly a learning curve with LDN. Nevertheless, with prior skills in similar procedures such as laparoscopic radical nephrectomies, it is feasible to diminish the learning curve and morbidity of LDN to yield results consistent with those in the published literature.

Graft Survival↗
PubMedDate not supplied

Cardiovascular disease and/or elderly donors in renal transplantation: the outcome of grafts and patients.

Kidney transplant programs nowadays increasingly use elderly, hypertensive and cardiac disease donors (expanded criteria donors). The impact of these donors on patient and graft outcome was investigated in our transplant population. Among 257 consecutive cadaveric kidney transplants, 56 were from expanded criteria donors. The frequency of anuria, delayed graft function, and the days of renal failure were higher using organs from the expanded criteria donor group. Serum creatinine was higher in this group, although the statistical significance disappeared at 36 months. There were no significant differences in graft or patient survival during the first 3 years. The use of expanded criteria donors should not be discouraged, but recipient selection and immunosuppression use should be adapted and cold ischemia minimized.

Age Factors↗
PubMed2004

Non-heart-beating donation: current state of the art.

The use of non-heart-beating donors (NHBD) helps us to deal with the problem of the organ shortage. In addition to difficulties with legal and ethical acceptability, there are concerns regarding medical safety, which prevent the widespread use of these donors. To make optimum use of this potential organ supply, the ischemic injury that occurs after a period of warm ischemia needs to be reversed. To minimize the warm ischemia time, once the subject is declared dead, most centers commence in situ cold perfusion via a femoral access or a rapid aortic cannulation. This usually occurs within minutes of arriving at the emergency department, before the next of kin have been notified of the patient's death. The European experience of kidney transplantation from NHBD shows promising results. The long-term outcomes are similar to HBD kidneys notwithstanding a higher rate of delayed graft function, which seems not to affect the long-term survival of these kidneys. In summary, NHBD may have an important impact on the large discrepancy that exists between the organ supply and the demand. Current data suggest that the results may be further improved by better patient selection and retrieval team organization.

Graft Survival↗
PubMed2004

Graft survival analysis in kidney transplantation: a 12-year experience in a Thai medical center.

INTRODUCTION: To analyze graft survival and to find the factors that influence survival in kidney transplantation recipients, we performed an analytic retrospective study. METHODS: A retrospective analysis was undertaken on records of all patients who underwent transplantation from December 25, 1990 to December 24, 2002. Survival studies were calculated using the Kaplan-Meier method. The outcome endpoints were death, redialysis, lost to follow-up, and study termination. RESULTS: One hundred thirty-eight operations (49 living-related kidney transplantations [LRKT] and 89 cadaveric kidney transplantations [CDKT])were recruited. Age of patients was 39.9 +/- 9.8 years (range, 9-57 years). The male to female ratio was 1.9:1. The waiting time was 24.25 +/- 25.2 months. Only 9 recipients had diabetes mellitus. The graft survival rate of the cadaveric group was slightly higher than the living related group: 90.65% vs 87.48%, 88.97% vs 85.05%, 83.04% vs 79.72%, and 76.65% vs 67.78% at 1, 2, 3, and 4 years, respectively (P = .94). Age, sex, waiting time, modality of dialysis, diabetes mellitus, ischemia time, HLA-mismatch, 2 DR-mismatch, delayed graft function (DGF), and body mass index (BMI) had no influence on graft survival. Acute rejection had a negative influence on graft survival in both the LRKT group (P = .09) and the CDKT group (P = .015). Patients who received cyclosporine (CSA), prednisone (Pred), and mycophenolate mofetil (MMF) showed better graft survival than ones on CSA, Pred, and azathioprine (Aza) (P = .18). CONCLUSION: There was no significant difference in graft survival between the LRKT and CDKT groups. In this study, only acute rejection was demonstrated to have negative influence on survival rates in CDKT. The timing of transplantation may play a major confounding factor on the results.

Adult↗
PubMed2004

The role of anti-IL-2 receptor in high-risk kidney transplant patients.

UNLABELLED: Anti-IL-2 receptor has been proved to be effective in reducing the rate of acute rejection in kidney transplantation and also improving both the rate of graft and patient survival. In this study, we retrospectively review the role of anti-IL-2 receptor as induction immunosuppression in immunologically high-risk kidney transplant patient compared with normally low-risk patients. METHODS: From January 1999 to December 2002, we performed 246 kidney transplantations in two transplant centers in Bangkok. These were divided into two groups: group 1, high-risk group containing 50 patients who had one of the following criteria: (1) high panel reactive antibody (>50%); (2) retransplantation; (3) marginal donor (with expectancy of delayed graft function); (4) spouse donor; (5) >4 HLA mismatch. All group 1 patients receive anti-IL-2 receptor as induction immunosuppression (either Basiliximab (n = 27) or Daclizumab (n = 23).) Group 2 consisted of the control group of 196 patients with normal immunological risk. The following data of both groups were collected and analyzed: patient demography, type of donor, acute rejection incidence, severity, and time. RESULTS: In this study, the anti-IL-2 receptors are 27 cases of Basiliximab and 23 cases of Daclizumab. The rates of acute rejection are not significantly different in both groups, namely, 46 of 194 (23.7%) in group 2 compared with 10 of 50 (20%) episodes in group 1 (P = .602). All rejections in both groups responded to pulse steroid treatment. The mortality rate and rate of graft failure were also not significantly different, i.e., 6 of 196 (3.1%) vs 2 of 50 (4.0%) (P = .666) and 7 of 196 (3.6%) vs 3 of 50 (6.0%) (P = .429) in low risk group versus high risk group, respectively. Kaplan-Meier estimates of the probabilities of acute rejection free, patient survival rate, and graft survival rate also showed no difference between groups. CONCLUSIONS: The use of anti-IL-2 receptor antibodies as induction immunosuppression in immunologically high-risk patients results in the same rate of acute rejection, severity of acute rejection, graft survival, and patient survival as recipients with normal immunological risk.

Antibodies, Monoclonal↗
PubMed2004

Laparoscopic donor nephrectomy: new combination of hand-assisted and standard approaches.

BACKGROUND: Although laparoscopic live donor nephrectomy (LLDN) was conceived to decrease morbidity and reduce donor disincentives, it requires considerable experience. We present a new combination of hand-assisted and standard laparoscopic approaches to live donor nephrectomy. METHODS: Between March 2002 and February 2003, ten LLDNs were performed with the new procedures. Using the new methodology the surgeon can withdraw his hand and insert a trocar through the hand-assisted device whenever he desires. Although the hand-assisted procedure was performed in most patients, we attempted to dissect the renal hilum without hand assistance in the final patient, successfully procuring the kidney. RESULTS: Mean operation time was 245 minutes and warm ischemic time was 179 seconds. No vascular, renal parenchymal, or ureteral injuries occurred. The patient with multiple left renal arteries had a longer warm ischemic time and delayed graft function. Mean predonation creatinine was 0.97 mg/dL, it increased to 1.44 and 1.15 mg/dL at 7 days and 3 months postdonation, respectively. One patient had chylous ascites and another had a transient left brachial plexus paralysis. CONCLUSIONS: Both pure laparoscopic and hand-assisted LLDN have advantages and disadvantages. In our modification, the free conversion from hand-assisted to a purely laparoscopic approach allows the surgeon to practice two procedures simultaneously. With this combination, 90% of the LLDN were accomplished, with pure laparoscopy in the last case.

Humans↗
PubMed2004

Microscopic examination of the urine helps to confirm the recovery of acute tubular necrosis after cadaveric renal transplantation: a case report.

INTRODUCTION: Delayed graft function due to acute tubular necrosis (ATN) is frequently seen in kidney transplants from non-heart-beating donors. However, only a biopsy can be used to assess the severity of ATN. Therefore, we studied the validity of microscopic findings in tubular epithelial cells (TECs) from urine as a means to monitor ATN. MATERIALS AND METHODS: The first voided urine in the morning was examined for the appearance and nuclear cytoplasmic (N/C) ratio of the TECs, using a murine staining with URO-3 monoclonal antibody to detect proximal tubular cells (PTCs). CASE: A 58-year-old man underwent cadaveric kidney transplantation in January, 2003 using tacrolimus, mycophenolate mofetil, and prednisone following basiliximab induction therapy. His graft did not function immediately; needle biopsy was performed on day 17. The pathological findings showed severe ATN without evidence of acute rejection. A large quantity of TECs was seen in his urine between days 7 and 14. After day 28, TECs with a large N/C ratio and that were URO-3 antibody-positive were detected. Urine volume increased gradually and hemodialysis was not necessary after day 36. CONCLUSION: The presence of URO-3-positive TECs with large N/C ratios suggests the reconstruction of PTCs. Therefore, it may be useful to monitor TEC findings to assess the severity ATN after cadaveric kidney transplantation.

Biopsy, Needle↗
PubMed2004

Risk factors on graft survival of living donor kidney transplantation.

UNLABELLED: Living donors have always been the basic resources of transplantation in our country, where cadaveric harvesting is still hampered for various reasons. OBJECTIVE: The aim of this study was to compare graft survival rates between living unrelated donor (LURD) and living related donor (LRD), to assess the potential risk factors for the graft survival, and to discuss the role of LURD. METHOD: From October 1991 to February 2003, 77 living donor renal transplants were performed: 41 were LURD and 36 were LRD transplants. The analyzed variables were donor relationship, recipient age and sex, donor age and sex, HLA-DR mismatching, nonspecific blood transfusion history of donor, acute rejection episodes, repeated rejection episode (more than 3 times), delayed graft function, recurred primary disease, and immunosuppressive regimen. Graft survival rate was assessed with the Kaplan-Meier method and the significance of possible variables with the Cox proportional hazard model. RESULTS: Eleven recipients lost their grafts (6 from LURD and 5 from LRD), most of them are due to chronic rejection (n = 7). Overall 3-, 5- and 10-year graft survival in live donors were 92.8%, 86.6%, and 76.9%, respectively. Graft survival at 3, 5, and 10 years being 91.9%, 88.5%, and 74.7% for the LURD versus 94%, 84%, and 78.8% for LRD transplants (P > .05). Acute rejection episodes, especially more than 3 times (risk ratio [RR] = 11.1) and preoperative multiple transfusion history (RR = 4.2) were significant factors on graft survival in our series. CONCLUSION: Acute rejection episodes markedly decreased the long-term graft survival in live donor renal transplants. The use of LURD transplants provides graft survival comparable with LRD transplants and proper management to acute rejection is essential for long-term graft survival.

Adult↗
PubMed2005

Relationship between donor factors, immunogenic up-regulation, and outcome after kidney transplantation.

Epidemiological data show that the cause of brain death as well as the condition of the organ donor have considerable influence on the outcome of kidney transplantation. An early immunogenic up-regulation, which already exists at the time of organ removal seems to be primarily responsible. So far it has remained unclear which donor factors cause this effect. In a prospective study of 37 organ donors a 0-hour biopsy was performed at the time of explantation to measure the expression of HLA-DR and endothelin-1 (ET-1) immunohistologically using the alkaline phosphatase anti-alkaline phosphatase (APAAP) method. The transplant outcome and the immunohistological results were correlated with various donor factors. Statistically significant correlations were seen with the following parameters: the donor serum creatinine prior to explantation correlated with the incidence of delayed graft function (DGF: 104 +/- 39 vs 78 +/- 35 micromol/L versus no DGF n = 37; P = .043). Early graft loss after transplantation correlated significantly with increased numbers of leukocytes as well as with decreased O2 saturation in the donor immediately before explantation (leucocytes: 16.7 +/- 6.8 vs 12.6 +/- 4.6/nL, n = 37; P = .036; O2 saturation: 94.1% +/- 6.9%, vs 97.7% +/- 2.3%, n = 37; P = .026). Further, donor-independent factors that correlated with acute rejections included cold ischemic time (P = .031), HLA mismatches (P = .028), and occurrence of DGF (P = .033). The degree of HLA-DR expression (range 0 to 2) correlated significantly with early graft loss (2.0 +/- 0.2 vs 1.33 +/- 0.9 for graft function, n = 37; P = .01) as well as the ET-1 expression with DGF (2.0 +/- 0.3 vs 1.5 +/- 0.7 versus no DGF, n = 37; P = .016). In summary, marginal donors should be seen as high immunological risk situations that need careful conditioning.

Biopsy↗
PubMed2004

Use of Hem-o-lok clips effectively lengthens renal vein during laparoscopic live donor nephrectomy.

We retrospectively reviewed our last 12 laparoscopic donor nephrectomies (LDNs) in which both the renal artery and the renal vein were controlled using 2 Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, United States) on the proximal sides and the vessels were divided without securing the graft-side vessels (group 1). We compared the results with our 12 immediately preceding LDN donors in whom the arteries were controlled with 3 endoclips and the veins were controlled with staplers (group 2). The length of the vein was significantly longer (approximately 4 mm difference) in group 1, mainly due to trimmed staples from the graft vessels. Both cohorts of donors had uneventful surgery with no complications, and all the recipients recovered smoothly without any delayed graft function. Average operation time and warm ischemia time were similar among both groups (189 vs 207 minutes; 168 vs 149 seconds, respectively; both P > .1). We conclude that the use of Hem-o-lok effectively lengthens graft renal veins and is less costly during LDN.

Adrenal Glands↗
PubMed2005

Technical modifications of laparoscopic donor nephrectomy: improved results with refinements in technique that mimic open nephrectomy.

INTRODUCTION: We have performed laparoscopic donor nephrectomy (lap Nx) since 2000. In June 2002, we modified the technique to minimize the known disadvantages of ATN and delayed graft function. We review our series of lap Nx before and after introduction of these modifications, respectively. METHODS: Four technical modifications of lap Nx were introduced following the initial previously described 28 cases (Group I) and applied to the consecutive 42 cases described herein (Group II): (1) decreasing the intra-abdominal pressure from 15 mm Hg to 8 mm Hg; (2) early dissection of the ureter and gonadal vein followed by vascular dissection (sharp and blunt using hydrodissection); (3) leaving the left gonadal vein in continuity with the left renal vein; and (4) early introduction of the Endocatch bag. RESULTS: Operative time was 276.6 +/- 67.1 min vs 210.0 +/- 38.0 min for groups I and II, respectively (P = .04). Warm ischemia was 4.9 +/- 1.9 min vs 1.5 +/- 0.9, min for groups I and II, respectively (P < .01). ATN occurred in 3/28 (10.7%) in group I vs 2/42 (4.8%) in-group II. There was one-vascular insult in the initial 5 Rt lap Nx, namely, transection of a segmental artery, that was reconstructed by bench repair without an impact on the outcome. Conversion was needed in 3/28 (10.7%) group I, but none of group II donors. CONCLUSION: The outcome of lap Nx can be significantly improved by applying technical modifications that simulate open Nx.

Abdomen↗
PubMed2005

Sirolimus delays recovery from posttransplant renal failure in kidney graft recipients.

The aim of this study was to evaluate the impact of sirolimus and cyclosporine (CsA) combined therapy on the incidence and duration of delayed graft function (DGF), and the impact of the latter on 1-year graft function. The study entailed 23 cadaveric renal recipients treated with sirolimus-CsA-prednisone regimen (sirolimus group). The reference group entailed 23 patients treated with CsA-azathioprine-prednisone. In the sirolimus group the frequency of DGF was 39% and was essentially the same as in reference group (34.8%). The duration of DGF was significantly longer in SRL group and lasted 21.2 +/- 12.2 days versus 6.8 +/- 2.5 in reference group (P = .004). Serum creatinine level decreased below 3.0 mg/dL after 36 +/- 22 days in sirolimus group versus 16.8 +/- 6 days in reference group (P < .04). Cold ischemia was slightly longer and donors were older in DGF patients in both groups. Sirolimus dose during first month was higher in DGF patients (3.5 versus 2.6 mg), whereas level of CsA was lower (230 versus 310 ng/mL). Biopsy-proven acute rejection (AR) occurred in most of DGF patients and during the DGF period. Serum creatinine level at the 12th month posttransplant was higher in DGF versus non-DGF patients (2.0 +/- 0.5 versus 1.5 +/- 0.4 mg/dL). One-year patient and graft survival was 100% in sirolimus group and 100% and 95% in reference group. In conclusion, sirolimus significantly retards the recovery from posttransplant renal failure; however, it does not increase the incidence of DGF. Patients who suffered from posttransplant acute renal failure had worse renal function at 1 year after transplantation, independent of the treatment protocol.

Adult↗
PubMed2005

Does pretransplant obesity affect the outcome in kidney transplant recipients?

UNLABELLED: The effect of obesity on renal transplant outcome remains unclear due to conflicting published studies. The purpose of this study was to assess whether obesity affects the outcome in renal transplant patients. METHODS: We retrospectively analyzed 33 obese (BMI >30; mean = 34.1 +/- 3.68; group I) and 35 nonobese (BMI < or = 30; mean = 23.6 +/- 3.18; group II) renal transplants performed at our center between March 1999 to December 2002. These two groups were well matched with respect to age, sex, donor source, hypertension, diabetes, ischemic heart disease, hyperlipidemia, native kidney disease (PCKD, 6 vs 4; diabetic, 5 vs 4; glomerulonephritis, 6 vs 7; FSGS, 2 vs 2 and IgA, 2 vs 7), HLA mismatch and immunosuppressants medications (Neoral, 21 vs 25; tacrolimus, 11 vs 10; Cellcept, 28 vs 31; Prednisone, 33 vs 35; ATG, 7 vs 8; Basiliximab, 14 vs 13 and Rapamycin, 5 vs 2, groups I and II, respectively). Follow-up was from 7 months to 4.4 years. RESULTS: Significant differences were noted in operating time, wound infection, perinephric hematoma, lymphocele, and number of hospital days. There were no significant differences between the two groups in the incidence of wound dehiscence, deep vein thrombosis, pulmonary embolism, atelectasis, urine leak, delayed graft function, acute rejection rate, and the following posttransplant variables: diabetes mellitus, myocardial infarction, hyperlipidemia, hypertension, and incisional hernia. We conclude that obesity significantly increases operating time, wound complications, and hospitalizations.

Adult↗
PubMed2005

Baseline glomerular sclerosis influences morphological changes, but not level of serum creatinine.

The aim of this study was to investigate whether glomerular sclerosis (GS) at the time of engraftment affects subsequent morphology and clinical course of renal allografts. Eighty-one renal transplant recipients were recruited for this study. Protocol biopsies of the renal allografts were performed at engraftment, as well as at 1, 3, 5, and 7 years after transplantation. All cases were divided into 2 groups based on the presence of GS at engraftment, namely, non-GS and GS groups. Morphological changes in the renal allografts were graded from 0 to 3+ based on the severity of chronic allograft nephropathy (CAN) of the Banff classification based on 5 factors: percentage of GS, extent of interstitial fibrosis, tubular atrophy, arterial intimal thickening, and arteriolar hyalinosis. Furthermore, the level of serum creatinine (s-Cr) at each year was examined by recipient age and gender, donor age and gender, type of donor (living/cadaver), delayed graft function, acute rejection within 1 year after transplantation, mean blood pressure, and use of calcineurin inhibitors as well as the presence of GS at engraftment. The extent of GS at engraftment significantly correlated with donor age (P = .0038) but with a weak correlation coefficient. Although the severity of CAN developed gradually in both non-GS and GS groups, differences in morphological changes at engraftment between the 2 groups persisted throughout 7 years. Donor age and recipient gender influenced s-Cr significantly. In conclusion, the presence of GS at engraftment aggravates subsequent morphological changes and affects short-term but not long-term allograft prognosis.

Adolescent↗
PubMedDate not supplied

Hepatic ischemia/reperfusion injury can be modulated with thymoglobulin induction therapy.

BACKGROUND: Thymoglobulin induction therapy has been shown to ameliorate delayed graft function and possibly decrease ischemia reperfusion injury in cadaver renal transplant recipients. This controlled randomized trial was designed to assess whether thymoglobulin also protects liver transplant recipients from ischemia reperfusion injury. PATIENTS AND METHODS: Twenty-two cadaver liver transplant recipients were randomized to receive either thymoglobulin (1.5 mg/kg per dose) during the anhepatic period and two doses every other day or no thymoglobulin. No differences in recipient or donor demographics were present. Maintenance immunosupression consisted of tacrolimus (or cyclosporine) and steroids for both groups. Donor biopsies were obtained during organ procurement, cold storage, and 1 hour after revascularization. Postoperative liver function tests were monitored. Early graft function, length of stay, patient and graft survival rates, incidence of primary nonfunction, and rate of rejection were assessed. RESULTS: Patient and graft survival at 3 months was 100%. There was no incidence of primary graft nonfunction and no need for retransplantation. The incidence of acute rejection was similar between the two groups. Although donor livers randomized to thymoglobulin had less optimal preimplantation biopsies, these recipients had significant decreases in ALT at day 1 compared to the control group (P = .02), near significant decreases of total bilirubin at day 5, and shorter length of hospitalization. CONCLUSION: Thymoglobulin allowed for more compromised liver grafts to be transplanted with less clinical evidence of ischemia reperfusion injury and improved function.

Antilymphocyte Serum↗
PubMed2005

Early corticosteroid withdrawal under modern immunosuppression in renal transplantation: multivariate analysis of risk factors for acute rejection.

UNLABELLED: Early corticosteroid withdrawal has been shown to be effective in low-risk patient populations in a number of US and European multicenter trials. However, patient populations traditionally considered to be at high risk for acute rejection (eg, African Americans, repeat transplant recipients, sensitized patients) are usually excluded from these trials. Since our initial experience with early withdrawal almost 10 years ago, we have included high-immunologic-risk patients. We have accumulated enough high-risk patients with early withdrawal to allow the first multivariate analysis of risk factors for acute rejection in early withdrawal under modern immunosuppression. METHODS: Early withdrawal was performed under prospective IRB-approved protocols. Statistical analysis included chi square test and logistic regression. All rejection episodes were biopsy proven and graded by Banff 1997 criteria. RESULTS: A total of 164 patients underwent early withdrawal: 82% had at least one mismatched DR antigen, 17% had delayed graft function, 33% were African American, and 18% were repeat transplant recipients. Multivariate analysis of risk factors for acute rejection indicated that two factors induced a statistically significant alteration in acute rejection risk: repeat transplant recipients (4.3-fold increased risk) and thymoglobulin induction (0.30 risk (ie, 70% reduction in risk compared to patients not receiving thymoglobulin induction). Sensitized recipients and African Americans were also at increased risk but did not quite reach statistical significance. These data strongly support the use of T-cell depleting antibody induction therapy in high-risk patients undergoing early withdrawal under modern immunosuppression.

Adrenal Cortex Hormones↗
PubMed2005

Limited-dose Daclizumab versus Basiliximab: a comparison of cost and efficacy in preventing acute rejection.

The purpose of this study was to compare the efficacy and cost of the limited-dose Daclizumab regimen to that of the standard-dose Basiliximab regimen. Two antibody induction regimens were compared in patients aged 18 years and older who received renal transplants from January 2002 to September 2003 and completed interleukin (IL)-2R antibody induction with standard-dose Basiliximab (20 mg x 2 doses) or limited-dose Daclizumab (1 mg/kg x 2 doses). The primary outcome measure was the incidence of acute rejection. Secondary outcomes included cost, changes in serum creatinine level, and delayed graft function. Of the 46 patients randomized, 42 patients completed the 6-month follow-up. Mean serum creatinine level at time of discharge was originally higher in the limited-dose Daclizumab group than the standard-dose Basiliximab group (1.89 vs 1.57, respectively). By 1, 3, and 6 months, mean serum creatinine values were similar between both groups, with a trend toward lower mean serum creatinine values in the limited-dose Daclizumab group. The incidence of acute rejection was also similar between the groups (6% vs 7%). The average cost difference between the 2 regimens was approximately $715. This study suggests that a limited-dose Daclizumab regimen may be an efficacious and less costly alternative to the standard-dose Basiliximab regimen for antibody induction therapy following renal transplantation.

Adult↗