Showing papers in "Clinical Transplantation in 1991"

Survival trends in long-term first cadaver-donor kidney transplants.

Abstract: 1. In 1966, the half-life (1-year posttransplantation) for first cadaver-donor kidney grafts reported to the UCLA Registry was around 7.5 years (1). Between 1985 and 1990, this half-life was 7.8 +/- 0.02 years. Since 1966, the corresponding 1-year graft survival rates increased by over 30 percentage points. Clearly, improvement in early graft survival has had little bearing on long-term graft outcome. 2. From a stratified multivariate analysis of 40,582 primary cadaveric renal transplants recorded in the UCLA Transplant Registry from 3 consecutive eras (1975-79, 1980-84, 1985-90), the following long-term graft survival trends in covariates have emerged: a) a constant strong negative effect associated with higher numbers of HLA-A,B mismatches, younger and older recipients, diabetics, and longer cold ischemia times in each era; b) an increased beneficial effect on female recipients; c) an increased detrimental effect on Black recipients, despite short-term gains; and d) a positive effect of CsA usage (only in the most recent era). 3. From a multivariate analysis of 15,027 primary cadaveric renal transplants reported to the UNOS Kidney Registry between 1987 and 1990, we analyzed the effects of transplantation factors on survival during 3 consecutive posttransplantation risk periods: 0-1 month; 1-3 months; and beyond 3 months. Few pretransplant factors affected risk of failure within 1-month posttransplantation. However, a good predischarge clinical course (as indicated by CsA usage, no required dialysis during the first postoperative week, and no rejection episodes) was associated with an immediate improvement in graft survival. The effects of most UNOS transplantation factors during the second risk period were comparable to the short-term coefficients estimated from the UCLA file; and the effects of the UNOS factors on "beyond 3-month" risk were comparable to the UCLA long-term coefficients. Conclusively, the dominant pretransplant factor on long-term risk was HLA-A,B tissue matching.

Sex and age effects in renal transplantation.

Abstract: 1. Since 1985, 1-year graft survival in first cadaver transplants has remained constant at 78-80%. One-year graft survival rates for recipients over age 50 improved with CsA from 58% in 1981-82 to 78% in 1985-86. Survival in recipients under age 10 was 70% from 1985 to 1988, but improved to 75% in transplants performed in 1989-90. 2. The percentage of immunologic failures decreased from 75% in recipients aged 1-10 to 54% in recipients aged over 50. Thirty percent of males aged 1-10 had rejection episodes during the transplant hospitalization compared with 15% of males over age 50. These findings support earlier studies suggesting young recipients have a stronger immune response. 3. The incidence of nonimmunological failures increased from 10% in recipients under age 30 to more than 30% in patients over age 50. 4. There were no significant differences in graft outcome associated with the recipient's sex. 5. Kidneys from donors aged 1-10 or over 50 yielded poorer results than those from adult donors aged 11-50. This donor age effect was most notable in broadly sensitized, retransplanted, or HLA-B,DR-mismatched recipients. 6. Discharge serum creatinine (SCr) levels over 2.5 mg/dl were reported for more than 40% of recipients given kidneys from donors under age 5 or over age 50. When the discharge SCr was less than 2.5 mg/dl, 1-year survival was 90%, regardless of the donor age. 7. Trauma deaths accounted for 90% of kidneys from male donors aged 15-30 and 70% of comparable aged female donors. Cerebrovascular accidents were the cause of donor death for 43% and 68% of kidneys from male and female donors over 30, respectively.

Work disability, functional limitations, and the health status of kidney transplantation recipients posttransplant.

Abstract: A primary objective of renal replacement therapy is patient rehabilitation. Studies have consistently shown that transplant recipients are better rehabilitated than patients maintained on dialysis, but diabetic transplant recipients do not do as well as nondiabetics. Few studies have evaluated the rehabilitation status of transplant recipients based upon their outcome following transplantation. Data were collected from 226 patients associated with 5 major transplant centers in the United States at 2.5-3.5 years posttransplant. Established survey procedures were followed and standard measures of work status, functional ability, and health status were incorporated into self-administered questionnaires. Patients were stratified into 3 groups based upon transplant outcome--those with functioning grafts, those whose grafts failed and were retransplanted, and those who returned to dialysis after graft failure. The presence of diabetes was also documented. Regardless of graft outcome, more patients were able to work than were actually working (61.5% vs 43.4%), although patients with successful transplants, and those who were retransplanted, were both better able to work than patients whose grafts had failed, necessitating a return to dialysis. Diabetic and nondiabetic patients differed in their ability to work (74.4% vs 34.7%). All patient groups reported work-related limitations in activity and associated functional impairments. These were less severe for patients who had functioning grafts. Perceived as well as actual health status varied according to graft outcome and primary disease diagnosis, with both dialysis patients and diabetics reporting poorer health status than patients who had retained their first grafts or who had been retransplanted. Graft outcome and primary renal diagnosis prior to transplant are important predictors of ability to work, functional ability, and health status posttransplant. Retransplantation is not detrimental to patient rehabilitation, whereas return to dialysis results in a measurable decline in activity status. Despite a successful graft, diabetes severely limits the rehabilitation potential of transplant recipients.

OKT3 and viral disease in pediatric liver transplant recipients.

Abstract: Seventy-four consecutive pediatric liver transplant recipients were reviewed to assess the effect of the monoclonal anti-T-lymphocyte antibody OKT3 on subsequent viral infection (9 patients were excluded due to postoperative demise during the 1st week). Twenty-two patients received OKT3 in addition to standard cyclosporine-prednisone immunosuppression for either steroid-resistant acute rejection (18) or to facilitate reduction of cyclosporine due to severe renal impairment (4). Invasive infections were diagnosed by histology or culture in tissue biopsies or bronchoalveolar lavage specimens. The overall incidence of viral infection was 58%, half of which was due to cytomegalovirus (CMV). Invasive viral disease was associated with increased mortality (37% vs. 3% p = 0.001). Viral-related deaths were due to CMV (5), disseminated adenovirus (3), disseminated enterovirus (1) and respiratory syncytial viral pneumonia (1). The use of OKT3 was associated with increased viral disease (59% vs. 33% p=0.04) and invasive primary CMV disease (58% vs. 19% p=0.04). Trends were observed toward increased overall viral infection (73% vs. 51 % p=0.08), primary CMV infection (58% vs. 25% p=0.08) and overall mortality (27% vs. 9% p =0.08) following OKT3 therapy. We conclude that pediatric liver transplant recipients who require OKT3 therapy may be at increased risk for invasive viral disease and especially invasive primary CMV disease.

Sensitization in renal transplantation.

Abstract: 1. The 1-year graft survival rate for 2,615 broadly sensitized patients of first cadaver-donor transplants between 1985 and 1990 was 72%, 7% lower than 15,615 nonsensitized patients and 6% lower than 4,824 moderately sensitized patients. For retransplants, 1,752 broadly sensitized patients had 61% 1-year graft survival rates, 12% lower than 1,299 nonsensitized patients and 8% lower than 1,104 moderately sensitized patients. 2. Rejection of a previous transplant, pretransplant blood transfusions, sex, and a history of pregnancies were the dominant causes of sensitization. 3. The percentage of nontransfused recipients of first cadaver transplants has increased yearly from 10% in 1985 to more than 40% in 1990 in both the UCLA and UNOS Registries. Over the same period, the percentage of broadly sensitized recipients has declined from 15% to 8%. 4. The beneficial effect of pretransplant transfusions (a 4% improvement at 1 year) was limited in first transplants to males and nonsensitized females. No difference in survival rates of sensitized patients comparing transfused and nontransfused was observed. Patients retransplanted without ever being transfused had very poor outcomes. 5. Delayed graft function (DGF) occurred in approximately 20% of nonsensitized, 28% of moderately (1-50% peak PRA), and 37% of broadly sensitized first transplant recipients. Among retransplanted patients, 28% of nonsensitized, 37% of moderately, and 48% of broadly sensitized patients had DGF. 6. HLA-A,B, and DR matching overcame the deleterious effect of sensitization on graft survival. Sensitization had no effect on the outcome of transplants from HLA-identical siblings, but survival decreased by 7-10% in sensitized recipients of mismatched transplants from relatives. Sensitized first cadaver transplant recipients matched for HLA-A,B, or HLA-DR antigens had 1-year survival rates comparable to those of mismatched nonsensitized recipients. 7. First transplant recipients who were nonsensitized using their current serum but had been broadly sensitized in an historical sample had 73% 1-year graft survival, the same as that of patients who were broadly sensitized in their current serum and 6% less than patients who were never sensitized (p less than 0.001). 8. Assuming a random distribution of sensitized patients at UNOS transplant centers using different methods to measure preformed antibody, the antihuman globulin (AHG) method was more sensitive than the NIH or 1-Wash tests. With AHG, 31% of first and 58% of retransplanted patients were broadly sensitized, whereas with the NIH and 1-Wash methods, the corresponding figures were 18-21% and 41-44%.(ABSTRACT TRUNCATED AT 400 WORDS)

Liver transplantation in the United States: 1988 to 1990.

Abstract: Between 1988 and 1990, the frequency of liver transplantation in the United States increased by 57%. During this same period, the number of transplant centers performing this procedure increased from 58 to 80. Despite this increase, only 15 centers reported a total of at least 100 procedures during these 3 years, compared to 25 centers that performed 12 or less liver transplantations. Recipient characteristics have been changing over time: a larger proportion of recipients were males in 1990 than in 1988 or 1989. The distribution of recipients changed dramatically; the median age increased by 4 years, due to an increased proportion of transplantations among those age 40 and older and a decrease in children younger then age 10. Another major change was in functional status; in 1988 and 1989, over half of the recipients were hospitalized while awaiting transplantation, but this was reversed in 1990, when the majority of patients was at home awaiting transplantation. Furthermore, the proportion of patients in the highest functional class more than tripled. Alcoholic liver disease, which in 1989 became the most common primary liver disease of patients undergoing liver transplantation, continues to be the indication for an increasing number of recipients. The proportion of recipients with biliary atresia and primary biliary cirrhosis, the most common diagnoses in 1988, continues to decrease. Most of the mortality was noted in the first 6 months, when overall cumulative patient mortality was about 20%, half of which occurred in the first 4 weeks after OLTX. The cumulative 3-year posttransplant survival rate was 67%. Similarly, cumulative retransplant-free survival rates were 84% at 1 month and 58% at 3 years. As previously described (1), recipient factors associated with survival included age, UNOS description, diagnosis, and ABO matching. Older recipients, those with poorer functional status at time of transplantation, recipients with either fulminant liver failure or malignancies, and those who received a graft from an ABO-compatible or -incompatible donor, had the worst survival rates. Furthermore, in the current analysis we found that the outcome of recipients was affected adversely by grafts from female donors. Racial differences were noted, but the large quantity of missing data precluded definitive statements regarding any association with survival. Both recipient and donor ages were significant prognostic factors. For adults in the multivariate model, increasing recipient age was associated with higher mortality. Among children, however, younger donor age seemed to have an adverse effect on recipient survival. Donor characteristics also changed during this period.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of transfusions.

Abstract: 1. The transfusion effect, which was apparent in 1981, disappeared in 1988, and reversed itself in 1990. In other words, for the first time, transfused patients have started to have lower graft survival rates than nontransfused patients. 2. The proportion of transfused to nontransfused patients has decreased from a ratio of 10:1 in 1981 down to 1:1 in 1990. 3. The transfusion effect in related donors has also disappeared in recent data. 4. Data revealed that HLA-A,B, and DR mismatching had no effect between 1988 and 1990. 5. A small transfusion effect continues to be seen in young recipients. 6. In earlier data, the transfusion effect was most marked in Blacks and Hispanics, but the reverse trend is now shown for these races. White recipients had exactly the same survival rates with and without transfusions. 7. Sensitization occurred more often with transfused patients who had a tendency toward slightly lower graft survival. This was true in males, females, and pregnant females. 8. Recipients who waited on dialysis for more than 2 years had slightly lower graft survival and data showed they had received more transfusions. 9. The loss of the transfusion effect occurred at both large and small centers. The centers with 1-year graft survival under 70% tended to have a transfusion effect, whereas those above 70% had either better or worse results with transfusions.

Smooth muscle tumor arising de novo in a liver allograft: A case report.

Abstract: The development of de novo malignancies is a well-recognized complication of the immunosuppressed state that follows organ transplantation (1-6). In the cyclosporine era, lymphomas, skin cancer and Kaposi’s sarcoma account for more than half of the reported cases (6). Other tumors of mesenchymal origin are uncommon. We describe a case of a primary smooth muscle tumor arising in a liver allograft. The tumor was of donor origin. To our knowledge this complication has not been seen before.

Results of pancreas transplantation in the United States for 1987-90 from the United Network for Organ Sharing (UNOS) Registry with comparison to 1984-87 results.

Abstract: An outcome analysis was performed on pancreas transplants in the United States reported to the United Network for Organ Sharing (UNOS) Registry from its inception on 1 October 1987 to 21 October 1990 (n=1021). These cases comprise nearly one-third of the 3082 pancreas transplants reported to the International Pancreas Transplant Registry (1819 U.S., 1263 non-U.S.) from 1 December 1966 to 31 December 1990, including 619 in 1990 (528 U.S., 91 non-U.S.). Nearly all pancreas transplants in the U.S. during the 1987-90 period were by the bladder-drainage (BD) technique (92%). The overall patient and pancreas graft actuarial survival rates were 92% and 72% at 1 year. Patient survival rates were similar in all recipient categories, but pancreas graft survival rates were significantly higher (p less than 0.001) in recipients of a simultaneous pancreas and kidney (SPK) transplant (n=883) than in recipients of a pancreas after a kidney (PAK, n=112) or a pancreas transplant alone (PTA, n=71), being 77%, 52%, and 54%, respectively, at 1 yr. Kidney graft survival at 1 yr in U.S. SPK recipients was 86%. Most grafts (81%) were preserved in University of Wisconsin (UW) solution, and more than half were stored greater than 12 hours, with no difference in outcome with increasing duration of storage. At 1 yr, functional survival rates were 72% for U.S. pancreas grafts stored for either less than 12 (n=439), 12-24 (n=422), or 24-30 h (n=42). For grafts stored greater than 30 h (n=8), the 1-yr functional survival rate was 50% (p=ns versus the other storage times). On univariate analysis, no effect of HLA antigen mismatching on outcome for 1987-90 U.S. cases could be discerned. The results in the UNOS Registry were compared to the results for U.S. cases in the International Pancreas Transplant Registry performed between 1 January 1984 and 30 September 1987. In all recipient categories the pancreas graft functional survival rates were significantly higher in the 1987-90 (UNOS) than in the 1984-87 (pre-UNOS) era. A Cox multivariate analysis of 1984-90 cases showed the relative risk for pancreas graft loss to be significantly less (p less than 0.05) with bladder-drainage, with simultaneous transplantation of the kidney, with use of UW solution for preservation, and with 0-1 HLA-A, B, DR or 0 HLA-DR mismatches.(ABSTRACT TRUNCATED AT 400 WORDS)

Overview of reduced-size liver transplantation.

Abstract: Organ donor availability is the major limiting factor in pediatric liver transplantation, and many children succumb from their liver disease before a suitable donor can be found. In an attempt to overcome this shortage, reduced-size liver transplantation, split liver transplantation, and living-donor liver transplantation have been introduced. The eventual role of these techniques will be determined by accumulated experience over the next several years.

Pancreatico-duodenal transplantation with enteric exocrine drainage: technical aspects.

Abstract: When a pancreatic transplant program was initiated in Stockholm in 1974 we elected to use enteric drainage of the pancreatic juice; 103 segmental pancreatic transplantations were performed with this technique. However, in 1988 we began to use pancreatico-duodenal grafts with enteric exocrine drainage and we have now performed 25 such procedures. Here we report the technical aspects of this procedure. The cumbersome pancreatico-enteric anastomosis previously needed for enteric drainage has now been replaced by a simple bowel-to-bowel anastomosis. In the present series, only one graft was lost due to the enteric drainage technique, i.e. because of exocrine leakage. No grafts were lost in thrombosis. In the uremic recipients of combined renal and pancreatic grafts the 1-year actuarial graft survival rate was 86%. Pancreatico-duodenal transplantation with enteric exocrine drainage would, therefore, seem to be a sound surgical procedure which is also physiological and not associated with any long-term sequelae.

Center effects in renal transplantation.

Abstract: 1 One-year graft survival rates for first cadaver transplants to adult recipients ranged from 60-93% at transplant centers reporting more than 50 transplants to the UNOS Renal Transplant Registry between October 1987 and December 1991 2 There was no apparent correlation between center size and success rates for primary or repeat cadaveric transplants when centers were grouped according to high, average, and low 1-year graft survival rates 3 Fifteen "high" centers had 88%, 15 "average" centers had 80%, and 15 "low" centers had 69% 1-year graft survival rates, respectively 4 Projected half-lives for transplants surviving the first year were not significantly different among the 3 center groups, suggesting that long-term survival did not correlate strictly with 1-year survival 5 The 20% difference in 1-year graft survival rates between the high and low center groups was reduced to 10% and to 5% when transplants functioning at discharge or at 6 months, respectively, were considered Thus, approximately half of the center effect was associated with events that occurred during the transplant hospitalization 6 At high and average centers, less than 10% of kidneys did not function on the first day compared with 17% at low centers (p less than 001) Twenty percent of patients at high and average centers required dialysis during the first week compared with 37% at low centers (p less than 001) Less than 5% of kidneys never functioned during the transplant hospitalization at high and average centers compared with 10% at low centers (p less than 001) 7 Graft survival rates for patients with early graft dysfunction were significantly higher at high centers than at average or low centers, suggesting that successful management of patients with poor early function differed among the center groups 8 Low centers transplanted more Blacks and fewer healthy patients than high centers, but when stratified for these variables, the center differences in graft outcome were undiminished 9 Other patient mix variables, including age, sensitization, and original disease, did not account for variation in survival rates for the center groups High centers transplanted more diabetics (33%) than average (25%) or low (18%) centers 10 There were no significant differences among the center groups in the incidence of early rejection episodes However, graft survival following rejection was 10-30% lower at average and low centers than at high centers(ABSTRACT TRUNCATED AT 400 WORDS)

A prospective study of quality of life in end-stage renal disease: Effects of cadaveric renal transplantation

Abstract: We prospectively examined quality of life in a sample of end-stage renal disease patients before and after undergoing renal transplantation

Ketone body ratio as an indicator of early graft survival in clinical liver transplantation

Abstract: Arterial ketone body ratio which reflects liver mitochondrial redox state, was serially measured after 56 clinical liver transplantations on 50 patients

A single institution's experience with solitary pancreas transplantation: a multivariate analysis of factors leading to improved outcome.

Abstract: The results of cadaveric donor pancreas transplantation at a single institution using the bladder drainage technique have been analyzed according to several factors that may impinge on outcome. Both multivariate and univariate statistical methods were used, with emphasis on solitary (pancreas after kidney and pancreas transplant alone) as opposed to simultaneous pancreas/kidney transplants. Of the 444 pancreas transplants performed at our institution from December 1966 through December 1991, we analyzed 249 bladder-drained cadaver donor pancreas transplants from November 1984 through August 1991. The factors that had a significant impact on outcome in the Cox multivariate analysis included retransplantation, age, preservation time, and degree of HLA mismatching. The results of solitary pancreas transplants improved with time as the factors that have an impact on graft survival rates were deliberately manipulated. During the 1988 to 1991 era, pancreas graft functional survival (insulin-independent) rates were not significantly different among the 3 recipient categories. Solitary pancreas transplant recipients less than 45 years old receiving primary grafts had a 1-year function rate of 61% in the pancreas transplant alone group (n = 32) and 74% in the pancreas after kidney group (n = 24). By placing emphasis on minimizing HLA mismatches, by giving adequate immunosuppression, and by detecting and treating rejection episodes early based on a decline in urine amylase, the results with solitary pancreas transplantation can be as good as those with simultaneous pancreas kidney transplantation. There are limitations to the interpretations that can be given to retrospective studies using inhomogeneous factors, as is the case in the analyses presented here. We cannot identify risk factors with certainty because the protocols changed over time, eg, immunosuppressive regimens, policies on HLA matching, and choice of duct-management techniques. Thus, in the analysis of all cases, not only was there a higher proportion by the bladder-drainage techniques in the later period, but the proportion of cases with good HLA matches was also higher: yet the earlier cases (more poorly matched, performed by the other techniques, and with worse results), were in the model. Retransplantation is also a problem for the analysis. The number performed was proportionately greater in the later period, and the possibility of retransplantation differed according to the patient's age. Over such a long time, we cannot evaluate our gain in experience statistically.(ABSTRACT TRUNCATED AT 400 WORDS)

Outcome of renal transplantation in different primary diseases.

Abstract: 1 Graft survival rates increased about 3-5 percentage points for patients with all primary diseases in 1989-1990 2 Patients with different diseases had 1-year graft survival rates that varied from 73% for noninsulin-dependent diabetes (NIDDM) to 83% for IgA nephropathy (IgAN) Five-year graft survival varied from 40% for NIDDM to 66% for IgAN 3 Our findings in Clinical Transplants 1990 that IgAN patients have a high graft survival was confirmed and 1-year graft survival improved by 5% in the last 2 years 4 There was a 20 percentage point increase in full-time work status of patients after transplantation; 68% of patients with polycystic kidney disease (PKD) and chronic glomerulonephritis (CGN) had full-time work status after 3 years whereas patients with diabetes mellitus (DM) and atheronephrosclerosis (NS) had about 50% 5 Good early graft function (urine output during the first 24 hours posttransplant, no dialysis within the first-week posttransplant, and no rejection episodes before discharge), predicted good 1-year graft survival for patients with different diseases but patients with NS and DM had a poorer graft survival beyond the first year posttransplant Patients who had poor early function had 20% lower graft survival than those who had good function However, in patients with IgAN, no urine at day 1 still resulted in graft survival comparable to those that produced urine 6 More patients with DM were transplanted within 1 year after going into ESRD than those with other diseases Conversely, 46% of those with NS did not get transplanted until more than 2 years after developing ESRD 7 Only 77% of NS patients had functioning grafts at discharge compared to DM (84%), PKD (81%), IgAN (81%), and CGN (80%) 8 Black patients had a statistically significant higher incidence of anuria on the first day compared with Whites They also had a higher incidence of dialysis and rejection during the first hospitalization This was true for CGN, DM, PKD, and NS patients Following excellent early function, Black CGN and DM patients had a higher incidence of rejection than White CGN and DM patients