Gunawansa N, Cassim MRN, Wijeyaratne SM. LIVE DONOR RENAL TRANSPLANTATION IN SRILANKA: FACTORS AFFECTING OVERALL OUTCOME
Gunawansa N, Cassim MRN,
Wijeyaratne SM.
LIVE DONOR RENAL TRANSPLANTATION
IN SRILANKA: FACTORS AFFECTING OVERALL OUTCOME
Kidney transplantation is the most effective therapy for ESRD Ojo, J Am Soc Neph, 2001;12:589
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 1
Introduction
• Medium and long-term patient / graft survival statistics after Live Donor Renal Transplantation (LDRT) in Sri Lanka is largely unknown
• The overall outcome of LDRT depends on numerous patient, donor and graft related variables
• Early identification of above predictors will help in optimizing overall graft and patient outcomes
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 2
Methodology
• Prospective computerized database• July 2006 – November 2011• University Vascular and Transplant Unit, Colombo.• Inclusion – All consecutive LDRT• Exclusion – re-transplants, cadaveric
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 3
Methodology contd.
• All transplants performed as simultaneous donor and recipient operations
• relatively constant cold ischaemia time of <2 hours
• Standardized immunosuppression regime (MMF, prednisolone, cyclosporin/tacrolimus)
• Single dose monoclonal Ab induction for those with a HLA mismatch >50%
Graft failure = need for maintenance dialysis, re-transplantation or death due to graft non-function within 1 yr of transplantation** Weiss-Salz et al. Clin Transplant 2004: 18: 571–575
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 4
Factors Determining Overall Outcome
• Type of donor (cadaveric vs. living)• HLA Matching (related, unrelated) • Sensitization• Duration of pre-Tx dialysis• Recipient Age• Donor Age• Cold ischaemia time, warm ischaemia time• Acute rejection, chronic rejection• Primary renal pathology• CMV status
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 5
Variables analyzed
• Type of donor (cadaveric vs. living)• HLA Matching and sensitization• Duration of pre-Tx dialysis• Recipient Age• Donor Age• Cold ischemia time• Acute rejection, chronic rejection• Primary renal pathology• CMV status• Multivariate log regression
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 6
Results
• 415 consecutive LDRT • Complete follow-up data available – 397 (95%)• Mean follow-up – 36 (3-66) months. • Mean recipient age – 42 (17-72) years• Mean donor age – 39 (20-60) years
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 7
18 Lost to follow up 397 (95%) complete follow up data
32 (8%) Graft failures365 (92%) Graft survival
24 PGF 8 SGF
337 (85%) overall patient survival
5 re-transplanted19 dead
5 re-transplanted or 3 on waiting list
415 LDRT
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 8
Results contd.
• Graft survival - 365/397 (92%)• Graft Failures (GF); 32 (8%)
– 24 primary GF– 05 successfully re-transplanted, 19 dead– 08 secondary GF (Mean graft survival – 10 months)– 05 re-transplanted, 03 activated on waiting list
• Overall patient survival – 337/397 (85%)
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 9
Causes of death
• Sepsis – 48 (80%)• myocardial ischaemia – 4 (7%)• stroke – 4 (7%)• PE – 2 (3%)• Unknown – 2 (3%)
Sepsis MI Stroke PE Other
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 10
Kaplan- Meir Curve – Graft survival
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 11
Predictors of GF
Variable Univariate analysisP
Multivariate analysisOR (95%CI) P
Recipient age: >50y/<50y 0.63 0.06-5.13 0.627
Donor age: >40y/<40y 0.85 0.12-4.22 0.71
CMV infection: Y/N 0.11 0.86-15.07 0.09
HLA mismatch: >50%/<50% 0.04 1.74-6.64 0.07
Pre-Tx dialysis: <12 months/<12 months
0.03 1.17-13.54 0.06
Biopsy proven ac. Rejection: Y/N
0.01 1.35-10.23 0.014
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 12
Conclusions
• Our mid-term graft / patient survival figures match favorably with comparable settings elsewhere
• Pre-Tx dialysis for >1 year, HLA mismatch of >50% showed a positive correlation to outcome although not statistically significant
• Acute rejection within the first month was an independent predictors of poor outcome
• Care of primary GF is suboptimal - restricted access to HD, advanced immunosuppressant regimes and the lack of a cadaveric transplant program until now
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 13
Recommendations
• Earlier referral for transplant• Better HLA match wherever possible• Increasing the donor pool (regular deceased donor
program)• A better balance of saving the graft versus saving
the patient
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 14