Factors Affecting Overall Outcome Live Donor Renal Transplantation in Sri Lanka

1. Gunawansa N,
Cassim MRN,
Wijeyaratne SM.
LIVE DONOR RENAL
TRANSPLANTATION
IN SRILANKA: FACTORS AFFECTING
OVERALL OUTCOME

2. 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
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3. 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
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4. 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
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5. 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 HL
A 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
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6. 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
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7. 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
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8. 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
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9. 18 Lost to follow up 397 (95%)
complete follow up data
32 (8%) Graft failures
365 (92%) Graft survival
24 PGF 8 SGF
337 (85%)
overall patient survival
5 re-transplanted
19 dead
5 re-transplanted or
3 on waiting list
415 LDRT
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME
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10. 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
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11. 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
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12. Kaplan- Meir Curve – Graft survival
LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME
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13. Predictors of GF
Variable Univariate analysis
P
Multivariate analysis
OR (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
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14. 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
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15. 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
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