|Year : 2022 | Volume
| Issue : 2 | Page : 161-165
Factors influencing survival outcome in deceased renal transplant recipients: A single-center study
Dilip Kumar Pal1, Arpita Ray Chaudhury2, Ankit Verma1, Debarshi Jana3
1 Department of Urology, IPGMER, Kolkata, West Bengal, India
2 Department of Nephrology, IPGMER, Kolkata, West Bengal, India
3 Department of Science and Technology, IPGMER, Kolkata, West Bengal, India
|Date of Submission||23-Feb-2021|
|Date of Acceptance||17-Oct-2021|
|Date of Web Publication||30-Jun-2022|
Prof. Dilip Kumar Pal
Department of Urology, IPGME&R, 242, AJC Bose Road, Kolkata - 700 020, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Renal replacement therapy is the gold standard treatment of end-stage renal disease. Since the number of cases of chronic kidney diseases are increasing exponentially in our country, only live-related transplant is not enough to bridge the gap between disease and their treatment which increased the demand for deceased renal transplant program in our country. Objective: The objective is to study donors and recipients' characteristics for association with survival of patients in deceased renal allograft transplant. Materials and Methods: It is an ambispective observational analysis of 42 deceased donor renal transplants performed in our institute from January 2012 to December 2019. The difference among donors and recipients' characteristics was analyzed for association with the outcome for survival or death of the patient. Statistical analysis was done using SSPS 21.0 software and P value < 0.05 was taken as statistically significant. Results: In association with survival and expired outcomes, donors and recipients age, donors sex, cause of brain death (traumatic/nontraumatic), standard or extended criteria of donor, serum creatinine at the time of death, dialysis vintage period, warm and cold ischemia time, duration of hospital stay had shown no significant association with survival. While donors' urine output at the time of death, recipients sex, previous sensitization of recipients either by previous episodes of blood transfusion or pregnancy, achievement of normal renal function at day 14 of transplant, and tacrolimus level at 1 month of transplant shown significant association with the outcome. Conclusion: Deceased donors' characteristics, mainly urine output at death, recipients characteristic, namely any previous sensitization, achievement of normal renal function at day 14, serum tacrolimus level at 1-month posttransplant have a significant association with survival of deceased renal allograft transplant recipients. Sepsis and severe acidosis were the main complications contributing to mortality.
Keywords: Deceased, renal transplant, survival
|How to cite this article:|
Pal DK, Chaudhury AR, Verma A, Jana D. Factors influencing survival outcome in deceased renal transplant recipients: A single-center study. Indian J Transplant 2022;16:161-5
|How to cite this URL:|
Pal DK, Chaudhury AR, Verma A, Jana D. Factors influencing survival outcome in deceased renal transplant recipients: A single-center study. Indian J Transplant [serial online] 2022 [cited 2022 Dec 4];16:161-5. Available from: https://www.ijtonline.in/text.asp?2022/16/2/161/349345
| Introduction|| |
Renal replacement therapy (RRT) is considered a gold standard treatment for irreversible kidney failure (end-stage renal disease [ESRD]). It is a major advance of modern medicine which provides good quality of life to patients with ESRD. The number of patients with ESRD receiving RRT are growing rapidly. An efficient renal transplant improves the quality of life and also corrects metabolic consequences of chronic kidney disease (CKD) and reduces the mortality risk for most patients when compared with maintenance dialysis., Interest in the research of factors that could prolong long-term outcomes and survival is increasing worldwide. This leads to accepting older and expanded criteria donor (ECD) kidneys, individualizing immunosuppression, using molecular therapy, and searching for mechanisms of immune tolerance. Since the number of cases of CKD are increasing exponentially in our country, only live-related transplant is not enough to bridge the gap, leading to a higher demand for deceased renal transplant programs in our country.
In this study, we have studied and analyzed the factors influencing the survival of the deceased renal transplant recipient. Our study aims to analyze the demographic profiles of the donors undergoing retrieval and recipients undergoing transplant and to analyze the factors of both donor and recipients influencing the survival in deceased donor renal transplant recipients.
| Materials and Methods|| |
This is an ambispective observational analysis of 42 deceased donor renal transplants performed in a tertiary care hospital of eastern India from January 2012 to December 2019.
All the recipients who underwent deceased renal allograft transplants who gave consent for the study were included in the study and the patients undergoing live renal transplant and those who did not give informed consent among deceased recipients were excluded. All transplants were HLA compatible. The approval from the institutional ethical committee was taken. The informed written consent was taken from both recipients and relatives of deceased donors.
The data analysis included age and gender of donors and recipients, cause of brain death, serum creatinine and urine output of the donor at the time of the death, the underlying cause of CKD, dialysis vintage period, previous sensitization, warm and cold ischemia time, postoperative complications, achievement of renal function at day 14, tacrolimus level 1-month posttransplant, and duration of hospital stay.
The difference among donors' and recipients' characteristics was studied for association with the outcome for survival or death of recipients.
All the deceased transplant recipients received immunosuppressive regimen consisting of steroids, tacrolimus, mycophenolate mofetil. Induction agents such as rabbit antithymocyte globulin (rATG) were used among all recipients.
rATG 1.0 mg/kg and methylprednisolone 500 mg IV.
rATG 1.0 mg/kg daily for 2 days and injection methylprednisolone 250 mg on day 1 and 125 mg in day 2 then oral prednisolone 25 mg from day 3. Mycophenolate mofetil 1 g BD PO as soon as patient can take oral medicine. Tacrolimus was started 0.1 mg/kg PO in two divided doses after 1 week of the last dose of ATG depending on graft function.
Initially, tacrolimus trough level is kept around 10 ng/mL which is brought down to around 5 ng/mL by 6 months. Tacrolimus will be changed to cyclosporine, if patient develops severe hyperglycemia poorly controlled with medication. MMF reduced to 500 mg twice daily after 6 months. Steroid tablet prednisolone: 3rd postoperative day 25 mg/day, which was decreased by 2.5 mg/week to achieve a dose of 5 mg/day except in high-risk cases where it is continued at a dose of 7.5 mg/day.
Patients' data were entered on an Excel spreadsheet and then analyzed by SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism version 5. Data had been summarized as mean and standard deviation for numerical variables and count and percentages for categorical variables. Two sample t-tests for a difference in mean involved independent samples or unpaired samples. Unpaired proportions were compared by the Chi-square test. P value ≤ 0.05 was considered statistically significant.
Declaration of patient consent
The patient consent has been taken for participation in the study and publication of clinical details and data. Patients and their relatives understood that the names, initials would not be published and all standard protocols will be followed to conceal their identity.
The study has been approved by institutional ethics committee of IPGME and R Research Oversight Committee (Institutional Ethics Committee)- IPGME&R and SSKM hospital, Kolkata-20 (IRB no.- IPGME&R/IEC/2020/046). Institute ethics board approved this analysis on January 18, 2020. All protocols as per the Declaration of Helsinki were followed. The authors confirm the availability of, and access to, all original data reported in this study. The study was performed according to the guidelines in Declaration of Helsinki.
| Results|| |
A total of 42 patients underwent deceased donor renal transplants, with a mean follow-up period of 12 months.
Among donors, there were 35 males and 7 females (M: F ratio: 5:1), with a mean age of 42.24 ± 12.84 years. There were 16 deceased donors with nontraumatic brain death and 7 were ECDs. Mean serum creatinine was 0.92 ± 0.28 mg/dl and mean urine output was 2426.67 ± 577.97 ml at the time of death of the donor, as shown in [Table 1].
Among recipients, there were 29 males and 13 females (M: F ratio: 2.2:1), with a mean age of 31.36 ± 10.53 years. Twenty-two recipients had a history of previous sensitization, namely pregnancy or prior blood transfusion. The mean dialysis vintage period was 29.52 ± 22.47 months, and among 42 recipients, only 4 of them have known underlying cause of CKD while the rest 38 were with unknown cause. Mean warm ischemia time was 5.37 ± 1.94 min and cold ischemia time was 76.43 ± 12.93 min. Mean duration of hospital stay was 25.31 ± 28.42 days as shown in [Table 2].
Among the deceased renal transplant recipients in our institute, only 30 (71.4%) survived out of 42, while 12 recipients were expired either immediately posttransplant or during the follow-up period between 2012 and 2019.
In association with survival and expired outcomes, donors and recipients age, donors sex, cause of brain death (traumatic/nontraumatic), standard criteria donor or expanded criteria donor, serum creatinine at the time of death, dialysis vintage period, warm and cold ischemia time, duration of hospital stay had shown no significant association (P value > 0.05). While donors urine output at the time of death, recipients sex, previous sensitization of recipients either by previous episodes of blood transfusion or pregnancy (in case of female recipients), achievement of normal renal function at day 14 of transplant, and tacrolimus level at 1 month of transplant shown significant association with the outcome (P value < 0.05), shown in [Table 3] and [Table 4].
|Table 4: Recipients factors association with survival and expired outcome|
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| Discussion|| |
With the emergence of modern lifestyle and environmental factors, the incidence of CKD is at rising trend for which renal transplant is the only promising remedy. Although live renal allograft transplant contributes, it cannot suffice the need solely, making deceased renal transplant an important alternative to reduce disease burden.
In our institute, the deceased renal allograft transplant program was started in 2012, making it the only government hospital performing the same in West Bengal.
In our study, 16.7% of donors and 31.0% of recipients were females. This is, in contrast, to live-related transplant in India, where females contribute to the majority of donors and recipients are mainly males. Bal and Saikia have also highlighted gender disparity in their study on live renal transplant, where 66% of donors were females and only 9.2% of recipients were female.
Aueglienė et al., in their study on deceased transplant, concluded that donor factors such as age, female gender, brain death of cerebrovascular cause, and ECD status had a significant negative impact on renal function while in our study, these factors had no association with the outcome.
Dziewanowski et al. concluded cold ischemia time as a strong independent factor influencing survival while recipient sex seemed to have no impact on renal transplant, in contrast to our study where recipients' sex had a significant association with the outcome while cold ischemia time has no association with the outcome.
Moosa, in his study, concluded donors age as an important determinant of outcome after renal transplant, while in our study, donors' age has no association with outcome.
Kute et al. analyzed the association of donors' age, gender, cause of death, and standard and extended donor criteria and recipients age, gender, underlying comorbidities, cause of CKD, dialysis duration with graft survival in deceased renal transplant and found that patient and graft survival rates were 81.7% and 92.6%, respectively, with a median serum creatinine of 1.5 mg/dL.
Among the deceased renal transplant recipients in our institute, only 30 (71.4%) survived out of 42, while 12 recipients were expired either immediately posttransplant or during the period of follow-up.
In our study, 12 out of 42 deceased transplant patients were expired, i.e., 28.57%. Major causes of mortality in our study were sepsis and severe acidosis that contributed 41.67% and 25%, respectively. Other causes of mortality were fluid overload leading to cardiogenic acute respiratory distress syndrome (8.3%), arrhythmia (8.3%), pulmonary embolism and disseminated intravascular coagulopathy (8.3%), and vascular anastomotic disruption (8.3%), as shown in [Table 5] and [Figure 1].
Gopalkrishnan et al., in their study also concluded severe acidosis and vascular complications as major contributors of mortality posttransplant.
In our center, the mortality was high during the initial phase of the deceased renal transplant program of our since the majority of the patients were managed postoperatively in intensive therapy unit under the supervision of intensivists, situated outside the urology department depriving the patients of constant supervision by transplant team constituting urologists and nephrologists.
As years passed and more deceased transplant procedures have been performed, there has been a significant decline in mortality and postoperative complication presumably due to a shift in the learning curve of the transplant team and better preoperative preparation, and also better intra-operative care and most importantly, the recipient being constantly observed by transplant team in the departments' critical care unit in urology department premises itself providing better postoperative care and management.
In the coming future, with constant learning and exploration in the transplant field, we would be able to manage the deceased transplant program more efficiently and will be able to reduce the intra- and postoperative complications mortality to nearly zero in near future.
A country wide multicentric study would be more representative.
| Conclusion|| |
Deceased donor characteristics mainly urine output at death, which is an indicator of renal function, recipients characteristic, namely any previous sensitization, achievement of normal renal function at day 14, serum tacrolimus level at 1-month posttransplant have a significant association with survival of deceased renal allograft transplant recipients. Sepsis and severe acidosis are the main complications contributing to the early mortality of transplant recipients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]