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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2014  |  Volume : 25  |  Issue : 3  |  Page : 520-523
Comparison between spousal donor transplantation treated with anti-thymocyte globulin induction therapy and, living related donor transplantation treated with standard immunosuppression


1 Department of Urology, Division of Nephrology Faculty of Medicine, Cukurova University, Adana, Turkey
2 Department of Internal Medicine, Division of Nephrology Faculty of Medicine, Cukurova University, Adana, Turkey

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Date of Web Publication9-May-2014
 

   Abstract 

The worldwide shortage of organs available for transplantation has led to the use of living-unrelated kidney donors. In this context, spouses represent an important source of organ donors. We compared the allograft outcomes of spousal donor transplantation (SDT) with anti-thymocyte globulin (ATG) induction therapy and living related donor transplantation (LRDT) with triple immonosuppression and basiliximab, in addition. Among the 335 living and deceased donor kidney transplantations performed between April 2001 and June 2010, there were 274 living donor kidney transplantations including 34 SDT and 240 LRDT. The minimum follow-up period was 36 months. All recipients of SDT received ATG (1.5 mg/kg) induction therapy, which was stopped five to seven days after surgery. Maintenance immunosuppression included tacrolimus (TAC), mycophenolate mofetil (MMF) and prednisolone. LRDT recipients received triple immunosuppressive protocol consisting of cyclosporine or TAC, MMF and prednisolone, in addition to basiliximab. There was a significant difference between the two groups in recipient age, while pre-operative duration on dialysis, recipient sex and donor age and sex were not significantly different. There was also a significant difference between the two groups in the number of human leukocyte antigen (HLA) mismatches. The 1-, 3- and 5-year graft survival rates of SDT were 94.1%, 88.2% and 79.4%, respectively, and the frequency of acute rejection episodes was 5.8% (two cases). The 1-, 3- and 5-year graft survival rates of LRDT were 95.8%, 91.6% and 83.3%, respectively, with the frequency of acute rejection being 16.2%. The graft survival rates of SDT were as good as LRDT, while the acute rejection rates in SDT were lower than in LRDT, although the difference was not statistically different (P = 0.13).

How to cite this article:
Demir E, Paydas S, Erken U. Comparison between spousal donor transplantation treated with anti-thymocyte globulin induction therapy and, living related donor transplantation treated with standard immunosuppression. Saudi J Kidney Dis Transpl 2014;25:520-3

How to cite this URL:
Demir E, Paydas S, Erken U. Comparison between spousal donor transplantation treated with anti-thymocyte globulin induction therapy and, living related donor transplantation treated with standard immunosuppression. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2021 Oct 26];25:520-3. Available from: https://www.sjkdt.org/text.asp?2014/25/3/520/132155

   Introduction Top


One of the major barriers confronting the field of transplantation today is the severe shortage of donor organs. One of the proposals designated to overcome this is to increase the use of organs from genetically unrelated living kidney donors. The greater use of living unrelated kidney donors is a worldwide trend in the current era of organ shortage, and spousal donors are an important source of such donors. [1],[2]

There are several published studies on unrelated (including spousal) donor transplantation with poor human leukocyte antigen (HLA) matching documenting higher incidences of acute rejection. [3],[4],[5],[6] Therefore, induction therapy with anti-thymocyte globulin (ATG) was administered to recipients of spousal donor transplantation (SDT) in our center. Until now, comparisons between SDT and living related or deceased donors using only standard immonosuppression have been reported. In this study, we compared the allograft outcomes in recipients of SDT using ATG induction therapy and recipients of living related donor transplantation (LRDT) on triple immonosuppression, in addition to basiliximab.


   Patients and Methods Top


Among the 335 kidney transplantations performed between April 2001 and June 2010 in our center, there were 274 living donor kidney transplantations including 34 SDT and 240 LRDTs. All donors had ABO blood group compatibility with the recipient, had normal physical examination, ancillary laboratory and radiological investigations and a negative lymphocyte cross-matching. Only recipients with panel-reactive antibody (PRA) levels less than 10% were enrolled into the study. The minimum follow-up period was 36 months. All recipients were receiving their first renal transplant. Donor nephrectomy was performed by open surgery in all cases.

Recipients of SDTs received ATG (1.5 mg/kg) induction therapy, which was stopped five to seven days after surgery. Maintenance immunosuppression included tacrolimus (TAC), mycophenolate mofetil (MMF) and prednisolone. Recipients of LRDT received triple immunosuppressive protocol consisting of cyclosporine or TAC, MMF and prednisolone. TAC was commenced in a dose of 0.1 mg/kg/day post-transplantation; the dose was adjusted to maintain whole blood trough levels at 8-12 ng/mL for one to two months post-operatively, and at 3-8 ng/mL thereafter. MMF was commenced in a dose of 2000 mg/ day. On the initial days following transplantation, the dose of methylprednisolone was 1000 mg/day, which was then tapered to 6-8 mg/day within one to two months post-operatively. Basiliximab was administered in a dose of 20 mg/day, one dose on the day of operation and the second dose on the fourth post-operative day.

The recipients of SDT and LRDT were compared in terms of clinical characteristics, outcomes as well as graft and patient survival rates. Graft loss was defined as patient death or return to chronic dialysis. The diagnosis of acute rejection was made by a clinical increase in serum blood urea nitrogen (BUN) and creatinine and confirmed by biopsy. Post-transplant glomerular filtration rate (GFR) was estimated by using the Modification of Diet in Renal Disease (MDRD) formula, which estimates the GFR using three variables: Serum creatinine, age and gender.

Statistical analysis was performed using computer software SPSS, version 13.0 (SPSS Inc., Chicago, IL, USA). Chi-square test was used to compare the categorical data. The Kaplan-Meier method was used to describe the graft and patient survival rates. Multivariate statistical analysis was performed using a Cox proportional hazards models. Data were expressed as mean ± standard deviation (SD) with minimum and maximum values of percentages (%), where appropriate. A P-value <0.05 was considered statistically significant.


   Results Top


The patient characteristics are shown in [Table 1]. There was a significant difference in the recipient age between the two donor type groups; the pre-transplant duration on dialysis, recipient sex and donor age and gender were not significantly different. There was a significant difference between the donor type groups and recipients in the number of HLA mismatches.
Table 1: Clinical characteristics of recipients of spousal donor transplantation and living related donor transplantation.

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The 1-, 3- and 5-year graft survival rates among SDT were 94.1%, 88.2% and 79.4%, respectively, and the frequency of occurrence of acute rejection episodes was 5.8% (two cases). The 1-, 3- and 5-year graft survival rates of LRDT were 95.8%, 91.6% and 83.3%, respectively, and the frequency of occurrence of acute rejection episodes was 16.2% [Table 2]. The GFR at 1, 6, 12 and 24 months of follow-up is shown in [Table 3]. Despite the older age of the recipients and the lower degree of HLA matching, the graft survival rates of SDT were as good as LRDT. The frequency of acute rejection episodes was lower among recipients of SDT when compared with LRDT, although the difference was not statistically significant (P = 0.13).
Table 2: Graft survival rates and rate of acute rejection.

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Table 3: Glomerular filtration rate at 1, 6, 12 and 24 months among recipients of SDT and LRDT.

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   Discussion Top


Because of the inadequate number of cadaveric kidney donors, the number of patients with end-stage renal disease on kidney transplant waiting lists is increasing every day. In our center, we do not perform living unrelated donor transplantations except from spousal donors and cadaveric kidney transplantations constituting 19% of all transplantations performed during the last five years.

Spousal donation of kidney grafts is an ethically approved part of kidney transplant programs in many centers, and has shown unexpectedly high rates of graft survival despite poor HLA matching. [7],[8] However, there are several published studies on SDT documenting higher incidences of acute rejection. [3],[4],[5],[6] In this study, despite the older age of the recipients and the lower degree of HLA matching, the graft survival rates in recipients of spousal donors were as good as in recipients of LRDT. Also, the acute rejection rate in recipients of SDT was lower than that among recipients of LRDT, although the difference was not statistically significant (P = 0.13).

SDT is considered to carry a high risk for acute rejection because of greater HLA mismatches and more frequent sensitization to donors, via pregnancy, than related donor transplantation. However, with the use of ATG, the risk of acute rejection was no longer particularly high and graft outcomes were comparable between recipients of LRDT and SDT.

In conclusion, the usage of ATG induction therapy for five to seven days helped in the prevention of acute rejection in the SDT group. Long-term graft survival was also similar to HLA-matched LRDT.

Conflict of interest: None

 
   References Top

1.Kikuchi K, Narumia Y, Hama K, et al. Kidney transplantation from spousal donors. Transplant Proc 2000;32:1817-8.  Back to cited text no. 1
    
2.Spital A. Evolution of attitudes at U.S. transplant centers toward kidney donation by friends and altruistic strangers. Transplantation 2000; 69:1728-31.  Back to cited text no. 2
    
3.Fuller TF, Feng S, Brennan TV, Tomlanovich S, Bostrom A, Freise CE. Increased rejection in living unrelated versus living related kidney transplants does not affect short-term function and survival. Transplantation 2004;78:1030-5.  Back to cited text no. 3
    
4.Long DG, Vernon WB, Yanover MJ. Increased acute rejection episodes among recipients of living unrelated donor compared with cadaver and living related donor renal transplants. Transplant Proc 2002;34:1673-4.  Back to cited text no. 4
    
5.Kwon OJ, Kim YH, Ahn BK, Kang CM, Kwak JY. Long-term graft outcome of living donor renal transplantation: Single center experience. Transplant Proc 2005;37:690-2.  Back to cited text no. 5
    
6.Gheith O, Sabry A, El-Baset SA, et al. Study of the effect of donor source on graft and patient survival in pediatric renal transplant recipients. Pediatr Nephrol 2008;23:2075-9.  Back to cited text no. 6
    
7.Mathieson PW, Jolliffe D, Jolliffe R, Dudley CR, Hamilton K, Lear PA. The spouse as a kidney donor: Ethically sound? Nephrol Dial Transplant 1999;14:46-8.  Back to cited text no. 7
    
8.Tuncer M, Gurkan A, Erdogan O, Yucetin L, Demirbas A. Lack of impact of human leukocyte antigen matching in living donor kidney transplantation: Experience at Akdeniz University. Transplant Proc 2005;37:2969-72.  Back to cited text no. 8
    

Top
Correspondence Address:
Dr. Saime Paydas
Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, Cukurova University, 01330 Adana
Turkey
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DOI: 10.4103/1319-2442.132155

PMID: 24821146

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