Saudi Journal of Kidney Diseases and Transplantation

ORIGINAL ARTICLE
Year
: 2013  |  Volume : 24  |  Issue : 4  |  Page : 696--701

Outcome of second kidney transplant: A single center experience


MR Gumber1, SH Jain1, VB Kute1, PR Shah1, HV Patel1, AV Vanikar2, PR Modi3, HR Trivedi1,  
1 Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, and Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
2 Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, Institute of Kidney Diseases and Research Center, and Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
3 Department of Urology and Transplantation, Institute of Kidney Diseases and Research Center, and Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India

Correspondence Address:
M R Gumber
Department of Nephrology and Clinical Transplantation, IKDRC-ITS, Civil Hospital Campus, Asarwa, Ahmedabad - 380016, Gujarat
India

Abstract

Nowadays, a repeat transplantation is considered to confer a better survival advantage to patients over dialysis. The cost-effectiveness of transplantation for end-stage renal disease patients shows benefits over dialysis even for re-transplanted patients. This retrospective single center ten-year study was undertaken to evaluate patient/graft survival, function vis-à-vis serum creatinine (SCr) and rejection episodes in 62 re-transplanted patients. Sixty-two patients underwent a second renal transplant (24 living related, 38 deceased donors) at our center between 2000 to 2009. The mean recipient age was 41.9 ± 12.27 years. Fifty-three recipients were male and nine recipients were female. Recipients had negative acceptable lymphocyte cross-matching using anti-human globulin complement-dependent cytotoxicity tests and flow cytometric cross-match before transplant. All recipients except those who were hepatitis C virus or hepatitis B surface antigen positive received single-dose rabbit-anti-thymocyte globulin induction and steroids, calcineurin inhibitor ± mycophenolate mofetil/azathioprine for maintenance immunosuppression. Of the 62 patients, 38 patients received kidneys from deceased donors and 24 patients received kidneys from live donors. Over the mean follow-up of 4.03 ± 2.93 years, the 1-year, 5-year and 10-year patient survival rates were 85.33%, 66.7% and 66.7%, respectively, and the graft survival rates were 96.7%, 79.7% and 79.7%, respectively. The acute rejection rates were 17.6%, with a mean SCr of 1.92 ± 0.5 mg/dL. There was unexplained interstitial fibrosis with tubular atrophy in 11.2% patients (n = 7), all leading to graft loss eventually. Overall, 25% (n = 16) of the patients were lost, mainly to infectious complications. Re-transplantation has acceptable graft and patient survival over a ten-year follow-up period and should be encouraged for better quality of life as compared with dialysis.



How to cite this article:
Gumber M R, Jain S H, Kute V B, Shah P R, Patel H V, Vanikar A V, Modi P R, Trivedi H R. Outcome of second kidney transplant: A single center experience.Saudi J Kidney Dis Transpl 2013;24:696-701


How to cite this URL:
Gumber M R, Jain S H, Kute V B, Shah P R, Patel H V, Vanikar A V, Modi P R, Trivedi H R. Outcome of second kidney transplant: A single center experience. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2021 Jan 21 ];24:696-701
Available from: https://www.sjkdt.org/text.asp?2013/24/4/696/113857


Full Text

 Introduction



Between 5% and 24% of all kidney transplants are lost because of chronic rejection during the first five years after transplantation, and 50-80% of patients undergoing transplantation who return for dialysis treatment do so because of the same reason. [1] Therefore, renal allograft failure has become one of the most common causes of end-stage renal disease (ESRD), accounting for 25-30% of patients awaiting renal transplantation. [2] The current opinion is that a repeat transplantation confers better survival advantage to patients over treatment with dialysis. Indeed, it has been shown that the survival benefits of primary kidney transplantation can also be extrapolated to repeat transplantation. [3] The United Nations Organ Sharing (UNOS) registry reports 1- and 5-year survival rates of 91% and 70%, respectively, for first renal transplants compared with 88% and 65% for repeated renal transplants, primarily second grafts. [4] However, graft survival rates following re-transplantation have improved substantially in recent years. [5],[6] Indeed, it has been demonstrated that the long-term survival of second transplants may be similar to that of primary transplants. [7] It has also been proven that the cost-effectiveness of transplantation for ESRD patients shows benefits over dialysis even for re-transplanted patients. [8],[9]

 Materials and Methods



This was a retrospective study of 62 second transplantations performed at our institute between 2000 and 2009 to evaluate patient survival, graft survival, graft function vis-à-vis serum creatinine (SCr), rejection episodes and mortality in these patients. Recipients had negative/acceptable lymphocyte cross-matching using anti-human globulin complement-dependent cytotoxicity tests and flow cytometric cross-matches before transplant .

Immunosuppressive regimen

All recipients except those who were hepatitis C virus (HCV) or hepatitis B surface antigen (HBsAg) positive received induction with rabbit-anti-thymocyte globulin (r-ATG) (1.5 mg/kg BW) and methylprednisolone (MP) 500 mg intravenously. MP was continued for three days post-operatively. Maintenance immunosuppression consisted of prednisolone (30 mg/day tapered to 10 mg/day at three months post-transplant and continued thereafter) and CNI [cyclosporine (CsA) (5 mg/kg BW/day or Tacrolimus 0.08-0.1 mg/kg BW/ day)] and/or mycophenolate mofetil (MMF) (1.5-2 g/day) or azathioprine (AZA) 1-2 mg/kg BW/day. Recipients who were HCV or HBsAg positive received a cyclosporine-based regime without induction. Doses of AZA or MMF were adjusted according to complete blood counts. Doses of CNI were adjusted as per trough levels. All patients received prophylaxis against cytomegalovirus (CMV) infection (gancyclovir 1 gm thrice a day × 3-6 months), fungal infections (fluconazole 100 mg once a day × 6 months) and Pneumocystis carinii pneumonia (trimethoprim/sulfamethaxazole 160/800 mg) once a day × 9 months).

Post-transplant follow-up

All patients were followed at weekly intervals for the first three months, fortnightly for the next three months, monthly for the next six months and three monthly intervals thereafter. On every visit, the complete blood counts, renal and liver function tests were routinely monitored and other tests like electrocardiogram and ultrasound Doppler studies were performed when required.

Diagnosis and treatment of rejection

Graft biopsy was performed in the event of graft dysfunction, diagnosed as per the modified Banff classification and treated accordingly. Rejection was treated with standard anti-rejection therapy. T-cell rejections were treated with MP 500 mg × three doses ± r-ATG 1.5 mg/kg BW × single dose. B-cell rejecttions were treated with MP 500 mg × three doses ± plasmapharesis (40 mL/kg BW per session × 4-8 sessions) + intravenous immunoglobulin 5 g/day × 5-10 doses ± Rituximab 375 mg/m 2 BSA single dose.

 Results



Of the 2010 RTx performed at our institute between 2000 and 2009, 62 (3.08%) RTx were second transplant. Of the 62 recipients, 53 were male and nine were female, with a mean age of 41.9 ± 12.27 years. Basic diseases leading to ESRD were chronic glomerulonephritis (n =28), hypertension (n = 10), chronic tubulointerstitial nephritis (n = 4), chronic pyelonephritis (n = 2), obstructive uropathy (n = 5), autosomal-dominant polycystic kidney disease (n = 3), IgA nephropathy (n = 2), focal segmental glomerulosclerosis (n = 2), Mesangiocapillary glomerulonephritis (n = 2), diabetic nephropathy (n = 2) and Alport's syndrome (n = 1) and primary oxalosis (n = 1). Thirty-eight patients received kidneys from deceased donors and 24 patients received kidneys from live donors. Live donors were two parents, eight extended family members, five spouses and one daughter; there were eight unrelated donors. The mean donor age was 39.9 ± 14.16 years and 36 were male and 26 were female patients. Baseline characteristics of donors and recipients for the deceased donor (DD) group and the live related (LD) group are shown in [Table 1]. The mean human leukocyte antigen (HLA) match was 1.44 ± 1.13. Over a mean follow-up of 4.03 ± 2.93 years, the 1-year, 5-year and 10-year patient survival rates were 85.33%, 66.7% and 66.7%, respectively, and the death censored graft survival rates were 96.7%, 79.7% and 79.7%, respectively. Survival graphs are shown by a Kaplan-Meier graph [Figure 1]. Clinical outcomes of the LD and DD groups are shown in [Table 2]. None of the patients in the DD group had reached ten years of transplantation at the time of the study. Survival graphs of the LD and DD groups is shown by Kaplan-Meier graphs [Figure 2] and [Figure 3]. Overall, 25% (n = 16) of the patients were lost, mainly to infections [pneumonia with acute respiratory distress (n = 4), tuberculosis (n = 1), CMV disease (n = 1), fungal infection (n = 1), hepatic encephalopathy due to HCV (n = 4) and hepatic encephalopathy due to hepatitis B virus (n = 1)], cerebrovascular accidents (CVA) (n = 2) and 1.6% (n = 1) died of coronary artery disease (CAD) and one had sudden cardiac death. The mean SCr (in mg/dL) at 1, 5 and ten years was 1.42, 1.70 and 1.94, respectively. There were 17.7% (n = 11) acute rejection (AR) episodes, of which 6.5% (n = 4) were acute B-cell rejections, 3.2% (n = 2) were acute T-cell rejections, 8% (n = 5) were acute T + B cell rejections and 14% (n = 9) responded to anti-rejection treatment. There was unexplained interstitial fibrosis with tubular atrophy in 11.2% patients (n = 7), all leading to graft loss eventually.{Figure 1}{Figure 2}{Figure 3}{Table 1}{Table 2}

 Discussion



We report on a single-center analysis of 62 re-transplant recipients who received a kidney between 2000 and 2009. Kidney re-transplantation has been historically associated with a poor prognosis. However, recent studies stressed the improvement of second kidney transplant outcome for the short and long term. [7],[10],[11] Coupel et al [7] reported in a monocentric retrospective study of 233 second and 1174 first transplantations similar short- and long-term survival rates.

Delmonico et al [12] reviewed their experience on second transplants, concluding that because excellent second renal allograft survival is attainable and because the costs are comparable, restricting suitable patients to subsequent lifelong dialysis becomes unethical. However, the re-transplantation rates are low in most centers. In our center, 62 patients were recipients of a non-primary allograft, which was only 3.2% of our 2010 transplants. In a study in Switzerland, [13] the survival rates at 1, 2 and 5 years were 75%, 68% and 60%, respectively, for second grafts in 271 cases, which was lower than our findings (96.7%, 88.7% and 79.7%, respectively). [8] In Delmonico's study, [12] the 1-, 3-, and 5-year actuarial allograft survival rates were 86%, 78% and 69%, respectively. In a study by Stratta et al [14] over a 42-month period, 76 non-primary renal transplants (66 second, seven third and three fourth allografts) were reviewed in 73 recipients. Graft survival was 63.6% for secondary grafts and 28.6% for tertiary grafts. Our second transplant results are comparable to theirs. The high infection rate, similar to that reported by other studies from India, was possibly due to multiple factors like ATG induction, living conditions with poor hygiene, late referral and diagnosis, limited availability and high costs of diagnostic tools, the tropical climate in addition to financial limitations for treatment in the majority of patients. [15],[16],[17]

It has been suggested that improvement in survival rates for re-transplant reflects mostly the impact of the efficacy of new immunosuppressive drugs and better cross-matching. [18],[19],[20] However, time-dependent improvement of long-term transplant survival could probably also result from multiple other variables: Better patient management, decreased cold ischemia time and immunization assessment.

The main limitation of this study is the small sample size, which may account for confounding factors, particularly over a long period of time. The other limitations include the retrospective and single center nature.

In conclusion, re-transplantation has acceptable graft and patient survival over ten years follow-up and should be encouraged for better quality of life as compared with dialysis.

 Disclosure



Financial support: None.

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