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      Chronic Kidney Disease and the Transplant Recipient

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          The recent Kidney Disease Outcomes Quality Initiative (K/DOQI) classification of chronic kidney disease (CKD) includes transplant recipients. Although there are important differences between kidney transplant recipients (KTRs) and patients with native kidney disease, the inclusion of KTRs along with other CKD patients is an important step to improve long-term outcomes among transplant recipients. In this article we discuss the applicability of the K/DOQI classification of CKD to transplant recipients and the importance of premature patient death with graft function as a cause of graft loss. The implementation of a comprehensive program of CKD care beginning prior to transplantation and continuing after graft failure is discussed as a strategy to improve patient outcomes and specific areas of concern for KTRs are highlighted.

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          Most cited references 7

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          Effect of waiting time on renal transplant outcome.

          Numerous factors are known to impact on patient survival after renal transplantation. Recent studies have confirmed a survival advantage for renal transplant patients over those waiting on dialysis. We aimed to investigate the hypothesis that longer waiting times are more deleterious than shorter waiting times, that is, to detect a "dose effect" for waiting time. We analyzed 73,103 primary adult renal transplants registered at the United States Renal Data System Registry from 1988 to 1997 for the primary endpoints of death with functioning graft and death-censored graft failure by Cox proportional hazard models. All models were corrected for donor and recipient demographics and other factors known to affect outcome after kidney transplantation. A longer waiting time on dialysis is a significant risk factor for death-censored graft survival and patient death with functioning graft after renal transplantation (P < 0.001 each). Relative to preemptive transplants, waiting times of 6 to 12 months, 12 to 24 months, 24 to 36, 36 to 48, and over 48 months confer a 21, 28, 41, 53, and 72% increase in mortality risk after transplantation, respectively. Relative to preemptive transplants, waiting times of 0 to 6 months, 6 to 12 months, 12 to 24 months, and over 24 months confer a 17, 37, 55, and 68% increase in risk for death-censored graft loss after transplantation, respectively. Longer waiting times on dialysis negatively impact on post-transplant graft and patient survival. These data strongly support the hypothesis that patients who reach end-stage renal disease should receive a renal transplant as early as possible in order to enhance their chances of long-term survival.
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            Association of chronic kidney graft failure with recipient blood pressure. Collaborative Transplant Study.

             G Opelz,  E. Ritz,  T Wujciak (1997)
            Immunological rejection is the most important cause of kidney transplant failure. Recently, nonimmunological causes of long-term allograft failure have become more widely appreciated. In primary chronic renal disease, blood pressure is of overriding importance for long-term renal function. The role of blood pressure in determining long-term transplant outcome has not yet been established. We studied the influence of blood pressure post-transplantation on long-term kidney graft outcome in 29,751 patients. Outpatient blood pressure measurements were recorded and reported to the Collaborative Transplant Study. Graft and patient survival rates were analyzed over seven years in relation to blood pressure. Increased levels of systolic and diastolic blood pressure post-transplantation were associated with a graded increase of subsequent graft failure (P < 0.0001). Chronic graft failure was significantly associated with blood pressure even when patient death was censored (P < 0.0001). Cox regression analysis established increased blood pressure as an independent risk factor for graft failure. We conclude that post-transplant blood pressure is a highly significant predictor of long-term kidney graft outcome. Whether aggressive lowering of blood pressure improves long-term transplant outcome will have to be studied prospectively.
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              Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors.

              The effect on allograft survival of the transplantation of kidneys from living donors without the previous initiation of long-term dialysis is controversial. Using data from the U.S. Renal Data System, we performed a retrospective cohort study of 8481 patients who were or who were not treated by long-term dialysis before receiving a kidney transplant from a living donor. The relative rate of allograft failure for patients who received a transplant without previously undergoing long-term dialysis, as compared with patients who underwent long-term dialysis before transplantation, was assessed by proportional-hazards analysis, with adjustment for potential confounding variables, including the transplantation center and median household income. The association between the receipt of a kidney transplant from a living donor without previous dialysis ("preemptive transplantation") and the risk of biopsy-confirmed acute rejection within six months after transplantation was evaluated by conditional logistic-regression analysis, with adjustment for the transplantation center. Transplantation of a kidney from a living donor without previous long-term dialysis was associated with a 52 percent reduction in the risk of allograft failure during the first year after transplantation (rate ratio, 0.48; P=0.002), an 82 percent reduction during the second year (rate ratio, 0.18; P=0.001), and an 86 percent reduction during subsequent years (rate ratio, 0.14; P=0.001), as compared with transplantation after dialysis. The reduction in the rate of allograft failure during the first year was attenuated when adjustment was made for the timing of acute rejection within the first year (rate ratio, 0.69; 95 percent confidence interval, 0.44 to 1.10; P=0.10). Increasing duration of dialysis was associated with increasing odds of rejection within six months after transplantation (P=0.001). Preemptive transplantation of kidneys from living donors without the previous initiation of dialysis is associated with longer allograft survival than transplantation performed after the initiation of dialysis.

                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                22 January 2003
                : 21
                : 1
                : 137-142
                aDivision of Nephrology, Tufts-New England Medical Center, Boston, Mass., USA and bDivision of Nephrology, St. Paul’s Hospital, University of British Columbia, Vancouver, B.C., Canada
                67871 Blood Purif 2003;21:137–142
                © 2003 S. Karger AG, Basel

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                Figures: 4, Tables: 1, References: 35, Pages: 6
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