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      Tackling the Shortage of Donor Kidneys: How to Use the Best that We Have

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          Shortage of kidney donor is still a major limitation for renal transplantation programs. This review focuses on the emerging practices, adopted to increase transplant activities, of expanding the criteria for donor and recipient selection without exposing the recipient to the drawbacks of a graft with inadequate nephron mass. Expanding the donor pool inevitably led to consideration for kidney transplantation of organs from older donors or from donors with hypertension, diabetes or other renal diseases. To fit the reduced performance of these suboptimal organs with the renal requirement of the recipient, selection of recipients with reduced metabolic requirements or increase of nephron mass by simultaneous transplantation of two suboptimal kidneys in the same recipient have been pursued. However, a critical aspect of both approaches is to quantify functioning nephron mass provided to the recipient by pre-transplant kidney biopsies. Morphological parameters assessed on kidney biopsies at the time of donor evaluation may serve to quantify the preserved tissue and to discriminate chronic irreversible lesions from acute changes that may account for a transiently impaired renal function in the donor, but that may recover after transplant.

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          Most cited references 24

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          Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients.

          To compare mortality risk among cadaveric renal transplant recipients vs transplant candidates on dialysis in the cyclosporine era. Patient mortality risk was analyzed by treatment modality for a completed statewide patient population. All Michigan residents younger than age 65 years who started endstage renal disease (ESRD) therapy between January 1, 1984, and December 31, 1989, were included. Patients were followed up from ESRD onset (n = 5020), to wait-listing for renal transplant (n = 1569), to receiving a cadaveric first transplant (n = 799), and to December 31, 1989. Mortality rates. Using a time-dependent variable based on the waiting time from date of wait-listing to transplantation and adjusting for age, sex, race, and primary cause of ESRD, the relative risk (RR) of dying was increased early after transplantation and then decreased to a beneficial long-term effect, given survival to 365 days after transplantation (RR, 0.36; P .05). Overall, the estimated times from transplantation to equal mortality risk was 117 +/- 28 days and to equal cumulative mortality was 325 +/- 91 days. The overall mortality risk following renal transplantation was initially increased, but there was a long-term survival benefit compared with similar patients on dialysis. These analyses allow improved description of comparative mortality risks for dialysis and transplant patients and allow advising patients regarding comparative survival outcomes.
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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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              Serum creatinine is an inadequate screening test for renal failure in elderly patients.

              Serum creatinine is the most commonly used screening test for renal failure. We hypothesized that serum creatinine would underestimate the degree of renal failure in elderly people because they have a reduced muscle mass. If so, this would lead to underrecognition and thus suboptimal care of patients with severe renal failure. We conducted a retrospective medical record review of all patients 65 years or older in an outpatient academic family medicine practice. The glomerular filtration rate was calculated using the Cockcroft and Gault formula and was used to evaluate the testing characteristics of serum creatinine for the detection of renal failure. We screened 1510 patients, 854 (56.6%) of whom met the inclusion criteria. Renal failure (glomerular filtration rate, 150 micro mol/L) had a sensitivity of 12.6% and a specificity of 99.9% for the detection of renal failure. For the detection of severe renal failure, the sensitivity was 45.5%, with a 99.1% specificity. Only 15 (27.3%) of the 55 patients with severe renal failure were referred to a nephrologist. Moreover, 34 (85%) of the 40 nonreferred patients with severe renal failure were incompletely evaluated regarding the metabolic complications associated with kidney dysfunction. Serum creatinine is a poor screening test for renal failure in elderly patients, leading to marked underinvestigation and underrecognition of renal failure in this population.

                Author and article information

                Am J Nephrol
                American Journal of Nephrology
                S. Karger AG
                August 2003
                31 July 2003
                : 23
                : 4
                : 245-259
                aDepartmentof Medicine and Transplantation, Ospedali Riuniti Bergamo, Mario Negri Institute for Pharmacological Research, Bergamo, and bCentro Trasfusionale e di Immunologia dei Trapianti Ospedale Maggiore Policlinico Milano, Centro Interregionale di Riferimento per l’Area Operativa Nord Italia Transplant, NITp, Milan, Italy
                72055 Am J Nephrol 2003;23:245–259
                © 2003 S. Karger AG, Basel

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                Page count
                Figures: 1, Tables: 2, References: 118, Pages: 15
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/72055
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