Delayed graft function requiring more than one-time dialysis treatment is associated with inferior clinical outcomes

Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, USA.
Clinical Transplantation (Impact Factor: 1.52). 09/2012; 26(5):E536-43. DOI: 10.1111/ctr.12029
Source: PubMed


Delayed graft function (DGF) is a common complication of deceased donor kidney transplantation with negative impact on clinical outcomes. In a single-center retrospective analysis, we compared patient and kidney survival, early renal function, and the incidence of acute rejection during the first year among all adult deceased donor kidney transplant patients without DGF, with DGF requiring one-time and/or more than one-time dialysis treatment between January 1, 2000, and December 31, 2008. Of 831 adult kidney transplant patients, 74 (8.9%) required one-time and 134 (16.1%) more than one-time dialysis treatment post-transplantation, respectively. While DGF patients with one-time dialysis treatment had comparable clinical outcomes to that of patients without DGF, patients with DGF requiring more than one-time dialysis treatment had a 45% increased risk for death (HR 1.45, 95% CI 1.02, 2.05, p = 0.04) after adjustment for the differences in demographic and baseline characteristics. Furthermore, DGF patients with more than one-time dialysis requirement displayed significantly lower renal function after recovery (OR 0.32, 95% CI 0.21, 0.49, p < 0.001, for eGFR ≥ 60 mL/min) and higher incidence of acute rejection during the first year (OR 1.66, 95% CI 1.11, 2.49, p = 0.015). Additional studies of therapeutic approaches to manage patients with prolonged DGF are needed.

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    ABSTRACT: Introduction: Delayed graft function (DGF), a well-known immediate postoperative complication is defined as the need for dialysis during the first week after deceased donor kidney transplantation. It affects 25% to 50% of recipients. In this study we identified risk factors for DGF and its impact on patient and graft survivals. Methods: We retrospectively analyzed medical records from renal transplant recipients aged above 18 years who received a deceased donor kidney graft between November 2008 and December 2011, excluding kidney losses during the first week. Results: Among 137 transplantations, 64 (46.5%) displayed DGF. Multivariate analysis showed secondary renal disease (OR 3.7, CI 1.36-10.30; P = .011), HLA mismatches > 3 (OR 4.4, CI 1.53-12.51; P = .006) and donor urine output ≤ 3000 ml/24h (OR 25.8, CI 3.60-185.70; P = .001) to be significant risk factors for DGF. The hospitalization time was longer in the DGF group (38,2 ± 20,75 vs. 25,6 ± 8,18; P < .001). At 1 month, DGF group showed worse graft function based upon serum creatinine: 207.7 ± 148.52 vs 118.1 ± 36.63 μmol/L (P < .001). At 1 year follow-up, incidence of biopsy-proven acute renal rejection episodes was higher in the DGF (28; 51,9%) vs. the non-DGF group (18; 33,3%; P = .05). The 1-year recipient survival in DGF and no DGF groups were 90% vs 97% respectively (P = .124). With 1-year death censored graft survivals of 92% vs 100% respectively (P = .062). Conclusion: Secondary renal disease, HLA mismatches and lower donor urinary output were associated with a greater incidence of DGF, leading to prolonged hospitalizations and an increased risk for an acute rejection episode.
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    ABSTRACT: Lack of an accepted definition for 'high immunological risk' hampers individualization of immunosuppressive therapy after kidney transplantation. For recipient-related risk factors for acute rejection, the most compelling evidence points to younger age and African American ethnicity. Recipient gender, body mass, previous transplantation and concomitant infection or disease do not appear to be influential. Deceased donation now has only a minor effect on rejection risk, but older donor age remains a significant predictor. Conventional immunological markers (human leukocyte antigen [HLA] mismatching, pre-transplant anti-HLA alloantibodies and panel reactive antibodies) are being reassessed in the light of growing understanding about the role of donor specific antibodies (DSA). At the time of transplant, delayed graft function is one of the most clear-cut risk factors for acute rejection. Extended cold ischemia time (≥24 hours) may also play a contributory role. While it is not yet possible to establish conclusively the relative contribution of different risk factors for acute rejection after kidney transplantation, the available data point to variables that should be taken into account at the time of transplant. Together, these offer a realistic basis for planning an appropriate immunosuppression regimen in individual patients. This article is protected by copyright. All rights reserved.
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