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ABSTRACT: OBJECTIVE:: Minimally invasive techniques have expanded the donor pool for living kidney donation. We changed our approach to single-port donor nephrectomy in 2009 and have compared outcomes with traditional multiple-port laparoscopic donor nephrectomy. BACKGROUND:: The development of minimally invasive surgical techniques to procure kidneys from living donors has allowed expansion of living donor renal transplantation to account for one third of all renal transplants. Recent technical advancement allows for the entire surgical procedure to be done through a single incision contained within the umbilicus. METHODS:: We compared outcomes from 135 single-port donor nephrectomies with an immediately preceding cohort of 100 multiple-port laparoscopic donor nephrectomies. Survey data were collected from both groups to compare outcomes. Additional comparisons were made to total center experience with 1300 laparoscopic donor nephrectomies. RESULTS:: A total of 135 patients completed successful single-port donor nephrectomy without major complication or open conversion. Another 16 patients required additional port placement because of excessive intra-abdominal fat or limited abdominal domain. Compared with multiple-port donor nephrectomy, single-port patients had similar operative times to cross clamp (2.8 vs 2.6 hours; P = 0.11) that normalized after a learning curve of approximately 50 cases. Recipient creatinine levels were similar at 1 week and 1 month posttransplant. Although 36-Item Short Form Health Surveys demonstrated no significant differences, additional survey data revealed that single-port patients were more satisfied with cosmetic outcomes (P < 0.01) and the overall donation process (P = 0.01). Single-port approach had similar outcomes compared with all previous laparoscopic donor nephrectomies. CONCLUSIONS:: Single-port donor nephrectomy can be integrated as a standardized approach for renal donation without additional donor risk, and with benefits of improved patient satisfaction with cosmetic and overall outcomes. Although the primary benefit is cosmetic, (a single incision predominantly contained within the umbilicus) outcomes justify application for kidney donors in experienced centers and may motivate additional living kidney donation.
Annals of surgery 09/2012; · 7.90 Impact Factor
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ABSTRACT: Controversy exists regarding the benefit of ureteral stents in kidney transplantation. We aimed to examine the association of stents with risk of ureteral complications, particularly in relationship with donor type.
Kidney transplants from 2005 to 2009 were evaluated (n=1224). Patients with previous or simultaneous nonkidney transplants, death, or lost to follow-up within 90 days were excluded, unless already developed a ureteral complication. Only cases with a single extravesical ureteroneocystostomy were included. The cohort (n=961) was divided into stent (32.2%) and no-stent (67.7%) groups. Poisson regression was used to examine the association of stent with ureteral complications (leak or stricture) and urinary tract infections (UTI).
Ureteral complication rate was 1.9% in stent versus 5.8% in no-stent group (P=0.007). UTI rate was 14.2% with stent versus 7.9% without stent (P=0.003). Stent use was independently associated with reduction in ureteral complications (incidence rate ratios [IRR], 0.40; P=0.04; 95% confidence interval [CI], 0.17-0.96) and an increase in UTI risk (IRR, 1.79; P=0.006; 95% CI, 1.18-2.74). Stent protective effect was primarily related to reduction in stricture risk (IRR, 0.23; P<0.05; 95% CI, 0.05-0.99). Stents were associated with a decrease in ureteral complications in deceased donor recipients (IRR, 0.34; P=0.03; 95% CI, 0.13-0.88), but not living donors (IRR, 1.24; P=0.84; 95% CI, 0.15-10.2).
Ureteral stents are associated with a significant reduction in ureteral complications but increases UTI risk. Routine stenting in deceased donor transplants is recommended as its protective effect was observed in this group. The value of stents in living donor transplants warrants further investigation.
Transplantation 12/2011; 93(3):304-8. · 4.00 Impact Factor
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ABSTRACT: Abstract Orlistat is a United States Food and Drug Administration (FDA)-approved drug indicated for the management of obesity. The FDA has issued a warning of rare, but severe, reports of liver injury after orlistat use. We describe a 40-year-old woman with no significant medical history who experienced fulminant liver failure after orlistat use. Two weeks after taking the drug at a low dosage of 60 mg/day for 4 days, she developed significant fatigue, nausea, right upper abdominal discomfort, and icterus, and her liver enzyme panel showed significant abnormalities. Five weeks later, after further deterioration in her clinical status, she was transferred to our medical center with severe cholestasis and coagulopathy. Liver ultrasonography, serologies for viral hepatitis, and autoimmune markers were unremarkable. Early cessation of the drug was not sufficient to stop the progression of liver injury, and she required an orthotopic liver transplant. Two weeks after transplantation, she was discharged in good condition. Published reports of liver injury associated with orlistat use describe a presentation similar to that of our patient. Although use of the Naranjo adverse reaction probability scale indicated a possible relationship (score of 3) between the patient's development of fulminant liver failure and orlistat, we believe this was a drug-induced case and is consistent with previous reports. To our knowledge, this is the first published report of orlistat-induced liver failure in the United States. Although orlistat may be a useful drug for weight loss, clinicians should be aware that its use can rarely cause idiosyncratic hepatotoxicty characterized by subacute hepatitis, which may progress to serious injury.
Pharmacotherapy 11/2011; 31(11):1145. · 2.90 Impact Factor
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ABSTRACT: Cytomegalovirus (CMV) infection is responsible for significant morbidity and mortality among solid organ transplant recipients. Prophylaxis using valganciclovir (VGCV) in orthotopic liver transplant (OLT) recipients is not approved by the Food and Drug Administration and its use is controversial. This study aimed to evaluate the effectiveness of VGCV in CMV prophylaxis in OLT recipients.
We carried out a retrospective, single-centre study including all OLT procedures performed during 2005-2008. Patients with early death (at ≤ 30 days), without CMV serology or prophylaxis, or with follow-up of <1 year were excluded.
The overall incidence of CMV disease was 6% (n= 9). The ganciclovir (GCV) and VGCV groups had similar incidences of CMV disease (4.6% vs. 7.0%; P= 0.4) and similar distributions of disease presentation (CMV syndrome vs. tissue-invasive CMV; P= 0.4). Incidences of CMV infection, as well as disease presentation, were similar between the high-risk (CMV D+/R-) and non-high-risk groups (P= 0.16). Although acute cellular rejection occurred more frequently in patients who developed CMV disease (P= 0.005), overall survival in these patients did not differ from that in patients who did not develop CMV infection (P= 0.5).
Valganciclovir is an effective antiviral for the prevention of CMV disease in liver transplant recipients. Our data support its use in high-risk OLT patients.
HPB 12/2010; 12(10):657-63. · 1.60 Impact Factor
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ABSTRACT: Major hepatic necrosis (MHN) is a common complication after angioembolization (AE) for severe liver injuries. We compared the outcomes of two treatment modalities.
Patients with MHN were retrospectively reviewed from January 2002 to October 2007. Demographics, Injury Severity Scale score, length of stay, admission Glasgow Coma Scale Score, mortality, transfusion requirements, intra-abdominal complications, admission physiologic variables, and the number and type of abdominal procedures (operative or nonoperative) were collected. These patients were then divided into two groups-those treated with hepatic lobectomy (HL) and those treated with multiple procedures including serial operative debridements and/or percutaneous drainage (IR/OR).
Thirty patients (41%) with MHN were identified from 71 patients who had AE. Sixteen patients with MHN underwent HL and 14 patients underwent multiple IR/OR procedures. The two groups were similar at baseline, except that the HL group had a higher Injury Severity Scale score. Outcomes between the two groups were similar. There was a significantly higher complication rate and increased number of procedures in the IR/OR group. There were no deaths in patients who had early HL (<5 days). There was one death in the later lobectomy group.
MHN is a common complication after AE. This complication can be safely managed with a series of operative debridements in conjunction with interventional procedures or with HL. Lobectomy is associated with a lower complication rate and a fewer number of procedures. Early lobectomy may be better than a delayed procedure.
The Journal of trauma 09/2010; 69(3):562-7. · 2.48 Impact Factor
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ABSTRACT: The benefits of renal transplantation for patients with end-stage renal disease on hemodialysis are well established, but currently there is a significant shortage of organs available for transplantation. In an effort to increase the size of the donor pool, donors that may have been excluded from donating previously are currently accepted. Frozen section evaluation of preimplantation donor kidney biopsies is particularly important for organs from these expanded criteria donors, both to determine organ suitability and as a tool to predict short- and long-term graft survival. Although significant progress has been made in the field, controversy still remains regarding the predictive value of the individual pathologic parameters to predict graft outcome. The Maryland Aggregate Pathology Index score is based on the identification of 5 histologic parameters and is used to stratify donor organs into low-, intermediate-, and high-risk groups, which correlate with overall graft survival. Irrespectively of the transplant donor population, preimplantation donor kidney frozen section evaluation is an invaluable tool for optimal use of the available organs.
Pathology Case Reviews 08/2010; 15(5):174-178.
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Clinical transplants 01/2010;
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ABSTRACT: Liver transplantation is performed based on ABO blood type compatibility without dependence on crossmatch results. Combined liver-kidney transplantation (CLKT) is similarly performed without dependence of crossmatch results as the liver is thought to confer protection to the renal allograft against alloantibody. We report a case of CLKT in a sensitized patient with antibody-mediated rejection (AMR) of the renal allograft. AMR was confirmed with C4d staining and serial monitoring of donor-specific antibody (DSA). Despite intensive therapy directed against AMR and the presence of the liver allograft, the patient demonstrated increasing titers of alloantibody, never demonstrated adequate renal function, and ultimately expired after two months. This result demonstrates the potential for AMR of the renal allograft in sensitized recipients of CLKT.
Clinical Transplantation 11/2009; 24(5):685-90. · 1.67 Impact Factor
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Transplantation 08/2009; 88(1):145-6. · 4.00 Impact Factor
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ABSTRACT: The specific role of different immunosuppressive agents as risk factors for BK virus nephropathy (BKN) has not been well studied.
In this case-control study, we examined the association of tacrolimus (TAC), mycophenolate mofetil (MMF), and prednisone with BKN in renal allograft recipients transplanted between 1997 and 2004 at our center who underwent biopsies for allograft dysfunction. Drug levels or doses were recorded during the 3 months before the index biopsy. Random effects logistic modeling was used for data analysis.
There were 33 cases with BKN, biopsied at 16.4+/-2.8 months and 66 matched controls with biopsies at 21.5+/-2.1 months posttransplant (P=0.16). After adjusting for sex, race, retransplant status, diabetes, donor source, and induction agent, TAC blood level was associated with increased risk of BKN (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.02-1.7, P=0.03), whereas MMF dose was not (OR 1.0, 95% CI 0.99-1.0, P=0.2). Moreover, prednisone dose was also found to be a significant risk factor for BKN (OR 1.22, 95% CI 1.04-1.4, P=0.02).
The results of this study show that BKN is associated with TAC level and prednisone dose and not with MMF dose. This suggests that reducing TAC and prednisone dose and maintaining MMF may be a more appropriate initial approach for the treatment of BKN. Further studies are needed to compare the efficacy and safety of this approach with the currently recommended one.
Transplantation 08/2009; 88(1):83-8. · 4.00 Impact Factor
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ABSTRACT: Optimal immunosuppression (IS) for elderly kidney transplant recipients is unknown. We conducted a retrospective cohort study of recipients aged 60 yr or older to examine the impact of reduced IS on graft outcomes. Group 1 patients (n = 101) were initiated on mycophenolate mofetil 2 g/d and tacrolimus, target level 10-12 ng/mL; Group 2 patients (n = 88) with 1 g/d and 8-10 ng/mL, respectively. Dose adjustments were made as required. The groups were comparable except for diabetes, end-stage renal disease duration, and induction. Mycophenolate mofetil dose was reduced in 62% and 38% of the patients, respectively (p < 0.01). Patients were followed for 23.8 +/- 14.2 and 21.3 +/- 11.8 months post-transplant (p = 0.2). Twenty-seven cases in Group 1 (26.7%) and eight in Group 2 (9.1%) lost their grafts (p = 0.01); 19 (18.8%) and 7 (8.0%) cases in each group because of death, respectively (p = 0.09). Sixteen patients in Group 1 (15.8%) and 18 in Group 2 (20.5%) experienced acute rejection (p = 0.36). Patients in Group 2 had a lower risk of graft loss compared with those in Group 1 [adjusted hazard ratio (HR): 0.27, p = 0.006, 95% CI: 0.11-0.69]. There were no significant differences between the groups regarding graft function, BK virus nephropathy, and CMV infection. Our results suggest that reduction in overall IS in this group was associated with improved graft and patient survival.
Clinical Transplantation 07/2009; 23(6):930-7. · 1.67 Impact Factor
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ABSTRACT: Renal transplantation (RTx) in the geriatric population (age >65 years) accounts for 14% of all RTx performed nationally in 2007.
We reviewed 3297 RTx recipients from our database over a 15-year period to evaluate recipient and donor age, date of transplant and graft loss, cause of graft loss, and cold ischemic time in the geriatric population.
Since 1991, we have performed 468 living donor RTx (LDRTx) and deceased donor RTx (DDRTx) in patients more than 65 years: 280 (65-69 years), 128 (70-74 years), and 60 (>75 years). Geriatric recipients of DDRTx demonstrated 83.0%, 74.1%, and 64.1% uncensored graft survival at 1, 3, and 5 years, respectively. Interestingly, these rates were similar compared with DDRTx in adults (18-64 years, P=0.49). Geriatric recipients of LDRTx demonstrated 1-year, 3-year, and 5-year graft survival rates of 94.3%, 88.8%, and 72.3%, respectively. Although better than geriatric DDRTx recipients, these results were not equal to the success of adult LDRTx recipients, potentially because of poorer graft survival in LDRTx recipients more than 75 years (P=0.004). Death-censored graft survivals were similar between adult and geriatric recipients of LDRTx (P=0.28). Graft loss secondary to death was twice as great in geriatric versus adult recipients (P<0.01).
DDRTx geriatric recipients of each group showed similar uncensored graft survivals to adult DDRTx recipients. LDRTx had better outcomes than DDRTx in geriatric recipients. Death-censored outcomes were similar between adult and geriatric LDRTx recipients. These data support the equivalent outcomes of RTx in appropriately selected geriatric recipients.
Transplantation 05/2009; 87(10):1549-54. · 4.00 Impact Factor
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ABSTRACT: Hepatocellular carcinoma (HCC) usually affects patients with chronic liver disease. While resection is the primary treatment of HCC in patients without cirrhosis, in the setting of moderate to severe cirrhosis, liver transplantation is the preferred therapy, as it simultaneously treats the tumor and the underlying liver condition. The optimal management of patients with HCC and early cirrhosis remains controversial. Although liver transplantation for HCC within the Milan criteria has been shown to have excellent long-term survival rates and low recurrence rates, its application is limited by organ availability. Due to the shortage of donors, a portion of patients drop out from the waiting list due to tumor progression. One alternative to transplantation is hepatic resection. In addition to the reported 50% 5-year survival rates, resection allows a better understanding of tumor biology through pathologic examination of the specimen, which may guide decision-making regarding salvage liver transplantation. Other nonsurgical locoregional therapies, such as transarterial chemoembolization and radiofrequency ablation, also serve as primary therapies and as a bridge to transplantation. The management of patients with early HCC is complex and multidimensional. The care of these patients is best served by a multidisciplinary approach, with consideration of the feasibility of transplantation weighed against the aggressiveness of the tumor biology and underlying hepatic dysfunction. All modalities of therapy should be viewed as complementary, not exclusive, therapeutic strategies.
Annals of Surgical Oncology 04/2009; 16(7):1820-31. · 4.17 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the basis for the racial/ethnic disparity in kidney allograft survival.
We conducted a retrospective study of 2130 patients who underwent kidney transplantation between January 1995 and December 2003. Patient and graft survivals were compared using Kaplan-Meier analysis.
Black recipients were more likely than white recipients to have hepatitis C infection (24.6% vs 7.1%), current tobacco use (21.2% vs 13.1%), previous alcohol use (22.6% vs 9.7%), and past illicit drug use (13.6% vs 3.9%). Current employment was less common among blacks. Additionally, black recipients were more likely to have a prior kidney transplant (16.7% vs 11.0%) and to have a cadaver kidney donor (74% vs 56.5%). The 5-year allograft survival rate was 72% for whites and 59% for blacks (p < .01). Previous kidney transplantation, cadaveric donor, donor age, recipient employment status, and recipient tobacco use were associated with allograft survival in a Cox proportional hazard model.
Graft survival rate in black kidney transplant recipients is significantly lower than whites, and this disparity can be partially explained by the low rate of live donors and a higher previous transplantation rate in blacks.
Journal of the National Medical Association 02/2009; 101(2):111-5. · 1.16 Impact Factor
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Clinical transplants 01/2009;
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Hari Nathan,
Gilles Mentha,
Hugo P Marques,
Lorenzo Capussotti,
Pietro Majno,
Luca Aldrighetti,
Carlo Pulitano,
Laura Rubbia-Brandt,
Nadia Russolillo, Benjamin Philosophe,
Eduardo Barroso,
Alessandro Ferrero,
Richard D Schulick,
Michael A Choti,
Timothy M Pawlik
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ABSTRACT: Several staging systems for patients with hepatocellular carcinoma (HCC) have been proposed, but studies of their prognostic accuracy have yielded conflicting conclusions. Stratifying patients with early HCC is of particular interest because these patients may derive the greatest benefit from intervention, yet no studies have evaluated the comparative performances of staging systems in patients with early HCC.
A retrospective cohort study was performed using data on 379 patients who underwent liver resection or liver transplantation for HCC at six major hepatobiliary centres in the USA and Europe. The staging systems evaluated were: the Okuda staging system, the International Hepato-Pancreato-Biliary Association (IHPBA) staging system, the Cancer of the Liver Italian Programme (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Japanese Integrated Staging (JIS) score and the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging system, 6th edition. A recently proposed early HCC prognostic score was also evaluated. The discriminative abilities of the staging systems were evaluated using Cox proportional hazards models and the bootstrap-corrected concordance index (c).
Overall survival of the cohort was 74% at 3 years and 52% at 5 years, with a median survival of 62 months. Most systems demonstrated poor discriminatory ability (P > 0.05 on Cox proportional hazards analysis, c approximately 0.5). However, the AJCC/UICC system clearly stratified patients (P < 0.001, c = 0.59), albeit only into two groups. The early HCC prognostic score also clearly stratified patients (P < 0.001, c = 0.60) and identified three distinct prognostic groups.
The early HCC prognostic score is superior to the AJCC/UICC staging system (6th edition) for predicting the survival of patients with early HCC after liver resection or liver transplantation. Other major HCC staging systems perform poorly in patients with early HCC.
HPB 01/2009; 11(5):382-90. · 1.60 Impact Factor
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ABSTRACT: Pancreas transplant alone (PTA) is a controversial procedure. Without clearly demonstrated patient survival, recipients report improved quality of life. Nephrotoxic immunosuppression (IS) may exacerbate diabetic renal injury post-PTA.
A single institution retrospective review of patients receiving PTA over a 14-year period was completed. Patient and donor demographics, surgical outcomes, rejection, and patient or graft survival were analyzed. Pre- and Postoperative estimated glomerular filtration rates (eGFR) were calculated based on the modification of diet and renal disease. Multivariate analysis was performed.
One hundred twenty-three patients undergoing 131 PTAs had an average age of 40.0 years. Seven patients were retransplanted and one received a third pancreas. Mean graft survival was 3.26 years (0-11.3 years) with 21 patients (17%) lost to follow-up. One- and 5-year patient survivals were 96.6% and 91.5%, respectively (mean, 7.15 year). Seventeen patients had an eGFR less than 50 mL/min/1.73 m preoperatively, whereas 64 patients did so post-PTA and 24 had an eGFR less than 30 mL/min. Mean eGFR pretransplantation was 88.9 vs. 55.6 posttransplantation (P<0.0001) with mean follow-up of 3.68 years. All but 16 (12%) patients showed a decrease in eGFR. Mean decrement was 32.1 mg/min/1.73 m. Thirteen developed end-stage renal disease chronic kidney disease (CKD 5) requiring kidney transplantation (KT) at a mean of 4.36 years. Eighty-three patients had an episode of rejection. In post-PTA RF, graft survival was 3.2 vs. 2.4 years (P=0.13). In those requiring KT, graft survival was 7.9 vs. 2.9 years (P<0.0001). Cold ischemia times, donor age, and preoperative eGFR for those with and without RF-requiring KT were not significant. Body mass index was statistically significant. Leukocyte-depleting agents was evaluated, but was not significant. All patients received calcineurin inhibitor IS.
Patients who undergo PTA may be at increased risk for RF. After comparing patient and donor demographics, IS, and human leukocyte antigen mismatch, it seems that PTA is an independent risk factor for the development of renal failure. Patients with more successful pancreatic grafts demonstrated lower eGFR. Patients should be made aware of the risks of long-term IS. Only the most appropriate patients should be chosen for PTA.
Transplantation 12/2008; 86(12):1789-94. · 4.00 Impact Factor
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Emily C Bellavance,
Kimberly M Lumpkins,
Gilles Mentha,
Hugo P Marques,
Lorenzo Capussotti,
Carlo Pulitano,
Pietro Majno,
Paulo Mira,
Laura Rubbia-Brandt,
Alessandro Ferrero,
Luca Aldrighetti,
Steven Cunningham,
Nadia Russolillo, Benjamin Philosophe,
Eduardo Barroso,
Timothy M Pawlik
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ABSTRACT: The surgical management of hepatocellular carcinoma in patients with well-compensated cirrhosis is controversial. The purpose of the current study was to compare the outcome of patients with well-compensated cirrhosis and early stage hepatocellular carcinoma treated with initial hepatic resection versus transplantation.
Between 1985 and 2008, 245 patients underwent hepatic resection, and 134 patients underwent liver transplantation for early stage hepatocellular carcinoma. All patients had well-compensated cirrhosis. Prognostic factors were evaluated using univariate and multivariate analyses; survival was calculated using the Kaplan-Meier method.
Compared with transplantation, patients undergoing resection had larger tumors and a higher incidence of microscopic vascular invasion. Transplantation was associated with better 5-year disease-free and overall survival compared with resection. Hepatitis status, presence of microscopic vascular invasion, and tumor size were predictors for recurrence, while the presence of microscopic vascular invasion and tumor size conferred an increased risk of death. The disease-free survival advantage with transplantation was more pronounced in hepatitis C patients compared with non-hepatitis and hepatitis B patients. The overall survival advantage with transplantation persisted in cases of solitary lesions < or = 3 cm, but was attenuated in patients with a MELD score < or = 8.
In well-compensated cirrhotic patients with early stage hepatocellular carcinoma, transplantation was associated with longer disease-free and overall survival. Patients undergoing resection did, however, have tumors with more advanced pathologic features. Patients best suited for initial resection as the treatment of hepatocellular carcinoma were those with a MELD score </= 8 without evidence of hepatitis.
Journal of Gastrointestinal Surgery 08/2008; 12(10):1699-708. · 2.83 Impact Factor
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ABSTRACT: Thymoglobulin (rATG) has become the agent of choice for induction therapy in high immunological risk kidney transplant recipients. However, its optimal dosing in this subgroup has not been studied.
To evaluate the effect of total rATG dosing on graft outcomes in such patients, we conducted a retrospective cohort study of 96 adult patients who received repeat transplants (85%) or had panel reactive antibody more than 40% (19%) and were maintained on tacrolimus, mycophenolate mofetil, and steroid. Group 1 (n=33) received less than or equal to 7.5 and group 2 (n=63) received more than 7.5 mg/kg rATG. Graft and patient survival, incidence of acute rejection (AR), and 12-month serum creatinine (SCr) were examined.
The groups were comparable regarding demographics, donor source, retransplantation, panel reactive antibody, and human leukocyte antigen mismatch. Group 2 had more African Americans (44.4% vs. 21.2%, P=0.03). During the 25.4+/-18.0 months follow-up graft survival was 82.5% and 79.4%, respectively (P=0.54). Three in group 1 and four in group 2 died (P=0.65). The incidence of biopsy proven AR during the first 12-months did not differ between the groups (9.5% vs. 8.8%, respectively, P=0.9). SCr at 12 months was 1.6+/-0.7 in group 1 and 1.8+/-1.0 in group 2 (P=0.3). There was no independent association between rATG dose and graft survival (hazard ratio: 0.85, P=0.79, 95% CI: 0.26-2.7 for group 2 vs. 1) or 1-year SCr (regression coefficient=0.02 for ln(SCr), P=0.3; 95%CI: -0.01 to 0.6).
Our results suggest that in high risk kidney transplant recipients total rATG doses less than or equal to 7.5 mg/kg are safe and effective in achieving a low rate of AR and graft outcomes comparable to higher doses.
Transplantation 06/2008; 85(10):1425-30. · 4.00 Impact Factor
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Transplantation 01/2007; 82(11):1549. · 4.00 Impact Factor
