The survival of 66 patients with retransplanted kidneys, from August 1963 to March 1973, was evaluated. The life expectancy after retransplantation is less than that after primary transplantation but the difference is mainly due to an increased early postoperative mortality. The prognosis after retransplantation is greatly improved if the second kidney is from a related donor. The prognosis is likewise improved if a longer period of time has elapsed between the two transplantations. Surprisingly, previous exposure to specific HL-A antigens does not worsen the prognosis for a subsequent transplanted kidney. © 1974, American Medical Association. All rights reserved

Husberg, BS

Starzl, TE

PubMed

Name not available

The outcome of kidney retransplantation

Bo S. Husberg

Crossref

Archives of Surgery

The Outcome of Kidney Retransplantation

D-Scholarship@Pitt

The Outcome of Kidney Retransplantation Bo S. Husberg, MD, Thomas E. Starzl, MD, PhD, Denver The survival of 66 patients with retrans- planted kidneys, from August 1963 to March 1973, was evaluated. The life expectancy af- ter retransplantation is less than that after primary transplantation but the difference is mainly due to an increased early postopera- tive mortalify. The prognosis after retrans- plantation is greatly improved if the second kidney is from a related donor. The progno- sis is likewise improved if a longer period of time has elapsed between the two transplan- tations. Surprisingly, prwious exposure to specific HL-A antigens does not worsen the prognosis for a subsequent transplanted kid- ney. M ost dialysis centers have an excessive number of uremic pa- tients. Since patients who have re- jected their transplanted kidneys add significantly to the pool of dialysis cases, i t  is an important question whether, and a t  what time, retrans- plantation should be carried out. A number of publications have implied that  the results after  retransplanta- tion are equivalent to those following a first procedure.'-'I This has not been our experience, as documented in this report of patient and kidney survival after retransplantation. An analysis is also presented of the contribution to the outcome of other factors, such as HL-A mismatch, time of retrans- plantation in relation to time of first transplantation, cause of primary graft  failure, and original kidney dis- ease. Clinical Population At our transplantation unit, 66 patients receiving their first renal homografts b e  tween November 1962 and August 1972 have later undergone one to four retrans- plantations. Follow-up data are available from a few months to more than nine years after the retransplantations. The im- munosuppressive treatment after retrans- plantation was frequently different from that used intially, since the therapy pro- vided was dependent on the management currently under evaluation for new cases.' Also, if the patients had received ALG ear- lier, they usually did not receive it after retransplantation. About half of the pa- tients underwent retransplantation with- out removal of the previous graft and without a period of dialysis prior to re- grafting.' Results Accepted for publication Dec 6, 1973. From the Department of Surgery, Denver The retrans- Veterans Administration Hospital and the Uni- plantation with our 66 patients is versity of Colorado Medical Center. Denver. Read before the 81st annual meeting of the summarized in Fig 1. More than one Western Surgical Association, Houston, Nov 17, half (35 of 66) have been followed UP 1973. for more than five vears from the Reprint requests to the Department of Sur- gery, University of Colorado Medical Center, time their primary transplantam 4200 E 9th St, Denver 50220 (Dr. Husberg). tion. The life survival, using the time of the first transplantation as the starting point, was superior a t  all subsequent levels of follow-up to that when the date of retransplantation was accepted as the starting basis for calculation. The main difference in survival was due to a heavier mortal- ity in the first three months after r e  transplantation than during the com- parable period after the primary grafting. This mortality was not a function of whether homograft ne- phrectomy and interval dialysis was elected versus prompt retransplanta- tion, leaving a failing graft  in situ without discontinuance of immuno- suppression. By the end of three months, in cases of retransplantation, there was a gap of almost 20% and, subsequently, the differential r e  mained about the same (Fig 1). The survival after  secondary trans- plantation was somewhat influenced by the kind of kidney that  was used a t  the first transplantation (Fig 2). If the first kidney was from a related donor, the overall five-year survival after the first transplant was 15 of 27 patients (56%), but after the second transplantation, the survival after five years, calculated from the time of retransplantation, was only 21% (three of 14 patients). The poor * sults were a t  least partly attributed to a heavy reliance on cadaveric kid- neys for retransplantation. When the primary kidney came from an unrelated donor, the early 584 Arch Surg/Vol 108, April 1974 IS- ed ed If ed ral 27 nd ;er ne 1% re- ;ed id- pa:ient survival after retransplanta- tion was less than that after primary transplantation, but the later sur- vi\-a1 figures were similar. I t  is note- worthy that three of the 21 recipients wcAre given kidneys from related do- nors the second time; after m&e than five years following retransplanta- tion, all three are well. As implied, the source of the sec- ondary kidney graft was profoundly influential in determining subsequent patient survival (Fig 3). When the or- gans could be obtained from related donors, the results, while not as good as for the primary consanguineous transplantations, represented a sur- vival better than 50% for five years. In contrast, recipients of unrelated (usually cadaveric) kidneys for re- transplantation had a much poorer long-term prognosis. In this latter category, none cf 12 patients has sur- vived four years. The time between first and second transplantation influenced the kidney sunrival after the second transplanta- tion (Fig 4). The kidney survival was better the longer the time between the two graft  procedures. The kidney survival with and with- out knqwn specific HL-A presen- sitization is shown in Fig 5. There were 65 grafts that, on the basis of the antigens then identifiable, did not share HL-A antigens with a previ- ously rejected transplant, and 18 grafts in which one (17 cases) or two (one case) antigens, clearly present in a nonprimary donor and foreign to  the recipient, had been present in a donor of a previous transplant. The differences in results were not differ- ent in a statistically significant way, but if anything, i t  was possibly slightly advantageous to have had an HL-A presensitization. The HL-A an- tigens involved in the cases of pre- sensitization were as follows: A2 in seven cases; A1 in three cases; A12 in two cases; and A3, A7, A10, A l l ,  W 17, W27, and Te60 in one case each (Tera- saki nomenclature). An attempt was also made to ana- lyze whether either the cause of the first graft failure or the original dis- ease of the patients influenced the re- sults. These attempts proved unre- warding in the first instance because Arch Surg/Vol 108, April 1974 n Survival after 1st Transplantation T o t a l  C a s e s  66 P a t i e n t s  Survival af ter  2nd Transplantation T l M E  I N  M O N T H S  Fig 1.-Numerators and denominators indicate patients surviving and patients at risk, re. spectively, during each time period (follow-up to Aug 1. 1973). Fig 2.-Top, Survival of 45 patients with retransplanted kidneys after first related grafts had failed. Bottom, Survival of 21 patients with retransplanted kidneys after first unrelated transplants were rejected. Numerators and denominators as in Fig 1 (follow-up to Oct 1, 1973). Survival aftsr let Related 1st Kidney Transplantation 45 Pot ients z Survival after 2nd Transplantation T l M E  IN MONTHS Survival after 1st Unrelated 1st Kidney Transplantation 21 Patients ~RTJ Survival after 2nd 0 100 Transplantation Z >5 80 a 3 * 60 Z E! 40 I- $ 2 0  LL T l M E  IN MONTHS Kidney Retransplantation/Husberg 585 Survival after 1st Fig 3.-Top, Survival of 14 pati- wit,, Related 2nd Kidney Transplantation retransplanted kidneys from a relatiw a h  first transplant had failed. Bottom, Survival 14 Patients survival after 2nd of 52 patients wtth retransplantd kidnNs Tronrplantotion I f (3 ti 100 from unrelated donors after first trans. Z plants had failed. Numerators and &nomi. I fil lt2 8 0  nators as In Fig 1 (follow-up to Oct 1,1973). > a gt ," Pi 2 60 hi of difiulties in clearly eeparatiag W $ 4 0  the patients into different nonmixed I- cause categories, and in the second in. U a 20 stance because of a heavy dominance ' a of chronic glomerulonephritie in the LL tr case material, exceeding 8046. Thie h: 3 6 9 12 18 24 30 36 42 4 8  54 60 proportion did not differ greatly from W that in our total transplant pop- PI T l M E  IN MONTHS iation. T Report of a Cars I f (  *: Survival after 1st , The course of a ayear-old woman with Unrelated 2nd Kidney Tran*pIanIation H G A  phenotype A3, W28, W10, W22 iilw 52 Patients Survival after 2nd trates same of the perplexing immunolopic 100 Transplantation considerations of primary and seco* Z renal transplantation. The first cadaverie 2 8 0  homograft, on April 13,1971, waa provided > from a donor with H L A  phenotype A2; a A7, A12 The kidney did not function wall, 2 6 0  failing to lower the blood urea nitrogen level below 70 mg/100 ml. On May 17,1971 5 4 0  - a. second cadaveric homograft woe p m  t- vided, this time from a donor with HLA $ 2 0  phenotype A2, A3, A7, Te52 Cytotoxic an- LL tigraft antibodies were not demonstrable 3 6 9 12 18 24 30 3 6  42 48 54 60 Fig 4.-Kidney survival of second trans T IME IN MONTHS plant (follow.up to Oct 1, 1973). Lass than 6rnonthr between 1st and a 2nd transplantation. 2 7  patients I Morr than 6 months brtrlaan 1st and 2nd transplantation, 39 potion18 Q More than 3 yaors between 1st and 2nd transplantation, I7 patients - 3 6 9 I 2  18 2 4  30 36 42 48 54 6 0  T l M E  IN MONTHS 586. Arch Surg/Vol 108, April 1974 Kidney Retranaplantat ion~HW 11 ith w gie uy !rie led Az; ell, >w 171, ro. rA  3n- ble (negative cross-match). In spite of the five weeks presensitization to H L A  antigens A2 and A7, the second kidney has func- tioned well until now. In July 1972, the first graft was removed, 15 months after its insertion, because of vague pain in the pneral area of the graft and poor kidney perfusion as determined by renal scan. On histopathologic examination, the kidney was found to be rejected. Comment I t  appears that  the outcome of re- transplantation in a group of patients having rejected their first grafts  is worse than that after  primary trans- plantation, but not to  a great  degree. The difference is mainly accounted for by an increased early postopera- tive mortality. I t  is an important and interesting practical consideration that such ~ a t i e n t s  also have a sub- stantially depreciated prognosis if they are returned to long-term hemo- dialysis." The type of kidney used primarily has not been considered an overriding factor in the decision of whether or not to perform a retransplantation. I t  has been considered justified to use kidneys of relatives for retransplanta- tion if such are available. as the sub- sequent result has been superior to that wikh secondary cadaveric kid- neys. The prognosis after  retrans- plantation has been better if a long period of time elapsed after  first transplantation. ~ o s s i b l ~  a long unin- terrupted period of immunosuppres- sive treatment makes the recipient better able to accept a second trans- plant. Alternatively, patients who have b o n e  chronically functioning homografts without dramatic, acute rejection episodes may represent a favorable subpopulation that  has been refined by natural selection. Specific HL-A presensitization i n  the absence of positive direct cross- match does not contraindicate a re- transplantation procedure. This could Transplantotion with known specific HLA presensit izat ion from a previous kidney gra f t  (kidney survival, 18 kidneys) Transplantotion without known specific HLA prasensitization from a previous kidney graft  (kidnay survival. 65 kidneys) T IME IN MONTHS Fig 5.-Numerators and denominators indicate kldneys funct~onlng and kidneys at risk during each time period (follow-up to Oct 1, 1973). be construed as further evidence of MD; Torben Johansen, MD; Israel Penn, MD; and the now well accepted poor dis- W. Putnam* MD. crimination of HL-A matching in predicting the outcome after  organ References transplantation.' Or if HL-A anti- gens are directly related to histocom- patibility, there is even a possibility that  specific blocking antibodies were produced as a response to the sensi- tizing antigen, since the results, if anything, were slightly better if there had been prior exposure to an  HL-A antigen found in a nonprimary donor. This investigation was supported in part by research grants from the Veterans Adminip tration Hospital, by Public Health Service re- search granta AI-AM-08898 and AM-07772, and by the General Clinical Research Centers P m  gram, Division of Research Resources, Public Health Service grants RR-00061 and RR-00069. The following doctors provided patient data for this investigation: Jacques L. Corman, MD; Robert M. Girard, MD; Gerhard Schroter, MD; Charles G. Halgrimson, MD; Makoto Ishikawa, 1. 0 elz G, Terasaki I P  Second kidney transpfants and presensitization. Trans- plant Proc 4743.748, 1972. 2. Wilson RE, et al: Panel discussion on long-term results in trans lant patients. Transplant Proc 4:749, 197i 3. Sterlin WA, et al: Rehabilitation of retransplant patients. Transplant A.oc 4751-753, 1972 4. Starzl TE, et al: Long term survival after renal transplantation in humans: With special reference to histocompatibil- ~ t y  matching, thymectomy, homograft glo- merulonephntis, heterologous ALG, and recipient malignancy. Ann Surg 172:437- 472. 1970. 5: Gustafsson A, et al: The fate of failed renal homo afts retained after retrans- plantation %rg Gqnerol Obstet 1374042, 1972 -" 6. Combined report on re lar dial sis and transplantation m #rope. l$oc EDTA 93-34, 1972. 7. Mickey MR, et al: Analysis of HLA incompatibility in human renal trans- plants. Tissue Antigens 1:57-67, 1971. 1; Arch Surg/Vol 108, April 1.4 Kidney RetranspIantationlHusberg 587 

http://d-scholarship.pitt.edu/3712/1/CV0326.pdf

The Outcome of Kidney Retransplantation

Abstract

Similar works

Full text

Available Versions

Name not available

Name not available

Crossref

D-Scholarship@Pitt