Stratta Robert J, Rohr Michael S, Sundberg Aimee K, Farney Alan C, Hartmann Erica L, Moore Phillip S, Rogers Jeffrey, Iskandar Samy S, Gautreaux Michael D, Kiger David F, Doares William, Anderson Teresa K, Hairston Gloria, Adams Patricia L
Department of General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157, USA.
Ann Surg. 2006 May;243(5):594-601; discussion 601-3. doi: 10.1097/01.sla.0000216302.43776.1a.
OBJECTIVE: To compare intermediate-term outcomes in adult recipients of expanded criteria (ECD) versus concurrent standard criteria (SCD) deceased donor kidney transplants at a single center using a standardized approach. SUMMARY BACKGROUND DATA: Expanded criteria donors (ECDs) are a source of kidneys that increase the donor organ pool, but the value of transplanting these kidneys has been questioned because of concerns regarding diminished survival and predicted poorer intermediate-term outcomes. METHODS: Over a 47-month period, we performed 244 deceased donor kidney transplants into adult recipients, including 143 from SCDs and 101 from ECDs. Management algorithms were implemented to preserve nephron function, and recipient selection for an ECD kidney transplant was based on low immunologic risk. All patients received depleting antibody induction in combination with tacrolimus and mycophenolate mofetil. A total of 188 patients (77%) had at least a 1-year follow-up. RESULTS: ECDs were older, had a higher BMI, had an increased incidence of cerebrovascular brain death and preexisting donor hypertension, and had a lower estimated creatinine clearance (CrCl, all P < 0.01) compared with SCDs. Cold ischemic times were similar between groups, but more ECD kidneys were preserved with pulsatile perfusion (P < 0.01). ECD kidney recipients were older, less sensitized, had a lower BMI, had fewer 0-antigen mismatches, and had a shorter waiting time (all P < 0.01) compared with SCD kidney recipients. Actual patient (93%) and kidney graft (83%) survival rates were similar between groups with a mean follow-up of 24 months. The rates of delayed graft function (DGF), acute rejection, readmissions, operative complications, major infections, and resource utilization were comparable between groups. Renal function followed longitudinally was consistently better in SCD patients (P < 0.05). Black recipients had higher rates of DGF, acute rejection, and graft loss (P < 0.05), but the effects were less pronounced in the ECD group. CONCLUSIONS: By appropriate donor and recipient profiling and the use of management algorithms to project and protect renal function, excellent intermediate-term outcomes can be achieved with ECD kidney transplants that are comparable to SCD kidney transplants.
目的：采用标准化方法，比较单一中心成年扩大标准（ECD）供者与同期标准标准（SCD）供者死亡后肾移植受者的中期结局。 总结背景数据：扩大标准供者（ECD）是增加供肾来源的一种途径，但由于担心其生存时间缩短以及预计中期结局较差，移植这些肾脏的价值受到质疑。 方法：在47个月的时间里，我们对成年受者进行了244例死亡供者肾移植，其中143例来自SCD供者，101例来自ECD供者。实施管理算法以保护肾单位功能，ECD肾移植的受者选择基于低免疫风险。所有患者均接受耗竭性抗体诱导治疗，并联合使用他克莫司和霉酚酸酯。共有188例患者（77%）进行了至少1年的随访。 结果：与SCD供者相比，ECD供者年龄更大、体重指数更高、脑血管性脑死亡和供者原有高血压的发生率更高，估计肌酐清除率（CrCl）更低（所有P<0.01）。两组间冷缺血时间相似，但更多的ECD供肾采用搏动灌注保存（P<0.01）。与SCD肾移植受者相比，ECD肾移植受者年龄更大、致敏程度更低、体重指数更低、0抗原错配更少、等待时间更短（所有P<0.01）。两组间实际患者生存率（93%）和肾移植存活率（83%）相似，平均随访24个月。两组间移植肾功能延迟恢复（DGF）、急性排斥反应、再次入院、手术并发症、严重感染和资源利用情况相当。纵向观察，SCD患者的肾功能始终更好（P<0.05）。黑人受者的DGF、急性排斥反应和移植肾丢失发生率更高（P<0.05），但在ECD组中这些影响不太明显。 结论：通过适当的供者和受者评估以及使用管理算法来预测和保护肾功能，ECD肾移植可取得与SCD肾移植相当的优异中期结局。
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