Carroll Robert P, Macgregor Lachlan, Walker Rowan G
Department of Nephrology, Royal Melbourne Hospital, Melbourne, Vic., Australia.
Clin Transplant. 2008 May-Jun;22(3):324-32. doi: 10.1111/j.1399-0012.2007.00789.x. Epub 2008 Jan 9.
To compensate for the shortage of donor kidneys, use of expanded donor criteria (ECD) has been adopted by many transplant centres. Multiple criteria on which to score such kidneys have been proposed but the evidence base for the definitions is derived from retrospective and registry data only. We aimed to see if analysis of ECD in our population would indicate the need to change our donor selection process.
Data on primary kidney transplants (minimum follow-up two yr) from 1989 to 2004 were reviewed (n = 635). The primary study endpoint was overall graft survival. Published ECD, including the United Network for Organ Sharing (UNOS) ECD criteria were assessed as potential prognostic variables, in a multivariable Cox proportional hazards model.
Patients transplanted after 1996 had improved graft survival compared to those transplanted pre-1996 HR = 0.51 (0.35-0.76), p = 0.0001. Pre-1996 UNOS defined ECD kidneys had a markedly increased risk of graft failure compared to live donor kidneys HR = 3.52 (1.9-6.35), p < 0.001. Post-1996 ECD kidneys had similar prognosis compared to live donor kidneys HR 0.38 (0.1-1.59), p = 0.184. The observed improvement in graft survival was not explained by changes in donor source, cause of end stage renal failure (ESRF), human leukocyte antigen mismatch, recipient age or any histological parameter on implantation biopsy.
The explanation for improved overall graft survival and marked improved survival of ECD kidneys is unclear, but introduction of mycophenolate and subsequent falls in calcineurin inhibitor doses over the study period could be potential factors. These results provide some justification for our current selection and management of ECD kidneys.
为弥补供肾短缺，许多移植中心已采用扩大标准供体（ECD）。已提出多种对这类肾脏进行评分的标准，但这些定义的证据基础仅来自回顾性研究和登记数据。我们旨在研究对我们人群中ECD的分析是否表明有必要改变我们的供体选择过程。
回顾了1989年至2004年原发性肾移植的数据（最小随访两年）（n = 635）。主要研究终点是移植肾总体存活率。在多变量Cox比例风险模型中，将已发表的ECD，包括器官共享联合网络（UNOS）的ECD标准评估为潜在的预后变量。
1996年后接受移植的患者与1996年前接受移植的患者相比，移植肾存活率有所提高，风险比（HR）= 0.51（0.35 - 0.76），p = 0.0001。1996年前UNOS定义的ECD肾脏与活体供肾相比，移植失败风险显著增加，HR = 3.52（1.9 - 6.35），p < 0.001。1996年后的ECD肾脏与活体供肾相比预后相似，HR = 0.38（0.1 - 1.59），p = 0.184。观察到的移植肾存活率提高不能用供体来源、终末期肾衰竭（ESRF）病因、人类白细胞抗原错配、受者年龄或植入活检时的任何组织学参数的变化来解释。
移植肾总体存活率提高以及ECD肾脏存活率显著提高的原因尚不清楚，但在研究期间引入霉酚酸酯以及随后钙调神经磷酸酶抑制剂剂量的降低可能是潜在因素。这些结果为我们目前对ECD肾脏的选择和管理提供了一些依据。
