Journal Information
Vol. 42. Issue. 4.July - August 2022
Pages 1-500
Vol. 42. Issue. 4.July - August 2022
Pages 1-500
Letter to the Editor
Open Access
Pre-emptive second renal transplant from deceased donor: A new trend
Segundo trasplante renal preventivo de donante cadáver: explorando un nuevo camino
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Antonio Franco Estevea, Patricio Mas Serranob,
Corresponding author
patricio.mas.serrano@gmail.com

Corresponding author.
, Noelia Balibrea Laraa, Cristina Gilaber Brotonsa
a Servicio de Nefrología, Hospital General Universitario de Alicante, Alicante, Spain
b Servicio de Farmacia Hospitalaria, Hospital General Universitario de Alicante, Alicante, Spain
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Dear Editor,

In the United States, 4% of kidney transplant (Tx) recipients restart dialysis annually, the fifth leading cause for starting dialysis.1 Extrapolating these data to Spain, approximately 1300 patients would restart dialysis after losing their Tx each year.

These patients represent a high-risk group when they start dialysis, and, in those in whom immunosuppression is maintained, the risk of mortality is 3.4 times greater than in those in whom it is suspended.2 A preventive transplant would solve these problems, since the patient would not return to dialysis and would maintain immunosuppression.

In addition, there is debate about whether it is ethical to transplant a patient who is not on dialysis when there are patients on replacement treatment. If the case is a living donor, it would not be competitive,3–5 but there is the possibility of using a deceased donor if there is no candidate on dialysis for that graft.

We have assessed the results of a programme of preventive transplantation exclusively from deceased donors in a retrospective observational study of matched cohorts.

The 30 transplant recipients in a pre-dialysis situation who received a second Tx between 2008 and 2019 were selected and compared with a control group of 30 patients who received Tx while on dialysis. All donors were brain dead. Preventive Tx was considered with a glomerular filtration rate <15ml/min, median 10.5ml/mn, and an expected time for starting dialysis >6 months. Post-transplant follow-up was greater than 12 months.

Table 1 shows the variables of homogenisation between the groups and Table 2 those of efficacy.

Table 1.

Homogenisation variables of second transplant recipients according to their status on dialysis or pre-dialysis.

  Dialysis  Pre-dialysis  P 
Age (donors)  51.5 (45.0−60.5)  57.0 (47.5−69.3)  .129 
Gender (donors)  18/12 (60/40%)  22/8 (73.3/26.7%)  .795 
Age (2 Tx)  54.5 (39.8−57.0)  58.5 (49.0−69.0)  .011 
Gender (recipients), M/F  17/13 (56.7/43.3%)  16/14 (53.3/46.7%)  .273 
Blood type      .194 
13 (43.3%)  15 (50.0%)   
1 (3.3%)  1 (3.3%)   
AB  0 (0.0%)  3 (10.0%)   
16 (53.3%)  11 (36.7%)   
Duration of first transplant (months)  84.0 (1.0−145.5)  118.5 (80.3−173.5)  .047 
Waiting list time (months)  5.0 (2.8−11.5)  2.0 (0.88−4.0)  .002 
Cold ischaemia time (h)  17.0 (15.0−21.0)  16.5 (13.8−18.3)  .309 
Follow-up time  32.0 (14.8−45.8)  29.5 (15.0−47.8)  .767 
HLA antibodies       
Class I-positive  16 (53.3%)  11 (36.7%)  .194 
Class II-positive  13 (43.3%)  13 (43.3%)  1.000 
Class I-positive or II-positive  18 (60.0%)  14 (46.7%)  .301 
HLA incompatibilities      .774 
0−3  9 (30.0%)  8 (26.7%)   
4−6  21 (70.0%)  22 (73.3%)   
Rituximab  10 (33.3%)  5 (16.7%)  .136 
Thymoglobuline  29 (96.7%)  26 (86.7%)  .353 
Tacrolimus  28 (93.3%)  30 (100.0%)  .492 
m-TOR  18 (60.0%)  20 (66.7%)  .592 
Mycophenolate  12 (40.0%)  11 (36.7%)  .791 

In bold, significance P<.05.

Table 2.

Efficacy variables.

  Dialysis  Pre-HD  P 
Early kidney failure  2 (6.7%)  0 (0.0%)  .492 
Delayed graft function  5 (16.7%)  1 (3.3%)  .195 
Acute rejection  2 (6.7%)  3 (10.0%)  1.000 
Final creatinine (mg/dl)  1.50 (1.20−2.20)  1.45 (1.10−2.15)  .589 
Final CKD-EPI (ml/min)  45.0 (29.0−53.0)  46.9 (28.0−59.4)  .762 
Albumin/creatinine ratio (mg/g)  45 (13−102)  89 (28−211)  .164 
Patient survival time, mean (95% CI), months  97 (69−124)  131 (94−168)  .707 
Graft survival time, mean (95% CI), months  74 (47−102)  131 (94−168)  .049 

In bold, significance P<.05.

There were no differences in the homogenisation variables except in the time on the waiting list, which was lower in the study group, and in the duration of the first graft, which was higher.

There were no differences in the efficacy variables, except in the mean survival time of the recipient, which was higher in the pre-dialysis group. Johnston et al.3 also concluded that pre-emptive transplant recipients had better survival that could be explained by the reduction in dead patients with a functioning graft. Similarly, the study by Girerd et al. concludes that preventive deceased-donor retransplantation has better graft survival, similar to preventive or non-preventive live-donor graft survival.4 This has motivated us towards preventive deceased-donor retransplantation in the event that the recipient does not have a living donor and there is no other candidate on dialysis.

The incidence of delayed graft function was lower in our series in the pre-dialysis group, which coincides with other series and is attributed to the residual renal function of this group.3–5

The duration of the first transplant was longer in our pre-dialysis group, which is similar to findings in other series,3–5 and may indicate a greater immunological tolerance of this group, which is reflected in a lower percentage of pre-transplant preformed antibodies.3–5 The longer duration of the first graft is also associated with better survival of the second.3,4,6

Several authors have demonstrated that patient sensitisation is higher in the dialysis group3–5 due to the suspension of immunosuppression when they are included in dialysis.7 This would make retransplantation difficult, and their time on the waiting list is longer as presented in published series,4 as in ours. It would mean an advantage of preventive transplantation in which immunosuppression is maintained, avoiding sensitisation and a possible graft intolerance syndrome.

The longer the time spent on the waiting list, the worse is the patient and graft survival after retransplantation.6,8 These data, together with the risk of mortality in patients on immunosuppressive treatment on dialysis,2 the difficulty of managing them on dialysis, and the side effects of the treatment,9 would force us to shorten this waiting time, an objective achieved by a preventive retransplantation.

It is noteworthy that preventive retransplantation avoids dialysis comorbidities, such as catheter placement, and a significant percentage of these patients present depression when restarting dialysis, and a high number of them reject a retransplant.10

The different series present more living donors in the preveemptive group to avoid a reduction of possibilities of Tx in patients on dialysis.3–5 In our case, all donors were all deceased, which gives great homogeneity to the series and a certain originality compared to published series.

Although the benefit of this type of transplant appears to be proven, we must consider the ethical problem of re-transplanting in a recipient, undoubtedly with special characteristics, but not yet on dialysis. For this reason, we insist on performing this type of transplant only if we do not have a candidate on dialysis.

This strategy seems promising since, in the published series, there has been an increase in this type of pre-emptive retransplantation over time.3,4 Our data confirms this, since we have gone from 1% in the previous three years to 9.5% in 2017–2019 (23 out of 241 Tx; P=.001).

In conclusion, retransplantation in patients with terminal chronic dysfunction has better graft survival, avoids the recipient's return to dialysis, shortens the time on the waiting list, decreases sensitisation and eliminates the dilemma of suspending immunosuppression.

Authors

All the authors have made substantial contributions in each of the following: 1) study conception and design, data acquisition, or data analysis and interpretation; 2) the drafting of the article or the critical review of the intellectual content, and 3) the final approval of the version submitted.

Funding

This study has received no specific funding from public, private or non-profit organisations.

References
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USRDS.
USRDS 2008 Annual Data Report: Atlas of End-Stage Renal Disease in the United States,
[2]
P.J.H. SmakGregoor, R. Zietse, J.L.C.M. Van Saase, C.T. De Op Hoek, J.N.M. Ijzermans, A.T.J. Lavrijssen, et al.
Immunosuppression should be stopped in patients with renal allograft failure.
[3]
O. Johnston, C.L. Rose, J.S. Gill, J.S. Gill.
Risks and benefits of preemptive second kidney transplantation.
[4]
S. Girerd, N. Girerd, K. Duarte, M. Giral, C. Legendre, G. Mourad, et al.
Preemptive second kidney transplantation is associated with better graft survival compared with non-preemptive second transplantation: a multicenter French 2000–2014 cohort study.
[5]
E.A. Florit, S. Bennis, E. Rodriguez, I. Revuelta, E. De Sousa, N. Esforzado, et al.
Pre-emptive retransplantation in patients with chronic kidney graft failure.
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M. Arnol, J.C. Prather, A. Mittalhenkle, J.M. Barry, D.J. Norman.
Long-term kidney regraft survival from deceased donors: Risk factors and outcomes in a single center.
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J.J. Augustine, K.J. Woodside, A. Padiyar, E.Q. Sanchez, D.E. Hricik, J.A. Schulak.
Independent of nephrectomy, weaning immunosuppression leads to late sensitization after kidney transplant failure.
[8]
C.A. Milton, G.R. Russ, S.P. Mcdonald.
Pre-emptive renal transplantation from living donors in Australia: effect on allograft and patient survival.
[9]
P. Altieri, G. Sau, R. Cao, A. Barracca, A. Menneas, B. Micchittu, et al.
Immunosuppressive treatment in dialysis patients.
Nephrol Dial Transplant [Internet]., 17 (2002), pp. 2-9
[10]
B. Akman, F.N. Özdemir, S. Sezer, H. Miçozkadio¿lu, M. Haberal.
Depression levels before and after renal transplantation.
Transplantation Proc., 36 (2004), pp. 111-113
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