Wednesday, April 21, 2010

The Earlier The Better

I am currently writing a chapter about Living Kidney Donation “the Gold Standard”. With that in mind and two recent discussions with my co-fellows, I decided to discuss a little bit about the choice of the kidney donor in transplantation. Let’s though start with a board-type quiz:

A 65 year-old man with a GFR 10ml/min is undergoing transplant evaluation. He has a question about whether he should wait for a cadaveric kidney or get a preemptive kidney transplant from a living donor. Assuming the cadaveric donor is available right away, which donor will give him the best chance for graft survival?

a. 45 yr old male cadaveric donor 6 out of 6 HLA matched
b. 25 yr old male cadaveric donor 4 out of 6 HLA matched
c. His 25 year old daughter with one haplotype match
d. His 55 yr old wife with 2 out of 6 HLA match
e. a + c
f. c + d

Couple of more interesting points before the answer. A preemptive transplant leads to the best allograft survival for both cadaveric and living kidney transplants. The longer you stay on dialysis, the worse the allograft outcome is. However, transplantation at any time is always better than staying on dialysis. Since our waiting list has just reached 85,000 patients this week and the annual number of deceased kidney donors is around 8,000 in the US, preemptive living kidney donation is the best option for patients with ESRD – deemed no contraindications for transplant exit.

Although deceased kidney donor survival depends on the degree of HLA match, HLA matching is not as important for living kidney donors with the exception of identical twins, which have the best outcomes. Therefore, the right answers is f. The graft survival from the daughter’s or wife’s kidney will likely be very similar. However, many transplant centers would advocate doing a nephrectomy on the wife rather than the young daughter because of her age and long-term potential consequences, presumed both cross-matches are negative.

Most important learning point: refer your advanced CKD patient early for transplant evaluation!!!!

Two landmark articles below:

Meier-Kriesche, et al. Effect of waiting time on renal transplant outcome. Kidney Int 2000. 58:1311-1317.

Terasaki , et al. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 1995.333:333-336.

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