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• W1980898407 abstract "It has been suggested that dual kidney transplantation (DKT) improves outcomes for expanded criteria donor (ECD) kidneys. However, no criteria for allocation to single or dual transplantation have been assessed prospectively. The strategy of DKT remains underused and potentially eligible kidneys are frequently discarded. We prospectively compared 81 DKT and 70 single kidney transplant (SKT) receiving grafts from ECD donors aged >65 years, allocated according to donor estimated glomerular filtration rate (eGFR): DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min. Patient and graft survival were similar in the two groups. In the DKT group, 13/81 patients lost one of their two kidneys due to hemorrhage, arterial or venous thrombosis. Mean eGFR at month 12 was similar in the DKT and SKT groups (47.8 mL/min and 46.4 mL/min, respectively). Simulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to our allocation based on donor eGFR. It has been suggested that dual kidney transplantation (DKT) improves outcomes for expanded criteria donor (ECD) kidneys. However, no criteria for allocation to single or dual transplantation have been assessed prospectively. The strategy of DKT remains underused and potentially eligible kidneys are frequently discarded. We prospectively compared 81 DKT and 70 single kidney transplant (SKT) receiving grafts from ECD donors aged >65 years, allocated according to donor estimated glomerular filtration rate (eGFR): DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min. Patient and graft survival were similar in the two groups. In the DKT group, 13/81 patients lost one of their two kidneys due to hemorrhage, arterial or venous thrombosis. Mean eGFR at month 12 was similar in the DKT and SKT groups (47.8 mL/min and 46.4 mL/min, respectively). Simulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to our allocation based on donor eGFR. The number and age of patients awaiting kidney transplantation continue to grow due to a limited supply of organs (1The Organ Procurement and Transplantation network (OPTN) Data Report. 2007. Available from: http://www.optn.orgGoogle Scholar). Consequently, waiting times on dialysis are projected to increase, which may be particularly deleterious for older recipients eligible for transplantation (1The Organ Procurement and Transplantation network (OPTN) Data Report. 2007. Available from: http://www.optn.orgGoogle Scholar, 2Rapport annuel de l‘Agence de la Biomédecine. 2007. Avail-able from: http://www.agence-biomedecine.fr/annexes/bilan2007/pdf/rapport.pdf.Google Scholar, 3Frei U Noeldeke J Machold-Fabrizii V et al.Prospective age-matching in elderly kidney transplant recipients–a 5-year analysis of the Eurotransplant Senior Program.Am J Transplant. 2008; 8: 50-57Crossref PubMed Scopus (266) Google Scholar). The death rate while awaiting a kidney transplant is higher among patients aged >50 years, and even greater among those aged >65 years (1The Organ Procurement and Transplantation network (OPTN) Data Report. 2007. Available from: http://www.optn.orgGoogle Scholar). Thus, organs from marginal or expanded criteria donors (ECD), which are associated with shorter graft survival (4Port FK Bragg-Gresham JL Metzger RA et al.Donor characteristics associated with reduced graft survival: An approach to expanding the pool of kidney donors.Transplantation. 2002; 74: 1281-1286Crossref PubMed Scopus (632) Google Scholar), are now routinely chosen for older recipients in view of their shorter life expectancies. Some centers have adopted dual kidney transplantation (DKT) of two kidneys from a single ECD donor into one recipient. It has been proposed that this approach may increase the number of viable nephrons, which is thought to be too low in a single ECD kidney. Outcomes following DKT have been reported based on American registry data (5Alfrey EJ Boissy AR Lerner SM Dual-kidney transplants: Long-term results.Transplantation. 2003; 75: 1232-1236Crossref PubMed Scopus (56) Google Scholar, 6Gill J Cho YW Danovitch GM et al.Outcomes of dual adult kidney transplants in the United States: An analysis of the OPTN/UNOS database.Transplantation. 2008; 85: 62-68Crossref PubMed Scopus (82) Google Scholar) and single center experiences (7Andres A Morales JM Herrero JC et al.Double versus single renal allografts from aged donors.Transplantation. 2000; 69: 2060-2066Crossref PubMed Scopus (125) Google Scholar, 8Dietl KH Wolters H Marschall B Senninger N Heidenreich S Cadaveric “two-in-one” kidney transplantation from marginal donors: Experience of 26 cases after 3 years.Transplantation. 2000; 70: 790-794Crossref PubMed Scopus (61) Google Scholar, 9Lee CM Carter JT Weinstein RJ et al.Dual kidney transplantation: Older donors for older recipients.J Am Coll Surg. 1999; 189 (discussion 91–92): 82-91Crossref PubMed Scopus (47) Google Scholar, 10Lu AD Carter JT Weinstein RJ et al.Excellent outcome in recipients of dual kidney transplants: A report of the first 50 dual kidney transplants at Stanford University.Arch Surg. 1999; 134 (discussion 975–976): 971-975Crossref PubMed Scopus (65) Google Scholar, 11Moore PS Farney AC Sundberg AK et al.Dual kidney transplantation: A case-control comparison with single kidney transplantation from standard and expanded criteria donors.Transplantation. 2007; 83: 1551-1556Crossref PubMed Scopus (44) Google Scholar, 12Tan JC Alfrey EJ Dafoe DC Millan MT Scandling JD Dual-kidney transplantation with organs from expanded criteria donors: A long-term follow-up.Transplantation. 2004; 78: 692-696Crossref PubMed Scopus (66) Google Scholar). These analyses have shown favorable short- and long-term outcomes, but comparisons to single kidney transplantation (SKT) have all been retrospective. However, this strategy of ECD kidney transplantation remains underused, accounting for only 4% of all transplant procedures performed using grafts from donors older than 50 years in the United States (6Gill J Cho YW Danovitch GM et al.Outcomes of dual adult kidney transplants in the United States: An analysis of the OPTN/UNOS database.Transplantation. 2008; 85: 62-68Crossref PubMed Scopus (82) Google Scholar). This is probably partly because kidneys that could be eligible for DKT are discarded due to their expanded characteristics. Moreover, the allocation criteria for donor kidneys to DKT or SKT, based upon clinical parameters of the donor and/or histological findings from preimplantation biopsies (6Gill J Cho YW Danovitch GM et al.Outcomes of dual adult kidney transplants in the United States: An analysis of the OPTN/UNOS database.Transplantation. 2008; 85: 62-68Crossref PubMed Scopus (82) Google Scholar, 7Andres A Morales JM Herrero JC et al.Double versus single renal allografts from aged donors.Transplantation. 2000; 69: 2060-2066Crossref PubMed Scopus (125) Google Scholar, 8Dietl KH Wolters H Marschall B Senninger N Heidenreich S Cadaveric “two-in-one” kidney transplantation from marginal donors: Experience of 26 cases after 3 years.Transplantation. 2000; 70: 790-794Crossref PubMed Scopus (61) Google Scholar, 13Remuzzi G Cravedi P Perna A et al.Long-term outcome of renal transplantation from older donors.N Engl J Med. 2006; 354: 343-352Crossref PubMed Scopus (415) Google Scholar, 14Remuzzi G Grinyo J Ruggenenti P et al.Early experience with dual kidney transplantation in adults using expanded donor criteria.J Am Soc Nephrol. 1999; 10: 2591-2598Crossref PubMed Google Scholar), has varied between and within studies since each center has developed its own algorithm for selection of donor grafts and recipients. Donor characteristics have differed widely, but results from some studies have suggested that DKT is appropriate for ‘very’ ECD kidneys obtained from older donors and/or from donors with low GFR (7Andres A Morales JM Herrero JC et al.Double versus single renal allografts from aged donors.Transplantation. 2000; 69: 2060-2066Crossref PubMed Scopus (125) Google Scholar, 11Moore PS Farney AC Sundberg AK et al.Dual kidney transplantation: A case-control comparison with single kidney transplantation from standard and expanded criteria donors.Transplantation. 2007; 83: 1551-1556Crossref PubMed Scopus (44) Google Scholar). Consequently, no simple and efficient allocation criterion that would result in similar outcomes in SKT and DKT is currently available to clinicians. The aim of our observational study (BIGRE) was to prospectively assess donor estimated glomerular filtration rate (eGFR) as a simple criterion for allocation of donor kidneys to DKT or SKT. We have tested this criterion using grafts from ECD donors >65 years that are frequently rejected by many transplantation centers. Patient enrollment took place at the Hospital Necker, Paris, France and the Foch Hospital, Suresnes, France, from February 2003 to October 2007. Patients aged over 65 years with a donor aged >65 years were eligible to take part in the study if they had not previously received a kidney transplant and had a panel reactive antibody percentage lower than 25%. Donors were required to have at least one of the following risk factors: history of hypertension, diabetes mellitus, atherosclerotic disease or death from a cardiovascular cause. Kidneys were allocated to DKT or SKT based on maximal donor eGFR, calculated by the Cockcroft and Gault formula (15Cockcroft DW Gault MH Prediction of creatinine clearance from serum creatinine.Nephron. 1976; 16: 31-41Crossref PubMed Scopus (13152) Google Scholar). Grafts from donors with eGFR greater than 60 mL/min were allocated to SKT, those with eGFR of 30–60 mL/min were allocated to DKT, and those with eGFR below 30 mL/min were discarded. All participants provided written information consent. The study was approved by the local hospital ethics committee. Dual kidneys were procured separately. Allografts were placed either monolaterally or bilaterally, with one or two classical iliac incisions, respectively. Ipsilateral placement was undertaken in cases of extended iliac calcifications or voluminous native polycystic kidney, or when the surgeon judged this technically feasible, to avoid the controlateral incision. Urinary drainage consisted of ureterovesical anastomosis, using the Lich–Gregoir technique, for both kidneys. In the event of ipsilateral placement, anastomosis of the upper graft was ureteroureteral. Anastomosis of the renal vessels was performed to either the common or external iliac vessels. The following baseline characteristics of donors and recipients were recovered from a computerized database: for donors, age, weight, height, body mass index (BMI), history of hypertension, diabetes and vascular disease, cause of death, cardiac arrest, vascular calcification of the graft, all available serum creatinine levels and corresponding eGFR values; for recipients, medical history, nephropathy, weight, height, BMI, waiting time on dialysis, panel reactive antibodies and HLA mismatches. The primary efficacy endpoint was eGFR at 1-year posttransplant (Cockcroft– Gault [15Cockcroft DW Gault MH Prediction of creatinine clearance from serum creatinine.Nephron. 1976; 16: 31-41Crossref PubMed Scopus (13152) Google Scholar]). Secondary efficacy endpoints included eGFR and serum creatinine at 3 months and 2 years. Iohexol clearance was measured in a subgroup of patients at 3 months and 1 year. All serious adverse events were recorded, defined as requirement for hospitalization, prolongation of hospital stay or risk of a life-threatening condition. Delayed graft function, defined as a need for dialysis during the first week after transplantation, was noted. Acute rejection episodes were biopsy proven and staged according to the Banff 1997 classification (16Racusen LC Solez K Colvin RB et al.The Banff 97 working classification of renal allograft pathology.Kidney Int. 1999; 55: 713-723Abstract Full Text Full Text PDF PubMed Scopus (2772) Google Scholar). A subgroup of patients in both groups underwent screening biopsies at day 0, month 3 and month 12. Only specimens with a minimum of seven glomeruli and one artery were included in analyses. Chronic changes were evaluated using percentage of glomerulosclerosis, Banff 1997 classification (16Racusen LC Solez K Colvin RB et al.The Banff 97 working classification of renal allograft pathology.Kidney Int. 1999; 55: 713-723Abstract Full Text Full Text PDF PubMed Scopus (2772) Google Scholar) and the 2005 update for interstitial fibrosis (CI score), tubular atrophy (CT), arteriolar hyaline thickening (AH) and fibrous intimal thickening (CV) (17Solez K Colvin RB Racusen LC et al.Banff ‘05 meeting report: Differential diagnosis of chronic allograft injury and elimination of chronic allograft nephropathy (‘CAN’).Am J Transplant. 2007; 7: 518-526Crossref PubMed Scopus (927) Google Scholar). All patients received induction therapy with either an anti-IL2 receptor monoclonal antibody or anti-thymocyte globulin. Introduction of calcineurin inhibitor therapy was delayed to day 6. Whole-blood cyclosporine 2-h concentration was maintained in the range 600–800 ng/mL. When tacrolimus was used, trough levels were between 5 and 10 ng/mL. All patients received mycophenolate mofetil (2 g/day) or enteric-coated sodium mycophenolate (1440 mg/day) and steroids at an initial dose of methylprednisolone 500 mg followed by oral prednisone progressively tapered at 10 mg/day within 1 month. All patients received pneumocystosis prophylaxis with cotrimoxazole and CMV prophylaxis with valganciclovir. The effect of allocation of kidneys to DKT or SKT based on parameters at day 0 according to three alternative systems was simulated, i.e. the scores developed by Remuzzi et al. (14Remuzzi G Grinyo J Ruggenenti P et al.Early experience with dual kidney transplantation in adults using expanded donor criteria.J Am Soc Nephrol. 1999; 10: 2591-2598Crossref PubMed Google Scholar), Andres et al. (7Andres A Morales JM Herrero JC et al.Double versus single renal allografts from aged donors.Transplantation. 2000; 69: 2060-2066Crossref PubMed Scopus (125) Google Scholar) and the UNOS scoring system (6Gill J Cho YW Danovitch GM et al.Outcomes of dual adult kidney transplants in the United States: An analysis of the OPTN/UNOS database.Transplantation. 2008; 85: 62-68Crossref PubMed Scopus (82) Google Scholar). Statistical analyses were performed using SAS software version 8.1 for Windows (SAS Institute, Inc., Cary, NC). Characteristics of donors and recipients at the time of transplantation were described using means ± SD or frequencies and compared using the chi-square test or analysis of variance, as appropriate. Graft and patient survival curves were calculated using the Kaplan–Meier method. Differences in survival between the two groups were estimated with the log-rank test. The impact of donor and recipient clinical characteristics at day 0 on 1-year graft function was assessed using 1-year eGFR <30 mL/min or death-censored graft loss as outcome variable. Given the size of the population and for clinical relevance, continuous variables have been recoded as categorical variables. Univariate logistic regression analysis was used to determine odds ratios and 95% confidence intervals (CIs). A 2-sided p-value of 0.05 was considered to be statistically significant. Eighty-one recipients underwent DKT and 70 patients underwent SKT (Table 1). Recipient age and donor age were significantly lower in the SKT group, while time on dialysis was significantly shorter in the DKT group. Distribution of initial nephropathies was similar between the two groups (data not shown), as were donor cardiovascular risk factors and the incidence of cerebrovascular death. As expected, donor eGFR was significantly lower in the DKT group. Mild acute renal failure occurred in both groups: 18/45 donors for whom information was available in the DKT group (mean change in serum creatinine 58 ± 74 μmol/L) compared with 40/69 in the SKT group (mean change 46 ± 30 μmol/L). No donor required dialysis during their stay in intensive care. Acute renal failure did not constitute a criterion for allocation to the DKT group since we chose minimal serum creatinine for allocation.Table 1Recipient, donor and transplant characteristics at baselineDual kidney transplantation (n = 81)Single kidney transplantation (n = 70)p-ValueRecipient characteristicsAge, years (mean ± SD)69.4 ± 3.059.9 ± 6.3<0.0001Male gender (%)63.065.7n.s.Weight, kg (mean ± SD)68.4 ± 14.172.8 ± 17.0n.s.BMI, kg/m2 (mean ± SD)24.3 ± 4.125.1 ± 4.7n.s.Time on dialysis (months)30.4 ± 29.854.9 ± 38.6<0.0001Diabetes history (%)18.518.6n.s.Ischemic cardiopathy (%)18.212.9n.s.Donor characteristicsAge, years (mean ± SD)75.1 ± 5.871.4 ± 4.1<0.0001Male gender (%)33.344.3n.s.Weight, kg (mean ± SD)66.4 ± 12.572.5 ± 13.8<0.01BMI, kg/m2 (mean ± SD)24.7 ± 3.625.9 ± 4.2n.s.Hypertension (%)52.152.5n.s.Diabetes mellitus (%)18.718.9n.s.Cerebrovascular death (%)82.774.3n.s.Cardiac arrest (%)13.67.3n.s.Collapsus (%)17.315.9n.s.HLA mismatches (mean ± SD)4.1 ± 1.13.1 ± 1.1n.s.Serum creatinine (μmol/L)97.2 ± 32.876.0 ± 25.7<0.0001eGFR (mL/min)52.2 ± 14.979.4 ± 26.0<0.0001TransplantationsCold ischemia time (h)21.8 ± 5.9/23.7 ± 5.922.4 ± 6.3n.s./n.s.Graft multiple arteries (%)21.022.4n.s.Graft vascular calcifications (%)Aorta45.078.3<0.0001Renal artery42.550.0n.s.Urinary anastomosisUreteroureteral33.368.6<0.0001Vesicoureteral66.731.4Treatment (%)Basiliximab/cyclosporine62.075.7n.s.Basiliximab/tacrolimus15.28.6ATG/cyclosporine12.75.7ATG/tacrolimus10.110.0ATG = anti-thymoglobulin; BMI = body mass index; eGFR = estimated glomerular filtration rate; n.s. = nonsignificant. Open table in a new tab ATG = anti-thymoglobulin; BMI = body mass index; eGFR = estimated glomerular filtration rate; n.s. = nonsignificant. Cold ischemia time was similar in the two cohorts, even if we consider the second kidney grafted in the DKT group. After a mean follow-up of 35.1 months, patient survival was similar between the DKT and SKT at 3 months, 1, 2 and 3 years (Figure 1). Nine patients died with a functioning graft in the DKT group, and six in the SKT. Non-death-censored graft survival was also similar in the two groups at each time point (Figure 2). When death with a functioning graft was censored as a cause of graft loss, graft survival remained non-statistically different in the two groups (data not shown). Six patients returned to dialysis, two in the DKT group (one graft loss due to antibody-mediated rejection and one due to chronic allograft dysfunction) and four in the SKT group (two arterial and one venous thrombosis, one chronic allograft dysfunction).Figure 2Kaplan–Meier estimates of non-death-censored graft survival.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In the DKT group, 13/81 patients lost one of their two kidneys early in the posttransplant course due to surgical complications, with a mean time to graft loss of 6 days (range 0–20 days). Causes of graft loss were arterial thrombosis (6/13), venous thrombosis (5/13) and hemorrhage (2/13). None of these patients returned to dialysis as a result. Biopsy-proven acute rejection within the first year of transplantation occurred more frequently in the SKT group (34.3% vs. 12.3% in the DKT, p < 0.005). Of the acute rejection episodes that occurred, high-grade rejection was encountered with the same frequency in both groups: 6/24 episodes were Banff 1997 grade ≥II in the SKT group and 2/9 episodes were grade II in the DKT group. The most frequent complications were surgical, particularly urinary and vascular complications (Table 2). Except for vascular thrombosis, the incidence of such complications was similar between the two groups. However, the total number of anastomoses was twice as high among DKT patients as SKT recipients. Acute coronary syndromes were observed only in the DKT group (10 episodes). Other medical complications were observed with a similar frequency in both groups. The mean duration of initial hospitalization was also similar (DKT, 21.6 days; SKT, 24.3 days).Table 2Medical and surgical complications, n (%)Dual kidney transplantation (n = 81)Single kidney transplantation (n = 70)p-ValueSurgical complications57 (70.4)54 (77.1)0.35Eventration, parietal abscess6 (7.4)8 (11.4)0.39Ureteral stenosis9 (11.1)12 (17.1)0.29Urinary fistula9 (11.1)15 (21.4)0.08Graft artery stenosis9 (11.1)3 (4.3)0.12Graft partial infarction3 (3.7)4 (5.7)0.56Graft vessel thrombosis11 (13.6)3 (4.3)0.049Artery thrombosis5 (6.2)2 (2.9)0.33Vein thrombosis6 (7.4)1 (1.4)0.08Hemorrhage10 (12.3)9 (12.9)0.85Cardiovascular complications35 (43.2)20 (28.6)0.06Atrial fibrillation8 (9.9)12 (17.1)0.19Cardiac insufficiency11 (13.6)4 (5.7)0.11Acute coronary syndrome10 (12.3)00.002Venous thromboembolism6 (7.4)4 (5.7)0.68Bacterial infections39 (48.1)34 (48.6)0.96Viral infections9 (11.1)2 (2.9)0.051CMV7 (8.6)1 (1.4)0.048BK virus nephropathy2 (2.5)1 (1.4)0.64 Open table in a new tab Incidence of delayed graft function was significantly lower in the DKT group, occurring in 31.6% of patients versus 51.4% of the SKT recipients (p = 0.015). Mean eGFR was similar at months 3, 12 and 24 in the DKT and SKT groups overall (Table 3). When DKT recipients who retained both kidneys were compared to SKT recipients, eGFR was numerically but not statistically higher in the DKT group. Within the DKT group, eGFR was significantly higher in recipients with two functioning grafts compared to the 13 patients who lost one of their two grafts (Table 3).Table 3Renal function in single kidney transplant recipients and in dual kidney transplant recipients with one or two functioning graftsSCreGFRGFRDualSinglep-ValueDualSinglep-ValueDualSinglep-ValueAll dual kidney transplantations versus single transplantationsMonth 3 (n)133.7 (77)165.0 (66)0.00245.9 (77)44.1 (66)n.s.52.0 (59)42.6 (62)0.004Month 12 (n)135.9 (65)164.0 (55)0.00147.8 (65)46.4 (55)n.s.44.8 (23)39.0 (43)0.12Month 24 (n)125.1 (32)161.7 (26)0.00749.4 (32)46.6 (26)n.s.n.a.DualSinglep-ValueDualSinglep-ValueDualSinglep-ValueDual kidney transplantations with two functioning grafts versus single transplantationsMonth 3 (n)121.0 (65)165.0 (66)0.000148.3 (65)44.1 (66)0.0955.1 (50)42.6 (62)0.0002Month 12 (n)126.4 (57)164.0 (55)0.000350.1 (57)46.4 (55)0.246.0 (20)39.0 (43)0.08Month 24 (n)121.9 (30)161.7 (26)0.00350.1 (30)46.6 (26)0.4n.a.OneTwop-ValueOneTwop-ValueOneTwop-ValueDual kidney transplantations with two versus one functioning graftMonth 3 (n)202.2 (12)121.9 (65)0.000132.9 (12)48.3 (65)0.000634.8 (9)55.1 (50)0.003Month 12 (n)203.6 (8)126.4 (57)0.00131.9 (8)50.1 (57)0.005n.a.eGFR = estimated glomerular filtration rate (Cockcroft–Gault formula [mL/min]); GFR = measured glomerular filtration rate with iohexol clearance (mL/min); n.a. = not available; n.s. = nonsignificant; SCr = serum creatinine (μmol/L). Open table in a new tab eGFR = estimated glomerular filtration rate (Cockcroft–Gault formula [mL/min]); GFR = measured glomerular filtration rate with iohexol clearance (mL/min); n.a. = not available; n.s. = nonsignificant; SCr = serum creatinine (μmol/L). Interestingly, measured GFR was statistically higher at month 3 but not at month 12 in DKT recipients (Table 3). Serum creatinine was significantly lower in DKT versus SKT patients at all time points. Protocol biopsies were performed at day 0, month 3 and month 12 in 38, 25 and 16 DKT patients and 50, 41 and 33 SKT patients, respectively. Preimplantation biopsies showed that chronic changes inherited from the donor were similar between the two groups. The distribution of Banff grades for each criterion and the mean percentage glomerulosclerosis (DKT, 14.4 ± 13.4%; SKT, 12.4 ± 14.8%; p = n.s.) were similar in the two groups (Figure 3). There was no difference in the mean score for any Banff criteria between the DKT and SKT cohorts: CI, 0.41 versus 0.36; CT, 0.41 versus 0.43; CV, 1.40 versus 1.51; AH, 1.10 versus 0.90, respectively (all p = n.s.). Glomerulosclerosis, interstitial fibrosis and tubular atrophy had worsened in both groups by month 3, but only a slight progression was observed between month 3 and month 12 (Figure 3). Mean CI score at month 3 was 1.6 in the DKT group and 1.2 in the SKT group (p = n.s.). Mean CT score at month 3 was significantly higher in the DKT group (1.7 vs. 1.1 in the SKT cohort, p = 0.025). There was a mild progression of fibrous intimal thickening in the DKT group, but mean CV score remained similar to the SKT cohort: 1.7 versus 1.2 at month 3 and 1.9 versus 1.3 at month 12, respectively. Three other allocation scoring systems, by Remuzzi et al. (14Remuzzi G Grinyo J Ruggenenti P et al.Early experience with dual kidney transplantation in adults using expanded donor criteria.J Am Soc Nephrol. 1999; 10: 2591-2598Crossref PubMed Google Scholar), Andres et al. (7Andres A Morales JM Herrero JC et al.Double versus single renal allografts from aged donors.Transplantation. 2000; 69: 2060-2066Crossref PubMed Scopus (125) Google Scholar) and the UNOS system (6Gill J Cho YW Danovitch GM et al.Outcomes of dual adult kidney transplants in the United States: An analysis of the OPTN/UNOS database.Transplantation. 2008; 85: 62-68Crossref PubMed Scopus (82) Google Scholar), were simultaneously available for 28 patients in the DKT group and 44 in the SKT group. Estimated GFR at month 12 could be calculated after simulating allocation to DKT or SKT using each of these three systems (Figure 4A). We have postulated that if an allocation system had an impact on 12-month renal function, simulated allocation to SKT would have resulted in a higher eGFR than a simulated allocation to DKT. Using the UNOS criteria, all kidney grafts actually allocated to the DKT group would have also been attributed to DKT. The only difference observed was with UNOS criteria in the SKT group, in which patients that would have been attributed to DKT reached a significantly lower 12-month eGFR than patients who actually underwent SKT. Figure 4B compares the impact of these three criteria and donor eGFR on the number of patients undergoing transplantation. It shows that allocation according to donor eGFR results in a greater number of transplants than either the UNOS or Andres criteria. Baseline (day 0) characteristics that could potentially be used to support kidney allocation decisions were assessed. Univariate logistic regression analysis explored the association between 1-year eGFR <30 mL/min or death-censored graft loss and donor and recipient clinical characteristics, or histological parameters observed on preimplantation biopsies (Table 4). In the DKT group, donor eGFR<50 mL/min and two histological parameters were associated with a bad outcome: percent glomerulosclerosis >10% and Remuzzi’s score >3 (corresponding to the cut-off value of allocation into DKT). In the SKT group, donor eGFR <65 mL/min, hypertension, diabetes and cold ischemic time were associated with a bad outcome.Table 4Univariate logistic regression analysis of day-0 factors associated with 1-year estimated GFR <30 mL/min or death-censored graft lossVariableOdds ratiop95% CIDual kidney groupDonor eGFR <50 mL/min4.030.0450.96–16.98Glomerulosclerosis >10%7.470.0031.95–8.58Remuzzi’s score >33.790.0151.39–21.30Single kidney groupDonor eGFR <65 mL/min3.390.0391.06–10.83Donor hypertension5.930.0121.48–23.75Donor diabetes6.560.0131.49–28.83Cold ischemic time >24 h3.880.0181.26–11.90Other variables tested for each group: donor age, serum creatinine, cerebrovascular death, BMI; preimplantation biopsy: Bannf score for fibrointimal thickening (CV), arteriolar hyalinosis (AH), interstitial fibrosis (CI, CT); recipient: age, BMI, waiting time, aortoiliac atherosclerosis. Open table in a new tab Other variables tested for each group: donor age, serum creatinine, cerebrovascular death, BMI; preimplantation biopsy: Bannf score for fibrointimal thickening (CV), arteriolar hyalinosis (AH), interstitial fibrosis (CI, CT); recipient: age, BMI, waiting time, aortoiliac atherosclerosis. This is the first prospective study to assess a potential criterion—donor eGFR—for allocation of donor kidneys to DKT or SKT. This criterion allowed us to test the strategy of DKT as a means to optimize the use of kidneys from ‘very’ ECDs, i.e. donors aged over 65 years with cardiovascular disease and eGFR <60 mL/min. We selected recipient 12-month eGFR as the primary endpoint. Indeed, differences in graft survival between ECD and standard criteria donors have been observed as early as 1 year posttransplantation, increasing at 3 years (4Port FK Bragg-Gresham JL Metzger RA et al.Donor characteristics associated with reduced graft survival: An approach to expanding the pool of kidney donors.Transplantation. 2002; 74: 1281-1286Crossref PubMed Scopus (632) Google Scholar, 18Metzger RA Delmonico FL Feng S Port FK Wynn JJ Merion RM Expanded criteria donors for kidney transplantation.Am J Transplant. 2003; 3: 114-125Crossref PubMed Scopus (519) Google Scholar). Both groups in our study, however, belonged to the ECD category and no difference in graft survival was observed at 1 or 3 years, although all patients did not have 3 years’ follow-up (median 32 months). Several studies have shown that 1-year renal function, expressed as serum creatinine" @default.
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• W1980898407 date "2009-11-01" @default.
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• W1980898407 title "Donor-Estimated GFR as an Appropriate Criterion for Allocation of ECD Kidneys into Single or Dual Kidney Transplantation" @default.
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