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• W2318821457 abstract "We appreciate the invitation to respond to the letter to the editor submitted by Sureshkumar et al. in this issue regarding our article (1). On the basis of an analysis of the Standard Transplant Analysis and Research files, they demonstrate inferior long-term graft survival from donors weighing less than or equal to 10 kg compared with donors weighing more than 10 to less than 20 kg. However, they demonstrate equivalent long-term graft survival of pediatric en-bloc kidneys from donors weighing less than or equal to 10 kg compared with pediatric single kidneys from donors weighing more than 10 to less than 20 kg. On the basis of these data, the authors advise caution in splitting pediatric en-bloc kidneys from donors weighing less than or equal to 10 kg. The Standard Transplant Analysis and Research registry data spans two decades, from 1987 to 2007, an era demonstrating tremendous advances in transplantation medicine through improvements in a variety of areas including immunosuppression, donor and recipient selection, and numerous factors that can affect the long-term function of the allograft. Given the 20-year analysis period, and the relatively small group of single pediatric donor kidney transplants from donors weighing less than or equal to 10 kg (n=177) compared with donors weighing more than 10 to less than 20 kg (n=2046), making conclusions about long-term outcomes in the present day is difficult secondary to the confounding factors outlined earlier. The authors note early graft losses in less than or equal to 10 kg donor transplants, which is shown in Figure 1(A) of their article. We suspect that these early graft losses are secondary to postoperative technical complications that have been reported by other groups in the past (2). We further suspect that if these early graft failures were removed from the analysis, the significant difference between graft survival in recipients of kidneys from donors weighing less than or equal to 10 kg and those from donors weighing more than 10 to less than 20 kg would disappear, given the curves are otherwise parallel. At our center, we did not experience these early graft failures, and outcomes were comparable with standard criteria donor (SCD) renal transplants (1).FIGURE 1.: Graft survival in recipients of standard criteria donor (SCD) renal allografts stratified by the presence of delayed graft function (DGF).The authors also suggest that differences in immunosuppression regimens do not affect the results of their analysis given that these regimens would vary equally between the groups analyzed. We disagree with this, because varying immunosuppressive protocols are likely to greatly affect the author's conclusions, particularly given the disparate sample sizes of the less than or equal to 10 kg and more than 10 to less than 20 kg cohorts. At our center, we have been able to achieve patient and graft survivals in deceased donor kidney transplantation that are statistically better than expected as reported by the Scientific Registry of Transplant Recipients. We believe that this is, in part, because of our immunosuppressive protocol, which uses lymphocyte depletion for induction, eliminates steroids postoperatively, and also minimizes calcineurin-inhibitor exposure. The authors also state that despite our data demonstrating equivalent outcomes between donors weighing less than or equal to 10 kg and those weighing more than 10 to less than 20 kg, we can expect poor long-term outcomes given the results of the registry analysis. In further support of their conclusion, the authors state that increased delayed graft function (DGF) in the smallest donors is a predictor of poorer long-term function. In our opinion, projecting historical outcomes into the future, given the rapidly changing landscape of transplantation, threatens to impede innovation and progress. Second, the association between DGF and poor long-term outcomes has been most closely associated with expanded criteria donor (ECD) kidneys, and data from our center support the conclusion that ECD allografts with DGF fair statistically worse than ECD allografts without DGF (data not shown). However, in predicting the effect of DGF on pediatric graft survival, an analysis of SCD kidneys with DGF compared with SCD kidney transplants without DGF is more appropriate. Pediatric allografts do not have the glomerulosclerosis, arterial narrowing, and interstitial fibrosis commonly seen in ECD renal allografts, indicating underlying renal damage present in the donor. Data from our institution comparing 127 SCD transplants without DGF with 63 SCD transplants with DGF demonstrate 1-year allograft survival of 100% and 93% in recipients without and with DGF, respectively. At 3 years, the graft survival was 93.8% and 89.7%, respectively, which is not statistically significant (P=0.2; Fig. 1). In conclusion, we note that some pediatric donor kidneys at our center were imported from outside our region secondary to surgical damage that made en-bloc transplantation, preferred by many centers, impossible. We support the use of single pediatric donor allografts at centers that are able to achieve acceptable short-term outcomes without technical complications. Long-term function will need to be assessed continually as transplant techniques and immunosuppression regimens change and improve. David B. Leeser Vinod P. Balachandran Meredith J. Aull Sandip Kapur Division of Transplant Surgery Department of Surgery New York-Presbyterian Hospital Weill Medical College of Cornell University New York, NY" @default.
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• W2318821457 date "2011-04-27" @default.
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• W2318821457 title "Authors' Reply: Expanding the Donor Pool: Optimal Utilization of Pediatric Donor Kidneys" @default.
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