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Transplantation
Kidney Transplantation
a report by
Helena Genberg, Lars Wennberg and Gunnar Tydén
Karolinska University Hospital and Karolinska Institute
For the vast majority of patients with end-stage renal disease, kidney failure.
12
The aetiology is not fully understood, but is almost certainly
transplantation is the best therapeutic alternative.
1
Kidney multifactorial and the consequence of continuous immunological and
transplantation provides a superior prognosis
2,3
and an improved nephrotoxic tearing.
quality of life
4
compared with any form of dialysis. Nowadays, with
growing experience and the development of more effective Several factors have been correlated to CAN as well as to long-term graft
immunosuppressive therapy, the quality of life for most kidney survival. The number and severity of acute rejection episodes affect graft
recipients is excellent.
5
Many centres report a one-year patient and survival.
13,14
In an analysis of >60,000 recipients, those experiencing acute
graft survival rate of >95% following living donor kidney rejection within the first six months developed CAN more often
transplantation.
6,7
The same result is reported in Organ Procurement compared with the other recipients.
15
Regarding delayed graft function
and Transplantation Network (OPTN)/United Network for Organs as a risk factor for CAN, the results are contradictory. In some patients,
Sharing (UNOS) registry data. For deceased donor (DD) delayed graft function seems to predispose to decreased long-term graft
transplantation, patient and graft survival rates are a little lower survival.
16
Immunological factors are also of great importance for the
(94.1% and 89%, respectively).
8
long-term results. In large, retrospective studies of DD recipients, it has
convincingly been shown that human leukocyte antigen (HLA) matching
With the introduction of cyclosporine in the mid-1980s, and during the improves outcome, and the policy of shipping 0-antigen mismatch
following 10-year period, the outcome of kidney transplantation kidneys has been widely adopted.
17
However, since extensive HLA
improved dramatically. One-year graft survival after DD kidney matching results in increased time on waiting lists (associated with poorer
transplantation increased from around 50% during the pre-cyclosporine long-term outcome), its benefits remain limited. In LD kidney
era to nearly 90%. Unfortunately, the rate of improvement has slowed transplantation, HLA matching appears to be unnecessary.
18
down. As a matter of fact, over the past 10 years, the improvement in
one-year graft survival has been modest at only 1%.
Helena Genberg is a Resident in Surgery at the
Department of Transplantation Surgery, Karolinska
More important than one-year survival, however, are the long-term University Hospital. Her clinical and scientific work is
results. Long-term patient and graft survival has indeed improved since
focused on kidney transplantation and she is involved
in the development of new desensitisation protocols. Dr
the introduction of cyclosporine, but only marginally during the past
Genberg graduated from the Karolinska Institute,
decade. In a regression analysis of >90,000 renal transplantations
Stockholm in 2000. During medical school she spent
one year at Université Paris VII, Hôpital Bichat, Paris and
performed in the US between 1988 and 1996, the projected one-year
shorter periods at Brown University School of Medicine,
survival rate for living donor (LD) grafts was estimated to have increased Rhode Island, US, and King’s College Hospital, London.
from 89 to 94%, and the rate for DD grafts from 76 to 88%. After
E: helena.genberg@karolinska.se
censoring the data for ‘death with a functioning graft’, the projected
half-life for LD grafts was estimated to have increased from 17 to 36
Lars Wennberg is Associate Professor in Experimental
Transplantation Surgery and Associate Professor in
years, and for DD grafts from 11 to 20 years.
9
Recently, however, the
Transplantation Surgery at the Karolinska Institute,
actual half-life was reported to be substantially shorter. On average,
Stockholm. He is also a Staff Surgeon at the Department of
between 1988 and 1995 the real half-life was improved by approximately
Transplantation Surgery, Karolinska University Hospital. In
2007 Dr Wennberg was appointed Assistant Director for the
two years compared with the previously projected six years.
10
In addition, Renal and Pancreas/Islet Transplantation Unit. He is a Board
in a more recent analysis, including that of a patient material for which
Member of the Union Européene des Medicins Spécialistes
(UEMS), Section of Surgery: Division of Transplantation.
acute rejection rates had been reduced by 50%, long-term graft survival
was not improved at all.
11
The expected graft survival is therefore still not
long enough to ensure adequate renal function throughout the patient’s
Gunnar Tydén has been the Professor of Transplantation
life after kidney transplantation.
Surgery at the Karolinska Institute (Department of
Transplantation Surgery), Karolinska University Hospital,
Huddinge, since 2000. He also serves as Director of the
In this study, progress in kidney transplantation over the past decade is Renal and Pancreas Transplantation Programme at the
discussed, including an overview of advances in immunosuppression and
Karolinska Institute. The founder member of the
Scandinavian Transplantation Society, the International
desensitisation, as well as of remaining challenges.
Pancreas and Islet Transplantation Association and the
Swedish Transplantation Society, Professor Tydén is also a
member of the European Society for Organ Transplantation.
Factors of Importance for Long-term Outcome
Chronic allograft nephropathy (CAN) is a leading cause of graft
© TOUCH BRIEFINGS 2007 55