Small Center Kidney Transplantation

0022-534 7/83/1306-1055$02.00/0 Vol. 130, December Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1983 by The Williams & Wilkins Co.

SMALL CENTER KIDNEY TRANSPLANTATION GEORGE E. BRANNEN, ROY J. CORREA, JR., ROBERT P. GIBBONS, JACK S. ELDER, KAREN R. STEVENSON, LESLIE K. SEMEN, PATRICIA A. PATON, ROBERT M. HEGSTROM, ROBERT L. WILBURN, BURTON M. ORME AND RICHARD R. PATON From the Sections of Urology, Renal Transplantation and Nephrology, Virginia Mason Medical Center, Seattle, Washington

ABSTRACT

We herein present the results of our first 100 kidney transplants. The 1-year patient and graft survivals were 94 and 74 per cent, respectively, for living related grafts, and 85 and 57 per cent, respectively, for cadaver grafts. These results compare favorably to the recent standards set by the American Society of Transplant Surgeons Standards Committee (95.1, 78.6, 88.6 and 55 per cent). Initial hospitalization averaged 21 plus or minus 7 days, while hospitalization during the first year after transplantation averaged 35 plus or minus 21 days. Average expenses (Medicare reimbursed) during the first 12 months after kidney placement were $29,572 plus or minus $6,468 for 15 successive patients. A total of 22 complications occurred within 1 year of transplantation and 11 required surgical management. Of 24 patients who survived 1 year with loss of graft function 15 (62 per cent) required transplant nephrectomy. Causes of death and types of complications are presented. Our results suggest that high quality kidney transplantation may be available to patients in small transplant centers. Recent modifications in the management of transplant patients 1 have been succeeded by reports of patient survival equal to that of patients on chronic hemodialysis. 1- 5 These reports suggest a remarkable improvement compared to patient survival rates before 1976 as reported by the World Transplant Registry. 6 •7 Subsequently, revised standards for treatment outcome have been published by the Standards Committee of the American Society of Transplant Surgeons. 8 The outcome of 881 successive kidney transplants performed during 1977 and 1978 in 7 large United States centers are reported. Although the Renal Transplant Registry Report suggested that the outcome is similar for transplants performed in large and small centers, only a single recent report suggested that small transplant centers may reflect the improved patient survival rates in accordance with the criteria set by the Standards Committee of the American Society of Transplant Surgeons. 5 MATERIALS AND METHODS

From January 1, 1972 through December 31, 1981, 100 renal transplants have been performed at our medical center, the maximum performed in a single year being 23. Patient age ranged from 18 to 58 years. There were 53 cadaver and 47 living related transplants. Of the patients 18 were insulin-dependent diabetics. Immunological criteria for cadaver kidney placement was a negative crossmatch between donor and recipient using fresh and stored recipient serum. Since 1979 antiglobulin crossmatching has been used in addition to the Amos-modified standard National Institutes of Health crossmatch. Although the criterion for cadaver kidney selection was negative crossmatching, many cadaver kidney recipients shared 1 or 2 HLA antigens with the donor. Recipients of living related kidneys all shared at least 1 haplotype with the donor. Since 1979 mixed lymphocyte culture also has been used to confirm haplotype sharing. All living related recipients had negative crossmatching with their donor. The following adjuvant treatments were used only occasionally: bilateral nephrectomy, splenectomy, antithymocyte globulin, preoperative transfusions and antibiotic prophylaxis. Most patients received at least 2 units of blood intraoperatively. lmmunosuppressive medications were prednisone and azathioAccepted for publication June 24, 1983.

prine. Rejection usually was treated with pulse steroid therapy (500 to 1,000 mg. intravenous methylprednisolone) daily for 3 days, often with an increase of oral prednisone and graft irradiation. Individual assessment was made in the treatment of second perioperative graft rejection episodes and third rejections seldom were treated. Variability in immunosuppressive management is explained by the individual patient assessment and by variations in approach by each of the 4 managing nephrologists. At our medical center the transplant patient is managed under the direction of the nephrology staff and followed closely by the transplant surgical staff. Clinical management by the nephrology staff includes immunosuppression, hypertension, diabetes and rejection, plus cardiopulmonary and systemic illnesses. Fever evaluation is conducted jointly by the nephrologist and transplant surgeon. Mechanical and potential operative problems are evaluated and managed by the transplant surgeon. Postoperative long-term followup is directed by the nephrologist with appropriate consultation with the transplant surgeons. We herein report the 1-year outcome of our first 100 transplants. Any death <1 year after transplantation was counted as a graft failure regardless of cause or circumstances. Success was regarded only as a patient who was alive with a functioning graft and off chronic dialysis 1 year after transplantation. RESULTS

Patient survival (1 year) was 94 and 85 per cent, respectively, for recipients of living related and first cadaver kidneys, while graft survival was 74 and 57 per cent, respectively. Actuarial graphs of patient and graft survival rates for nondiabetic first living related and first cadaver kidney transplants are shown in the figure. Initial hospitalization averaged 21 ± 7 days (range 10 to 45 days). The average number of hospital days, including initial hospitalization and 1 year after transplantation was 35 ± 21 days (range 12 to 90 days). Total medical expenses for kidney transplantation, including 1 year of care after placement of the kidney, averaged $29,572 ± $6,468 (range $20,143 to $39,084) for 15 consecutive transplants performed from October 1980 through May 1981 (including graft failures). The expenses were covered by Medicare

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Actuarial graph of patient and graft survivals. A, recipients of living related A match kidney transplants. B, recipients of living related kidney transplant with 1 haplotype mismatch. C, recipients of cadaver kidney transplants.

reimbursements. For statistics on hospital days and costs a single inordinately elevated value was discarded for each average. The causes of death <1 year after graft placement were voluntary cessation of dialysis in 3 patients, acute cardiac arrhythmias in 3, sepsis in 2, pulmonary embolism in 2 and infected ruptured vascular anastomosis in 1. Over-all survival was 89 per cent. Two patients achieved pregnancy and normal term delivery. A total of 34 complications occurred in 28 patients (including all age groups and diabetics) during the entire followup (1 to 10 years). Of these complications 20 were managed surgically, 8 percutaneously or endoscopically and 6 noninvasively (table 1). Only 22 complications (11 surgical and 11 nonsurgical) occurred <1 year after transplantation. Of the 28 patients 24

suffered 1, 2 suffered 2 and 2 suffered 3 complications. No patient suffered > 1 surgical complication. Transplant nephrectomy was required in 15 of 35 patients (43 per cent) who lost graft function <1 year after transplantation (62 per cent, or 15 of 24 who survived 1 year with loss of graft function, if the 11 deaths within 1 year are excluded). The indications for graft nephrectomy were systemic toxicity related to rejection, infection of the rejected graft or severe hypertension. All patients who underwent graft nephrectomy survived 1 year. DISCUSSION

The patient and graft survivals do not differ significantly from the results determined by the American Society of Trans-

1057

SMALL CENTER KIDNEY TRANSPLANTATION TABLE

1. Complications during followup (I to 10 years) according to method of management 2.

No. Surgical: Acute abdomen Abscess Hip necrosis Urinary fistula Cataracts Lymphocele Arterial stenosis Endoscopic: Ureteral obstruction Lymphocele Urinary calculus Arterial stenosis Noninvasive: Diabetes Sepsis Chronic urinary tract infection

5 5 3 3

3.

2 1 1

4.

3 3 1

5.

1

6.

3 2 1

7. TABLE

2. Percentage I -year patient and graft survivals Living Related

Virginia Mason Medical Center* American Society of Transplant Surgeons Standards Committee World Transplant Registryt

Cadaver

8.

Pt.

Graft

Pt.

Graft

94

74

85

57

95.1 ± 3.7

78.6 ± 8.5

88.6 ± 7.7

55.0 ± 5.7

85

70

70

50

* Of 24 patients 15 who survived 1 year and whose grafts failed required graft nephrectomy. t Data for patient survival were presented in multiple subgroupings. Consequently, the over-all results were estimated.

plant Surgeons Standards Committee (table 2). These results suggest that small centers also may reflect recent improvements in patient survival reported by large kidney transplant centers. In addition, the acceptable results reflect the dependability of the private practice transplant surgeon who maintains high clinical and surgical volume independently of transplant activity. Variability in management approaches depended on individualized patient assessment and on the philosophy of the managing nephrologist. No differences in results could be discerned. No innovative approaches were used. The patient survival reflects the fine immunosuppressive and medical management directed by private practice nephrologists. REFERENCES

1. Vincenti, F., Amend, W., Feduska, N. J., Duca, R. M. and Salvatierra, 0., Jr.: Improved outcome following renal transplan-

tation with reduction in the immunosuppression therapy for rejection episodes. Amer. J. Med., 69: 107, 1980. Novick, A. C., Braun, W. E., Magnusson, M. and Stowe, N.: Current status of renal transplantation at the Cleveland Clinic. J. Urol., 122: 433, 1979. Tilney, N. L., Strom, T. B., Vineyard, G. C. and Merrill, J. P.: Factors contributing to the declining mortality rate in renal transplantation. New Engl. J. Med., 299: 1321, 1978. Lowrie, E. G., Lazarus, J. M., Mocelin, A. J., Bailey, G. L., Hampers, C. L., Wilson, R. E. and Merrill, J. P.: Survival of patients undergoing chronic hemodialysis and renal transplan tation. New Engl. J. Med., 288: 863, 1973. Banowsky, L. H., Chauvenet, P.A., Nicastro-Lutton, J. J., Radwin, H. M. and Richardson, J. M.: Patient survival in cadaveric renal transplantation: report from a small center. J. Urol., 127: 867, 1982. Advisory Committee to the Renal Transplant Registry: The 12th report of the Human Renal Transplant Registry. J.A.M.A., 233: 787, 1975. Advisory Committee to the Renal Transplant Registry: The 13th report of the Human Renal Transplant Registry. Transplant. Proc., 9: 9, 1977. Standards Committee of the American Society of Transplant Surgeons: Current results and expectations of renal transplantation. J.A.M.A., 246: 1330, 1981. EDITORIAL COMMENTS

These investigators report that kidney transplantation can be performed in a clinic setting, with a number of different surgeons and nephrologists caring for the patient, and still achieve excellent patient and graft survival. The results certainly disprove the often expressed viewpoint that high quality transplant care can be provided only in a large transplant center. Russell K. Lawson Department of Urology Medical College of Wisconsin Milwaukee, Wisconsin

Renal transplantation is a specialized form of treatment and it is reasonable to assume that a numerically large experience should enhance the expertise of the involved clinicians and, thereby, optimize the therapeutic outcome. However, as this report illustrates, excellent results also can be obtained on a smaller scale by close collaboration between skilled urologic and nephrologic physicians committed to high quality patient care in transplantation. The authors are to be commended for their perseverance, dedication and demonstrated expertise in this field. Andrew C. Novick Department of Urology The Cleveland Clinic Foundation Cleveland, Ohio