Faculty Bibliography

CONTEXT: More than 6000 healthy US individuals every year undergo nephrectomy for the purposes of live donation; however, safety remains in question because longitudinal outcome studies have occurred at single centers with limited generalizability. OBJECTIVES: To study national trends in live kidney donor selection and outcome, to estimate short-term operative risk in various strata of live donors, and to compare long-term death rates with a matched cohort of nondonors who are as similar to the donor cohort as possible and as free as possible from contraindications to live donation. DESIGN, SETTING, AND PARTICIPANTS: Live donors were drawn from a mandated national registry of 80 347 live kidney donors in the United States between April 1, 1994, and March 31, 2009. Median (interquartile range) follow-up was 6.3 (3.2-9.8) years. A matched cohort was drawn from 9364 participants of the third National Health and Nutrition Examination Survey (NHANES III) after excluding those with contraindications to kidney donation. MAIN OUTCOME MEASURES: Surgical mortality and long-term survival. RESULTS: There were 25 deaths within 90 days of live kidney donation during the study period. Surgical mortality from live kidney donation was 3.1 per 10,000 donors (95% confidence interval [CI], 2.0-4.6) and did not change during the last 15 years despite differences in practice and selection. Surgical mortality was higher in men than in women (5.1 vs 1.7 per 10,000 donors; risk ratio [RR], 3.0; 95% CI, 1.3-6.9; P = .007), in black vs white and Hispanic individuals (7.6 vs 2.6 and 2.0 per 10,000 donors; RR, 3.1; 95% CI, 1.3-7.1; P = .01), and in donors with hypertension vs without hypertension (36.7 vs 1.3 per 10,000 donors; RR, 27.4; 95% CI, 5.0-149.5; P < .001). However, long-term risk of death was no higher for live donors than for age- and comorbidity-matched NHANES III participants for all patients and also stratified by age, sex, and race. CONCLUSION: Among a cohort of live kidney donors compared with a healthy matched cohort, the mortality rate was not significantly increased after a median of 6.3 years.

The field of desensitization and incompatible transplantation has made great gains over the past decade. There are now several options and effective therapies for many patients who face antibody barriers. Kidney paired donation (KPD) and desensitization have traditionally been considered competing strategies and patients have been offered one or the other without regard for the probability of a successful outcome. It is now possible to predict which donor/recipient phenotypes will benefit from each of these modalities. KPD should be favored among patients with immunologic phenotypes that are likely to match without prolonged waiting times. However, as many as 50% of patients with incompatible donors will fail to find a match in a KPD pool and many of these patients could be desensitized to their donor. Positive crossmatch and ABO incompatible transplantation has been accomplished in selective cases without the need for heavy immunosuppression or B-cell ablative therapy. Patients who are both difficult-to-match due to broad sensitization and hard-to-desensitize because of strong donor reactivity can often be successfully transplanted through a combination of desensitization and KPD. Using these various modalities it is estimated that most patients with incompatible live donors can undergo successful renal transplantation.

BACKGROUND: We have monitored ABO antibody titers in 53 ABO-incompatible kidney transplants (INKTs) using a time-consuming, conventional test tube (CTT) method that included a 30-minute room temperature (RT) phase, followed by incubation for 30 minutes at 37 degrees C and conversion to the anti-human globulin (AHG) phase. Our studies have indicated that AHG ABO antibody titers are critical for clinical management, but RT titers do not supplement clinical decision making. Therefore, we assessed AHG titers by two methods: 1) a revised test tube (TT) method without RT and 2) an anti-immunoglobulin G (IgG) gel microcolumn (IgG gel) method with a goal of streamlining ABO antibody titrations. STUDY DESIGN AND METHODS: Fifty frozen samples from our INKT collection with anti-A and/or anti-B AHG titers of 2 to 512 were titrated by revised TT method with 30 minutes at 37 degrees C and conversion to AHG and by IgG gel method with 15 minutes at 37 degrees C and centrifugation. RESULTS: The titers using the revised TT and IgG gel methods had 64 and 52% concordance, respectively, with CTT AHG titers. Neither the revised TT AHG titers nor the IgG gel titers varied by more than one standard dilution from the CTT AHG titers, which is within acceptable limits for titration techniques. CONCLUSIONS: The revised TT and IgG gel titers are comparable to the CTT AHG titers. The IgG gel method offers the best titer turnaround time, eliminating 45 minutes of incubation time alone. Implementation of this technique would benefit ABO INKT patients by providing titer results in a more timely manner.