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Jose Maria Morales - Spain - Tuesday 29 - HLA for Renal Allocation
1. HLA for renal allocation in the modern immunosuppressive era Jose M. Morales Hospital 12 de Octubre Madrid (Spain) Buenos Aires 29 Nov 2011 2011 ORGAN DONATION CONGRESS
8. Influence of HLA matching and cold ischemia time on graft survival G Opelz, TP 1999
9. Effect of HLA matching on outcome of first kidney transplantation in black recipients G Opelz, TP 1999
10. UNOS point system for allocation of deceased donor kidneys (2009) Danovitch, 2010 ECD longest waiting patient 4 Organ donor Pediatric recipient priority for donors younger than 35 yr +80% PAR and Neg CM 4 PAR Zero DR MM One DR MM 2 1 Quality of HLA match 0-a, B, DR mismatch 1 for each yr Of waiting time Time waiting CONDITION POINTS FACTOR
14. Conclusions. DR matching is critically important in kidney retransplantation. There was no significant difference in survival of zero ABDR mismatched retransplants compared with one to four AB and zero DR mismatched retransplants. On the other hand, kidney graftsurvival of all one to four AB and zero DR mismatches Exceed ed that of one or two DR mismatched retransplants. We propose that the association of decreasing regraft survival with increasing PRA reflects undetected sensitization to class II, and possibly class I, antigens.
21. Patient Survival for Patients With a Functioning Graft and After Graft Loss Adjusted Patient Survival (%) Time Since Transplant/Graft Loss (months) 100 90 80 70 60 50 40 30 0 12 24 36 48 60 72 84 96 108 120 Meier-Kriesche H-U et al. Am J Transplant. 2003. Patients with transplant Patients after return to dialysis
26. Transplants & Waiting list for kidney and liver in Europe* along time (Newsletter Transplant) *EuroTx, France, ScandiaTx, Spain, United Kingdom, 1989 1994 2001 2009 1989 1994 2001 2009 KIDNEY LIVER 928 patients dead while on the liver WL in 2009
27. Improvements in acute rejection and graft survival are associated with more efficient immunosuppression Acute rejection/Graft survival rates (%) 100 80 60 40 20 0 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Year of transplantation 1yr graft survival Acute rejection Azathioprine Antilymphocyte Antibodies Prednisone Radiation Cyclosporine Tacrolimus Mycophenolate mofetil Rapamycine Thymoglobuline Daclizumab Basiliximab 95% 10% Graft Survival Acute Rejection Courtesy Dr H Ekberg
30. Patient and graft projected half life in Spain 1990-1998 Serón, Arias, Campistol, Morales et al.Transplantation 2003;76:1588 Long-term results improved is spite of an increase of donor age and poor HLA matching (3.4 mean MM). Why? Acute rejection New immunosuppressive drugs VHC statins? a 1994 or 1998 vs 1990, p<0.05. b 1998 vs 1994, p<0.05
31. In spite of a minor HLA compatibility Transplant Int 2010
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33. Graft and patient survival according recipient age at 5 years (2600 from Spain 2000-2002) 95% received S+CNI+ MMF 88% 84.2% 79.1% (death censored) (death not censored) 97% 91% 78% Morales et al, ESOT Congress Glasgow 2011 Patient survival Graft survival 64.7% 80.3% 82.1%
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35. AJKD 2008;52:553-586 Graft Survival Country, n Donor age, years of GS, % Morris 1999 UK, 6363 >60 5a 44% vs 18-39 68% Miranda 2003 Spain (Cat), 4008 60-69 5a 57% vs 40-49 76% >69 5a 50% Oppenheimer 2004 Spain (1 año funcionando), 3365 RR Graft loss 61-70 2.89 ; >70 4.19 (RR 1 si <20 a) Andreoni 2007 USA ECD 5a 53% vs SCD 5 a 70% Miles 2007 USA, 2908 retrasplantes No más supervivencia con reTR que siguiendo en lista si el reTR es con ECD Leichtman 2008 USA ECD 5a 55.1% vs SCD 5 a 70%
37. Mortality RR* for 23,275 first cadaveric transplant versus 46,164 wait-listed (WL) dialysis patients * Adjusted for age, sex, race, end-stage renal disease (ESRD) cause, WL year, region and time to WL 0 106 183 244 365 548 0.32 2.84 Equal risk Equal survival Transplant WL dialysis = reference Days since transplantation (equal time since WL) Relative risk (RR) 1 Wolfe RA, et al. N Engl J Med 1999;341:1725–30
38. Old for old Meier-Kriesche HU et al. AJT 2005; 5: 1725. Posttransplant years Donor age <50
42. Prospective Age-Matching in Elderly Kidney Transplant Recipients—A 5-Year Analysis of the Eurotransplant Senior Program 1. The ESP age matching of elderly donors and recipients is an effective organ allocation system for the use of organs from elderly donors. 2. The principles of decreasing the importance of HLA matching and emphasizing shorter CIT may be a promising option for other regional and national kidney allocation systems to increase the utilization of kidneys that would otherwise be at risk of being discarded. 3. Graft and patient survival were not negatively affected by the ESP allocation when compared to the standard allocation. Frei U.et al. Am J Transplant 2008; 8: 50-57
47. Irreversible Cardiac Arrest Occurring on the Street: A Source of Transplantable Kidneys Sánchez Fructuoso et al, Ann Internal Med 2006 BD (donor < 60 y) N=458 BD (donor 60 y) N=126 Uncontroled NHBD N=320 p Donor age 35.4 ± 14.2 65.4 ± 4.6 36.4 ± 11.5 <0.001 Donor Sex (%M) 64.3 54.0 88.1 <0.001 Recipient age 47.0 ± 13.1 55.1 ± 11.6 48.8 ± 13.6 <0.001 Recipient sex (%M) 63.5 63.5 61.9 0.89 HLA matching 1.83 ± 1.04 1.90 ± 1.13 1.45 ± 1.07 <0.001 PRA 6.0 ± 17.3 5.5 ± 15.0 5.3 ± 17.2 0.84 % Retransplants 14.2 13.5 14.4 0.97 Cold ischemia 18.7 ± 5.5 19.5 ± 5.7 17.7 ± 3.5 0.001
48. GRAFT SURVIVAL BD (donor < 60 y.) NHBD p=0.0006 BD < 60 y vs BD>=60 p=0.0001 BD < 60 y vs NHBD p=ns NHBD vs BD >=60 p=0.014 BD (donor >= 60 y.) months Cum. survival Sanchez-Fructuoso et al, Ann Intern Med 2006
51. NON-HEART BEATING DONATION PROGRAMS SUMMA 112-E.SESCAM-HOSPITAL 12 DE OCTUBRE Transfer by helicopter and by ambulance Transfer by Helicopter only
52. Outcomes of kidney transplant with non-heart beating donors who died in the street or at home (31/12/2010 ) NON-HEART BEATING DONOR GROUP N=151 DBD DONOR CONTROL GROUP N=93 p HLA Incompatibilities 4.4 ± 1.2 (1-6) 2.2 ± 1.6 (0-6) 0.001 Cold Ischemia Time (hours) 12.7 ± 5.7 (3-28) 16 ± 6.9 (2.6-30) 0.001 Primary non-function 13/151 (8.6%) 2/93 (2.2%) 0.04 Immediate kidney function 23/151 (15.2%) 40/93 (43%) 0.001 Delayed graft function 128/151 (84.8%) 53/93 (57%) 0.001 Number of HD 3 ± 2.6 (0-9) 2.1 ± 2.8 (0-14) 0.02 Days until onset of decrease of SCr 13.9 ± 6.7 (0-38) 8.2 ± 7.6 (1-41) 0.001
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Notas del editor
En general se recomienda se la compatibilidad en el locus DR pero no hay que olvidar, sin embargo. que el blanco de los de los anticuerpos anti HLA que son el arma biológica de los pacientes sensibilizados son los antígenos de Clase I, de los locus A y B, y aquí entra la discusión sobre la repetición del locus de antígenos incompatibles del primer trasplante en los pacientes sensibilizados, ya que puede ser un riesgo aumentado de rechazo humoral agudo ó crónico. En síntesis el retrasplante debe hacerse con la mayor compatibilidad DR posible y es prudente, sobre todo si hay anticuerpos HLA, máxime si son donante-específicos, buscar también la compatibilidad A-B y no repetir incompatibilidades del primer injerto.
En general se recomienda se la compatibilidad en el locus DR pero no hay que olvidar, sin embargo. que el blanco de los de los anticuerpos anti HLA que son el arma biológica de los pacientes sensibilizados son los antígenos de Clase I, de los locus A y B, y aquí entra la discusión sobre la repetición del locus de antígenos incompatibles del primer trasplante en los pacientes sensibilizados, ya que puede ser un riesgo aumentado de rechazo humoral agudo ó crónico. En síntesis el retrasplante debe hacerse con la mayor compatibilidad DR posible y es prudente, sobre todo si hay anticuerpos HLA, máxime si son donante-específicos, buscar también la compatibilidad A-B y no repetir incompatibilidades del primer injerto.
La Ciclosporina mejoró los resultados de los retrasplantes
LE en Europa para diferentes órganos vs tx
Figura 5.3. Evolución anual del trasplante renal con riñón procedente de donante vivo en España y en la Comunidad de Madrid