Objective
To review a single center's experience and outcome with living donor transp
lants,
Summary Background Data
Outcome after living donor transplants is better than after cadaver donor t
ransplants. Since the inception of the authors' program, they have performe
d 2,540 living donor transplants. For the most recent cohort of recipients,
improvements in patient care and immunosuppressive protocols have improved
outcome. In this review, the authors analyzed outcome in relation to proto
col.
Methods
The authors studied patient and graft survival by decade. For those transpl
anted in the 1990s, the impact of immunosuppressive protocol, donor source,
diabetes, and preemptive transplantation was analyzed. The incidence of re
jection, posttransplant steroid-related complications, and return to work w
as determined. Finally, multivariate analysis was used to study risk factor
s for worse 1-year graft survival and, for those with graft function at 1 y
ear, to study risk factors for worse long-term survival.
Results
For each decade since 1960, outcome has improved after living donor transpl
ants. Compared with patients transplanted in the 1960s, those transplanted
in the 1990s have better 8-year actuarial patient and graft survival rates.
Death with function and chronic rejection have continued to be a major cau
se of graft loss, whereas acute rejection has become a rare cause of graft
loss. Cardiovascular deaths have become a more predominant cause of patient
death; infection has decreased. Donor source (e.g., ideally HLA-identical
sibling) continues to be important. For living donor transplants, rejection
and graft survival rates are related to donor source. The authors show tha
t patients who had preemptive transplants or less than I year of dialysis h
ave better 5-year graft survival and more frequently return to full-time em
ployment. Readmission and complications remain problems; of patients transp
lanted in the 1990s, only 36% never required readmission. Similarly, steroi
d-related complications remain common. The authors' multivariate analysis s
hows that the major risk factor for worse 1-year graft survival was delayed
graft function, For recipients with 1-year graft survival, risk factors fo
r worse long-term outcome were pretransplant smoking, pretransplant periphe
ral vascular disease, pretransplant dialysis for more than I year, one or m
ore acute rejection episodes, and donor age older than 55.
Conclusions
These data show that the outcome of living donor transplants has continued
to improve. However, for living donors, donor source affects outcome. The a
uthors also identify other major risk factors affecting both short- and lon
g-term outcome.