Tissue Antigens (1975), 6, 163-166
Newsletter
Published by Munksgaard, Copenhagen, Denmark No part may be reproduced by any process without written permission from the author(s)
Kidney Transplantation and Donor Age N. M O R L I N CJ., ~LADEFOGED,~ P. LANCE,^ B. NERSTR0M,4 B. NIELSEN,~ L. STAUB N I E L S E NA N~D B. L. SORENSENG Typing Laboratory, Blood Bank & Blood Grouping Department of the State University Hospital (Rigshospitalet), Copenhagen; 2 Nephrologic Department P, Rigshospitalet; 3 Renal Unit B, Glostrup Hospital; 4 Surgical Department D, Rigshospitalet ; 5 Section of Nephrology, 3rd Medical Department, Kommunehospitalet, Copenhagen; and 0 Surgical Department H, Gentofte Hospital, Copenhagen, Denmark 1 ‘Tissue
The cumulative graft survival after 355 cadaver kidney transplantations was analyzed with special reference to the age of the donors. A significant decrease in cumulative graft survival with increasing donor age was found.
Received for publkution 3 J u n r , czrcrzpted 6 June 1975
In a preliminary communication (Darmady 1974) it was shown that when life tables were prepared for recipients of kidney grafts in the United States, the proportion of recipients surviving was strictly arranged in order of decades of donor age in all types of donor studies - sibling, parent and cadaver. This suggests that the older the donor kidney the smaller the chance of a successful kidney transplantation. The purpose of this study has been to confirm or disprove this statement concerning transplantations with cadaver kidneys in Copenhagen.
Materials and Methods A total of 297 first and 58 second cadaver kidney transplantations performed since the beginning of transplantation (August 1969) until December 1974 a t the State University Hospital in Copenhagen and at the Copenhagen County Hospital in Glostrup have been analysed. No exclusions have been made in estimating the number of graft failures. All removed grafts, dead recipients and kidneys without function were considered as graft failures in estimating the cumulative graft survival (Merril & Shulmann 1955). The difference in cumulative graft survival for different groups a t the same observation time was tested statistically by a non parametric rank sum test (Kendall 1962).
164
MORLING ET AI..
Results Fig. 1 shows the cumulative graft survival (CGS) for the first and second transplants separately and combined. There appears
to be very little difference in CGS between the first and second transplants, we therefore decided in the following calculations to pool the two groups.
CUMULATIVE GRAFT SURVIVAL OF CADAVER KIDNEY TRANSPLANTS Per cent 1001 A
FIRST TRANSPLANTATION l n = 2 9 7 J
_I
v
SECOND TRANPLANTATION ln.58)
w
I
FIRST+SECOND TRANPLANTATION i n - 3 5 5 1
P> 3
cn
w
P
L
a
d
3
=2
20.1
1°1
I
,
,
%2%2
1
,
b
3
2
4
5
DURATION OF TRANSPLANT ( Y R )
Figure I . Cumulative graft survival of cadaver kidney transplants.
CUMULATIVE GRAFT SURVIVAL FOR THREE GROUPS OF DONOR AGE Per cent
10 -19 yr ( n = 7 3 )
20 - 4 9 yr ( n = 2 0 2 ) 50 - 66 yr ( n . 7 6 ) L
,
,
%2%2
w
,
1
2
3
4
5
DURATION OF TRANSPLANT ( Y R )
Figure 2. Cumulative graft survival for three groups of donor age.
165
KIDNEY TRANSPLANTATION AND CONOR AGE
Donor Age When CGS is arranged in decades of donor age there is a marked tendency to higher CGS for the donor age 10 to 19 years and a lower CGS for the donor age 50 to 66 years compared to the rest of the material. Fig. 2 shows CGS for the three donor groups, 10 to 19 years, 20 to 49 years and 50 to 66 years. At each observation time from 3 months to three years there is a significantly lower CGS with increasing donor age. The basis for this difference is a dcreasing graft survival with increasing age within the first 3 months after which time the slopes of the curves are about equal for all donor ages. Recipient Age There is a slightly higher proportion of recipients over 50 years of age transplanted with kidneys from donors above 50 years but the difference is not significant. I n each decade of recipient age there is a general - but insignificant - tendency to lower CGS with increasing donor age. There is no difference in CGS between different groups of recipient ages until 60 years. Above this age there is a pronounced fall in CGS (P < 0.05). Cause of Donors’ Death There is highly significant (P < 1 0 - 5 ) correlation between young age and accident as the cause of donors’ death. When considering only kidneys from donors dying from accidents there is the same tendency seen in Fig. 2 to a lower CGS with increasing donor age (Table 1 ) although the difference is not statistically significant due to the small numbers within each group. There is an insignificantly higher CGS in the group of transplants with kidneys taken from donors with accident as the cause of death compared to the rest of the transplants, however, in each donor
Table 1 The 3 months graft survival after transplantation with kidneys from donors with accident as cause of death
1
-.-s”
I
Donor age (years)
10-19
1
20-49
I
50-66
3 months
3
no. of grafts
> 3 months 0/O i
age group, CGS is not influenced by the cause o f death of the donor.
Warm lschaemia Time The transplantations with kidneys removed on “beating heart” show precisely the same tendency to lower CGS with increasing donor age. CGS is insignificantly higher in the beating heart group compared to the non-beating heart group, but the average age is 27 years in the beating heart group as compared to 36 years in the nonbeating heart group. HL-A Matching There was no tendency towards poor matching of kidneys from older donors or to older recipients in respect of HL-A than kidneys from younger donors. In general, it seemed that poorly matched kidneys fared worse than others, and this tendency was most pronounced in the donor age group 50 to 66 years, in which it was statistically significant ( P < 0.01). Discussion I t can be concluded that the cumulative graft survival after cadaver kidney transplantations decreases with increasing age of the donors. The difference is established almost exclusively within the first three
166
MOKI.ING ET AI..
months after grafting. This effect could hardly be attributed to differences in the cause of death of the donors since, in each group of donor age, the donor’s cause of death has almost no influence on CGS. Differences in warm ischaemia time could not be the explanation either since, in each group of donor age, the CGS is the same whether or not the kidneys are removed “on beating heart”.
AcknowledgementJ Many of the kidneys were donated from other centres within Scandiatransplant and a few from other regions. We are grateful to Drs. J. Hess Thaysen and A. Svejgaard for helpful discussions during the preparation of this manuscript. This
study was aided by grants from the Danish Medical Research Council.
References Darmady, E. M. (1974) ‘Transplantation and the ageing kidney. Lancet ti, 1046-1047. Merril, M. & Shulmann, L. ( 1955) Determination of prognosis in chronic disease, illustrated by systemic lupus erythernatosus. J . chronic. Dis. 1, 12-32. Kendall, M. (1962) Rank Correlntion Methods. Charles Griffin, London. Address: N . Morling Tissue Typing Laboratory Blood Bank and Blood Grouping Dept. Rigshospitalet Blegdamsvej 9 DK-2100 Copenhagen 0, Denmark
Newsletter
Published by Munksgaard, Copenhagen, Denmark No part may be reproduced by any process without written permission from the author(s)
Kidney Transplantation and Donor Age N. M O R L I N CJ., ~LADEFOGED,~ P. LANCE,^ B. NERSTR0M,4 B. NIELSEN,~ L. STAUB N I E L S E NA N~D B. L. SORENSENG Typing Laboratory, Blood Bank & Blood Grouping Department of the State University Hospital (Rigshospitalet), Copenhagen; 2 Nephrologic Department P, Rigshospitalet; 3 Renal Unit B, Glostrup Hospital; 4 Surgical Department D, Rigshospitalet ; 5 Section of Nephrology, 3rd Medical Department, Kommunehospitalet, Copenhagen; and 0 Surgical Department H, Gentofte Hospital, Copenhagen, Denmark 1 ‘Tissue
The cumulative graft survival after 355 cadaver kidney transplantations was analyzed with special reference to the age of the donors. A significant decrease in cumulative graft survival with increasing donor age was found.
Received for publkution 3 J u n r , czrcrzpted 6 June 1975
In a preliminary communication (Darmady 1974) it was shown that when life tables were prepared for recipients of kidney grafts in the United States, the proportion of recipients surviving was strictly arranged in order of decades of donor age in all types of donor studies - sibling, parent and cadaver. This suggests that the older the donor kidney the smaller the chance of a successful kidney transplantation. The purpose of this study has been to confirm or disprove this statement concerning transplantations with cadaver kidneys in Copenhagen.
Materials and Methods A total of 297 first and 58 second cadaver kidney transplantations performed since the beginning of transplantation (August 1969) until December 1974 a t the State University Hospital in Copenhagen and at the Copenhagen County Hospital in Glostrup have been analysed. No exclusions have been made in estimating the number of graft failures. All removed grafts, dead recipients and kidneys without function were considered as graft failures in estimating the cumulative graft survival (Merril & Shulmann 1955). The difference in cumulative graft survival for different groups a t the same observation time was tested statistically by a non parametric rank sum test (Kendall 1962).
164
MORLING ET AI..
Results Fig. 1 shows the cumulative graft survival (CGS) for the first and second transplants separately and combined. There appears
to be very little difference in CGS between the first and second transplants, we therefore decided in the following calculations to pool the two groups.
CUMULATIVE GRAFT SURVIVAL OF CADAVER KIDNEY TRANSPLANTS Per cent 1001 A
FIRST TRANSPLANTATION l n = 2 9 7 J
_I
v
SECOND TRANPLANTATION ln.58)
w
I
FIRST+SECOND TRANPLANTATION i n - 3 5 5 1
P> 3
cn
w
P
L
a
d
3
=2
20.1
1°1
I
,
,
%2%2
1
,
b
3
2
4
5
DURATION OF TRANSPLANT ( Y R )
Figure I . Cumulative graft survival of cadaver kidney transplants.
CUMULATIVE GRAFT SURVIVAL FOR THREE GROUPS OF DONOR AGE Per cent
10 -19 yr ( n = 7 3 )
20 - 4 9 yr ( n = 2 0 2 ) 50 - 66 yr ( n . 7 6 ) L
,
,
%2%2
w
,
1
2
3
4
5
DURATION OF TRANSPLANT ( Y R )
Figure 2. Cumulative graft survival for three groups of donor age.
165
KIDNEY TRANSPLANTATION AND CONOR AGE
Donor Age When CGS is arranged in decades of donor age there is a marked tendency to higher CGS for the donor age 10 to 19 years and a lower CGS for the donor age 50 to 66 years compared to the rest of the material. Fig. 2 shows CGS for the three donor groups, 10 to 19 years, 20 to 49 years and 50 to 66 years. At each observation time from 3 months to three years there is a significantly lower CGS with increasing donor age. The basis for this difference is a dcreasing graft survival with increasing age within the first 3 months after which time the slopes of the curves are about equal for all donor ages. Recipient Age There is a slightly higher proportion of recipients over 50 years of age transplanted with kidneys from donors above 50 years but the difference is not significant. I n each decade of recipient age there is a general - but insignificant - tendency to lower CGS with increasing donor age. There is no difference in CGS between different groups of recipient ages until 60 years. Above this age there is a pronounced fall in CGS (P < 0.05). Cause of Donors’ Death There is highly significant (P < 1 0 - 5 ) correlation between young age and accident as the cause of donors’ death. When considering only kidneys from donors dying from accidents there is the same tendency seen in Fig. 2 to a lower CGS with increasing donor age (Table 1 ) although the difference is not statistically significant due to the small numbers within each group. There is an insignificantly higher CGS in the group of transplants with kidneys taken from donors with accident as the cause of death compared to the rest of the transplants, however, in each donor
Table 1 The 3 months graft survival after transplantation with kidneys from donors with accident as cause of death
1
-.-s”
I
Donor age (years)
10-19
1
20-49
I
50-66
3 months
3
no. of grafts
> 3 months 0/O i
age group, CGS is not influenced by the cause o f death of the donor.
Warm lschaemia Time The transplantations with kidneys removed on “beating heart” show precisely the same tendency to lower CGS with increasing donor age. CGS is insignificantly higher in the beating heart group compared to the non-beating heart group, but the average age is 27 years in the beating heart group as compared to 36 years in the nonbeating heart group. HL-A Matching There was no tendency towards poor matching of kidneys from older donors or to older recipients in respect of HL-A than kidneys from younger donors. In general, it seemed that poorly matched kidneys fared worse than others, and this tendency was most pronounced in the donor age group 50 to 66 years, in which it was statistically significant ( P < 0.01). Discussion I t can be concluded that the cumulative graft survival after cadaver kidney transplantations decreases with increasing age of the donors. The difference is established almost exclusively within the first three
166
MOKI.ING ET AI..
months after grafting. This effect could hardly be attributed to differences in the cause of death of the donors since, in each group of donor age, the donor’s cause of death has almost no influence on CGS. Differences in warm ischaemia time could not be the explanation either since, in each group of donor age, the CGS is the same whether or not the kidneys are removed “on beating heart”.
AcknowledgementJ Many of the kidneys were donated from other centres within Scandiatransplant and a few from other regions. We are grateful to Drs. J. Hess Thaysen and A. Svejgaard for helpful discussions during the preparation of this manuscript. This
study was aided by grants from the Danish Medical Research Council.
References Darmady, E. M. (1974) ‘Transplantation and the ageing kidney. Lancet ti, 1046-1047. Merril, M. & Shulmann, L. ( 1955) Determination of prognosis in chronic disease, illustrated by systemic lupus erythernatosus. J . chronic. Dis. 1, 12-32. Kendall, M. (1962) Rank Correlntion Methods. Charles Griffin, London. Address: N . Morling Tissue Typing Laboratory Blood Bank and Blood Grouping Dept. Rigshospitalet Blegdamsvej 9 DK-2100 Copenhagen 0, Denmark
