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Excerpt
Patients awaiting a second kidney transplant are more and more numerous on the lists as 10 to 15 years after the introduction of CsA, given the calculated half life of a renal transplant under CsA, at least 50% of the patients transplanted in the eighties will require dialysis again. These transplantations are also more difficult to perform, as most of the recipients have developed high titers of panel reactive antibodies (PRA). We have analyzed, in a population of 202 consecutive recipients of a 2nd renal transplant, all grafted at the same institution over the last 12 years, the pre and post-grafting, clinical and immunological factors that significantly influenced graft survival. All patients received the same immunosuppressive protocol, a quadruple sequential induction therapy based on ATG or a monoclonal antibody, and a maintenance treatment with CsA bi or triple therapy. Mean PRA before transplantation was 41+/-36% and 29% of the patients were hyperimmunized. Patient survival was 92% and graft survival (GS) 68% at 10 years. Duration of first transplantation, the cause of first graft loss and the degree of pre transplant immunization did not appear to have a significant impact on the outcome of the 2nd transplant. A high HLA matching between donor and recipient was the most important factor, resulting in significantly higher GS (p<0.03) in patients having <=2 mismatches (MM) vs >=3 MM, whatever the pre-graft immunization. Clinical parameters predictive of bad long term GS were the occurrence of a first acute rejection(33% of the patients) (p<0.01) and delayed graft function, defined as dialysis requirement in the 1st week post-transplant (p<0.05) or as the length of the period with creatinine clearance <10 ml/mn (p<0.006). This study indicates that with a high HLA matching, good results can be achieved in second transplantations receiving an induction treatmentbased on ATG and indeed, allograft survival in retransplantations is as high as in first transplantations in our center.
