Retransplantation

Hark RimKosin University College of Medicine

대한이식학회지 2006;20:73-78

6.1%4,635 283 589 18 2005686 27 2004684 25 2003669 32 2002690 26 2001557 30 2000생체이식

173 22 2005167 22 2004124 20 200370 11 2002

101 21 2001125 29 2000사체이식

총이식재이식년

2005년 연보, 국립장기이식관리센터, 2005

Do it ?

KTP provides a survival advantages and better QOL compared with dialysis.The most who failed 1st Tx consider the 2nd.Improved immunosuppressive regimens and recognition of appropriate administration targets → ↓ rejections and ↑graft survivals

Do it ?

Ethical issuesShortage of organs

2점4촌이내

3점형제자매

4점과거에 장기등을 기증한 사실이 있는지의 여부 및 배우자, 직계존비속바. 과거에 장기등을 기증한 사실이 있는지

의 여부 및 배우자, 직계존․비속, 형제자매또는 4촌이내의 친족중 뇌사자 장기기증을한 사실이 있는지의 여부

2점1회 또는 2회 이식받은자마. 과거에 신장을 이식 받았는지의 여부

2점2회 이상 양성반응라. 과거에 사람백혈구항원 교차검사 결과2회이상 양성반응이 나타났는지의 여부

이식대기자의 대기 시간 산정 시작 시점은 사람백혈구항원 조직형 검사 일자를 참고로 함

- 2000년 2월8일 이전의 대기시간에 대하여는 다음과 같이 가산하고, 1년 미만 : 0점1년이상 2년미만 : 1점2년이상 3년미만 : 2점3년이상 4년미만 : 3점4년이상 : 4점

- 2000년2월9일 이후부터는 매 1년마다 1점씩 가산함

(총대기자수-대기자순위/총대기자수) ×1점

다. 장기등이식대기자의대기시간

3점만 12세 내지 18세

4점만 11세 이하나. 장기등이식대기자의 나이

0.5점A 또는 B 1match

1점DR 1match가. 사람백혈구항원검사(Antigen Match)

점수내용항목

http://www.konos.go.kr/doc/work.konos.hwp

장기이식관리 업무안내 2004. 4 - 장기별 항목 점수 [신장 및 췌장]

Candidates for ReTx

No big differenceRisks of

Presensitization,CVD,Malignancies andInfections

Age-appropriate screeningMalignancyFrank discussionNoncomplianceTreatment and screening for continued presenceInfectionDisease -specific evaluationRecurrent diseaseSensitive assay to evaluate donor-specific AbsRejection

Etiology of graft lossStress tests, cardiac cath, vascular studiesCVD and PVDObservation, 6-minute walk testOverall function statusEvaluationRisk Factor

Considerations before ReTx

Koch MJ. Adv Chronic Kidney Dis. 2006; 13: 18-28

Outcomes of ReTx

Inferior to 1st TxOssareh S et al. Transplant Proc 1999;31:3122-3Rigden S et al. Nephrol Dial Transplant 1999;14:566-9

No differenceStratta RJ et al. Transplantation 1988;45:40-5Coupel S et al. Kidney Int 2003;64:674-80Park YK et al. J Korean Soc Transplant 1999;13:87-92Kim MS et al. J Korean Soc Transplant 1995;9:59-64

UNOS Annual Report 2006

대한이식학회지 2006;20:69-72대한이식학회지 2006;20:73-78

Fig. 1. Graft survival rate after first and re-transplantation.

Risk Factors

General> 40 y-o recipientBlacksDiabeticDegree of HLA mismatch

2nd TxFunction duration of first graftNepherctomy of first graftType of first donor kidneyCause of graft lossTime of first graft loss

Transplantation Proceedings, 33, 1188–1189 (2001)

USRDS data 1988-1997; 4,039 repeat transplants

The highest incidence of repeat graft failure occurs in the first 6 months and is conferred by a first transplant graft loss within the first 12 months.

The 5-year risk of second graft loss was highest for patients who lost their primary graft between 4 and 12 months posttransplant and 2 weeks to 3 months posttransplant as compared to those who lost their grafts at greater than 48 months posttransplant (RR 5 2.34 and 2.28, respectively, P<0.0001).

Allograft Nephrectomy

~20% of patients eventually require a transplant nephrectomyNot necessary in the majority of cases before transplantation.No clinically apparent evidence of acute rejection or infection at the time of retransplantation.

Allograft Nephrectomy

Primary graft nephrectomy can be indicated if symptoms or signs related with immunosuppressant withdrawal (e.g., fever, malaise, graft swelling, thrombocytopenia and hematuria)Nephrectomy can be avoided by temporary reinstitution of immunosuppressants.Avoidance of nephrectomy is preferred due to possibly elevation in the percentage of preformed cytotoxicantibodies.Morbidity (e.g., bleeding) and mortality of primary transplant nephrectomy are not negligible.

Allograft Nephrectomy

Removal of primary transplant can be performed in concordance with placement of the subsequent transplantation.

57/66 primary graft nephrectomized (CMC, 2006)

0/22 primary graft nephrectomized (Kosin, 2006)

Immunosuppression

High immunological riskHigh PRARetranplantSPKTxPediatric transplant

High functional riskCold ischemic time > 24 hDGF

Pretransplant immunological evaluation in detail is required.Induction therapy required.

Transplantation Proceedings, 33, 2315–2316 (2001)

159 retransplants analyzed accordong to the immunosuppressive regimens

* * *

P<0.05*

Transplantation Proceedings, 33, 2315–2316 (2001)

Cantarovich D. J NEPHROL 2004; 17: 40-46

Prevention of acute rejection with antithymocyte globulin (Thymoglobuline) : Its potential to reduce corticosteroidsD. Cantarovich

Induction therapy applied (thymoglobuline or tymphoglobuline)

El-Agroudy AE et al. BJU International 2004;26:369-73

54 second transplants (48 relatives) of 1,406 all transplants

All patients received induction antibody therapy (ATG, OKT3, basiliximab or daclizumab)

The overall graft and patient survival was good; 15 grafts (27%) lost during the follow up of 1–17 years.

El-Agroudy AE et al. BJU International 2004;26:369-73

Predictors of graft survival (multivariate analysis)

Donor relationship, Primary immunosuppression,Duration of first graft and Scr level at 1 year

Renal retransplantation is the treatment of choice in patients who have lost their graft.

The use of related living-donors and potent immunosuppression could help to improve the outcome.

Surgical complications

No notable difference

Transplantation Proceedings, 37, 2154–2156 (2005)

1,108 all transplants65 second Vs 1,043 primary The rates of surgical complications were 4.6% in second and 3.8%primary (p=ns).

Surgical complications : Male sexual dysfunction

J Urol 2004, 172; 2335

50 patients with CRF on HD without associated vascular risk factors.Evaluated before and after KTP with 6-month follow-up.

J Urol. 1979 Jun;121(6):719-20At least 2 Tx : 65%First Tx : 10%Suggest that the second Tx be placed end-to-side into the common iliac artery

Surgery. 1984 Apr;95(4):415-9Bilateral: 46% (11/24)Unilateral 21% (5/24)Avoidable by sparing at least one internal iliac artery

Scand J Urol Nephrol. 2004;38(6):511-6Unilateral interruption of the internal iliac artery, an adequate penile blood supply is maintained in the majority of cases.

Noncompliance

2nd leading cause of allograft failureDonor organ scarce is an issue.Is retransplantation justifiable?

Noncompliance

52 of 3,525 transplants who had lost the first organ due to noncompliancePatients had to give a clear statement on compliance.16 retransplants

1 technical failure1 chronic rejection14 stable and compliant (mean followup 4.7 y).

Noncompliance is a potentially reversible cause for renal allograft loss.

Troppmann C et al. Transplantation 59;467,1995

Summary

Retransplantation : immunologically high riskOutcome of retransplantation may not be inferior to primary transplant.Function duration of first graft is considered to be a risk factor.Induction therapy (e.g., thymoglobulin) is recommended.Primary graft nephrectomy is controversial.Male sexual dysfunction can be an issue (esp., in case of bilateral internal iliac artery use).

not SFO but PUS