This study was designed to explore the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes in kidney transplantation.
A retrospective analysis between Jan 2006 to Dec 2014, at Houston Methodist JC Walter Jr Transplant Centre aimed:
To compare the clinical outcomes of KTs from donors with or without a history of diabetes into diabetic or non-diabetic recipients
There were 706 patients who received kidneys from deceased donors. 49 of these patients received a kidney from a diabetic donor. Among 49 recipients, 23 had a history of diabetes, and 26 were non-diabetic.
Nondiabetic patients had low levels of BMI, lowest mean age, least proportion of males, highest prevalence of glomerulonephritis and polycystic kidney disease as the reason for transplantation.
Diabetic recipients had the highest BMI and percentage of males and Hispanics.
Hypertension in the donor was most prevalent in patients with a history of diabetes.
By the Kaplan-Meier analysis of patient survival at five years, was highest in the recipients who were non-diabetic and received kidneys from deceased diabetic donors.
The analysis of death-censored graft survival was highest in the diabetic recipients and the non-diabetic donors.
Diabetes status of the recipient was associated with an increase in patient mortality.
There was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
Among 49 kidneys that were transplanted from deceased donors with a history of diabetes, post-perfusion biopsies were done on 26. 20 cases did not show evidence of DN. The others showed features of class IIa DN (mild mesangial sclerosis, hypercellularity, thickened glomerular basement membrane). Other features that were seen in some were features of arterionephrosclerosis, interstitial fibrosis, tubular atrophy, acute tubular necrosis, myoglobin casts, incidental IgA nephropathy.
No correlation could be found between the duration of donor diabetic history and the severity of the DN lesions found.
To examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Among 26 post-perfusion biopsies, follow-up biopsies were done in 17 recipients. Progression of DN was seen in 2 of the recipients, both of whom were diabetic.
Among 20 patients who had had no features of DN on post-perfusion biopsy, 12 were re-biopsied. Out of the 12, 9 patients continued to show no evidence of DN, while 3 developed de novo DN (all 3 were patients with diabetes).
This study suggests:
The recipient’s diabetic status has the greatest impact and adverse effect on mortality and graft survival
Kidneys from donors who have a history of diabetes have no or mild diabetic-related changes on histology.
Kidneys from donors with diabetes did as well as kidneys from non-diabetic donors when they were transplanted in recipients who did not have diabetes.
Patient survival was lower in recipients that had a history of diabetes, compared to those that did not. Survival was the poorest in diabetic recipients who received kidneys from diabetic donors.
Diabetic patients who received kidneys with DN, showed an acceleration of the DN. This may have led to graft failure and subsequent death.
There was better death-censored graft survival in the group of diabetic recipients of the kidneys from donors with no diabetic history, compared to the group of non-diabetic recipients of donors with no history of diabetes.
Therefore, as seen in prior studies, the risk associated with receiving a kidney from a donor with a history of diabetes depends on the diabetes status of the recipient.
What is the level of evidence provided by this article?
This is a level III evidence
Last edited 2 years ago by Theepa Mariamutu
amiri elaf
2 years ago
Outcomes of kidney transplantation using deceased donors with history of diabetes Please provide a summary of this article
The objectives of the study:
(a) To compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
(b) To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes.
(c) To examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Introduction:
*The outcome benefit from renal transplantation for those patients with ESRD, has led to an increased demand for donor kidneys, so utilization of kidneys from deceased diabetic donors has emerged in the last two decades as a possible solution to this shortage.
*Although deceased diabetic donor kidneys are routinely used in several centers, few studies evaluating this practice have been published.
*Ahmad et al noted similar patient survival, but slightly inferior graft survival in recipients of deceased diabetic donor kidneys when compared to recipients of deceased non-diabetic donor kidneys.
*Mohan et al conducted that they did not have a significant effect on graft and patient survival and even suggested that diabetic donor kidneys may be superior to using extended criteria donor kidney.
*Cohen et al showed that discordant recipient pair analysis of diabetic donor kidneys, using United Network of Organ Sharing data, and found that although a risk was associated with diabetic donor kidneys.
*The methods:
*Retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
*All recipients of deceased donor kidney transplants were further stratified into four groups based on recipient (R) and donor (D) diabetes history status (DM vs No DM history [N]).
*The groups were R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N. Recipient and donor characteristics, and peri-transplant factors were analyzed. Donor characteristics such as diabetes history, race, donor age, and BMI were obtained from the United Network of Organ Sharing (UNOS) dataset.
*All transplant candidates at this center undergo electrocardiogram, echocardiogram, stress test, and cardiology consultation.
*No patients were listed with evidence of myocardial ischemia, or heart failure or markedly reduced LVEF attributable to coronary artery disease.
Discussion:
*This is the first study to analyze the complex relationship between donor and recipient’s diabetes status pre- and post-transplantation
*Recipient’s diabetes status has the greatest impact and
adverse effect on mortality and graft survival.
*Kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
*Patient survival at 5 years was comparable to that reported in the 2015 SRTR/OPTN annual report (86.3%). However, 5-year death-censored graft survival was 88.5% despite the fact that 6.9% of the kidneys transplanted came from donors with a history of diabetes.
*Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
*Patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history.
*Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
The limitation:
* Both the small sample size and the limited number of post-perfusion and follow-up biopsies.
The strengths:
*Largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies and correlation with clinical outcome.
The conclusion:
*Transplantation risk of a kidney from a deceased donor with a diabetic depends on the diabetes status of the recipient.
*Diabetic renal changes in accepted kidneys from donors with a diabetes are mild to minimal.
*The current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
*Given the low 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history need more evaluation.
What is the level of evidence provided by this article? Level (3)
Last edited 2 years ago by amiri elaf
Mahmud Islam
2 years ago
With the need to extend the pool of donors, kidneys from deceased donors with diabetes were utilized. Some studies showed that survival is not inferior, rather some data showed superior graft survival. This study evaluated kidneys from deceased donors transplanted to both diabetics and non-diabetics. 6 out of 26 post-perfusion biopsies showed evidence of diabetic nephropathy, with /0% having no diabetic nephropathy on repeat biopsies. Survival of grafts from diabetic donors depends on the previous state of the recipient. Survival is worse in recipients with DM compared to non-diabetics. This study examined and reviewed post-perfusion biopsies and subsequent “for the indication” biopsies. Electron microscopy was used in the evaluation. Preexisting Dm or NODAT was defined in accordance with ADA guidelines. Of a total of 706 recipients, donated kidneys from previously DM donors were 49 (23 for DM recipients and 26 non-DM). As in figüre 1 , both survival is better in (R-N/D-DM) gruup. Death-censored survival was better in the (R-DM/D-N) group. The previous situation of recipients is essential. Diabetic recipients experience higher mortality because of the increased risk of infection and micro- and macrovascular disease.
Hamdy Hegazy
2 years ago
Please provide a summary of this article This is a retrospective study at Houston Methodist Transplant Center between January 2006-December 2014. Study population: 706 renal transplant recipients from deceased donors. 49 were from diabetic donors. 23 of these recipients had history of DM. Post perfusion biopsies were done in 26 of those 49 recipients. Follow up biopsies were done in 17 recipients. Aim: assess clinical and histological graft outcomes in correlation to donor diabetic history and recipient diabetic status. Primary outcome:
1- Recipient survival and death censored allograft survival
2- Illustrate the histological findings of post-perfusion biopsies from renal transplant from donors with diabetic history Results: Patient survival after 5 years was highest in non-diabetic recipients who received their graft from diabetic donors. Death-censored graft survival was highest in diabetic recipients who received their graft from no-diabetic donors. Diabetic recipients are more prone to increased mortality. 06/26 post perfusion biopsies showed evidence of diabetic nephropathy. There was no significant relation between severity of diabetic nephropathy changes and duration of donors’ DM. 02/17 follow up biopsies showed progressive diabetic nephropathy, both of them were diabetics. 03/20 follow up biopsies developed denovo diabetic nephropathy, all of them were diabetics. Conclusions: 1- The greatest impact on mortality and graft survival was seen in recipients with diabetes. 2- The lowest survival was seen in diabetic recipients who received kidneys from diabetic donors. Strengths: 1- This is the largest reported study group for transplant recipients from diabetic donors. 2- Inclusion of post perfusion biopsies. 3- Inclusion of follow up biopsies. Limitations: 1- Small Study population. 2- Small number of post perfusion and follow up biopsies. What is the level of evidence provided by this article? Level III evidence.
Mohammed Sobair
2 years ago
Introduction:
The survival benefit that end-stage renal disease (ESRD) patients derive from kidney transplantation has led to an increased demand for donor kidneys.
As a result, utilization of kidneys from deceased diabetic donors has emerged in the last two decades as a possible solution to this shortage.
the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation . AIM of the study:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes.
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history. Materials and Methods:
For the first aim, retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
The primary outcomes in the study were recipient survival and death-censored allograft survival.
The criterion for accepting a kidney from a donor with a diabetic history at this center is the absence of high-grade proteinuria (>2+).
For the second and third aims, post-perfusion biopsies and subsequent “for indication” biopsies were examined and reviewed.
The time in days that a kidney resided in a “hyperglycemic environment” was calculated from the time of transplantation in diabetic recipients or from the time of onset of NODA. On multivariate analysis of patient survival:
diabetes status of the recipient was associated with an increase in patient mortality.
Compared to control (R-N/D-N), the R-DM/D-N subgroup had nearly a twofold higher patient mortality at 5 years (HR 1.99, P = .017). Risk to a diabetic recipient was greater still, at 3-fold higher patient mortality at 5 years, with receipt of a kidney from a donor with diabetic history (R-DM/D-DM .
Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years.
Postperfusion biopsy finding:
Of the 49 kidneys from deceased donors with diabetic history transplanted, post-perfusion biopsy was performed in 26 cases (53%) (. Twenty cases did not exhibit evidence of diabetic nephropathy even after EM examination (Table 4). One biopsy showed thickened glomerular basement membrane by EM, but did not have any evidence of DN on light microscopy. Five biopsies showed class IIa DN characterized by mild mesangial sclerosis, hypercellularity, and thickened glomerular basement membrane. Diabetic nephropathy of higher severity (class IIb-IV) was not seen in any biopsy. Discussion:
This study suggests that
(a) recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival, and (b) kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
What is the level of evidence provided by this article?
Level of evidence 3.
Amit Sharma
2 years ago
Please provide a summary of this article
Studies have shown similar patient survival and slightly inferior graft survival on transplanting deceased diabetic donor kidneys. Such kidneys expand the donor pool. Hence this study was conducted retrospectively to assess the effect of donor diabetes on the clinical and histological graft outcomes.
A total of 706 deceased donor recipients were included in this retrospective study done at a single centre between 2006 and 2014. Patients were divided into 4 groups: Donor diabetic (D-DM) with recipient diabetic (R-DM) – 23 patients, D-DM with non-diabetic recipient (R-N) – 26 patients, R-DM with non-diabetic donor (D-N) – 211 patients, and R-N with D-N – 446 patients.
Recipient survival, graft survival, and graft biopsies (post-perfusion, and indication biopsies) were evaluated.
5.5% of R-N patients received a D-DM kidney, while 9.8% of R-DM patients received a D-DM kidney, Median follow-up was 50 months. 5-year patient survival was 71.6%, 96.2%, 80%, and 89.7% in R-DM/D-DM, R-N/D-DM, R-DM/D-N, and R-N/D-N groups (poorest survival in R-DM/D-DM group). 5-year risk of mortality in R-DM group was 2 times with D-N and 3 times with D-DM kidneys. Mortality was higher in age more than 65 years and dialysis vintage.
5-year death censored graft survival between the 4 groups was 87.5%, 87.4%, 93.5%, and 86.3% in R-DM/D-DM, R-N/D-DM, R-DM/D-N, and R-N/D-N groups.
Only 5 of 26 post-perfusion renal biopsies showed features of diabetic nephropathy, that too of mild severity (class IIa) on light microscopy while 1 biopsy showed thickened GBM on electron microscopy. In the 12 follow-up biopsies of D-N patients, 3 developed de-novo DN. Progression of DN was noted in 2 R-DM patients. Among the 17 D-DM biopsies, 6 showed progression, 1 showed regression, while 10 had stable or no DN lesions.
The study concluded that the recipient diabetic status is the most important factor for graft and patient survival, and diabetic donor kidneys have graft and patient survival similar to non-diabetic donor kidneys, with histologically showing, at the most, mild changes. Hence diabetic donor kidneys can be utilized to expand the donor pool, especially in non-diabetic recipients.
Limitations of the study were small sample size, limited post-perfusion and follow-up biopsies, retrospective nature, and single centre study. The strengths of the study include largest reported cohort with using histological parameters with clinical outcomes.
2. What is the level of evidence provided by this article?
The level of evidence is level 3 (retrospective cohort study).
Hussam Juda
2 years ago
Outcomes of kidney transplantation using deceased donors with a history of diabetes Introduction
· As kidney transplantation has a better outcome than being on dialysis, deceased diabetic kidneys were used to overcome the shortage of donated kidneys.
· Ahmad et al found that diabetic donors can be accepted choice to expand the pool of donors.
· Mohan et al found that kidneys from diabetic donors can be superior to kidneys from extended criteria. MATERIALS AND METHODS
· Study aims:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
· analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
· All recipients of deceased donor kidney transplants were further stratified into four groups: R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N.
· Donor characteristics such as DM history, race, donor age, and BMI were obtained from the UNOS dataset.
· The criterion for accepting a kidney from a donor with a diabetic history at this center is the absence of high-grade proteinuria (>2+).
· The rate of post-reperfusion biopsies at this center is approximately 50%
· Diabetes was defined as a fasting blood sugar ≥ 126 on 2 separate occasions or a HbA1c ≥ 6.5%.
· New onset diabetes after transplantation (NODAT) was defined by similar criteria or the presence of antidiabetic agents 3 months after transplantation.
· CKD-EPI Equation was used to estimate GFR. Discussion
· This study found that DM had the highest effect on recipient mortality and graft survival
· Kidneys from diabetic donors had negligible histological diabetic changes.
· 5-year death-censored graft survival was 88.5% despite the fact that 6.9% of the kidneys transplanted came from donors with a history of diabetes
· Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients. However, patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history
· Patient survival was lower in diabetic recipients than in non-diabetic recipients, but the survival was poorest in diabetic recipients of kidneys from donors with a diabetic history
· The development of diabetic nephropathy in a diabetic environment in the transplant setting is accelerated, which may lead to graft failure and death.
· the risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient
· Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
· Histological examination of kidneys from donors with a diabetic history in the present study suggests that the main cause of pre-transplant renal injury was due to donor-derived microvascular disease from a combination of both hypertension and diabetes.
Limitations of the study: small sample size and the limited number of post-perfusion and follow-up biopsies
Strength of the study: this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
CONCLUSION
· Risk outcome of the deceased diabetic donated kidney depends mainly on the recipient status
· Diabetic renal changes from diabetic donors are minimal
· the current emphasis of the KDPI on a donor diagnosis of diabetes needs a revision with the presence of high-grade proteinuria and renal function impairment
· Since a 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history, transplanting such kidneys into diabetic recipients needs a revision.
This is a retrospective case-control study, evidence 3
Tahani Ashmaig
2 years ago
Introduction:
Deceased diabetic kidneys are increasingly utilized in transplantation. Although deceased diabetic donor kidneys are routinely used in several centers, few studies evaluating this practice have been published.
This study examined the relationship of recipient diabetic status
and donor diabetic history to clinical and histological outcomes of
kidney transplantation.
Results:
The relationship of donor’s history of diabetes to clinical and histological outcomes was examined. Forty-nine diabetic deceased donor kidneys (D-DM) were transplanted into 26
normal (R-N/D-DM) and 23 diabetic recipients (R-DM/D-DM) and compared to 211diabetic recipients of normal kidneys(R-DM/D-N) and 466 normal recipients of normal kidneys (R-N/D-N). Patient survival at 5 years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and a 71.6% in R-DM/D-DM (P = .008). Deathcensored graft survival at 5 years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM (P = .24). Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality. In this cohort, there was no impact on deathcensored graft survival of diabetic donor status. Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression. Survival of recipients of diabetic donor kidneys appears
dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this cohort, donor kidneys had paucity of structural diabetic lesions and most did not show progression
This study is limited by:
1.The small sample size.
2. The limited number of post-perfusion and follow-up biopsies.
The strengths of this study:
1. Being the largest reported cohort of transplanted kidneys from donors with a
diabetic history with post-perfusion biopsies, follow-up, and correlation with clinical outcome.
Conclusion:
The risk associated with transplantation of a kidney from a deceased donor with
a diabetic history appears to be largely dependent on the diabetes
status of the recipient.
Diabetic renal changes in conventionally accepted kidneys from donors with a diabetic history in this cohort are mild to minimal.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
Given the low 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history the propriety of transplanting such kidneys into diabetic recipients should be questioned
Hussein Bagha baghahussein@yahoo.com
2 years ago
Introduction
It is well known that kidney transplantation has increased the survival benefit of patients with end-stage renal disease (ESRD). Therefore, there is an increased demand for donor kidneys. There are a few studies done that show similar patient survival and a non-significant inferior graft survival in recipients of deceased diabetic donor kidneys when compared to deceased non-diabetic donor kidneys. Single case reports have also been published showing reversal of diabetic lesions in the kidney once a euglycemic state was restored. However, further studies were required to help better understand the relationship.
This study was designed to examine the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes in kidney transplantation.
Materials and methods
The aims of the study included:
1.To compare the clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
This was a retrospective analysis, at Houston Methodist JC Walter Jr Transplant Center
Time frame was between between Jan 2006 to Dec 2014
The primary outcome was recipient survival and death-censored allograft survival
The reason for accepting a kidney from a donor with a diabetic history at this center was the absence of high-grade proteinuria (>2+)
2. To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
3.To examine histologic changes following transplantation in kidneys from donors with a diabetic history.
For the second and third aims, electron microscopy (EM) was used to examine the biopsies, with special attention to features of diabetic nephropathy (DN). The changes were graded. A pre-existing history of diabetes or new-onset diabetes after transplantation (NODAT) was defined by the American Diabetic Association criteria.
Results
Aim 1 – Patient population and outcomes
There were 706 patients who received kidneys from deceased donors. 49 of these patients received a kidney from a diabetic donor. From these 49 recipients, 23 had a history of diabetes, and 26 were non-diabetic.
The groups with the nondiabetic patients had low levels of BMI, lowest mean age, least proportion of males, highest prevalence of glomerulonephritis and polycystic kidney disease as the reason for transplantation. Diabetic recipients had the highest BMI and percentage of males and Hispanics. Hypertension in the donor was most prevalent in patients with a history of diabetes.
By the Kaplan-Meier analysis of patient survival at five years, was highest in the recipients who were non-diabetic and received kidneys from deceased diabetic donors. The analysis of death-censored graft survival was highest in the diabetic recipients and the non-diabetic donors.
Diabetes status of the recipient was associated with an increase in patient mortality. there was no statistical significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
Aim 2 – post-perfusion renal transplant biopsy findings
Of the 49 kidneys that were transplanted from deceased donors with a history of diabetes, post-perfusion biopsies were done on 26. 20 cases did not show evidence of DN. The others showed features of class IIa DN (mild mesangial sclerosis, hypercellularity, thickened glomerular basement membrane). Other features that were seen in some were features of arterionephrosclerosis, interstitial fibrosis, tubular atrophy, acute tubular necrosis, myoglobin casts, incidental IgA nephropathy.
No correlation could be found between the duration of donor diabetic history and the severity of the DN lesions found.
Aim 3 – follow-up biopsy findings
Of the 26 post-perfusion biopsies, follow-up biopsies were done in 17 recipients. Progression of DN was seen in 2 of the recipients, both of whom were diabetic.
Of the 20 patients who had had no features of DN on post-perfusion biopsy, 12 were re-biopsied. Out of the 12, 9 patients continued to show no evidence of DN, while 3 developed de novo DN (all 3 were patients with diabetes).
Discussion
This study suggests:
1.The recipient’s diabetic status has the greatest impact and adverse effect on mortality and graft survival
2. Kidneys from donors who have a history of diabetes have no or mild diabetic-related changes on histology.
Kidneys from donors with diabetes did as well as kidneys from non-diabetic donors, when they were transplanted in recipients who did not have diabetes. Patient survival was lower in recipients that had a history of diabetes, compared to those that did not. Survival was the poorest in diabetic recipients who received kidneys from diabetic donors.
Diabetic patients who received kidneys with DN, showed an acceleration of the DN. This may have led to graft failure and subsequent death.
There was better death-censored graft survival in the group of diabetic recipients of the kidneys from donors with no diabetic history, compared to the group of non-diabetic recipients of donors with no history of diabetes.
Therefore, as seen in prior studies, the risk associated with receiving a kidney from a donor with a history of diabetes depends on the diabetes status of the recipient.
Limitations
The limitations of this study include:
1. Small sample size
2. Limited number of post-perfusion and follow-up biopsies.
Strengths
The strengths of this study include:
1.The largest reported cohort of transplanted kidneys from donors with a history of diabetes with post-perfusion biopsies
2. It included follow-up biopsies and correlation with clinical outcome.
This is a level III evidence
rindhabibgmail-com
2 years ago
This was a retrospective study done at deceased donors kidney transplants between 2006 to 2014 and with follow-up till 2016.
The aim and objective of this study was to compare the clinical outcomes of kidney transplantation from deceased donors with and without diabetes recipient, findings in post perfusion biopsies in kidneys from diabetic donors, examine histologic changes following transplantation in the kidneys from diabetic donors.
Several studies has shown similar patient survival, graft survival and the risk was dependent on the recipient diabetes, additionally there was no histological studies done to look at the diabetic donors, however few studies have evaluated the outcomes when deceased diabetic donors are taken.
Balaji Kirushnan
2 years ago
The survival of the kidney transplant recipient seems very important rather than staying on dialysis, hence the utilization of diabetic kidney donors have increased the last 2 decades….Many institutes accept diabetic kidney donors with normal renal function and mild proteinuria…Some institutes do a protocol biopsy if there is azotemia or proteinuria and then decide based on the chronicity….In fact Diabetic kidney donors have shown to be far superior compared to extended criteria donors…Way back in 1983, there was one paper reported reversal of diabetic nephropathy changes 7 months after transplant of a diabetic kidney donor into a recipient..
This study examined the effects of transplant of diabetic kidney donors into the recipients…They studied the effect of diabetic kidney donors into diabetic and non diabetic recipients and also had analyzed the histopathological changes at the time of post perfusion and after renal transplantation….
this was a retrospective review study from Houston Texas from 2006 to 2014..And they were followed up till 2016…
Among the 706 recipients, 49 patients who received kidneys from diabetic donors..of the 49, 23 were transplanted into the diabetic recipients and 26 were implanted in non diabetic recipients…
Kaplan Meir analysis of patient survival and death censored graft survival were analyzed in 4 groups…Recipient Normal/Donor normal, Recipient diabetes/donor diabetes, Recipient normal/donor diabetes, Recipient diabetes/donor normal….5 year patient survival was highest in the recipient normal and donor diabetic individuals….5 year death censored graft survival was highest in recipient diabetic/donor normal followed by donor diabetic/recipient normal groups…On multivariate analysis of the patient survival, recipient diabetic state was associated with overall patient mortality…for the death censored graft survival donor diabetic or recipient diabetic status was not associated with 5 year graft survival in this study…
of the 49 kidneys in the group, 26 kidneys were subjected to post perfusion biopsy…20 cases did not exhibit features of diabetic nephropathy even after EM examination….6 patients showed RPS/ISN diabetic nephropathy class IIa changes only…There was no correlation between duration of the diabetes in the donor and severity of the histopathological changes that were observed….
38 follow up biopsies were done and progression of diabetic nephropathy was noted in diabetic recipients 6, 10 showed stable features as compared to the post perfusion biopsy and 1 showed regression of the diabetic lesions…
This study concluded that the recipient diabetes status is most important when considering overall patient survival than the donor diabetic status…The diabetic kidney changes seen in histology are very mild or minimal in diabetic kidney donors ….The study even questions Kidney Donor Profile index (KDPI) and says the duration of diabetes should not be the only one included in the index, rather the degree of proteinuria and renal impairment should be included as donor diabetic kidneys from deceased donors have comparable graft survival as non diabetic kidney donors…
Esraa Mohammed
2 years ago
The aims of this study were as follows:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
. This study suggests that
(a) recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival
(b) kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
-Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
-patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history
-The development of diabetic nephropathy in a diabetic environment in the transplant setting is accelerated
– This acceleration of pre-existing diabetic lesions may well contribute to graft failure and consequent patient death in this latter group
– the risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient.
-Diabetic recipients experience higher mortality
-Histological examination of post-perfusion biopsies showed either absent or mild diabetic lesions
-The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome.
In conclusion, the risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient.
Zahid Nabi
2 years ago
Expanding donor pool is one way of tackling immense organ shortage. Accepting deceased donor with diabetes can help to bridge the gap of organ shortage.
The relation- ship of donor’s history of diabetes to clinical and histological outcomes was examined in this paper by khan and her colleagues.
The aims of this study were as follows:
To compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipient
To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
To examine histologic changes following transplantation in kidneys from donors with a diabetic history. Approval for this retrospective review was obtained from the Houston Methodist Institutional Review Board.
For the first aim, retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
All recipients of deceased donor kidney transplants were further stratified into four groups based on recipient (R) and donor (D) diabetes history status (DM vs No DM history).
For the second and third aims, post-perfusion biopsies and sub- sequent “for indication” biopsies were examined and reviewed.
The diabetic changes were graded on a scale of 0-IV, as defined by the Renal Pathology Society (RPS)
Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality.
In this cohort, there was no impact on death- censored graft survival of diabetic donor status. Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this cohort, donor kidneys had paucity of structural diabetic lesions and most did not show progression.
Reterspective study
level of evidence 111
Muntasir Mohammed
2 years ago
1. Please provide a summary of this article. Introduction Because of organ shortage utilization of ECD kidneys including diabetic has emerged recently. This is retrospective study in Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 with follow-up through May 1, 2016. The objectives are: 1. To compare clinical outcomes of kidney transplants from diabetic and non-diabetic donors into diabetic and non-diabetic recipients. 2. To describe histologic changes post perfusion in kidneys from diabetic donors. 3. To check histologic changes post transplantation in kidneys from diabetic donors. Recipients were divided in to 4 groups: · Diabetic donor to non diabetic recipients. · Diabetic donor to diabetic recipients. · Non diabetic donors to non diabetic recipient · Non diabetic donor to diabetic recipients. Results Out of 706 renal transplants: ü 23 diabetic recipient from diabetic donors. ü 26 non diabetic recipient from diabetic donors ü 211 diabetic recipient from non diabetic donors ü 446 non diabetic recipient from non diabetic donors. Of 706 primary renal transplants, subcategories included the following: R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 21,1 and R-N/D-N446 patients. Median follow up was 50months. 5years patient and death censored graft survival for the entire group was 88.5 and 86.5% respectively. No significant difference was found between the different groups in patient or graft survival. On multivariate analysis, diabetic recipient status was associate with increased mortality. Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years. No significant difference in the in diabetic versus non diabetics. This study is limited by small number size and limited number of biopsies What is the level of evidence provided by this article? Level 111
Naglaa Abdalla
2 years ago
This study evaluate the outcome of deceased diabetic donors. This is the first study to analyze the complex relationship between donor and recipient’s diabetes status pre- and post-transplantation in the context of both clinical and histological data.
The objectives: (a) to compare clinical outcomes
of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
The permission was taken from Houston Methodist Institutional Review Board.
Donors are selected if there is absence of high-grade proteinuria (>2+).
Post perfusion biopsies are taken.
Four groups are identified:
1- Diabetic donors to diabetic recipients
2- Diabetic donors to non-diabetic recipients
3- Non-diabetic donors to diabetic recipients
4- Non-diabetic donors to non-diabetic recipients
Results and discussion:
1- Recipient’s diabetes status has the greatest bad effect on mortality and graft survival
2- kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
3- Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients
4- Diabetic recipients experience higher mortality because of increased risk of infection, sepsis, and micro- and macrovascular disease.
4- The development of diabetic nephropathy in a diabetic environment in the transplant setting is accelerated .
This study is limited by both the small sample size and the limited number of post-perfusion and follow-up biopsies.
The strengths of this study is that it is the
largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
Hussein Bagha baghahussein@yahoo.com
2 years ago
Introduction: There is an increasing utilization of deceased diabetic donors to increase the donor pool and to reduce the waiting time for a kidney transplant Few studies have evaluated the outcomes when deceased diabetic donors are used. Several studies have shown similar patient survival and graft survival and that the risk was dependent on the recipient diabetes status There are also no histological studies looking at the diabetic lesions post-transplant.
Aims:
To compare the clinical outcomes of kidney transplants from donors with or without a history of diabetes in to diabetic or non-diabetic recipients
Describe historic findings in post-perfusion biopsies in kidneys form diabetic donors
Examine histologic changes following transplantation In kidneys from diabetic donors
Methodology: This was a retrospective review where analysis of electronic medical records of recipients of deceased donor kidney transplants between January 2006 to December 2014 was performed with follow up through to May 2016. All the recipients were stratified in to 4 groups based on recipient (R) and donor (D) diabetes history status (DM or no DM). The 4 groups were:
R-N/D-N
R-N/D-DM
R-DM/D-N
R-DM/D-DM
Donor characteristics such as diabetes Hx, race, age and BMI were obtained from the UNOS data. The primary outcomes were Patient survival Death-censored graft survival For the 2nd and 3rd aims, post-perfusion biopsies and subsequent ‘for indication’ biopsies were examined and reviewed The diabetic changes on histology were graded on a scale of 0-4 as defined by the Renal Pathology Service (RPS) Recipients’ GFR was estimated using the CKD-EPI formula
Results: 49 out of 706 (6.9%) recipients received a kidney from a diabetic donor. 23 (47%) were implanted in diabetic recipients and 26 (53%) were implanted in non-diabetic recipients. The R-N/D-N had the least proportion of males, lowest mean age, lowest BMI, highest prevalence ofGN and PKD and the lowest median donor age and donor BMI. Median follow up for the primary analysis was 50 months. Kaplan Meier analysis of patient survival by sub-group was: 89% in R-N/D-N 96.2% in R-N/D-DM 80% in R-DM/D-N 71.6% in R-DM/D-DM Kaplan Meier analysis of DCGS at 5 years by the sub-group was · 86.3% in R-N/D-N · 87.4% in R-N/D-DM · 93.5% in R-DM/D-N · 87.5% in R-DM/D-DM On multivariate analysis of patient survival, diabetic status of recipient was associated with an increase in patient mortality. Compared to controls (R-N/D-N), the R-DM/D-N group had a nearly 2 fold higher mortality at five years Age > 65 years and dialysis vintage were associated with an increase in patient mortality. By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetic status on death censored graft survival (DCGS)/ Aim 2: Post perfusion biopsies were performed in 26 of the 49 deceased donors. 6 showed evidence of diabetic nephropathy (DN). One biopsy only showed GBM thickening while 6 had class IIa DN. Aim 3: Of the 26 post-perfusion biopsies, follow up biopsies were performed ‘for indication’ in 17 recipients Progression of DN was noted in 2 recipients. Of the 20 recipients with no DN on post-perfusion biopsy, 3 developed de novo DN (all 3 recipients were diabetic)
Discussion: Patient survival was at five years was similar to that reported in the 2015 SPTR/OPTN annual report. The patient survival in R-N/D-DM was higher than in the group R-N/D-N. This may reflect a higher proportion of females, re-transplants and a higher cPRA in that recipient group. The better graft censored survival in the R-DM/D/N compared to R-N/D-N could have been related to the higher patient mortality in the R-DM/D-N group (20%) compared to the R-N/D-N group (10.3%)
Limitations: The study is limited by the small sample size and the limited number of post-perfusion and follow up biopsies. Neither the post perfusion nor the follow up biopsies were performed per protocol. They were performed at the discretion of the surgeon
Conclusion: Although further studies are needed, the risk associated with transplantation of a kidney from a deceased diabetic donor appear to be largely dependent on the recipient diabetes status. From this study, it would be advisable to give a kidney from a diabetic donor to a diabetic recipient as this was shown to have the worse outcome Diabetic renal changes from the deceased diabetic donors are mild to minimal. Progression of DN depends on the time the kidney was in the hyperglycemic milieu.
Marius Badal
2 years ago
Summary: Kidney disease continues to increase and the problem rise concerns for nephrologists and the country as the cost of renal replacement is high. This is why all possible avenues must be investigated to ensure the pool for kidney transplants increases. This article is about the outcomes of kidney transplantation using deceased donors with a history of DM. That is why deceased diabetic donors were investigated. The possible outcome was investigated and elaborated on in this article to better understand if diabetic patients can be used. The study included 49 DM deceased donors whose kidneys were used by 26 recipients non diabetics and 23 DM recipients. From there the outcome was compared with 211 DM recipients of normal kidney donors and 466 normal recipients of normal kidney donors. The study was followed up 5 years and the patient survival was about 86.5%. The patient survival rate was: 1) Normal recipients to normal donors was 89.7% 2) Normal recipient to DM donors was 96.2% 3) DM recipients of the normal donor were 80.1% 4) DM recipient of DM donor was 71.6% As it relates to 5-year death and graft survival: 1) Normal recipients to normal donors was 86.3% 2) Normal recipient to DM donors was 87.4% 3) DM recipients of the normal donor was 93.5% 4) DM recipient of DM donor was 87.5% So it was found that DM recipients have a 2 to 3-fold increased risk of mortality when compared with the non-DM. The group that did the worse was the DM recipients with DM donors. It was noted that from the biopsy 6 from 26 showed evidence of diabetic nephropathy and on repeating 70% had no evidence of progression. The study was a good one but was limited since the population size was small and its strength was that it was the largest study ever conducted that is a cohort study. The level of evidence of this study was level 3 since it was a retrospective cohort study.
Abdul Rahim Khan
2 years ago
Please provide a summary of this article
The use of deceased kidney donation is increasing due to large waiting list, especially in last two decades. Kidney from deceased donors have been used in may centres but outcome of such donation has been evaluated by few studies.
This study evaluated the donation from deceased diabetic donors to non diabetic recipient . The clinical and histological outcomes were evaluated.
Methodology.
49 kidney from diabetic donors were transplanted in 26 non diabetic and 23 diabetic recipients.
The outcome was compared with 211 diabetics who received kidney from non diabetics.
Also comparison was done with 422 non diabetics who received kidney from non diabetics
So essentially there were 4 groups
Diabetic donor : Non diabetic recipient
Diabetic donor : Diabetic recipient
Non Diabetic donor : Diabetic recipient
Non Diabetic donor : Non diabetic recipient
Diabetes was labelled if fasting sugar was more than 126 mg and HbA1C was 6.5%.
Biopsies were done in 26 recipients post perfusion and only 6 showed nephropathy changes.
Results and Conclusions.
Kidney from diabetic vs Non diabetic donors- when transplanted to non diabetic recipients did equally good.
As regards death censored graft survival , not much difference was noted diabetic donor and diabetic recipient
Outcome of kidney donation from diabetic donors depends upon recipient diabetic profile.
Limitations
Small sample
Limited use of biopsies.
Strengths
Largest cohort of diabetic donors with follow up and post perfusion biopsies.
What is the level of evidence provided by this article?
Retrospective study
Level 111
Wael Jebur
2 years ago
a retrospective study was conducted to evaluate the outcome of transplanting deceased diabetic donor kidneys to diabetic and non diabetic recipients, emphasizing on the impact of diabetic allograft on long term survival of the allograft and the confounding effects of being diabetic recipient versus nondiabetic recipient.
49 diabetic deceased donors kidneys were transplanted into 23 diabetic recipients and 26 normal recipients, the outcome was compared to 211 diabetic patients received normal non diabetic deceased donors kidneys and 422 non diabetic patients received non diabetic deceased donors kidneys. So 4 groups of patients were followed comparatively:
D,DM/R,N
D DM/R, DM
D,N/ R, DM
D,N/R,N
5 years ,death censored graft survival was evaluated across the 4 groups.
Diabetic was diagnosed as per the known guideline with fasting blood glucose of 126 and HbA1c of more than 6.5.
New onset diabetes after transplantation NODAT was explicated similarly , in addition to being on anti-diabetics for more than 3 months.
Post perfusion allograft biopsy was done in 26 recipients, 6 biopsies only featured histologic changes of diabetic nephropathy, which on subsequent biopsies , 70% failed to show any progression of the lesions.
Diabetic recipients had 2 -3 folds increased mortality rates in comparison to non diabetic recipients.
CARLOS TADEU LEONIDIO
2 years ago
Please provide a summary of this article
Given the lack of organs for patients on the waiting list, another criterion for assessing the donor’s expandability was the existence of diabetes in the donor. This study evaluated the relationship between the recipient’s diabetic status and the donor’s diabetic history with the clinical and histological outcomes of kidney transplantation at their institution.
The aims of this study were as follows: (a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients; (b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes; (c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history. It was a retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014
Among the results I highlight:
– On multivariate analysis of patient survival, diabetes status of the recipient was associated with an increase in patient mortality.
– Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years
– By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
– However, By multivariate analysis demonstred that recipient Black race, dialysis vintage, cPRAp as a continuous variable, and donor age greater than 50 years were associated with poorer graft survival at 5 years.
– No correlation could be found between the duration of donor diabetic history and the severity of diabetic nephropa[1]thy lesions observed.
– In all patients with progressive or de novo diabetic nephropathy , diabetes was present post-transplant.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this study, donor kidneys had paucity of structural diabetic lesions and most did not show progression
2.What is the level of evidence provided by this article? This article have a level 3 of evidence, because a retrospective study.
Abdullah hindawy
2 years ago
e, examined the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation at our institution.
The aims of this study :
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
result : patient population and outcome :
e R-N/D-N group had the least proportion of males, the lowest mean age, the lowest BMI, the highest prevalence of glomerulonephritis, and polycystic kidney disease as indication for transplantation, and the lowest median donor age and donor BMI.
patient and alograft result : diabetes reciepent has more risk of death
, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival
Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
limitation :
1- Given the histological findings in this study, the high numeric value given by KDPI to a diagnosis of diabetes results in a “labeling effect” and underutilization of otherwise acceptable kidneys
2-limited by both the small sample size and the limited number of post-perfusion and follow-up biopsies
conclusion :
, the risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recepient .
transplanting such kidneys into diabetic recipients should be questioned cause of low rate survival after five years .
What is the level of evidence provided by this article?
cause it is retrospective it is level 3
Last edited 2 years ago by Abdullah hindawy
Huda Saadeddin
2 years ago
Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality. In this cohort, there was no impact on deathcensored graft survival of diabetic donor status. Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this cohort, donor kidneys had paucity of structural diabetic lesions and most did not show progression.
The aims of this study were as follows:
a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
All transplant candidates at this center undergo electrocardiogram, echocardiogram, stress test, and cardiology consultation.
No patients were listed with evidence of myocardial ischemia, or heart failure or markedly reduced LVEF attributable to coronary artery disease.
The primary outcomes in the study were recipient survival and death-censored allograft survival. Recipient survival and death-censored allograft survival were verified in the SRTR (Scientific Registry of Transplant Recipients) database.
The criterion for accepting a kidney from a donor with a diabetic history at this center is the absence of high-grade proteinuria (>2+).
This study suggests that
(a) recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival
(b) kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients. However, patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history
the risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient. On multivariate analysis, a nearly 2-fold increase in patient mortality was noted when diabetic recipients were compared to non-diabetic recipients.
Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
Histological examination of post-perfusion biopsies showed either absent or mild diabetic lesions (only 6 of 26 immediate post-perfusion biopsies showed early diabetic changes).
The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome.15 Histological examination of kidneys from donors with a diabetic history in the present study suggests that the main cause of pre-transplant renal injury was due to donor-derived microvascular disease from a combination of both hypertension and diabetes.
The strengths of this study include that, though small, this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
In conclusion, although further studies are needed, the risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient.
———————-
level III
Reem Younis
2 years ago
Please provide a summary of this article
-The utilization of kidneys from deceased diabetic donors has emerged in the last two decades as a possible solution to the shortage of donor.
-It is retrospective study of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 with follow-up through May 1, 2016.
– The study suggests that recipient’s diabetes status has the greatest impact and
adverse effect on mortality and graft survival, and kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
-Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
-Patient survival was lower in diabetic recipients than in non-diabetic recipients, but the survival was poorest in diabetic recipients of kidneys from donors with a diabetic history compared to 80% survival in diabetic recipients of kidneys from donors with no diabetic history.
-The risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient.
-A nearly 2-fold increase in patient mortality was noted when diabetic recipients were compared to non-diabetic recipients.
-Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
– Despite varying duration of diabetic history, histological evidence of diabetic nephropathy was not seen in a majority of the post-perfusion biopsies, and where seen was mild.
-The history of diabetes rather than the presence of diabetic nephropathy (as evidenced by proteinuria or impaired renal function) that is heavily weighted in the KDPI scoring.
– This study is limited by both the small sample size and the limited number of post-perfusion and follow-up biopsies.
-The strengths of this study is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome. What is the level of evidence provided by this article?
Level 3
KAMAL ELGORASHI
2 years ago
Summary of the articles: Introduction:
The increasing deriving ESKD towards transplantation, lead to increase demand of kidney donation, as well as deceased donation.
ECD as emerged as one of the solution in inceasing donor pool, as well as utilizing donor with history of diabetes. Ahmed et al.; noted similar patient survival, but slightly inferior graft survival in recipients of deceased diabetic kidney donor, compared with the kidney of non-diabetic donors.
In 2012, Mohan et al.;show that donor diabetes, did not have a significant effect on graft and patient survival . Cohen et al.; found that risk was associated with diabetic donor, it dependently associated with recipient diabetes status.
Repeated biopsies 7 month afterward showed resolution of BM thickening, mesangial matrix expansion, and diffuse glomerulosclerosis.
Material and methods: Goal of the study:
To compare clinical outcome of kidney transplant from D/non-D donors to recipients with or without diabetes.
T describe histological biopsy finding post perfusion in kidney from donor with history of diabetes.
To examine histologic changes following transplantation, in donors with a diabetic history.
Recipient of deceased donor kidney transplant were furthurly classified into 4 groups;
R-DM/D-DM.
R-N/D-DM.
R-DM/D-N
R-N/D-N.
Donor charectristics:
DM history.
Race
Donor age
BMI.
All transplant candidates underwent:
ECG
ECHO
Stress test
Cardiology consultation
Exclusion criteria:
MI
HF
Marked reduced LVEF
High grade proteinuria
Primary outcome of this study is :
Recipient survival
Death -censored allograft survival
Biopsy based diabetic changes, graded from 0-IV as follow:
G-O = no diabetics changes by LM or EM.
G-I = no obvious LM changes, but thickenings of GBM by EM
G-IIa = mild mesangial expansion by LM
G-IIb = marked mesangial expansion by LM
G-III = nodular mesangial sclerosis
G-IV = advanced diabetic sclerosis
Pre-existing DM or NODAT defined according to ADA by:
Fasting blood glucose >/126 or;
Tow separate occasion of HBA1C >/6.5
In addition to above criteria , new NODAT defined by use of anti-hyperglycemic medX 3 month after Tx.
Results: Population characteristics:
49 recipient of 706 recipients receive a kidney from DM donors.
5.5% of non-DM recipients receive a kidney from DM donor
9.8% was DM recipients and receive a kidney from a DM donor
From total 49 kidney from DM donors; 23 implanted in DM recipients , while 26 implanted in non-DM recipients.
Patient survival, by Kaplan-Meier;
5 years follow-up patient survival was 86.5%
5 years follow-up patientsurvival was 88.5%
5 years patient survival in R-N/D-N was 87.4%
5 years patient survival in R-N/D-DM was 96.2%
5 years patient survival in R-DM/D-N was 80.0%
5 years patient survival in R-DM/D-DM was 71.6%
Graft survival, by Kaplan-Meier;
5years graft was 86.35 in R-N/D-N.
5 years graft survival was 87.4% in R-N/D-DM.
5 years graft survival was 93.5% in R-DM/D-N.
5 years graft survival was 87,5% in R-DM/D-DM.
multivariate analysis;
Patient survival in DM recipient associated with increased mortality
compared with control (R-N/D-N), the R-DM/D-N had a higher towfold pateint mortality at 5 years .
Risk of DM recipient was still higher 3 fold in recipients with donor with DM history.
Older recipients and time been on dialysis was associated with greater risk
Biopsy post perfusion transplant finding:
26 graft post perfusion biopsy done over 49 kidneys from DCD with DM;
20 of 26 biopsy did no show evidence of DN even with EM
1 biopsy show thickened GBM by EM, but no evidence of DN by LM.
5 biopsies showed class IIa DN
High grade DN no seen
Follow up biopsies:
Of 26 biopsy done before, 17 biopsies by indication done median time follow up was 562 days;
Progressive DN noted in 2 patients which were Diabetics before Tx.
Other remeining 20 recipient on no DN noted post perfusion ; 9 showed no evidence of DN changes, 3 develop denovo DN all were diabetics.
In summary:
DM recipients had higher chance to develop DM
NODAT has an impact on graft kidney
Other variables may contribute to patients and graft survival other than DM.
level of evidence:
Retrospective study level((III)).
Heba Wagdy
2 years ago
Deceased diabetic donors are recently used to increase the donor pool, they are associated with comparable patient and graft survival to kidneys from nondiabetic donors.
Previous studies suggested that using kidneys from diabetic donor is better than extended criteria donor kidneys, also showed reversal of diabetic lesions post transplant with restoring euglycemia.
This retrospective study aimed to determine the effect of kidneys from diabetic donors and nondiabetic donors in recipients with diabetes and without diabetes, it also described histological changes in post perfusion and follow up biopsies in kidneys from donors with diabetes.
It included recipients of deceased donors and classified them into 4 groups according to donor and recipient diabetes history with exclusion of recipients with cardiovascular disease.
Primary outcomes were patient survival and death censored graft loss.
The study suggested that recipient diabetes status has the main impact on patient and graft survival.
Kidneys from diabetic donors had mild histological changes before transplantation.
Graft outcome was similar in kidneys from diabetic and nondiabetic donors when transplanted in nondiabetic recipients.
Patient survival was lower in diabetic recipients than in nondiabetic recipients and was the lowest in diabetic recipients of kidneys from diabetic donors.
Accelerated progression in preexisting diabetic lesions was observed when kidneys from diabetic donors were transplanted in diabetic recipients.
The study suggested that recipient’s diabetic status has the greatest adverse effect on mortality.
Limitations:
Small sample size,
Post perfusion biopsies were per surgeon assessment and follow up biopsies were per indication with no protocol biopsies performed.
Strength:
Included largest cohort of kidney recipients from deceased diabetic donors with post perfusion and follow up biopsies and correlation to clinical outcomes.
The study suggested that KDPI should be revised to include presence of proteinuria and renal impairment rather than donor diagnosis of diabetes to decrease discarding kidneys from diabetic donors.
Level 3 retrospective cohort study.
Nandita Sugumar
2 years ago
Summary
This study refers to outcomes of kidney transplant when using deceased donors with diabetic history.
Two major lessons learned from this study include :
recipient’s diabetic status effects where the mortality and graft survival
donor kidneys having nil or mild histological diabetic changes give better graft outcome.
Recurrence of glomerulonephritis are a leading cause of graft loss with these donor kidneys.
Patient survival is better in non-diabetic recipients, but diabetic recipients have better outcome than diabetic recipients with diabetic donor kidneys. The risks associated with diabetic recipients include infection, sepsis, microvascular and microvascular disease. A major factor associated with decreased risk of graft survival in diabetic recipients is an increase in alloreactive T cells leading to higher rate of rejection episodes.
Both diabetes and hypertension are indicators of poor graft outcome. Risk of high grade proteinuria and renal functional impairment are to be looked out for in the case of diabetic donor kidneys.
In conclusion, the diabetic status of the recipient is of far more effect on adverse graft outcomes than diabetic donor kidneys with nil or mild histological diabetic changes.
Level of evidence 3 because this is a retrospective cohort study
Rihab Elidrisi
2 years ago
This study was conducted with the aim to increase the donor pool ,for that in this study it included 49 diabetic deceased donors whose their kidneys were transplanted into 26 normal recipients and 23 diabetic recipients. the outcome was compared to 211 diabetic recipients of normal kidney donors and 466 normal recipients of normal kidney donors.
RESULT;
patient survival & graft survival at 5 ys showed that diabetic recipients had 2-3 folds increased risk of mortality compared to non diabetic recipients .
– Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy and on repeat biopsies 70% showed no evidence of progression.
– Survival appears to be dependent on the diabetic status of the recipient with the worst outcome was in diabetic recipients from diabetic donors .
What is the level of evidence provided by this article?
level III as it was a retrospective cohort study.
Ibrahim Omar
2 years ago
Please provide a summary of this article :
owing to the best outcome of renal transplantation in ESRD patients and due to the growing big shortage of the donor kidney pool, trials have been in place to include grafts of less quality. of these grafts, are those of diabetic deceased donors.
the outcome of such serious practices were examined in this article. it included 49 diabetic deceased donors whose their kidneys were transplanted into 26 normal recipients and 23 diabetic recipients. the outcome was compared to 211 diabetic recipients of normal kidney donors and 466 normal recipients of normal kidney donors.
the results were as following :
I- 5 year patient survival :
1- in normal recipients of normal donors, it was 89.7%
2- in normal recipients of diabetic donors, it was 96.2%
3- in diabetic recipients of normal donors, it was 80.1%
4- in diabetic recipients of diabetic donors, it was 71.6%
II- 5 year death censored graft survival :
1- in normal recipients of normal donors, it was 86.3%
2- in normal recipients of diabetic donors, it was 87.4%
3- in diabetic recipients of normal donors, it was 93.5%
4- in diabetic recipients of diabetic donors, it was 87.5%
the regression analysis revealed that diabetic recipients have a 2-3 fold increased risk of mortality, if compared with non-diabetic recipients.
the survival of recipients of diabetic donors is dependent on the diabetic stage of recipients. however, it should be noted that in these diabetic donors who were included in this cohort, the diabetic renal changes were mild to minimal.
the worst survival was that of diabetic recipients of diabetic donors. therefore, this practice should be questioned.
What is the level of evidence provided by this article?
– this study examines the relationship of donors hx of diabetes to clinical & histological outcomes in deceased donor transplantation.
– 49 diabetic degassed donor kidney were transplanted into 26 normal non diabetic recipients & 23 diabetic recipients .
– co pared to 211 diabetic recipients of normal kidneys & 466 normal recipients of normal kidneys .
– patient survival & graft survival at 5 ys showed that diabetic recipients had 2-3 folds increased risk of mortality compared to non diabetic recipients .
– Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy and on repeat biopsies 70% showed no evidence of progression.
– Survival appears to be dependent on the diabetic status of the recipient with the worst outcome was in diabetic recipients from diabetic donors .
– Limitations : small sample size & limited number of post perfusion & follow up biopsies .
– Strengths : the largest reported cohort study of transplanted kidneys from diabetic donors with post perfusion & follow up biopsies
Conclusion :
– the risk association of using deceased kidney donation from diabetic donors mostly is dependent on diabetic status of the recipient
– This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
The aims of this study were:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
Median follow-up for the primary analysis was 50 months
5 years patient survival 86.5%
Graft survival 88.5%
There were 4 groups
R D SURVIVAL GRAFT
SUVIVAL
N N 89.7% 86%
N DM 96.2% 87%
DM N 80% 93%
DM DM 71.6% 87%
By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
Post perfusion biopsies
From 49 patients only 26 perform biopsies 53%
20 biopsies were normal
One biopsy was I DM
5 biopsies were II A
Recipients Follow biopsies
Due to DGF- PROTEINURIA- DSA
Only 17 recipients perform biopsy- 38 biopsies in total
recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival,
kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome
evolution of diabetic nephropathy often requires long duration of diabete
limitations
small sample size
Strengths
this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
Introduction
Few studies evaluating the outcome of deceased transplant kidney donors with diabetes
Aims of the study
1. Compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
2. Describe the histology in post-perfusion biopsies in kidneys from donors with diabetes
3. Examine histology following transplantation in kidneys from donors with diabetes
Materials and Methods
Retrospective study of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center (2006-2014)
Based on recipient (R) and donor (D) diabetes history, further classified into four groups: R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N
The primary outcomes were recipient survival and death-censored allograft survival
Post-perfusion biopsiesl/subsequent “for indication” biopsies were examined. EM for diabetic nephropathy which is graded on a scale of 0-IV according to Renal Pathology Society (RPS)
Indications for subsequent biopsies are proteinuria, worsening graft function, or the development DSA
Results
Of 706 primary renal transplants: R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 211 and R-N/D-N 446 patients
Forty-nine diabetic deceased donor kidneys (D-DM) were transplanted into 26 normal (R-N/D-DM) and 23 diabetic recipients (R-DM/D-DM) and compared to 211 diabetic recipients of normal kidneys(R-DM/D-N) and 466 normal recipients of normal kidneys (R-N/D-N)
Patient survival at 5 years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.0% in R-DM/D-N, and 71.6% in R-DM/D-DM
Death-censored graft survival at 5 years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM
Diabetic recipients had a 2 fold increased risk of mortality when compared to non-diabetic recipients
NO significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival
Only 6 of 17 recipients with follow-up biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression
Weakness of the study
1. small sample size
2. small number of post-perfusion and follow-up biopsies/not per protocol
Strengths of the study
The largest study of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome
Conclusion
Recipient diabetes status is the main factor which determine the risk of kidney transplant from deceased kidney donors with diabetes (worst survival in recipients of a diabetic donor kidney)
Recipient diabetic renal changes were mild to minimal in kidney transplant with deceased donors with diabetes
Further studies are needed
What is the level of evidence provided by this article?
This study looked for the outcomes of kidney transplantation using diabetic deceased donors. It had involved a retrospective review of the medical records of recipients of deceased donor kidney transplants and they were stratified into four groups: normal recipient of diabetic donors, normal recipients of normal donors , diabetic recipients of diabetic donors and diabetic recipients of normal donors. Diabetic donor were approved for donation if they had no high-grade proteinuria (>2+).
In this study 49 diabetic deceased donor kidneys were transplanted into 26 normal and 23 diabetic recipients. These were compared with normal kidneys donated to 211 diabetic recipients and 466 normal recipients. The 5 year survival was best in the group of normal recipient of diabetic donors and followed by normal recipients of normal donors. The worst survival was on the diabetic recipients of diabetic donors followed by diabetic recipients of normal donors. The 5-year death censored graft survival was more in the group of diabetic recipients of normal donors and it was approximately similar in the other three groups. The factors associated with poor 5-year graft survival were recipient Black race, dialysis vintage, cPRA p and donor age of 50 or more. Diabetic recipients had a 2- to 3-fold increased risk of mortality when compared to non-diabetic recipients. The histopathological examination showed evidence of diabetic nephropathy in 23% only with no evidence of progression. There was no correlation between the duration of diabetic history of the donor and the severity of histopathological biopsy lesions.
This study showed that diabetic deceased donors lead to mild changes in the recipients and that the diabetic status of the recipient is the most important factor in graft survival. Diabetic donors’ kidneys are equivalent, to some extent, to normal donors’ kidneys if transplanted to non-diabetic recipients
This is a cohort study, so the level of evidence is 4
Thank you, Hinda It is always nice to see your reply. Why level 4?
Filipe prohaska Batista
2 years ago
This is a single-center retrospective study collecting data from January 2006 to December 2014, separating patients who underwent kidney transplantation from a deceased donor into four groups with different combinations of donors and recipients with and without diabetes.
All study patients underwent investigation for cardiovascular disease prior to transplantation.
The four groups were divided as follows:
Recipient with Diabetes / Donor with Diabetes
23 patients
Five-year survival 71.6%
Hazard Ratio 3.14
Recipient without Diabetes / Donor with Diabetes
26 patients
Five-year survival 96.2%
Recipient with Diabetes / Donor without Diabetes
21 patients
Five-year survival of 80%
Hazard ratio 1.99%
Recipient without diabetes / Donor without diabetes
446 patients
Five-year survival 89.7%
Diabetic recipient risk factors were Hispanics and high BMI. Arterial hypertension is a recurrent finding. Graft survival is lower in patients of black ethnicity, time on dialysis, high cPRA, and donor age over 50 years.
In the biopsies, even in patients with previously diabetic donors, the biopsies showed no evolution of diabetic glomerulopathy, in some cases even normalizing the findings.
This study suggests that recipients with diabetes mellitus are at increased risk of graft loss and survival when compared with donated organs, regardless of donor status. The evolution of diabetic nephropathy is greater mainly in the D DM / R DM group, increasing mortality, risk of infection, and vascular disease.
Despite the low number of patients in the groups, this is the largest study relating clinical and histopathological findings considering the four groups discussed. With the difficulty in making organs from deceased donors available and the findings of this study strengthen the discussion of not dispensing with diabetic donors, and should work on improving the performance status of recipients, especially in relation to arterial hypertension, glycated hemoglobin, and fasting glucose,
1- Summary of this article
Introduction
Diabetic donors could be used to expand the donor pool ,many studies carried on to conclude that diabetic donor kidney the risk was associated with diabetic donor kidney ,it was depend on recipient DM status.
The aim of this study to show the relationship of recipient diabetic status and donor DM history to clinical and histological outcome of kidney transplantation at our institution
Method
This retrospective analysis of medical records done in transplant centre between-n 1/2006 and 12 /2014and follow up through may 2016.
All recipients of deceased donor kidney transplants were divided in to four groups:
Group were R-. DM/D-DM.
Group R-M/D-DM.
Group R-DM /D-N.
R-N/D-N.
Primary out come of this study were recipient survival and death-censored allograft survival.
Absence of high grate proteinuria is mandatory to be accept a kidney from a donor with DM in this centre.
NODAT was defined FBG . or more 126 on two separate occasion or HbA1C . or more 6,5%. Orv presence of antidiabetic agents 3 month after transplantation.
Result
Patient and allograft outcome:
5 years patients and death-censored graft survival were 86.5% and 88.5%,respectively.
Patient and graft survival
On multivariate analysis of patient survival, DM status of the recipient was associated with increase in patient mortality compared to control.
Post-perfusion renal transplant biopsy findings
49 kidneys from deceased donors with DM history transplanted pos-perfusion biopsy was performed in 26 cases.
20 cases did not show evidence of DN
One biopsy showed thickened GBM by EM but no DN On light microscopy.
5 biopsies showed class 2a DN.
Sever DN(class 2b-4) was not seen kidney biopsy.
No correlation could be found between the duration of donor DM history and the severity of DM nephropathy lesion observed.
17 recipients with follow up biopsies,6 with DM lesion,10 with stable or no DM lesion and 1 recipients with regression of DM lesions.
Discussion
This the first study to analyse the complex relationship between donor and recipients DM status pre-and post-transplantation in the context of both clinical and histological data.
Summary of this study suggest that recipients DM status has the greatest impact and adverse effect on mortality and graft survival. And kidney from donors with a history of DM selected for transplantation at this centre have no or mild histological DM changes.
5-years death -censored graft survival was 88.5% despite the fact that 6.9% of the kidney transplanted came from donors with a history of DM.
Kidney from donors with a DM history did as well as normal kidney when transplant into non-DM recipients.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of DM should be function impairment.
The survival benefit that end-stage renal disease (ESRD) patients derive from kidney transplantation has led to an increased demand for donor kidneys.
Utilization of kidneys from deceased diabetic donors has emerged in the last two decades .
Ahmad et al noted similar patient survival, but slightly inferior graft survival in recipients of deceased diabetic donor kidneys when compared to recipients of deceased non-diabetic donor kidneys.
In 2012, Mohan et al demonstrated that donor diabetes did not have a significant effect on graft and patient survival and even suggested that diabetic donor kidneys may be superior to using extended criteria donor kidney.
Recently, Cohen et al reported discordant recipient pair analysis of diabetic donor kidneys, using United Network of Organ Sharing data, and found that although a risk was associated with diabetic donor kidneys, it was dependent on recipient diabetes status.
In 1983, Abouna 6 transplanted a deceased diabetic donor kidney with histological evidence of diabetic nephropathy into a nondiabetic recipient.
Aim of the study ===To detect the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation.
This retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
All d recipients of deceased donor kidney transplants were further stratified into 4 groups based on recipient (R) and donor (D) diabetes history status (DM vs No DM history.
Of 706 recipients with deceased donor kidney transplants
1- 49 recipients (6.9%) received a kidney from a D-DM history.
2- Of R-N/D 5,5% received a kidney from a D-DM history.
3- and of the R-DM 9.8% received a kidney from a D-DM.
4- Of these 49 kidneys from D-DM, 23 (47%) were implanted in R-DM and 26 (53%) were implanted in R-N/DM.
5-Five year patient and death-censored graft survival were 86.5% and 88.5% respectively..
Kaplan-Meier analysis of patient survival at 5 years by sub-
group was
89.7% in R-N/D-N,
96.2% in R-N/D-DM,
80.0% in R-DM/D-N,
and 71.6% in R-DM/D-DM
Kaplan-Meier analysis of death-censored graft survival at
5 years by subgroup was
86.3% in R-N/D-N.
87.4% in R-N/D-DM.
93.5% in R-DM/D-N.
and 87.5% in R-DM/D-DM.
Recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival.
kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
Patient survival at 5 years in the present cohort (706 pts; 86.5%)
However, 5-year death-censored graft survival was 88.5% despite the fact that 6.9% of the kidneys transplanted came from donors with a history of diabetes.
Kidneys from D/DM history did as well as normal kidneys when transplanted into R-N/DM.
However, patient survival in R-N/DM of kidneys from D-N/DM history was inferior to that ofR-N/DM of kidneys from D-DM history (89.7% and 96.2% 5-year patient survival, respectively).
Other factors that may have contributed to this discrepancy in patient survival include longer dialysis vintage (a known risk factor for all-cause mortality ), as well as a higher proportion of recipients with glomerulonephritis in the R-N/D-N group.
Recurrence of glomerulonephritis as the second leading cause of graft loss.
Patient survival was lower in R-DM than in R-N/DM, but the survival was poorest inR-DMof kidneys from D-DM (R-DM/D-DM; 71.6%),compared to 80% survival in R-DM of kidneys from D-N/DM history.
R-DM/D-DM had the lowest patient survival of all four groups.
Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
Histological examination of post-perfusion biopsies showed
A- Mild diabetic lesions (only 6 of 26 immediate post-perfusion biopsies showed early diabetic changes).
B- Only 29% (5 of 17 patients with follow-up biopsies) showed evidence of histologic progression of diabetic lesions.
C- Other papers 75% development of DN lesions in diabetic recipients of kidneys from donors with no diabetic history at 5-6 years post-transplant.
The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome.
This study is limited by both the small sample size and the limited number of post-perfusion and follow-up biopsies.
-The strengths of this study include
Though small, this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
All prior analyses have had no biopsy correlation with outcomes.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
Diabetic renal changes in conventionally accepted kidneys from donors with a diabetic history in this cohort are mild to minimal.
Aim of the study: to examine the relationship between recipient diabetic statusand donor diabetic history to clinical and histological outcomes of kidney transplantation.
Material and method:
The retrospective analysis included all recipients of deceased kidney donors between 2006 – 2014 and was performed with follow-up through May 1, 2016. Donors (D)and recipients( R )were further stratified based on diabetic history into 4 groups: R-DM/D-DM. R- N/D- DM R- DM/D-N R-N/D-N.
Recipient and donor characteristics and peri-transplant factors were analyzed. No patients were listed with evidence of myocardial ischemia, or heart failure or markedly reduced LVEF attributable to coronary artery disease. Only donors without high-grade proteinuria (>2+) were accepted. Post-perfusion biopsies and any indicated biopsies were examined and reviewed with special attention to features of DN, which was defined and graded from 0-IV based on the Renal Pathology Society (RPS). Pre-existing DM in recipients was defined as an FBG>=126 on two separate occasions or HgA1C >= 6.5 NODAT onset diabetes after transplantation was defined as the same or the presence of antidiabetic agents 3 months after transplantation.
Results: Total of706 recipients with deceased donor kidney transplants
49 diabetic deceased donor kidneys (D-DM) were transplanted into: 26 normal (R-N/D-DM) 53% 23 diabetic recipients (R-DM/D-DM) 47% compared to: 211diabetic recipients of normal kidneys (R-DM/D-N) 466 normal recipients of normal kidneys (R-N/D-N).
R-DM had the highest BMI, while HTN was most prevalent in D-DM.
Patient and allograft outcome: In general, the 5-year patient was 86.5%, and death-censored graft survival was 88.5%.
Patient survival at 5 years by subgroup was: 89.7% in R-N/D-N 96.2% in R-N/D-DM 80.0% in R-DM/D-N 71.6% in R-DM/D-DM
Death-censored graft survival at 5 years was : 86.3% in R-N/D-N, a higher proportion of cPRA and a higher proportion of recipients with GN. 87.4% in R-N/D-DM, 93.5% in R-DM/D-N 87.5% in R-DM/D-DM
Multivariable regression analysis Diabetic recipients had a 2- to 3-fold higher mortality risk than non-diabetic recipients. Age > 65 and dialysis vintage were associated with increased patient mortality at 1, 3, and 5 years. There was no impact on death-censored graft survival of diabetic donor status.
Post-perfusion renal transplant biopsy finding: Post-perfusion biopsy was performed in only 26 out of 49 deceased donors with diabetic history. 20 did not exhibit evidence of DN. 6 of 26 biopsies showed evidence of DN (<IIa). No correlation could be found between the duration of donor diabetic history and the severity of DN lesions observed.
Follow-up biopsy finding: Repeat biopsies were done in 17 recipients only for clinical indication. 70% showed no evidence of progression. Progression of diabetic nephropathy was noted in 2 recipients, both of whom were diabetic of DN, and three developed de novo DN. Recipients with progressive or de novo diabetic nephropathy had longer exposure to a hyperglycemic.
Conclusion: Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients. However, patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment. With such a change, it would be anticipated that fewer kidneys from donors with a diabetic history would be discarded than is currently the case.
Limitations: -Small sample size -a limited number of post-perfusion and follow-up biopsies.
To compare clinical outcomes of a kidney transplants from a donor with or without a history of diabetes to a diabetic or non diabetic recipients.
To describe histologic findings of a post perfusion biopsy findings in kidneys from a donor with a history of diabetes.
To identify histological changes following transplantation of a kidney from donors with a history of diabetes.
The primary outcome of the study were recipient survival and death-censored allograft survival.
The criteria for accepting a kidney from a diabetic history is the the abscence of high grade proteinuria.
Median follow up for the primary analysis was fifty months.5-year patient and death censored survival were 86.5% and 88.5% respectively.
There was no statistically significant of donor diabetic history or recipient diabetes
Out of 49, 26 cases were performed post transfusion biopsy. 20 cases do not exibit evidence of diabetic nephropathy. 5 showed class II a DN. Diabetic nephropathy of higher severity was not found in any biopsy.
A total of 38 follow up biopsies were examined for the evolution of diabetic lesions, Progression of diabetic nephropathy was found in 2 patients.
The risk associated with the recipient of a kidney from a donor with a diabetic history appears to be dependant on the diabetes status of the recipients. A nearly 2 fold increase in patient mortality was noted in diabetic patients.
Diabetic patients experience higher mortality due to increased risk of infection, sepsis, micro or macro vascular disease.
This study is limited by both small sample size and limited number of post perfusion and follow up biopsy.
In the last two decades, the utilization of kidneys from deceased diabetic donors has emerged as a potential solution to this shortage. Due to the increased demand for kidneys, diabetic donors’ organs have been added to the donor pool.
The supplied study, a retrospective study with a level of evidence of 3, assessed the long-term effects of kidney allografts from diabetic donors.
The objectives of this study:
-To compare the clinical outcomes of kidney transplants from donors with or without a history of diabetes into recipients with or without diabetes.
To compare the clinical outcomes of kidney transplants from donors with or without a history of diabetes to recipients with or without diabetes.
To report the histologic findings in post-perfusion kidney biopsies from donors with a history of diabetes.
-To investigate histologic alterations following kidney transplantation from diabetes donors.
-Review of post-perfusion biopsies and subsequent biopsies for specific indications
Material and procedure:
The authors of the study conducted a retrospective examination of electronic medical records of kidney transplant recipients from deceased donors at Houston Methodist JC Walter Jr. Transplant Center between January 1, 2006 and December 31, 2014, with follow-up through May 1, 2016.
All recipients of kidney transplants from deceased donors were categorized into four groups based on recipient (R), donor (D), diabetes history (DM), and absence of diabetes history (N).
Analytical Statistics:
Data at baseline were presented as medians and interquartile ranges (IQR) for continuous variables, and as frequencies and proportions for categorical variables. The chi-square test for categorical variables and the Kruskal-Wallis test for continuous variables were used to assess baseline data differences between groups.
Result
Subcategories for 706 primary renal transplants included R-DM/D-DM 23, R-N/D-DM 26, R-DM/N 21,1 and R-N/N 446 patients.
At five years, patient survival was 89.7% for R-N/D-N, 96.2% for R-N/D-DM, 80.1% for R-DM/D-N, and 71.6% for R-DM/D-DM (P =.008).
Death-censored graft survival at five years was 86.3% for R-N/D-N, 87.4% for R-N/D-DM, 93.5% for R-DM/D-N, and 87.7% for R-DM/D-N (P =.24).
Only six of twenty-six post-perfusion biopsies revealed diabetic nephropathy.
The highlights of this study include the largest known cohort of transplanted kidneys from donors with a history of diabetes who underwent post-perfusion biopsies, follow-up biopsies (in 50% of these), and connection with clinical outcome.
In this study, the number of post-perfusion and follow-up biopsies and the size of the samples are small.
Until further studies, the risk associated with transplanting a kidney from a deceased donor with a history of diabetes appears to be mostly reliant on the recipient’s diabetes status.
This study suggests that the KDPI’s present emphasis on the diagnosis of diabetes should be amended to highlight the presence of high-grade proteinuria and renal impairment.
function impairment.
Introduction
The remarkable improvements in the quality of life seen in those that has done kidney transplantation has encouraged many patients with ESRD to opt more for the procedure but has also led to scarcity of organs. Hence, the need to revisit use of organs from donor with diabetes mellitus. Therefore, there is a need to assess whether the risk from diseased DM donor is from the graft or from the recipient with or without DM.
Aim
to see the clinical outcome of kidney from a diseased donor with or without DM to the recipient with or without DM
to see the histological pattern of post perfusion biopsy from donor with history of DM
to describe the histological changes after the initial post perfusion kidney biopsy
Materials and Methods
a retrospective study where the data were retrieved from diseased donor at Methodist JC water Jr transplant centre between 1/2006 to 12/2014 and follow up done in May 2016.
donor and recipient were divided into four groups, R-DM/ D-DM, R-N/D-DM, R-DM/D-N, and R-N/D-N.
demographic data were retrived from UNOS
post perfusion biopsies and subsequent indication biopsies were done and reported by LM, and EM
all analysis were done by Stata version 15.1 (1 (Stata Corp LLC) with P-value of <.05 was considered statistically significant.
Results
out of the 706 diseased donor in the year under study, 49, diabetic donor kidneys were used
over 50% of the diabetic donor kidneys used had post perfusion biopsy done and 17 of also had follow up biopsy
of the 49 diabetic donor kidneys, 23 of them were implanted in DM recipients and 26 of them in non-DM recipients
10 among those with follow up biopsy had stable or DM lesions with 6 of them had progressive DM lesions
the median follow up is 50 months
using the Kaplan – Meier analysis, the 5 years patient survival according to the subdivisions were 89.7%, 96.2%, 80.0%, and 71.6% for R-N/D-N, R-N/D-DM, R-DM/R-N, and R-DM/D-DM respectively
meidan time for follow up biopsies was 562 days
kidneys from donors with DM did well when transplanted into recipient without background DM
the diabetic status of the recipient has the greatest effect on mortality and graft survival
Limitations of the study
small sample size
limited number of post perfusion kidney biopsy
both post perfusion and follow up biopsies were not per protocols
single centre study
Strength of the study
largest sample size of cohort with post perfusion and follow kidney biopsy
Conclusion
The attributable risk to kidney from diseased donor with DM is not as severe at as was believed to be, but actually worse in recipient with DM and hence this will reduce the discard rate of such organ. However, a decision needs to be reached in accepting organs from donor with DM to a potential recipient with DM as this has been short to be with worse mortality and graft survival
Ø This study suggests that the recipient’s diabetes status has the most significant impact and adverse effect on mortality and graft survival.
Ø Kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
Ø Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
Objectives :
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in donors with a history of diabetes in post-perfusion biopsies in kidneys.
(c) To examine histologic changes following kidney transplantation from donors with a diabetic history.
(d) Post-perfusion biopsies and subsequent “for the indication” biopsies were discussed and reviewed.
Material and method:
Ø We performed a retrospective analysis of electronic medical records of deceased donor kidney transplant recipients at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 with follow-up through May 1, 2016.
Ø All recipients of deceased donor kidney transplants were divided into four groups based on1- recipient (R),2- donor (D) 3-diabetes history status (DM,4-No DM history [N].
Statistical Analysis:
Ø Baseline data were reported as medians and interquartile ranges (IQR) for continuous variables and as frequencies and proportions for categorical variables. Differences in baseline data across groups were compared using the chi-square test for categorical variables and a Kruskal-Wallis test for continuous variables
Result
706 primary renal transplants, subcategories included the following: R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 21,1 and R-N/D-N 446 patients,
Patient survival at five years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and 71.6% in R-DM/D-DM (P = .008).
Death-censored graft survival at five years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM (P = .24).
Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy.
The strengths of this study are the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
This study is a small sample size and a limited number of post-perfusion and follow-up biopsies.
Conclusion :
Further studies are needed. The risk associated with the transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient
This study suggests that should revise the current emphasis of the KDPI on the diagnosis of diabetes should reflect the presence of high-grade proteinuria and renal
1. Please provide a summary of this article Introduction ·The use of kidneys from DDD has appeared as a way expand the donors pool. ·Many centers routinely use DDD; however, few studies are published. · Ahmad et al compared recipients of DDD to recipients of deceased non-diabetic donor kidneys & found similar patient survival, but slightly inferior graft survival in the recipients of DDD. ·Mohan et al noted that donor diabetes did not affect graft & patient survival; he thinks that diabetic donor kidneys may be superior to ECD kidney. ·Cohen et al (UNOS data) found that the risk associated with diabetic donor kidneys was related to recipient diabetes status. · Abouna (1983) transplanted a DDD kidney with histological DN into a non-diabetic patient. A biopsy 7 months later showed reversal of diabetic changes; other single case reports reported similar results once euglycemia was restored. ·This study examined the relationship of recipient diabetic status & donor diabetic history to clinical & histological outcomes of kidney transplantation. The study The aims ·To compare outcomes of transplants from donors with or without diabetes into diabetic or non-diabetic recipients ·To describe histology in post-perfusion biopsies in kidneys from donors with diabetes ·To examine histology after transplantation in kidneys from donors with diabetes. Population
All recipients of DKD transplants were divided into 4 groups based on recipient (R) & donor (D) diabetes status:
R-DM/D-DM
R- N/D- DM
R- DM/D-N
R-N/D-N. Primary outcomes:
Recipient survival & death-censored graft survival.
Criteria for accepting a donor with diabetes is the absence of >2+. Diabetic changes grading
0 = no changes by LM or EM
I = no LM changes, thickened GBM by EM
IIa = mild mesangial expansion by LM
IIb = marked mesangial expansion by LM
III = nodular mesangial sclerosis
IV = advanced diabetic glomerulosclerosis. Diabetes & NODAT (ADA definitions):
FBG=/> 126 on 2 occasions or HgA1C =/> 6.5% .
NODAT similar criteria or the presence of anti-diabetic agents 3 months post-transplant. Results 706deceased donor kidney transplants
R-DM/D-DM: 23
R-N/D-DM: 26
R-DM/D-N: 211
R-N/D-N: 446 Population characteristics Out of 706 recipients, 49 kidneys (6.9%) from donors with DM: 23 (47%) implanted in DM recipients 26 (53%) implanted in non-DM recipients Of non-DM recipient cohort, 5.5% received a kidney from a DM donor. Of DM recipient cohort, 9.8% received a kidney from a DM donor. R-N/D-N group: Least males Lowest mean age Lowest BMI Highest GN prevalence & ADPKD as indication for transplant Lowest median donor age Lowest donor BMI Diabetic recipients: Highest BMI Highest males & Hispanics Patient & allograft outcome Median follow-up was 50 months. 5-year patient & death-censored graft survival: 86.5% & 88.5%, respectively. 5-year graft survival (subgroups):
R-N/D-N 89.7% R-N/D-DM 96.2% R-DM/D-N 80.0% R-DM/D-DM 71.6%/5 deaths (3 CVD, 1 PTLD, 1 graft failure with refusal of dialysis) in this group 5 years death-censored graft survival (subgroup): R-N/D-N 86.3% R-N/D-DM 87.4% R-DM/D-N 93.5% R-DM/D-DM 87.5% Multivariate analysis DM in recipient associated with an increase in patient mortality R-DM/D-N: 2-fold higher 5-yr patient mortality compared R-N/D-N (control) R-DM/D-DM: 2-fold higher risk
No significant impact of donor DM or recipient DM on death-censored graft survival. However, recipient Associations with poorer 5-year graft survival:
Black race
Dialysis vintage
cPRA
Donor age =/>50 Post-perfusion real biopsy Done in 26 (53%) out of 49 kidneys from DD donors with DM transplanted. 20: no DN 1: thickened GBM by EM, but DN on LM 5: class IIa DN Class IIb-IV not seen in any No correlation between the duration of donor DM & the severity of DN. Follow up biopsy Done in 17/26 (post-perfusion biopsies) Done for indication (DGF, proteinuria, &/or DSA) Median time for follow-up biopsies: 562 days. Progression of DN: 2 recipients (both diabetic) Re-biopsy in 12/20 with no DN on post-perfusion biopsy: 9 continued no DN, 3 de novo DN (all 3 diabetic) In all progressive or de novo DN, DM was present post-transplant. Discussion The study suggests: Recipient’s DM has the greatest impact & adverse effect on mortality & graft survival Kidneys from donors with DM selected for transplant have no/mild DM histology changes 5-year patient survival comparable to that in 2015 SRTR/OPTN annual report (86.3%). 5-year death-censored graft survival was 88.5% though 6.9% of kidneys transplanted came from donors with DM. Kidneys from donors with DM did as well as normal kidneys when transplanted into non-diabetic recipients. Patient survival lower in DM recipients than in non-DM recipients; survival was poorest in DM recipients of kidneys from donors with DM. R-DM/D-DM had the lowest patient survival of all 4 groups. Better death-censored graft survival in R-DM/D-N versus R-N/D-N may be related to the higher patient mortality in the R-DM/D-N group versus R-N/D-N group. Limitations Small sample size Limited number of biopsies. Strengths Though small, this is the largest reported cohort of transplanted kidneys from donors with a DM with post-perfusion biopsies, follow-up biopsies, & correlation with clinical outcome. Conclusion The risk associated with KTX from a deceased donor with DM appears to depend on the diabetes status of the recipient. Diabetic renal changes in accepted kidneys from donors with DM are mild to minimal. Given the low 5-year patient survival in diabetic recipients of kidneys from donors with DM, this type of transplantation needs to be revised. ============================== 2. What is the level of evidence provided by this article? Level III, retrospective study
to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes.
to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Methods:
retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
All recipients of deceased donor kidney transplants were further stratified into four groups based on recipient and donor diabetes history status.
The primary outcomes in the study were recipient survival and death-censored allograft survival.
For the second and third aims, post-perfusion biopsies and subsequent “for indication” biopsies were examined and reviewed.
Results:
Forty-nine diabetic deceased donor kidneys were transplanted into 26
normal (R-N/D-DM) and 23 diabetic recipients (R-DM/D-DM) and compared to 211
diabetic recipients of normal kidneys(R-DM/D-N) and 466 normal recipients of normal kidneys (R-N/D-N).
Patient survival at 5 years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and 71.6% in R-DM/D-DM.
Death-censored graft survival at 5 years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM,
93.5% in R-DM/D-N and 87.5% in R-DM/D-DM.
Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality. In this cohort, there was no impact on death-censored graft survival of diabetic donor status.
Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies, 70% showed no evidence of progression.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney.
Conclusion:
The risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient. Diabetic renal changes in conventionally accepted kidneys from donors with a diabetic history in this cohort are mild to minimal.
the current emphasis on a donor diagnosis of diabetes should be revised, in such a case, fewer kidneys from donors with a diabetic history would be discarded than is currently.
Given the low 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history, the propriety of transplanting such kidneys into diabetic recipients should be questioned.
Limitation:
small sample size.
a limited number of post-perfusion and follow-up biopsies.
Strength:
It is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
What is the level of evidence provided by this article?
Summary of the article “Outcomes of kidney transplantation using deceased donors with history of diabetes’’
This is a retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014, was performed with follow-up through May 1st 2016. a) Recipients were further stratified into four groups based on recipient (R) and donor (D) diabetes history status (DM vs No DM history [N]). b) The groups were R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N.Of 706 primary renal transplants, subcategories included the following: R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 21, and R-N/D-N 446 patients. c) Donor characteristics such as diabetes history, race, donor age, and BMI were obtained from the United Network of Organ Sharing (UNOS) data- set. d) The primary outcomes in the study were recipient survival and death-censored allograft survival. e) The aims of this study: i. to compare clinical out-comes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients. ii. to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes. iii. to examine histologic changes following transplantation in kidneys from donors with a diabetic history. Study Analysis and Outcome 1. Diabetes status of the recipient was associated with an increase in patient mortality. 2. Compared to control (R-N/D-N), the R-DM/D-N subgroup had nearly a twofold higher patient mortality at 5 years. 3. Risk to a diabetic recipient was greater still, at 3-fold higher patient mortality at 5 years, with receipt of a kidney from a donor with diabetic history (R-DM/D-DM. 4. Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years. 5. By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival. However, recipient Black race, dialysis vintage, cPRAp as a continuous variable, and donor age > 50 years were associated with poor graft survival at 5 years. 6. Post-perfusion renal transplant biopsy findings: No correlation could be found between the duration of donor diabetic history and the severity of diabetic nephropathy lesions observed. 7. Only 29% (5 of 17 patients with follow-up biopsies) showed evidence of histologic progression of diabetic lesions. 8. Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients. 9. Patient survival in (R-N/D-N) was inferior to that in (R-N/D-DM) (89.7% and 96.2% 5-year patient survival, respectively). a) This finding may reflect the higher proportion of females (47.5% vs 42.3%), re-transplants (8.5% vs 3.9%), and a nearly fivefold higher proportion of recipients with a cPRAp >80% (19.6% vs 3.9%) in the R-N/D-N than in the R-N/D-DM cohort. b) Other factors that may have contributed to this discrepancy in patient survival include longer dialysis vintagehigher proportion of recipients with glomerulonephritis in the R-N/D-N group. 10.Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease. 11.The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome. Limitations of the study:
a) The study has mall sample size. b) The limited number of post-perfusion and follow-up biopsies.
Strengths of the study: a) though small, this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome. b) All prior analyses have had no biopsy correlation with outcomes or are extensive clinical data analyses from the OPTN/SRTR database absent biopsy data. c) This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
What is the level of evidence provided by this article?
This is a retrospective study cohort
Level of evidence 3
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Study design:
Retrospective cohort study
Results:
Of 706 recipients with deceased donor kidney transplants, 49 recipients
(6.9%) received a kidney from a donor with diabetic history and 5.5% received a kidney from a donor with a diabetic history of non-diabetic recipients, and 9.8% received a kidney from a donor with a history of diabetes of the diabetic recipients.
Of these 49 kidneys from donors with a diabetic history, 23 (47%) were implanted in diabetic recipients and 26 (53%) were implanted in non-diabetic recipients.
Median follow-up for the primary analysis was 50 months
5-year patient and death-censored graft survival were 86.5% and 88.5%, respectively.
Kaplan-Meier analysis of patient survival at 5 years by sub group was
89.7% in R-N/D-N,
96.2% in R-N/D-DM,
80.0% in R-DM/D-N
71.6% in R-DM/D-DM
Kaplan-Meier analysis of death-censored graft survival at 5 years by subgroup was
86.3% in R-N/D-N,
87.4% in R-N/D-DM,
93.5% in R-DM/D-N,
87.5% in R-DM/D-DM
diabetes status of the recipient was associated with an increase in patient mortality
Twenty cases did not exhibit evidence of diabetic nephropathy even after EM examination
Severe diabetic nephropathy (class IIb-IV) was not seen in any biopsy.
No correlation could be found between the duration of donor diabetic history and the severity of diabetic nephropathy lesions observed
Limitation:
Small sample size
Post-perfusion or follow-up biopsies were not protocol biopsies but at the discretion of physician.
Conclusion:
Recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival
Diabetic donor kidneys have mild tom minimal DM changes
KDPI should take into consideration renal function with proteinuria which giving points for diabetic donors, this will decrease the discard rate of diabetic donor kidneys.
Level of evidence: III retrospective case-control study
Outcomes of kidney transplantation using deceased donors with history of diabetes.
Accepting donation from diabetic donors is established in many centers and some studies shown that donor diabetes did not have a significant effect on graft and patient survival and even suggested that diabetic donor kidneys may be superior to using extended criteria donor kidney, other referred this to recipient diabetic status and some studies shown histological improvement of diabetic changes in the kidney from diabetic donor. Aim of the study :
To detect the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation. Material and methods:
Retrospective cohort study and recipients are classified into 4 groups: based on recipient (R) and donor (D) diabetes history. 1-Recipient DM/Donor-DM(23 patients).
2-Recipent- N/donor- DM(26 patients).
3-Recipent- DM/Donor-N(211patients).
4-Recipent-N/Donor-N(446 patients).
Clinical data collected about DM and renal biopsy post perfusion and for indication, examined by E/M. Result:
Regarding patient and graft survival, study shown 5-year patient and death-censored graft survival were 86.5% and 88.5%.
The diabetic recipient was associated with an increase in patient mortality compared to control (R-N/D-N).
Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years.
There was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
Diabetic recipient has 3-fold higher patient mortality at 5 year.
No correlation could be found between the duration of donor diabetic history and the severity of diabetic nephropathy lesions observed.
Follow up indicated biopsies shown progression of diabetic nephropathy in 2 recipients both of whom were diabetic and three developed de novo . Conclusion:
Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
Survival of diabetic recipient depends mainly on diabetic status control and the worst outcome from diabetic donor to diabetic recipient, most of kidney pathology showing no progression of structural changes.
Previous studies reported either slightly poor outcome of using deceased diabetic kidney donors when compared to non-diabetic kidney donors, others reported good outcome when compared to ECD due to factors other than DM
Moreover, early study found resolution of histologic features of diabetic nephropathy when the deceased diabetic donor kidney transplanted in a non-diabetic recipient
This is a retrospective cohort study (level of evidence III) evaluating the effect of deceased donor diabetes on the recipient (diabetic or non-diabetic) outcome
The cohort is divided into 4 categories
R-N/D-DM including 26 patients
R-DM/D-DM including 23 patients
R-DM/D-N including 211 patients
R-N/D-N including 466 patients
Results:
5 years patient survival was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and a 71.6% in R-DM/D-DM (graft survival is worst if both donor and recipient are diabetic)
Diabetic recipients has 2-3 fold increase in the risk of death when compared to non-diabetic
5 yeas death censored graft survival was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM (no significant difference)
In R-N/D-DM category, 6 of 26 patients have diabetic nephropathy <IIa at the post perfusion biopsy with progression detected in only one third of cases on repeated biopsy, and regression of diabetic nephropathy was seen in one patient
Conclusion
Recipient survival is mainly depending on his/her diabetic status with the least survival observed when the donor is also diabetic
Inferior patient survival in diabetic recipients may be explained by the increase in the risk of infection, micro and macrovascular complications
Donor diabetic kidney is associated with low risk of progression of diabetic nephropathy after transplantation
Diabetic deceased donor kidneys can be used to expand the donor pool
The aims: of this study were as follows: to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
Introduction:
End-stage renal disease (ESRD) patients benefit from kidney transplantation, increasing demand. In the past two decades, kidneys from diabetic donors have become a feasible possibility.
Material:
retrospective investigation of electronic medical data of kidney transplant patients at Houston Methodist JC Walter Jr Transplant Center between 2006 and 2014, with follow-up until May 1, 2016. All deceased donor kidney transplant patients were sorted by the recipient (R) and donor (D) diabetes history (DM vs No DM history [N]). R-DM/D-DM, R-N/D-DM, R-DM/D-N, R-N/D-N. Analyzed: recipient, donor, and peri-transplant variables.
Results:
49 (7.9%) of 706 kidney transplant patients had a diabetic donor. 5.5% of non-diabetic receivers got a kidney from a diabetic donor, while 9.8% of diabetic recipients did.
23 kidneys from diabetes donors were implanted in diabetic recipients and 26 in non-diabetic recipients.
-Death-censored transplant survival was unaffected by donor or recipient diabetes. Black recipient race, dialysis vintage, cPRAp as a continuous variable, and donor age>50 years was associated with poor graft survival.
-No association was discovered between donor diabetes duration and diabetic nephropathy lesions.
-Post-transplant, all progressive or de novo DN patients had diabetes. Progressive or de novo diabetic nephropathy recipients experienced greater hyperglycemic exposure and biopsies were acquired later post-transplant.
Conculsion:
The danger of transplanting a kidney from a diabetic donor depends on the recipient’s diabetes. In this group, typically accepted kidneys from diabetic donors had modest to minimal diabetic renal alterations. This research implies that the KDPI should be changed to represent high-grade proteinuria and renal function impairment.Given the dismal 5-year patient survival among diabetes receivers of kidneys from diabetic donors, the practice should be questioned.
What is the level of evidence provided by this article?
This is a Cohort observational study conducted to compare clinical outcomes of kidney transplants from donors with or without history of DM in to either diabetic or non-diabetic recipients, and to describe the histologic findings in post perfusion biopsy form diabetic donors, and follow up the histologic finding changes, for a mean follow up time of 50 months.
They divide the groups of patients to 4 groups: D-N/R-N,
D-DM/R-N, D-DM/R-DM, and D-DM/R-N. Primary outcomes = Patient and graft survival.
Results:
Patient survival at 5 years by subgroup was 89.7% in
R-N/D-N, 96.2% in R-N/D-DM, 80.0% in R-DM/D-N, and 71.6% in R-DM/D-DM.(P=0.0008).
– The patient death was due to cardiovascular disease in most.
graft survival at 5 years by subgroup was 86.3% in R-N/D-N,
87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM.(P=0.24).
Increased patient death was higher among R-DM/D-N nearly a
twofold higher patient mortality at 5 years (P = .017) and 3-fold higher
patient mortality at 5 years, with receipt of a kidney from a donor with
diabetic history R-DM/D-DM (P = .034). age >65 and dialysis vintage
associated with increased mortality at 1,3, and 5 years.
Graft survival was worse among Black race recipient,
dialysis vintage, donor age >50 and continuous variables, but not statically
significant on impact of either donor or recipient were diabetic.
Kidney biopsy are shown in figure attached.
Conclusion:
Kidneys from donors with history of diabetes is a safe
option to non-diabetic recipients, with minimal or improving diabetic changes
ensue.
It is better not to transplant kidneys from diabetic D to
diabetic R.
The KDPI on a donor diagnosis of diabetes should be
revised to reflect the presence of high-grade proteinuria and renal function
impairment.
What is the level of evidence provided by this article? Level of evidence III
· Previous studies reported inferior graft outcome from diabetic cadaveric donors. however, resolution of diabetic nephropathy changes as thickened GBM and mesangial expansion after transplantation in well controlled or normglycemic recipient. so, cadaveric donors with DM were utilized in order to expand the donor pool.
· The current study aimed to evaluate the impact of DM in the donor on the graft outcome by comparing 4 groups: diabetic and none diabetic donors with both diabetics and none diabetic recipients. The 5-year patient survival was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and a 71.6% in R-DM/D-DM.
· The worst survival was when both were diabetic as sustained diabetic state in the recipient accelerates the diabetic changes of preexisting diabetes from diabetic donor.
· The recipient diabetes had worse outcome than that of the donor on both patient survival and death censored graft loss. However, no association was found with DM in the donor.
· post perfusion biopsy was performed in 53% of the grafts, only 6 of 26 of diabetic donors had evidence of diabetic nephropathy in post perfusion graft biopsy with no further progression in later biopsies in 70 % of them.
· The development of diabetic nephropathy changes needs long time.
· The most important predictor here is diabetic state control in the recipient.
· Patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history (89.7% and 96.2% 5-year patient survival, respectively). this can be explained by other contributing factors of worse graft outcome as recurrent glomerular disease.
· DM was defined if fasting blood glucose> 126 mg/dl, HbA1c > 6.5
· NODAT was diagnosed if anti diabetic drugs were needed 3 month post transplantation.
· GFR was estimated by CKD-EPI equation.
· Points of strength:
o correlation of both clinical and histological findings of diabetic donors to both patient and graft outcome.
· Points of weakness:
· Retrospective cohort.
· Small sample size (only 112)
Level of evidence: III
based on this article, kidney from diabetic donors cab be used for none diabetic recipient (after his agreement and consent, when there is no other options and he had no vascular access).
This retrospective cohort study aimed at evaluating
1- impact of diabetes in both donor and recipient on graft function and survival.
2- descripe the histological changes in diabetic kidney graft in both post perfusion and subsequent indication biopsy . These changes were classified according to renal pathology society into stages (0-IV ) depending on LM and EM examination.
The 5 years graft survival in the present cohort was comparable to that reported in the 2015 SRTR/OPTN annual report (86%).The function of the kidney graft from diabetic donors were comparable to non diabetic donors when transplanted to non diabetic recipients but the survival of those recipients were inferior compared with recipients of kidney graft from non diabetic donors.The poor recipient survival were significantly related to black race recipients, dialysis vintage and high cPRA and older donors>50 years.
The patients survival was lower in diabetic recipients compared with non diabetics , while the lowest patients survival were in diabetic recipients receiving kidney from diabetic donors . This high mortality in diabetic recipients could be related to micro and macro vascular diabetic complications, increased risk and severity of infections and sepsis in diabetic recipients
Post perfusion biopsy were performed in 26/49 grafts and only 5 biopsies revealed gread II DN, indication biopsy (in cases of DGF , increasing proteinuria ) were performed in 38 biopsies and progression of DN were diagnosed in some recipients(29%) who were diabetic pre transplantion or developed de no vo diabetes after transplantion , as diabetic environment accelerate the development and progression of DN , however in 58 % of cases , biopsy revealed significant arteriosclerosis, tubular atrophy and interstitial fibrosis specially in presence of concomitant HPN in the donor.
Limitation of the study are small sample size and limited number of post perfusion biopsies.
Conclusions:
the outcome of kidney graft from diabetic donors depends mainly on presence of DN in the donor and recipient being diabetic rather than just history of diabetes in the donor as in KDPI, so diabetic donors with no or early DN can be used rather than being discarded.
Level of evidence: 3.
Retrospective case – control
This study was designed to explore the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes in kidney transplantation.
A retrospective analysis between Jan 2006 to Dec 2014, at Houston Methodist JC Walter Jr Transplant Centre aimed:
To compare the clinical outcomes of KTs from donors with or without a history of diabetes into diabetic or non-diabetic recipients
To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
To examine histologic changes following transplantation in kidneys from donors with a diabetic history.
This study suggests:
What is the level of evidence provided by this article?
This is a level III evidence
Outcomes of kidney transplantation using deceased donors with history of diabetes
Please provide a summary of this article
The objectives of the study:
(a) To compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
(b) To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes.
(c) To examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Introduction:
*The outcome benefit from renal transplantation for those patients with ESRD, has led to an increased demand for donor kidneys, so utilization of kidneys from deceased diabetic donors has emerged in the last two decades as a possible solution to this shortage.
*Although deceased diabetic donor kidneys are routinely used in several centers, few studies evaluating this practice have been published.
*Ahmad et al noted similar patient survival, but slightly inferior graft survival in recipients of deceased diabetic donor kidneys when compared to recipients of deceased non-diabetic donor kidneys.
*Mohan et al conducted that they did not have a significant effect on graft and patient survival and even suggested that diabetic donor kidneys may be superior to using extended criteria donor kidney.
*Cohen et al showed that discordant recipient pair analysis of diabetic donor kidneys, using United Network of Organ Sharing data, and found that although a risk was associated with diabetic donor kidneys.
*The methods:
*Retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
*All recipients of deceased donor kidney transplants were further stratified into four groups based on recipient (R) and donor (D) diabetes history status (DM vs No DM history [N]).
*The groups were R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N. Recipient and donor characteristics, and peri-transplant factors were analyzed. Donor characteristics such as diabetes history, race, donor age, and BMI were obtained from the United Network of Organ Sharing (UNOS) dataset.
*All transplant candidates at this center undergo electrocardiogram, echocardiogram, stress test, and cardiology consultation.
*No patients were listed with evidence of myocardial ischemia, or heart failure or markedly reduced LVEF attributable to coronary artery disease.
Discussion:
*This is the first study to analyze the complex relationship between donor and recipient’s diabetes status pre- and post-transplantation
*Recipient’s diabetes status has the greatest impact and
adverse effect on mortality and graft survival.
*Kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
*Patient survival at 5 years was comparable to that reported in the 2015 SRTR/OPTN annual report (86.3%). However, 5-year death-censored graft survival was 88.5% despite the fact that 6.9% of the kidneys transplanted came from donors with a history of diabetes.
*Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
*Patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history.
*Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
The limitation:
* Both the small sample size and the limited number of post-perfusion and follow-up biopsies.
The strengths:
*Largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies and correlation with clinical outcome.
The conclusion:
*Transplantation risk of a kidney from a deceased donor with a diabetic depends on the diabetes status of the recipient.
*Diabetic renal changes in accepted kidneys from donors with a diabetes are mild to minimal.
*The current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
*Given the low 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history need more evaluation.
What is the level of evidence provided by this article?
Level (3)
With the need to extend the pool of donors, kidneys from deceased donors with diabetes were utilized. Some studies showed that survival is not inferior, rather some data showed superior graft survival. This study evaluated kidneys from deceased donors transplanted to both diabetics and non-diabetics. 6 out of 26 post-perfusion biopsies showed evidence of diabetic nephropathy, with /0% having no diabetic nephropathy on repeat biopsies. Survival of grafts from diabetic donors depends on the previous state of the recipient. Survival is worse in recipients with DM compared to non-diabetics. This study examined and reviewed post-perfusion biopsies and subsequent “for the indication” biopsies. Electron microscopy was used in the evaluation. Preexisting Dm or NODAT was defined in accordance with ADA guidelines. Of a total of 706 recipients, donated kidneys from previously DM donors were 49 (23 for DM recipients and 26 non-DM). As in figüre 1 , both survival is better in (R-N/D-DM) gruup. Death-censored survival was better in the (R-DM/D-N) group. The previous situation of recipients is essential. Diabetic recipients experience higher mortality because of the increased risk of infection and micro- and macrovascular disease.
Please provide a summary of this article
This is a retrospective study at Houston Methodist Transplant Center between January 2006-December 2014.
Study population:
706 renal transplant recipients from deceased donors. 49 were from diabetic donors. 23 of these recipients had history of DM. Post perfusion biopsies were done in 26 of those 49 recipients. Follow up biopsies were done in 17 recipients.
Aim: assess clinical and histological graft outcomes in correlation to donor diabetic history and recipient diabetic status.
Primary outcome:
1- Recipient survival and death censored allograft survival
2- Illustrate the histological findings of post-perfusion biopsies from renal transplant from donors with diabetic history
Results:
Patient survival after 5 years was highest in non-diabetic recipients who received their graft from diabetic donors.
Death-censored graft survival was highest in diabetic recipients who received their graft from no-diabetic donors.
Diabetic recipients are more prone to increased mortality.
06/26 post perfusion biopsies showed evidence of diabetic nephropathy. There was no significant relation between severity of diabetic nephropathy changes and duration of donors’ DM.
02/17 follow up biopsies showed progressive diabetic nephropathy, both of them were diabetics.
03/20 follow up biopsies developed denovo diabetic nephropathy, all of them were diabetics.
Conclusions:
1- The greatest impact on mortality and graft survival was seen in recipients with diabetes.
2- The lowest survival was seen in diabetic recipients who received kidneys from diabetic donors.
Strengths:
1- This is the largest reported study group for transplant recipients from diabetic donors.
2- Inclusion of post perfusion biopsies.
3- Inclusion of follow up biopsies.
Limitations:
1- Small Study population.
2- Small number of post perfusion and follow up biopsies.
What is the level of evidence provided by this article? Level III evidence.
Introduction:
The survival benefit that end-stage renal disease (ESRD) patients derive from kidney transplantation has led to an increased demand for donor kidneys.
As a result, utilization of kidneys from deceased diabetic donors has emerged in the last two decades as a possible solution to this shortage.
the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation .
AIM of the study:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes.
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Materials and Methods:
For the first aim, retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
The primary outcomes in the study were recipient survival and death-censored allograft survival.
The criterion for accepting a kidney from a donor with a diabetic history at this center is the absence of high-grade proteinuria (>2+).
For the second and third aims, post-perfusion biopsies and subsequent “for indication” biopsies were examined and reviewed.
The time in days that a kidney resided in a “hyperglycemic environment” was calculated from the time of transplantation in diabetic recipients or from the time of onset of NODA.
On multivariate analysis of patient survival:
diabetes status of the recipient was associated with an increase in patient mortality.
Compared to control (R-N/D-N), the R-DM/D-N subgroup had nearly a twofold higher patient mortality at 5 years (HR 1.99, P = .017). Risk to a diabetic recipient was greater still, at 3-fold higher patient mortality at 5 years, with receipt of a kidney from a donor with diabetic history (R-DM/D-DM .
Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years.
Postperfusion biopsy finding:
Of the 49 kidneys from deceased donors with diabetic history transplanted, post-perfusion biopsy was performed in 26 cases (53%) (. Twenty cases did not exhibit evidence of diabetic nephropathy even after EM examination (Table 4). One biopsy showed thickened glomerular basement membrane by EM, but did not have any evidence of DN on light microscopy. Five biopsies showed class IIa DN characterized by mild mesangial sclerosis, hypercellularity, and thickened glomerular basement membrane. Diabetic nephropathy of higher severity (class IIb-IV) was not seen in any biopsy.
Discussion:
This study suggests that
(a) recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival, and (b) kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
Level of evidence 3.
Studies have shown similar patient survival and slightly inferior graft survival on transplanting deceased diabetic donor kidneys. Such kidneys expand the donor pool. Hence this study was conducted retrospectively to assess the effect of donor diabetes on the clinical and histological graft outcomes.
A total of 706 deceased donor recipients were included in this retrospective study done at a single centre between 2006 and 2014. Patients were divided into 4 groups: Donor diabetic (D-DM) with recipient diabetic (R-DM) – 23 patients, D-DM with non-diabetic recipient (R-N) – 26 patients, R-DM with non-diabetic donor (D-N) – 211 patients, and R-N with D-N – 446 patients.
Recipient survival, graft survival, and graft biopsies (post-perfusion, and indication biopsies) were evaluated.
5.5% of R-N patients received a D-DM kidney, while 9.8% of R-DM patients received a D-DM kidney, Median follow-up was 50 months. 5-year patient survival was 71.6%, 96.2%, 80%, and 89.7% in R-DM/D-DM, R-N/D-DM, R-DM/D-N, and R-N/D-N groups (poorest survival in R-DM/D-DM group). 5-year risk of mortality in R-DM group was 2 times with D-N and 3 times with D-DM kidneys. Mortality was higher in age more than 65 years and dialysis vintage.
5-year death censored graft survival between the 4 groups was 87.5%, 87.4%, 93.5%, and 86.3% in R-DM/D-DM, R-N/D-DM, R-DM/D-N, and R-N/D-N groups.
Only 5 of 26 post-perfusion renal biopsies showed features of diabetic nephropathy, that too of mild severity (class IIa) on light microscopy while 1 biopsy showed thickened GBM on electron microscopy. In the 12 follow-up biopsies of D-N patients, 3 developed de-novo DN. Progression of DN was noted in 2 R-DM patients. Among the 17 D-DM biopsies, 6 showed progression, 1 showed regression, while 10 had stable or no DN lesions.
The study concluded that the recipient diabetic status is the most important factor for graft and patient survival, and diabetic donor kidneys have graft and patient survival similar to non-diabetic donor kidneys, with histologically showing, at the most, mild changes. Hence diabetic donor kidneys can be utilized to expand the donor pool, especially in non-diabetic recipients.
Limitations of the study were small sample size, limited post-perfusion and follow-up biopsies, retrospective nature, and single centre study. The strengths of the study include largest reported cohort with using histological parameters with clinical outcomes.
2. What is the level of evidence provided by this article?
The level of evidence is level 3 (retrospective cohort study).
Outcomes of kidney transplantation using deceased donors with a history of diabetes
Introduction
· As kidney transplantation has a better outcome than being on dialysis, deceased diabetic kidneys were used to overcome the shortage of donated kidneys.
· Ahmad et al found that diabetic donors can be accepted choice to expand the pool of donors.
· Mohan et al found that kidneys from diabetic donors can be superior to kidneys from extended criteria.
MATERIALS AND METHODS
· Study aims:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
· analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
· All recipients of deceased donor kidney transplants were further stratified into four groups: R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N.
· Donor characteristics such as DM history, race, donor age, and BMI were obtained from the UNOS dataset.
· The criterion for accepting a kidney from a donor with a diabetic history at this center is the absence of high-grade proteinuria (>2+).
· The rate of post-reperfusion biopsies at this center is approximately 50%
· Diabetes was defined as a fasting blood sugar ≥ 126 on 2 separate occasions or a HbA1c ≥ 6.5%.
· New onset diabetes after transplantation (NODAT) was defined by similar criteria or the presence of antidiabetic agents 3 months after transplantation.
· CKD-EPI Equation was used to estimate GFR.
Discussion
· This study found that DM had the highest effect on recipient mortality and graft survival
· Kidneys from diabetic donors had negligible histological diabetic changes.
· 5-year death-censored graft survival was 88.5% despite the fact that 6.9% of the kidneys transplanted came from donors with a history of diabetes
· Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients. However, patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history
· Patient survival was lower in diabetic recipients than in non-diabetic recipients, but the survival was poorest in diabetic recipients of kidneys from donors with a diabetic history
· The development of diabetic nephropathy in a diabetic environment in the transplant setting is accelerated, which may lead to graft failure and death.
· the risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient
· Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
· Histological examination of kidneys from donors with a diabetic history in the present study suggests that the main cause of pre-transplant renal injury was due to donor-derived microvascular disease from a combination of both hypertension and diabetes.
Limitations of the study: small sample size and the limited number of post-perfusion and follow-up biopsies
Strength of the study: this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
CONCLUSION
· Risk outcome of the deceased diabetic donated kidney depends mainly on the recipient status
· Diabetic renal changes from diabetic donors are minimal
· the current emphasis of the KDPI on a donor diagnosis of diabetes needs a revision with the presence of high-grade proteinuria and renal function impairment
· Since a 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history, transplanting such kidneys into diabetic recipients needs a revision.
This is a retrospective case-control study, evidence 3
Introduction:
Deceased diabetic kidneys are increasingly utilized in transplantation. Although deceased diabetic donor kidneys are routinely used in several centers, few studies evaluating this practice have been published.
This study examined the relationship of recipient diabetic status
and donor diabetic history to clinical and histological outcomes of
kidney transplantation.
Results:
The relationship of donor’s history of diabetes to clinical and histological outcomes was examined. Forty-nine diabetic deceased donor kidneys (D-DM) were transplanted into 26
normal (R-N/D-DM) and 23 diabetic recipients (R-DM/D-DM) and compared to 211diabetic recipients of normal kidneys(R-DM/D-N) and 466 normal recipients of normal kidneys (R-N/D-N). Patient survival at 5 years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and a 71.6% in R-DM/D-DM (P = .008). Deathcensored graft survival at 5 years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM (P = .24). Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality. In this cohort, there was no impact on deathcensored graft survival of diabetic donor status. Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression. Survival of recipients of diabetic donor kidneys appears
dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this cohort, donor kidneys had paucity of structural diabetic lesions and most did not show progression
This study is limited by:
1.The small sample size.
2. The limited number of post-perfusion and follow-up biopsies.
The strengths of this study:
1. Being the largest reported cohort of transplanted kidneys from donors with a
diabetic history with post-perfusion biopsies, follow-up, and correlation with clinical outcome.
Conclusion:
The risk associated with transplantation of a kidney from a deceased donor with
a diabetic history appears to be largely dependent on the diabetes
status of the recipient.
Diabetic renal changes in conventionally accepted kidneys from donors with a diabetic history in this cohort are mild to minimal.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
Given the low 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history the propriety of transplanting such kidneys into diabetic recipients should be questioned
Introduction
It is well known that kidney transplantation has increased the survival benefit of patients with end-stage renal disease (ESRD). Therefore, there is an increased demand for donor kidneys. There are a few studies done that show similar patient survival and a non-significant inferior graft survival in recipients of deceased diabetic donor kidneys when compared to deceased non-diabetic donor kidneys. Single case reports have also been published showing reversal of diabetic lesions in the kidney once a euglycemic state was restored. However, further studies were required to help better understand the relationship.
This study was designed to examine the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes in kidney transplantation.
Materials and methods
The aims of the study included:
1.To compare the clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
This was a retrospective analysis, at Houston Methodist JC Walter Jr Transplant Center
Time frame was between between Jan 2006 to Dec 2014
The primary outcome was recipient survival and death-censored allograft survival
The reason for accepting a kidney from a donor with a diabetic history at this center was the absence of high-grade proteinuria (>2+)
2. To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
3.To examine histologic changes following transplantation in kidneys from donors with a diabetic history.
For the second and third aims, electron microscopy (EM) was used to examine the biopsies, with special attention to features of diabetic nephropathy (DN). The changes were graded. A pre-existing history of diabetes or new-onset diabetes after transplantation (NODAT) was defined by the American Diabetic Association criteria.
Results
Aim 1 – Patient population and outcomes
There were 706 patients who received kidneys from deceased donors. 49 of these patients received a kidney from a diabetic donor. From these 49 recipients, 23 had a history of diabetes, and 26 were non-diabetic.
The groups with the nondiabetic patients had low levels of BMI, lowest mean age, least proportion of males, highest prevalence of glomerulonephritis and polycystic kidney disease as the reason for transplantation. Diabetic recipients had the highest BMI and percentage of males and Hispanics. Hypertension in the donor was most prevalent in patients with a history of diabetes.
By the Kaplan-Meier analysis of patient survival at five years, was highest in the recipients who were non-diabetic and received kidneys from deceased diabetic donors. The analysis of death-censored graft survival was highest in the diabetic recipients and the non-diabetic donors.
Diabetes status of the recipient was associated with an increase in patient mortality. there was no statistical significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
Aim 2 – post-perfusion renal transplant biopsy findings
Of the 49 kidneys that were transplanted from deceased donors with a history of diabetes, post-perfusion biopsies were done on 26. 20 cases did not show evidence of DN. The others showed features of class IIa DN (mild mesangial sclerosis, hypercellularity, thickened glomerular basement membrane). Other features that were seen in some were features of arterionephrosclerosis, interstitial fibrosis, tubular atrophy, acute tubular necrosis, myoglobin casts, incidental IgA nephropathy.
No correlation could be found between the duration of donor diabetic history and the severity of the DN lesions found.
Aim 3 – follow-up biopsy findings
Of the 26 post-perfusion biopsies, follow-up biopsies were done in 17 recipients. Progression of DN was seen in 2 of the recipients, both of whom were diabetic.
Of the 20 patients who had had no features of DN on post-perfusion biopsy, 12 were re-biopsied. Out of the 12, 9 patients continued to show no evidence of DN, while 3 developed de novo DN (all 3 were patients with diabetes).
Discussion
This study suggests:
1.The recipient’s diabetic status has the greatest impact and adverse effect on mortality and graft survival
2. Kidneys from donors who have a history of diabetes have no or mild diabetic-related changes on histology.
Kidneys from donors with diabetes did as well as kidneys from non-diabetic donors, when they were transplanted in recipients who did not have diabetes. Patient survival was lower in recipients that had a history of diabetes, compared to those that did not. Survival was the poorest in diabetic recipients who received kidneys from diabetic donors.
Diabetic patients who received kidneys with DN, showed an acceleration of the DN. This may have led to graft failure and subsequent death.
There was better death-censored graft survival in the group of diabetic recipients of the kidneys from donors with no diabetic history, compared to the group of non-diabetic recipients of donors with no history of diabetes.
Therefore, as seen in prior studies, the risk associated with receiving a kidney from a donor with a history of diabetes depends on the diabetes status of the recipient.
Limitations
The limitations of this study include:
1. Small sample size
2. Limited number of post-perfusion and follow-up biopsies.
Strengths
The strengths of this study include:
1.The largest reported cohort of transplanted kidneys from donors with a history of diabetes with post-perfusion biopsies
2. It included follow-up biopsies and correlation with clinical outcome.
This is a level III evidence
This was a retrospective study done at deceased donors kidney transplants between 2006 to 2014 and with follow-up till 2016.
The aim and objective of this study was to compare the clinical outcomes of kidney transplantation from deceased donors with and without diabetes recipient, findings in post perfusion biopsies in kidneys from diabetic donors, examine histologic changes following transplantation in the kidneys from diabetic donors.
Several studies has shown similar patient survival, graft survival and the risk was dependent on the recipient diabetes, additionally there was no histological studies done to look at the diabetic donors, however few studies have evaluated the outcomes when deceased diabetic donors are taken.
The survival of the kidney transplant recipient seems very important rather than staying on dialysis, hence the utilization of diabetic kidney donors have increased the last 2 decades….Many institutes accept diabetic kidney donors with normal renal function and mild proteinuria…Some institutes do a protocol biopsy if there is azotemia or proteinuria and then decide based on the chronicity….In fact Diabetic kidney donors have shown to be far superior compared to extended criteria donors…Way back in 1983, there was one paper reported reversal of diabetic nephropathy changes 7 months after transplant of a diabetic kidney donor into a recipient..
This study examined the effects of transplant of diabetic kidney donors into the recipients…They studied the effect of diabetic kidney donors into diabetic and non diabetic recipients and also had analyzed the histopathological changes at the time of post perfusion and after renal transplantation….
this was a retrospective review study from Houston Texas from 2006 to 2014..And they were followed up till 2016…
Among the 706 recipients, 49 patients who received kidneys from diabetic donors..of the 49, 23 were transplanted into the diabetic recipients and 26 were implanted in non diabetic recipients…
Kaplan Meir analysis of patient survival and death censored graft survival were analyzed in 4 groups…Recipient Normal/Donor normal, Recipient diabetes/donor diabetes, Recipient normal/donor diabetes, Recipient diabetes/donor normal….5 year patient survival was highest in the recipient normal and donor diabetic individuals….5 year death censored graft survival was highest in recipient diabetic/donor normal followed by donor diabetic/recipient normal groups…On multivariate analysis of the patient survival, recipient diabetic state was associated with overall patient mortality…for the death censored graft survival donor diabetic or recipient diabetic status was not associated with 5 year graft survival in this study…
of the 49 kidneys in the group, 26 kidneys were subjected to post perfusion biopsy…20 cases did not exhibit features of diabetic nephropathy even after EM examination….6 patients showed RPS/ISN diabetic nephropathy class IIa changes only…There was no correlation between duration of the diabetes in the donor and severity of the histopathological changes that were observed….
38 follow up biopsies were done and progression of diabetic nephropathy was noted in diabetic recipients 6, 10 showed stable features as compared to the post perfusion biopsy and 1 showed regression of the diabetic lesions…
This study concluded that the recipient diabetes status is most important when considering overall patient survival than the donor diabetic status…The diabetic kidney changes seen in histology are very mild or minimal in diabetic kidney donors ….The study even questions Kidney Donor Profile index (KDPI) and says the duration of diabetes should not be the only one included in the index, rather the degree of proteinuria and renal impairment should be included as donor diabetic kidneys from deceased donors have comparable graft survival as non diabetic kidney donors…
The aims of this study were as follows:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
. This study suggests that
(a) recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival
(b) kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
-Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
-patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history
-The development of diabetic nephropathy in a diabetic environment in the transplant setting is accelerated
– This acceleration of pre-existing diabetic lesions may well contribute to graft failure and consequent patient death in this latter group
– the risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient.
-Diabetic recipients experience higher mortality
-Histological examination of post-perfusion biopsies showed either absent or mild diabetic lesions
-The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome.
In conclusion, the risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient.
Expanding donor pool is one way of tackling immense organ shortage. Accepting deceased donor with diabetes can help to bridge the gap of organ shortage.
The relation- ship of donor’s history of diabetes to clinical and histological outcomes was examined in this paper by khan and her colleagues.
The aims of this study were as follows:
To compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipient
To describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
To examine histologic changes following transplantation in kidneys from donors with a diabetic history. Approval for this retrospective review was obtained from the Houston Methodist Institutional Review Board.
For the first aim, retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
All recipients of deceased donor kidney transplants were further stratified into four groups based on recipient (R) and donor (D) diabetes history status (DM vs No DM history).
For the second and third aims, post-perfusion biopsies and sub- sequent “for indication” biopsies were examined and reviewed.
The diabetic changes were graded on a scale of 0-IV, as defined by the Renal Pathology Society (RPS)
Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality.
In this cohort, there was no impact on death- censored graft survival of diabetic donor status. Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this cohort, donor kidneys had paucity of structural diabetic lesions and most did not show progression.
Reterspective study
level of evidence 111
1. Please provide a summary of this article.
Introduction
Because of organ shortage utilization of ECD kidneys including diabetic has emerged recently.
This is retrospective study in Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 with follow-up through May 1, 2016.
The objectives are:
1. To compare clinical outcomes of kidney transplants from diabetic and non-diabetic donors into diabetic and non-diabetic recipients.
2. To describe histologic changes post perfusion in kidneys from diabetic donors.
3. To check histologic changes post transplantation in kidneys from diabetic donors.
Recipients were divided in to 4 groups:
· Diabetic donor to non diabetic recipients.
· Diabetic donor to diabetic recipients.
· Non diabetic donors to non diabetic recipient
· Non diabetic donor to diabetic recipients.
Results
Out of 706 renal transplants:
ü 23 diabetic recipient from diabetic donors.
ü 26 non diabetic recipient from diabetic donors
ü 211 diabetic recipient from non diabetic donors
ü 446 non diabetic recipient from non diabetic donors.
Of 706 primary renal transplants, subcategories included the following:
R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 21,1 and R-N/D-N446 patients.
Median follow up was 50months.
5years patient and death censored graft survival for the entire group was 88.5 and 86.5% respectively. No significant difference was found between the different groups in patient or graft survival.
On multivariate analysis, diabetic recipient status was associate with increased mortality.
Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years.
No significant difference in the in diabetic versus non diabetics.
This study is limited by small number size and limited number of biopsies
What is the level of evidence provided by this article?
Level 111
This study evaluate the outcome of deceased diabetic donors. This is the first study to analyze the complex relationship between donor and recipient’s diabetes status pre- and post-transplantation in the context of both clinical and histological data.
The objectives: (a) to compare clinical outcomes
of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
The permission was taken from Houston Methodist Institutional Review Board.
Donors are selected if there is absence of high-grade proteinuria (>2+).
Post perfusion biopsies are taken.
Four groups are identified:
1- Diabetic donors to diabetic recipients
2- Diabetic donors to non-diabetic recipients
3- Non-diabetic donors to diabetic recipients
4- Non-diabetic donors to non-diabetic recipients
Results and discussion:
1- Recipient’s diabetes status has the greatest bad effect on mortality and graft survival
2- kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
3- Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients
4- Diabetic recipients experience higher mortality because of increased risk of infection, sepsis, and micro- and macrovascular disease.
4- The development of diabetic nephropathy in a diabetic environment in the transplant setting is accelerated .
This study is limited by both the small sample size and the limited number of post-perfusion and follow-up biopsies.
The strengths of this study is that it is the
largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
Introduction:
There is an increasing utilization of deceased diabetic donors to increase the donor pool and to reduce the waiting time for a kidney transplant
Few studies have evaluated the outcomes when deceased diabetic donors are used.
Several studies have shown similar patient survival and graft survival and that the risk was dependent on the recipient diabetes status
There are also no histological studies looking at the diabetic lesions post-transplant.
Aims:
Methodology:
This was a retrospective review where analysis of electronic medical records of recipients of deceased donor kidney transplants between January 2006 to December 2014 was performed with follow up through to May 2016.
All the recipients were stratified in to 4 groups based on recipient (R) and donor (D) diabetes history status (DM or no DM). The 4 groups were:
Donor characteristics such as diabetes Hx, race, age and BMI were obtained from the UNOS data.
The primary outcomes were
Patient survival
Death-censored graft survival
For the 2nd and 3rd aims, post-perfusion biopsies and subsequent ‘for indication’ biopsies were examined and reviewed
The diabetic changes on histology were graded on a scale of 0-4 as defined by the Renal Pathology Service (RPS)
Recipients’ GFR was estimated using the CKD-EPI formula
Results:
49 out of 706 (6.9%) recipients received a kidney from a diabetic donor. 23 (47%) were implanted in diabetic recipients and 26 (53%) were implanted in non-diabetic recipients.
The R-N/D-N had the least proportion of males, lowest mean age, lowest BMI, highest prevalence ofGN and PKD and the lowest median donor age and donor BMI.
Median follow up for the primary analysis was 50 months.
Kaplan Meier analysis of patient survival by sub-group was:
89% in R-N/D-N
96.2% in R-N/D-DM
80% in R-DM/D-N
71.6% in R-DM/D-DM
Kaplan Meier analysis of DCGS at 5 years by the sub-group was
· 86.3% in R-N/D-N
· 87.4% in R-N/D-DM
· 93.5% in R-DM/D-N
· 87.5% in R-DM/D-DM
On multivariate analysis of patient survival, diabetic status of recipient was associated with an increase in patient mortality. Compared to controls (R-N/D-N), the R-DM/D-N group had a nearly 2 fold higher mortality at five years
Age > 65 years and dialysis vintage were associated with an increase in patient mortality.
By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetic status on death censored graft survival (DCGS)/
Aim 2:
Post perfusion biopsies were performed in 26 of the 49 deceased donors. 6 showed evidence of diabetic nephropathy (DN). One biopsy only showed GBM thickening while 6 had class IIa DN.
Aim 3:
Of the 26 post-perfusion biopsies, follow up biopsies were performed ‘for indication’ in 17 recipients
Progression of DN was noted in 2 recipients. Of the 20 recipients with no DN on post-perfusion biopsy, 3 developed de novo DN (all 3 recipients were diabetic)
Discussion:
Patient survival was at five years was similar to that reported in the 2015 SPTR/OPTN annual report.
The patient survival in R-N/D-DM was higher than in the group R-N/D-N. This may reflect a higher proportion of females, re-transplants and a higher cPRA in that recipient group.
The better graft censored survival in the R-DM/D/N compared to R-N/D-N could have been related to the higher patient mortality in the R-DM/D-N group (20%) compared to the R-N/D-N group (10.3%)
Limitations:
The study is limited by the small sample size and the limited number of post-perfusion and follow up biopsies.
Neither the post perfusion nor the follow up biopsies were performed per protocol. They were performed at the discretion of the surgeon
Conclusion:
Although further studies are needed, the risk associated with transplantation of a kidney from a deceased diabetic donor appear to be largely dependent on the recipient diabetes status. From this study, it would be advisable to give a kidney from a diabetic donor to a diabetic recipient as this was shown to have the worse outcome
Diabetic renal changes from the deceased diabetic donors are mild to minimal. Progression of DN depends on the time the kidney was in the hyperglycemic milieu.
Summary:
Kidney disease continues to increase and the problem rise concerns for nephrologists and the country as the cost of renal replacement is high. This is why all possible avenues must be investigated to ensure the pool for kidney transplants increases. This article is about the outcomes of kidney transplantation using deceased donors with a history of DM. That is why deceased diabetic donors were investigated. The possible outcome was investigated and elaborated on in this article to better understand if diabetic patients can be used. The study included 49 DM deceased donors whose kidneys were used by 26 recipients non diabetics and 23 DM recipients. From there the outcome was compared with 211 DM recipients of normal kidney donors and 466 normal recipients of normal kidney donors.
The study was followed up 5 years and the patient survival was about 86.5%. The patient survival rate was:
1) Normal recipients to normal donors was 89.7%
2) Normal recipient to DM donors was 96.2%
3) DM recipients of the normal donor were 80.1%
4) DM recipient of DM donor was 71.6%
As it relates to 5-year death and graft survival:
1) Normal recipients to normal donors was 86.3%
2) Normal recipient to DM donors was 87.4%
3) DM recipients of the normal donor was 93.5%
4) DM recipient of DM donor was 87.5%
So it was found that DM recipients have a 2 to 3-fold increased risk of mortality when compared with the non-DM. The group that did the worse was the DM recipients with DM donors. It was noted that from the biopsy 6 from 26 showed evidence of diabetic nephropathy and on repeating 70% had no evidence of progression.
The study was a good one but was limited since the population size was small and its strength was that it was the largest study ever conducted that is a cohort study.
The level of evidence of this study was level 3 since it was a retrospective cohort study.
Please provide a summary of this article
The use of deceased kidney donation is increasing due to large waiting list, especially in last two decades. Kidney from deceased donors have been used in may centres but outcome of such donation has been evaluated by few studies.
This study evaluated the donation from deceased diabetic donors to non diabetic recipient . The clinical and histological outcomes were evaluated.
Methodology.
49 kidney from diabetic donors were transplanted in 26 non diabetic and 23 diabetic recipients.
The outcome was compared with 211 diabetics who received kidney from non diabetics.
Also comparison was done with 422 non diabetics who received kidney from non diabetics
So essentially there were 4 groups
Diabetic donor : Non diabetic recipient
Diabetic donor : Diabetic recipient
Non Diabetic donor : Diabetic recipient
Non Diabetic donor : Non diabetic recipient
Diabetes was labelled if fasting sugar was more than 126 mg and HbA1C was 6.5%.
Biopsies were done in 26 recipients post perfusion and only 6 showed nephropathy changes.
Results and Conclusions.
Kidney from diabetic vs Non diabetic donors- when transplanted to non diabetic recipients did equally good.
As regards death censored graft survival , not much difference was noted diabetic donor and diabetic recipient
Outcome of kidney donation from diabetic donors depends upon recipient diabetic profile.
Limitations
Small sample
Limited use of biopsies.
Strengths
Largest cohort of diabetic donors with follow up and post perfusion biopsies.
What is the level of evidence provided by this article?
Retrospective study
Level 111
a retrospective study was conducted to evaluate the outcome of transplanting deceased diabetic donor kidneys to diabetic and non diabetic recipients, emphasizing on the impact of diabetic allograft on long term survival of the allograft and the confounding effects of being diabetic recipient versus nondiabetic recipient.
49 diabetic deceased donors kidneys were transplanted into 23 diabetic recipients and 26 normal recipients, the outcome was compared to 211 diabetic patients received normal non diabetic deceased donors kidneys and 422 non diabetic patients received non diabetic deceased donors kidneys. So 4 groups of patients were followed comparatively:
D,DM/R,N
D DM/R, DM
D,N/ R, DM
D,N/R,N
5 years ,death censored graft survival was evaluated across the 4 groups.
Diabetic was diagnosed as per the known guideline with fasting blood glucose of 126 and HbA1c of more than 6.5.
New onset diabetes after transplantation NODAT was explicated similarly , in addition to being on anti-diabetics for more than 3 months.
Post perfusion allograft biopsy was done in 26 recipients, 6 biopsies only featured histologic changes of diabetic nephropathy, which on subsequent biopsies , 70% failed to show any progression of the lesions.
Diabetic recipients had 2 -3 folds increased mortality rates in comparison to non diabetic recipients.
Given the lack of organs for patients on the waiting list, another criterion for assessing the donor’s expandability was the existence of diabetes in the donor. This study evaluated the relationship between the recipient’s diabetic status and the donor’s diabetic history with the clinical and histological outcomes of kidney transplantation at their institution.
The aims of this study were as follows: (a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients; (b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes; (c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history. It was a retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014
Among the results I highlight:
– On multivariate analysis of patient survival, diabetes status of the recipient was associated with an increase in patient mortality.
– Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years
– By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
– However, By multivariate analysis demonstred that recipient Black race, dialysis vintage, cPRAp as a continuous variable, and donor age greater than 50 years were associated with poorer graft survival at 5 years.
– No correlation could be found between the duration of donor diabetic history and the severity of diabetic nephropa[1]thy lesions observed.
– In all patients with progressive or de novo diabetic nephropathy , diabetes was present post-transplant.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this study, donor kidneys had paucity of structural diabetic lesions and most did not show progression
2.What is the level of evidence provided by this article?
This article have a level 3 of evidence, because a retrospective study.
e, examined the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation at our institution.
The aims of this study :
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
result :
patient population and outcome :
e R-N/D-N group had the least proportion of males, the lowest mean age, the lowest BMI, the highest prevalence of glomerulonephritis, and polycystic kidney disease as indication for transplantation, and the lowest median donor age and donor BMI.
patient and alograft result : diabetes reciepent has more risk of death
, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival
Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
limitation :
1- Given the histological findings in this study, the high numeric value given by KDPI to a diagnosis of diabetes results in a “labeling effect” and underutilization of otherwise acceptable kidneys
2-limited by both the small sample size and the limited number of post-perfusion and follow-up biopsies
conclusion :
, the risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recepient .
transplanting such kidneys into diabetic recipients should be questioned cause of low rate survival after five years .
cause it is retrospective it is level 3
Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality. In this cohort, there was no impact on deathcensored graft survival of diabetic donor status. Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney. In this cohort, donor kidneys had paucity of structural diabetic lesions and most did not show progression.
The aims of this study were as follows:
a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes
c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
All transplant candidates at this center undergo electrocardiogram, echocardiogram, stress test, and cardiology consultation.
No patients were listed with evidence of myocardial ischemia, or heart failure or markedly reduced LVEF attributable to coronary artery disease.
The primary outcomes in the study were recipient survival and death-censored allograft survival. Recipient survival and death-censored allograft survival were verified in the SRTR (Scientific Registry of Transplant Recipients) database.
The criterion for accepting a kidney from a donor with a diabetic history at this center is the absence of high-grade proteinuria (>2+).
This study suggests that
(a) recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival
(b) kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients. However, patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history
the risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient. On multivariate analysis, a nearly 2-fold increase in patient mortality was noted when diabetic recipients were compared to non-diabetic recipients.
Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
Histological examination of post-perfusion biopsies showed either absent or mild diabetic lesions (only 6 of 26 immediate post-perfusion biopsies showed early diabetic changes).
The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome.15 Histological examination of kidneys from donors with a diabetic history in the present study suggests that the main cause of pre-transplant renal injury was due to donor-derived microvascular disease from a combination of both hypertension and diabetes.
The strengths of this study include that, though small, this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
In conclusion, although further studies are needed, the risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient.
———————-
level III
Please provide a summary of this article
-The utilization of kidneys from deceased diabetic donors has emerged in the last two decades as a possible solution to the shortage of donor.
-It is retrospective study of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 with follow-up through May 1, 2016.
– The study suggests that recipient’s diabetes status has the greatest impact and
adverse effect on mortality and graft survival, and kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
-Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
-Patient survival was lower in diabetic recipients than in non-diabetic recipients, but the survival was poorest in diabetic recipients of kidneys from donors with a diabetic history compared to 80% survival in diabetic recipients of kidneys from donors with no diabetic history.
-The risk associated with receipt of a kidney from a donor with a diabetic history appears to be dependent on the diabetes status of the recipient.
-A nearly 2-fold increase in patient mortality was noted when diabetic recipients were compared to non-diabetic recipients.
-Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
– Despite varying duration of diabetic history, histological evidence of diabetic nephropathy was not seen in a majority of the post-perfusion biopsies, and where seen was mild.
-The history of diabetes rather than the presence of diabetic nephropathy (as evidenced by proteinuria or impaired renal function) that is heavily weighted in the KDPI scoring.
– This study is limited by both the small sample size and the limited number of post-perfusion and follow-up biopsies.
-The strengths of this study is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
What is the level of evidence provided by this article?
Level 3
Summary of the articles:
Introduction:
The increasing deriving ESKD towards transplantation, lead to increase demand of kidney donation, as well as deceased donation.
ECD as emerged as one of the solution in inceasing donor pool, as well as utilizing donor with history of diabetes.
Ahmed et al.; noted similar patient survival, but slightly inferior graft survival in recipients of deceased diabetic kidney donor, compared with the kidney of non-diabetic donors.
In 2012, Mohan et al.;show that donor diabetes, did not have a significant effect on graft and patient survival .
Cohen et al.; found that risk was associated with diabetic donor, it dependently associated with recipient diabetes status.
Repeated biopsies 7 month afterward showed resolution of BM thickening, mesangial matrix expansion, and diffuse glomerulosclerosis.
Material and methods:
Goal of the study:
Recipient of deceased donor kidney transplant were furthurly classified into 4 groups;
Donor charectristics:
All transplant candidates underwent:
Exclusion criteria:
Primary outcome of this study is :
Biopsy based diabetic changes, graded from 0-IV as follow:
Pre-existing DM or NODAT defined according to ADA by:
Results:
Population characteristics:
Patient survival, by Kaplan-Meier;
Graft survival, by Kaplan-Meier;
multivariate analysis;
Biopsy post perfusion transplant finding:
Follow up biopsies:
In summary:
level of evidence:
Retrospective study level((III)).
Deceased diabetic donors are recently used to increase the donor pool, they are associated with comparable patient and graft survival to kidneys from nondiabetic donors.
Previous studies suggested that using kidneys from diabetic donor is better than extended criteria donor kidneys, also showed reversal of diabetic lesions post transplant with restoring euglycemia.
This retrospective study aimed to determine the effect of kidneys from diabetic donors and nondiabetic donors in recipients with diabetes and without diabetes, it also described histological changes in post perfusion and follow up biopsies in kidneys from donors with diabetes.
It included recipients of deceased donors and classified them into 4 groups according to donor and recipient diabetes history with exclusion of recipients with cardiovascular disease.
Primary outcomes were patient survival and death censored graft loss.
The study suggested that recipient diabetes status has the main impact on patient and graft survival.
Kidneys from diabetic donors had mild histological changes before transplantation.
Graft outcome was similar in kidneys from diabetic and nondiabetic donors when transplanted in nondiabetic recipients.
Patient survival was lower in diabetic recipients than in nondiabetic recipients and was the lowest in diabetic recipients of kidneys from diabetic donors.
Accelerated progression in preexisting diabetic lesions was observed when kidneys from diabetic donors were transplanted in diabetic recipients.
The study suggested that recipient’s diabetic status has the greatest adverse effect on mortality.
Limitations:
Small sample size,
Post perfusion biopsies were per surgeon assessment and follow up biopsies were per indication with no protocol biopsies performed.
Strength:
Included largest cohort of kidney recipients from deceased diabetic donors with post perfusion and follow up biopsies and correlation to clinical outcomes.
The study suggested that KDPI should be revised to include presence of proteinuria and renal impairment rather than donor diagnosis of diabetes to decrease discarding kidneys from diabetic donors.
Level 3 retrospective cohort study.
Summary
This study refers to outcomes of kidney transplant when using deceased donors with diabetic history.
Two major lessons learned from this study include :
Recurrence of glomerulonephritis are a leading cause of graft loss with these donor kidneys.
Patient survival is better in non-diabetic recipients, but diabetic recipients have better outcome than diabetic recipients with diabetic donor kidneys. The risks associated with diabetic recipients include infection, sepsis, microvascular and microvascular disease. A major factor associated with decreased risk of graft survival in diabetic recipients is an increase in alloreactive T cells leading to higher rate of rejection episodes.
Both diabetes and hypertension are indicators of poor graft outcome. Risk of high grade proteinuria and renal functional impairment are to be looked out for in the case of diabetic donor kidneys.
In conclusion, the diabetic status of the recipient is of far more effect on adverse graft outcomes than diabetic donor kidneys with nil or mild histological diabetic changes.
Level of evidence 3 because this is a retrospective cohort study
This study was conducted with the aim to increase the donor pool ,for that in this study it included 49 diabetic deceased donors whose their kidneys were transplanted into 26 normal recipients and 23 diabetic recipients. the outcome was compared to 211 diabetic recipients of normal kidney donors and 466 normal recipients of normal kidney donors.
RESULT;
patient survival & graft survival at 5 ys showed that diabetic recipients had 2-3 folds increased risk of mortality compared to non diabetic recipients .
– Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy and on repeat biopsies 70% showed no evidence of progression.
– Survival appears to be dependent on the diabetic status of the recipient with the worst outcome was in diabetic recipients from diabetic donors .
What is the level of evidence provided by this article?
Please provide a summary of this article :
I- 5 year patient survival :
1- in normal recipients of normal donors, it was 89.7%
2- in normal recipients of diabetic donors, it was 96.2%
3- in diabetic recipients of normal donors, it was 80.1%
4- in diabetic recipients of diabetic donors, it was 71.6%
II- 5 year death censored graft survival :
1- in normal recipients of normal donors, it was 86.3%
2- in normal recipients of diabetic donors, it was 87.4%
3- in diabetic recipients of normal donors, it was 93.5%
4- in diabetic recipients of diabetic donors, it was 87.5%
What is the level of evidence provided by this article?
Thank you, well done
– this study examines the relationship of donors hx of diabetes to clinical & histological outcomes in deceased donor transplantation.
– 49 diabetic degassed donor kidney were transplanted into 26 normal non diabetic recipients & 23 diabetic recipients .
– co pared to 211 diabetic recipients of normal kidneys & 466 normal recipients of normal kidneys .
– patient survival & graft survival at 5 ys showed that diabetic recipients had 2-3 folds increased risk of mortality compared to non diabetic recipients .
– Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy and on repeat biopsies 70% showed no evidence of progression.
– Survival appears to be dependent on the diabetic status of the recipient with the worst outcome was in diabetic recipients from diabetic donors .
– Limitations : small sample size & limited number of post perfusion & follow up biopsies .
– Strengths : the largest reported cohort study of transplanted kidneys from diabetic donors with post perfusion & follow up biopsies
Conclusion :
– the risk association of using deceased kidney donation from diabetic donors mostly is dependent on diabetic status of the recipient
– This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
– Further studies are needed.
Level of evidence :
Level 3 , retrospective cohort study
Thank you, well done
The aims of this study were:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history
Median follow-up for the primary analysis was 50 months
5 years patient survival 86.5%
Graft survival 88.5%
There were 4 groups
R D SURVIVAL GRAFT
SUVIVAL
N N 89.7% 86%
N DM 96.2% 87%
DM N 80% 93%
DM DM 71.6% 87%
By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
Post perfusion biopsies
From 49 patients only 26 perform biopsies 53%
Recipients Follow biopsies
Due to DGF- PROTEINURIA- DSA
Only 17 recipients perform biopsy- 38 biopsies in total
recipient’s diabetes status has the greatest impact and adverse effect on mortality and graft survival,
kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome
evolution of diabetic nephropathy often requires long duration of diabete
limitations
small sample size
Strengths
this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
Leve III
Thank you, well done, why level 3 Ghalia?
Please provide a summary of this article
Introduction
Few studies evaluating the outcome of deceased transplant kidney donors with diabetes
Aims of the study
1. Compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients
2. Describe the histology in post-perfusion biopsies in kidneys from donors with diabetes
3. Examine histology following transplantation in kidneys from donors with diabetes
Materials and Methods
Retrospective study of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center (2006-2014)
Based on recipient (R) and donor (D) diabetes history, further classified into four groups: R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N
The primary outcomes were recipient survival and death-censored allograft survival
Post-perfusion biopsiesl/subsequent “for indication” biopsies were examined. EM for diabetic nephropathy which is graded on a scale of 0-IV according to Renal Pathology Society (RPS)
Indications for subsequent biopsies are proteinuria, worsening graft function, or the development DSA
Results
Of 706 primary renal transplants: R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 211 and R-N/D-N 446 patients
Forty-nine diabetic deceased donor kidneys (D-DM) were transplanted into 26 normal (R-N/D-DM) and 23 diabetic recipients (R-DM/D-DM) and compared to 211 diabetic recipients of normal kidneys(R-DM/D-N) and 466 normal recipients of normal kidneys (R-N/D-N)
Patient survival at 5 years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.0% in R-DM/D-N, and 71.6% in R-DM/D-DM
Death-censored graft survival at 5 years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM
Diabetic recipients had a 2 fold increased risk of mortality when compared to non-diabetic recipients
NO significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival
Only 6 of 17 recipients with follow-up biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies 70% showed no evidence of progression
Weakness of the study
1. small sample size
2. small number of post-perfusion and follow-up biopsies/not per protocol
Strengths of the study
The largest study of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome
Conclusion
Recipient diabetes status is the main factor which determine the risk of kidney transplant from deceased kidney donors with diabetes (worst survival in recipients of a diabetic donor kidney)
Recipient diabetic renal changes were mild to minimal in kidney transplant with deceased donors with diabetes
Further studies are needed
What is the level of evidence provided by this article?
Level 3 (retrospective case control study)
Thank you, well done
This study looked for the outcomes of kidney transplantation using diabetic deceased donors. It had involved a retrospective review of the medical records of recipients of deceased donor kidney transplants and they were stratified into four groups: normal recipient of diabetic donors, normal recipients of normal donors , diabetic recipients of diabetic donors and diabetic recipients of normal donors. Diabetic donor were approved for donation if they had no high-grade proteinuria (>2+).
In this study 49 diabetic deceased donor kidneys were transplanted into 26 normal and 23 diabetic recipients. These were compared with normal kidneys donated to 211 diabetic recipients and 466 normal recipients. The 5 year survival was best in the group of normal recipient of diabetic donors and followed by normal recipients of normal donors. The worst survival was on the diabetic recipients of diabetic donors followed by diabetic recipients of normal donors. The 5-year death censored graft survival was more in the group of diabetic recipients of normal donors and it was approximately similar in the other three groups. The factors associated with poor 5-year graft survival were recipient Black race, dialysis vintage, cPRA p and donor age of 50 or more. Diabetic recipients had a 2- to 3-fold increased risk of mortality when compared to non-diabetic recipients. The histopathological examination showed evidence of diabetic nephropathy in 23% only with no evidence of progression. There was no correlation between the duration of diabetic history of the donor and the severity of histopathological biopsy lesions.
This study showed that diabetic deceased donors lead to mild changes in the recipients and that the diabetic status of the recipient is the most important factor in graft survival. Diabetic donors’ kidneys are equivalent, to some extent, to normal donors’ kidneys if transplanted to non-diabetic recipients
This is a cohort study, so the level of evidence is 4
Thank you, Hinda
It is always nice to see your reply.
Why level 4?
This is a single-center retrospective study collecting data from January 2006 to December 2014, separating patients who underwent kidney transplantation from a deceased donor into four groups with different combinations of donors and recipients with and without diabetes.
All study patients underwent investigation for cardiovascular disease prior to transplantation.
The four groups were divided as follows:
Recipient with Diabetes / Donor with Diabetes
23 patients
Five-year survival 71.6%
Hazard Ratio 3.14
Recipient without Diabetes / Donor with Diabetes
26 patients
Five-year survival 96.2%
Recipient with Diabetes / Donor without Diabetes
21 patients
Five-year survival of 80%
Hazard ratio 1.99%
Recipient without diabetes / Donor without diabetes
446 patients
Five-year survival 89.7%
Diabetic recipient risk factors were Hispanics and high BMI. Arterial hypertension is a recurrent finding. Graft survival is lower in patients of black ethnicity, time on dialysis, high cPRA, and donor age over 50 years.
In the biopsies, even in patients with previously diabetic donors, the biopsies showed no evolution of diabetic glomerulopathy, in some cases even normalizing the findings.
This study suggests that recipients with diabetes mellitus are at increased risk of graft loss and survival when compared with donated organs, regardless of donor status. The evolution of diabetic nephropathy is greater mainly in the D DM / R DM group, increasing mortality, risk of infection, and vascular disease.
Despite the low number of patients in the groups, this is the largest study relating clinical and histopathological findings considering the four groups discussed. With the difficulty in making organs from deceased donors available and the findings of this study strengthen the discussion of not dispensing with diabetic donors, and should work on improving the performance status of recipients, especially in relation to arterial hypertension, glycated hemoglobin, and fasting glucose,
Retrospective cohort study
Level III
Thank you, well done
1- Summary of this article
Introduction
Diabetic donors could be used to expand the donor pool ,many studies carried on to conclude that diabetic donor kidney the risk was associated with diabetic donor kidney ,it was depend on recipient DM status.
The aim of this study to show the relationship of recipient diabetic status and donor DM history to clinical and histological outcome of kidney transplantation at our institution
Method
This retrospective analysis of medical records done in transplant centre between-n 1/2006 and 12 /2014and follow up through may 2016.
All recipients of deceased donor kidney transplants were divided in to four groups:
Group were R-. DM/D-DM.
Group R-M/D-DM.
Group R-DM /D-N.
R-N/D-N.
Primary out come of this study were recipient survival and death-censored allograft survival.
Absence of high grate proteinuria is mandatory to be accept a kidney from a donor with DM in this centre.
NODAT was defined FBG . or more 126 on two separate occasion or HbA1C . or more 6,5%. Orv presence of antidiabetic agents 3 month after transplantation.
Result
Patient and allograft outcome:
5 years patients and death-censored graft survival were 86.5% and 88.5%,respectively.
Patient and graft survival
On multivariate analysis of patient survival, DM status of the recipient was associated with increase in patient mortality compared to control.
Post-perfusion renal transplant biopsy findings
49 kidneys from deceased donors with DM history transplanted pos-perfusion biopsy was performed in 26 cases.
20 cases did not show evidence of DN
One biopsy showed thickened GBM by EM but no DN On light microscopy.
5 biopsies showed class 2a DN.
Sever DN(class 2b-4) was not seen kidney biopsy.
No correlation could be found between the duration of donor DM history and the severity of DM nephropathy lesion observed.
17 recipients with follow up biopsies,6 with DM lesion,10 with stable or no DM lesion and 1 recipients with regression of DM lesions.
Discussion
This the first study to analyse the complex relationship between donor and recipients DM status pre-and post-transplantation in the context of both clinical and histological data.
Summary of this study suggest that recipients DM status has the greatest impact and adverse effect on mortality and graft survival. And kidney from donors with a history of DM selected for transplantation at this centre have no or mild histological DM changes.
5-years death -censored graft survival was 88.5% despite the fact that 6.9% of the kidney transplanted came from donors with a history of DM.
Kidney from donors with a DM history did as well as normal kidney when transplant into non-DM recipients.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of DM should be function impairment.
2- retrospective cohort study level3
Thank you, well done
Outcomes of kidney transplantation using deceased donors with history of diabetes
====================================================================
Introduction
====================================================================
Material and methods
1-R-DM/D-DM 23pateint ..
2-R-N/D-DM 26.pateint .
3-R-DM/D-N 21,1 pateint .
4-R-N/D-N 446 patients.
====================================================================
Results:
1- 49 recipients (6.9%) received a kidney from a D-DM history.
2- Of R-N/D 5,5% received a kidney from a D-DM history.
3- and of the R-DM 9.8% received a kidney from a D-DM.
4- Of these 49 kidneys from D-DM, 23 (47%) were implanted in R-DM and 26 (53%) were implanted in R-N/DM.
5-Five year patient and death-censored graft survival were 86.5% and 88.5% respectively..
Kaplan-Meier analysis of patient survival at 5 years by sub-
group was
Kaplan-Meier analysis of death-censored graft survival at
A- Mild diabetic lesions (only 6 of 26 immediate post-perfusion biopsies showed early diabetic changes).
B- Only 29% (5 of 17 patients with follow-up biopsies) showed evidence of histologic progression of diabetic lesions.
C- Other papers 75% development of DN lesions in diabetic recipients of kidneys from donors with no diabetic history at 5-6 years post-transplant.
– Limitation:
-The strengths of this study include
===================================================================
Conclusion:
The level of evidence provided by this article
level of evidence 3
Retrospctive Cohort study
Thank you
Aim of the study: to examine the relationship between recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation.
Material and method:
The retrospective analysis included all recipients of deceased kidney donors between 2006 – 2014 and was performed with follow-up through May 1, 2016.
Donors (D)and recipients( R )were further stratified based on diabetic history into 4 groups:
R-DM/D-DM.
R- N/D- DM
R- DM/D-N
R-N/D-N.
Recipient and donor characteristics and peri-transplant factors were analyzed.
No patients were listed with evidence of myocardial ischemia, or heart failure or markedly reduced LVEF attributable to coronary artery disease.
Only donors without high-grade proteinuria (>2+) were accepted.
Post-perfusion biopsies and any indicated biopsies were examined and reviewed with special attention to features of DN, which was defined and graded from 0-IV based on the Renal Pathology Society (RPS).
Pre-existing DM in recipients was defined as an FBG>=126 on two separate occasions or HgA1C >= 6.5
NODAT onset diabetes after transplantation was defined as the same or the presence of antidiabetic agents 3 months after transplantation.
Results:
Total of 706 recipients with deceased donor kidney transplants
49 diabetic deceased donor kidneys (D-DM) were transplanted into:
26 normal (R-N/D-DM) 53%
23 diabetic recipients (R-DM/D-DM) 47%
compared to:
211diabetic recipients of normal kidneys (R-DM/D-N)
466 normal recipients of normal kidneys (R-N/D-N).
R-DM had the highest BMI, while HTN was most prevalent in D-DM.
Patient and allograft outcome:
In general, the 5-year patient was 86.5%, and death-censored graft survival was 88.5%.
Patient survival at 5 years by subgroup was:
89.7% in R-N/D-N
96.2% in R-N/D-DM
80.0% in R-DM/D-N
71.6% in R-DM/D-DM
Death-censored graft survival at 5 years was :
86.3% in R-N/D-N, a higher proportion of cPRA and a higher proportion of recipients with GN.
87.4% in R-N/D-DM,
93.5% in R-DM/D-N
87.5% in R-DM/D-DM
Multivariable regression analysis
Diabetic recipients had a 2- to 3-fold higher mortality risk than non-diabetic recipients.
Age > 65 and dialysis vintage were associated with increased patient mortality at 1, 3, and 5 years.
There was no impact on death-censored graft survival of diabetic donor status.
Post-perfusion renal transplant biopsy finding:
Post-perfusion biopsy was performed in only 26 out of 49 deceased donors with diabetic history.
20 did not exhibit evidence of DN.
6 of 26 biopsies showed evidence of DN (<IIa).
No correlation could be found between the duration of donor diabetic history and the severity of DN lesions observed.
Follow-up biopsy finding:
Repeat biopsies were done in 17 recipients only for clinical indication.
70% showed no evidence of progression.
Progression of diabetic nephropathy was noted in 2 recipients, both of whom were diabetic of DN, and three developed de novo DN.
Recipients with progressive or de novo diabetic nephropathy had longer exposure to a hyperglycemic.
Conclusion:
Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
However, patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history.
This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment. With such a change, it would be anticipated that fewer kidneys from donors with a diabetic history would be discarded than is currently the case.
Limitations:
-Small sample size
-a limited number of post-perfusion and follow-up biopsies.
Level of evidence; 3, retrospective cohort study
Thank you
Aims:
The primary outcome of the study were recipient survival and death-censored allograft survival.
The criteria for accepting a kidney from a diabetic history is the the abscence of high grade proteinuria.
Median follow up for the primary analysis was fifty months.5-year patient and death censored survival were 86.5% and 88.5% respectively.
There was no statistically significant of donor diabetic history or recipient diabetes
Out of 49, 26 cases were performed post transfusion biopsy. 20 cases do not exibit evidence of diabetic nephropathy. 5 showed class II a DN. Diabetic nephropathy of higher severity was not found in any biopsy.
A total of 38 follow up biopsies were examined for the evolution of diabetic lesions, Progression of diabetic nephropathy was found in 2 patients.
The risk associated with the recipient of a kidney from a donor with a diabetic history appears to be dependant on the diabetes status of the recipients. A nearly 2 fold increase in patient mortality was noted in diabetic patients.
Diabetic patients experience higher mortality due to increased risk of infection, sepsis, micro or macro vascular disease.
This study is limited by both small sample size and limited number of post perfusion and follow up biopsy.
level III
Thank you
In the last two decades, the utilization of kidneys from deceased diabetic donors has emerged as a potential solution to this shortage. Due to the increased demand for kidneys, diabetic donors’ organs have been added to the donor pool.
The supplied study, a retrospective study with a level of evidence of 3, assessed the long-term effects of kidney allografts from diabetic donors.
The objectives of this study:
-To compare the clinical outcomes of kidney transplants from donors with or without a history of diabetes into recipients with or without diabetes.
To compare the clinical outcomes of kidney transplants from donors with or without a history of diabetes to recipients with or without diabetes.
To report the histologic findings in post-perfusion kidney biopsies from donors with a history of diabetes.
-To investigate histologic alterations following kidney transplantation from diabetes donors.
-Review of post-perfusion biopsies and subsequent biopsies for specific indications
Material and procedure:
The authors of the study conducted a retrospective examination of electronic medical records of kidney transplant recipients from deceased donors at Houston Methodist JC Walter Jr. Transplant Center between January 1, 2006 and December 31, 2014, with follow-up through May 1, 2016.
All recipients of kidney transplants from deceased donors were categorized into four groups based on recipient (R), donor (D), diabetes history (DM), and absence of diabetes history (N).
Analytical Statistics:
Data at baseline were presented as medians and interquartile ranges (IQR) for continuous variables, and as frequencies and proportions for categorical variables. The chi-square test for categorical variables and the Kruskal-Wallis test for continuous variables were used to assess baseline data differences between groups.
Result
Subcategories for 706 primary renal transplants included R-DM/D-DM 23, R-N/D-DM 26, R-DM/N 21,1 and R-N/N 446 patients.
At five years, patient survival was 89.7% for R-N/D-N, 96.2% for R-N/D-DM, 80.1% for R-DM/D-N, and 71.6% for R-DM/D-DM (P =.008).
Death-censored graft survival at five years was 86.3% for R-N/D-N, 87.4% for R-N/D-DM, 93.5% for R-DM/D-N, and 87.7% for R-DM/D-N (P =.24).
Only six of twenty-six post-perfusion biopsies revealed diabetic nephropathy.
The highlights of this study include the largest known cohort of transplanted kidneys from donors with a history of diabetes who underwent post-perfusion biopsies, follow-up biopsies (in 50% of these), and connection with clinical outcome.
In this study, the number of post-perfusion and follow-up biopsies and the size of the samples are small.
Until further studies, the risk associated with transplanting a kidney from a deceased donor with a history of diabetes appears to be mostly reliant on the recipient’s diabetes status.
This study suggests that the KDPI’s present emphasis on the diagnosis of diabetes should be amended to highlight the presence of high-grade proteinuria and renal impairment.
function impairment.
Thank you, what is the level of evidence?
SUMMARY
Introduction
The remarkable improvements in the quality of life seen in those that has done kidney transplantation has encouraged many patients with ESRD to opt more for the procedure but has also led to scarcity of organs. Hence, the need to revisit use of organs from donor with diabetes mellitus. Therefore, there is a need to assess whether the risk from diseased DM donor is from the graft or from the recipient with or without DM.
Aim
Materials and Methods
Results
Limitations of the study
Strength of the study
Conclusion
The attributable risk to kidney from diseased donor with DM is not as severe at as was believed to be, but actually worse in recipient with DM and hence this will reduce the discard rate of such organ. However, a decision needs to be reached in accepting organs from donor with DM to a potential recipient with DM as this has been short to be with worse mortality and graft survival
The level of evidence is 3
Thank you
Ø This study suggests that the recipient’s diabetes status has the most significant impact and adverse effect on mortality and graft survival.
Ø Kidneys from donors with a history of diabetes selected for transplantation at this center have no or mild histological diabetic changes.
Ø Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
Objectives :
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in donors with a history of diabetes in post-perfusion biopsies in kidneys.
(c) To examine histologic changes following kidney transplantation from donors with a diabetic history.
(d) Post-perfusion biopsies and subsequent “for the indication” biopsies were discussed and reviewed.
Material and method:
Ø We performed a retrospective analysis of electronic medical records of deceased donor kidney transplant recipients at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 with follow-up through May 1, 2016.
Ø All recipients of deceased donor kidney transplants were divided into four groups based on1- recipient (R),2- donor (D) 3-diabetes history status (DM,4-No DM history [N].
Statistical Analysis:
Ø Baseline data were reported as medians and interquartile ranges (IQR) for continuous variables and as frequencies and proportions for categorical variables. Differences in baseline data across groups were compared using the chi-square test for categorical variables and a Kruskal-Wallis test for continuous variables
Result
706 primary renal transplants, subcategories included the following: R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 21,1 and R-N/D-N 446 patients,
Patient survival at five years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and 71.6% in R-DM/D-DM (P = .008).
Death-censored graft survival at five years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM (P = .24).
Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy.
The strengths of this study are the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
This study is a small sample size and a limited number of post-perfusion and follow-up biopsies.
Conclusion :
Further studies are needed. The risk associated with the transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient
This study suggests that should revise the current emphasis of the KDPI on the diagnosis of diabetes should reflect the presence of high-grade proteinuria and renal
function impairment.
It IS A RETROSPECTIVE STUDY LEVEL 111
Thank you
1. Please provide a summary of this article
Introduction
·The use of kidneys from DDD has appeared as a way expand the donors pool.
·Many centers routinely use DDD; however, few studies are published.
· Ahmad et al compared recipients of DDD to recipients of deceased non-diabetic donor
kidneys & found similar patient survival, but slightly inferior graft survival in the
recipients of DDD.
·Mohan et al noted that donor diabetes did not affect graft & patient survival; he thinks that diabetic donor kidneys may be superior to ECD kidney.
·Cohen et al (UNOS data) found that the risk associated with diabetic donor kidneys was related to recipient diabetes status.
· Abouna (1983) transplanted a DDD kidney with histological DN into a non-diabetic
patient. A biopsy 7 months later showed reversal of diabetic changes; other single case
reports reported similar results once euglycemia was restored.
·This study examined the relationship of recipient diabetic status & donor diabetic history to clinical & histological outcomes of kidney transplantation.
The study
The aims
·To compare outcomes of transplants from donors with or without diabetes into diabetic or non-diabetic recipients
·To describe histology in post-perfusion biopsies in kidneys from donors with diabetes
·To examine histology after transplantation in kidneys from donors with diabetes.
Population
All recipients of DKD transplants were divided into 4 groups based on recipient (R) & donor (D) diabetes status:
R-DM/D-DM
R- N/D- DM
R- DM/D-N
R-N/D-N.
Primary outcomes:
Recipient survival & death-censored graft survival.
Criteria for accepting a donor with diabetes is the absence of >2+.
Diabetic changes grading
0 = no changes by LM or EM
I = no LM changes, thickened GBM by EM
IIa = mild mesangial expansion by LM
IIb = marked mesangial expansion by LM
III = nodular mesangial sclerosis
IV = advanced diabetic glomerulosclerosis.
Diabetes & NODAT (ADA definitions):
FBG=/> 126 on 2 occasions or HgA1C =/> 6.5% .
NODAT similar criteria or the presence of anti-diabetic agents 3 months post-transplant.
Results
706 deceased donor kidney transplants
R-DM/D-DM: 23
R-N/D-DM: 26
R-DM/D-N: 211
R-N/D-N: 446
Population characteristics
Out of 706 recipients, 49 kidneys (6.9%) from donors with DM:
23 (47%) implanted in DM recipients
26 (53%) implanted in non-DM recipients
Of non-DM recipient cohort, 5.5% received a kidney from a DM donor.
Of DM recipient cohort, 9.8% received a kidney from a DM donor.
R-N/D-N group:
Least males
Lowest mean age
Lowest BMI
Highest GN prevalence & ADPKD as indication for transplant
Lowest median donor age
Lowest donor BMI
Diabetic recipients:
Highest BMI
Highest males & Hispanics
Patient & allograft outcome
Median follow-up was 50 months.
5-year patient & death-censored graft survival: 86.5% & 88.5%, respectively.
5-year graft survival (subgroups):
R-N/D-N 89.7%
R-N/D-DM 96.2%
R-DM/D-N 80.0%
R-DM/D-DM 71.6%/5 deaths (3 CVD, 1 PTLD, 1 graft failure with refusal of dialysis) in this group
5 years death-censored graft survival (subgroup):
R-N/D-N 86.3%
R-N/D-DM 87.4%
R-DM/D-N 93.5%
R-DM/D-DM 87.5%
Multivariate analysis
DM in recipient associated with an increase in patient mortality
R-DM/D-N: 2-fold higher 5-yr patient mortality compared R-N/D-N (control)
R-DM/D-DM: 2-fold higher risk
No significant impact of donor DM or recipient DM on death-censored graft survival. However, recipient Associations with poorer 5-year graft survival:
Black race
Dialysis vintage
cPRA
Donor age =/>50
Post-perfusion real biopsy
Done in 26 (53%) out of 49 kidneys from DD donors with DM transplanted.
20: no DN
1: thickened GBM by EM, but DN on LM
5: class IIa DN
Class IIb-IV not seen in any
No correlation between the duration of donor DM & the severity of DN.
Follow up biopsy
Done in 17/26 (post-perfusion biopsies)
Done for indication (DGF, proteinuria, &/or DSA)
Median time for follow-up biopsies: 562 days. Progression of DN: 2 recipients (both diabetic)
Re-biopsy in 12/20 with no DN on post-perfusion biopsy: 9 continued no DN, 3 de novo DN (all 3 diabetic)
In all progressive or de novo DN, DM was present post-transplant.
Discussion
The study suggests:
Recipient’s DM has the greatest impact & adverse effect on mortality & graft survival
Kidneys from donors with DM selected for transplant have no/mild DM histology changes
5-year patient survival comparable to that in 2015 SRTR/OPTN annual report (86.3%).
5-year death-censored graft survival was 88.5% though 6.9% of kidneys transplanted came from donors with DM.
Kidneys from donors with DM did as well as normal kidneys when transplanted into non-diabetic recipients.
Patient survival lower in DM recipients than in non-DM recipients; survival was poorest in DM recipients of kidneys from donors with DM.
R-DM/D-DM had the lowest patient survival of all 4 groups.
Better death-censored graft survival in R-DM/D-N versus R-N/D-N may be related to the higher patient mortality in the R-DM/D-N group versus R-N/D-N group.
Limitations
Small sample size
Limited number of biopsies.
Strengths
Though small, this is the largest reported cohort of transplanted kidneys from donors with a DM with post-perfusion biopsies, follow-up biopsies, & correlation with clinical outcome.
Conclusion
The risk associated with KTX from a deceased donor with DM appears to depend on the diabetes status of the recipient.
Diabetic renal changes in accepted kidneys from donors with DM are mild to minimal.
Given the low 5-year patient survival in diabetic recipients of kidneys from donors with DM, this type of transplantation needs to be revised.
==============================
2. What is the level of evidence provided by this article?
Level III, retrospective study
Thank you, well done
Summary:
Aim of the study:
Methods:
retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014 was performed with follow-up through May 1, 2016.
All recipients of deceased donor kidney transplants were further stratified into four groups based on recipient and donor diabetes history status.
The primary outcomes in the study were recipient survival and death-censored allograft survival.
For the second and third aims, post-perfusion biopsies and subsequent “for indication” biopsies were examined and reviewed.
Results:
Forty-nine diabetic deceased donor kidneys were transplanted into 26
normal (R-N/D-DM) and 23 diabetic recipients (R-DM/D-DM) and compared to 211
diabetic recipients of normal kidneys(R-DM/D-N) and 466 normal recipients of normal kidneys (R-N/D-N).
Patient survival at 5 years was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and 71.6% in R-DM/D-DM.
Death-censored graft survival at 5 years was 86.3% in R-N/D-N, 87.4% in R-N/D-DM,
93.5% in R-DM/D-N and 87.5% in R-DM/D-DM.
Multivariable regression analysis showed that compared to non-diabetic recipients, diabetic recipients had a 2- to 3-fold increased risk of mortality. In this cohort, there was no impact on death-censored graft survival of diabetic donor status.
Only 6 of 26 post-perfusion biopsies showed evidence of diabetic nephropathy (<IIa), and on repeat biopsies, 70% showed no evidence of progression.
Survival of recipients of diabetic donor kidneys appears dependent on the diabetic status of the recipient with the worst survival being in diabetic recipients of a diabetic donor kidney.
Conclusion:
The risk associated with transplantation of a kidney from a deceased donor with a diabetic history appears to be largely dependent on the diabetes status of the recipient. Diabetic renal changes in conventionally accepted kidneys from donors with a diabetic history in this cohort are mild to minimal.
the current emphasis on a donor diagnosis of diabetes should be revised, in such a case, fewer kidneys from donors with a diabetic history would be discarded than is currently.
Given the low 5-year patient survival in diabetic recipients of kidneys from donors with a diabetic history, the propriety of transplanting such kidneys into diabetic recipients should be questioned.
Limitation:
Strength:
It is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
Level 3 (retrospective study)
Thank you, well done
Summary of the article
“Outcomes of kidney transplantation using deceased donors with history of diabetes’’
This is a retrospective analysis of electronic medical records of recipients of deceased donor kidney transplants at Houston Methodist JC Walter Jr Transplant Center between 1/2006 and 12/2014, was performed with follow-up through May 1st 2016.
a) Recipients were further stratified into four groups based on recipient (R) and donor (D) diabetes history status (DM vs No DM history [N]).
b) The groups were R-DM/D-DM, R- N/D- DM, R- DM/D-N, and R-N/D-N. Of 706 primary renal transplants, subcategories included the following: R-DM/D-DM 23, R-N/D-DM 26, R-DM/D-N 21, and R-N/D-N 446 patients.
c) Donor characteristics such as diabetes history, race, donor age, and BMI were obtained from the United Network of Organ Sharing (UNOS) data- set.
d) The primary outcomes in the study were recipient survival and death-censored allograft survival.
e) The aims of this study:
i. to compare clinical out-comes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
ii. to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes.
iii. to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Study Analysis and Outcome
1. Diabetes status of the recipient was associated with an increase in patient mortality.
2. Compared to control (R-N/D-N), the R-DM/D-N subgroup had nearly a twofold higher patient mortality at 5 years.
3. Risk to a diabetic recipient was greater still, at 3-fold higher patient mortality at 5 years, with receipt of a kidney from a donor with diabetic history (R-DM/D-DM.
4. Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years.
5. By multivariate analysis, there was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival. However, recipient Black race, dialysis vintage, cPRAp as a continuous variable, and donor age > 50 years were associated with poor graft survival at 5 years.
6. Post-perfusion renal transplant biopsy findings: No correlation could be found between the duration of donor diabetic history and the severity of diabetic nephropathy lesions observed.
7. Only 29% (5 of 17 patients with follow-up biopsies) showed evidence of histologic progression of diabetic lesions.
8. Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
9. Patient survival in (R-N/D-N) was inferior to that in (R-N/D-DM) (89.7% and 96.2% 5-year patient survival, respectively).
a) This finding may reflect the higher proportion of females (47.5% vs 42.3%), re-transplants (8.5% vs 3.9%), and a nearly fivefold higher proportion of recipients with a cPRAp >80% (19.6% vs 3.9%) in the R-N/D-N than in the R-N/D-DM cohort.
b) Other factors that may have contributed to this discrepancy in patient survival include longer dialysis vintagehigher proportion of recipients with glomerulonephritis in the R-N/D-N group.
10.Diabetic recipients experience higher mortality due to both an increased risk of infection, sepsis, and micro- and macrovascular disease.
11.The Kidney Donor Profile Index (KDPI) includes diabetes and hypertension as risk factors predictive of poorer graft outcome.
Limitations of the study:
a) The study has mall sample size.
b) The limited number of post-perfusion and follow-up biopsies.
Strengths of the study:
a) though small, this is the largest reported cohort of transplanted kidneys from donors with a diabetic history with post-perfusion biopsies, follow-up biopsies (in 50% of these), and correlation with clinical outcome.
b) All prior analyses have had no biopsy correlation with outcomes or are extensive clinical data analyses from the OPTN/SRTR database absent biopsy data.
c) This study suggests that the current emphasis of the KDPI on a donor diagnosis of diabetes should be revised to reflect the presence of high-grade proteinuria and renal function impairment.
What is the level of evidence provided by this article?
This is a retrospective study cohort
Level of evidence 3
Thank you. Well done
Aim:
(a) to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients;
(b) to describe the histologic findings in post-perfusion biopsies in kidneys from donors with a history of diabetes;
(c) to examine histologic changes following transplantation in kidneys from donors with a diabetic history.
Study design:
Retrospective cohort study
Results:
Limitation:
Conclusion:
Level of evidence: III retrospective case-control study
Thank you
Outcomes of kidney transplantation using deceased donors with history of diabetes.
Accepting donation from diabetic donors is established in many centers and some studies shown that donor diabetes did not have a significant effect on graft and patient survival and even suggested that diabetic donor kidneys may be superior to using extended criteria donor kidney, other referred this to recipient diabetic status and some studies shown histological improvement of diabetic changes in the kidney from diabetic donor.
Aim of the study :
To detect the relationship of recipient diabetic status and donor diabetic history to clinical and histological outcomes of kidney transplantation.
Material and methods:
Retrospective cohort study and recipients are classified into 4 groups: based on recipient (R) and donor (D) diabetes history. 1-Recipient DM/Donor-DM(23 patients).
2-Recipent- N/donor- DM(26 patients).
3-Recipent- DM/Donor-N(211patients).
4-Recipent-N/Donor-N(446 patients).
Clinical data collected about DM and renal biopsy post perfusion and for indication, examined by E/M.
Result:
Regarding patient and graft survival, study shown 5-year patient and death-censored graft survival were 86.5% and 88.5%.
The diabetic recipient was associated with an increase in patient mortality compared to control (R-N/D-N).
Age greater than 65 and dialysis vintage were associated with an increase in patient mortality at 1, 3, and 5 years.
There was no statistically significant impact of donor diabetic history or recipient diabetes status on death-censored graft survival.
Diabetic recipient has 3-fold higher patient mortality at 5 year.
No correlation could be found between the duration of donor diabetic history and the severity of diabetic nephropathy lesions observed.
Follow up indicated biopsies shown progression of diabetic nephropathy in 2 recipients both of whom were diabetic and three developed de novo .
Conclusion:
Kidneys from donors with a diabetic history did as well as normal kidneys when transplanted into non-diabetic recipients.
Survival of diabetic recipient depends mainly on diabetic status control and the worst outcome from diabetic donor to diabetic recipient, most of kidney pathology showing no progression of structural changes.
Thank you
Previous studies reported either slightly poor outcome of using deceased diabetic kidney donors when compared to non-diabetic kidney donors, others reported good outcome when compared to ECD due to factors other than DM
Moreover, early study found resolution of histologic features of diabetic nephropathy when the deceased diabetic donor kidney transplanted in a non-diabetic recipient
This is a retrospective cohort study (level of evidence III) evaluating the effect of deceased donor diabetes on the recipient (diabetic or non-diabetic) outcome
The cohort is divided into 4 categories
Results:
Conclusion
Thank you, I like your conclusion
The aims: of this study were as follows: to compare clinical outcomes of kidney transplants from donors with or without a history of diabetes into diabetic or non-diabetic recipients.
Introduction:
End-stage renal disease (ESRD) patients benefit from kidney transplantation, increasing demand. In the past two decades, kidneys from diabetic donors have become a feasible possibility.
Material:
retrospective investigation of electronic medical data of kidney transplant patients at Houston Methodist JC Walter Jr Transplant Center between 2006 and 2014, with follow-up until May 1, 2016. All deceased donor kidney transplant patients were sorted by the recipient (R) and donor (D) diabetes history (DM vs No DM history [N]). R-DM/D-DM, R-N/D-DM, R-DM/D-N, R-N/D-N. Analyzed: recipient, donor, and peri-transplant variables.
Results:
49 (7.9%) of 706 kidney transplant patients had a diabetic donor. 5.5% of non-diabetic receivers got a kidney from a diabetic donor, while 9.8% of diabetic recipients did.
23 kidneys from diabetes donors were implanted in diabetic recipients and 26 in non-diabetic recipients.
-Death-censored transplant survival was unaffected by donor or recipient diabetes. Black recipient race, dialysis vintage, cPRAp as a continuous variable, and donor age>50 years was associated with poor graft survival.
-No association was discovered between donor diabetes duration and diabetic nephropathy lesions.
-Post-transplant, all progressive or de novo DN patients had diabetes. Progressive or de novo diabetic nephropathy recipients experienced greater hyperglycemic exposure and biopsies were acquired later post-transplant.
Conculsion:
The danger of transplanting a kidney from a diabetic donor depends on the recipient’s diabetes. In this group, typically accepted kidneys from diabetic donors had modest to minimal diabetic renal alterations. This research implies that the KDPI should be changed to represent high-grade proteinuria and renal function impairment.Given the dismal 5-year patient survival among diabetes receivers of kidneys from diabetic donors, the practice should be questioned.
retrospective study, level III
Thank you, Weam
Please provide a summary of this article
This is a Cohort observational study conducted to compare clinical outcomes of kidney transplants from donors with or without history of DM in to either diabetic or non-diabetic recipients, and to describe the histologic findings in post perfusion biopsy form diabetic donors, and follow up the histologic finding changes, for a mean follow up time of 50 months.
They divide the groups of patients to 4 groups: D-N/R-N,
D-DM/R-N, D-DM/R-DM, and D-DM/R-N.
Primary outcomes = Patient and graft survival.
Results:
Patient survival at 5 years by subgroup was 89.7% in
R-N/D-N, 96.2% in R-N/D-DM, 80.0% in R-DM/D-N, and 71.6% in R-DM/D-DM.(P=0.0008).
– The patient death was due to cardiovascular disease in most.
graft survival at 5 years by subgroup was 86.3% in R-N/D-N,
87.4% in R-N/D-DM, 93.5% in R-DM/D-N, and 87.5% in R-DM/D-DM.(P=0.24).
Increased patient death was higher among R-DM/D-N nearly a
twofold higher patient mortality at 5 years (P = .017) and 3-fold higher
patient mortality at 5 years, with receipt of a kidney from a donor with
diabetic history R-DM/D-DM (P = .034). age >65 and dialysis vintage
associated with increased mortality at 1,3, and 5 years.
Graft survival was worse among Black race recipient,
dialysis vintage, donor age >50 and continuous variables, but not statically
significant on impact of either donor or recipient were diabetic.
Kidney biopsy are shown in figure attached.
Conclusion:
Kidneys from donors with history of diabetes is a safe
option to non-diabetic recipients, with minimal or improving diabetic changes
ensue.
It is better not to transplant kidneys from diabetic D to
diabetic R.
The KDPI on a donor diagnosis of diabetes should be
revised to reflect the presence of high-grade proteinuria and renal function
impairment.
What is the level of evidence provided by this article?
Level of evidence III
Thank you
Summary
· Previous studies reported inferior graft outcome from diabetic cadaveric donors. however, resolution of diabetic nephropathy changes as thickened GBM and mesangial expansion after transplantation in well controlled or normglycemic recipient. so, cadaveric donors with DM were utilized in order to expand the donor pool.
· The current study aimed to evaluate the impact of DM in the donor on the graft outcome by comparing 4 groups: diabetic and none diabetic donors with both diabetics and none diabetic recipients. The 5-year patient survival was 89.7% in R-N/D-N, 96.2% in R-N/D-DM, 80.1% in R-DM/D-N, and a 71.6% in R-DM/D-DM.
· The worst survival was when both were diabetic as sustained diabetic state in the recipient accelerates the diabetic changes of preexisting diabetes from diabetic donor.
· The recipient diabetes had worse outcome than that of the donor on both patient survival and death censored graft loss. However, no association was found with DM in the donor.
· post perfusion biopsy was performed in 53% of the grafts, only 6 of 26 of diabetic donors had evidence of diabetic nephropathy in post perfusion graft biopsy with no further progression in later biopsies in 70 % of them.
· The development of diabetic nephropathy changes needs long time.
· The most important predictor here is diabetic state control in the recipient.
· Patient survival in non-diabetic recipients of kidneys from donors without a diabetic history was inferior to that of non-diabetic recipients of kidneys from donors with a diabetic history (89.7% and 96.2% 5-year patient survival, respectively). this can be explained by other contributing factors of worse graft outcome as recurrent glomerular disease.
· DM was defined if fasting blood glucose> 126 mg/dl, HbA1c > 6.5
· NODAT was diagnosed if anti diabetic drugs were needed 3 month post transplantation.
· GFR was estimated by CKD-EPI equation.
· Points of strength:
o correlation of both clinical and histological findings of diabetic donors to both patient and graft outcome.
· Points of weakness:
· Retrospective cohort.
· Small sample size (only 112)
Level of evidence: III
based on this article, kidney from diabetic donors cab be used for none diabetic recipient (after his agreement and consent, when there is no other options and he had no vascular access).
Thank you
This retrospective cohort study aimed at evaluating
1- impact of diabetes in both donor and recipient on graft function and survival.
2- descripe the histological changes in diabetic kidney graft in both post perfusion and subsequent indication biopsy . These changes were classified according to renal pathology society into stages (0-IV ) depending on LM and EM examination.
The 5 years graft survival in the present cohort was comparable to that reported in the 2015 SRTR/OPTN annual report (86%).The function of the kidney graft from diabetic donors were comparable to non diabetic donors when transplanted to non diabetic recipients but the survival of those recipients were inferior compared with recipients of kidney graft from non diabetic donors.The poor recipient survival were significantly related to black race recipients, dialysis vintage and high cPRA and older donors>50 years.
The patients survival was lower in diabetic recipients compared with non diabetics , while the lowest patients survival were in diabetic recipients receiving kidney from diabetic donors . This high mortality in diabetic recipients could be related to micro and macro vascular diabetic complications, increased risk and severity of infections and sepsis in diabetic recipients
Post perfusion biopsy were performed in 26/49 grafts and only 5 biopsies revealed gread II DN, indication biopsy (in cases of DGF , increasing proteinuria ) were performed in 38 biopsies and progression of DN were diagnosed in some recipients(29%) who were diabetic pre transplantion or developed de no vo diabetes after transplantion , as diabetic environment accelerate the development and progression of DN , however in 58 % of cases , biopsy revealed significant arteriosclerosis, tubular atrophy and interstitial fibrosis specially in presence of concomitant HPN in the donor.
Limitation of the study are small sample size and limited number of post perfusion biopsies.
Conclusions:
the outcome of kidney graft from diabetic donors depends mainly on presence of DN in the donor and recipient being diabetic rather than just history of diabetes in the donor as in KDPI, so diabetic donors with no or early DN can be used rather than being discarded.
Level of evidence: 3.
Retrospective case – control
Thank you