Skip Navigation



NDT Advance Access published online on January 18, 2008
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfm912
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
23/6/2043    most recent
gfm912v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Bentas, W.
Right arrow Articles by Gossmann, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bentas, W.
Right arrow Articles by Gossmann, J.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


Renal transplantation in the elderly: surgical complications and outcome with special emphasis on the Eurotransplant Senior Programme

Wassilios Bentas1, Jon Jones1, Akay Karaoguz1, Ursula Tilp2, Michael Probst1, Ernst Scheuermann3, Ingeborg A. Hauser3, Dietger Jonas1 and Jan Gossmann3,4

1 Department of Urology and Paediatric Urology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany 2 Department of Urology and Paediatric Urology, Division of Biostatistics, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany 3 Department of Nephrology, Medical Clinic III, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany 4 KfH Kidney Centre, Frankfurt am Main, Germany

Correspondence and offprint requests to: Wassilios Bentas, Department of Urology and Paediatric Urology, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany. Tel: +49-69-6301-5065; Fax: +49-69-6301-6464; E-mail: Bentas{at}em.uni-frankfurt.de



   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 Conclusions
 References
 
Background. The purpose of this retrospective study was to evaluate the results of the Eurotransplant Senior Programme (ESP) within our centre compared to elderly recipients ≥60 years from the regular Eurotransplant Kidney Allocation System (ETKAS), specifically focusing on surgical aspects.

Methods. Data from 73 ESP patients (average donor/recipient age: 71.1/67.1) were compared with those from 51 patients (49.7/63.6) treated within the framework of the ETKAS program between the years 1999 and 2006. The mean follow-up was 39.5 months.

Results. Cold ischaemic time (ESP versus ETKAS: 10.3 versus 15.0 h), duration of renal replacement therapy (42.2 versus 76.8 months), donor glomerular filtration rate (81.7 versus 109.9 ml/min/1.73 m2) and HLA mismatches (4.1 versus 2.4) were significantly different between the two groups (all P < 0.001). Primary graft function was seen in 74% ESP versus 69% of ETKAS patients (P > 0.05). The rate of surgical complications in the ESP versus ETKAS group was 47% versus 28% (P = 0.031) and the revision rate, 33% versus 24% (P = 0.259). Three-year patient and censored graft survival was 84% versus 92% and 85% versus 88% in the ESP and ETKAS group, respectively (all P > 0.05). Ninety-five percent of all deceased patients died with a functioning graft.

Conclusions. The donor and recipient pool has been markedly expanded through ESP with similar patient and graft survival compared to elderly recipients grafted according to ETKAS criteria. However, patients and their physicians should be aware of the high surgical complication rate in elderly recipients, particularly when receiving elderly donor kidneys. This might seriously influence postoperative patient management but ultimately does not compromise the transplant outcome.

Keywords: elderly renal transplant recipient; Eurotransplant Kidney Allocation System (ETKAS); Eurotransplant Senior Programme (ESP); renal transplantation; surgical complications



   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 Conclusions
 References
 
Low survival rates and a comparatively low quality of life on dialysis make transplantation an attractive treatment alternative with good clinical results even in elderly patients [1]. In 1999, Eurotransplant (ET) initiated the ET Senior Programme (ESP), designed both to reduce the waiting time of elderly patients and to achieve a higher efficiency in the use of kidneys from elderly donors [2]. In the ESP, kidney transplant matches are made between deceased donors 65 years and above and recipients 65 years and above. Through the use of regional allocation based on waiting time and blood group only but regardless of the HLA match, a short cold ischaemic time (CIT) should be achieved resulting in good primary organ function.

In the ESP, nephrologists and surgeons are faced with the situation of having to transplant an aged organ with possibly arteriosclerotic vessels to an elderly, chronically ill and often multimorbid organ recipient with similarly altered vessels. Although initiated in 1999, there are only a handful of reports from transplant centres on first experiences with the ESP, often limited by relatively small patient groups and short periods of follow-up as well as by comparisons with historical controls [3–7]. Very few authors have reported on surgical problems [8,9]. Follow-up information, particularly on long-term complications after surgery, is completely missing. Therefore, the goal of our study was to evaluate the results of the ESP at our centre in comparison with a control group of elderly recipients from the regular ET Kidney Allocation System (ETKAS), specifically focusing on surgical aspects and the long-term follow-up.



   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 Conclusions
 References
 
Patients
From January 1999 to May 2006, 406 renal grafts from deceased donors were transplanted at our centre by a total of 12 experienced urology consultants, 2 of them operating together in each procedure. Seventy-three (18%) of these transplants followed ESP protocol. As a control group, all 51 (13%) patients were selected who were at least 60 years old at the time of the transplant and transplanted according to ETKAS criteria within the same time frame [10]. The control group was chosen in order to achieve a meaningful group size, as all but 12 patients 65 years and above have been treated at our centre in the ESP since 1999. The groups were compared retrospectively. All but two (3%) ESP patients and seven (14%) ETKAS patients were first-time transplant patients.

Data collection and assessment
Data from donors were collected according to ET donor kidney reports and ET donor information forms. Information regarding intraoperative findings was compiled on the basis of post-surgical reports. Arteriosclerosis of both the donor and recipient was reported by the surgeon as absent, mild, moderate or pronounced. Following surgery, data were compiled with the aid of patient files and hospital discharge reports. Glomerular filtration rates (GFR) were calculated with the four-variable modification of diet in renal disease (MDRD) formula [11].

A delayed onset of kidney function was defined by a patient's need for dialysis within the first postoperative week. Cases of acute transplant rejection were only included in statistical analysis if they were bioptically confirmed and treated. From a total of 113 patients who could be discharged from the hospital with a functioning transplant, 102 (90.3%) received continuing care in our kidney centre, while the other 11 (9.7%) were treated at other institutions. Follow-up data and demographical data were ascertained in all patients with the help of records and results from outpatient files. Mean follow-up was 39.5 ± 23.6 months.

Surgical technique
During donor organ back table preparation, secure ligation of dissected lymphatics was assured through the use of clamps and ligatures. Renal transplants were performed according to the standardized techniques including a Gibson incision, extraperitoneal preparation and end-to-side anastomosis of the donor vessels to the iliac vessels of the recipient using two halves of running 5 x 0 or 6 x 0 non-absorbable polypropylene sutures. Intravesical ureteral implantation was performed in an antirefluxive manner according to the Politano–Leadbetter technique until 2003, after which the Lich–Gregoir technique was followed according to the European Association of Urology (EAU) recommendations. A double-J-catheter was placed for a 6-week period along with a transurethral catheter for 1 week in all patients. Following placement of two closed suction drains, fascia closure was carried out using an absorbable No. 1 polyglactin 910 running suture until August 2004 and interrupted sutures in the subsequent years. A colour Doppler flow study was performed intraoperatively in critical cases and immediately following surgery on the other patients, and repeated every day for the length of hospital stay. Sonographic abnormalities were clarified using CT scanning, MRI, arteriography, renal scanning and retrograde or antegrade ureteropyelography. Suction drains were removed when the secretion was <50 ml in 24 h.

Surgical complications
Any type of event, irrespective of symptoms, that was reported either during the initial hospital stay or during out-patient follow-up and was directly related to surgery, even if minimal, was considered a surgical complication. Vascular complications included renal artery stenosis, including haemodynamically relevant kinking of the artery and vascular thrombosis. Complications involving healing of the surgical wound were reported and analysed. Any spontaneous separation of skin or fascia that was significant enough to require either surgical intervention or application of dressing was defined as wound dehiscence. Fascial dehiscence occurring 3 months after transplantation was defined as incisional hernia. All accumulated fluid was categorized as either epi- or subfascial and as haematomas, seromas or lymphoceles depending on the composition. If cell counts from direct aspirates showed lymphatic content and maximal diameter was >3.0 cm in all projections, the accumulated fluid was designated as a lymphocele. Urine leaks were defined by the presence of a high concentration of creatinine relative to serum, in perinephric aspirate or drainage fluid. Ureteric stricture was defined as intrinsic narrowing of the ureter with dilation of the renal pelvis and calices. The presence of an infected surgical wound was determined by positive culture results. Voiding dysfunction of the bladder was diagnosed via uroflow, residual urine, urodynamic evaluation and urethrocystoscopy. The necessity for a transurethral resection of prostate following transplantation was noted but not considered to be a surgical complication.

Immunosuppression
Induction therapy in the form of IL-2 receptor blockade with basiliximab was given to recipients with high immunologic risk and/or recipients with delayed or slow graft function. This was applied to 80% of patients in the ESP and 29% of patients in the ETKAS group (P < 0.001). Ninety-six percent of the patients in the ESP and the ETKAS group were treated according to our regular immunosuppressive protocol with a triple combination consisting of cyclosporine A (ESP versus ETKAS: 74% versus 77%) or tacrolimus (33% versus 35%) together with azathioprine (33% versus 41%) or mycophenolate mofetil (MMF) (80% versus 61%) and corticosteroids (99% versus 98%). There was no statistically significant difference in the application of these drugs between the two groups (all P > 0.05). Only three (4%) patients in the ESP and one (2%) patient in the ETKAS received an immunosuppressive regimen free of calcineurin inhibitors.

Therapy of acute rejections consisted of pulsed methylprednisolone boluses and changes in the immunosuppressive regimen if necessary. Plasmapheresis due to humoral rejection was performed in three (4%) ESP and two (4%) ETKAS patients.

Statistics
The program SPSS version 13.0 was used for statistical analysis (SPSS Inc., Chicago, IL, USA). Metric variables were presented by their mean value ± standard deviation. Nominal variables were analysed by means of the {chi}2 test, metric variables depending on their distribution by Student's t-test or the Mann–Whitney U-test. Organ survival was calculated according to the Kaplan–Meier method. The log-rank test was used to analyse the survival curves for significant differences. A P-value of ≤0.05 was considered statistically significant.



   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 Conclusions
 References
 
Donor and recipient data
The 124 grafts were recovered from a total of 100 (50 ESP, 50 ETKAS) heartbeating donors. Relevant donor data are shown in Table 1. According to the study definition, ESP donors were significantly older with a higher percentage of hypertension and diabetes mellitus, ultimately resulting in a significantly reduced GFR compared to the significantly younger ETKAS donors.


View this table:
[in this window]
[in a new window]

  		Table 1 Donor data

 
Demographic data from all study patients are presented in Table 2. While in 1999, just 11.1% of all in-house transplants from deceased donors were carried out according to the ESP protocol, this percentage increased to 29% by 2006. Analysis of 157 renal transplants from deceased donors from 1996 to 1998, i.e. prior to the introduction of ESP at our centre, showed, that only 13 (8%) of the donor kidneys and only 8 (5%) of the recipients were 65 years and above. In contrast, in 406 renal transplants from deceased donors performed after introduction of the ESP, 85 (21%) of the donor kidneys and 86 (21%) of the recipients were 65 years and above (P < 0.001, Figure 1).


View this table:
[in this window]
[in a new window]

  		Table 2 Recipient demographic data

 

Figure 1
View larger version (27K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Fig. 1 Proportion of transplant recipients and donors ≥65 years old.

 
Intraoperative results
The surgeons reported a significantly higher frequency of arteriosclerosis of both donors (P = 0.004) and recipients (P = 0.025) in the ESP group (Table 3), leading to a prolonged mean anastomosis time of 50.8 ± 34.7 min in the ESP group compared to 39.5 ± 11.2 min in the ETKAS group (P = 0.027). A detachment of the intima of either donor or recipient arteries occurred during arterial anastomosis in five ESP patients, causing blockage of the arterial perfusion. In all cases, the arterial anastomosis could be restored by shortening the donor artery and/or by fixation of the intima and re-anastomosis. All arterial anastomosis procedures in the ETKAS group were performed without complications. Pathological changes in the renal vein of the donor or the recipient's veins were not documented in either group and no intraoperative complications arose during venous anastomosis. Ureteral implantation was performed on 66 patients (53%) according to the Politano–Leadbetter technique and on 58 patients (47%) according to the Lich–Gregoir technique without complications. The mean intraoperative blood loss was 391 ± 336 ml in the ESP group and 307 ± 239 ml in the ETKAS group (P = 0.180).


View this table:
[in this window]
[in a new window]

  		Table 3 Intraoperative arterial vascular calcifications

 
Postoperative surgical complications
Postoperative surgical complications were reported in 34 (47%) of ESP cases and 14 (28%) of ETKAS cases (P = 0.031, Table 4). In the ESP group, 21 (29%) patients experienced one, 12 (16%) patients two and one (1%) patient three different complications. In the ETKAS group seven (14%) patients faced one, six (12%) patients two and one (2%) patient three different complications. Surgical revision was necessary in 24 (33%) ESP patients due to complications arising anywhere from immediately postoperatively to 685 days after surgery and in 12 (24%) ETKAS patients within the immediate postoperative period to 844 days after surgery (P = 0.259). The rate of surgical complications and revisions within 90 days following initial transplantation in the ESP group was 38 and 27% compared to 22 (P = 0.048) and 18% (P = 0.560), respectively, in the ETKAS group.


View this table:
[in this window]
[in a new window]

  		Table 4 Postoperative surgical complications

 
As risk factors for ESP and ETKAS, the BMI of the recipient correlated significantly with surgical complications (P = 0.050). Donor age showed a trend towards statistical significance (P = 0.060). No correlation with the age of the recipient was discovered (P = 0.225).

In five ESP cases, immediate surgical revision of the arterial anastomosis was required due to poor organ perfusion. In one case, removal of the transplant kidney became necessary due to advanced arterial thrombosis. In two ESP cases, renal vein thrombosis of unclear aetiology led to the removal of the transplant kidney on postoperative days 7 and 8, respectively. Statistically significant correlations of vascular complications with donor age, recipient age and BMI did not exist (all P > 0.05). Two of the four patients requiring surgical revision due to postoperative haemorrhage were treated preoperatively with a coagulation-inhibiting substance (one received acetylsalicylic acid and one acetylsalicylic acid and clopidogrel); one patient received a largely decapsulated kidney due to inadequate organ retrieval.

The most common cause of surgical revision in both groups was fascial dehiscence, independent of the fascial closure technique. When considering both groups, a statistically significant correlation was found with the primary function of the renal transplant and the recipient's BMI. Just 7 (8%) of 89 patients with the primary function of the renal transplant suffered from fascial dehiscence compared to 9 (26%) of the 35 patients showing a delayed graft function (P = 0.008). The mean BMI of the patients with fascial dehiscence was 28.0 ± 4.9 compared to the BMI of 25.7 ± 3.5 of the unaffected patients (P = 0.014).

On the other hand, the formation of lymphoceles was correlated with donor age. The mean donor age in patients with a lymphocele was 69.3 ± 8.6 years and 60.9 ± 14.1 years in patients without a lymphocele (P = 0.012). Of the 20 total patients with lymphoceles, 8 of the donor organs were over 60 years of age and 12 over 70 years.

Immunosuppressive drugs were without statistically significant influence on lymphocele formation (all P > 0.05), although there was a trend towards an increased lympocele formation in patients receiving MMF (P = 0.052).

Ureteral complications were generally rare and in most cases, an obstruction due to ureteral stricture could be treated conservatively with dilatation and temporary application of a pigtail catheter.

In 12 (24%) of 51 male patients from the ESP group and 7 (26%) of 27 male patients from the ETKAS group, a diagnosis of bladder outlet obstruction due to a benign prostatic hyperplasia was made and a transurethral resection of prostate performed after a mean of 30.9 ± 9.3 days following transplantation. All patients complained of recurrent urinary retention despite conservative therapeutic attempts.

Short-term outcome
Table 5 shows initial results from both the ESP and ETKAS groups. In five (7%) of the ESP patients and two (4%) of the ETKAS patients, function of the transplanted organ was never achieved and the kidney was removed in all cases. Mean hospital stay for patients with and without surgical complications was 37.1 ± 21.7 days and 29.4 ± 15.9 days (P = 0.027), respectively.


View this table:
[in this window]
[in a new window]

  		Table 5 Short-term outcome (initial hospital stay)

 
Long-term outcome
In total, 24 (33%) ESP patients and 16 (31%) ETKAS patients were treated for acute rejection during the postoperative hospital stay or follow-up. The transplant was biopsied in 16 (22%) and 11 (22%) of all ESP and ETKAS patients (P = 0.726), confirming rejection in 11 (15%) of the 73 ESP patients and 8 (16%) of the 51 ETKAS patients respectively (P = 0.93). Long-term outcomes concerning graft function, graft survival and patient survival are presented in Table 6. Patient survival and graft survival censored for death with functioning graft were not significantly different between the two groups after 1, 3 and 5 years. Nevertheless, GFR was significantly better in the ETKAS group in the 1- and 3-year follow-ups. Kaplan–Meier analyses of cumulated patient survival and graft survival censored for death with functioning graft are shown in Figures 2 and 3. Log-rank tests showed no significant differences between the two groups (all P > 0.05).


View this table:
[in this window]
[in a new window]

  		Table 6 Long-term outcome

 

Figure 2
View larger version (12K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Fig. 2 Kaplan–Meier analysis of cumulated patient survival.

 

Figure 3
View larger version (12K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Fig. 3 Kaplan–Meier analysis of cumulated graft survival censored for death with functioning graft.

 
Thirteen (18%) ESP patients and eight (16%) ETKAS patients died within a mean of 20.6 ± 20.5 months versus 32.5 ± 27.5 months following transplantation (P = 0.273). Causes of death were recorded as sepsis in nine ESP cases, malignant neoplasms in two cases and one case each of cardiac infarction and cerebral insult. In the ETKAS group, three patients died of sepsis, one of cardiac infarction, one of malignant neoplasm and three of unknown causes (P = 0.163). All of the deceased patients from the ESP group and seven of the eight ETKAS patients showed good renal function up to the time of death.



   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
Conclusions
 References
 
It has been shown previously that renal transplantation in the ESP can be carried out without fundamental disadvantages for the short to mid-term survival of patient and renal graft [6,7,12]. The principal goals of the ESP allocation procedure—shortest possible cold ischaemia times for aged donor kidneys and a decrease in the length of renal replacement therapy—were clearly met in our study. This is important in that older organs are more susceptible to damage from cold ischaemia and even small differences of just a few hours can have a verifiable and significant impact on organ function [4,13]. Furthermore, a longer duration of renal replacement therapy more likely results in worse organ function following transplantation [14]. Ultimately, the mortality rate on the waiting list, especially in elderly patients, is extremely high [15].

Surgical findings
Detailed reports on surgical aspects in the ESP are a rare exception despite the fact that the ESP, with its older aged donors and recipients, is, by nature, predisposed to surgical complications. Our study did indeed find a high rate of surgical complications (47%) that has not been reported in the ESP to this extent, which is significantly higher compared to the group of younger ETKAS donor recipients (28%). Within the ESP, Giessing et al. reported wound-healing disorder as the only surgical complication in 1 of 26 patients [8]. Bodingbauer et al. reported surgical complications in 21 (41%) of 56 cases, with 16% of patients requiring surgical follow-up [9]. Voiculescu et al. reported surgical, cardiovascular, gastrointestinal and neuropsychological complications in 80% of 25 patients, albeit without expanding these reports [5]. Unlike the aforementioned studies, our findings not only took into account the initial postoperative stay but also all the surgical complications during follow-up. This covered a longer time period than any other study in ESP patients. Outside the ESP, Battaglia et al. reported a rate of surgical complications of 34.5% in transplantations involving a suboptimal donor [16]. An additional current publication on complications of renal transplantation in low-risk groups involving new immunosuppressive drug regimens reported surgical complications in up to 34% of patients within the first 3 months following transplant surgery. The rate of surgical revisions was 14.5%, with 4.3% of graft loss due to surgical complications [17]. Wahlberg et al. reported that recipients of older organs were more susceptible to surgical complications (35%) than recipients of younger organs (12%) [18].

In spite of this relatively high rate of complications on the whole, the percentage of complications within each individual aspect of renal transplantation was still within the margins described in the literature. Giessing et al. found significantly more vascular arteriosclerosis in their ESP group donors, coupled with intraoperative complications in 3 of 26 cases [8]. Outside the ESP, Jordan et al. reported vascular complications in a single-surgeon experience for 9% of all transplant patients [19]. Hernandez et al. identified vascular arteriosclerosis of both donor and recipient as the most important factor affecting the frequency of vascular complications [17].

Lymphocele formation after kidney transplantation has been attributed to open lymphatics in the recipient created by extensive dissection around the iliac blood vessels (mainly around the external iliac artery) or disrupted lymphatics in the donor kidney [20]. In a recent study by Bodingbauer et al., lymphoceles were found in 14.2% of ESP cases with 9% requiring surgical intervention [9]. Other authors outside of ESP reported lymphocele formation in up to 43% of patients with an intervention rate of up to 15.7% and a higher risk in elderly recipients [17,20,21].

A significantly elevated rate of lymphoceles when transplanting elderly organs, as seen in our study, with a higher incidence in the ESP group, has not been described up till now. Possible reasons may be a higher fragility of renal lymphatic vessels and more abundant perihilar fatty tissue of older donor kidneys ultimately leading to a more difficult surgical dissection. Nevertheless, our data highlight the influence of the donor graft in the pathogenesis of lymphocele formation after renal transplantation. A meticulous surgical approach to the donor organ and the consequent ligation of lymphatic vessels appears to be as important as the dissection of the recipient vessels.

The unequivocal effect of maintenance immunosuppressive drugs on lymphocele formation and lymphocele treatment was demonstrated in several larger studies.

Goel et al. presented in their landmark study the lowest incidence of lymphoceles for patients treated with cyclosporine A, azathioprine and prednisone, while a regimen with cyclosporine A, MMF and prednisone resulted in significantly more frequent lymphocele formation. However, the highest incidence in lymphoceles was seen in the group on sirolimus, MMF and prednisone treatment. The requirement for a surgical intervention increased accordingly [20].

Flechner et al. found a dose-dependent influence of MMF on lymphocele formation with significantly more lymphoceles in the higher dosage group [21].

In another study, the use of sirolimus, tacrolimus and prednisone was associated with a greater incidence of lymphoceles as compared to contemporary patients treated with MMF, tacrolimus and prednisone. Furthermore, sirolimus had an independent effect on wound complications in general, and on lymphocele formation in particular [22].

Langer et al. showed that addition of sirolimus to a cyclosporine A, prednisone and azathioprine regimen resulted in both a higher incidence and a requirement for more aggressive treatment of perinephric fluid collections and lymphoceles [23]. There was no statistically significant association of lymphocele formation with the use of different immunosuppressive agents in our study, even though more lymphoceles were seen in patients on MMF. Sirolimus was used in only three patients.

Complications of ureteral implantation were relatively rare in our study compared to the other literature [24], as were the rates of wound infections and superficial wound dehiscence.

Fascial dehiscence represented the largest group of surgical complications for both groups in our study. Outside the ESP, fascial dehiscence is reported in the current literature as occurring in 1–11% of all patients [25,26]. The correlations with recipient BMI and organ function found here can also be found in previously published literature [25]. The aggrandized occurrence of fascial dehiscence independent of wound closure technique in our study was due, on one hand, to the inclusion of incisional hernia in follow-up, and on the other hand, most probably, to the more advanced age and therefore weaker fascia and muscle tone of our recipient group.

The high rate of recurrent urinary retention that led to a resection of the prostate must also be attributed to the advanced age of our recipient group. Koziolek et al. found a benign prostatic hyperplasia in 8 of 11 newly renal transplanted patients 55 years and above. All affected patients complained of recurrent urinary retention and required transurethral prostate resection. The bladder's diminished ability to adjust to a bladder outlet obstruction was discussed as being causative [27].

Short-term outcome
The rate of primary organ function was higher in the ESP group compared to the ETKAS patients and exceeded findings from single-centre studies with lower patient counts as well as comprehensive studies from ET [2,3,5,12]. This is seen quite positively as the primary organ function serves as an established predictor of favourable conditions for graft survival [28]. Furthermore, regarding ESP, the rate of permanently non-functioning kidneys, the frequency of acute renal allograft rejection as well as in-hospital deaths were all in the lower range of the published data and without significant difference to the ETKAS group [12]. Organ function measured at the time of discharge showed a significantly higher GFR in the ETKAS group while serum creatinine did not prove significantly better. Prolonged hospital stay and therefore higher costs for the ESP recipient as described by Schlieper et al. could not be confirmed by our study [3].

Long-term outcome
Our study showed no statistically significant differences in patient and transplant survival between ESP and ETKAS patients. Organ function in the ETKAS group did, however, prove to be better in the first and third year. Our findings thus confirm those of other authors reporting similar results with shorter follow-up periods [6–9,12]. The inferior immunological matching of the ESP patients did not lead to a higher rate of rejection or immunological graft loss. In the long range, similar to previous reports, a relatively high mortality rate could be found with the vast majority of cases being attributed to septic complications.



   Conclusions
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusions
References
 
Since the implementation of the ESP at our centre in 1999, we saw a significant expansion of the donor and recipient pool with a considerable proportion of renal transplants performed according to ESP criteria.

Despite an advanced age in both donor as well as recipient along with inferior HLA matching and significantly reduced donor kidney function in the ESP group, our study shows no relevant differences, neither in short nor in long-term results when compared to the younger ETKAS group.

While we see a statistically significant difference in surgical complications in the ESP group as compared to the ETKAS group, our results do not allow conclusions on the impact of the allocation system (ESP versus ETKAS) in general, as the ETKAS recipient group was selected as ≥60 years. Nevertheless, our report is demonstrates a relevant impact of donor age on postoperative surgical problems in an elderly recipient population.

Although a high rate of surgical complications, particularly in the ESP group, occurred in our study, these complications were good to handle and did not compromise patient and graft survival in most cases. On the other hand, surgical complications do have a major impact on rehabilitation, hospital readmissions and re-operations, as well as on overall transplant cost, and can thereby significantly influence patients’ and doctors’ acceptance of the procedure. Thus, a careful evaluation of older transplant candidates before they are accepted onto the waiting list is imperative, especially in terms of vascular status and comorbidity. Furthermore, in the first months postoperatively, careful monitoring with respect to surgical complications may prevent major disadvantages for both, the recipient and the graft.

Finally, potential recipients need thorough counselling in terms of surgical complications prior to making their decision of being transplanted, always keeping in mind that patient survival for patients older than 60 years remains higher after transplantation than during dialysis [29].

Conflict of interest statement. All authors declare that there is no conflict of interest. The results presented in this paper have not been published previously in whole or part.



   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusions
 References
 

  1. Roodnat JI, Zietse R, Mulder PG, et al. The vanishing importance of age in renal transplantation. Transplantation (1999) 67:576–580.[CrossRef][Web of Science][Medline]
  2. Smits JMA, van Houwelingen HC, De Meester J, et al. Analysis of the renal transplant waiting list. Application of a parametric competing risk method. Transplantation (1998) 66:1146–1153.[CrossRef][Web of Science][Medline]
  3. Schlieper G, Ivens K, Voiculescu A, et al. Eurotransplant Senior Program ‘old for old’: results from 10 patients. Clin Transplant (2001) 15:100–105.[CrossRef][Web of Science][Medline]
  4. Kruger B, Zulke C, Fischereder M, et al. Early experience with the ET Senior Program "Old For Old"; better to be number one? Transpl Int (2002) 15:541–545.[Web of Science][Medline]
  5. Voiculescu A, Schlieper G, Hetzel GR, et al. Kidney transplantation in the elderly: age-matching as compared to HLA-matching: a single center experience. Transplantation (2002) 73:1356–1359.[CrossRef][Web of Science][Medline]
  6. Fabrizii V, Kovarik J, Bodingbauer M, et al. Long-term patient and graft survival in the Eurotransplant Senior Program: a single-center experience. Transplantation (2005) 80:582–589.[CrossRef][Web of Science][Medline]
  7. Fritsche L, Horstrup J, Budde K, et al. Old-for-old kidney allocation allows successful expansion of the donor and recipient pool. Am J Transplant (2003) 3:1434–1439.[CrossRef][Web of Science][Medline]
  8. Giessing M, Budde K, Fritsche L, et al. "Old-for-old" cadaveric renal transplantation: surgical findings, perioperative complications and outcome. Eur Urol (2003) 44:701–708.[CrossRef][Web of Science][Medline]
  9. Bodingbauer M, Pakrah B, Steininger R, et al. The advantage of allocating kidneys from old cadaveric donors to old recipients: a single-center experience. Clin Transplant (2006) 20:471–475.[CrossRef][Web of Science][Medline]
  10. De Meester J, Persijn GG, Wujciak T, et al. (Eurotransplant International Foundation). The new Eurotransplant Kidney Allocation System: report one year after implementation. Transplantation (1998) 66:1154–1159.[CrossRef][Web of Science][Medline]
  11. Poggio ED, Wang X, Weinstein DM, et al. Assessing glomerular filtration rate by estimation equations in kidney transplant recipients. Am J Transplant (2006) 6:100–108.[CrossRef][Web of Science][Medline]
  12. Cohen B, Smits JM, Haase B, et al. Expanding the donor pool to increase renal transplantation. Nephrol Dial Transplant (2005) 20:34–41.[Abstract/Free Full Text]
  13. Lindeman RD. Overview: renal physiology and pathophysiology of aging. Am J Kidney Dis (1990) 16:275–282.[Web of Science][Medline]
  14. Meier-Kriesche HU, Kaplan B. Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis. Transplantation (2002) 74:1377–1381.[CrossRef][Web of Science][Medline]
  15. Ojo AO, Hanson JA, Meier-Kriesche H, et al. Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates. J Am Soc Nephrol (2001) 12:589–597.[Abstract/Free Full Text]
  16. Battaglia M, Ditonno P, Selvaggio O, et al. Medical and surgical complications after kidney transplantation from "suboptimal donors": one centre's experience. Transplant Proc (2004) 36:493–494.[CrossRef][Web of Science][Medline]
  17. Hernandez D, Rufino M, Armas S, et al. Retrospective analysis of surgical complications following cadaveric kidney transplantation in the modern transplant era. Nephrol Dial Transplant (2006) 21:2908–2915.[Abstract/Free Full Text]
  18. Wahlberg J, Tufveson G, Larsson A, et al. Influence of the age of cadaveric kidney donors on transplantation outcome and rate of surgical complications. Scand J Urol Nephrol Suppl (1990) 131:39–42.[Medline]
  19. Jordan ML, Cook GT, Cardella CJ. Ten years of experience with vascular complications in renal transplantation. J Urol (1982) 128:689–692.[Web of Science][Medline]
  20. Goel M, Flechner SM, Zhou L, et al. The influence of various maintenance immunosuppressive drugs on lymphocele formation and treatment after kidney transplantation. J Urol (2004) 171:1788–1789.[CrossRef][Web of Science][Medline]
  21. Flechner SM, Feng J, Mastroianni B, et al. The effect of 2-gram versus 1-gram concentration controlled mycophenolate mofetil on renal transplant outcomes using sirolimus-based calcineurin inhibitor drug-free immunosuppression. Transplantation (2005) 79:926–934.[CrossRef][Web of Science][Medline]
  22. Valente JF, Hricik D, Weigel K, et al. Comparison of sirolimus versus mycophenolate mofetil on surgical complications and wound healing in adult kidney transplantation. Am J Transplant (2003) 3:1128–1134.[CrossRef][Web of Science][Medline]
  23. Langer RM, Kahan BD. Incidence, therapy, and consequences of lymphocele after sirolimus-cyclosporine-prednisone immunosuppression in renal transplant recipients. Transplantation (2002) 74:804–808.[CrossRef][Web of Science][Medline]
  24. Streeter EH, Little DM, Cranston DW, et al. The urological complications of renal transplantation: a series of 1535 patients. BJU Int (2002) 90:627–634.[CrossRef][Web of Science][Medline]
  25. Flechner SM, Zhou L, Derweesh I, et al. The impact of sirolimus, mycophenolate mofetil, cyclosporine, azathioprine, and steroids on wound healing in 513 kidney-transplant recipients. Transplantation (2003) 76:1729–1734.[CrossRef][Web of Science][Medline]
  26. Dean PG, Lund WJ, Larson TS, et al. Wound-healing complications after kidney transplantation: a prospective, randomized comparison of sirolimus and tacrolimus. Transplantation (2004) 77:1555–1561.[CrossRef][Web of Science][Medline]
  27. Koziolek MJ, Wolfram M, Muller GA, et al. Benign prostatic hyperplasia (BPH) requiring transurethral resection in freshly transplanted renal allograft recipients. Clin Nephrol (2004) 62:8–13.[Web of Science][Medline]
  28. Hetzel GR, Klein B, Brause M, et al. Risk factors for delayed graft function after renal transplantation and their significance for long-term clinical outcome. Transpl Int (2002) 15:10–16.[CrossRef][Web of Science][Medline]
  29. Oniscu GC, Brown H, Forsythe JL. Impact of cadaveric renal transplantation on survival in patients listed for transplantation. J Am Soc Nephrol (2005) 16:1859–1865.[Abstract/Free Full Text]
Received for publication: 26. 7.07
Accepted in revised form: 3.12.07


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
23/6/2043    most recent
gfm912v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Bentas, W.
Right arrow Articles by Gossmann, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bentas, W.
Right arrow Articles by Gossmann, J.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?