FORECASTING ONE-YEAR RENAL ALLOGRAFT FUNCTION AND
SURVIVAL Yuriy Yushkov1, Nikolina Icitovic1, Ruslan Fedkiv1, and
Michael J. Goldstein1,2 (1)New York Organ Donor Network, New York, NY,
(2) Mount Sinai Medical Center, New York, NY.
ISODP 2011 Buenos Aires, Argentina
Material and Method• Aim: To identify donor and renal allograft parameters that can be utilized in
predicting renal transplant one-year graft function and survival• Method: we performed retrospective analysis of renal allograft outcomes
of1176 deceased donor kidneys. All kidneys were transplanted in the NYODN Donor Service Area.
• Allografts were evaluated using machine measured renal resistance (MMRR) and optimized needle renal biopsy technique.
• Allografts were divided into three groups by MMRR (<0.2, 0.2-0.3, >0.3).• Donor age, gender, race, type (SCD/ECD/DCD), eGFR (MDRD), renal biopsy
(glomerulosclerosis (GS), tubular interstitial scarring (TIS), vascular fibrous narrowing (VN), as well as MMRR were correlated with one-year graft function and survival.
• Kaplan-Meier curves, Log-rank tests were used to investigate the relationship between MMRR at 1.5, 3 and 5 hours (<0.2, 0.2-0.3, >0.3) and one-year graft function and survival.
• For 954 allografts multifactorial Cox regression analysis was used to reveal the relationship among donor characteristics, biopsy parameters and MMRR at 1.5, 3 and 5 hours (<0.2, 0.2-0.3, >0.3).
DONOR CHARACTERISTICS
91
451637
Donor Type
DCD
ECD
SCD
Graft Status up to 1 year Freq. %
Functioning 1086 92.35%
Failed 90 7.65%
Total 1176 100
Donor Race Frequency PercentAmer Ind/Alaska Native 3 0.26Asian 42 3.57Black 234 19.90Hispanic 231 19.64Multiracial 12 1.02White 654 55.61
Correlation amongone year graft survival, age,
gender and race
White
Non-White
Log-rank test for equality of survivor functions P<0.00
0.8
00
.85
0.9
00
.95
1.0
0
0 90 180 270 360analysis time
K-M 1-Year Survival Estimate for White/Non-White
35 yrs
50 yrs
60 yrs
75 yrs
Cox PH Regression P=0.01.8.8
5.9
.95
1S
urv
iva
l
0 90 180 270 360analysis time
1-Year Survival Estimate for Donor Age
Male
Female
Log-rank test for equality of surival functions P=0.2867
0.80
0.85
0.90
0.95
1.00
0 90 180 270 360analysis time
K-M 1-Year Survival Estimate for Gender
The absence of correlation between donors’ e-GFR
(MDRD) and MMRR
<30
30-60>60
Log-rank test for equality of survivor functions P=0.77
0.8
00
.85
0.9
00
.95
1.0
0
0 90 180 270 360analysis time
K-M 1-Year Survival Estimate for GFR
e-GFR p= 0.372
Resistance @3 hrs <30 30-60 >60 Total<0.2 70 150 245 465 15.05 32.26 52.69 100 44.87 46.44 52.46 49.15
0.2-0.3 62 126 164 352 17.61 35.8 46.59 100 39.74 39.01 35.12 37.21
>0.3 24 47 58 129 18.6 36.43 44.96 100 15.38 14.55 12.42 13.64
Correlation between MMRR at 3 hours and one-year renal allograft survival
Correlation between MMRR at 5 hours and one-year renal allograft survival
Correlation between MMRR and one year graft eGFR (MDRD)
Box Plot comparing MMRR at 3 hours and 1 year graft functionOverall p-value < 0.0001
0 < resistance <= 0.2 0.2 < resistance <= 0.3 resistance > 0.3
0
25
50
75
100
125
Rec
ipie
nt e
GF
R a
t 1
yea
r
Resistance at 3 hours
Correlation between MMRR and three year graft
eGFR (MDRD)
Recipient eGFR at 3 year
1: < 0.2 2: 0.2-0.3 3: > 0.3
0
25
50
75
100
125
150
Rec
ipie
nt e
GF
R a
t 3
year
Resistance at 3 hours
P<0.0001
.1.2
.3.4
.5P
redi
cte
d P
rob
abili
ty
<=10% 10-25% 26-50%Scarring
<0.2 0.2-0.3 >0.3Resistance at 3 hrs
Predicted Probabilities for Resistance at 3 hrs vs. Scarring(%)
P=0.002
P=0.160.1
.2.3
.4.5
Pre
dict
ed P
roba
bilit
y
<=10% 10-25% 26-50%Vasc. Narr.
<0.2 0.2-0.3 >0.3Resistance at 3 hrs
Predicted Probabilities for Resistance at 3 hrs vs. Vasc. Narrowing(%)
Correlation amongpredicted probabilities of higher MMRR and GS, TIS and Vascular Narrowing
.1.2
.3.4
.5P
redi
cte
d P
rob
abili
ty
0 10 20 30 40 50 60 70 80 90 100Glomerulosclerosis (%)
<0.2 0.2-0.3 >0.3Resistance at 3 hrs
Predicted Probabilities for Resistance at 3 hrs vs. Glomerulosclerosis(%)
P=0.035
P=0.087P=0.015
High MMRR for TIS Odds Ratio:TIS 11-25%: 1.23 TIS 26-50%:4.06
High MMRR for VN Odds Ratio:IVN 11-25%: 1.25 IVN 26-50%:1.67
High MMRR for GSOdds Ratio 1.02
Conclusion
1. MMRR together with renal allograft biopsy should be utilized to evaluate the quality of a donated kidney.
2. MMRR can be used to predict the probability of a one-year, two and three year of renal graft function and graft failure.
3. Renal pathology parameters such as GS and TIS showed a linear relationship with MMRR.
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KIDNEY ASSESSMENT TOOLS
• Donor clinical assessment and lab data• Allograft Renal Biopsy performed using Optimized
Needle Biopsy Technique (ONBT) (1,2) • Biopsy frozen section evaluation performed by a single
Transplant Pathology Lab 24h/7days a week1. Total number of glomeruli/number of obsolete glomeruli2. Tubular interstitial scarring (%)3. Intimal fibrous narrowing of arteries (%)4. Presence of ATN, inflammation
• Machine preservation
1. Renal resistance/flow value (at 1,5 h, 3h, 5h)1. An Approach to Needle Biopsy Technique to Improve Glomerulus Yield. Y. Yushkov, F.W. Selck, and the Kidney–Pancreas Committee of the New York Organ Donor Network, Transplantation Proceedings, 40, 1051–1053 (2008)
2. Optimized Technique in Needle Biopsy Shown to Be of Greater Sensitivity and Accuracy Compared to the Wedge Biopsy. Y. Yushkov, S. Dikman, J. Alvarez-Casas et al . Transplantation Proceedings, 42, 2493-2497 (2010)
An Approach to Needle Biopsy Technique to Improve Glomerulus Yield. Y. Yushkov, F.W. Selck, and the Kidney–Pancreas Committee of the New York Organ Donor Network, Transplantation Proceedings, 40, 1051–1053 (2008)
Mann-Whitney test: ONBT results reported significantly more tubular interstitial scarring, intimal fibrous narrowing, (p<0.001, p<0.001).
BIOPSY TECHNIQUE
Correlation between MMRR and allograft survival
RES. 5h TOTAL FAILED Censored Censored%
<0.2 528 42 486 92.05
0.2-0.3 384 41 343 89.66
>0.3 115 19 96 83.48
TOTAL 1027 102 925 90.07
RES. 3h TOTAL FAILED Censored Censored%
<0.2 522 42 480 91.95
0.2-0.3 406 42 364 89.66
>0.3 148 23 125 84.46
TOTAL 1076 107 969 90.06