Transplantation of the human kidney is the treatment of choice for advanced chronic renal failure. Worldwide, tens of thousands of these procedures have been performed. When azathioprine and prednisone initially were used as immunosuppressive drugs in the 1960s, the results with properly matched familial donors were superior to those with organs from deceased donors: 75–90% compared with 50–60% graft survival rates at 1 year. During the 1970s and 1980s, the success rate at the 1-year mark for deceased-donor transplants rose progressively. Currently, deceased-donor grafts have an 89% 1-year survival and living-donor grafts have a 95% 1-year survival. Although there has been improvement in long-term survival, it has not been as impressive as the short-term survival, and currently the "average" (t1/2) life expectancy of a living-donor graft is around 20 years and that of a deceased-donor graft is close to 14 years.
Mortality rates after transplantation are highest in the first year and are age-related: 2% for ages 18–34 years, 3% for ages 35–49 years, and 6.8% for ages ≥50–60 years. These rates compare favorably with those in the chronic dialysis population even after risk adjustments for age, diabetes, and cardiovascular status. Occasionally, acute irreversible rejection may occur after many months of good function, especially if the patient neglects to take the prescribed immunosuppressive drugs. Most grafts, however, succumb at varying rates to a chronic process consisting of interstitial fibrosis, tubular atrophy, vasculopathy, and glomerulopathy, the pathogenesis of which is incompletely understood. Overall, transplantation returns most patients to an improved lifestyle and an improved life expectancy compared with patients on dialysis. There are at least 100,000 patients with functioning kidney transplants in the United States, and when one adds in the numbers of kidney transplants in centers around the world, the total activity is doubled.
In 2008 there were more than 10,500 deceased-donor kidney transplants and 6000 living-donor transplants in the United States, with the ratio of deceased to living donors being stable over the last few years. The backlog of patients with end-stage renal disease (ESRD) has been increasing every year, and it always lags behind the number of available donors. As the number of patients with end-stage kidney disease increases, the demand for kidney transplants continues to increase. In 2008, 33,051 new registrants were added to the waiting list and under 17,000 patients were transplanted. This imbalance is set to worsen over the coming years with the predicted increased rates of obesity and diabetes worldwide. In an attempt to increase utilization of deceased-donor kidneys and reduce discard rates of organs, criteria for the use of so-called expanded criteria donor (ECD) kidneys and kidneys from donors after cardiac death (DCD) have been developed (Table 282-1). ECD kidneys are usually used for older patients who are expected to fare less well on dialysis.
Table 282-1 Definition of an Expanded Criteria Donor (ECD) and a Non-Heart-Beating Donor [Donation after Cardiac Death (DCD)]...