Speciality
Spotlight

   




   

Surgery


   

 





Transplant

  

  • Ashok Jain, MD, Jorge Reyes, MD, Randeep Kashyap, MD, S. Forrest Donson, MD, Anthony J. demetris, MD, Kris Ruppert, PhD, Kareem Abu-Almagd, MD, Wallis Marsh, MD, Juan Madariaga, MD, George Mazariegos, MD, David Geller, MD, C. Andrew Bonham, MD Timothy Gayowski, MD, Thomas Cacciarelli, MD, Paulo Fontes, MD, Thomas E. Starzl, MD, PhD, and John J. Fung, MD, PhD [ From the Thomas E. Starzl Transplantation Institute and the Departments of Surgery and Pathology, the School of pharmaceutical Sciences, and the Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania]

    Long –Term Survival After Liver Transplantation 4,000 Consecutive Patients at a Single Center

    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 490-500

        


    Although many reports, including registry data have delineated short-term factors that influence survival, few reports have examined factors that affect long-term survival after liver transplantation.

        

    4000 consecutive patients who underwent liver transplantation [February 1981 to April 1988] were analyzed and followed upto March 2000. The effect of donor and recipient age at the time of transplantation, recipient genders, diagnosis, and year of transplantation were compared. Rate of retransplantation, causes of re-transplantation and causes of death were examined.

       

    The overall survival was 59%. The actuarial 18 year survival was 48%. Survival was significantly better in children, in female recipients and in those operated after 1990. The rates of re-transplantation for acute and chronic rejection were significantly lower with tacrolimus-based immunosuppression. The risk of graft failure and death was relatively stable after the first year with recurrence of disease, malignancies and age-related complications being major factors for loss.

        

    They conclude that significantly improved patient and graft survival has been observed over time and graft rejection has emerged as a rarity.

        

  • Marcos A, Fisher RA, et al (Virginia Commonwealth Univ, Richmond)

    right lobe living donor liver transplantation

    Transplantation 68: 798-803, 1999

       

    Left lateral segmentectomy from living donors has proved safe and effective in children. Left lobectomy has proved inadequate for average sized adults. The authors have attempted a right lobectomy transplant for adults.

      

    25 right lobe living donor transplants were carried out between adults. Preoperatively donors were assessed by liver biopsy, MRI, and coeliac and mesenteric angiography.

        

    Donors experienced no significant complications. Recipient and graft survival was 88%. 3 high risk recipients died of septicaemia. The grafts were functioning in all 3. 

        

    Right lobectomy provides adequate liver mass for an average sized adult. It is a safe procedure.

           

  • Tanabe K, Oshima T, et al (Tokyo Women’s Med Univ, Niigata Univ, Japan)

    Long-term Renal Function in Non-Heart-beating Donor Kidney Transplantation: A Single-center Experience

    Transplantation 66: 1708-1713, 1998

      

    One type of non traditional is the non-heart-beating donor (NHBD). The long-term results of NHBD renal transplantation have been reported.

      

    125 NHBD cadaver renal transplants over a 13-year period have been analyzed. All cases were given cyclosporine- or tacrolimus-based immunosuppression. The recipients were 86 males and 39 females (mean age 36 years). The mean number of HLA-AB mismatches was 1.3, and the mean number of HLA-DR mismatches was 0.9.

      

    Total ischemic time was 761 minutes, and warm ischemic time averaged 7.4 minutes. The patients were followed up for a median of 8 years.

       

    Delayed graft function (DGF) developed in 98 patients and lasted a mean of 16 days. However 86% of cases were not receiving dialysis at discharge. 9% of the grafts were primarily non-functional.

      

    In 108 patients who were off dialysis at discharge, the average nadir of serum creatinine levels was 1.4 mg/dL. 78% of recipients had a creatinine nadir of <2.0 mg/dL. 57% had acute rejection.

      

    The 5-year survival was 90% and 10-year survival was 88%. However, the graft survival rate was 65% and 46% respectively, with 38% of graft losses resulting from chronic rejection.

       

    The only significant risk factor affecting graft survival was acute rejection; harvesting conditions, HLA-AB and -DR mismatches, graft weight, donor and recipient age and sex, DGF, acute rejection and ischemic times were non-significant.

         

    No significant risk factors for primary non functioning were identified. Mean serum creatinine levels as an indicator of long-term renal function was 1.76 mg/dL at 1 year, 1.7 mg/dL at 5 years and 1.53 mg/dL at 10 years.

        

    The experience demonstrates acceptable results of NHBD renal transplantation.

       

  • Ghobrial RM, Farmer DG, et al (Univ of California, Los Angeles)

    orthotopic liver transplantation for Hepatitis C: Outcome, Effect of Immunosuppression, and Causes of retransplantation during an 8-Year single-center experience

    Ann Surg 229: 824-833, 1999

      

    The most common cause of orthotopic liver transplantation (OLT) is infection with Hepatitis C Virus (HCV) infection leading to liver failure. This infection is likely to recur potentially leading to graft loss and retransplantation. The effects of immunosuppression on posttransplant recurrence of HCV and ensuring graft damage are unclear.

      

    A retrospective study on 374 patients undergoing OLT (for HCV liver failure) has been made. 298 received a single transplant, and 76 underwent retransplantation. The patients were followed up for a median period of 2 years. The survival was compared with that of 701 patients undergoing OLT for other indications. 190 patients received cyclosporine-based immunosuppression and 132 received tacrolimus-based immunosuppression. The remaining 48 patients started one form of immunosuppression before being switched to the other.

        

    The overall actuarial survival was 86% at 1 year, 82% at 2 years and 76% at 5 years. 2-year survival rates were comparable in the 3 immunosuppression groups. Survival for patients receiving 1 OLT was 85% at 1 year, 81% at 2 years and 75% at 5 years; again the 2-year survival was similar in all 3 immunosuppression groups. The overall graft survival was 70% at 1 year, 65% at 2 years and 60% at 5 years.

       

    The rate of retransplantation within 1 month was 11% (graft dysfunction), 3% (hepatic artery thrombosis), chronic rejection in 2%, and recurrent HCV infection in 3%.

       

    Survival after retransplantation was 63% at 1 year and 58% at 2 years. OLT done for liver failure following HCV has an excellent outcome.

        

  • Lee CM, Carter JT, et al (Stanford Univ, Calif)

    Dual Kidney Transplantation: Older Donors for Older Recipients

    J Am Coll Surg 189: 82-92, 1999

       

    The use of older kidney donors and the increased use of dual kidney transplantation has been attempted to compensate for decreased renal function in older donors. A retrospective study to evaluate donor characteristics and recipient renal functions and the outcomes over a 3-year period has been performed.

       

    Out of 240 cadaveric renal transplants, 41(17%) were dual transplants. They were done when the kidney did not have a minimum creatinine clearance of 45 ml/min and when the donor was older than 60 years.

       

    Donors were significantly older than the donors of single kidney transplants (59 years vs 42 years), had a higher incidence of hypertension (51% vs 29%) had a lower creatinine clearance (82 vs 105 ml/min), were more likely to die of intracranial bleeding and less likely to die of trauma.

      

    The waiting time of the recipients was shorter (450 vs 737 days). The respective 1-year patient and kidney survival was 98% and 89% versus 97% and 90%. The complication incidence was similar as also the serum creatinine levels (1.6 mg/dL). The incidence of delayed graft rejection was also similar.

        

    The prognosis of dual kidney transplant is good for selected patients.

         

  • Greenstein S, Siegal B (Montefiore Med Ctr, Bronx, NY; Kontracted Health-Associated Services LLP, Brooklyn, NY)

    Compliance and Noncompliance in Patients with a Functioning Renal Transplant: A Multicenter Study

    Transplantation 66: 1718-1726, 1998

      

    This multicenter study attempts to identify variables that affect the likelihood of compliance and non-compliance among renal transplant patients.

      

    Questionnaires were completed in 1402 patients (>18 years) from 56 renal transplant centers, who were taking cyclosporine or similar drugs. Patients were asked if they had missed their doses within the last month. They were also questioned about dialysis, posttransplant symptoms and the regularity of immunosuppressant therapy.

        

    The average age was 46.6 years and the most recent transplant was 38.3 months ago (49.4% males, 65.4% whites, 93.6% were born in USA, 50.8% had college education, 42.6% were employed and had insurance).

      

    88.3% had received one kidney, 24% from a living related donor. Noncompliance was reported by 22.4%. According to logistic regression analysis, older age, blue collar employment, shorter time since transplantation and strong beliefs that drugs are important and should be taken regularly at the prescribed time were predictors of compliance. Non compliers were 3 types
    – accidental non compliers (47%), invulnerables (28%), who believed they did not need to take their medication regularly; and decisive noncompliers (25%) who had their own decision making habits.

       

  • Schnitzler MA, Hollenbeak CS, et al (Washington Univ, St Louis; SangStat Med Corp, Menlo Park, Calif)

    The Economic Implications of HLA Matching in Cadaveric Renal Transplantation

    N Engl J Med 341: 1440-1446, 1999

       

    The cost of transplanting cadaveric kidneys with various numbers of HLA mismatches was analyzed and the potential relative economic benefits of a local compared with a national system to minimize HLA mismatches between donor and recipient in first cadaveric renal transplantation were determined.

      

    Data on all Medicare payments (1991-1997) for recipients of first cadaveric renal transplants were analyzed according to the number of HLA-A, B and DR mismatches between donor and recipient and the duration of cold ischemia before transplantation.

       

    The mean Medicare payment for renal transplant recipients in the 3 years after transplantation rose from $ 60,436 per patient for fully matched (HLA) to $80,807 for kidneys with 6 HLA mismatches between donor and recipient (34% increase). By 3 years after transplantation, the mean Medicare payment was $64,119 for transplanting kidneys with less than 12 hours of cold ischemia time and $74,997 for those with more than 36 hours.

      

    Simulations suggested that using a technique that minimized HLA mismatching in a local geographic region resulted in the greatest cost serving and improvements in graft survival rate when the potential cost of longer cold ischemia was considered.

       

  • Showstack J, for the NIDDK Liver Transplantation Database Group (Univ of California, San Francisco)

    Resource Utilization in Liver Transplantation: Effects of Patient Characteristics and Clinical Practice

    JAMA 281: 1381-1386, 1999

      

    The relationship between pretransplant patient characteristics and clinical practices with utilization of hospital resources was examined in a prospective cohort of patients who received liver transplants between 1991 to 1994.

     

    Demographic and clinical characteristics and outcomes of liver transplantation were reviewed. A resource utilization database was created by matching all services to a single price list to add economic data for 711 patients who underwent liver transplantation. All patients were more than 16 years of age and had nonfulminant liver disease.

      

    Higher adjusted resource utilization was correlated with donor age of 50 years or older, alcoholic liver disease, Child-Pugh class C, care from intensive care unit at the time of transplant, death in the hospital and multiple liver transplants during the index hospitalization.

      

    Adjusted length of stay and resource utilization varied significantly among transplant centers.

       

    Higher average costs were needed in older patients, alcoholic liver disease or when severely ill. Clinical practice and resource utilization were strikingly different among transplant centers. Guidelines are needed to standardize utilization of resources for liver transplantation.

       

  • Wolfe RA, Ashby VB, et al (Univ of Michigan, Ann Arbor; Brigham and Women’s Hosp, Boston; Univ of California, Los Angeles; et al)

    Comparison of Mortality in All Patients on Dialysis, Patients on Dialysis Awaiting Transplantation, and Recipient’s of a First Cadaveric Transplant

    N Engl J Med 341: 1725-1730, 1999

       

    The extent to which renal transplantation improves survival in patients with end stage renal disease compared with long-term dialysis is unclear. An attempt is made to distinguish between the effects of patient selection and of transplantation.

       

    The study included 228,552 patients receiving long-term dialysis for end stage renal disease. 46,164 were put on a waiting list for transplantation and 23,275 receive a first cadaveric transplant.

      

    The standard mortality ratio for those awaiting transplantation was 38% to 58% (lower than that for all patients on dialysis). The annual death rates were 6.3 and 16.1 per 100 patient years respectively.

          

    In the first 2 weeks (posttransplant period) the relative risk of death was 2.8 times as high as that for patients on dialysis with equal lengths of follow-up since waiting list placement. However at 18 months the former group had a much lower risk. In all sub groups, the likelihood of survival became equal after transplantation.

      

    The long-term mortality was 48% to 82% lower among transplant recipients than among patients on the waiting list. Benefits were greater for patients between 20 to 39 years, whites and diabetic patients who were young.

      

    Amongst patients with end stage renal disease, those who are healthier are placed on the waiting list for transplantation. The long-term survival is higher amongst such patients.

       



 

   

Speciality Spotlight

   

   
Surgery
   

 

Transplant
  

  • Ashok Jain, MD, Jorge Reyes, MD, Randeep Kashyap, MD, S. Forrest Donson, MD, Anthony J. demetris, MD, Kris Ruppert, PhD, Kareem Abu-Almagd, MD, Wallis Marsh, MD, Juan Madariaga, MD, George Mazariegos, MD, David Geller, MD, C. Andrew Bonham, MD Timothy Gayowski, MD, Thomas Cacciarelli, MD, Paulo Fontes, MD, Thomas E. Starzl, MD, PhD, and John J. Fung, MD, PhD [ From the Thomas E. Starzl Transplantation Institute and the Departments of Surgery and Pathology, the School of pharmaceutical Sciences, and the Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania]
    Long –Term Survival After Liver Transplantation 4,000 Consecutive Patients at a Single Center
    Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 490-500
        

    Although many reports, including registry data have delineated short-term factors that influence survival, few reports have examined factors that affect long-term survival after liver transplantation.
        
    4000 consecutive patients who underwent liver transplantation [February 1981 to April 1988] were analyzed and followed upto March 2000. The effect of donor and recipient age at the time of transplantation, recipient genders, diagnosis, and year of transplantation were compared. Rate of retransplantation, causes of re-transplantation and causes of death were examined.
       
    The overall survival was 59%. The actuarial 18 year survival was 48%. Survival was significantly better in children, in female recipients and in those operated after 1990. The rates of re-transplantation for acute and chronic rejection were significantly lower with tacrolimus-based immunosuppression. The risk of graft failure and death was relatively stable after the first year with recurrence of disease, malignancies and age-related complications being major factors for loss.
        
    They conclude that significantly improved patient and graft survival has been observed over time and graft rejection has emerged as a rarity.
        

  • Marcos A, Fisher RA, et al (Virginia Commonwealth Univ, Richmond)
    right lobe living donor liver transplantation
    Transplantation 68: 798-803, 1999
       
    Left lateral segmentectomy from living donors has proved safe and effective in children. Left lobectomy has proved inadequate for average sized adults. The authors have attempted a right lobectomy transplant for adults.
      
    25 right lobe living donor transplants were carried out between adults. Preoperatively donors were assessed by liver biopsy, MRI, and coeliac and mesenteric angiography.
        
    Donors experienced no significant complications. Recipient and graft survival was 88%. 3 high risk recipients died of septicaemia. The grafts were functioning in all 3. 
        
    Right lobectomy provides adequate liver mass for an average sized adult. It is a safe procedure.
           

  • Tanabe K, Oshima T, et al (Tokyo Women’s Med Univ, Niigata Univ, Japan)
    Long-term Renal Function in Non-Heart-beating Donor Kidney Transplantation: A Single-center Experience
    Transplantation 66: 1708-1713, 1998
      
    One type of non traditional is the non-heart-beating donor (NHBD). The long-term results of NHBD renal transplantation have been reported.
      
    125 NHBD cadaver renal transplants over a 13-year period have been analyzed. All cases were given cyclosporine- or tacrolimus-based immunosuppression. The recipients were 86 males and 39 females (mean age 36 years). The mean number of HLA-AB mismatches was 1.3, and the mean number of HLA-DR mismatches was 0.9.
      
    Total ischemic time was 761 minutes, and warm ischemic time averaged 7.4 minutes. The patients were followed up for a median of 8 years.
       
    Delayed graft function (DGF) developed in 98 patients and lasted a mean of 16 days. However 86% of cases were not receiving dialysis at discharge. 9% of the grafts were primarily non-functional.
      
    In 108 patients who were off dialysis at discharge, the average nadir of serum creatinine levels was 1.4 mg/dL. 78% of recipients had a creatinine nadir of <2.0 mg/dL. 57% had acute rejection.
      
    The 5-year survival was 90% and 10-year survival was 88%. However, the graft survival rate was 65% and 46% respectively, with 38% of graft losses resulting from chronic rejection.
       
    The only significant risk factor affecting graft survival was acute rejection; harvesting conditions, HLA-AB and -DR mismatches, graft weight, donor and recipient age and sex, DGF, acute rejection and ischemic times were non-significant.
         
    No significant risk factors for primary non functioning were identified. Mean serum creatinine levels as an indicator of long-term renal function was 1.76 mg/dL at 1 year, 1.7 mg/dL at 5 years and 1.53 mg/dL at 10 years.
        
    The experience demonstrates acceptable results of NHBD renal transplantation.
       

  • Ghobrial RM, Farmer DG, et al (Univ of California, Los Angeles)
    orthotopic liver transplantation for Hepatitis C: Outcome, Effect of Immunosuppression, and Causes of retransplantation during an 8-Year single-center experience
    Ann Surg 229: 824-833, 1999
      
    The most common cause of orthotopic liver transplantation (OLT) is infection with Hepatitis C Virus (HCV) infection leading to liver failure. This infection is likely to recur potentially leading to graft loss and retransplantation. The effects of immunosuppression on posttransplant recurrence of HCV and ensuring graft damage are unclear.
      
    A retrospective study on 374 patients undergoing OLT (for HCV liver failure) has been made. 298 received a single transplant, and 76 underwent retransplantation. The patients were followed up for a median period of 2 years. The survival was compared with that of 701 patients undergoing OLT for other indications. 190 patients received cyclosporine-based immunosuppression and 132 received tacrolimus-based immunosuppression. The remaining 48 patients started one form of immunosuppression before being switched to the other.
        
    The overall actuarial survival was 86% at 1 year, 82% at 2 years and 76% at 5 years. 2-year survival rates were comparable in the 3 immunosuppression groups. Survival for patients receiving 1 OLT was 85% at 1 year, 81% at 2 years and 75% at 5 years; again the 2-year survival was similar in all 3 immunosuppression groups. The overall graft survival was 70% at 1 year, 65% at 2 years and 60% at 5 years.
       
    The rate of retransplantation within 1 month was 11% (graft dysfunction), 3% (hepatic artery thrombosis), chronic rejection in 2%, and recurrent HCV infection in 3%.
       
    Survival after retransplantation was 63% at 1 year and 58% at 2 years. OLT done for liver failure following HCV has an excellent outcome.
        

  • Lee CM, Carter JT, et al (Stanford Univ, Calif)
    Dual Kidney Transplantation: Older Donors for Older Recipients
    J Am Coll Surg 189: 82-92, 1999
       
    The use of older kidney donors and the increased use of dual kidney transplantation has been attempted to compensate for decreased renal function in older donors. A retrospective study to evaluate donor characteristics and recipient renal functions and the outcomes over a 3-year period has been performed.
       
    Out of 240 cadaveric renal transplants, 41(17%) were dual transplants. They were done when the kidney did not have a minimum creatinine clearance of 45 ml/min and when the donor was older than 60 years.
       
    Donors were significantly older than the donors of single kidney transplants (59 years vs 42 years), had a higher incidence of hypertension (51% vs 29%) had a lower creatinine clearance (82 vs 105 ml/min), were more likely to die of intracranial bleeding and less likely to die of trauma.
      
    The waiting time of the recipients was shorter (450 vs 737 days). The respective 1-year patient and kidney survival was 98% and 89% versus 97% and 90%. The complication incidence was similar as also the serum creatinine levels (1.6 mg/dL). The incidence of delayed graft rejection was also similar.
        
    The prognosis of dual kidney transplant is good for selected patients.
         

  • Greenstein S, Siegal B (Montefiore Med Ctr, Bronx, NY; Kontracted Health-Associated Services LLP, Brooklyn, NY)
    Compliance and Noncompliance in Patients with a Functioning Renal Transplant: A Multicenter Study
    Transplantation 66: 1718-1726, 1998
      
    This multicenter study attempts to identify variables that affect the likelihood of compliance and non-compliance among renal transplant patients.
      
    Questionnaires were completed in 1402 patients (>18 years) from 56 renal transplant centers, who were taking cyclosporine or similar drugs. Patients were asked if they had missed their doses within the last month. They were also questioned about dialysis, posttransplant symptoms and the regularity of immunosuppressant therapy.
        
    The average age was 46.6 years and the most recent transplant was 38.3 months ago (49.4% males, 65.4% whites, 93.6% were born in USA, 50.8% had college education, 42.6% were employed and had insurance).
      
    88.3% had received one kidney, 24% from a living related donor. Noncompliance was reported by 22.4%. According to logistic regression analysis, older age, blue collar employment, shorter time since transplantation and strong beliefs that drugs are important and should be taken regularly at the prescribed time were predictors of compliance. Non compliers were 3 types – accidental non compliers (47%), invulnerables (28%), who believed they did not need to take their medication regularly; and decisive noncompliers (25%) who had their own decision making habits.
       

  • Schnitzler MA, Hollenbeak CS, et al (Washington Univ, St Louis; SangStat Med Corp, Menlo Park, Calif)
    The Economic Implications of HLA Matching in Cadaveric Renal Transplantation
    N Engl J Med 341: 1440-1446, 1999
       
    The cost of transplanting cadaveric kidneys with various numbers of HLA mismatches was analyzed and the potential relative economic benefits of a local compared with a national system to minimize HLA mismatches between donor and recipient in first cadaveric renal transplantation were determined.
      
    Data on all Medicare payments (1991-1997) for recipients of first cadaveric renal transplants were analyzed according to the number of HLA-A, B and DR mismatches between donor and recipient and the duration of cold ischemia before transplantation.
       
    The mean Medicare payment for renal transplant recipients in the 3 years after transplantation rose from $ 60,436 per patient for fully matched (HLA) to $80,807 for kidneys with 6 HLA mismatches between donor and recipient (34% increase). By 3 years after transplantation, the mean Medicare payment was $64,119 for transplanting kidneys with less than 12 hours of cold ischemia time and $74,997 for those with more than 36 hours.
      
    Simulations suggested that using a technique that minimized HLA mismatching in a local geographic region resulted in the greatest cost serving and improvements in graft survival rate when the potential cost of longer cold ischemia was considered.
       

  • Showstack J, for the NIDDK Liver Transplantation Database Group (Univ of California, San Francisco)
    Resource Utilization in Liver Transplantation: Effects of Patient Characteristics and Clinical Practice
    JAMA 281: 1381-1386, 1999
      
    The relationship between pretransplant patient characteristics and clinical practices with utilization of hospital resources was examined in a prospective cohort of patients who received liver transplants between 1991 to 1994.
     
    Demographic and clinical characteristics and outcomes of liver transplantation were reviewed. A resource utilization database was created by matching all services to a single price list to add economic data for 711 patients who underwent liver transplantation. All patients were more than 16 years of age and had nonfulminant liver disease.
      
    Higher adjusted resource utilization was correlated with donor age of 50 years or older, alcoholic liver disease, Child-Pugh class C, care from intensive care unit at the time of transplant, death in the hospital and multiple liver transplants during the index hospitalization.
      
    Adjusted length of stay and resource utilization varied significantly among transplant centers.
       
    Higher average costs were needed in older patients, alcoholic liver disease or when severely ill. Clinical practice and resource utilization were strikingly different among transplant centers. Guidelines are needed to standardize utilization of resources for liver transplantation.
       

  • Wolfe RA, Ashby VB, et al (Univ of Michigan, Ann Arbor; Brigham and Women’s Hosp, Boston; Univ of California, Los Angeles; et al)
    Comparison of Mortality in All Patients on Dialysis, Patients on Dialysis Awaiting Transplantation, and Recipient’s of a First Cadaveric Transplant
    N Engl J Med 341: 1725-1730, 1999
       
    The extent to which renal transplantation improves survival in patients with end stage renal disease compared with long-term dialysis is unclear. An attempt is made to distinguish between the effects of patient selection and of transplantation.
       
    The study included 228,552 patients receiving long-term dialysis for end stage renal disease. 46,164 were put on a waiting list for transplantation and 23,275 receive a first cadaveric transplant.
      
    The standard mortality ratio for those awaiting transplantation was 38% to 58% (lower than that for all patients on dialysis). The annual death rates were 6.3 and 16.1 per 100 patient years respectively.
          
    In the first 2 weeks (posttransplant period) the relative risk of death was 2.8 times as high as that for patients on dialysis with equal lengths of follow-up since waiting list placement. However at 18 months the former group had a much lower risk. In all sub groups, the likelihood of survival became equal after transplantation.
      
    The long-term mortality was 48% to 82% lower among transplant recipients than among patients on the waiting list. Benefits were greater for patients between 20 to 39 years, whites and diabetic patients who were young.
      
    Amongst patients with end stage renal disease, those who are healthier are placed on the waiting list for transplantation. The long-term survival is higher amongst such patients.
       

 

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