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Dual Kidney Transplantation: A Review of Past and Prospect for Future.

1. Introduction

KT when compared with dialysis offers improved survival, better quality of life, better social rehabilitation, and less economic cost. The number of kidney transplantations is increasing worldwide. Similarly the number of patients waiting to get a kidney has also increased tremendously. The number of patients on waiting list for kidney in July 2016 was 99,413 in USA as per data of Organ Procurement and Transplantation Network (OPTN). Unfortunately only 17,878 patients could get a kidney [1]. Despite recent relaxation of rules to accept expanded criteria donors (ECD), the gap between demand and supply is still huge. Around 20 to 40% of ECD and dual kidneys recovered were discarded in US [2]. The discard rate is 8% in Europe which is comparatively lower than the United States of America [3-5]. Theoretically, increased nephron mass supply by simultaneously transplanting two suboptimal kidneys to the same recipient may work better than a single kidney. This will both reduce the number of the patients on waiting lists and discard rates. In this review we will examine the current evidence available and discuss the concept of DKT, criteria for donor and recipient evaluation, surgical techniques and its complications, outcomes of DKT, and new prospects and future directions for DKT. This review does not include pediatric dual kidney donation or implantation.

2. Concept of Dual Kidney Transplant

Adequate nephron mass is a predictor of long term graft outcome. The nephron dose concept is a known terminology to transplant physicians. Nephron dose concept conveys that any reduction in nephron mass causes hyperfiltration and hemodynamically mediated glomerular injury [6]. The theory of hyperfiltration related injury is well known in transplant nephrology. It has been shown to be associated with reduced graft survival, when the kidney-to-recipient weight ratio is below 2.0 g/kg [7]. Animal studies have shown that sufficient nephron mass by doing DKT when compared to SKT prevented long term deterioration in kidney functions [8, 9]. Higher nephron mass in humans through DKT should theoretically reduce the deterioration in long term graft function [10]. Logically, single kidney from ECD has less number of functional nephrons when compared with two ECD kidneys which should translate to better overall kidney function. Organ preservation, ischemia reperfusion injury, exposure to calcineurin inhibitors, rejections, and hypertension in posttransplantation period have deleterious effects on renal parenchyma. Single kidney from ECD by virtue of having less functional renal parenchyma will be more vulnerable to damage by these factors.

3. Criteria for Selection of Donor

Criteria for dual kidney transplantation are highly variable among centers across the world. The decision for DKT has to be taken with great caution and deliberation. The practice of discarding kidneys from ECD has generated many discussions about wastages and prodigality, especially in the current climate where transplant waiting lists are ever increasing. There is now plenty of evidence that DKT can achieve good long term outcomes, often comparable to SKT. On the other hand, putting dual kidneys with inadequate nephron mass may be hazardous because some evidence has shown that patients who require dialysis after failed marginal grafts had higher mortality and morbidity compared to those without a history of kidney transplantation [11, 12]. Keeping these pros and cons in mind, we feel that a meticulous scrutiny of criteria is needed to ensure that recipients achieved desirable outcomes. Unfortunately the criteria for selection are highly variable among various transplant centers and there is no universal consensus on the best way forward.

ECD is defined as all deceased donors [greater than or equal to] 60 years of age or donors who were 50-59 years of age and had two of the following: donor history of hypertension; donor death due to cerebrovascular accident/stroke; or terminal serum creatinine value greater than 1.5mg/dl. ECD needs meticulous evaluation before deciding to do SKT or DKT. Since the start of DKT in 1996 to 2013, various selection criteria were proposed and utilized. Various criteria are considered: age, presence of comorbidity (diabetes or hypertension), cold ischemiatime, creatinine clearance, and preimplantation biopsy finding for allocation. Preimplantation biopsy finding predicts long term outcome of the graft. Karpinski et al. found that donor vessel scores can predict delayed graft function and graft survival after transplantation [13]. Using Banff criteria in preimplantation biopsy and doing combined evaluation of donor glomerulosclerosis, chronic vascular and interstitial damage allows a precise prediction of graft outcome [14]. Various other studies used biopsy scores to decide to opt for DKT or SKT [15,16].

Johnson et al. in 1996 did preimplantation biopsy and did DKT in donors having less than 40% glomerulosclerosis without severe interstitial fibrosis or arteriosclerosis on biopsy [15]. Beside biopsy they considered age, comorbidity (diabetes/hypertension), and cold ischemia time and creatinine clearance. They included donors with cold ischemia time less than 30 hours and with creatinine clearance levels between 40 and 80 mL/min. Using histology together with other donor factors their criteria for selection of donor led to 100% survival at 6 months.

Remuzzi et al. [16] assessed their biopsies and used scores for glomerulosclerosis, tubular atrophy, interstitial fibrosis, and arterial and arteriolar narrowing. They graded each element from 0 to +3, with a total maximal score of 12. The final grade was labelled mild if the score was 0-3, moderate 4-6, and severe 7-12. The kidney with mild grade label was allocated for SKT and moderate grade (4-6) for DKT.

The kidneys with severe grade (7-12) were discarded. Beside biopsy they also considered age, comorbidity, and proteinuria while selecting donors for DKT. Despite slight differences from Johnson et al. criteria the graft survival reported by Remuzzi et al. was 100% at 6 months and 93% at 3 years.

Preimplantation biopsy also helps in selection of donors across a wide range of donors irrespective of their age. Using age and histological finding together can help in sensible allocation for SKT or DKT with reasonable outcome irrespective of age limit. Andres and his colleagues [17] selected cadaveric donors with normal creatinine irrespective of age limits and performed pregraft biopsy in donors with age greater than 60 years to assess glomerulosclerosis. A DKT was done when the donor age was 75 years or older or when the donors between 60 and 74 years old and had a glomerulosclerosis of more than 15%. Using this selection criterion the graft survival was 95% graft survival at 1 year and 93% at 2 years. Promising graft survival was reported despite the fact that their cohort received kidneys from very elderly population.

In a data review of UNOS kidney biopsy along with other parameters was used to select donors for DKT [18]. Preimplantation glomerulosclerosis between 15% and 50% was one of the tools for selecting donors. Parameters considered for selection included age greater than 60 years, creatinine clearance greater than 65 mL/min, rising serum creatinine greater than 2.5 mg/dL at retrieval, chronic hypertension or type 2 diabetes mellitus, and glomerulosclerosis on biopsy between 15% and 50%. DKT was done if any of the two parameters was present. The selection criterion was reasonable as translated by 5-year patient survival 95.6% in their cohort.

Yet in another study kidney biopsy was restricted for allocation in high risk ECD [19] for allocation. Criteria used for high risk ECD included elderly donor with age [greater than or equal to] 70 or 60-69 with one of the following risk factors:

(i) Serum creatinine > 1.5 mg/dl.

(ii) Calculated creatinine clearance [less than or equal to] 60ml/minute.

(iii) History of hypertension and/or diabetes.

(iv) Proteinuria > than 1 gram.

(v) Cause of death cerebrovascular accident.

They did kidney biopsy in high risk marginal donor and assessed biopsies using Karpinski and Remuzzi histological scores. SKT was done when score was 0-3. Kidneys with score 4-6 were allocated for DKT and those with score 7-12 were discarded. The group demonstrated that graft ad patient were similar to SKT.

Some centers used kidneys for DKT refused by other local centers for a variety of reasons. One of the reasons was suboptimal pretransplantation biopsy. This subgroup underwent DKT and was studied by Lu et al. [20]. Reasons for refusal were multiple including history of hypertension, donor instability, donor age, or marked elevation in donor creatinine level after hospital admission, suboptimal pre-transplantation biopsy findings, or a combination of these factors. Lu et al. found that recipients of DKT from these ECDs have excellent outcomes. The good outcome in this data was promising despite the fact that recipients of double kidneys were older and had a lower creatinine clearance on hospital admission. Other authors also used biopsy along with various clinical parameters for selection of the donor [21, 22].

From reviewing the evidence so far discussed it is evident that biopsy before transplantation was a vital selection tool. However, work from other colleagues used selection criteria not using preimplantation biopsy. Interestingly parameters from hypothermic machine perfusion with measurement of enzymes for ischemic injury have been used in donation for DKT after cardiac death. Donation after cardiac death (nonheart beating) is considered ECD because of long warm ischemia time. Navarro et al. [23] used hypothermic machine perfusion to preserves the organs. They assessed pressure flow index (defined as flow per 100 grams renal mass divided by systolic blood pressure) and concentration of glutathione transferase, an enzyme marker of ischemic injury. SKT was done when pressure flow index was 0.4mL/min per 100 g/mm Hg and glutathione transferase was less than 100 IU/L/100 grams renal mass. Kidneys were discarded if pressure flow index was less than 0.4. DKT was done when if pressure flow index was satisfactory but glutathione transferase was higher than the cut-off value. Patients having comorbidities and prolonged cold ischaemia also underwent DKT. The group concluded that viability testing in nonheart beating donors can help in distinguishing kidneys that may be unsuitable for SKT but when used as double transplant have the potential to produce sufficient renal function.

Similarly glomerular filtration rate (GFR) alone in elderly patients was used in allocation of the kidneys either for DKT or SKT without doing a kidney biopsy before implantation. Snanoudj and his colleagues [24] prospectively compared DKT and SKT receiving grafts from ECD donors aged > 65 years and allocated kidneys according to donor estimated glomerular filtration rate. DKT was done if estimated glomerular filtration rate was between 30 and 60 mL/min and SKT if estimated glomerular filtration rate was greater than 60 mL/min. At the end of 12-month follow-up, GFR was similar between the two groups. The group then advocated the importance of GFR in allocation of kidney from elderly population without doing a biopsy. They argued that delaying the transplant to obtain histology will increase cold ischemia time. Moreover, emergency histopathological reporting is also an issue at various centers. There are also some critics who are of the opinion that kidney biopsy may lead to more discard [25].

Organ Procurement and Transplantation Network (OPTN) and United Network for Organ Sharing (UNOS) introduced KDRI (Kidney Donor Risk Index) and KDPI (Kidney Donor Profile Index) to quantify risk scores for deceased donor kidneys. The KDRI is an estimate of the relative risk of posttransplant kidney graft failure from a particular deceased donor compared to a reference healthy donor of age 40 years [26]. KDPI of higher than 80% predicts high risk of graft failure; however there is no cut-off for accepting or rejecting a kidney [27]. Therefore one must be cautious while taking decision on the basis of KDPI. However, Klair et al. used KDRI for DKT and concluded that KDRI > 2.2 is a useful discriminatory cut-off for the determination of graft survival [28].

It is cleared from discussion so far that many centers used histological tool along with various clinical parameter for allocation. Others relied on hypothermic perfusion parameters or estimation of GFR or kidney donor profile index (KDPI) without doing a biopsy. The preimplantation biopsy can have pitfalls. They may sample a zonal scar and may not be a true representation of the kidney. Superficial biopsies may not sample adequate arteries and arterioles; therefore the vasculature may not get evaluated. That is a significant disadvantage. Moreover, Shallow wedge biopsies can overestimate glomerulosclerosis, owing to the increased incidence of this in the subcapsular region [29]. The methodology for preparing the histologic sections of the preimplantation biopsy is also important. Frozen sections contain substantial freeze artifact, making interpretation difficult. Frozen sections are not reliable for assessment of mesangial cellularity, glomerular capillary wall thickening, some diabetic lesions, microthrombi, and acute tubular necrosis [30]. We advise rapid processing of formalin fixed permanent sections [30]. Lastly, it is also important for who reads this preimplantation biopsy. Not all pathologists are familiar with reading kidney pathology. All these factors are potential problems with preimplantation biopsies. Therefore, it is important to integrate histological scoring with clinical criteria and donor risk index. The aim should be to avoid discard and benefit greater number of patients waiting on the list. At the same time one should take care not to implant two kidneys where one kidney will be sufficient to provide optimal long term benefits. On the other side one should be careful not to implant kidneys with little reserves. This is due to fact that recipient with failed graft do worse latter on hemodialysis [11,12].

A reasonable way forward will be to estimate GFR or KDRI in all ECD. If e GFR is greater than 60 ml/minute or KDRI is less than 2.2 then kidneys should go for SKT [24,28]. If e GFR is less than 60 ml/minute or KDRI is greater than 2.2 then these patients should undergo biopsy to decide for SKT versus DKT. The biopsy can be evaluated by Karpinski et al. or Remuzzi et al. histological scores [13,16]. SKT should be done if score is 0-3. Kidneys with score 4-6 should be allocated for DKT and those with score 7-12 should be discarded. Figure 1 showed the allocation scheme.

It will be nice to integrate histological score into multifactor score for selection of the donor to reduce discard and improve outcome. A consensus in transplant community for integrating various scores and coming up with selection criteria is also needed. Table 1 summarizes the criteria for DKT.

4. Criteria for Selection of Recipient

Generally, the recipients of DKT were older when compared to SKT. Results of most studies showed that elderly patients who had DKT tend to have lower metabolic rate and low body mass index than the average SKT patients [16, 19, 20, 24, 28, 31, 32]. DKT is considered better for age and weight matched recipient. Greater number of nephrons in DKT is suitable for elderly patients with low basal metabolism and reduced body mass. The results of DKT in elderly were comparable with the younger SKT population [32].Theoretically elderly recipients tend to have blunted immunologic responses and, therefore, despite increased nephron mass, the chances of rejection are lower. Furthermore, there were promising results showing that DKT in a younger cohort (mean age 60 [+ or -] 5 years) from older donors (mean age 75 [+ or -] 7 years) had fewer episodes of acute rejection and good graft survival [17].

Bearing this evidence in mind, DKT should be offered to elderly patients with lower immunological risk and a normal body mass index. Younger patients may invariably have better outcomes but should be made aware that long term survivability of grafts may not match their life expectancy and may complicate their sensitization for future transplants. Table 2 summarizes characteristics of the recipient who underwent DKT.

5. Surgical Technique for DKT

Various techniques are used for DKT including the extra- or intraperitoneal bilateral placement of the two kidneys [33-35] through two separate Gibson incisions or one midline incision [34-36]. Masson and Hefty were the first to transplant both adult donor kidneys unilaterally (monolateral or ipsilateral) into the same iliac fossa [37]. Their point of view was that there will be less trauma and less operative time is required to do the procedure. Furthermore, they argued that other side can be used for future transplantation if needed. However extensive dissection is needed in the later technique and there is a fear that this approach may be associated with renal vein thrombosis due to compression by dual kidney [19]. However Ekser et al. compared unilateral placement of dual kidneys and compared their results with SKT. They found the procedure safe and with good outcome [19].

Compared to SKT, dual anastomosis of the vessels and ureters is needed in DKT. Implantation of the two kidneys requires more dissection, surgical, and anesthetic time. This means that intraoperative medical and surgical complications are expected to be higher than SKT. Monolateral placement through a single Gibson incision reduces operating time significantly and is shown to be associated with lower surgical morbidity [28]. Some studies have suggested that bilateral DKT in recipients >60 years old due to longer period of anesthesia results in greater surgical risk [34, 38]. In view of these findings they suggested that DKT should be done in recipients of less than 60 years of age. However, Remuzzi et al. [16] who did bilateral placement of the kidneys reported that overall incidence of major surgical complications were comparable to SKT. Similarly, Esker and his colleagues [19] who did unilateral kidney placement found that there were no significant increases in the surgical or anesthetic complications in 60% of their cohort who were >60 years of age at the time of the transplant.

Renal vein thrombosis is a potentially serious complication that often leads to graft loss. The incidence is around 0.5 to 4% [39] in SKT. It is argued that unilateral DKT may be associated with renal vein thrombosis [19]. Ekser et al. in their cohort of unilateral DKT transplants showed that the incidence of renal vein thrombosis was 1% as compared to 5% in SKT [19]. Similar incidence of renal vein thrombosis was reported in other studies [24, 31]. Few other studies done in DKT did not show any renal vein thrombosis [16, 21, 40]. Similarly the incidence of arterial thrombosis was not significant between DKT and SKT [21, 24].

Lymphocele has been reported in 0.6-36% of SKT [41]. In DKT, the incidence of lymphocele has been reported as 3-15%. The occurrence of lymphocele was not statistically different between DKT and SKT in some studies [19,21]. Even some studies done in DKT did not show any lymphocele [16, 18, 24]. Islam et al. [22] reported significant ureteral strictures in DKT. However other authors reported similar incidence of ureteral strictures between DKT versus SKT [19, 24]. In other studies no ureteral stricture was found [16, 21]. Table 3 summarizes complications of DKT reported by various authors.

DKT requires more time and the number of anastomosis doubles for the surgeon. However, with experience accumulating the complications associated with DKT are comparable with SKT. Keeping in mind good graft and patient survival in DKT and comparable complication rate with SKT, DKT will not only reduce discard of organ but also give an opportunity for recipients to live long and lead a healthy life.

6. Outcome of Dual Kidney Transplantation

Outcome of DKT transplantation can be measured by assessing various outcome variables. Like SKT, DKT can have delayed graft function and rejection. Long term outcome can be measured by looking into data for graft and patient survival.

Delayed graft function occurs in 10-31% cases in patients with DKT [16, 18-22, 24, 32, 34]. Snanoduj et al. [24] reported significantly less delayed graft function in DKT when compared with SKT (31.6% versus 51.4%) suggesting that DKT may be associated with less delayed graft function. However, this could not be reciprocated by various other studies [16, 18-22, 32, 34]. All these studies showed that delayed graft function between the two groups was not statistically significant. From this we can assume that delayed graft function is in DKT is similar to SKT.

DKT theoretically poses greater immunological challenge by providing more nephron mass to activate the immune system. However, acute rejection occurred in 12-20.8% in patients with DKT as compared to 17.6%-34.3% in SKT [16, 18,19,22,24]. In most of these studies the occurrence of acute rejection in DKT was not significant statistically. The reason for less rejection despite increased nephron mass could be due the facts that recipient of DKT is the elderly who have blunted immune responses.

Since the first report of DKT by Johnson et al. [42] for graft survival, multiple comparative studies have been published on patient and graft survival in DKT and SKT. Various studies assessed graft survival at various intervals and it was found to be comparable with SKT. Johnson et al. and Remuzzi et al. reported 100% graft survival at 6-month follow-up [15, 16] in patients with DKT. Graft survival at 1 year has been reported to be 87-96% in various studies [36, 42-44]. Some studies have reported graft survival at 2 and 3 years as 96% and 93%, respectively [24, 44]. All these studies reported similar graft survival for both DKT and SKT except Jerius et al. [33] who reported better 1- and 2-year graft survival in DKT (96/96%) compared to SKT (77/73%). Gill and his colleague [18] found that death-censored allograft survival of DKT and extended criteria donor transplants were not significantly different up to 4 years after transplant. Snanoudj et al. [24] found that Kaplan-Meier estimates of non-death-censored graft survival up to 3 years were similar between DKT and SKT.

Patient survival is another important outcome and has been reported by various authors at various intervals. Six-month patient's survival has been 100% in various studies [15,16]. Similarly 1-year survival has been reported as 96-98% [36, 42]. Lu et al. [20] followed their patients for 2 years and reported patient survival as 86% by the end of two years.

Snanoudj et al. [24] found that Kaplan-Meier estimates of patient survival were similar up to 3 years in both DKT and SKT. Five-year graft survival has been reported as 87.3% in one study [19]. Table 4 summarizes the outcome of DKT reported in various studies.

These findings suggest that graft and patient survival in DKT is encouraging and comparable with SKT. Keeping in view similar surgical complications risk and similar incidence of delayed graft function and rejection with reasonable survival benefit DKT is considered as one of the viable option. In 2014 around 2,885 (17%) kidneys were discarded in USA [45]. Discard rate in Europe though 7.5% (304 donors) is still high [3]. Discard of 7.5-17% kidneys across the globe is an alarming figure. One can significantly reduce discard of these precious kidneys by implanting them through DKT. For instant, reducing discard rate in USA by 50% will provide around 1480 kidneys which can be utilized for DKT. Therefore, instead of discarding ECD kidney, one can sensibly allocate them for DKT. This will provide chronic kidney disease patients with an opportunity to come off dialysis and lead a healthy life with full functional status.

7. New Prospects and Future Direction

With the abundance of evidence based literature and cumulative experience now available for DKT, the transplant community has continued to open new frontiers for DKT. The preferred surgical technique in many developed centers has shifted from open donor nephrectomy to laparoscopic hand assisted nephrectomy. Another modern alternative is robotic assisted surgery which was first reported by Frongia et al. 2013 for dual kidney implantation [46]. The procedure was carried out by a 7-port intraperitoneal approach using the da Vinci surgical system. The total operative time was 400 minutes and blood loss was 120 ml. There were no intraoperative complications. The patient was discharged on the seventh postoperative day with normal renal function. They concluded that minimally invasive robotic assisted technology is a promising technique that provides exceptional patient outcomes by reducing operative morbidity, immobilization, and time to recovery, while affording better esthetic results. Further experience is required for robotic assisted surgery for dual kidney implantation.

Most patients with cirrhotic liver have either preexisting chronic kidney disease or develop acute kidney injury which results in chronic kidney disease. Combined liver and kidney transplant is becoming increasingly common. Di Laudo et al. [47] reported their experience of combined liver and DKT in 2016 and found no difference in graft and patient survival outcome with combined liver and SKT.

8. Conclusion

DKT is helpful in expanding donor pool and preventing discard. Various histological and clinical parameters are used to select a donor. There is a need to integrate histological score into multifactor score and to develop a consensus in selection of the donor for DKT. Recent advances and experience have accorded the use of various surgical techniques without compromising the rates of surgical complications. Long term graft and patient survival are promising and comparable to SKT.

https://doi.org/10.1155/2017/2693681

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The corresponding author acknowledges all the coauthors for their valuable input and drafting of this manuscript.

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[40] B. Ekser, N. Baldan, G. Margani et al., "Monolateral placement of both kidneys in dual kidney transplantation: low surgical complication rate and short operating time," Transplant International, vol. 19, no. 6, pp. 485-491, 2006.

[41] R. B. Khauli, J. S. Stoff, T. Lovewell, R. Ghavamian, and S. Baker, "ost-transplant lymphoceles: a critical look into therisk factors, pathophysiology and management," Journal of Urology, vol. 150, no. 1, pp. 22-26, 1993.

[42] L. B. Johnson, P. C. Kuo, D. C. Dafoe et al., "The use of bilateral adult renal allografts--a method to optimize function from donor kidneys with suboptimal nephron mass," Transplantation, vol. 61, no. 8, pp. 1261-1263,1996.

[43] E. J. Alfrey, C. M. Lee, J. D. Scandling, M. Pavlakis, A. J. Markezich, and D. C. Dafoe, "When should expanded criteria donor kidneys be used for single versus dual kidney transplants?" Transplantation, vol. 64, no. 8, pp. 1142-1146,1997

[44] R. J. Stratta and L. Bennett, "Preliminary experience with double kidney transplants from adult cadaveric donors: analysis of united network for organ sharing data," Transplantation Proceedings, vol. 29, no. 8, pp. 3375-3376,1997

[45] P. R. Barach, J. P. Jacobs, S. E. Lipshultz, and P. C. Laussen, Pediatric and Congenital Cardiac Care, Springer, 2015.

[46] M. Frongia, R. Cadoni, and A. Solinas, "First robotic-assisted dual kidney transplant: surgical technique and report of a case with 24-month follow-up," Transplantation Direct, vol. 1, no. 9, p. e34, 2015.

[47] M. Di Laudo, M. Ravaioli, G. La Manna et al., "Combined liver-dual kidney transplant: Role in expanded donors," Liver Transplantation, vol. 23, no. 1, pp. 28-34, 2017

Muhammad Abdul Mabood Khalil, (1) Jackson Tan, (2) Taqi F. Toufeeq Khan, (3) Muhammad Ashhad Ullah Khalil, (4) and Rabeea Azmat (5)

(1) Diaverum Prince Abdul Majeed Renal Centre, Al Imam Ahmad ibn Hanbal, Jeddah 21146, Saudi Arabia

(2) RIPAS Hospital, Bandar Seri Begawan BA1710, Brunei Darussalam

(3) King Salman Armed Forces Hospital, TabukKing Abdul Aziz Rd., Tabuk 47512, Saudi Arabia

(4) Khyber Teaching Hospital, Peshawar, Khyber Pakhtunkhwa 25000, Pakistan

(5) Aga Khan University Hospital, Karachi 74800, Pakistan

Correspondence should be addressed to Muhammad Abdul Mabood Khalil; doctorkhalil1975@hotmail.com

Received 18 December 2016; Revised 8 March 2017; Accepted 10 April 2017; Published 2 July 2017

Academic Editor: Anjali Satoskar

Caption: FIGURE 1
TABLE 1: Selection criteria for the donors.

Authors       Journal name/year   Number/surgical technique/
                                  immunosuppression used/
                                  selection criteria

Johnson et    Journal of          9/Dual kidneys were transplanted
  al. [15]      Surgery/1996        intraperitoneally or through
                                    bilateral extraperitoneal
                                    incision/induction was either
                                    with [ATG.sup.*] or [OKT3.sup.*]
                                    followed by cyclosporine, AZA
                                    and prednisolone/selection
                                    Criteria: donor older than 60
                                    years and/or long history of
                                    hypertension or diabetes with
                                    cold ischemia time less than 30
                                    hours. Further criteria included
                                    creatinine clearance levels
                                    between 80 and 40mL/min and with
                                    kidneys that showed less than 40%
                                    glomerulosclerosis without severe
                                    interstitial ibrosis or
                                    arteriosclerosis on biopsy
Remuzzi et    Journal of          24/Bilateral placement through
  al. [16]    American              double inguinal incision/
                Society of          Prednisolone, Cyclosporine
                Nephrology/1999     & mycophenolate mofetil.
                                    No comment on induction/
                                    Selection Criteria: brain
                                    dead donors having 1 of
                                    the following * Age > 60 year
                                    * History of diabetes or
                                    hypertension * Clinical
                                    proteinuria (urinary protein
                                    excretion rate up to 3
                                    g/24 h) plus renal
                                    histopathology score of 4-6
Lu et         Archives of         50/Bilateral placement in right
  al. [20]      Surgery/1999        and left iliac fossa via
                                    midline extra peritoneal
                                    approach/Cyclosporine, steroids
                                    & [MMF.sup.*] or [AZA.sup.*].
                                    Induction with [OKT3.sup.*]
                                    or [IF-2.sup.*] inhibitor
                                    /Selection Criteria: [ECD.sup.*]
                                    refused by other centers due
                                    to hypertension, donor
                                    instability, donor age or
                                    pretransplantation biopsy
                                    result and creatinine clearance
                                    less than 90 ml/minute in donors
                                    with age greater than 60 years
Andres et     Transplantation     21/Each kidney was implanted
  al. [17]      /2000               extraperitoneally in each
                                    iliac fossae/Prednisolone,
                                    cyclosporine or tacrolimus
                                    and MMF/selection criteria
                                    /age greater than 75 or 60-74
                                    and pregraft biopsy showing
                                    greater than 15%
                                    glomerulosclerosis and lesser
                                    than 50% glomerulosclerosis
Gill et       Transplantation     625 received DKT/no comment on
  al. [18]      /2008               surgical technique or
                                    immunosuppression/selection
                                    criteria: any 2 of the following
                                    criteria present: age greater
                                    than 60 years, creatinine
                                    clearance greater than 65
                                    mE/min, rising serum creatinine
                                    greater than 2.5 mg/dL at
                                    retrieval, chronic hypertension
                                    or type 2 diabetes mellitus, and
                                    glomerulosclerosis on biopsy
                                    between 15% and 50%
Navarro et    Journal of          23 non heart beating DKT
  al. [23]      Urology/2008        /ipsilateral dual transplant,
                                    the 2 kidneys from a single
                                    donor are implanted into the
                                    right iliac fossa with
                                    anastomoses to the common
                                    (right kidney) and external
                                    iliac (left kidney) arterial
                                    circulation/no comment on
                                    immunosuppression medications
                                    /selection criteria: machine
                                    perfusion pressure flow index
                                    0.4 mL/min per 100 g/mm Hg
                                    and glutathione transferase
                                    was greater than 100IU/L/100
                                    grams renal mass
Snanoudj et   American Journal    81/Allografts were placed
  al. [24]      of                  either monolaterally or
                Transplantation     bilaterally, with one
                /2009               or two classical iliac
                                    incisions, respectively
                                    /received IL-2 receptor
                                    antagonist or ATG *.
                                    Cyclosporine or tacrolimus,
                                    prednisolone and MMF were
                                    used after induction
                                    /selection criteria:
                                    ECD donors aged > 65 years
                                    and estimated glomerular
                                    filtration rate was between
                                    30 and 60 mL/min
Ekser et      American Journal    100/Unilateral extraperitoneal
  al. [19]      of                  placement via Gibson incision
                Transplantation     /induction therapy consisted
                /2010               of antithymocyte globulin
                                    (ATG) or Basiliximab.
                                    Maintenance immunosuppressive
                                    sirolimus or everolimus either
                                    without a calcineurin inhibitor
                                    ([CNI.sup.*]) or with a reduced
                                    CNI /selection criteria: high
                                    risk marginal donor (donor with
                                    age [greater than or equal to]
                                    70 Or 60-69 with either one
                                    of the Serum creatinine > 1.5
                                    mg/dl, calculated creatinine
                                    clearance [less than
                                    or equal to] 60 ml/minute,
                                    history of hypertension and
                                    or diabetes, proteinuria
                                    > than 1 gram, cause of death
                                    cerebrovascular accident) plus
                                    biopsy score 4-6
Klair et      American Journal    1308/No comment on surgical
  al. [28]      of                  technique or
                Transplantation     immunosuppressive
                /2013               medications used/selection
                                    criteria: DKT was done in
                                    KDRI score 1.4, 1.41-1.8,
                                    1.8-2.2 and greater than 2.
                                    DKT showed superior graft
                                    survival when KDRI was
                                    greater than 2
Frutos et     Nefrolgia/2012      20/Dual kidney transplantation
  al. [21]                          was performed through 2
                                    independent incisions in
                                    each of the recipient's
                                    iliac fossae/Immunosuppressive
                                    medications included induction
                                    with basiliximab. Maintenance
                                    immunosuppression included
                                    prednisolone, tacrolimus & MMF
                                    /selection criteria: DKT was
                                    done through biopsy scoring
                                    plus clinical parameter
                                    including Donor's age, medical
                                    history, kidney size and
                                    creatinine clearance were
                                    also considered
Islam et      Journal of          29/Extraperitoneal placement
  al. [22]      Transplantation     in right iliac fossa through
                /2016               curvilinear incision/high
                                    risk recipients received ATG
                                    and the rest either daclizumab
                                    or basiliximab. Maintenance
                                    immunosuppression consisted
                                    of tacrolimus, MMF, and
                                    prednisone/selection criteria:
                                    Expanded criteria donors (ECD),
                                    defined as deceased donors
                                    (1) greater than 60 years old
                                    or (2) greater than 50 years
                                    old and with at least 2 of the
                                    following criteria: (a) a
                                    history of hypertension,
                                    (b) terminal serum creatinine
                                    greater than 1.5 mg/dL, or
                                    (c) death due to a
                                    cerebrovascular accident OR
                                  Kidneys from standard criteria
                                    donors (SCD) that were deemed
                                    functionally compromised due
                                    to high serum creatinine, poor
                                    pump characteristics, or
                                    unfavorable histology on biopsy

Authors       Outcome

Johnson et    100% graft survival at 6 months
  al. [15]
Remuzzi et    100% graft survival at 6
  al. [16]      months and 93% at 3 years
Lu et         86% graft survival at 1
  al. [20]      year and 76% at 2 years
Andres et     95% graft survival at 1
  al. [17]      year and 93% at 2 years
Gill et       79.8% graft survival at 3 years
  al. [18]
Navarro et    Glomerular filtration rate
  al. [23]      at 3 and 6 months was 46.2
                 & 45.5 ml/minute
Snanoudj et   Glomerular filtration
  al. [24]      rate at 12 months 47.8
                mL/min
Ekser et      Glomerular filtration
  al. [19]      rate at 1 year and 2 years
                was 115 [+ or -] 32 and 128
                [+ or -] 45 ml/minute
Klair et      Five-year graft survival rates
  al. [28]      of SKT and DKT by KDRI were
                as follows: 1.4 (74%, 72%),
                1.41-1.8 (63%, 64%), 1.81-2.2
                (55%, 59%) and >2.2 (48%,
                54%).
Frutos et     Creatinine clearance at 6
  al. [21]      months and 1 year was
                59.0 [+ or -] 18 ml/
                minute 55.0 [+ or -]
                18.5 ml/minute
Islam et      Median e [GFR.sup.*] (IQR) in
  al. [22]      mL /min/1.73 [m.sup.2] at 12
                months was 56.0 (42.6-67.9)
                & at 24 months 53.4
                (46.4-66.4) ml/minute

* .[MMF.sup.*] (mycophenolate mofetil), [AZA.sup.*]
(azathioprine), [IL-2.sup.*] (interleukin-2),
[ECD.sup.*] (extended Criteria Donor), e [GFR.sup.*]
(estimated glomerulofilteration rate), [ATG.sup.*]
(antithymocyte globulin), and [SCD.sup.*] (standard
criteria donor), [OKT3.sup.*] (muromonab-CD3).

TABLE 2: Recipient characteristics DKT versus SKT.

Author            Journal/year/number           DKT
                     of recipient
                                                Age

Remuzzi et        Journal of American    59.4 [+ or -] 9.9
  al. [16]       Society of Nephrology
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/      57 [+ or -] 11
                      1999/50 DKT
Snanoudj          American Journal of    69.4 [+ or -] 3.0
  et al. [24]    Transplantation/2009
                        /81 DKT
Ekser et          American Journal of    61.7 [+ or -] 5.6
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of    58.9 [+ or -] 10.5
  al. [28]       Transplantation/2013
                       /1308 DKT
Bunnapradist      Journal of American    55.1 [+ or -] 11.5
  et al. [31]    Society of Nephrology
                       /403 DKT

Author            Journal/year/number               DKT
                     of recipient
                                              Immunosuppression

Remuzzi et        Journal of American    Prednisolone, Cyclosporine
  al. [16]       Society of Nephrology    & mycophenolate mofetil.
                     /1999/24 DKT          No comment on induction
Lu et al. [20]   Archives of Surgery/     Cyclosporine, steroids &
                      1999/50 DKT        [MMF.sup.*] or [AZA.sup.*].
                                         Induction with [OKT3.sup.*]
                                          or [IL-2.sup.*] inhibitor
Snanoudj          American Journal of      Received IL-2 receptor
  et al. [24]    Transplantation/2009    antagonist or [ATG.sup.*].
                        /81 DKT          Cyclosporine or tacrolimus,
                                          prednisolone and MMF were
                                            used after induction
Ekser et          American Journal of    Induction therapy consisted
  al. [19]          Transplantation       of antithymocyte globulin
                     /2010/100 DKT          (ATG) or Basiliximab.
                                                 Maintenance
                                              immunosuppressive
                                           sirolimus or everolimus
                                              either without a
                                                 calcineurin
                                         inhibitor ([CNI.sup.*]) or
                                             with a reduced CNI
Klair et          American Journal of           No comment on
  al. [28]       Transplantation/2013          immunosuppressive
                       /1308 DKT               medications used
Bunnapradist      Journal of American           No comment on
  et al. [31]    Society of Nephrology         immunosuppressive
                       /403 DKT                medications used

Author            Journal/year/number           DKT
                     of recipient
                                               Weight

Remuzzi et        Journal of American    71.4 [+ or -] 19.1
  al. [16]       Society of Nephrology
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/            --
                      1999/50 DKT
Snanoudj          American Journal of    68.4 [+ or -] 14.1
  et al. [24]    Transplantation/2009
                        /81 DKT
Ekser et          American Journal of            --
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of            --
  al. [28]       Transplantation/2013
                       /1308 DKT
Bunnapradist      Journal of American    77.1 [+ or -] 17.1
  et al. [31]    Society of Nephrology
                       /403 DKT

Author            Journal/year/number           DKT
                     of recipient
                                                BMI

Remuzzi et        Journal of American    25.3 [+ or -] 5.4
  al. [16]       Society of Nephrology
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/           --
                      1999/50 DKT
Snanoudj          American Journal of    24.3 [+ or -] 4.1
  et al. [24]    Transplantation/2009
                        /81 DKT
Ekser et          American Journal of    25.5 [+ or -] 3.5
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of          25.1
  al. [28]       Transplantation/2013
                       /1308 DKT
Bunnapradist      Journal of American           --
  et al. [31]    Society of Nephrology
                       /403 DKT

Author            Journal/year/number            SKT
                     of recipient
                                               Comorbid

Remuzzi et        Journal of American     [HTN.sup.*] 77.3%
  al. [16]       Society of Nephrology     [DM.sup.*] 4.4%
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/             --
                      1999/50 DKT
Snanoudj          American Journal of      [DM.sup.*] 18.5%
  et al. [24]    Transplantation/2009    ischemic cardiopathy
                        /81 DKT                 18.2%
Ekser et          American Journal of
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of      [DM.sup.*] 37.5%
  al. [28]       Transplantation/2013     [HTN.sup.*] 25.6%
                       /1308 DKT
Bunnapradist      Journal of American             --
  et al. [31]    Society of Nephrology
                       /403 DKT

Author            Journal/year/number           SKT
                     of recipient
                                            Age (years)

Remuzzi et        Journal of American    50.2 [+ or -] 12.1
  al. [16]       Society of Nephrology
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/      50 [+ or -] 12
                      1999/50 DKT
Snanoudj          American Journal of    59.9 [+ or -] 6.3
  et al. [24]    Transplantation/2009
                        /81 DKT
Ekser et          American Journal of    57.7 [+ or -] 8.6
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of    49.6 [+ or -] 14.8
  al. [28]       Transplantation/2013
                       /1308 DKT
Bunnapradist      Journal of American    48.1 [+ or -] 13.7
  et al. [31]    Society of Nephrology
                       /403 DKT

Author            Journal/year/number           SKT
                     of recipient
                                               Weight

Remuzzi et        Journal of American    73.1 [+ or -] 16.2
  al. [16]       Society of Nephrology
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/            --
                      1999/50 DKT
Snanoudj          American Journal of    72.8 [+ or -] 17.0
  et al. [24]    Transplantation/2009
                        /81 DKT
Ekser et          American Journal of            --
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of            --
  al. [28]       Transplantation/2013
                       /1308 DKT
Bunnapradist      Journal of American    77.4 [+ or -] 19.2
  et al. [31]    Society of Nephrology
                       /403 DKT

Author            Journal/year/number           SKT
                     of recipient
                                                BMI

Remuzzi et        Journal of American    25.3 [+ or -] 4.7
  al. [16]       Society of Nephrology
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/           --
                      1999/50 DKT
Snanoudj          American Journal of    25.1 [+ or -] 4.7
  et al. [24]    Transplantation/2009
                        /81 DKT
Ekser et          American Journal of    24.5 [+ or -] 3.4
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of          29.6
  al. [28]       Transplantation/2013
                       /1308 DKT
Bunnapradist      Journal of American           --
  et al. [31]    Society of Nephrology
                       /403 DKT

Author            Journal/year/number          SKT
                     of recipient
                                             Comorbid

Remuzzi et        Journal of American    [HTN.sup.*] 71.7%
  al. [16]       Society of Nephrology    [DM.sup.*] 6.4%
                     /1999/24 DKT
Lu et al. [20]   Archives of Surgery/           --
                      1999/50 DKT
Snanoudj          American Journal of    [DM.sup.*] 18.6%
  et al. [24]    Transplantation/2009        Ischemic
                        /81 DKT          Cardiopathy 12.9%
Ekser et          American Journal of           --
  al. [19]          Transplantation
                     /2010/100 DKT
Klair et          American Journal of    [DM.sup.*] 28.4%
  al. [28]       Transplantation/2013    [HTN.sup.*] 34.9%
                       /1308 DKT
Bunnapradist      Journal of American           --
  et al. [31]    Society of Nephrology
                       /403 DKT

*. [HTN.sup.*] (hypertension), [DM.sup.*] (diabetes mellitus),
[PRA.sup.*] (panel reactive antibody), [HLA MM.sup.*] (human
leukocyte antigen mismatches), [M.sup.*] (male), [F.sup.*]
(female), [MMF.sup.*] (mycophenolate mofetil), [AZA.sup.*]
(azathioprine), [IL-2.sup.*] (interleukin-2), [ATG.sup.*]
(antithymocyte globulin), and [OKT3.sup.*] (muromonab-CD3).

TABLE 3: Surgical complication of DKT versus SKT.

                                                  DKT

Author             Journal/year           Surgical technique
                                       /number/immunosuppression

Frutos            Nefrologia/2012         20 bilateral Kidney
  et al. [21]                              placement through
                                             2 independent
                                           incisions in each
                                           of the recipients
                                        iliac fossae/induction
                                           with basiliximab
                                            + prednisolone,
                                       tacrolimus & [MMF.sup.*]
Snanoudj         American Journal     81 monolateral or bilateral
  et al. [24]   of Transplantation     placement with one or two
                       /2009           classical iliac incisions
                                        /received [IL-2.sup.*]
                                        receptor antagonist or
                                       [ATG.sup.*]. Cyclosporine
                                      or tacrolimus, prednisolone
                                       and [MMF.sup.*] were used
                                            after induction
Remuzzi         Journal of American     24 bilateral placement
  et al. [16]       Society of          through double inguinal
                  Nephrology/1999       incision/Prednisolone,
                                            Cyclosporine &
                                         mycophenolate mofetil
Ekser            American Journal           100 unilateral
  et al. [19]   of Transplantation          extraperitoneal
                       /2010             placement via Gibson
                                          incision/Induction
                                           therapy consisted
                                           of antithymocyte
                                           globulin (ATG) or
                                             Basiliximab.
                                              Maintenance
                                           immunosuppressive
                                             sirolimus or
                                           everolimus either
                                         without a calcineurin
                                        inhibitor ([CNI.sup.*])
                                           or with a reduced
                                          [CNI.sup.*] dosage
Islam               Journal of            29 extraperitoneal
  et al. [22]     Transplantation         placement in right
                       /2016              iliac fossa through
                                         curvilinear incision
                                         /high risk recipients
                                         received [ATG.sup.*]
                                          and the rest either
                                             daclizumab or
                                             basiliximab.
                                              Maintenance
                                           immunosuppression
                                             consisted of
                                       tacrolimus, [MMF.sup.*],
                                            and prednisone

                                           DKT

Author                 Complication             SKT Complications

Frutos              Hemorrhage 8 (40%)         Hemorrhage 10 (25%)
  et al. [21]       Lymphocele 3 (15%)          Lymphocele 2 (5%)
                     Resurgery 1 (5%)          Resurgery 1 (2.5%)
                Arterial thrombosis 2 (10%)         Arterial
                                                thrombosis 2 (5%)
Snanoudj           Eventration, parietal      Eventration, parietal
  et al. [24]        abscess 6 (7.4%),          abscess 8 (11.4%)
                     Ureteral stenosis          Ureteral stenosis
                        9 (11.1%),                 12 (17.1%)
                      Urinary fistula            Urinary fistula
                         9 (11.1%)                 15 (21.4%)
                       Graft artery               Graft artery
                    stenosis 9 (11.1%),         stenosis 3 (4.3%)
                       Graft partial              Graft partial
                   infarction 3 (3.7%),        infarction 4 (5.7%)
                     Artery thrombosis          Artery thrombosis
                        5 (6.2%) &                  2 (2.9%)
                 Vein thrombosis 6 (7.4%)        Vein thrombosis
                   Hemorrhage 10 (12.3%)            1 (1.4%)
                                              Hemorrhage 9 (12.9%)
Remuzzi           Urinary tract fistula 4         Urinary tract
  et al. [16]   Sepsis from urinary Tract 2         fistula 1
                  Deep vein thrombosis 1           Sepsis from
                        Hematoma 1               urinary Tract 2
                Gastrointestinal Bleeding 1         Deep vein
                     Bowel occlusion 0            thrombosis 1
                                                   Hematoma 1
                                                Gastrointestinal
                                                   Bleeding 0
                                                Bowel occlusion 0
Ekser           Renal vein thrombosis 1(1%)        Renal vein
  et al. [19]     Wound dehiscence 5 (5%)          thrombosis
                     Lymphocele 3 (3%)              1 (1.4%)
                      Hematoma 1 (1%)                 Wound
                 Incisional hernia 1 (1%)          dehiscence
                  Stenosis of ureteroneo            2 (2.7%)
                 -cystoanastomoses 2 (2%)          Lymphocele
                                                    2 (2.7%)
                                                 Hematoma 0 (0%)
                                                   Incisional
                                                  hernia 0 (0%)
                                                   Stenosis of
                                                  ureteroneocy
                                                 -stoanastomoses
                                                    2 (2.7%)
Islam             Urologic complications            Urologic
  et al. [22]           4/29 (14%)                complications
                   All 4 having ureteral          10/487 (2%) 6
                         stricture               out of 10 have
                                                   anastomotic
                                                 strictures and
                                                4 has urine leak

                    DKT

Author          Significance
                  P value

Frutos              NSN
  et al. [21]       SNS
                     NS
Snanoudj             NS
  et al. [24]       NSN
                    SNS
                    NSN
                    SNS
                     NS
Remuzzi              --
  et al. [16]        --
                     --
                     --
                     --
                     --
Ekser                NS
  et al. [19]       NSN
                   SNS NS
                     NS
Islam                S
  et al. [22]

*. [IL-2.sup.*] (interleukin-2), [ATG.sup.*]
(antithymocyte globulin), [MMF.sup.*]
(mycophenolate mofetil), and CNI
(calcineurin inhibitors).

TABLE 4: Outcome of DKT.

Author        Journal/year/number     Number and surgical technique
                     Of DKT            /Immunosuppression for DKT

Johnson et     Transplan tation/     Six paired kidneys were placed
  al. [42]     1996 Surgery/1996      intraperitoneally, while the
                                        remaining four pairs were
                                        placed in bilateral retro
                                         -peritoneal iliac fossa
                                         locations/no comment on
                                      immunosuppressive medications
Johnson et                           Dual kidneys were transplanted
  al. [15]                            intraperitoneally or through
                                        bilateral extraperitoneal
                                      incision/Induction was either
                                           with [ATG.sup.*] or
                                          [OKT3.sup.*] followed
                                          by cyclosporine, AZA
                                            and prednisolone

Alfrey et     Transplantation/1997    20 DKT as two single kidneys
  al. [43]                             on the back table. Through
                                      a midline incision the iliac
                                        vessels were exposed via
                                       extraperitoneal dissection
                                         /all patients received
                                        cyclosporine-based triple
                                              -drug therapy

Stratta and   Transplant Proc/1997     60 DKT (25 young donors 35
  Bennett                              old donors)/No comments on
  [44]                                    surgical teqhnique or
                                            immunosuppressive
                                            medications used
Lu et al.     Archives of Surgery       50 bilateral placement in
  [20]               /1999             right and left iliac fossa
                                      via midline extra peritoneal
                                         approach/Cyclosporine,
                                         steroids & MMF or AZA.
                                         Induction with OKT3 or
                                             IL-2 inhibitor
Remuzzi et    Journal of American        24 bilateral placement
  al. [16]         Society of            through double inguinal
                Nephrology/1999          incision/Prednisolone,
                                             Cyclosporine &
                                         mycophenolate mofetil.
                                         No comment on induction
Jerius et      Journal of Urology        28 kidneys were placed
  al. [33]           /2000                   bilaterally or
                                           unilaterally using
                                         standard right and left
                                             lower quadrant
                                             extraperitoneal
                                          approaches/4 patients
                                           receiving pancreas
                                        received OKT3 induction.
                                           Triple drug immuno
                                         -suppression consisted
                                           of cyclosporine or
                                        tacrolimus, azathioprine
                                        or mycophenolate mofetil
                                         and prednisone was used

Lee et        Journal of American         41 dual kidneys were
  al. [32]    College of Physician        procured in the usual
                     /1999                  fashion and were
                                          prepared as 2 single
                                           kidneys on the back
                                        table. Through a midline
                                           incision the iliac
                                          vessels were exposed
                                           by extraperitoneal
                                         dissection; one kidney
                                         was anastomosed to the
                                         left iliac vessels, and
                                         the other to the right
                                            iliac vessels/the
                                             majority of the
                                         recipients transplanted
                                          received cyclosporine
                                          based triple therapy
                                              that included
                                              mycophenolate
                                         mofetil and prednisone
Gill et         Transplan tation           625 received DKT/no
  al. [18]           /2008                 comment on surgical
                                              technique or
                                            immunosuppression

Snanoudj      American Journal of      81 monolateral or bilateral
  et al.      Transplantation/2009      placement with one or two
  [24]                                  classical iliac incisions
                                         /received [IL-2.sup.*]
                                         receptor antagonist or
                                        [ATG.sup.*]. Cyclosporine
                                       or tacrolimus, prednisolone
                                        and [MMF.sup.*] were used
                                             after induction
Frutos et       Nefrologia/2012            20 bilateral Kidney
  al. [21]                                 placement through 2
                                          independent incisions
                                             in each of the
                                            recipients iliac
                                            fossae/induction
                                            with basiliximab
                                             + prednisolone,
                                              tacrolimus &
                                               [MMF.sup.*]
Ekser et        American Journal             100 unilateral
  al. [19]     of Transplantation            extraperitoneal
                     /2010                    placement via
                                             Gibson incision
                                           /Induction therapy
                                              consisted of
                                              antithymocyte
                                                globulin
                                              ([ATG.sup.*])
                                             or basiliximab.
                                               Maintenance
                                            immunosuppressive
                                              sirolimus or
                                            everolimus either
                                          without a calcineurin
                                                inhibitor
                                            ([CNF.sup.*]) or
                                             with a reduced
                                               [CNF.sup.*]
Islam et        Journal of Trans           29 extraperitoneal
  al. [22]      -plantation/2016           placement in right
                                           iliac fossa through
                                          curvilinear incision
                                          /high risk recipients
                                          received ATG and the
                                         rest either daclizumab
                                             or basiliximab.
                                               Maintenance
                                            immunosuppression
                                        consisted of tacrolimus,
                                           MMF, and prednisone

Author                      Delayed graft function   Acute rejection

                   DKT                 SKT                 DKT

Johnson et          --                 --                   --
  al. [42]

Johnson et          --                 --                   --
  al. [15]

Alfrey et           9%                 45%
  al. [43]

Stratta and         --                 --                   --
  Bennett
  [44]

Lu et al.          26%                 39%           0.2 [+ or -] 0.5
  [20]

Remuzzi et        20.8%               20.8%               20.8%
  al. [16]

Jerius et     6 out 28 cases    7 out of 31 cases           --
  al. [33]

Lee et             24%                 33%                  --
  al. [32]

Gill et            293%         33.6% [ECD.sup.*]    12.1% at 1 year
  al. [18]

Snanoudj          31.6%        51.4% (Significant)   12.3% at 1 year
  et al.
  [24]

Frutos et          30%                 35%                  -
  al. [21]

Ekser et           31%                 30%                 17%
  al. [19]

Islam et          10.3%               9.2%                20.7%
  al. [22]

Author        Acute rejection     Graft survival/kidney
                                   function (creatinine

                    SKT                    DKT

Johnson et           --           Overall graft survival
  al. [42]                        of 90.0% and actuarial
                                  1-year graft survival
                                   of 83.3%. (no death
                                   occurred in cohort)
Johnson et           --            Graft survival at 6
  al. [15]                          month in dual was
                                   100% (no death till
                                     6 month) in <50
                                     years cadaveric
                                     kidney donor and
                                   75% graft t survival
                                   (no comment whether
                                    death censored or
                                    not) in recipient
                                   who got kidney from
                                   cadaveric donor age
                                        > 60 years
Alfrey et                           87% survival at 1
  al. [43]                            year (nondeath
                                   censored. Graft loss
                                    defined as return
                                      to dialysis or
                                          death)
Stratta and          --           90.8% 1 year survival
  Bennett                          (No comment whether
  [44]                              death censored or
                                           not)
Lu et al.     0.7 [+ or -] 0.9     Death censored graft
  [20]                             survival at 2 years
                                         was 85%
Remuzzi et         18.8%           Cr 1.5 [+ or -] 0.4
  al. [16]                        mg/dl & 100% Survival
                                     at 6 months (no
                                  death till follow-up)
Jerius et            --           In an intent to treat
  al. [33]                       analysis with inclusion
                                  of all patients 1 and
                                  2-year graft survival
                                 rates were 93% and 86%.
                                  These differences were
                                    not statistically
                                     significant. The
                                      data were then
                                  adjusted to eliminate
                                    nongraft dependent
                                    loss factors. The
                                  patient in each group
                                     with loss due to
                                     subacute humoral
                                      rejection was
                                      excluded from
                                   analysis. The graft
                                   loss due to patient
                                     noncompliance in
                                  group 1 was treated as
                                   censored data at the
                                   time of loss instead
                                    of graft failure.
                                  With these adjustments
                                   1- and 2-year graft
                                  survival rates for DKT
                                  were 96% and 96% which
                                 was significantly better
                                         than SKT
Lee et               --               GFR at 1 year
  al. [32]                            54 [+ or -] 23
                                     ml/min & 1 year
                                      graft survival
                                     89% (graft loss
                                        defined as
                                     permanent return
                                       to dialysis)

Gill et       17.6% at 1 year         Death-censored
  al. [18]                          allograft survival
                                      of DKT and ECD
                                     transplants were
                                    not significantly
                                    different up to 4
                                  years after transplant
Snanoudj      34.3% at 1 year     Kaplan-Meier estimates
  et al.                           of nondeath-censored
  [24]                             graft survival up to
                                     3 years similar
Frutos et            -                GFR at 1 year
  al. [21]                         55.0 [+ or -] 18.5.
                                    Graff survival at
                                     3 years was 90%
                                  (not death censored).
Ekser et            28%           Actuarial Kaplan-Meier
  al. [19]                        graft survival curves
                                   at 5-year follow-up
                                  was 90.9% (no comment
                                   about death censored
                                  or not death censored)
Islam et           22.4%            Median e GFR (IQR)
  al. [22]                          at 36 months 45.9
                                  ml/minute (36.8-62.6).
                                     Actuarial graft
                                     survivals 93% at
                                    3 years (No death
                                     occurred in this
                                         cohort)

Author        Graft survival/kidney     Patient survival
              function (creatinine

                       SKT                    DKT

Johnson et             --                      --
  al. [42]
Johnson et      62.5 [+ or -] 5.4     100% in recipient of
  al. [15]     & 24.5 [+ or -] 5.3     cadaveric kidneys
                ml/minute in age       from less than 50
                < 50 & age > 60.        year & 83% from
               Graft survival 95%      donor greater than
                in age < 50 & 75%           60 years
                 survival in age
                   > 60 years
Alfrey et      Cr 2.8 [+ or -] 2.0     Cr .4 [+ or -] 0.5
  al. [43]     mg/dl at 4 weeks &      mg/dl at 4 weeks &
                81% survival at 1       93% survival at
                      year                   1 year
Stratta and   87.5% 1 year survival            --
  Bennett
  [44]
Lu et al.     Death censored graft    86% 2-year survival
  [20]         survival at 2 years
                was 84%. years in
               ECD SKT and 86% in
                 control single
Remuzzi et     Cr 1.9 [+ or -] 0.7      100% Survival at
  al. [16]     mg/dl 100% Survival          6 months
                   at 6 months
Jerius et      1- and 2-year graft             --
  al. [33]      survival rates of
                   77% and 73%
Lee et            GFR at 1 year          1-year patient
  al. [32]       57 [+ or -] 25            survival 97%
                  ml/min 1-year
               graft survival 90%
Gill et          Death-censored                --
  al. [18]     allograft survival
                 of DKT and ECD
                transplants were
                not significantly
                different up to 4
                   years after
                   transplant
Snanoudj          Kaplan-Meier            Kaplan-Meier
  et al.          estimates of            estimates of
  [24]          nondeath-censored       patient survival
                graft survival up       similar up to 3
               to 3 years similar            years
Frutos et         GFR at 1 year                --
  al. [21]      51.3 [+ or -] 6.2
Ekser et         4 GFR at 5 year         5-year patient
  al. [19]        9 [+ or -] 13         survival, 95.6%
                  (12 patients)
Islam et       Median e GFR (IQR)      Actuarial patient
  al. [22]      at 36 months 56.7      survivals 100% at
                   (43.7-71.8)              3 years

Author         Patient survival

                      SKT

Johnson et            --
  al. [42]
Johnson et      95% & 83% at 6
  al. [15]    months in age < 50
               & age > 60 years
Alfrey et       96% survival at
  al. [43]          1 year
Stratta and           --
  Bennett
  [44]
Lu et al.     96% 2-year survival
  [20]
Remuzzi et     100% survival at
  al. [16]         6 months
Jerius et             --
  al. [33]
Lee et          1-year patient
  al. [32]        survival 98%
Gill et               --
  al. [18]
Snanoudj         Kaplan-Meier
  et al.         estimates of
  [24]         patient survival
                similar up to 3
                     years
Frutos et             --
  al. [21]
Ekser et        5-year patient
  al. [19]      survival, 87.3%
Islam et
  al. [22]

*. [IL-2.sup.*] (interleukin-2), [ATG.sup.*]
(antithymocyte globulin), [MMF.sup.*] (mycophenolate
mofetil), [AZA.sup.*] (azathiopurine), [CN1.sup.*]
(calcineurin inhibitors), [ECD.sup.*] (extended
criteria donor), e [GFR.sup.*] (estimated
glomerulofilteration rate), and [GFR.sup.*]
(glomerulofilteration rate).
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Author:Khalil, Muhammad Abdul Mabood; Tan, Jackson; Khan, Taqi F. Toufeeq; Khalil, Muhammad Ashhad Ullah; A
Publication:International Scholarly Research Notices
Date:Jan 1, 2017
Words:9868
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