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Original Article

Survival Benefit with Kidney Transplants from HLA-Incompatible Live Donors

B.J. Orandi, X. Luo, A.B. Massie, J.M. Garonzik‑Wang, B.E. Lonze, R. Ahmed, K.J. Van Arendonk, M.D. Stegall, S.C. Jordan, J. Oberholzer, T.B. Dunn, L.E. Ratner, S. Kapur, R.P. Pelletier, J.P. Roberts, M.L. Melcher, P. Singh, D.L. Sudan, M.P. Posner, J.M. El‑Amm, R. Shapiro, M. Cooper, G.S. Lipkowitz, M.A. Rees, C.L. Marsh, B.R. Sankari, D.A. Gerber, P.W. Nelson, J. Wellen, A. Bozorgzadeh, A.O. Gaber, R.A. Montgomery, and D.L. Segev


N Engl J Med 2016;374:940-50. DOI: 10.1056/NEJMoa1508380

BACKGROUND
A report from a high-volume single center indicated a survival benefit of receiving a kidney transplant from an HLA-incompatible live donor as compared with remaining on the waiting list, whether or not a kidney from a deceased donor was received. The generalizability of that finding is unclear.

METHODS
In a 22-center study, we estimated the survival benefit for 1025 recipients of kidney transplants from HLA-incompatible live donors who were matched with controls who remained on the waiting list or received a transplant from a deceased donor (waitinglist-or-transplant control group) and controls who remained on the waiting list but did not receive a transplant (waiting-list-only control group). We analyzed the data with and without patients from the highest-volume center in the study.

RESULTS
Recipients of kidney transplants from incompatible live donors had a higher survival rate than either control group at 1 year (95.0%, vs. 94.0% for the waiting-list-ortransplant control group and 89.6% for the waiting-list-only control group), 3 years (91.7% vs. 83.6% and 72.7%, respectively), 5 years (86.0% vs. 74.4% and 59.2%), and 8 years (76.5% vs. 62.9% and 43.9%) (P<0.001 for all comparisons with the two control groups). The survival benefit was significant at 8 years across all levels of donorspecific antibody: 89.2% for recipients of kidney transplants from incompatible live donors who had a positive Luminex assay for anti-HLA antibody but a negative flowcytometric cross-match versus 65.0% for the waiting-list-or-transplant control group and 47.1% for the waiting-list-only control group; 76.3% for recipients with a positive flow-cytometric cross-match but a negative cytotoxic cross-match versus 63.3% and 43.0% in the two control groups, respectively; and 71.0% for recipients with a positive cytotoxic cross-match versus 61.5% and 43.7%, respectively. The findings did not change when patients from the highest-volume center were excluded.

CONCLUSIONS
This multicenter study validated single-center evidence that patients who received kidney transplants from HLA-incompatible live donors had a substantial survival benefit as compared with patients who did not undergo transplantation and those who waited for transplants from deceased donors. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.) 

 Originally Appeared in The New England Journal of Medicine on March 10, 2016.

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