Ten- to 20-year follow-up of 123 consecutive HLA-identical living-related kidney transplants from the pre-cyclosporine era

We studied the long-term morbidity and mortality of 123 consecutive HLA-ID living-related kidney transplants performed at a single institution more than 10 years ago. Type I diabetes was the cause of renal failure in 39% of patients; mean age at transplant was 32 ± 12 yr (range 2-64). Immunosuppression consisted of prednisone and Imuran; most patients received ALG perioperatively. For nondiabetics, 10-, 15-, and 20-yr actuarial patient survival was 85%, 75%, and 68%; for diabetics, 10- and 15-yr survival was 65% and 34% (p = 0.0015). Cardiovascular complications were the main cause of death in diabetics, affecting mostly males; sepsis, malignancy, and graft loss were the main cause of death in nondiabetics. Graft survival paralleled patient survival; 76% of grafts lost were due to patient death. Graft survival at 10 and 15 yr was 81% and 73% for nondiabetics; for diabetics, it was 63% and 24%, respectively (p = 0.0013). When death as a cause of graft loss was excluded, there was no difference between diabetics and nondiabetics. Mean serum creatinine at 10 yr was 1.4 ± 0.5. Thirty-two patients (26%) had one or more acute rejection episodes, most of them occurring within the 1st yr posttransplant. Only 7 grafts have been lost either to acute (4) or chronic (3) rejection. Twenty-four percent of the patients had no complications. Cardiovascular complications (28%) were the major cause of morbidity and mortality, affecting mostly diabetic males. Sepsis was also a significant problem (19.5%), CMV being the most common pathogen. Malignancy occurred in 12.2% of cases, affecting most frequently the skin. Liver dysfunction, mainly of viral etiology, was the cause of 2 deaths and contributed to several others. Nontraumatic osteonecrosis occurred in 4.9% of the patients; it tended to present in young patients soon after their transplant. We conclude that the long-term results of HLA-ID transplantation are excellent when compared to other options in patients with ESRD. Mortality due to the underlying disease (diabetes) and morbidity due to the immunosuppression remain as major obstacles to the long-term survival and successful rehabilitation of these patients.