CHAPTER 13 Renal Transplantation Goh Bak Leong Fan Kin Sing Rohan Malek Bin Dato Dr. Johan Rosnawati Yahya S. Prasad Menon Tan Si Yen Wong Hin Seng Source: 20 th MDTR Report 2012, NRR Table :Stock and flow of renal transplantation, Year New transplant patients Died Graft failure Lost to Follow up Functioning graft at 31 st December Year New transplant patients Died Graft failure Lost to Follow up Functioning graft at 31 st December Source: 20 th MDTR Report 2012, NRR Figure : Stock and flow of renal transplantation, Source: 20 th MDTR Report 2012, NRR Table :New transplant rate per million population (pmp), Year New transplant patients New transplant rate (pmp) Year New transplant patients New transplant rate (pmp) Source: 20 th MDTR Report 2012, NRR Figure : New transplant rate, Source: 20 th MDTR Report 2012, NRR New Transplant rate, pmp '93'94'95'96'97'98'99'00'01'02'03'04'05'06'07'08'09'10'11'12 Year Rate, pmp Table :Transplant prevalence rate per million population (pmp), Year Functioning graft at 31 st December Transplant prevalence rate (pmp) Year Functioning graft at 31 st December Transplant prevalence rate (pmp) Source: 20 th MDTR Report 2012, NRR Figure : Transplant prevalence rate, Source: 20 th MDTR Report 2012, NRR Transplant Prevalence rate, pmp '93'94'95'96'97'98'99'00'01'02'03'04'05'06'07'08'09'10'11'12 Year Rate, pmp Table :Renal transplant recipients characteristics, Year New Transplant Patients Age at transplant (years), Mean Age at transplant (years), SD % Male % Diabetic (co-morbid/ primary renal disease) % HbsAg positive % Anti-HCV positive Year New Transplant Patients Age at transplant (years), Mean Age at transplant (years), SD % Male % Diabetic (co-morbid/ primary renal disease) % HbsAg positive % Anti-HCV positive Source: 20 th MDTR Report 2012, NRR Table :Primary causes of end stage renal failure, Source: 20 th MDTR Report 2012, NRR Table :Type of renal transplantation, Source: 20 th MDTR Report 2012, NRR Table :Place of transplantation, Source: 20 th MDTR Report 2012, NRR Table :Post-transplant complications, Source: 20 th MDTR Report 2012, NRR Table :Biochemical data, Source: 20 th MDTR Report 2012, NRR Table :Transplant patients death rate and graft loss, Year Number at risk Transplant death Transplant death rate % Graft loss Graft loss rate % Acute rejection Acute rejection rate % All losses All losses rate % Year Number at risk Transplant death Transplant death rate % Graft loss Graft loss rate % Acute rejection Acute rejection rate % All losses All losses rate % Source: 20 th MDTR Report 2012, NRR Figure (a): Transplant recipient death rate, Source: 20 th MDTR Report 2012, NRR Death rate % '93'94'95'96'97'98'99'00'01'02'03'04'05'06'07'08'09'10'11'12 Year Annual death rate Figure (b): Transplant recipient graft loss rate, Source: 20 th MDTR Report 2012, NRR Graft loss rate % '93'94'95'96'97'98'99'00'01'02'03'04'05'06'07'08'09'10'11'12 Year Annual graft loss rate Table (a): Causes of death in transplant recipients, Source: 20 th MDTR Report 2012, NRR Table (b): Causes of graft failure, Source: 20 th MDTR Report 2012, NRR Table : Patient survival, Interval (years)n% SurvivalSE Source: 20 th MDTR Report 2012, NRR Figure : Patient survival, Source: 20 th MDTR Report 2012, NRR Table : Risk factors for transplant patient survival Source: 20 th MDTR Report 2012, NRR Table : Graft survival, Interval (years)n% SurvivalSE Source: 20 th MDTR Report 2012, NRR Figure : Graft survival, Source: 20 th MDTR Report 2012, NRR Table : Risk factors for transplant graft survival Source: 20 th MDTR Report 2012, NRR Table :Unadjusted patient survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Cadaver Interval (years)n % Survival SEn % Survival SEn % Survival SEn %Survival SE *n=Number at riskSE=standard error Source: 20 th MDTR Report 2012, NRR Figure : Patient survival by type of transplant, Source: 20 th MDTR Report 2012, NRR Table : Graft survival by type of transplant, Type of Transplant Commercial Cadaver Commercial Live Donor Cadaver Interval (years)n % Survival SEn % Survival SEn % Survival SEn % Survival SE *n=Number at riskSE=standard error Source: 20 th MDTR Report 2012, NRR Figure : Graft survival by type of transplants, Source: 20 th MDTR Report 2012, NRR Table : Patient survival by year of transplant (Living related transplant, ) Year of Transplant Interval (years)n% SurvivalSEn% SurvivalSE Source: 20 th MDTR Report 2012, NRR Figure : Patient survival by year of transplant (Living related transplant, ) Source: 20 th MDTR Report 2012, NRR Table : Graft survival by year of transplant (Living related transplant, ) Year of Transplant Interval (years)n% SurvivalSEn% SurvivalSE Source: 20 th MDTR Report 2012, NRR Figure : Graft survival by year of transplant (Living related transplant, ) Source: 20 th MDTR Report 2012, NRR Table : Patient survival by year of transplant (Commercial cadaver transplant, ) Year of Transplant Interval (years)n% SurvivalSEn% SurvivalSE Source: 20 th MDTR Report 2012, NRR Figure : Patient survival by year of transplant (Commercial cadaver transplant, ) Source: 20 th MDTR Report 2012, NRR Table : Graft survival by year of transplant (Commercial cadaver transplant, ) Year of Transplant Interval (years)n% SurvivalSEn% SurvivalSE Source: 20 th MDTR Report 2012, NRR Figure : Graft survival by year of transplant (Commercial cadaver transplant, ) Source: 20 th MDTR Report 2012, NRR Table : Medication data, Source: 20 th MDTR Report 2012, NRR Figure (a)(i): Calcineurin inhibitors: Cyclosporin vs Tacrolimus Source: 20 th MDTR Report 2012, NRR Proportion of patients '04'05'06'07'08'09'10'11'12 Year CsATacrolimus Figure (a)(ii): Antimetabolites: Azathioprine vs Mycophenolic Acid Source: 20 th MDTR Report 2012, NRR Proportion of patients '04'05'06'07'08'09'10'11'12 Year AzathioprineMycophenolic Acid Table : Use of anti-hypertensive medications Source: 20 th MDTR Report 2012, NRR Table : Risk factors for IHD in renal transplant recipients at year Diabetes27 (1.8)21 (1.4) 25 (1.6)18 (1.1) Hypertension**501 (34.1)508 (33.1)452 (30.9)586 (37.2)662 (41.7) CKD121 (8.2)142 (9.3)177 (12.1)127 (8.1)117 (7.4) Diabetes + Hypertension**149 (10.1)163 (10.6)158 (10.8)179 (11.4)204 (12.8) Diabetes + CKD21 (1.4)20 (1.3)18 (1.2)11 (0.7)22 (1.4) CKD + Hypertension**530 (36.1)537 (35.0)489 (33.4)515 (32.7)456 (28.7) Diabetes + CKD + Hypertension** 120 (8.2)143 (9.3)148 (10.1)134 (8.5)110 (6.9) Diabetes28 (1.8)35 (2.1)38 (2.2)37 (2.2) Hypertension**644 (41.0)635 (37.8)674 (38.9)596 (36.1) CKD156 (9.9)166 (9.9)159 (9.2)225 (13.6) Diabetes + Hypertension**164 (10.4)197 (11.7)215 (12.4)203 (12.3) Diabetes + CKD18 (1.1)22 (1.3)33 (1.9)33 (2.0) CKD + Hypertension**472 (30.1)514 (30.6)508 (29.3)457 (27.7) Diabetes + CKD + Hypertension** 88 (5.6)109 (6.5)105 (6.1)100 (6.1) **Hypertension: BP systolic > 140 and BP diastolic > 90, or on anti-hypertensive drugs Source: 20 th MDTR Report 2012, NRR Figure (a): Venn diagram for pre and post transplant complications (in %) at year , Source: 20 th MDTR Report 2012, NRR Figure (b): Venn diagram for pre and post transplant complications (in %) at year Source: 20 th MDTR Report 2012, NRR Figure (c): Venn diagram for pre and post transplant complications (in %) at year Source: 20 th MDTR Report 2012, NRR Figure (d): Venn diagram for pre and post transplant complications (in %) at year Source: 20 th MDTR Report 2012, NRR Figure (e): Venn diagram for pre and post transplant complications (in %) at year Source: 20 th MDTR Report 2012, NRR Table (a): Systolic BP, Year n%n%n%n%n% < >= Year n%n%n%n% < >= Source: 20 th MDTR Report 2012, NRR Figure (a): Systolic BP, Source: 20 th MDTR Report 2012, NRR Table (b): Diastolic BP, Year n%n%nn%n%n < >= Year n%n%n%n% < >= Source: 20 th MDTR Report 2012, NRR Figure (b): Diastolic BP, Source: 20 th MDTR Report 2012, NRR Table : CKD stages, Year n%n%n%n%n% Stage Stage Stage Stage Stage Year n%n%n%n% Stage Stage Stage Stage Stage Source: 20 th MDTR Report 2012, NRR Figure : CKD stages by year Source: 20 th MDTR Report 2012, NRR Percent Year CKD Stage 1CKD Stage 2CKD Stage 3 CKD Stage 4CKD Stage 5 Table : BMI, Year n%n%n%n%n% < > Year n%n%n%n% < > Source: 20 th MDTR Report 2012, NRR Figure : BMI, Source: 20 th MDTR Report 2012, NRR Percent Year BMI 30 Table (a): LDL, Year n%n%n%n%n% < >= Year n%n%n%n% < >= Source: 20 th MDTR Report 2012, NRR Figure (a): LDL, Source: 20 th MDTR Report 2012, NRR Percent Year LDL = 3.4 Table (b): Total cholesterol, Year n%n%n%n%n% < > Year n%n%n%n% < > Source: 20 th MDTR Report 2012, NRR Figure (b): Total cholesterol, Source: 20 th MDTR Report 2012, NRR Percent Year Total Cholesterol 7.2 Table (c): HDL, Year n%n%n%n%n% < > Year n%n%n%n% < > Source: 20 th MDTR Report 2012, NRR Figure (c): HDL, Source: 20 th MDTR Report 2012, NRR Percent Year HDL 1.3 Table (a): Treatment for hypertension, Yearn % on anti- hypertensive drug % on 1 anti- hypertensive drug % on 2 anti- hypertensive drug % on 3 anti- hypertensive drug Source: 20 th MDTR Report 2012, NRR Table (b): Distribution of systolic BP without anti-hypertensive, YearnMeanSDMedianLQUQ% Patients 160mmHg Source: 20 th MDTR Report 2012, NRR Table (c): Distribution of diastolic BP without anti-hypertensive, YearnMeanSDMedianLQUQ% patients 90mmHg Source: 20 th MDTR Report 2012, NRR Table (d): Distribution of systolic BP on anti-hypertensives, YearnMeanSDMedianLQUQ% Patients 160mmHg Source: 20 th MDTR Report 2012, NRR Table (e): Distribution of diastolic BP on anti-hypertensives, YearnMeanSDMedianLQUQ% Patients 90 mmHg Source: 20 th MDTR Report 2012, NRR Table : Allograftraft and patient survival, Azathioprine vs Mycophenolic Acid AzathioprineMycophenolic Acid Survival (%)nGraftPatientnGraftPatient 1 year years years years Source: 20 th MDTR Report 2012, NRR Figure (a): Graft survival, Azathioprine vs Mycophenolic Acid Source: 20 th MDTR Report 2012, NRR Figure (b): Patient survival, Azathioprine vs Mycophenolic Acid, Source: 20 th MDTR Report 2012, NRR Table : Graft and patient survival, CsA vs Tacrolimus CsATacrolimus Survival (%)nGraftPatientnGraftPatient 1 year years years years Source: 20 th MDTR Report 2012, NRR Figure (a): Graft survival, CsA vs Tacrolimus, Source: 20 th MDTR Report 2012, NRR Figure (b): Patient survival, CsA vs Tacrolimus, Source: 20 th MDTR Report 2012, NRR Table : Mean SBP, CsA vs Tacrolimus, Mean SBP CsAMean SBP Tacrolimus Source: 20 th MDTR Report 2012, NRR Figure : Mean SBP, CsA vs Tacrolimus, Source: 20 th MDTR Report 2012, NRR Table : Mean GFR, CsA vs Tacrolimus, Mean GFR CsAMean GFR Tacrolimus Source: 20 th MDTR Report 2012, NRR Figure : Mean GFR, CsA vs Tacrolimus, Source: 20 th MDTR Report 2012, NRR Table : Mean LDL, CsA vs Tacrolimus, Mean LDL CsAMean LDL Tacrolimus Source: 20 th MDTR Report 2012, NRR Figure : Mean LDL, CsA vs Tacrolimus, Source: 20 th MDTR Report 2012, NRR Table : Incidence of post transplant diabetes mellitus, CsA vs Tacrolimus, Post Tx DM CsAPost Tx DM Tacrolimus Source: 20 th MDTR Report 2012, NRR Figure : Cumulative incidence of post transplant diabetes, CsA vs Tacrolimus, Source: 20 th MDTR Report 2012, NRR Table : Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients Dialysis modalityQoL score Number of patients2227 Centile (LQ) (median) (UQ) Source: 20 th MDTR Report 2012, NRR Figure : Cumulative distribution of QoL-Index score in relation to dialysis modality, transplant recipient patients Source: 20 th MDTR Report 2012, NRR Table : Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients Diabetes mellitusNoYes Number of patients Centile (LQ) (median) (UQ) Source: 20 th MDTR Report 2012, NRR Figure : Cumulative distribution of QoL-Index score in relation to diabetes mellitus, transplant recipient patients Source: 20 th MDTR Report 2012, NRR Table : Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients GenderMaleFemale Number of patients Centile (LQ) (median) (UQ) Source: 20 th MDTR Report 2012, NRR Figure : Cumulative distribution of QoL-Index score in relation to gender, transplant recipient patients Source: 20 th MDTR Report 2012, NRR Table : Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients Age group (years)< >=60 Number of patients Centile (LQ) (median) (UQ) Source: 20 th MDTR Report 2012, NRR Figure : Cumulative distribution of QoL-Index score in relation to age, transplant recipient patients Source: 20 th MDTR Report 2012, NRR Table : Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients Source: 20 th MDTR Report 2012, NRR Figure : Cumulative distribution of QoL-Index score in relation to year of entry, transplant recipient patients Source: 20 th MDTR Report 2012, NRR