Expanded criteria donors for kidney transplantation
2003; Elsevier BV; Volume: 3; Linguagem: Inglês
10.1034/j.1600-6143.3.s4.11.x
ISSN1600-6143
AutoresRobert A. Metzger, Francis L. Delmonico, Sandy Feng, Friedrich K. Port, J. D. Wynn, Robert M. Merion,
Tópico(s)Organ Donation and Transplantation
ResumoThe ideal deceased organ donor is a younger person who dies from traumatic head injury that is isolated to the brain and leaves the thoracic and abdominal organ function intact. Such a deceased donor provides excellent transplantable organs with an opportunity to achieve immediate allograft function and long-term patient survival. As the size of the recipient waiting list and the number of waiting list deaths increase, older donors and donors with characteristics once thought to preclude organ donation are being used more and more frequently (1Kauffman MH Bennett LE McBride MA Ellison MD The expanded donor.Transplant Rev. 1997; 11: 165-190Crossref Scopus (54) Google Scholar). The clinical characteristics that differentiate 'marginal' renal allografts are derived from the social and medical history of the donor (age, history of hypertension or diabetes, the risk of transmitting infectious disease and/or malignancy), the cause of donor death (trauma vs. cerebrovascular accident), the mechanism of donor death (brain death vs. cardiac death), the anatomy of the allograft (vessel abnormalities), the morphology on biopsy (glomerulosclerosis, interstitial nephritis and/or fibrosis), and the functional profile (serum creatinine or calculated glomerular filtration rate) prior to transplantation (2Becker TY Use of marginal donors in kidney transplantation.Graft. 2000; 3: 216-220Google Scholar, 3Randhawa P Role of donor kidney biopsies in renal transplantation.Transplantation. 2001; 71: 1361-1365Crossref PubMed Scopus (82) Google Scholar). Kauffman suggests that the term 'expanded' be used to refer to the donor whose organs may be associated with poorer outcome because the term 'marginal' may be considered pejorative by the patients who receive them, as well as by the programs that transplant them (1Kauffman MH Bennett LE McBride MA Ellison MD The expanded donor.Transplant Rev. 1997; 11: 165-190Crossref Scopus (54) Google Scholar). Kidneys transplanted from older donors are considered to be from the expanded pool because these allografts have a higher rate of delayed graft function, more acute rejection episodes, and decreased long-term graft function. Several factors, including prolonged cold ischemia time (CIT), increased immunogenicity, impaired ability to repair tissue, and impaired function with decreased nephron mass may contribute to this (4De Fijter JW Mallat MJK Doxiadis IIN et al.Increased immunogenicity and cause of graft loss of old donor kidneys..J Am Soc Nephrol. 2001; 12: 1538-1546Crossref PubMed Google Scholar). But recently, Ojo et al. have demonstrated that the recipients of expanded kidneys receive the benefit of extra life-years when compared to wait-listed dialysis patients (5Ojo AO Hanson JA Meier-Kriesche H et al.Survival in recipients of marginal cadaveric donor kidneys compared with other recipients and wait-listed transplant candidates.J Am Soc Nephrol. 2001; 12: 589-597Crossref PubMed Google Scholar). Still, placement of these organs is often difficult and delayed, and some centers continue to prefer not to utilize them (6Lee CM Scandling JD Pavlakis M Markezich AJ Dafoe DC Alfrey EJ A review of kidneys that nobody wanted: determinants of optimal outcome.Transplantation. 1998; 65: 213-219Crossref PubMed Scopus (34) Google Scholar). The crisis in organ supply presents a compelling responsibility for the transplant community to maximize the use of organs procured from all deceased donors. In March, 2001, representatives of the transplant community convened in Crystal City, VA, in order to develop guidelines that would improve the recovery and transplantation of organs from the deceased donor. This meeting, sponsored by The American Society of Transplantation and The American Society of Transplant Surgeons, produced the 'Report of the Crystal City Meeting to Maximize the Use of Organs Recovered from the Cadaver Donor', published in the American Journal of Transplantation (7Rosengard BR Feng S Alfrey EJ et al.Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor.Am J Transplant. 2002; 2: 1-10Crossref PubMed Scopus (275) Google Scholar). At the meeting, five work groups were assembled that focussed upon increasing the use of hearts, lungs, livers, and kidneys, from deceased donors with a history of malignancy or serology testing positive for hepatitis B or C. The Kidney Work Group (7Rosengard BR Feng S Alfrey EJ et al.Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor.Am J Transplant. 2002; 2: 1-10Crossref PubMed Scopus (275) Google Scholar) noted that in recent years the discard rate of kidneys from deceased donors has increased substantially and approaches 50% for kidneys recovered from donors over age 60. They estimated a potential increase of 38% in the rate of donors per million population if the United States could match Spain's rate of recovery of kidneys from donors over age 45. The work group recommended, and the conference participants endorsed, expedited placement of kidneys from all donors over age 60, based upon waiting time only, to a list of preselected and preinformed recipients who would accept these kidneys. Expanded criteria kidneys are expected to increase overall kidney utilization by stimulating higher procurement rates and lower discard rates. Under the work group's proposed plan, the Organ Procurement and Transplantation Network (OPTN), through its contract with the United Network for Organ Sharing (UNOS) would be asked to develop a standard policy whereby a local organ procurement organization (OPO) could adopt the policy upon notification to OPTN/UNOS of local OPO approval. Finally, allocation would occur primarily at the level of the OPO or the region, except for the identification of zero antigen mismatched recipients, which would be allocated nationally. Another objective of the work group was to evaluate the use of biopsies in the decision to transplant a kidney from an older donor. Currently, biopsies at the time of recovery assume a high importance in kidney distribution; however, available evidence remains controversial (see below). The work group recommended assessing the glomerular filtration rate (GFR) using the Cockcroft–Gault formula or creatinine clearance and to compare the GFR value to biopsy findings to determine the utility of either or both in predicting immediate and long-term function of the older donor's kidney. At the same time, the OPTN/UNOS Organ Availability and Kidney/Pancreas Committees were each seeking to better define the expanded criteria donor (ECD) in order to provide the transplant community with a more objective basis for decision-making for utilization of these organs for transplantation. The Crystal City kidney proposal was subsequently modified by a collaboration of the OPTN/UNOS Organ Availability Committee, OPTN/UNOS Kidney/Pancreas Committee, and the Scientific Registry of Transplant Recipients (SRTR) contracted to University Renal Research and Education Association (URREA). The result of their interaction with the Crystal City Kidney Group was to define the ECD based upon not only age but also using other statistically significant risk factors determined by the SRTR analyses. Three additional significant donor medical risk factors were identified: history of hypertension, cerebrovascular accident as a cause of death, and final preprocurement creatinine >1.5 mg/dL. Donor kidneys were characterized according to combinations of these four parameters, and a relative risk of graft loss was determined for each donor profile. The ECD kidney was then precisely defined as any kidney whose relative risk of graft failure exceeded 1.7 when compared to a reference group of ideal donor kidneys: those from donors of age 10–39 years, who were without hypertension, who did not die of a cerebrovascular accident, and whose terminal predonation creatinine level was <1.5 mg/dL (Table 1). Using this definition based on the relative risk of graft loss, all donors over age 60 and donors aged 50–59 with at least two of the three medical criteria are identified as ECDs (Table 2) (8Port FK Bragg JL Metzger RA et al.Donor characteristics associated with reduced graft survival. an approach to expanding the pool of kidney donors.Transplantation. 2002; 74: 1281-1286Crossref PubMed Scopus (632) Google Scholar). Since the number of donors under age 10 was very small they were not included in the ECD definition in order to keep the defined matrix less complicated.Table 1Relative Risk (RR) of graft loss by four donor characteristicsRRAgeNormal creatinineHigh creatinine(years)No HTNHTNNo HTNHTNCause of death was not cerebrovascular accident0–91.40**p <0.0005.1.59**p <0.0005.1.52**p <0.0005.–10–391.001.14**p <0.0005.1.09*p <0.051.24**p <0.0005.40–491.17**p <0.0005.1.33**p <0.0005.1.28**p <0.0005.1.45**p <0.0005.50–591.41**p <0.0005.1.60**p <0.0005.1.53**p <0.0005.1.74 **p <0.0005.60+1.90 **p <0.0005.2.16 **p <0.0005.2.07 **p <0.0005.2.36 **p <0.0005.Cause of death was cerebrovascular accident0–91.60**p <0.0005.1.82 **p <0.0005.1.74 **p <0.0005.1.98 **p <0.0005.10–391.14**p <0.0005.1.30**p <0.0005.1.24**p <0.0005.1.41**p <0.0005.40–491.34**p <0.0005.1.52**p <0.0005.1.46**p <0.0005.1.66**p <0.0005.50–591.61**p <0.0005.1.83 **p <0.0005.1.75 **p <0.0005.1.99 **p <0.0005.60+2.17 **p <0.0005.2.47 **p <0.0005.2.37 **p <0.0005.2.69 **p 1.7.* p <0.05** p 1.7 (see Table 1) for donors older than 10 years of age, shown below, are now the OPTN-approved expanded criteria by which kidney donors are defined as expanded and placed into the expedited systemDonor age categories (years)Donor condition 1.5XXCVA+HTNXXCVA+ Creat >1.5XXHTN+ Creat >1.5XXCVAXHTNXCreatinine >1.5XNone of the aboveXSource: OPTN.CVA=cerebrovascular accident was cause of death.HTN = history of hypertension.Creat >1.5 = creatinine >1.5mg/dL. Open table in a new tab Source: SRTR data analyses as of August 1, 2002. HTN = donor hypertension. Numbers in boldface indicate RR>1.7. Source: OPTN. CVA=cerebrovascular accident was cause of death. HTN = history of hypertension. Creat >1.5 = creatinine >1.5mg/dL. This consistent definition of an ECD was adopted by the OPTN/UNOS Board of Directors in November, 2001, and allocation of ECD became operative within the current allocation policy (UNOS Policy 3.5, Allocation of Cadaveric Kidneys) in October, 2002. The policy states, 'Kidneys procured from the ECD will be allocated to patients determined to be suitable candidates: first, for zero antigen mismatched patients among this group of patients with time limitations; and next, for all other eligible patients locally, regionally, and nationally, based upon time waiting and not HLA matching. The UNOS Organ Center will attempt to place expanded criteria donor organs for the zero antigen mismatched patients, according to the national list of patients waiting for expanded criteria kidneys for a period of two hours, after which time the UNOS Organ Center will notify the Host OPO that it may allocate the expanded criteria kidneys by the standard geographical sequence of local, regional, and national allocation. OPOs are required to identify potential recipients (i.e. perform a match run and start the process for notifying the appropriate transplant program(s) regarding the organ offer) for kidneys they procure from expanded criteria donors within six hours post cross-clamp or offer the organs for eligible patients listed regionally and then nationally' (7Rosengard BR Feng S Alfrey EJ et al.Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor.Am J Transplant. 2002; 2: 1-10Crossref PubMed Scopus (275) Google Scholar). UNOS Policy 3.5.1 defines standard donors as all other (non-ECD) donors, and notes that potential recipients electing to join the waiting list for the ECD kidneys would also be eligible to receive standard kidneys. Given the clear definition of an ECD, there are important issues that must be addressed about the use of organs recovered from such donors. The foremost is deciding whether to transplant kidneys from the ECD or, by not accepting them, permit them to be discarded. The discard of kidneys after recovery from the deceased donor has been increasing at an alarming rate in the United States. During the past 5 years, the discard rate has increased from 12% to 15%—mostly because of the increase in the number of donors older than 50, who now represent over 30% of the national donor population. In the SRTR analysis, roughly 40% of kidneys defined as ECD with >1.7 relative risk of graft failure were discarded in 2001. In contrast, only 8% of standard kidneys were discarded the same year (Table 3, Table 4. The reason for the high rate of kidney discard is often attributed to poor organ function and quality; 47% of ECD kidneys were discarded because of biopsy findings in 2001 (see Table 5).Table 3Disposition of kidneys from nonexpanded criteria donors, 1992–2001YearOrgan disposition1992199319941995199619971998199920002001Total7837835682068341827281988544852087178864Local transplant5111568155945172521252105372537055615727Shared transplant2173207120342581242024322603254324542399Local not used314311324349364355367438433440Shared not used8683637912280101110194209Research152207183152151120100587187Export1384–1––42Unknown–––43–11––Total (%)100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0Local transplant (%)65.268.068.262.063.063.662.963.063.864.6Shared transplant (%)27.724.824.830.929.329.730.529.828.227.1Not transplanted (%)7.07.27.06.97.76.86.77.18.08.4Source: OPTN/SRTR data as of August 1, 2002.(%) = Percentages are based on totals including missing and unknown.(–) = None in category. Open table in a new tab Table 4Disposition of kidneys from expanded criteria donors, 1992–2001YearOrgan disposition1992199319941995199619971998199920002001Total66480713231596174818902051218221922123Local transplant357377647731804839896868904901Shared transplant133162232306350371418440365380Local not used109133224324389440502593554519Shared not used18394146667498152241212Research4796176184139164137129128109Export––35–––––2Unknown–––––2––––Total (%)100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0Local transplant (%)53.846.748.945.846.044.443.739.841.242.4Shared transplant (%)20.020.117.519.220.019.620.420.216.717.9Not transplanted (%)26.233.233.535.034.136.036.040.142.139.6Source: OPTN/SRTR data as of August 1, 2002.(%) = Percentages are based on totals including missing and unknown.(–) = None in category.Includes organs recovered for transplant but not transplanted, as well as organs transplanted. Open table in a new tab Table 5Reasons for nonuse of recovered expanded criteria donor kidneys, 1992–2001Reason for nonuseYearof recovered organs1992199319941995199619971998199920002001Total (%)100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0Extended ischemia time (%)––1.52.41.10.82.31.91.62.3Organ unsatisfactory (%)1Organ unsatisfactory: organ damage or anatomic abnormalities.––13.211.411.99.78.311.110.78.9Poor organ function/infection (%)–––3.815.69.713.211.116.717.0Donor medical/social history (%)––11.35.44.67.04.74.32.84.2Biopsy findings (%)––29.152.744.648.647.241.247.246.5Positive hepatitis/CMV/HIV (%)––0.83.21.82.31.51.70.81.8No recipient found (%)2No recipient found: recipient not located or list exhausted. Reasons for nonuse not collected prior to April 1, 1994. Includes organs recovered for transplant but not transplanted, as well as organs transplanted.––0.81.67.06.87.36.75.24.2Other (%)––21.916.813.014.414.812.39.45.7Unknown (%)–––2.70.40.60.79.55.79.3Not collected prior to 4/94 (%)100.0100.021.5–––––––Source: OPTN/SRTR data as of August 1, 2002.(%) = Percentages are based on totals including missing and unknown.(–) = None in category.1 Organ unsatisfactory: organ damage or anatomic abnormalities.2 No recipient found: recipient not located or list exhausted. Reasons for nonuse not collected prior to April 1, 1994. Includes organs recovered for transplant but not transplanted, as well as organs transplanted. Open table in a new tab Source: OPTN/SRTR data as of August 1, 2002. (%) = Percentages are based on totals including missing and unknown. (–) = None in category. Source: OPTN/SRTR data as of August 1, 2002. (%) = Percentages are based on totals including missing and unknown. (–) = None in category. Includes organs recovered for transplant but not transplanted, as well as organs transplanted. Source: OPTN/SRTR data as of August 1, 2002. (%) = Percentages are based on totals including missing and unknown. (–) = None in category. The correlation of kidney biopsy findings with immediate and long-term function remains both controversial and influential. The seminal paper (9Gaber LW Moore LW Alloway RR Amiri MH Vera SR Gaber AO Glomerulosclerosis as a determinant of posttransplant function of older donor renal allografts.Transplantation. 1995; 60: 334-339Crossref PubMed Scopus (211) Google Scholar) in the field, by Gaber et al., has been criticized for not providing sufficient data to support its conclusion that a biopsy revealing >20% glomerulosclerosis renders a donor kidney generally unacceptable for transplantation (3Randhawa P Role of donor kidney biopsies in renal transplantation.Transplantation. 2001; 71: 1361-1365Crossref PubMed Scopus (82) Google Scholar). This study included only a small number of allografts with poor function 6 months following transplantation and a mean glomerulosclerosis of 20% at the time of implantation; 13 had a serum creatinine >2.5 mg/dL and four had undergone nephrectomy. Only eight of these 17 kidneys had glomerulosclerosis ≥20%. Nevertheless, the determinant of >20% glomerulosclerosis has become a common reason for a transplant physician not to accept a kidney for transplantation. Gaber et al. concluded by advocating the use of routine biopsies of kidneys from older (>50 year) donors and those donors with nontraumatic, cerebrovascular accidents, even those with seemingly normal preprocurement serum creatinine levels (9Gaber LW Moore LW Alloway RR Amiri MH Vera SR Gaber AO Glomerulosclerosis as a determinant of posttransplant function of older donor renal allografts.Transplantation. 1995; 60: 334-339Crossref PubMed Scopus (211) Google Scholar). Subsequently, Pokorna and colleagues reported a prospective series of 387 biopsies of deceased donor kidneys, and showed that kidneys whose biopsies demonstrated 25% or more glomerulosclerosis had an acceptable 3-year graft survival rate of 75% (10Pokorna E Vitko S Chadimova M Schuck O Ekberg H Proportion of glomerulosclerosis in procurement wedge biopsy cannot alone discriminate for acceptance of marginal donors.Transplantation. 2000; 69: 36-43Crossref PubMed Scopus (130) Google Scholar). However, only 27% of these donors were older than 50. Pokorna et al. concluded that procurement biopsies provide only limited information for the decision whether or not to accept a donor kidney for transplantation. A definitive, prospective study of kidneys recovered from the ECD that analyzes donor kidney function and pretransplant histology along with post-transplant kidney function and outcome remains to be accomplished. Such a study could significantly affect the transplantation rate of kidneys from older donors. The New England Organ Bank, in collaboration with Life Choice Donor Services, the Transplantation Society of Michigan, and URREA, has received grant funding from the Division of Transplantation (DoT) of the Health Resources and Services Administration (HRSA) to systematically carry out such a study. Others are encouraged to explore this also. Analyses by the SRTR show that there are significant differences (p = 0.001) between the demographic profiles of ECD kidney recipients and standard kidney recipients in 2001, in the areas of recipient age, history of a previous kidney or kidney–pancreas transplant, HLA match, and cause of end-stage renal disease (ESRD) (Table 6). Recipients over the age of 50 (18%) were more likely to receive an ECD kidney than patients under the age of 50 (7%), while recipients who had had a prior kidney or kidney–pancreas transplant were less likely to receive an ECD kidney (8% and 13%, respectively). ECD transplants were less likely to have a 0 HLA mismatch than non-ECD transplants (8% and 13%). Recipients with ESRD due to diabetes or hypertension were more likely to receive an ECD kidney compared to those whose ESRD was caused by glomerulonephritis (14%, 14%, and 10%, respectively). Gender, race, blood type, and PRA at transplant were not associated with significant differences in the use of ECD kidneys.Table 6Recipients of expanded criteria donor kidneys, 2001VariableECD transplants*As percent of all kidney transplants.p-value**Analysis of proportions by chi square.Age under 506.6%≤0.001Age over 5017.5%No previous transplant12.6%≤0.001Previous transplant8.1%0 HLA mismatch8.1%≤0.001>0 HLA mismatch12.6%ESRD due to diabetes mellitus14.1%≤0.001ESRD due to hypertension13.6%≤0.001ESRD due to glomerulonephritis9.9%Ref.Source: SRTR Data Analysis, August, 2002.* As percent of all kidney transplants.** Analysis of proportions by chi square. Open table in a new tab Source: SRTR Data Analysis, August, 2002. When Port et al. used multivariate logistic regression to examine the odds of receiving an ECD kidney for the years 1995–2000, more significant differences appeared (8Port FK Bragg JL Metzger RA et al.Donor characteristics associated with reduced graft survival. an approach to expanding the pool of kidney donors.Transplantation. 2002; 74: 1281-1286Crossref PubMed Scopus (632) Google Scholar). Characteristics that differed significantly (p < 0.05) in the odds (OR) of receiving an ECD rather than a non-ECD kidney included the following: age (OR = 1.03 per year), years of dialysis (OR = 1.03 per year), African American race (OR = 0.92 vs. white), Hispanic/Latino ethnicity (OR = 0.89), male (OR = 0.93), glomerulonephritis as cause of ESRD (OR = 0.68 vs. diabetes), PRA of 10–79% (OR = 0.84 vs. <10%), and PRA of 80% or higher (OR = 0.65 vs. <10%). Common practice in the United States is to place older donor kidneys in older patients. This practice has been formally implemented in Europe through the Eurotransplant Senior Program (11Voiculescu A Schlieper G Hetzel GR et al.Kidney transplantation in the elderly: age-matching as compared to HLA-matching: a single center experience.Transplantation. 2002; 73: 1356-1359Crossref PubMed Scopus (29) Google Scholar, 12Smits JM Persijn GG Van Houwelingen HC Claas FH Frei U Evaluation of the Eurotransplant Senior Program. The results of the first year.Am J Transplant. 2002; 2: 664-670Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar), and has been advocated in the United States as well (13Lee CM Carter JT Weinstein RJ et al.Dual kidney transplantation: older donors for older recipients.J Am College Surgeons. 1999; 189: 82-91Crossref PubMed Scopus (47) Google Scholar). Kasiske and Snyder, in an analysis of first kidney transplants from 1988 to 1998 using the United States Renal Data System (USRDS), demonstrated that giving older kidneys to older recipients did not improve overall graft survival (14Kasiske BL Snyder J Matching older kidneys with older patients does not improve allograft survival.J Am Soc Nephrol. 2002; 13: 1067-1072Crossref PubMed Google Scholar). However, they noted that there may be ethical reasons to do so even if outcomes are not improved. A recent French study, although defining the ECD differently, noted that these older donor kidneys transplanted into significantly older recipients had similar 2-year patient and graft survival as the control donor-recipient group (15Dahmane D Hiesse C Pessione F Cohen S Lang P Survival and renal function of kidney transplants refused and finally accepted.Transplantation. 2002; 74: 77Google Scholar). Ongoing analyses following implementation of the expedited ECD kidney allocation policy should clarify which subsets of candidates may be most appropriate for ECD kidneys. Graft survival of ECD kidney transplants is by definition inferior to that of standard kidney transplants. Unadjusted (Kaplan–Meier) graft survival estimates at 3 months and 1 year for 1958 ECD kidney transplants performed in 1999 and 2000 are 90% and 82%, respectively (Table 7). These compare to graft survival rates of 94% and 89%, respectively, for 13 892 standard kidney transplants performed during the same years (Table 8). Graft survival estimates show an absolute difference of 15% and 16% at 3 and 5 years, respectively (80% vs. 65% at 3 years for 1997–98 transplants; 65% vs. 49% at 5 years for 1995–96 transplants). Multivariate analysis that adjusts for differences in recipient characteristics indicates that the relative risk of graft failure for ECD recipients is 69% higher than for all standard organ recipients (8Port FK Bragg JL Metzger RA et al.Donor characteristics associated with reduced graft survival. an approach to expanding the pool of kidney donors.Transplantation. 2002; 74: 1281-1286Crossref PubMed Scopus (632) Google Scholar).Table 7Graft survival for expanded criteria donor kidney transplants at 3 months, 1 year, 3 years, and 5 years3months1 year3 years5 yearsCategoriesn%n%n%n%TotalAll195890.4195881.7190965.1169848.6Age (years) at Tx<1 year0–0–0–0–1–5 years1*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.1*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.1*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.2*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.6–10 years2*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.2*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.2*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.4*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.11–17 years7*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for patient and graft survival are different because a patient may have more than one transplant for a type of organ. Multi-organ transplants are excluded.7*Values suppressed due to small numbers (0–9). Cohorts are transplants performed during 1999–2000 for 3 months and 1 year; 1997–1998 for 3 years; and 1995–96 for 5-year survival. Graft survival follows individual transplants until graft failure. Counts for pat
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