THE FATE OF RENAL-ALLOGRAFTS FUNCTIONING FOR A MINIMUM OF 20 YEARS (LEVEL-5A) - INDEFINITE SUCCESS OR BEGINNING OF THE END - A PROPOSED CLASSIFICATION OF LONG-TERM ALLOGRAFT SURVIVALS

Fifty-five renal allografts (44 from Living-related and 11 from cadaver donors) that have functioned for at least 20 years (mean 22.9+/-2.3, range 20.1 to 30.7 years) were evaluated in three groups based on renal function: group I (n=26), with a GFR of greater than or equal to 60 ml/min/1.73 m(2) or serum creatinine less than or equal to 1.4 mg/dl and no proteinuria; group II (n=9), with a GFR of greater than or equal to 60 ml/min/1.73 m(2) or serum creatinine less than or equal to 1.4 mg/dl but >150 mg protein-uria/24 hr; and group III (n=20), with a GFR <60 ml/min/1.73 m(2) and/or serum creatinine >1.4 mg/dL with or without proteinuria. Allograft factors, including acute rejection (AR) in 62% (34/55) and delayed function (DF) in 55% (6/11) of the cadaver grafts, did not preclude 20-year success and the prospect of continued survival since they were not significantly more frequent in group I, II, or III. However, AR was confined 60 a limited period within the first three months posttransplant in 18/18 recipients in groups I and II but only in 7/16 of group m (P=0.0002), In groups I and II AR was treated with IVMP in 14/18 cases and only 6/16 in group III (P=0.035), Donor age less than or equal to 50 years and recipient age less than or equal to 40 years each occurred in 87% (48/55) of these transplants. One- or two-HLA haplotype matching was present in 98% (43/44) of living related transplants. Major risks to the recipient were coronary artery disease (11 cases and 3 deaths), malignancy (18 cases and 1 death), and severe infection and hepatitis (35 cases and 3 deaths, 2 of whom also had coronary artery disease). Hypertension occurred in 25 recipients and diabetes mellitus in 12. Potential open-end success was compromised by renal dysfunction in groups II and III, but appeared possible in 12 of the 26 patients in group I, There is no apparent ''safe-haven'' point of time for immunosuppressed renal allograft recipients, who remain at increased risk for eventual renal allograft dysfunction, as well as cardiovascular, neoplastic, infectious, and metabolic diseases. In order to clarify and standardize the words ''long-term,'' a simple classification of long-term allograft survivals is proposed.