Early Urine Output Predicts Graft Survival After Kidney

Transplantation
Q. Lai, R. Pretagostini, L. Poli, G.B. Levi Sandri, F. Melandro, M. Grieco, G. Spoletini, M. Rossi, and
P.B. Berloco

ABSTRACT
Background. In kidney transplantations, the identification of early postoperative param-
eters with high predictive power for the development of late allograft dysfunction has
important implications for clinical practice. This study sought to determine these param-
eters in a single-center cohort.
Methods. We studied 82 deceased donor renal transplantation. We assessed the
following measures: dialysis-dependent delayed graft function (ddDGF), extended DGF,
serum creatinine level at day 7, creatinine reduction ratio at day 7, urine output at day 1
and at day 7 posttransplantation (UO7).
Results. Only UO7 showed a significant result upon multivariate analysis (P ⬍ .0001). It
was less influenced by dialysis with respect to measures based upon serum creatinine. By
Receiver Operating characteristic (ROC) analysis, it showed an elevated area under the
curve (0.811), with a cut-off value of 500 mL/24 h, showing high sensitivity (98.5%).
Conclusions. UO7 may be of clinical utility to assess the risk for subsequent renal
dysfunction.

N RECENT years, several studies have documented that
I early (first week) graft function post– kidney transplan-
tation impacts long-term graft survival.1 The evaluation of
immediate postoperative markers for graft loss has great
implications for the clinical and immunological manage-
ment of recipients. However, the best postoperative mea-
sure of early graft function remains undetermined. The aim
of this study was to seek the best variable in the first
postoperative week, evaluating its predictive role for 1-year
allograft dysfunction.
fined as the need for dialysis within 1 week; extended DGF
(extDGF); defined in our previous study3 as the presence of 1 of
the 2 following conditions: at least 1 day of oligoanuria [ⱕ500
mL/24 h] during the first week or an increased, unchanged, or
ⱕ30% decreased 7-day serum creatinine level compared with the
preoperative value); serum creatinine level at day 7 posttransplan-
tation (Cr7)4; low creatinine reduction ratio at day 7 (CCR7)5;
urine output at day 1 posttransplantation (UO1)4; and urine output
at day 7 posttransplantation (UO7). The abbreviated Modification
of Diet in Renal Disease 4 equation (MDRD)6 was used to define
the 1-year eGFR.

MATERIALS AND METHODS Statistical Analysis

Study Design
Categorical data were summarized as proportions and percentages;
From May 1, 2006 through May 31, 2008, 82 consecutive adult continuous data were summarized as mean values ⫾ standard
(ⱖ18 years) deceased donor renal recipients underwent transplan-
tation in our institution. We retrospectively categorized the entire
From the Department of General Surgery and Organ Trans-
cohort into 2 groups according to 1-year graft function: Group A
plantation, La Sapienza Università di Roma, Umberto I Poli-
with one-year estimated glomerular filtration rate (eGFR) ⱖ30
clinico di Roma, Rome, Italy.
mL/min/1.73 m2 (n ⫽ 66), and Group B with eGFR ⬍30 mL/min/
This study was supported by “Consorzio Inter-Universitario
1.73 m2 (n ⫽ 15).
Per i Trapianti.”
Address reprint requests to Q. Lai, Department of General
Measures
Surgery and Organ Transplantation, La Sapienza Università di
The early postoperative measures analyzed in our study were as Roma, Umberto I Policlinico di Roma, Viale del Policlinico 155,
follows: dialysis-dependent delayed graft function (ddDGF)2; de- Rome 00161, Italy. E-mail: lai.quirino@libero.it

0041-1345/10/$–see front matter © 2010 by Elsevier Inc. All rights reserved.

doi:10.1016/j.transproceed.2010.03.088 360 Park Avenue South, New York, NY 10010-1710

1090 Transplantation Proceedings, 42, 1090 –1092 (2010)

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EARLY URINE OUTPUT 1091

Table 1. Donor and Recipient Demographics A patients (P .002). Creatinine values at day 7 posttrans-
Variables plantation were increased in Group B patients (7.6 vs 3
mg/dL; P ⬍ .0001), with a minor reduction in the ratio of
Donor age (y) 49.7 ⫾ 16.8
creatinine values between 1 and 7 days posttransplanta-
Donor gender (M/F) (%) 46/35 (56.8/43.2)
Donor BMI 25.4 ⫾ 3.5
tion (3.5 vs ⫺59.4). In Group B, 73.3% of patients
ECD (%) 39 (48.1) showed ratios ⬍30% versus 16.7% in Group A (P ⬍
Recipient age (y) 54.7 ⫾ 10.9 .0001). In both cohorts the measures of UO1 and UO7
Recipient gender (M/F) (%) 52/29 (64.2/35.8) showed Group B to include 40% of patients with UO
Recipient BMI 24.8 ⫾ 3.1 ⱕ500 mL, versus 3% and 1.5% in the other group,
Recipient hypertension (%) 28 (34.6) respectively. Upon multivariate analysis, only UO7 was
Recipient diabetes (%) 6 (7.4) significant (P ⬍ .0001). ROC analysis revealed both UO1
Retransplantation (%) 8 (9.9) and UO7 to represent good predictive tests for 1-year
Cold ischemia time (h) 15 ⫾ 3.2
eGFR ⱖ30 mL/min/1.73 m2 (area under the curve [AUC] ⫽
Total HLA mismatch 3.2 ⫾ 1
0.882 and 0.811, respectively). Observing various thresh-
Abbreviations: M, male; F, female; BMI, body mass index; ECD, expanded old values, a UO1 and UO7 cut-off value of 500 mL
criteria donors; HLA, human leukocyte antigen.
showed the best sensitivities (98.5% in both the cases).
The UO7 of 1500 mL/24 h showed a similar value of
deviations. Differences in discrete variables were tested with the sensitivity (97%), but a better specificity (40%), there-
exact Fisher test. Continuous variables were compared with Stu-
fore revealing a greater capability to detect patients with
dent’s t test. A P value ⬍ .05 was considered significant. Multivar-
iate analysis of significant variables was performed using a Cox
good 1-year graft function (Table 3; Fig 1).
logistic regression test. Specificity and sensitivity of threshold
values of the examined measures were evaluated with ROC DISCUSSION
receiver operating characteristic (ROC) curves. All calculations
and plots were performed using SPSS software (version 16.0; SPSS, The main objective of this study was to determine the
Chicago, Ill, United States). predictive role of early graft function measures as “base-
line” indicators for early and late renal dysfunction. By
ROC analysis, both UO1 and UO7 yielded optimal results
RESULTS
to predict good graft function within 1 year; but only UO7
Patient demographics are shown in Table 1. The mean yielded a significant result upon multivariate analysis,
patient follow-up was 25.3 ⫾ 8.5 months (range, 1– 43). emerging as the best predictive factor for the development
Analyzing the entire group of 82 patients, we noted 4 of 1-year renal dysfunction. UO7 presented several advan-
deaths (4.9%) due in 1 case each to subarachnoid tages with respect to other parameters like Cr7 and CCR7.
hemorrhage, necrotic hemorrhagic pancreatitis, myocar- First, the measures on which creatinine is based are under-
dial infarction, and cardiac failure. Twelve patients ex- estimated by postoperative dialysis,1 whereas urine output
perienced graft loss (14.6%) due to the following; recip- is not particularly influenced by dialysis. Moreover, in-
ient death (n ⫽ 3), biopsy-proven acute rejection episode creased urine volume represents the first sign of progressive
(BPARE) (n ⫽ 3), primary nonfunction (PNF) (n ⫽ 3), recovery of kidney function, ahead of a decrease in serum
or chronic allograft nephropathy (CAN; n ⫽ 3). The creatinine or blood urea nitrogen.7 However, the definition
results of univariate and multivariate analyses are shown of a threshold value of UO7 was difficult; a cut-off value of
in Table 2. 500 mL/24 h showed good sensitivity, giving the possibility
In Group B, 73.3% of patients needed at least 1 dialysis to predict future poor graft function, but it had low
treatment within 1 week after transplantation versus 6.1% specificity. A UO7 of 1500 mL/24 h showed similar sensi-
of Group A subjects (P ⬍ .0001). A diagnosis of extDGF tivity, but better specificity. It could represent a possible
was seen in 80% of group B patients versus 27.3% of Group threshold value for clinical practice.

Table 2. Univariate and Multivariate Analysis of the Association of Postoperative Variables With Graft Loss at
1-year Posttransplantation
Variables Group A (n ⫽ 66) Group B (n ⫽ 15) P Univariate Analysis P Multivariate Analysis

ddDGF (%) 4 (6.1) 11 (73.3) ⬍.0001 .217

extDGF (%) 18 (27.3) 12 (80) .002 .511
Cr7 (mg/dL) 3 ⫾ 2.5 7.6 ⫾ 3.6 ⬍.0001 .367
CRR7 ⫺59.4 ⫾ 34 3.5 ⫾ 43 ⬍.0001 .405
⬍⫺70% (%) 11 (16.7) 11 (73.3) ⬍.0001 .450
UO1 (mL/24 h) 5522.7 ⫾ 3849.6 1726.7 ⫾ 2190 ⬍.0001 .348
ⱕ500 mL (%) 2 (3) 6 (40) ⬍.0001 .692
UO7 (mL/24 h) 5337.9 ⫾ 1919 2566.7 ⫾ 2520 ⬍.0001 ⬍.0001
ⱕ500 mL (%) 1 (1.5) 6 (40) ⬍.0001 .995

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1092 LAI, PRETAGOSTINI, POLI ET AL

Table 3. Threshold Values of UO1 and UO7 According to 1-Year Graft Function (eGFR >30 mL/min/1.73 m2): ROC Analysis
95% CI

Variables AUC Standard Error P Lower Bound Upper Bound

UO1 .882 .057 ⬍.0001 .771 .993

UO7 .811 .079 ⬍.0001 .656 .965
UO1 (mL) 500 1000 1500 2000 2500
Sensitivity (%) 98.5 95.5 92.4 87.9 84.8
Specificity (%) 33.3 40.0 46.7 73.3 73.3
UO7 (mL) 500 1000 1500 2000 2500
Sensitivity (%) 98.5 97.0 97.0 95.5 93.9
Specificity (%) 26.7 40.0 40.0 46.7 53.3
Abbreviation: CI, confidence interval.

In summary, this study suggested that UO7 may be an
easy, safe parameter with evident clinical utility to assess
the risk for subsequent renal dysfunction. External treat-
ments do not cause excessive interference in its detection.
Fig 1. ROC curves for UO1 and UO7 according to 1-year graft
function (eGFR ⱖ30 mL/min/1.73 m2).
This measure may be used for the clinical management of
individuals in the early postoperative period.
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