Early remote ischaemic preconditioning leads to sustained improvement in allograft function after live donor kidney transplantation: long-term outcomes in the REnal Protection Against Ischaemia-Reperfusion in transplantation (REPAIR) randomised trial.Veighey, K. V., Nicholas, J. M. et al. (2019).
Br J Anaesth [record in progress].
This paper aims to report pre-specified clinical outcomes up to 5 years after recipients were enrolled in REPAIR, using eGFR, graft loss, and mortality.
Patients randomised to sham RIPC, early RIPC only (immediately pre-surgery), late RIPC only (24hr pre-surgery), or dual RIPC (early and late RIPC) in the REPAIR trial were analysed.
406 adult live donor kidney transplant donor-recipient pairs from 15 European transplant centres from the REPAIR trial.
This paper explores the secondary outcomes of eGFR, graft loss and mortality at 3 months, 12 months and annually up to 5 years after transplantation.
This is a top-quality RCT that has been well reported in this paper. The study was a multicentre, randomised and double-blinded study of remote ischaemic preconditioning in both donor and recipient in live donor renal transplant. The study was powered for the primary outcome of measured GFR (iohexol) at 12 months, which did not show a statistically significant difference. Here the 5-year outcome is reported and there was a clear difference in estimated GFR at 5 years, when early remote ischaemic preconditioning was compared to the control. The adjusted mean difference in GFR was 4.7ml/min (95% CI= 1.54-7.89). Given the slow decline in renal function of live donor transplants, a difference in mean GFR of this magnitude could translate to several extra years of satisfactory renal function. Given the minimal morbidity associated with the blood-pressure cuff, and no serious adverse events, this is an important study. However, the results are not necessarily transferable to deceased donors due to the heterogeneity of this donor type and variability of cold ischaemic time. It should be noted that 93% of patients had complete data at the 5-year follow up time point. A missing GFR because of death or graft loss was imputed as 0 and the impact of this was tested in a sensitivity analysis.