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Summary The incidence and relevance of histological findings in removed allografts is unknown. In this study, we investigated the outcome of routine histopathological examination of removed allografts. We performed a retrospective cohort study in patients with kidney graft failure ≥3 months after transplantation. In this cohort, 244 allograft nephrectomies were performed. We routinely sent removed grafts for histopathological examination. In 197 cases, a pathology report was available for analysis. In 21 of the 197 grafts, gross necrosis precluded adequate interpretation. Signs of rejection were reported in 163 of the remaining 176 allografts. Recurrences of the original disease were found in 13 cases. These were all known from prior biopsies. Relevant secondary findings were present in eight cases: renal cell carcinoma (n = 2), urothelial cell carcinoma, candida pyelonephritis (n = 2), post‐transplant lymphoproliferative disease, polyomavirus inclusions, and membranous nephropathy. All conditions were diagnosed before graft nephrectomy, except for one case of papillary renal cell carcinoma of 0.8 cm. As expected, signs of acute and/or chronic rejection are the main histopathological finding in grafts that are removed after late graft failure. Unexpected secondary findings are very rare. Therefore, it is justifiable to restrict histopathological examination of removed kidney allografts to specific cases.

Research has shown that a home-based educational intervention for patients with chronic kidney disease results in better knowledge and communication, and more living donor kidney transplantations (LDKT). Implementation research in the field of renal care is almost nonexistent. The aims of this study were (1) to demonstrate generalizability, (2) evaluate the implementation process, and (3) to assess the relationship of intervention effects on LDKT-activity. Eight hospitals participated in the project. Patients eligible for all kidney replacement therapies (KRT) were invited to participate. Effect outcomes were KRT-knowledge and KRT-communication, and treatment choice. Feasibility, fidelity, and intervention costs were assessed as part of the process evaluation. Three hundred and thirty-two patients completed the intervention. There was a significant increase in KRT-knowledge and KRT-communication among participants. One hundred and twenty-nine out of 332 patients (39%) had LDKT-activity, which was in line with the results of the clinical trials. Protocol adherence, knowledge, and age were correlated with LDKT-activity. This unique implementation study shows that the results in practice are comparable to the previous trials, and show that the intervention can be implemented, while maintaining quality. Results from the project resulted in the uptake of the intervention in standard care. We urge other countries to investigate the uptake of the intervention.

Transplantation of a living donor kidney is in general the best treatment option for patients with end-stage renal disease. Two major advantages as compared to transplantation with a deceased donor kidney are the avoidance of waiting time and the superior results in terms of renal function and graft survival. In some patients who are lucky enough to have a person in their neighborhood who are willing to donate a kidney, the transplantation cannot be performed directly because there is ABO blood type incompatibility between donor and recipient, or because of a positive lymphocyte crossmatch, based on the presence of donor-specific antibodies. During recent years, several strategies have been developed to enable transplantation in these cases. A first approach is to use a living donor kidney exchange program, which can result in successful matches in more than half of the crossmatch-positive couples [1]. With the incorporation of kidneys from nondirected, anonymous donors in such an exchange program, domino-paired chains of transplantations can be set up, which end with the transplantation of a living donor kidney to a recipient from the waiting list [2]. However, for a substantial number of recipients, these exchange programs do not result in a successful donor–recipient match. In these cases, desensitization strategies to reduce the titer of ABO blood group antibodies or anti-HLA antibodies can be employed. Desensitization techniques are based on the extracorporeal removal of antibodies, treatment with intravenous immunoglobulins, and on immunosuppressive therapy. Since these procedures carry additional risks for the transplant recipient, desensitization treatment should ideally be reserved for recipients who cannot be served with a donor kidney after several rounds of matching in a (multicenter) exchange program. Unfortunately, kidney exchange programs are not allowed by legislation in every country. In this issue of Transplant International, Morath et al. present the results of living donor kidney transplantation in nine crossmatch-positive patients with peritransplant immunoadsorption (IA) and induction therapy with the anti-CD20 antibody rituximab [3]. Three patients also underwent pretransplant plasmapheresis. In one additional patient with a negative crossmatch but high titers Correspondence L. B. Hilbrands, Department of Nephrology, Radboud University Nijmegen, PO Box 9101, 6500, HB Nijmegen, The Netherlands. E-mail: l.hilbrands@nier.umcn.nl

There are no detailed data on the relative contributions to overall health care costs of the various drugs that are commonly used in renal transplant patients. We performed a cost analysis in 122 patients, using the medical records and our hospital administration service as data sources, for all health carerelated costs during the first year after renal transplantation. During the first 3 months all patients were on cyclosporine (CsA) and prednisone. Subsequently, they were randomly allocated to CsA monotherapy or to conversion from CsA to azathioprine. Cost of drugs comprised about 25% of total health care expenses. In CsA-treated patients, the following costs per patient per year were calculated: CsA, DFL 9929 (1 DFL is about US $ 0.60; 67.5% of total drug costs); antilymphocyte agents, DFL 2613 (17.8%); other immunosuppressive drugs, DFL 455 (3.1%); antimicrobial agents, DFL 687 (4.7%); antihypertensive drugs, DFL 467 (3.2%); remaining drugs, DFL 554 (3.8%). Conversion from CsA to azathioprine resulted in a decrease in mean drug costs for the remainder of the first posttransplant year of DFL 4597 (P < 0.01). Although the incidence of acute rejections tended to be higher after steroid withdrawal than after conversion (39% versus 26%, not significant), the costs of anti-rejection therapy, hospitalization, and laboratory services did not differ. We conclude that CsA is the main determinant of overall drug costs. When compared to CsA monotherapy, conversion from CsA to azathioprine at 3 months after transplantation may result in subsequent cost savings of about DFL 5000 per patient per year without a higher incidence of rejection or graft loss.