Living related and living unrelated kidney transplantations: A systematic review and meta-analysis

Table 1 Study design

Patients	Patients underwent kidney transplantation
Literature search	Keyword search in PubMed, Google scholar and Scopus
Databases	Pubmed, Ovid, MEDLINE, EMBASE, the Cochrane Controlled Trials Register, HealthSTAR, CINAHL, Google, and Google Scholar
Limits	Only comprehensive articles without time limit Humans In English
Keywords	Kidney transplantation Renal transplant Related Unrelated
Eligibility criteria	Article in Full-text (no abstracts) Unique publication (no duplicate articles) Reported each of the interested outcomes (graft survival rate, and acute rejection rate) Original report as determined from reading the abstract or if necessary the full text Outcome reported in a usable form (each surgical approach was reported as a separate cohort, no additional confounding treatments, no missing or unreliable data; could not have > 10% difference in values between text and tables Reported on surgical approaches of interest
Exclusion criteria	Duplicate patient population, where some or all of the same patients were included in a different study reporting on the same parameters (prevents double counting) Early case experience (prevents bias toward approaches with more experienced surgeons)
Data abstraction	Articles needed to report which contain each of outcome of interest to be included in the analysis Data were abstracted by two individuals into a custom database table including list of variables. 50% of articles were abstracted by one reviewer and other 50% with other one. The data for 50% of the articles was double-entered by a second individual, and any discrepancies were resolved through repeated review and discussion prior to data analysis All primary outcomes were then double-checked and any discrepancies resolved Variables in four types were abstracted from each study: Those necessary to determine inclusion and exclusion criteria, surgical approach, baseline patient characteristics, and clinical outcomes All studies were reviewed by two independent reviewers using the total QASs (Table 3) to assess the methodological quality of the studies that were included. Although the QASs were reported for each study, they were not used to weight the studies in the meta-analysis
Primary outcomes	Graft survival rate
Secondary outcomes	Acute rejection rate
Controls for Publication bias	Performed a funnel plot analysis

QASs: Quality assessments.

Table 2 Quality assessment items and possible scores

Was the assigned treatment adequately concealed prior to allocation?

2 = method did not allow disclosure of assignment

1 = small but possible chance of disclosure of assignment or unclear

0 = quasi-randomized or open list/tables

Were the outcomes of participants who withdrew described and included in the analysis (intention-to-treat)?

2 = withdrawals well described and accounted for in analysis

1 = withdrawals described and analysis not possible

0 = no mention, inadequate mention, or obvious differences and no adjustment

Were the outcome assessors blinded to treatment status?

2 = effective action taken to blind assessors

1 = small or moderate chance of unblinding of assessors

0 = not mentioned or not possible

Were the treatment and control groups comparable at entry? (likely confounders may be age, partial or total rupture, activity level, acute or chronic injury)

2 = good comparability of groups, or confounding adjusted for in analysis

1 = confounding small; mentioned but not adjusted for

0 = large potential for confounding, or not discussed

Were the participants blind to assignment status after allocation?

2 = effective action taken to blind participants

1 = small or moderate chance of unblinding of participants

0 = not possible, or not mentioned (unless double-blind), or possible but not done

Were the treatment providers blind to assignment status?

2 = effective action taken to blind treatment providers

1 = small or moderate chance of unblinding of treatment providers

0 = not possible, or not mentioned (unless double-blind), or possible but not done

Were care programes, other than the trial options, identical?

2 = care programes clearly identical

1 = clear but trivial differences

0 = not mentioned or clear and important differences in care programes

Were the inclusion and exclusion criteria clearly defined?

2 = clearly defined

1 = inadequately defined

0 = not defined

Were the interventions clearly defined?

2 = clearly defined interventions are applied with a standardized protocol

1 = clearly defined interventions are applied but the application protocol is not standardized

0 = intervention and/or application protocol are poorly or not defined

Were the outcome measures used clearly defined? (by outcome)

2 = clearly defined

1 = inadequately defined

0 = not defined

Were diagnostic tests used in outcome assessment clinically useful? (by outcome)

2 = optimal

1 = adequate

0 = not defined, not adequate

Was the surveillance active, and of clinically appropriate duration?

2 = active surveillance and appropriate duration

1 = active surveillance, but inadequate duration

0 = surveillance not active or not defined

Table 3 The characteristics of included study which reported related vs unrelated living kidney transplantation outcomes

Ref.	Number	Mean follow up (mo)	Recipient mean age (yr)	Recipient sex M/F	Immunosuppression regimen	One year graft survival rate	five years graft survival rate	10 yr graft survival rate	Acute rejection rate	Mean serum Cr at 1 yr	Mean serum Cr at final follow up	Post-transplant infectious complications
Cortesini et al[9], 2002	302 vs 172	42	32.8 ± 7.3 vs 44 ± 9.9	215/87 vs 133/39	Cyclosporine	275 (91) vs 150 (87)	232 (77) vs 136 (79)	199 (66) vs 118 (69)	N/D	1.9 ± 0.8 vs 2.0 ± 0.8	2.0 ± 0.8 vs 1.9 ± 0.8	N/D
Simforoosh et al[5], 2016	411 vs 3305	N/D	27.6 ± 10.1 vs 35.6 ± 15.6	270/138 vs 2164/1136	Cyclosporine	89% vs 90%	288 (70.2) vs 2697 (81.6)	225 (54.9) vs 2350 (71.1)	N/D	N/D	N/D	N/D
Voiculescu et al[10], 2003	38 vs 24	19.6 ± 15.4	37.7 ± 12.1 vs 53.6 ± 7.8	26/12 vs 14/10	Steroids, cyclosporine, mycophenolate mofetil	36 (94.8) vs 24 (100)	N/D	N/D	20 (52.5) vs 13 (54.2)	N/D	1.76 ±0.6 vs 1.62 ±0.5	25 (66.7) vs 9 (36.4)
Ahmad et al[15], 2008	261 vs 61	45	28 ± 16 vs 48 ± 12	N/D	Cyclosporine	247 (94.8) vs 60 (98.4)	N/D	N/D	107 (41) vs 21 (35)	N/D	N/D	N/D
Kizilisik et al[11], 2004	85 vs 24	36	N/D	N/D	Cyclosporine, azathioprine, steroid, tacrolimus, mycofenolatemofetil	81 (95) vs 23 (95.8)	75(88.3) vs 21 (87.5)	N/D	11(13) vs 5 (20)	N/D	N/D	7 (8.3) vs 8 (3.5)
Park et al[12], 2004	36 vs 41	N/D	33.6 vs 38.3	21/15 vs 28/13	Cyclosporine, steroid and mycophenolatemofetil	N/D	30 (84) vs 36 (88.5)	28 (78.8) vs 41 (74.7)	11 (30) vs 13 (31)	N/D	N/D	N/D
Wolters et al[13], 2005	66 vs 29	35	31 ± 12.5 vs 51 ± 8.5	41/25 vs 23/6	Cyclosporine/MMF/prednisone vs MMF/prednisone	N/D	62 (94.7) vs 23 (94.7)	N/D	6 (9) vs 5 (17.2)	N/D	N/D	N/D
Simforoosh et al[14], 2006	374 vs 1760	45.68 ± 46.80	28.97 ± 9.58 vs 33.46 ± 14.61	N/D	Cyclosporine, azathioprine, and prednisone	342 (91.6) vs 1610 (91.5)	286 (76.4) vs 1432 (81.4)	241 (64.4) vs 1200 (68.2)	N/D	N/D	N/D	N/D
Ishikawa et al[16], 2012	66 vs 44	12	36.1 ± 12.4 vs 55.0 ± 8.8	29/15 vs 38/28	Plasmaphresis, tacro, celecpt, Basiliximab, rituximab, methyl prednisolone, cyclosporine, deoxypergualin	65 (98.5) vs 43 (97.7)	N/D	N/D	16 (24.2) vs 14 (31.8)	N/D	N/D	N/D
Santori et al[17], 2012	111 vs 24	128.17 ± 86.64 vs 103.53 ± 86.85	26.94 ± 13.51 vs 50.04 ± 8.86	78/33 vs 18/6	Cyclosporine, tacro, steroids, celecept	N/D	N/D	71 (63.8) vs 21 (87.8)	N/D	N/D	N/D	N/D
Matter et al[18], 2016	2075 vs 410	7.72 ± 6.15	28.8 ± 9.8 vs 34.8 ± 11.1	1554/521 vs 297/113	Steroid- Azathioprine or MMF	2012 (97) vs 389 (95)	1784 (86) vs 340 (83)	1660 (67) vs 270 (66)	71 (3.4) vs 26 (6.3)	1.38 ± 0.69 vs 1.35 ± 0.61	1.71 ± 1.04 vs 1.59 ± 0.89	N/D
Ali et al[19]	92 vs 143	5	N/D	N/D	Methyl prednisolone, Cyclosporine or tacrolimus MMF	90 (97) vs 141 (98.6)	80 (86) vs 125 (87.4)	N/D	N/D	N/D	N/D	N/D

Data is presented as n (%) and Mean ± SD. N/D: Not determined; MMF: Mycophenolatemofetil.