Comparing Kidney Transplant Rates and Outcomes Among Adults With and Without Intellectual and Developmental Disabilities

Impact of Multiple Kidney Retransplants on Post-Transplant Outcomes in the United States

BACKGROUND

Kidney retransplantation offers a valuable treatment option for patients who experience graft failure after their initial transplant. There is an increasing number of patients undergoing multiple retransplants. However, the impact of multiple kidney retransplants on post-transplant outcomes remains unclear. This study aimed to assess the association between the number of kidney retransplants and post-transplant outcomes in kidney retransplant recipients.

METHODS

We used the Organ Procurement and Transplantation Network and United Network for Organ Sharing (OPTN/UNOS) database to identify kidney-only retransplant recipients in United States from 2010 through 2019. We categorized kidney retransplant recipients based on their number of kidney retransplant into one and two plus kidney retransplant groups. The association of one vs two plus kidney retransplants with death-censored graft failure and patient death was assessed using Cox proportional hazard analysis, and acute rejection using logistic regression analysis.

RESULTS

Of 17,433 kidney retransplant recipients included in this study, 15,821 (91%) and 1612 (9%) had one and two plus kidney retransplants, respectively. Patients with two plus kidney retransplants were younger, predominantly White, had higher panel reactive antibody (PRA), public insurance, and education, but had less history of diabetes mellitus and total HLA mismatch compared with patients with one kidney retransplant. After adjusting for potential confounders, having two plus kidney retransplants was significantly associated with increased risk of death-censored graft failure (hazard ratio [HR] = 1.20, 95% confidence interval [CI] = 1.02-1.42) and allograft rejection (odds ratio [OR] = 1.30, 95% CI = 1.09-1.54), but it was not significantly associated with patient death.

CONCLUSIONS

Patients undergoing multiple kidney retransplants face a higher risk of graft failure and rejection compared with those with a single retransplant. These findings underscore the need for tailored management and monitoring strategies to improve outcomes for patients receiving multiple kidney retransplants.

Embedding Equity and Inclusion Principles Into Nephrology Board Examinations: An Essential Part of Our Path Toward Kidney Health Justice

Recognition of widespread health inequalities across disease conditions and their startling impact on morbidity and health care costs have motivated multiple professional societies to ensure board examinations reflect and enhance inclusive, anti-biased, and equitable care. In this perspective, we offer five nephrology case examples and accompanying learning objectives to demonstrate how principles of inclusion, equity, and anti-bias can be embedded into nephrology examinations to enhance care for all populations.

Children and adolescents with severe motor and intellectual disabilities who underwent kidney transplantation

BACKGROUND

Kidney transplantation (KT) in children and adolescents with severe motor and intellectual disabilities (SMID) has been a topic of controversy. A multicenter study in Japan showed that KT was not contraindicated for children with multiple handicaps, but no consensus has been reached on KT for patients with SMID. This study aimed to determine whether KT is a viable treatment option for children and adolescents with SMID.

METHODS

A single-center, retrospective study was conducted on children and adolescents with SMID who underwent KT. SMID was defined based on Oshima's classification. Clinical information was collected through a review of medical records.

RESULTS

Of 453 children and adolescents who underwent KT between 1983 and 2023 in our institution, six (1.3%) patients with SMID were identified. One patient received KT twice. All patients underwent living KT. Five patients used medical devices, including gastrostomy and a ventriculoperitoneal shunt, prior to KT. Perioperative complications, including hemothorax related to central venous catheter insertion, ventilator-associated pneumonia, and common iliac artery thrombosis requiring graftectomy, occurred in three patients. One patient required vesicostomy owing to refractory urinary tract infection. There was no significant difference in the graft survival rate between patients with SMID and those without SMID. One patient developed graft failure and died after selecting conservative kidney management.

CONCLUSION

Our study showed a favorable graft survival in children and adolescents with SMID who underwent KT. Although careful perioperative management and continued medical care are required, KT may be a viable option for these patients.

Outcome of Solid Organ Transplantation in Patients With Intellectual Disability: A Systematic Literature Review

Access to solid organ transplantation in patients with intellectual disability is associated with health inequities due to concerns about treatment adherence, survival rates, and post-transplant quality of life. This systematic literature review aims to compare outcomes after organ transplantation in patients with intellectual disability compared to patients without intellectual disability. Embase, Medline Ovid, PsycINFO, Web of Science, Cochrane Central Register of Trials, and Google Scholar databases were systematically searched for studies concerning pediatric or adult solid organ transplantation in recipients with a diagnosis of intellectual disability prior to transplantation. Primary outcomes were patient and graft survival rates. Secondary outcomes were acute rejection rate, adherence rates, and quality of life. Nine studies were included, describing kidney (n = 6), heart (n = 4) and liver (n = 1) transplantation. Reported graft survival rates were non-inferior or better compared to patients without intellectual disability, while patient survival was reportedly slightly lower in two studies reporting on kidney transplantation. Although current evidence has a potential selection bias based on including patients with a sufficient support network, intellectual disability alone should not be regarded a relative or absolute contra-indication for solid organ transplantation.

Inconsistent values and algorithmic fairness: a review of organ allocation priority systems in the United States

BACKGROUND

The Organ Procurement and Transplant Network (OPTN) Final Rule guides national organ transplantation policies, mandating equitable organ allocation and organ-specific priority stratification systems. Current allocation scores rely on mortality predictions.

METHODS

We examined the alignment between the ethical priorities across organ prioritization systems and the statistical design of the risk models in question. We searched PubMed for literature on organ allocation history, policy, and ethics in the United States.

RESULTS

We identified 127 relevant articles, covering kidney (19), liver (60), lung (24), and heart transplants (23), and transplant accessibility (1). Current risk scores emphasize model performance and overlook ethical concerns in variable selection. The inclusion of race, sex, and geographical limits as categorical variables lacks biological basis; therefore, blurring the line between evidence-based models and discrimination. Comprehensive ethical and equity evaluation of risk scores is lacking, with only limited discussion of the algorithmic fairness of the Model for End-Stage Liver Disease (MELD) and the Kidney Donor Risk Index (KDRI) in some literature. We uncovered the inconsistent ethical standards underlying organ allocation scores in the United States. Specifically, we highlighted the exception points in MELD, the inclusion of race in KDRI, the geographical limit in the Lung Allocation Score, and the inadequacy of risk stratification in the Heart Tier system, creating obstacles for medically underserved populations.

CONCLUSIONS

We encourage efforts to address statistical and ethical concerns in organ allocation models and urge standardization and transparency in policy development to ensure fairness, equitability, and evidence-based risk predictions.

Disparities in outcomes of colorectal cancer surgery among adults with intellectual and developmental disabilities

BACKGROUND

Disparities in colorectal cancer screening have been documented among people with intellectual and developmental disabilities (IDD). However, surgical outcomes in this population have yet to be studied. The present work aimed to evaluate the association of IDD with outcomes following colorectal cancer resection.

METHODS

All adults undergoing resection for colorectal cancer in the 2011-2020 National Inpatient Sample were identified. Multivariable linear and logistic regression models were developed to examine the association of IDD with risk factors as well as outcomes including mortality, complications, costs, length of stay (LOS), and non-home discharge. The study is limited by its retrospective nature and did not capture disease staging or time of diagnosis.

RESULTS

Among 722,736 patients undergoing colorectal cancer resection, 2,846 (0.39%) had IDD. Compared to patients without IDD, IDD patients were younger and had a higher burden of comorbidities. IDD status was associated with increased odds of non-elective admission (AOR 1.40 [95% CI 1.14-1.73]) and decreased odds of treatment at high-volume centers (AOR 0.64 [95% CI 0.51-0.81]). Furthermore, IDD patients experienced significantly greater LOS (9 vs 6 days, p<0.001) and hospitalization costs ($23,500 vs $19,800, p<0.001) relative to neurotypical patients. Upon risk adjustment, IDD was significantly associated with 2-fold increased odds of mortality (AOR 2.34 [95% CI 1.48-3.71]), 1.4-fold increase in complications (AOR 1.41 [95% CI 1.15-1.74]), and 6.8-fold increase in non-home discharge (AOR 6.83 [95% CI 5.46-8.56]).

CONCLUSIONS

IDD patients undergoing colorectal cancer resection experience increased likelihood of non-elective admission, adverse clinical outcomes, and resource use. Our findings highlight the need for more accessible screening and patient-centered interventions to improve quality of surgical care for this at-risk population.

Disparities in Breast Cancer Screening Rates Among Adults With and Without Intellectual and Developmental Disabilities

BACKGROUND

Individuals with intellectual and developmental disabilities may face barriers in accessing healthcare, including cancer screening and detection services. We sought to assess the association of intellectual and developmental disabilities (IDD) with breast cancer screening rates.

METHODS

Data from 2018 to 2020 was used to identify screening-eligible individuals from Medicare Standard Analytic Files. Adults aged 65-79 years who did not have a previous diagnosis of breast cancer were included. Multivariable regression was used to analyze the differences in breast cancer screening rates among individuals with and without IDD.

RESULTS

Among 9,383,349 Medicare beneficiaries, 11,265 (0.1%) individuals met the criteria for IDD. Of note, individuals with IDD were more likely to be non-Hispanic White (90.5% vs. 87.3%), have a Charlson Comorbidity Index score ≤ 2 (66.2% vs. 85.5%), and reside in a low social vulnerability index neighborhood (35.7% vs. 34.4%). IDD was associated with reduced odds of undergoing breast cancer screening (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.74-0.80; p < 0.001). Breast cancer screening rates in individuals with IDD were further influenced by social vulnerability and belonging to a racial/ethnic minority.

CONCLUSIONS

Individuals with IDD may face additional barriers to breast cancer screening. The combination of IDD and social vulnerability placed patients at particularly high risk of not being screened for breast cancer.