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Rampersad C, Bau J, Orchanian-Cheff A, Kim SJ. Impact of donor smoking history on kidney transplant recipient outcomes: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100854. [PMID: 38608414 DOI: 10.1016/j.trre.2024.100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/01/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Impact of donor smoking history on kidney transplant recipient outcomes is undefined. METHODS We systematically searched, critically appraised, and summarized associations between donor smoking and primary outcomes of death-censored and all-cause graft failure (DCGF, ACGF), and secondary outcomes of allograft histology, delayed graft function, serum creatinine, estimated glomerular filtration rate, and mortality. We searched MEDLINE, Embase, and Cochrane Databases from 2000 to 2023. Risk of bias was assessed using Risk of Bias in Non-randomized Studies - of Exposure tool. Quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation Working Group recommendations. We pooled results using inverse variance, random-effects model and reported hazard ratios for time-to-event outcomes or binomial proportions. Statistical heterogeneity was assessed with I2 statistic. RESULTS From 1785 citations, we included 17 studies. Donor smoking was associated with modestly increased DCGF (HR 1.05 (95% CI: 1.01, 1.09); I2 = 0%; low quality of evidence), predominantly in deceased donors, and ACGF in adjusted analyses (HR 1.12 (95% CI: 1.06, 1.19); I2 = 20%; very low quality of evidence). Other outcomes could not be pooled meaningfully. CONCLUSIONS Kidney donor smoking history was associated with modestly increased risk of death-censored graft failure and all-cause graft failure. This review emphasizes the need for further research, standardized reporting, and thoughtful consideration of donor factors like smoking in clinical decision-making on kidney utilization and allocation.
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Affiliation(s)
- Christie Rampersad
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Jason Bau
- Department of Medicine, Division of Transplant Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - S Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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2
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Levin A. Predicting Outcomes in Nephrology: Lots of Tools, Limited Uptake: How Do We Move Forward? J Am Soc Nephrol 2024; 35:361-363. [PMID: 38087445 PMCID: PMC10914199 DOI: 10.1681/asn.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Affiliation(s)
- Adeera Levin
- Medicine, Division of Nephrology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
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3
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Almeida M, Ribeiro C, Silvano J, Pedroso S, Tafulo S, Martins LS, Ramos M, Malheiro J. Clinical performance of the iPREDICTLIVING tool for the prediction of the post-transplant recipient and living donor outcomes in a European cohort. Clin Transplant 2024; 38:e15283. [PMID: 38485667 DOI: 10.1111/ctr.15283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/19/2024]
Abstract
A living donor kidney transplant (LDKT) is the best treatment for ESRD. A prediction tool based on clinical and demographic data available pre-KT was developed in a Norwegian cohort with three different models to predict graft loss, recipient death, and donor candidate's risk of death, the iPREDICTLIVING tool. No external validations are yet available. We sought to evaluate its predictive performance in our cohort of 352 pairs LKDT submitted to KT from 1998 to 2019. The model for censored graft failure (CGF) showed the worse discriminative performance with Harrell's C of .665 and a time-dependent AUC of .566, with a calibration slope of .998. For recipient death, at 10 years, the model had a Harrell's C of .776, a time-dependent AUC of .773, and a calibration slope of 1.003. The models for donor death were reasonably discriminative, although with a poor calibration, particularly for 20 years of death, with a Harrell's C of .712 and AUC of .694 with a calibration slope of .955. These models have moderate discriminative and calibration performance in our population. The tool was validated in this Northern Portuguese cohort, Caucasian, with a low incidence of diabetes and other comorbidities. It can improve the informed decision-making process at the living donor consultation joining clinical and other relevant information.
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Affiliation(s)
- Manuela Almeida
- Department of Nephrology, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Catarina Ribeiro
- Department of Nephrology, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
| | - José Silvano
- Department of Nephrology, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
| | - Sofia Pedroso
- Department of Nephrology, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Sandra Tafulo
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- Instituto Portugês do Sangue e Transplantação, Porto, Portugal
| | - La Salete Martins
- Department of Nephrology, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Miguel Ramos
- Department of Urology, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
| | - Jorge Malheiro
- Department of Nephrology, Centro Hospitalar Universitário de Santo António (CHUdSA), Porto, Portugal
- UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
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4
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Verbesey J, Thomas AG, Waterman AD, Karhadkar S, Cassell VR, Segev DL, Hogan J, Cooper M. Unrecognized opportunities: The landscape of pediatric kidney-paired donation in the United States. Pediatr Transplant 2024; 28:e14657. [PMID: 38317337 PMCID: PMC10857737 DOI: 10.1111/petr.14657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/31/2023] [Accepted: 11/13/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Pediatric (age < 18 years) kidney transplant (KT) candidates face increasingly complex choices. The 2014 kidney allocation system nearly doubled wait times for pediatric recipients. Given longer wait times and new ways to optimize compatibility, more pediatric candidates may consider kidney-paired donation (KPD). Motivated by this shift and the potential impact of innovations in KPD practice, we studied pediatric KPD procedures in the US from 2008 to 2021. METHODS We describe the characteristics and outcomes of pediatric KPD recipients with comparison to pediatric non-KPD living donor kidney transplants (LDKT), pediatric LDKT recipients, and pediatric deceased donor (DDKT) recipients. RESULTS Our study cohort includes 4987 pediatric DDKTs, 3447 pediatric non-KPD LDKTs, and 258 pediatric KPD transplants. Fewer centers conducted at least one pediatric KPD procedure compared to those that conducted at least one pediatric LDKT or DDKT procedure (67, 136, and 155 centers, respectively). Five centers performed 31% of the pediatric KPD transplants. After adjustment, there were no differences in graft failure or mortality comparing KPD recipients to non-KPD LDKT, LDKT, or DDKT recipients. DISCUSSION We did not observe differences in transplant outcomes comparing pediatric KPD recipients to controls. Considering these results, KPD may be underutilized for pediatric recipients. Pediatric KT centers should consider including KPD in KT candidate education. Further research will be necessary to develop tools that could aid clinicians and families considering the time horizon for future KT procedures, candidate disease and histocompatibility characteristics, and other factors including logistics and donor protections.
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Affiliation(s)
| | - Alvin G Thomas
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Surgery, New York University Langone Health, New York, New York, USA
| | - Amy D Waterman
- Department of Surgery, Houston Methodist, Houston, Texas, USA
| | - Sunil Karhadkar
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Dorry L Segev
- Department of Surgery, New York University Langone Health, New York, New York, USA
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Julien Hogan
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France
- Pediatric Nephrology Department, Robert Debré Hospital, APHP, Paris, France
| | - Matt Cooper
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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5
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Dawes J, Gregor A, Kolansky J, Wirshup K, Di Carlo A, Karhadkar S. Longevity Matching for Living Donor Renal Transplantation. Transplant Proc 2024; 56:31-36. [PMID: 38199853 DOI: 10.1016/j.transproceed.2023.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/26/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION This study identifies the effect of individual donor and recipient characteristics on graft survival in living-donor kidney transplantation (LDKT) using a recently described novel measure, kidney life years (KLYs). MATERIALS AND METHODS The Organ Procurement and Transplantation Network/United Network for Organ Sharing database was used to identify first-time kidney-only LDKT recipients between 1987 and 2020 who did not experience death with a functioning graft (DWFG) and were not missing relevant information (n = 87,290). Patient characteristics were evaluated using Cox and multiple regression analyses, with the dependent variable being KLYs. An equation for expected KLYs based on patient characteristics was created using regression coefficients. The equation was validated using bootstrapped Pearson correlations and then applied to the DWFG group for comparison. RESULTS Based on statistical significance from Cox and multiple linear regression analyses, 9 of the original 18 variables were selected for inclusion in the equation. Variables with notable impact included HLA match points (0.021 KLYs; 95% CI: [0.019,0.024]; P ≤ .001), Donor Age (-0.030 KLYs; 95% CI: [-0.035,-0.025]; P ≤ .001), and Donor African American Ethnicity (-2.356 KLYs; 95% CI: [-2.552,-2.159]; P ≤ .001). Equation validation was supported, given a negative correlation (r = -0.071; P ≤ .001) between expected KLY change and observed graft failure. Expected KLY change was found to be greater in those who eventually DWFG when compared with all other LDKTs (t = -5.735, P ≤ .001). CONCLUSIONS Increasing HLA match points may be more beneficial for graft longevity than minimizing donor age in comparisons using realistic between-donor differences. Additionally, greater average expected KLYs in those who ultimately DWFG may illustrate an opportunity for improved donor-recipient matching.
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Affiliation(s)
- Jack Dawes
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.
| | - Andrew Gregor
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jonathan Kolansky
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Kathleen Wirshup
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Antonio Di Carlo
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Sunil Karhadkar
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
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Kim HJ, Min E, Yim SH, Choi MC, Kim HW, Yang J, Kim BS, Huh KH, Kim MS, Lee J. Clinical relevance of the living kidney donor profile index in Korean kidney transplant recipients. Clin Transplant 2024; 38:e15178. [PMID: 37922208 DOI: 10.1111/ctr.15178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND The Living Kidney Donor Profile Index (LKDPI) was developed in the United States to predict graft outcomes based on donor characteristics. However, there are significant differences in donor demographics, access to transplantation, proportion of ABO incompatibility, and posttransplant mortality in Asian countries compared with the United States. METHODS We evaluated the clinical relevance of the LKDPI score in a Korean kidney transplant cohort by analyzing 1860 patients who underwent kidney transplantation between 2000 and 2019. Patients were divided into three groups according to LKDPI score: <0, 1-19.9, and ≥20. RESULTS During a median follow-up of 119 months, 232 recipients (12.5%) experienced death-censored graft loss, and 98 recipients (5.3%) died. High LKDPI scores were significantly associated with increased risk of death-censored graft loss independent of recipient characteristics (LKDPI 1-19.9: HR 1.389, 95% CI 1.036-1.863; LKDPI ≥20: HR 2.121, 95% CI 1.50-2.998). High LKDPI score was also significantly associated with increased risk of biopsy-proven acute rejection and impaired graft renal function. By contrast, overall patient survival rates were comparable among the LKDPI groups. CONCLUSION High LKDPI scores were associated with an increased risk of death-censored graft loss, biopsy-proven acute rejection, and impaired graft renal function among a Korean kidney transplant cohort.
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Affiliation(s)
- Hyun Jeong Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eunki Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hyuk Yim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mun Chae Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyung Woo Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoug Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
- The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
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7
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Lyden GR, Vock DM, Helgeson ES, Finger EB, Matas AJ, Snyder JJ. Transportability of causal inference under random dynamic treatment regimes for kidney-pancreas transplantation. Biometrics 2023; 79:3165-3178. [PMID: 37431172 DOI: 10.1111/biom.13899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/14/2023] [Indexed: 07/12/2023]
Abstract
A difficult decision for patients in need of kidney-pancreas transplant is whether to seek a living kidney donor or wait to receive both organs from one deceased donor. The framework of dynamic treatment regimes (DTRs) can inform this choice, but a patient-relevant strategy such as "wait for deceased-donor transplant" is ill-defined because there are multiple versions of treatment (i.e., wait times, organ qualities). Existing DTR methods average over the distribution of treatment versions in the data, estimating survival under a "representative intervention." This is undesirable if transporting inferences to a target population such as patients today, who experience shorter wait times thanks to evolutions in allocation policy. We, therefore, propose the concept of a generalized representative intervention (GRI): a random DTR that assigns treatment version by drawing from the distribution among strategy compliers in the target population (e.g., patients today). We describe an inverse-probability-weighted product-limit estimator of survival under a GRI that performs well in simulations and can be implemented in standard statistical software. For continuous treatments (e.g., organ quality), weights are reformulated to depend on probabilities only, not densities. We apply our method to a national database of kidney-pancreas transplant candidates from 2001-2020 to illustrate that variability in transplant rate across years and centers results in qualitative differences in the optimal strategy for patient survival.
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Affiliation(s)
- Grace R Lyden
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Erika S Helgeson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Erik B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arthur J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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8
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Riley S, Tam K, Tse WY, Connor A, Wei Y. An external validation of the Kidney Donor Risk Index in the UK transplant population in the presence of semi-competing events. Diagn Progn Res 2023; 7:20. [PMID: 37986130 PMCID: PMC10662562 DOI: 10.1186/s41512-023-00159-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 09/11/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Transplantation represents the optimal treatment for many patients with end-stage kidney disease. When a donor kidney is available to a waitlisted patient, clinicians responsible for the care of the potential recipient must make the decision to accept or decline the offer based upon complex and variable information about the donor, the recipient and the transplant process. A clinical prediction model may be able to support clinicians in their decision-making. The Kidney Donor Risk Index (KDRI) was developed in the United States to predict graft failure following kidney transplantation. The survival process following transplantation consists of semi-competing events where death precludes graft failure, but not vice-versa. METHODS We externally validated the KDRI in the UK kidney transplant population and assessed whether validation under a semi-competing risks framework impacted predictive performance. Additionally, we explored whether the KDRI requires updating. We included 20,035 adult recipients of first, deceased donor, single, kidney-only transplants between January 1, 2004, and December 31, 2018, collected by the UK Transplant Registry and held by NHS Blood and Transplant. The outcomes of interest were 1- and 5-year graft failure following transplantation. In light of the semi-competing events, recipient death was handled in two ways: censoring patients at the time of death and modelling death as a competing event. Cox proportional hazard models were used to validate the KDRI when censoring graft failure by death, and cause-specific Cox models were used to account for death as a competing event. RESULTS The KDRI underestimated event probabilities for those at higher risk of graft failure. For 5-year graft failure, discrimination was poorer in the semi-competing risks model (0.625, 95% CI 0.611 to 0.640;0.611, 95% CI 0.597 to 0.625), but predictions were more accurate (Brier score 0.117, 95% CI 0.112 to 0.121; 0.114, 95% CI 0.109 to 0.118). Calibration plots were similar regardless of whether the death was modelled as a competing event or not. Updating the KDRI worsened calibration, but marginally improved discrimination. CONCLUSIONS Predictive performance for 1-year graft failure was similar between death-censored and competing event graft failure, but differences appeared when predicting 5-year graft failure. The updated index did not have superior performance and we conclude that updating the KDRI in the present form is not required.
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Affiliation(s)
- Stephanie Riley
- Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, UK.
| | - Kimberly Tam
- School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Wai-Yee Tse
- Department of Renal Medicine, South West Transplant Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Andrew Connor
- Department of Renal Medicine, South West Transplant Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Yinghui Wei
- Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, UK.
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9
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Husain SA, Crew RJ. It's All Relative: Donor-Recipient Relationships, Disease Heritability, and Kidney Transplant Outcomes. Am J Kidney Dis 2023; 82:518-520. [PMID: 37632489 DOI: 10.1053/j.ajkd.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 08/28/2023]
Affiliation(s)
- S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York.
| | - R John Crew
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
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10
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Nguyen NTQ, Courtney AE, Nguyen HQ, Quinn M, Maxwell AP, O'Neill C. Early clinical and economic outcomes of expanded criteria living kidney donors in the United States. J Nephrol 2023; 36:957-968. [PMID: 36592302 DOI: 10.1007/s40620-022-01541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/20/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The donation of what might be termed expanded criteria kidneys has become an increasingly common practice. This study aimed to assign expanded criteria and non-expanded criteria donation status and examine early clinical and economic outcomes among expanded criteria and non-expanded criteria living kidney donor (LKD) hospitalizations in the US. METHODS Healthcare cost and Utilization Project-National (Nationwide) Inpatient Sample (HCUP-NIS) data (Jan 2008-Dec 2019, N = 12,020) were used. Expanded criteria LKDs were identified as admitted patients aged ≥ 60 years, or 50-59 years with any comorbidity that historically precluded donation. The Clavien-Dindo system was applied to classify surgical complications as grade I-IV/V. RESULTS The number of LKD admissions decreased by 31% over the study period, although this trend fluctuated over time. Compared to non-expanded criteria LKD admissions, expanded criteria LKD admissions had comparable surgical complication rates in Grade I (aOR 1.0, 0.8-1.3), but significantly higher surgical complication rates in Grade II (aOR 1.5, 1.1-2.2) and Grade III (aOR 1.4, 1.0-2.0). The two groups had comparable hospital length of stay and cost in the adjusted models. Notably, Grade II complications were significantly higher in private, for-profit hospitals (15%) compared to government hospitals (2.9%). CONCLUSIONS Expanded criteria LKDs had comparable early outcomes compared to non-expanded criteria LKDs, but the trends evident in LKDs over time and the variation in complication records warrant further research.
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Affiliation(s)
- Nga T Q Nguyen
- Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, 41-43 Dinh Tien Hoang Street, Ben Nghe Ward, District 1, Ho Chi Minh City, Vietnam.
| | - Aisling E Courtney
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, UK
| | - Hoa Q Nguyen
- Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, 41-43 Dinh Tien Hoang Street, Ben Nghe Ward, District 1, Ho Chi Minh City, Vietnam
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Michael Quinn
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, UK
| | - Alexander P Maxwell
- Belfast City Hospital, Belfast, UK
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Ciaran O'Neill
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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11
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Heiden BT, Yang Z, Bai YZ, Yan Y, Chang SH, Park Y, Colditz GA, Dart H, Hachem RR, Witt CA, Vazquez Guillamet R, Byers DE, Marklin GF, Pasque MK, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Development and validation of the lung donor (LUNDON) acceptability score for pulmonary transplantation. Am J Transplant 2023; 23:540-548. [PMID: 36764887 PMCID: PMC10234600 DOI: 10.1016/j.ajt.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
There is a chronic shortage of donor lungs for pulmonary transplantation due, in part, to low lung utilization rates in the United States. We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients database (2006-2019) and developed the lung donor (LUNDON) acceptability score. A total of 83 219 brain-dead donors were included and were randomly divided into derivation (n = 58 314, 70%) and validation (n = 24 905, 30%) cohorts. The overall lung acceptance was 27.3% (n = 22 767). Donor factors associated with the lung acceptance were age, maximum creatinine, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, mechanism of death by asphyxiation or drowning, history of cigarette use (≥20 pack-years), history of myocardial infarction, chest x-ray appearance, bloodstream infection, and the occurrence of cardiac arrest after brain death. The prediction model had high discriminatory power (C statistic, 0.891; 95% confidence interval, 0.886-0.895) in the validation cohort. We developed a web-based, user-friendly tool (available at https://sites.wustl.edu/lundon) that provides the predicted probability of donor lung acceptance. LUNDON score was also associated with recipient survival in patients with high lung allocation scores. In conclusion, the multivariable LUNDON score uses readily available donor characteristics to reliably predict lung acceptability. Widespread adoption of this model may standardize lung donor evaluation and improve lung utilization rates.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yun Zhu Bai
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hank Dart
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | | | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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12
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van der Horst DEM, Engels N, Hendrikx J, van den Dorpel MA, Pieterse AH, Stiggelbout AM, van Uden-Kraan CF, Bos WJW. Predicting outcomes in chronic kidney disease: needs and preferences of patients and nephrologists. BMC Nephrol 2023; 24:66. [PMID: 36949427 PMCID: PMC10035227 DOI: 10.1186/s12882-023-03115-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/10/2023] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Guidelines on chronic kidney disease (CKD) recommend that nephrologists use clinical prediction models (CPMs). However, the actual use of CPMs seems limited in clinical practice. We conducted a national survey study to evaluate: 1) to what extent CPMs are used in Dutch CKD practice, 2) patients' and nephrologists' needs and preferences regarding predictions in CKD, and 3) determinants that may affect the adoption of CPMs in clinical practice. METHODS We conducted semi-structured interviews with CKD patients to inform the development of two online surveys; one for CKD patients and one for nephrologists. Survey participants were recruited through the Dutch Kidney Patient Association and the Dutch Federation of Nephrology. RESULTS A total of 126 patients and 50 nephrologists responded to the surveys. Most patients (89%) reported they had discussed predictions with their nephrologists. They most frequently discussed predictions regarded CKD progression: when they were expected to need kidney replacement therapy (KRT) (n = 81), and how rapidly their kidney function was expected to decline (n = 68). Half of the nephrologists (52%) reported to use CPMs in clinical practice, in particular CPMs predicting the risk of cardiovascular disease. Almost all nephrologists (98%) reported discussing expected CKD trajectories with their patients; even those that did not use CPMs (42%). The majority of patients (61%) and nephrologists (84%) chose a CPM predicting when patients would need KRT in the future as the most important prediction. However, a small portion of patients indicated they did not want to be informed on predictions regarding CKD progression at all (10-15%). Nephrologists not using CPMs (42%) reported they did not know CPMs they could use or felt that they had insufficient knowledge regarding CPMs. According to the nephrologists, the most important determinants for the adoption of CPMs in clinical practice were: 1) understandability for patients, 2) integration as standard of care, 3) the clinical relevance. CONCLUSION Even though the majority of patients in Dutch CKD practice reported discussing predictions with their nephrologists, CPMs are infrequently used for this purpose. Both patients and nephrologists considered a CPM predicting CKD progression most important to discuss. Increasing awareness about existing CPMs that predict CKD progression may result in increased adoption in clinical practice. When using CPMs regarding CKD progression, nephrologists should ask whether patients want to hear predictions beforehand, since individual patients' preferences vary.
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Affiliation(s)
- Dorinde E M van der Horst
- Santeon, Utrecht, The Netherlands.
- Department of Internal Medicine, Leiden University Medical Centre, Leiden, the Netherlands.
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | - Noel Engels
- Santeon, Utrecht, The Netherlands
- Department of Internal Medicine, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, the Netherlands
| | | | | | - Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anne M Stiggelbout
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Willem Jan W Bos
- Santeon, Utrecht, The Netherlands
- Department of Internal Medicine, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
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13
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Tomizawa M, Hori S, Nishimura N, Omori C, Nakai Y, Miyake M, Torimoto K, Yoneda T, Fujimoto K. Comprehensive Analysis of Donor Factors for Allograft Survival in Living Kidney Transplantation: A Single-Center Study in Japan. Transplant Proc 2023:S0041-1345(23)00093-3. [PMID: 36990885 DOI: 10.1016/j.transproceed.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/04/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Various donor characteristics have been reported as predictive factors for graft survival in kidney transplantations. The living kidney donor profile index (LKDPI) was established in 2016 to evaluate the quality of living donor kidneys. Herein, we verified whether the index score was associated with graft survival and analyzed various donor factors to identify predictors of graft survival in living donor kidney transplantations. METHODS This retrospective study included 130 patients who received a living donor kidney between 2006 and 2019 at our hospital. Clinical and laboratory data were obtained from the medical records. Living donor kidneys were categorized into 3 groups by LKDPI score, and the death-censored graft survival and predictors of graft survival were evaluated. RESULTS The median LKDPI score was 35 (IQR: 17-53). The index scores of the living donor kidneys in this study were higher than in previous studies. The groups with the highest scores (LKDPI >40) had significantly shorter death-censored graft survival compared with the group with the lowest scores (LKDPI <20; hazard ratio = 4.0, P = .005). There were no significant differences between the group with the middle scores (LKDPI, 20-40) and the other 2 groups. Donor/recipient weight ratio <0.9, ABO incompatibility, and 2 HLA-DR mismatches were identified as independent predictive factors for shorter graft survival. CONCLUSION The LKDPI was correlated with death-censored graft survival in this study. However, more studies are required to establish a modified index that is more accurate for Japanese patients.
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Affiliation(s)
| | - Shunta Hori
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Chihiro Omori
- Department of Urology, Nara Medical University, Nara, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Nara, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Nara, Japan
| | | | - Tatsuo Yoneda
- Department of Urology, Nara Medical University, Nara, Japan
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14
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Irish GL, McMichael LC, Kadatz M, Boudville N, Campbell S, Chadban S, Chang D, Kanellis J, Sharples E, Gill JS, Clayton PA. The living kidney donor profile index fails to discriminate allograft survival: implications for its use in kidney paired donation programs. Am J Transplant 2023; 23:232-238. [PMID: 36804131 DOI: 10.1016/j.ajt.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 02/19/2023]
Abstract
The inclusion of blood group- and human leukocyte antigen-compatible donor and recipient pairs (CPs) in kidney paired donation (KPD) programs is a novel strategy to increase living donor (LD) transplantation. Transplantation from a donor with a better Living Donor Kidney Profile Index (LKDPI) may encourage CP participation in KPD programs. We undertook parallel analyses using data from the Scientific Registry of Transplant Recipients and the Australia and New Zealand Dialysis and Transplant Registry to determine whether the LKDPI discriminates death-censored graft survival (DCGS) between LDs. Discrimination was assessed by the following: (1) the change in the Harrell C statistic with the sequential addition of variables in the LKDPI equation to reference models that included only recipient factors and (2) whether the LKDPI discriminated DCGS among pairs of prognosis-matched LD recipients. The addition of the LKDPI to reference models based on recipient variables increased the C statistic by only 0.02. Among prognosis-matched pairs, the C statistic in Cox models to determine the association of the LKDPI with DCGS was no better than chance alone (0.51 in the Scientific Registry of Transplant Recipient and 0.54 in the Australia and New Zealand Dialysis and Transplant Registry cohorts). We conclude that the LKDPI does not discriminate DCGS and should not be used to promote CP participation in KPD programs.
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Affiliation(s)
- Georgina L Irish
- Transplant Epidemiology Group, Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lachlan C McMichael
- Transplant Epidemiology Group, Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew Kadatz
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Neil Boudville
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Scott Campbell
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Steven Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia; Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Doris Chang
- Transplant Research, Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - John Kanellis
- Department of Nephrology, Monash Health, Melbourne, Victoria, Australia; Department of Medicine, Centre for Inflammatory Diseases, Monash University, Melbourne, Victoria, Australia
| | | | - John S Gill
- Kidney Transplant Program, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada; Transplant Research, Providence Health Research Institute, Vancouver, British Columbia, Canada; Tufts-New England Medical Center, Boston, Massachusetts, USA.
| | - Philip A Clayton
- Transplant Epidemiology Group, Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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15
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Lemos JRN, Baidal DA, Poggioli R, Fuenmayor V, Chavez C, Alvarez A, Ricordi C, Alejandro R. HLA-B Matching Prolongs Allograft Survival in Islet Cell Transplantation. Cell Transplant 2023; 32:9636897231166529. [PMID: 37526141 PMCID: PMC10395153 DOI: 10.1177/09636897231166529] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 08/02/2023] Open
Abstract
Islet cell transplantation (ITx) is an effective therapeutic approach for selected patients with type 1 diabetes with hypoglycemia unawareness and severe hypoglycemia events. In organ transplantation, human leukocyte antigen (HLA) mismatching between donor and recipient negatively impacts transplant outcomes. We aimed to determine whether HLA matching has an impact on islet allograft survival. Forty-eight patients were followed up after islet transplantation at our institution from 2000 to 2020 in a retrospective cohort. Patients underwent intrahepatic ITx or laparoscopic omental approach. Immunosuppression was dependent upon the protocol. We analyzed HLA data restricted to A, B, and DR loci on allograft survival using survival and subsequent multivariable analyses. Patients were aged 42.8 ± 8.4 years, and 64.3% were female. Diabetes duration was 28.6 ± 11.6 years. Patients matching all three HLA loci presented longer graft survival (P = 0.030). Patients with ≥1 HLA-B matching had longer graft survival compared with zero matching (P = 0.025). The number of HLA-B matching was positively associated with time of graft survival (Spearman's rho = 0.590; P = 0.034). Analyses adjusted for confounders showed that ≥1 matching for HLA-B decreased the risk of allograft failure (P = 0.009). Our data suggest that HLA-B matching between recipients and donors improved islet allograft survival. Matching all three HLA loci (A, B, and DR) was also associated with prolonged islet allograft survival. Prospective studies and a larger sample size are warranted to validate our findings.
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Affiliation(s)
- Joana R. N. Lemos
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - David A. Baidal
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Raffaella Poggioli
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Virginia Fuenmayor
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Carmen Chavez
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ana Alvarez
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Camillo Ricordi
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
- Division of Cellular Transplantation, Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Rodolfo Alejandro
- Diabetes Research Institute (DRI) and Clinical Cell Transplant Program, Miller School of Medicine, University of Miami, Miami, FL, USA
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16
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Frutos MÁ, Crespo M, Valentín MDLO, Alonso-Melgar Á, Alonso J, Fernández C, García-Erauzkin G, González E, González-Rinne AM, Guirado L, Gutiérrez-Dalmau A, Huguet J, Moral JLLD, Musquera M, Paredes D, Redondo D, Revuelta I, Hofstadt CJVD, Alcaraz A, Alonso-Hernández Á, Alonso M, Bernabeu P, Bernal G, Breda A, Cabello M, Caro-Oleas JL, Cid J, Diekmann F, Espinosa L, Facundo C, García M, Gil-Vernet S, Lozano M, Mahillo B, Martínez MJ, Miranda B, Oppenheimer F, Palou E, Pérez-Saez MJ, Peri L, Rodríguez O, Santiago C, Tabernero G, Hernández D, Domínguez-Gil B, Pascual J. Recommendations for living donor kidney transplantation. Nefrologia 2022; 42 Suppl 2:5-132. [PMID: 36503720 DOI: 10.1016/j.nefroe.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023] Open
Abstract
This Guide for Living Donor Kidney Transplantation (LDKT) has been prepared with the sponsorship of the Spanish Society of Nephrology (SEN), the Spanish Transplant Society (SET), and the Spanish National Transplant Organization (ONT). It updates evidence to offer the best chronic renal failure treatment when a potential living donor is available. The core aim of this Guide is to supply clinicians who evaluate living donors and transplant recipients with the best decision-making tools, to optimise their outcomes. Moreover, the role of living donors in the current KT context should recover the level of importance it had until recently. To this end the new forms of incompatible HLA and/or ABO donation, as well as the paired donation which is possible in several hospitals with experience in LDKT, offer additional ways to treat renal patients with an incompatible donor. Good results in terms of patient and graft survival have expanded the range of circumstances under which living renal donors are accepted. Older donors are now accepted, as are others with factors that affect the decision, such as a borderline clinical history or alterations, which when evaluated may lead to an additional number of transplantations. This Guide does not forget that LDKT may lead to risk for the donor. Pre-donation evaluation has to centre on the problems which may arise over the short or long-term, and these have to be described to the potential donor so that they are able take them into account. Experience over recent years has led to progress in risk analysis, to protect donors' health. This aspect always has to be taken into account by LDKT programmes when evaluating potential donors. Finally, this Guide has been designed to aid decision-making, with recommendations and suggestions when uncertainties arise in pre-donation studies. Its overarching aim is to ensure that informed consent is based on high quality studies and information supplied to donors and recipients, offering the strongest possible guarantees.
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Affiliation(s)
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | | | | | - Juana Alonso
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | | | - Esther González
- Nephrology Department, Hospital Universitario 12 Octubre, Spain
| | | | - Lluis Guirado
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | - Jorge Huguet
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | | | - Mireia Musquera
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | - David Paredes
- Donation and Transplantation Coordination Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Ignacio Revuelta
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Antonio Alcaraz
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | - Manuel Alonso
- Regional Transplantation Coordination, Seville, Spain
| | | | - Gabriel Bernal
- Nephrology Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alberto Breda
- RT Surgical Team, Fundació Puigvert, Barcelona, Spain
| | - Mercedes Cabello
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Joan Cid
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and RT Department, Hospital Clinic Universitari, Barcelona, Spain
| | - Laura Espinosa
- Paediatric Nephrology Department, Hospital La Paz, Madrid, Spain
| | - Carme Facundo
- Nephrology Department, Fundacio Puigvert, Barcelona, Spain
| | | | | | - Miquel Lozano
- Apheresis and Cell Therapy Unit, Haemotherapy and Haemostasis Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | | | - Eduard Palou
- Immunology Department, Hospital Clinic i Universitari, Barcelona, Spain
| | | | - Lluis Peri
- Urology Department, Hospital Clinic Universitari, Barcelona, Spain
| | | | | | | | - Domingo Hernández
- Nephrology Department, Hospital Regional Universitario de Málaga, Spain
| | | | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain.
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17
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Patel A, Shertel T, Wynd M, Wadhera V, Serur D, Schleich B, Yushkov Y, Goldstein M. Outcomes of de novo belatacept-based immunosuppression regimen and avoidance of calcineurin inhibitors in recipients of kidney allografts at higher risk for underutilization. Nephrology (Carlton) 2022; 27:901-905. [PMID: 36047901 DOI: 10.1111/nep.14106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/21/2022] [Accepted: 08/23/2022] [Indexed: 01/11/2023]
Abstract
To describe an experience using a protocol using de novo belatacept (DNB) based maintenance immunosuppression in the setting of lymphocyte depletion. A retrospective, observational study was performed on 37 kidney transplant recipients treated with the DNB protocol, which was defined as belatacept initiated within 7 days after a kidney transplant with steroids and mycophenolate with anti-thymocyte globulin (ATG) induction without concomitant calcineurin inhibitors (CNIs). Patients who received a deceased donor kidney meeting one or more of the following criteria: anticipated cold ischemia time (CIT) greater than 24 h, donation after cardiac death, donor acute kidney injury, and a Kidney Donor Profile Index (KDPI) >85% during the study period were included. Patient survival at 1 year was 97.3% and graft survival was 94.6%. Delayed graft function (DGF) occurred in 40.54% of the patients. Two patients experienced a Banff 1B acute cellular rejection. BK viremia was detected in 32.4% of patients. The mean estimated glomerular filtration rate (eGFR) calculated with the use of modification of diet in renal disease (MDRD) equation at 1 year in the study group was 54.7 ml/min/1.73 m2 . We believe that utilization of the DNB protocol, which allows early CNI avoidance, may decrease organ discard rates.
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Affiliation(s)
- Ankita Patel
- Nephrology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Tara Shertel
- Pharmacy, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Michael Wynd
- Pharmacy, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Vikram Wadhera
- Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - David Serur
- Nephrology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Benjamin Schleich
- Quality, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Yuriy Yushkov
- Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Michael Goldstein
- Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
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18
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Engels N, de Graav GN, van der Nat P, van den Dorpel M, Stiggelbout AM, Bos WJ. Shared decision-making in advanced kidney disease: a scoping review. BMJ Open 2022; 12:e055248. [PMID: 36130746 PMCID: PMC9494569 DOI: 10.1136/bmjopen-2021-055248] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To provide a comprehensive overview of interventions that support shared decision-making (SDM) for treatment modality decisions in advanced kidney disease (AKD). To provide summarised information on their content, use and reported results. To provide an overview of interventions currently under development or investigation. DESIGN The JBI methodology for scoping reviews was followed. This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. DATA SOURCES MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO, PROSPERO and Academic Search Premier for peer-reviewed literature. Other online databases (eg, clinicaltrials.gov, OpenGrey) for grey literature. ELIGIBILITY FOR INCLUSION Records in English with a study population of patients >18 years of age with an estimated glomerular filtration rate <30 mL/min/1.73 m2. Records had to be on the subject of SDM, or explicitly mention that the intervention reported on could be used to support SDM for treatment modality decisions in AKD. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened and selected records for data extraction. Interventions were categorised as prognostic tools (PTs), educational programmes (EPs), patient decision aids (PtDAs) or multicomponent initiatives (MIs). Interventions were subsequently categorised based on the decisions they were developed to support. RESULTS One hundred forty-five interventions were identified in a total of 158 included records: 52 PTs, 51 EPs, 29 PtDAs and 13 MIs. Sixteen (n=16, 11%) were novel interventions currently under investigation. Forty-six (n=46, 35.7%) were reported to have been implemented in clinical practice. Sixty-seven (n=67, 51.9%) were evaluated for their effects on outcomes in the intended users. CONCLUSION There is no conclusive evidence on which intervention is the most efficacious in supporting SDM for treatment modality decisions in AKD. There is a lot of variation in selected outcomes, and the body of evidence is largely based on observational research. In addition, the effects of these interventions on SDM are under-reported.
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Affiliation(s)
- Noel Engels
- Department of Shared Decision-Making and Value-Based Health Care, Santeon, Utrecht, The Netherlands
- Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Internal Medicine, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Paul van der Nat
- Department of Value-Based Health Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Anne M Stiggelbout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan Bos
- Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Value-Based Health Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
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19
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Riley S, Zhang Q, Tse WY, Connor A, Wei Y. Using Information Available at the Time of Donor Offer to Predict Kidney Transplant Survival Outcomes: A Systematic Review of Prediction Models. Transpl Int 2022; 35:10397. [PMID: 35812156 PMCID: PMC9259750 DOI: 10.3389/ti.2022.10397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022]
Abstract
Statistical models that can predict graft and patient survival outcomes following kidney transplantation could be of great clinical utility. We sought to appraise existing clinical prediction models for kidney transplant survival outcomes that could guide kidney donor acceptance decision-making. We searched for clinical prediction models for survival outcomes in adult recipients with single kidney-only transplants. Models that require information anticipated to become available only after the time of transplantation were excluded as, by that time, the kidney donor acceptance decision would have already been made. The outcomes of interest were all-cause and death-censored graft failure, and death. We summarised the methodological characteristics of the prediction models, predictive performance and risk of bias. We retrieved 4,026 citations from which 23 articles describing 74 models met the inclusion criteria. Discrimination was moderate for all-cause graft failure (C-statistic: 0.570–0.652; Harrell’s C: 0.580–0.660; AUC: 0.530–0.742), death-censored graft failure (C-statistic: 0.540–0.660; Harrell’s C: 0.590–0.700; AUC: 0.450–0.810) and death (C-statistic: 0.637–0.770; Harrell’s C: 0.570–0.735). Calibration was seldom reported. Risk of bias was high in 49 of the 74 models, primarily due to methods for handling missing data. The currently available prediction models using pre-transplantation information show moderate discrimination and varied calibration. Further model development is needed to improve predictions for the purpose of clinical decision-making.Systematic Review Registration:https://osf.io/c3ehp/l.
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Affiliation(s)
- Stephanie Riley
- Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, United Kingdom
| | - Qing Zhang
- Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, United Kingdom
| | - Wai-Yee Tse
- Department of Renal Medicine, South West Transplant Centre, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Andrew Connor
- Department of Renal Medicine, South West Transplant Centre, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Yinghui Wei
- Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, United Kingdom
- *Correspondence: Yinghui Wei,
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20
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Bachmann Q, Haberfellner F, Büttner-Herold M, Torrez C, Haller B, Assfalg V, Renders L, Amann K, Heemann U, Schmaderer C, Kemmner S. The Kidney Donor Profile Index (KDPI) Correlates With Histopathologic Findings in Post-reperfusion Baseline Biopsies and Predicts Kidney Transplant Outcome. Front Med (Lausanne) 2022; 9:875206. [PMID: 35573025 PMCID: PMC9100560 DOI: 10.3389/fmed.2022.875206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background The increasing organ shortage in kidney transplantation leads to the necessity to use kidneys previously considered unsuitable for transplantation. Numerous studies illustrate the need for a better decision guidance rather than only the classification into kidneys from standard or expanded criteria donors referred to as SCD/ECD-classification. The kidney donor profile index (KDPI) exhibits a score utilizing a much higher number of donor characteristics. Moreover, graft biopsies provide an opportunity to assess organ quality. Methods In a single center analysis 383 kidney transplantations (277 after deceased and 106 after living donation) performed between January 1st, 2006, and December 31st, 2016, retrospectively underwent SCD/ECD and KDPI scoring. Thereby, the quality of deceased donor kidneys was assessed by using the KDPI and the living donor kidneys by using the living KDPI, in the further analysis merged as (L)KDPI. Baseline biopsies taken 10 min after the onset of reperfusion were reviewed for chronic and acute lesions. Survival analyses were performed using Kaplan-Meier analysis and Cox proportional hazards analysis within a 5-year follow-up. Results The (L)KDPI correlated with glomerulosclerosis (r = 0.30, p < 0.001), arteriosclerosis (r = 0.33, p < 0.001), interstitial fibrosis, and tubular atrophy (r = 0.28, p < 0.001) as well as the extent of acute tubular injury (r = 0.20, p < 0.001). The C-statistic of the (L)KDPI concerning 5-year death censored graft survival was 0.692. Around 48% of ECD-kidneys were classified as (L)KDPI<85%. In a multivariate Cox proportional hazard analysis including (preformed) panel reactive antibodies, cold ischemia time, (L)KDPI, and SCD/ECD-classification, the (L)KDPI was significantly associated with risk of graft loss (hazard ratio per 10% increase in (L)KDPI: 1.185, 95% confidence interval: 1.033–1.360, p = 0.025). Survival analysis revealed decreased death censored (p < 0.001) and non-death censored (p < 0.001) graft survival in kidneys with an increasing (L)KDPI divided into groups of <35, 35–85, and >85%, respectively. Conclusion With a higher granularity compared to the SCD/ECD-classification the (L)KDPI is a promising tool to judge graft quality. The correlation with chronic and acute histological lesions in post-reperfusion kidney biopsies underlines the descriptive value of the (L)KDPI. However, its prognostic value is limited and underlines the urgent need for a more precise prognostic tool adopted to European kidney transplant conditions.
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Affiliation(s)
- Quirin Bachmann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Flora Haberfellner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Carlos Torrez
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- School of Medicine, Institute of AI and Informatics in Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Volker Assfalg
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephan Kemmner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- *Correspondence: Stephan Kemmner
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21
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Recomendaciones para el trasplante renal de donante vivo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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Jackson KR, Segev DL. Rethinking incompatibility in kidney transplantation. Am J Transplant 2022; 22:1031-1036. [PMID: 34464500 DOI: 10.1111/ajt.16826] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 08/16/2021] [Accepted: 08/26/2021] [Indexed: 01/25/2023]
Abstract
Donor/recipient incompatibility in kidney transplantation classically refers to ABO/HLA-incompatibility. Kidney paired donation (KPD) was historically established to circumvent ABO/HLA-incompatibility, with the goal of identifying ABO/HLA-compatible matches. However, there is a broad range of donor factors known to impact recipient outcomes beyond ABO/HLA-incompatibility, such as age and weight, and quantitative tools are now available to empirically compare potential living donors across many of these factors, such as the living donor kidney donor profile index (LKDPI). Moreover, the detrimental impact of mismatch at other HLA antigens (such as DQ) and epitope mismatching on posttransplant outcomes has become increasingly recognized. Thus, it is time for a new paradigm of incompatibility that considers all of these risks factors together in assessing donor/recipient compatibility and the potential utility for KPD. Under this new paradigm of incompatibility, we show how the LKDPI and other tools can be used to identify donor/recipient incompatibilities that could be improved through KPD, even for those with a traditionally "compatible" living donor.
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Affiliation(s)
- Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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23
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How MDRD (and CKD-epi and Cystatin C) eGFRs Obscure Interpretation of Kidney Transplant Studies. Transplantation 2022; 106:432-435. [PMID: 33756545 DOI: 10.1097/tp.0000000000003769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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24
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Wang W, Leichtman AB, Rees MA, Song PXK, Ashby VB, Shearon T, Kalbfleisch JD. Kidney Paired Donation Chains Initiated by Deceased Donors. Kidney Int Rep 2022; 7:1278-1288. [PMID: 35685310 PMCID: PMC9171627 DOI: 10.1016/j.ekir.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/01/2022] [Accepted: 03/21/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Rather than generating 1 transplant by directly donating to a candidate on the waitlist, deceased donors (DDs) could achieve additional transplants by donating to a candidate in a kidney paired donation (KPD) pool, thereby, initiating a chain that ends with a living donor (LD) donating to a candidate on the waitlist. We model outcomes arising from various strategies that allow DDs to initiate KPD chains. Methods We base simulations on actual 2016 to 2017 US DD and waitlist data and use simulated KPD pools to model DD-initiated KPD chains. We also consider methods to assess and overcome the primary criticism of this approach, namely the potential to disadvantage blood type O-waitlisted candidates. Results Compared with shorter DD-initiated KPD chains, longer chains increase the number of KPD transplants by up to 5% and reduce the number of DDs allocated to the KPD pool by 25%. These strategies increase the overall number of blood type O transplants and make LDs available to candidates on the waitlist. Restricting allocation of blood type O DDs to require ending KPD chains with LD blood type O donations to the waitlist markedly reduces the number of KPD transplants achieved. Conclusion Allocating fewer than 3% of DD to initiate KPD chains could increase the number of kidney transplants by up to 290 annually. Such use of DDs allows additional transplantation of highly sensitized and blood type O KPD candidates. Collectively, patients of each blood type, including blood type O, would benefit from the proposed strategies.
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25
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Kiberd BA, Vinson A, Acott PD, Tennankore KK. Optimal Sequencing of Deceased Donor and Live Donor Kidney Transplant Among Pediatric Patients With Kidney Failure. JAMA Netw Open 2022; 5:e2142331. [PMID: 34989796 PMCID: PMC8739763 DOI: 10.1001/jamanetworkopen.2021.42331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE In the US, live donor (LD) kidney transplant rates have decreased in pediatric recipients. Pediatric patients with kidney failure will likely need more than 1 kidney transplant during their lifetime, but the optimal sequence of transplant (ie, deceased donor [DD] followed by LD or vice versa) is not known. OBJECTIVE To determine whether pediatric recipients should first receive a DD allograft followed by an LD allograft (DD-LD sequence) or an LD allograft followed by a DD allograft (LD-DD sequence). DESIGN, SETTING, AND PARTICIPANTS This decision analytical model examined US pediatric patients with kidney failure included in the US Renal Data System 2019 Report who were waiting for a kidney transplant, received a transplant, or experienced graft failure. INTERVENTIONS Kidney transplant sequences of LD-DD vs DD-LD. MAIN OUTCOMES AND MEASURES Difference in projected life-years between the 2 sequence options. RESULTS Among patients included in the analysis, the LD-DD sequence provided more net life-years in those 5 years of age (1.82 [95% CI, 0.87-2.77]) and 20 years of age (2.23 [95% CI, 1.31-3.15]) compared with the DD-LD sequence. The net outcomes in patients 10 years of age (0.36 [95% CI, -0.51 to 1.23] additional life-years) and 15 years of age (0.64 [95% CI, -0.15 to 1.39] additional life-years) were not significantly different. However, for those aged 10 years, an LD-DD sequence was favored if eligibility for a second transplant was low (2.09 [95% CI, 1.20-2.98] additional life-years) or if the LD was no longer available (2.32 [95% CI, 1.52-3.12] additional life-years). For those aged 15 years, the LD-DD sequence was favored if the eligibility for a second transplant was low (1.84 [95% CI, 0.96-2.72] additional life-years) or if the LD was no longer available (2.49 [95% CI, 1.77-3.27] additional life-years). Access to multiple DD transplants did not compensate for missing the LD opportunity. CONCLUSIONS AND RELEVANCE These findings suggest that the decreased use of LD kidney transplants in pediatric recipients during the past 2 decades should be scrutinized. Given the uncertainty of future recipient eligibility for retransplant and future availability of an LD transplant, the LD-DD sequence is likely the better option. This strategy of an LD transplant first would not only benefit pediatric recipients but allow DD kidneys to be used by others who do not have an LD option.
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Affiliation(s)
- Bryce A. Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda Vinson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Philip D. Acott
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
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26
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Chipman V, Cooper M, Thomas AG, Ronin M, Lee B, Flechner S, Leeser D, Segev DL, Mandelbrot DA, Lunow-Luke T, Syed S, Hil G, Freise CE, Waterman AD, Roll GR. Motivations and outcomes of compatible living donor-recipient pairs in paired exchange. Am J Transplant 2022; 22:266-273. [PMID: 34467618 PMCID: PMC10016327 DOI: 10.1111/ajt.16821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/23/2021] [Accepted: 08/21/2021] [Indexed: 01/25/2023]
Abstract
Increasing numbers of compatible pairs are choosing to enter paired exchange programs, but motivations, outcomes, and system-level effects of participation are not well described. Using a linkage of the Scientific Registry of Transplant Recipients and National Kidney Registry, we compared outcomes of traditional (originally incompatible) recipients to originally compatible recipients using the Kaplan-Meier method. We identified 154 compatible pairs. Most pairs sought to improve HLA matching. Compared to the original donor, actual donors were younger (39 vs. 50 years, p < .001), less often female (52% vs. 68%, p < .01), higher BMI (27 vs. 25 kg/m², p = .03), less frequently blood type O (36% vs. 80%, p < .001), and had higher eGFR (99 vs. 94 ml/min/1.73 m², p = .02), with a better LKDPI (median 7 vs. 22, p < .001). We observed no differences in graft failure or mortality. Compatible pairs made 280 additional transplants possible, many in highly sensitized recipients with long wait times. Compatible pair recipients derived several benefits from paired exchange, including better donor quality. Living donor pairs should receive counseling regarding all options available, including kidney paired donation. As more compatible pairs choose to enter exchange programs, consideration should be given to optimizing compatible pair and hard-to-transplant recipient outcomes.
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Affiliation(s)
- Valerie Chipman
- Division of Transplant, Department of Surgery, University of California, San Francisco, California, USA.,Donor Network West, San Ramon, California, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Georgetown University, Washington, District of Columbia, USA
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Brian Lee
- Department of Medicine, University of California, San Francisco, California, USA
| | - Stuart Flechner
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Leeser
- Department of Surgery, East Carolina University, Greenville, North Carolina, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA.,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | | | - Tyler Lunow-Luke
- Division of Transplant, Department of Surgery, University of California, San Francisco, California, USA
| | - Shareef Syed
- Division of Transplant, Department of Surgery, University of California, San Francisco, California, USA
| | - Garet Hil
- National Kidney Registry, Babylon, New York, USA
| | - Chris E Freise
- Division of Transplant, Department of Surgery, University of California, San Francisco, California, USA
| | - Amy D Waterman
- Department of Medicine, University of California, Los Angeles, California, USA.,Terasaki Institute of Biomedical Innovation, Los Angeles, California, USA
| | - Garrett R Roll
- Division of Transplant, Department of Surgery, University of California, San Francisco, California, USA
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27
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Gonen LD, Bokek-Cohen Y, Azuri P, Tarabeih M. Differential Willingness to Pay for Kidney Transplantation From Living and Deceased Donors: Empirical Study Among End-Stage Kidney Disease (ESKD) Patients. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580221139368. [PMID: 36484339 DOI: 10.1177/00469580221139368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Kidney transplantation has developed to the stage where it is currently the most cost-effective treatment for patients suffering from end-stage kidney disease (ESKD) and, when available, offers them the highest quality of life. Yet, kidney transplantation is challenged by cultural and traditional beliefs; thus, this study sought to evaluate the willingness to pay for a kidney transplant in a culturally sensitive population. A self-administered survey was completed by 734 end-stage kidney disease (ESKD) patients. A quantitative method and survey design were chosen and employed descriptive, correlational, nonparametric, and multivariate statistical tests. Participants were willing to pay a mean amount of $40 751.36 for a living donor kidney transplant, whereas the mean is considerably lower, $18 350.51, for a deceased donor kidney. Significant predictors of the willingness to pay (WTP) for a kidney transplant from a living donor and a deceased donor were found, among them: religiosity and ethnicity. The participants' willingness to pay for a kidney transplant could attest to significant benefits in enhancing patient well-being. The willingness to pay differentially for a donation from a deceased or a living donor stems from the higher chances of success with a living-donor organ as well as from moral and religious motives. In Israel kidney transplantation is not tradable in the free market and is fully funded by the state. The average cost of kidney transplantation in Israel is $61 714.50. Since the cost exceeds the utility and since the economic literature suggests that the funding of healthcare interventions should be provided up to the point where the costs of that funding equal the benefits that society derives from it, crucial revisions in public health policy should be made. Education may have a significant impact on the approach to kidney donation and organ donation in general.
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Affiliation(s)
- Limor Dina Gonen
- Department of Economics and Business Administration, Ariel University, Ariel, Israel
| | - Ya'arit Bokek-Cohen
- Department of behavioral sciences, Academic College of Israel, Ramat-Gan, Israel
| | - Pazit Azuri
- Tel Aviv-Yafo Academic College, Tel Aviv, Israel
| | - Mahdi Tarabeih
- School of Nursing Science, Tel Aviv-Yafo Academic College, Tel Aviv, Israel
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28
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Osbun N, Thomas AG, Ronin M, Cooper M, Flechner SM, Segev DL, Veale JL. The benefit to waitlist patients in a national paired kidney exchange program: Exploring characteristics of chain end living donor transplants. Am J Transplant 2022; 22:113-121. [PMID: 34212501 PMCID: PMC8720056 DOI: 10.1111/ajt.16749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/27/2021] [Accepted: 06/27/2021] [Indexed: 01/25/2023]
Abstract
Nondirected kidney donors can initiate living donor chains that end to patients on the waitlist. We compared 749 National Kidney Registry (NKR) waitlist chain end transplants to other transplants from the NKR and the Scientific Registry of Transplant Recipients between February 2008 and September 2020. Compared to other NKR recipients, chain end recipients were more often older (53 vs. 52 years), black (32% vs. 15%), publicly insured (71% vs. 46%), and spent longer on dialysis (3.0 vs. 1.0 years). Similar differences were noted between chain end recipients and non-NKR living donor recipients. Black patients received chain end kidneys at a rate approaching that of deceased donor kidneys (32% vs. 34%). Chain end donors were older (52 vs. 44 years) with slightly lower glomerular filtration rates (93 vs. 98 ml/min/1.73 m2 ) than other NKR donors. Chain end recipients had elevated risk of graft failure and mortality compared to control living donor recipients (both p < .01) but lower graft failure (p = .03) and mortality (p < .001) compared to deceased donor recipients. Sharing nondirected donors among a multicenter network may improve the diversity of waitlist patients who benefit from living donation.
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Affiliation(s)
- Nathan Osbun
- Department Urology, University of California Los Angeles, Los Angeles, CA
| | - Alvin G. Thomas
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC,Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | | | | | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University, Baltimore, MD,Department of Epidemiology, Johns Hopkins University, Baltimore, MD,Scientific Registry of Transplant Recipients, Minnesota, MN
| | - Jeffrey L. Veale
- Department Urology, University of California Los Angeles, Los Angeles, CA
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29
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Equity or Equality? Which Approach Brings More Satisfaction in a Kidney-Exchange Chain? J Pers Med 2021; 11:jpm11121383. [PMID: 34945855 PMCID: PMC8709455 DOI: 10.3390/jpm11121383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022] Open
Abstract
In United States (U.S.), government-funded organizations, such as NLDAC, reimburse travel and subsistence expenses incurred during living-organ donation process. However, in Iran, there is a non-governmental organization called Iranian Kidney Foundation (IKF) that funds the direct and indirect costs of donors through charitable donations and contributions from participants in the exchange program. In this article, for countries outside the U.S. that currently use an equality approach, we propose a potential new compensation-apportionment approach (equitable approach) for kidney-exchange chains and compare it with the currently available system (equality approach) in terms of the apportionment of compensation in a kidney-exchange chain to cover the expenses incurred by the initiating living donor of the chain in the act of donation. To this end, we propose a mechanism to apportion compensation among all participating pairs based on the equity approach by utilizing a prediction model to calculate the probability of graft survival in each transplant operation. These probabilities are then used to define the utility of any transplantation, considering the quality of each pair’s donated and received kidney in the chain. Afterward, the corresponding cost is apportioned by a mechanism based on the normalized differences between the utility of donated and received kidneys for each incompatible pair of the chain. In summary, we demonstrate that by utilizing the equitable approach, there is more fairness and equity in the allocation of resources in organ-procurement systems, which results in more satisfaction among incompatible pairs. Additional future prospective studies are needed to assess this proposed equitable approach for kidney-exchange chains in countries outside the U.S., such as Iran, that currently use an equality approach.
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30
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Lee JY, Cha SH, Kim SH, Jeong KH, Chung KY, Cho HR, Lee J, Huh KH, Yang J, Kim MS, Kim DG. Risk Due to ABO Incompatibility and Donor-Recipient Weight Mismatch in Living Donor Kidney Transplantation: A National Cohort Study. J Clin Med 2021; 10:jcm10235674. [PMID: 34884376 PMCID: PMC8658727 DOI: 10.3390/jcm10235674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
The effect of donor-recipient weight mismatch is not well established in ABO-incompatible living donor kidney transplantation (LDKT). A total of 2584 LDKT patients in the Korean Organ Transplantation Registry were classified into four groups according to the presence or absence of ABO incompatibility and donor-recipient weight mismatch (donor-to-recipient weight ratio (DRWR) < 0.8). In a multivariable Cox analysis, the combination of ABO incompatibility and DRWR incompatibility (n = 124) was an independent risk factor for graft survival (HR = 2.73, 95% CI = 1.11-6.70) and patient survival (HR = 3.55, 95% CI = 1.39-9.04), whereas neither factor alone was a significant risk factor for either outcome. The combination of ABO incompatibility and DRWR incompatibility was not an independent risk factor for biopsy-proven graft rejection (HR = 1.27, 95% CI = 0.88-1.82); however, it was an independent risk factor for pneumonia (HR = 2.94, 95% CI = 1.64-5.57). The mortality rate due to infection was higher among patients with both ABO incompatibility and DRWR incompatibility than among patients with neither factor or with either factor alone. The combination of ABO incompatibility and DRWR incompatibility was an independent risk factor for graft and patient survival after LDKT, whereas neither factor alone significantly affected graft or patient survival. Thus, donor-recipient weight matching should be cautiously considered in LDKT with ABO incompatibility.
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Affiliation(s)
- Jun Young Lee
- Transplantation Center, Wonju Severance Christian Hospital, Wonju 26426, Korea;
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
| | - Sung Hwan Cha
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Sung Hwa Kim
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Kyung Hwan Jeong
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul 02447, Korea;
| | - Ku Yong Chung
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea;
| | - Hong Rae Cho
- Department of Surgery, Ulsan University Hospital, Ulsan 44030, Korea;
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.L.); (K.H.H.); (M.S.K.)
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.L.); (K.H.H.); (M.S.K.)
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea; (J.L.); (K.H.H.); (M.S.K.)
| | - Deok Gie Kim
- Transplantation Center, Wonju Severance Christian Hospital, Wonju 26426, Korea;
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
- Correspondence: ; Tel.: +82-33-741-0510
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31
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Parajuli S, Kaufman DB, Djamali A, Welch BM, Sollinger HW, Mandelbrot DA, Odorico JS. Association of human leukocyte antigen mismatches between donor-recipient and donor-donor in pancreas after kidney transplant recipients. Transpl Int 2021; 34:2803-2815. [PMID: 34644422 DOI: 10.1111/tri.14138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 09/24/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
The effects of HLA mismatching on pancreas outcomes among pancreas after kidney (PAK) recipients are undefined. Outcomes might potentially differ depending on whether there is a mismatch between pancreas donor and recipient (PD-R) or pancreas donor and kidney donor(PD-KD). All primary PAK at our centre were included in this study. Patients were divided into two groups based on the degree of HLA mismatching: low (L-MM) as 0-4 and high (H-MM) as 5-6. We analysed all (N = 73) PAK for PD-R mismatch and the subset of PAK for PD-KD mismatch (N = 71). Comparing PD-R L-MM (n = 39) and H-MM (n = 34) PAKs, we observed no difference in the rate of pancreas graft failure. There was also no difference in the rate of rejection (L-MM 33% vs. H-MM 41%) or the severity of rejection. However, we observed a significantly (P < 0.01) shorter time to acute pancreas rejection in the H-MM group (6.8 ± 8.7 mo) versus the L-MM cohort (29.0 ± 36.2 mo) (P < 0.001). Similar to the PD-R mismatched cohort, we did not observe a detrimental effect of HLA mismatching on graft outcomes in the PD-KD cohort; time to rejection was again shorter in the H-MM subset. In this study, we found no impact of HLA mismatch on either pancreas graft survival or rejection rates, though rejection occurred earlier in high mismatched PAK transplants.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Bridget M Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Hans W Sollinger
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Wilson EM, Chen A, Johnson M, Perkins JA, Purnell TS. Elucidating measures of systemic racism to mitigate racial disparities in kidney transplantation. Curr Opin Organ Transplant 2021; 26:554-559. [PMID: 34456271 DOI: 10.1097/mot.0000000000000913] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Given recent national attention to the role of racism in perpetuating racial inequities in society and health, this review provides a timely and relevant summary of key measures of systemic racism in kidney transplantation. More specifically, the review identifies current and promising interventions, whereas highlighting the need for more sustainable and impactful interventions. RECENT FINDINGS Racial disparities persist in kidney transplantation. Black and Hispanic individuals are less likely to receive a kidney transplant than non-Hispanic Whites despite disproportionately higher rates of kidney failure. Studies demonstrate that socioeconomic factors do not fully explain existing racial disparities in transplantation. Systemic racism at all levels, individual, interpersonal, institutional, and structural, is at the core of racial disparities, and current interventions are insufficient in mitigating their effects. Thus, targeted and sustainable interventions must be implemented to mitigate systemic racism in kidney transplantation. SUMMARY Systemic racism in all its forms continues to influence disparities at all stages of kidney transplantation. This paper highlights recent findings that shed light on how racism contributes to racial disparities in kidney transplantation. Using these findings to identify targets and strategies for mitigation, relevant interventions and policies that show promise are detailed.
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Affiliation(s)
- Elena M Wilson
- Epidemiology Research Group in Organ Transplantation, Division of Transplantation, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andy Chen
- Epidemiology Research Group in Organ Transplantation, Division of Transplantation, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Morgan Johnson
- Epidemiology Research Group in Organ Transplantation, Division of Transplantation, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Columbia University Mailman School of Public Health, New York City, New York
| | - Jamilah A Perkins
- Epidemiology Research Group in Organ Transplantation, Division of Transplantation, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanjala S Purnell
- Epidemiology Research Group in Organ Transplantation, Division of Transplantation, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Al Ammary F, Yu S, Muzaale AD, Segev DL, Liyanage L, Crews DC, Brennan DC, El-Meanawy A, Alqahtani S, Atta MG, Levan ML, Caffo BS, Welling PA, Massie AB. Long-term kidney function and survival in recipients of allografts from living kidney donors with hypertension: a national cohort study. Transpl Int 2021; 34:1530-1541. [PMID: 34129713 DOI: 10.1111/tri.13947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/08/2021] [Accepted: 06/06/2021] [Indexed: 12/27/2022]
Abstract
Allografts from living kidney donors with hypertension may carry subclinical kidney disease from the donor to the recipient and, thus, lead to adverse recipient outcomes. We examined eGFR trajectories and all-cause allograft failure in recipients from donors with versus without hypertension, using mixed-linear and Cox regression models stratified by donor age. We studied a US cohort from 1/1/2005 to 6/30/2017; 49 990 recipients of allografts from younger (<50 years old) donors including 597 with donor hypertension and 21 130 recipients of allografts from older (≥50 years old) donors including 1441 with donor hypertension. Donor hypertension was defined as documented predonation use of antihypertensive therapy. Among recipients from younger donors with versus without hypertension, the annual eGFR decline was -1.03 versus -0.53 ml/min/m2 (P = 0.002); 13-year allograft survival was 49.7% vs. 59.0% (adjusted allograft failure hazard ratio [aHR] 1.23; 95% CI 1.05-1.43; P = 0.009). Among recipients from older donors with versus without hypertension, the annual eGFR decline was -0.67 versus -0.66 ml/min/m2 (P = 0.9); 13-year allograft survival was 48.6% versus 52.6% (aHR 1.05; 95% CI 0.94-1.17; P = 0.4). In secondary analyses, our inferences remained similar for risk of death-censored allograft failure and mortality. Hypertension in younger, but not older, living kidney donors is associated with worse recipient outcomes.
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Affiliation(s)
- Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abimereki D Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Luckmini Liyanage
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deidra C Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel C Brennan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashraf El-Meanawy
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saleh Alqahtani
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohamed G Atta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Macey L Levan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian S Caffo
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Paul A Welling
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Physiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Garg N, Poggio ED, Mandelbrot D. The Evaluation of Kidney Function in Living Kidney Donor Candidates. KIDNEY360 2021; 2:1523-1530. [PMID: 35373109 PMCID: PMC8786144 DOI: 10.34067/kid.0003052021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/28/2021] [Indexed: 02/04/2023]
Abstract
Living kidney donors incur a small increased risk of ESKD, of which predonation GFR is an important determinant. As a result, kidney function assessment is central to the donor candidate evaluation and selection process. This article reviews the different methods of GFR assessment, including eGFR, creatinine clearance, and measured GFR, and the current guidelines on GFR thresholds for donor acceptance. eGFR obtained using the 2009 CKD Epidemiology Collaboration equation that, although the best of estimating estimations, tends to underestimate levels and has limited accuracy, especially near-normal GFR values. In the United States, the Organ Procurement and Transplantation Network policy on living donation mandates either measured GFR or creatinine clearance as part of the evaluation. Measured GFR is considered the gold standard, although there is some variation in performance characteristics, depending on the marker and technique used. Major limitations of creatinine clearance are dependency on accuracy of timed collection, and overestimation as a result of distal tubular creatinine secretion. GFR declines with healthy aging, and most international guidelines recommend use of age-adapted selection criteria. The 2017 Kidney Disease: Improving Global Outcomes Guideline for the Evaluation and Care of Living Kidney Donors diverges from other guidelines and recommends using absolute cutoff of <60 ml/min per 1.73m2 for exclusion and ≥90 ml/min per 1.73m2 for acceptance, and determination of candidacy with intermediate GFR on the basis of long-term ESKD risk. However, several concerns exist for this strategy, including inappropriate acceptance of younger candidates due to underestimation of risk, and exclusion of older candidates whose kidney function is in fact appropriate for age. The role of cystatin C and other newer biomarkers, and data on the effect of predonation GFR on not just ESKD risk, but also advanced CKD risk and cardiovascular outcomes are needed.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Emilio D. Poggio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Didier Mandelbrot
- Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Vinson AJ, Kiberd BA, Tennankore KK. In Search of a Better Outcome: Opting Into the Live Donor Paired Kidney Exchange Program. Can J Kidney Health Dis 2021; 8:20543581211017412. [PMID: 34104454 PMCID: PMC8161848 DOI: 10.1177/20543581211017412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background Live donor (LD) kidney transplantation is the best option for patients with end-stage kidney disease (ESKD). However, this may not be the best option if a patient's donor is older and considerably smaller in weight. Patient (A) with a less than ideal donor (Donor A) might enter into a live donor paired exchange (LDPE) program with the hopes of swapping for a better-quality organ. A second patient (B) who is in the LDPE may or may not benefit from this exchange with Donor A. Methods This medical decision analysis examines the conditions that favor Patient A entering into the LDPE compared to directly accepting a kidney from their intended donor, as well as the circumstances where Patient B also benefits by accepting a lower-quality organ. Results Under select circumstances, a paired exchange could benefit both Patients A and B. For example, a 30-year-old Patient A with a lower-quality donor might gain 1.201.521.84 quality adjusted life years (QALYs) by entering into a LDPE for a better-quality kidney, whereas a 60-year-old Patient B might gain 0.931.031.13 QALYs by accepting Donor A's kidney rather than waiting longer in the LDPE. The net benefit (or loss) of entering the LDPE differs by recipient age, donor organ quality, likelihood of Patient B being transplanted in LDPE, and likelihood of Patient A finding an ideal donor in the LDPE. Conclusion This study shows there are ways to increase live donor utilization and effectiveness that require further research and potentially changes to the LDPE process.
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Affiliation(s)
- Amanda J Vinson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
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Husain SA, King KL, Sanichar N, Crew RJ, Schold JD, Mohan S. Association Between Donor-Recipient Biological Relationship and Allograft Outcomes After Living Donor Kidney Transplant. JAMA Netw Open 2021; 4:e215718. [PMID: 33847748 PMCID: PMC8044734 DOI: 10.1001/jamanetworkopen.2021.5718] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE The proportion of living donor kidney transplants from donors unrelated to their recipients is increasing in the US. OBJECTIVE To examine the association between donor-recipient biological relationship and allograft survival after living donor kidney transplant. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used Organ Procurement and Transplantation Network data on US adult living donor kidney transplants (n = 86 154) performed from January 1, 2000, to December 31, 2014, excluding cases in which recipients previously received a kidney transplant (n = 10 342) or key data were missing (n = 2832). Last follow-up was March 20, 2020. EXPOSURES Donor-recipient biological relationship. MAIN OUTCOMES AND MEASURES The primary outcome was death-censored allograft failure. Univariate and multivariable time-to-event analyses were performed for death-censored allograft failure for the overall cohort, then separately for recipients with and without primary diagnoses of cystic kidney disease and for transplants from African American and non-African American donors. RESULTS Among the 72 980 transplant donor and recipients included in the study (median donor age, 41 years; interquartile range [IQR], 32-50 years; 43 990 [60%] female; 50 014 [69%] White), 43 174 (59%) donors and recipients were biologically related and 29 806 (41%) were unrelated. Donors related to their recipients were younger (median [IQR] age, 39 [31-48] vs 44 [35-52] years) and less likely to be female (24 848 [58%] vs 19 142 [64%]) or White (26 933 [62%] vs 23 081 [77%]). Recipients related to their donors were younger (median [IQR] age, 48 [34-58] vs 50 [40-58] years), more likely to be female (18 035 [42%] vs 10 530 [35%]), and less likely to have cystic kidney disease (2530 [6%] vs 4600 [15%]). Related pairs had fewer HLA mismatches overall (median [IQR], 3 [2-3] vs 5 [4-5]). After adjustment for HLA mismatches, donor and recipient characteristics, and transplant era, donor-recipient biological relationship was associated with higher death-censored allograft failure (hazard ratio, 1.05; 95% CI, 1.01-1.10; P = .03). When stratified by primary disease, this association persisted only for recipients without cystic kidney disease. When stratified by donor race, this association persisted only for transplants from African American donors. CONCLUSIONS AND RELEVANCE In this cohort study, living donor kidney transplants from donors biologically related to their recipients had higher rates of allograft failure than transplants from donors unrelated to their recipients after HLA matching was accounted for. Further study is needed to determine which genetic or socioenvironmental factors are associated with this finding.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Navin Sanichar
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - R. John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Jesse D. Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Abstract
Living kidney donation represents the best treatment for end stage renal disease patients, with the potentiality to pre-emptively address kidney failure and significantly expand the organ pool. Unfortunately, there is still limited knowledge about this underutilized resource. The present review aims to describe the general principles for the establishment, organization, and oversight of a successful living kidney transplantation program, highlighting recommendation for good practice and the work up of donor selection, in view of potential short- and long-terms risks, as well as the additional value of kidney paired exchange programs. The need for donor registries is also discussed, as well as the importance of lifelong follow up.
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38
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Smeulders B, Mankowski MA, van de Klundert J. Kidney Exchange Program Reporting Standards: Evidence-Based Consensus From Europe. Front Public Health 2021; 9:623966. [PMID: 33681134 PMCID: PMC7928410 DOI: 10.3389/fpubh.2021.623966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/15/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Kidney Exchange Programs can play an important role to increase access to the life saving and most cost-effective treatment for End Stage Renal Disease. The rise of national KEPs in Europe brings a need for standardized performance reporting to facilitate the development of an international evidence base on program practices. Methods: We systematically searched and reviewed the literature to extract kidney exchange program performance measures. Reported measures were initially categorized as structure, process, and outcome measures. Expert feedback was used to redefine categories and extend the set of measures to be considered. Using the Delphi method and a panel of 10 experts, the resulting measures were subsequently classified as mandatory (Base set), optional (Extended set), or deleted. Results: Out of the initial 1,668 articles identified by systematic literature search, 21 European publications on kidney exchange programs were included to collect performance measures, accompanied by three national program reports. The final measurement categories were Context, Population, Enrollment, Matching, Transplantation, and Outcomes. The set of performance measures resulting from the literature review was modified and classified as mandatory or optional. The resulting Base set and Extended set form the kidney exchange program reporting standard. Conclusions: The evidence-based and consensus-based kidney exchange program reporting standard can harmonize practical and scientific reporting on kidney exchange programs, thus facilitating the advancement of national programs. In addition, the kidney exchange program reporting standard can promote and align cross-national programs.
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Affiliation(s)
- Bart Smeulders
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Michal A Mankowski
- Computer, Electrical, and Mathematical Sciences and Engineering Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
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Adler JT, Tsai TC, Jin G, Cron DC, Ross-Driscoll KH, Malek SK, Tullius SG, Weissman JS. Association of balanced abdominal organ transplant center volumes with patient outcomes. Clin Transplant 2021; 35:e14217. [PMID: 33405324 DOI: 10.1111/ctr.14217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/12/2020] [Accepted: 12/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The volume-outcome relationship for organ-specific transplantation is well-described; it is unknown if the relative balance of kidney compared with liver volumes within an institution relates to organ-specific outcomes. We assessed the association between relative balance within a transplant center and outcomes. METHODS National retrospective analysis of isolated kidney and liver transplants in United States 2005-2014 followed through 2019. Latent class analysis defined transplant center phenotypes. Multivariate Cox models estimated death-censored graft loss and mortality. RESULTS Latent class analysis identified four phenotypes: kidney only (n = 117), kidney dominant (n = 36), mixed/balanced (n = 90), and liver dominant (n = 13). Compared to mixed centers, the risk of kidney graft loss was higher at kidney-dominant (HR 1.07, p < .001) and liver-dominant (HR 1.10, p < .001) centers, while kidney-only (HR 1.06, p = .01) centers had higher mortality. Liver graft loss was not associated with phenotype, but risk of patient death was lower (HR 0.93, p = .02) at liver dominant and higher (HR 1.06, p = .02) at kidney-dominant centers. CONCLUSIONS A mixed phenotype was associated with improved kidney transplant outcomes, whereas liver transplant outcomes were best at liver-dominant centers. While these findings need to be verified with center-level resources, optimization of shared resources could improve patient and organ outcomes.
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Affiliation(s)
- Joel T Adler
- Division of Transplantation, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas C Tsai
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.,Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Katherine H Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Sayeed K Malek
- Division of Transplantation, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Stefan G Tullius
- Division of Transplantation, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
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40
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Chandar J, Chen L, Defreitas M, Ciancio G, Burke G. Donor considerations in pediatric kidney transplantation. Pediatr Nephrol 2021; 36:245-257. [PMID: 31932959 DOI: 10.1007/s00467-019-04362-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/18/2019] [Accepted: 09/06/2019] [Indexed: 01/10/2023]
Abstract
This article reviews kidney transplant donor options for children with end-stage kidney disease (ESKD). Global access to kidney transplantation is variable. Well-established national policies, organizations for organ procurement and allocation, and donor management policies may account for higher deceased donor (DD transplants) in some countries. Living donor kidney transplantation (LD) predominates in countries where organ donation has limited national priority. In addition, social, cultural, religious and medical factors play a major role in both LD and DD kidney transplant donation. Most children with ESKD receive adult-sized kidneys. The transplanted kidney has a finite survival and the expectation is that children who require renal replacement therapy from early childhood will probably have 2 or 3 kidney transplants in their lifetime. LD transplant provides better long-term graft survival and is a better option for children. When a living related donor is incompatible with the intended recipient, paired kidney exchange with a compatible unrelated donor may be considered. When the choice is a DD kidney, the decision-making process in accepting a donor offer requires careful consideration of donor history, kidney donor profile index, HLA matching, cold ischemia time, and recipient's time on the waiting list. Accepting or declining a DD offer in a timely manner can be challenging when there are undesirable facts in the donor's history which need to be balanced against prolonging dialysis in a child. An ongoing global challenge is the significant gap between organ supply and demand, which has increased the need to improve organ preservation techniques and awareness for organ donation.
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Affiliation(s)
- Jayanthi Chandar
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami Transplant Institute, PO Box 016960 (M714), Miami, FL, 33101, USA.
| | - Linda Chen
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
| | - Marissa Defreitas
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami Transplant Institute, PO Box 016960 (M714), Miami, FL, 33101, USA
| | - Gaetano Ciancio
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
| | - George Burke
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
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41
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Wang W, Rees MA, Leichtman AB, Song PXK, Bray M, Ashby VB, Shearon T, Whiteman A, Kalbfleisch JD. Deceased donors as nondirected donors in kidney paired donation. Am J Transplant 2021; 21:103-113. [PMID: 32803856 PMCID: PMC9436421 DOI: 10.1111/ajt.16268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 01/25/2023]
Abstract
As proof of concept, we simulate a revised kidney allocation system that includes deceased donor (DD) kidneys as chain-initiating kidneys (DD-CIK) in a kidney paired donation pool (KPDP), and estimate potential increases in number of transplants. We consider chains of length 2 in which the DD-CIK gives to a candidate in the KPDP, and that candidate's incompatible donor donates to theDD waitlist. In simulations, we vary initial pool size, arrival rates of candidate/donor pairs and (living) nondirected donors (NDDs), and delay time from entry to the KPDP until a candidate is eligible to receive a DD-CIK. Using data on candidate/donor pairs and NDDs from the Alliance for Paired Kidney Donation, and the actual DDs from the Scientific Registry of Transplant Recipients (SRTR) data, simulations extend over 2 years. With an initial pool of 400, respective candidate and NDD arrival rates of 2 per day and 3 per month, and delay times for access to DD-CIK of 6 months or less, including DD-CIKs increases the number of transplants by at least 447 over 2 years, and greatly reduces waiting times of KPDP candidates. Potential effects on waitlist candidates are discussed as are policy and ethical issues.
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Affiliation(s)
- W. Wang
- University of Michigan, Department of Biostatistics, Ann Arbor, MI,University of Michigan, Kidney Epidemiology and Cost Center; Ann Arbor, MI
| | - M. A. Rees
- University of Toledo Medical Center, Department of Urology, Toledo, OH
| | - A. B. Leichtman
- University of Michigan, Kidney Epidemiology and Cost Center; Ann Arbor, MI,University of Michigan, Department of Medicine, Ann Arbor MI
| | - P. X-K. Song
- University of Michigan, Department of Biostatistics, Ann Arbor, MI,University of Michigan, Kidney Epidemiology and Cost Center; Ann Arbor, MI
| | - M. Bray
- GSK, Research statistics. Collegeville, PA
| | - V. B. Ashby
- University of Michigan, Department of Biostatistics, Ann Arbor, MI,University of Michigan, Kidney Epidemiology and Cost Center; Ann Arbor, MI
| | - T. Shearon
- University of Michigan, Department of Biostatistics, Ann Arbor, MI,University of Michigan, Kidney Epidemiology and Cost Center; Ann Arbor, MI
| | - A Whiteman
- University of Michigan, Department of Biostatistics, Ann Arbor, MI
| | - J. D. Kalbfleisch
- University of Michigan, Department of Biostatistics, Ann Arbor, MI,University of Michigan, Kidney Epidemiology and Cost Center; Ann Arbor, MI
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42
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Charnaya O, Chiang TPY, Wang R, Motter JD, Boyarsky BJ, King EA, Werbel WA, Durand CM, Avery RK, Segev DL, Massie AB, Garonzik-Wang JM. Effects of COVID-19 pandemic on pediatric kidney transplant in the United States. Pediatr Nephrol 2021; 36:143-151. [PMID: 32980942 PMCID: PMC7519856 DOI: 10.1007/s00467-020-04764-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND In March 2020, COVID-19 infections began to rise exponentially in the USA, placing substantial burden on the healthcare system. As a result, there was a rapid change in transplant practices and policies, with cessation of most procedures. Our goal was to understand changes to pediatric kidney transplantation (KT) at the national level during the COVID-19 epidemic. METHODS Using SRTR data, we examined changes in pediatric waitlist registration, waitlist removal or inactivation, and deceased donor and living donor (DDKT/LDKT) events during the start of the disease transmission in the USA compared with the same time the previous year. RESULTS We saw an initial decrease in DDKT and LDKT by 47% and 82% compared with expected events and then a continual increase, with numbers reaching expected prepandemic levels by May 2020. In the early phase of the pandemic, waitlist inactivation and removals due to death or deteriorating condition rose above expected values by 152% and 189%, respectively. There was a statistically significant decrease in new waitlist additions (IRR 0.49 0.65 0.85) and LDKT (IRR 0.17 0.38 0.84) in states with high vs. low COVID activity. Transplant recipients during the pandemic were more likely to have received a DDKT, but had similar calculated panel-reactive antibody (cPRA) values, waitlist time, and cause of kidney failure as before the pandemic. CONCLUSIONS The COVID-19 pandemic initially reduced access to kidney transplantation among pediatric patients in the USA but has not had a sustained effect.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N Wolfe St., Room 3055, Baltimore, MD, 21287, USA.
| | - Teresa Po-Yu Chiang
- grid.21107.350000 0001 2171 9311Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Richard Wang
- grid.21107.350000 0001 2171 9311Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Jennifer D. Motter
- grid.21107.350000 0001 2171 9311Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Brian J. Boyarsky
- grid.21107.350000 0001 2171 9311Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Elizabeth A. King
- grid.21107.350000 0001 2171 9311Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - William A. Werbel
- grid.21107.350000 0001 2171 9311Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Christine M. Durand
- grid.21107.350000 0001 2171 9311Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Robin K. Avery
- grid.21107.350000 0001 2171 9311Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Dorry L. Segev
- grid.21107.350000 0001 2171 9311Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA ,grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD USA ,Scientific Registry of Transplant Recipients, Minneapolis, MN USA
| | - Allan B. Massie
- grid.21107.350000 0001 2171 9311Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA ,grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD USA
| | - Jacqueline M. Garonzik-Wang
- grid.21107.350000 0001 2171 9311Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Garg N, Lentine KL, Inker LA, Garg AX, Rodrigue JR, Segev DL, Mandelbrot DA. Metabolic, cardiovascular, and substance use evaluation of living kidney donor candidates: US practices in 2017. Am J Transplant 2020; 20:3390-3400. [PMID: 32342601 DOI: 10.1111/ajt.15964] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 01/25/2023]
Abstract
We surveyed US transplant centers to assess practices regarding the evaluation and selection of living kidney donors based on metabolic, cardiovascular, and substance use risk factors. Our companion article describes renal aspects of the evaluation. Response rate was 31%. Compared with 2005, programs have become more accepting of hypertensive candidates: 65% in 2017% vs 41% in 2005 consider candidates with hypertension well controlled with 1 medication. One notable exception is black hypertensive candidates, who are frequently excluded regardless of severity. The most common body mass index (BMI) cutoff remains 35 kg/m2 , and fewer programs now consider candidates with BMI >40 kg/m2 . A 2-hour oral glucose tolerance test of ≥140 mg/dL remains the most common criterion for exclusion of prediabetic candidates. One quarter to one third of programs exclude based on isolated cardiac abnormalities, such as mild aortic stenosis; a similar proportion consider these candidates only if older than 50 years. Cigarette or marijuana smoking are infrequently criteria for exclusion, although 45% and 37% programs, respectively, require cessation 4 weeks prior to surgery. In addition to providing an overview of current practices in living kidney donor evaluation, our study highlights the importance of research evaluating outcomes with various comorbidities to guide practice.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Lesley A Inker
- Division of Nephrology, Department of Medicine, Tufts Medical Center Boston, Boston, Massachusetts, USA
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - James R Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Departments of Surgery and Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Abstract
PURPOSE OF REVIEW To summarize the current state of evidence regarding the role of apolipoprotein L1 (APOL1) genotyping in evaluating donors for kidney transplantation. RECENT FINDINGS African ancestry is associated with an increased risk of kidney failure following living donation. Moreover, kidney transplants from African ancestry deceased donors have an increased risk of graft failure. Preliminary evidence suggests that APOL1 genotype may mediate at least a portion of this racial variation, with high-risk APOL1 genotypes defined by presence of two renal risk variants (RRVs). A pilot study 136 African ancestry living donors found that those with APOL1 high-risk genotypes had lower baseline kidney function and faster rates of kidney function decline after donation. To date, three retrospective studies identified a two-to-three times greater risk of allograft failure associated with kidneys from donors with high-risk APOL1 genotype. Active research initiatives seek to address unanswered questions, including reproducibility in large national samples, the role of 'second hits' injuries, and impact of recipient genotype, with a goal to build consensus on applications for policy and practice. SUMMARY As evidence evolves, APOL1 genotyping may have applications for organ quality scoring in deceased donor kidney allocation, and for the evaluation and selection of living donor candidates.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Roslyn B Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Ten Years of Kidney Paired Donation at Mayo Clinic: The Benefits of Incorporating ABO/HLA Compatible Pairs. Transplantation 2020; 104:1229-1238. [PMID: 31490859 DOI: 10.1097/tp.0000000000002947] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We examined the 10-year experience of Mayo Clinic's kidney paired donation (KPD).We aimed to determine the benefits for the recipients of enrolled ABO/HLA compatible pairs and determine the factors associated with prolonged KPD waiting time. METHODS We performed a retrospective study of 332 kidney transplants facilitated by the Mayo 3-site KPD program from September 2007 to June 2018. RESULTS The median (interquartile range) time from KPD entry to transplantation was 89 days (42-187 days). The factors independently associated with receiving a transplant >3 months after KPD entry included recipient blood type O and calculated panel reactive antibodies ≥98%. Fifty-four ABO/HLA compatible pairs participated in KPD for the following reasons: cytomegalovirus mismatch (18.5% [10/54]), Epstein-Barr virus (EBV) mismatch (EBV) (9.3% [5/54]), age/size mismatch (51.9% [28/54]), or altruistic reasons (20.3% [11/54]). Cytomegalovirus and EBV mismatch were avoided in 90% (9/10) and 100% (5/5) of cases. Recipients who entered KPD for age/size mismatch and altruistic reasons received kidneys from donors with lower Living Kidney Donor Profile Index scores than their actual donor (median [interquartile range] 31.5 [12.3-47]; P < 0.001 and 26 (-1 to 46); P = 0.01 points lower, respectively). Median time to transplant from KPD entry for compatible pair recipients was 70 days (41-163 days), and 44.4% (24/54) of these transplants were preemptive. All chains/swaps incorporating compatible pairs included ABO/HLA incompatible pairs. CONCLUSIONS KPD should be considered for all living donor/recipient pairs because the recipients of these pairs can derive personal benefit from KPD while increasing the donor pool for difficult to match pairs.
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Charnaya O, Chiang TPY, Wang R, Motter J, Boyarsky B, King E, Werbel W, Durand CM, Avery R, Segev D, Massie A, Garonzik-Wang J. Effects of COVID19 Pandemic on Pediatric Kidney Transplant in the United States. RESEARCH SQUARE 2020. [PMID: 32935089 PMCID: PMC7491577 DOI: 10.21203/rs.3.rs-72427/v1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In March 2020, COVID-19 infections began to rise exponentially in the United States, placing substantial burden on the healthcare system. As a result, there was a rapid change in transplant practices and policies, with cessation of most procedures. Our goal was to understand changes to pediatric kidney transplantation (KT) at the national level during the COVID-19 epidemic. Using SRTR data, we examined changes in pediatric waitlist registration, waitlist removal or inactivation, and deceased donor and living donor (DDKT/LDKT) events during the start of the disease transmission in the United States compared to the same time the previous year. We saw an initial decrease in DDKT and LDKT by 47% and 82% compared to expected events and then a continual increase, with numbers reaching expected pre-pandemic levels by May 2020. In the early phase of the pandemic, waitlist inactivation and removals due to death or deteriorating condition rose above expected values by 152% and 189%, respectively. There was a statistically significant decrease in new waitlist additions (IRR 0.49 0.65 0.85) and LDKT (IRR 0.17 0.38 0.84) in states with high vs low COVID activity. Transplant recipients during the pandemic were more likely to have received a DDKT, but had similar cPRA, waitlist time and cause of ESRD as before the pandemic. The COVID-19 pandemic initially reduced access to kidney transplantation among pediatric patients in the United States, but has not had a sustained effect.
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Analysis of Risk Factors and Long-Term Outcomes in Kidney Transplant Patients with Identified Lymphoceles. J Clin Med 2020; 9:jcm9092841. [PMID: 32887366 PMCID: PMC7563120 DOI: 10.3390/jcm9092841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/24/2020] [Accepted: 08/29/2020] [Indexed: 11/22/2022] Open
Abstract
The collection of lymphatic fluids (lymphoceles) is a frequent adverse event following renal transplantation. A variety of surgical and medical factors has been linked to this entity, but reliable data on risk factors and long-term outcomes are lacking. This retrospective single-center study included 867 adult transplant recipients who received a kidney transplantation from 2006 to 2015. We evaluated for patient and graft survival, rejection episodes, or detectable donor-specific antibodies (dnDSA) in patients with identified lymphoceles in comparison to controls. We identified 305/867 (35.2%) patients with lymphocele formation, of whom 72/867 (8.3%) needed intervention. Multivariate analysis identified rejection episode as an independent risk factor (OR 1.61, CI 95% 1.17–2.21, p = 0.003) for lymphocele formation, while delayed graft function was independently associated with symptomatic lymphoceles (OR 1.9, CI 95% 1.16–3.12, p = 0.011). Interestingly, there was no difference in detectable dnDSA between groups with a similar graft and patient survival in all groups after 10 years. Lymphoceles frequently occur after transplantation and were found to be independently associated with rejection episodes, while symptomatic lymphoceles were associated with delayed graft function in our cohort. As both are inflammatory processes, they might play a causative role in the formation of lymphoceles. However, development or intervention of lymphoceles did not lead to impaired graft survival in the long-term.
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Altheaby A, Almukhlifi A, Aldoukhi A, Alfaleh A, Aboalsamah G, Alshareef A, Alruwaymi M, Bin Saad K, Arabi Z. Why Living Kidney Donor Candidates Are Turned Down? A Single-Center Cohort Study. Cureus 2020; 12:e9877. [PMID: 32963917 PMCID: PMC7500709 DOI: 10.7759/cureus.9877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/19/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction Living donor kidney transplantation is the best replacement therapy for patients with end-stage renal disease. It offers more benefits than deceased donor transplantation. However, living kidney donors (LKDs) undergo an extensive evaluation to ensure their suitability for donation, and this can result in rejection of many potential donors. Aim The aim of this study was to recognize the reasons for declining LKDs in our Organ Transplant Center at King Abdulaziz Medical City. Settings and Design This was a retrospective study to determine the various reasons to reject an LKD at the Organ Transplant Center. Methods and Material All the LKDs from January 2016 to December 2019 were included. Declined donors were reviewed and data were obtained from the electronic database and transplant nephrology shared files. Statistical analysis We performed data analysis using SPSS version 24.0 (IBM Corp., Armonk, NY, USA). Data for continuous variables were presented as mean ± standard deviation and were compared using t-test. Categorical variables were presented as frequencies and percentages; chi-square test was used to test for main association and then Bonferroni adjustment was used for post-hoc testing. Statistical significance was considered if a two-tailed p-value of <0.05 was achieved. Results A total of 410 potential LKDs were evaluated, of whom 241 (58.8%) successfully underwent donor nephrectomy and 169 (41.2%) were unable to proceed for kidney donation. The most common reasons for rejection of LKDs were medical (47.9%) followed by immunological reasons mainly blood group incompatibility (19.5%). Other reasons were donor withdrawal (15.4%), recipient-related reasons (7.1%), surgically unfit to proceed for nephrectomy (4.7%), or psychological reasons (2.3%). Conclusions A significant proportion of potential LKDs did not complete the kidney donation process due to medical, immunological, and surgical reasons. In addition, a proportion of LKDs decided to withdraw at some point during the evaluation process. Investing in donors' educational programs and implementing a standardized evaluation process are essential to increase LKDs pool.
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Affiliation(s)
- Abdulrahman Altheaby
- Organ Transplant Center and Hepatobiliary Sciences Department, King Abdulaziz Medical City, Riyadh, SAU
| | - Ahmed Almukhlifi
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | - Abdullah Alfaleh
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Ghaleb Aboalsamah
- Organ Transplant Center and Hepatobiliary Sciences Department, King Abdulaziz Medical City, Riyadh, SAU
| | - Ala Alshareef
- Organ Transplant Center and Hepatobiliary Sciences Department, King Abdulaziz Medical City, Riyadh, SAU
| | - Mohamed Alruwaymi
- Organ Transplant Center and Hepatobiliary Sciences Department, King Abdulaziz Medical City, Riyadh, SAU
| | - Khaled Bin Saad
- Organ Transplant Center and Hepatobiliary Sciences Department, King Abdulaziz Medical City, Riyadh, SAU
| | - Ziad Arabi
- Organ Transplant Center and Hepatobiliary Sciences Department, King Abulaziz Medical City, Riyadh, SAU
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Kinoshita Y, Yagisawa T, Sugihara T, Hara K, Takeshima S, Kubo T, Shinzato T, Shimizu T, Suzuki M, Maeshima A, Kamei J, Fujisaki A, Ando S, Suzuki M, Kume H, Fujimura T. Clinical outcomes in donors and recipients of kidney transplantations involving medically complex living donors - a retrospective study. Transpl Int 2020; 33:1417-1423. [PMID: 32654198 DOI: 10.1111/tri.13699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/14/2020] [Accepted: 07/06/2020] [Indexed: 02/06/2023]
Abstract
We retrospectively compared the post-transplantation graft survival and the donor's estimated glomerular filtration rates (eGFRs) following living donor kidney transplantations (LDKTs) involving medically complex living donors (MCLDs) (the elderly and patients with obesity, hypertension, diabetes mellitus, or reduced renal function) and standard living donors (SLDs). The clinical data on patients who underwent LDKTs at our institution from 2006-2019, including 192 SLDs and 99 MCLDs, were evaluated. Regarding recipients, the log-rank test and multivariable Cox proportional hazards analyses showed a higher incidence of overall and death-censored graft loss in the recipients who received kidneys from MCLDs (Hazard ratio = 2.16 and 3.25, P = 0.015 and 0.004, respectively), after adjusting for recipient-related variables including age, sex, duration of dialysis, ABO compatibility, and donor-specific antibody positivity. Regarding donors, a linear mixed model showed significantly lower postdonation eGFRs (-2.25 ml/min/1.73 m2 , P = 0.048) at baseline in MCLDs than SLDs, but comparable change (difference = 0.01 ml/min/1.73 m2 /year, P = 0.97). In conclusion, although kidneys from MCLDs are associated with impaired graft survival, the donation did not adversely affect the MCLDs' renal health in at least the short-term. LDKTs involving carefully selected MCLDs would be an acceptable alternative for recipients with no SLDs.
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Affiliation(s)
- Yoshitaka Kinoshita
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan.,Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Takashi Yagisawa
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Toru Sugihara
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Konan Hara
- Department of Public Health, The University of Tokyo, Tokyo, Japan
| | - Saki Takeshima
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Taro Kubo
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Takahiro Shinzato
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Toshihiro Shimizu
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Michiko Suzuki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Akito Maeshima
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Jun Kamei
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Akira Fujisaki
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Satoshi Ando
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Motofumi Suzuki
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tetsuya Fujimura
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
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50
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Tafulo S, Malheiro J, Dias L, Lobato L, Ramalhete L, Martinho A, Bolotinha C, Costa R, Ivo M. Improving HLA matching in living donor kidney transplantation using kidney paired exchange program. Transpl Immunol 2020; 62:101317. [PMID: 32634478 DOI: 10.1016/j.trim.2020.101317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The inclusion of compatible pairs within kidney paired exchange programs has been described as a way to enhance these programs. Improved immunological matching for the recipient in compatible pair has been described to be a possible benefit. METHODS The main purpose of our study was to determine if the introduction of compatible pairs in the Portuguese kidney paired exchange program would result in a better match for these patients, but also to assess if this strategy would increase the number of incompatible pairs with a possible match. We included 17 compatible pairs in kidney paired exchange pool of 35 pairs and performed an in-silico simulation determining HLA eplet mismatch load between the co-registered and matched pairs using HLA MatchMaker, version 3.0. RESULTS Our study showed that the inclusion of fully HLA-A, -B, -DR mismatched compatible pairs within the national Portuguese KEP increased matched rate within ICP (0.71%) and improved HLA eplet matching within compatible pairs. 16 of 17 (94.12%) of the CP obtained one or more transplants possibilities and 13 (81.25%) would have been transplanted with significantly lower HLA class I and class II total and antibody-verified eplet mismatch load (83.9 ± 16.9 vs. 59.8 ± 12.2, P = .002 and 30.1 ± 5.5 vs. 21.2 ± 3.0, P = .003, respectively). CONCLUSIONS This strategy is a viable alternative for compatible pairs seeking a better matched kidney and Portuguese KEP program should allow them this possibility.
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Affiliation(s)
- Sandra Tafulo
- Blood and Transplantation Center of Porto, Instituto Português do Sangue e da Transplantação, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal.
| | - Jorge Malheiro
- Unit for Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal; Department of Nephrology, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Portugal
| | - Leonídio Dias
- Department of Nephrology, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Portugal
| | - Luísa Lobato
- Unit for Multidisciplinary Research in Biomedicine (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal; Department of Nephrology, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Portugal
| | - Luís Ramalhete
- Blood and Transplantation Center of Lisbon, Instituto Português do Sangue e da Transplantação, Lisbon, Portugal
| | - António Martinho
- Blood and Transplantation Center of Coimbra, Instituto Português do Sangue e da Transplantação, Coimbra, Portugal
| | - Catarina Bolotinha
- National Transplantation Coordination, Instituto Português do Sangue e da Transplantação, Lisbon, Portugal
| | - Rita Costa
- National Transplantation Coordination, Instituto Português do Sangue e da Transplantação, Lisbon, Portugal
| | - Margarida Ivo
- National Transplantation Coordination, Instituto Português do Sangue e da Transplantação, Lisbon, Portugal
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