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Patient and Graft Survival After A1/A2-incompatible Living Donor Kidney Transplantation. Transplant Direct 2022; 8:e1388. [PMID: 36284928 PMCID: PMC9584180 DOI: 10.1097/txd.0000000000001388] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
ABO type B and O kidney transplant candidates have increased difficulty identifying a compatible donor for living donor kidney transplantation (LDKT) and are harder to match in kidney paired donation registries. A2-incompatible (A2i) LDKT increases access to LDKT for these patients. To better inform living donor selection, we evaluated the association between A2i LDKT and patient and graft survival. Methods We used weighted Cox regression to compare mortality, death-censored graft failure, and all-cause graft loss in A2i versus ABO-compatible (ABOc) recipients. Results Using Scientific Registry of Transplant Recipients data 2000-2019, we identified 345 A2i LDKT recipients. Mortality was comparable among A2i and ABOc recipients; weighted 1-/5-/10-y mortality was 0.9%/6.5%/24.2%, respectively, among A2i LDKT recipients versus 1.4%/7.7%/22.2%, respectively, among ABOc LDKT recipients (weighted hazard ratio [wHR], 0.811.041.33; P = 0.8). However, A2i recipients faced higher risk of death-censored graft failure; weighted 1-/5-/10-y graft failure was 5.7%/11.6%/22.4% for A2i versus 1.7%/7.5%/17.2% for ABOc recipients (wHR in year 1 = 2.243.565.66; through year 5 = 1.251.782.53; through year 10 = 1.151.552.07). By comparison, 1-/5-/10-y wHRs for A1-incompatible recipients were 0.631.966.08/0.390.942.27/0.390.831.74. Conclusions A2i LDKT is generally safe, but A2i donor/recipient pairs should be counseled about the increased risk of graft failure and be monitored as closely as their A1-incompatible counterparts posttransplant.
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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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Bastos J, Machado DJDB, David-Neto E. Increasing transplantability in Brazil: time to discuss Kidney Paired Donation. J Bras Nefrol 2021; 44:417-422. [PMID: 35107119 PMCID: PMC9518625 DOI: 10.1590/2175-8239-jbn-2021-0141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/19/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction: Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT. Discussion: KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America. Conclusion: KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.
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Affiliation(s)
- Juliana Bastos
- Santa Casa de Misericórdia de Juiz de Fora, Departamento de Transplante, Juiz de Fora, MG, Brasil
| | | | - Elias David-Neto
- Hospital das Clínicas da Universidade de São Paulo, Departamento de Transplante, São Paulo, SP, Brasil
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Huang E, Jordan SC. Rationalizing Incompatible Living Donor Kidney Transplantation for Highly Sensitized Candidates. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Matas AJ, Helgeson ES. The family voucher program: A 50-year simulation. Am J Transplant 2021; 21:1350-1351. [PMID: 33040494 DOI: 10.1111/ajt.16344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/10/2020] [Accepted: 10/04/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Arthur J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Erika S Helgeson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
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de Klerk M, Kal-van Gestel JA, van de Wetering J, Kho ML, Middel-de Sterke S, Betjes MGH, Zuidema WC, Roelen D, Glorie K, Roodnat JI. Creating Options for Difficult-to-match Kidney Transplant Candidates. Transplantation 2021; 105:240-248. [PMID: 32101984 DOI: 10.1097/tp.0000000000003203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Most transplantation centers recognize a small patient population that unsuccessfully participates in all available, both living and deceased donor, transplantation programs for many years: the difficult-to-match patients. This population consists of highly immunized and/or ABO blood group O or B patients. METHODS To improve their chances, Computerized Integration of Alternative Transplantation programs (CIAT) were developed to integrate kidney paired donation, altruistic/unspecified donation, and ABO and HLA desensitization. To compare CIAT with reality, a simulation was performed, including all patients, donors, and pairs who participated in our programs in 2015-2016. Criteria for inclusion as difficult-to-match, selected-highly immunized (sHI) patient were as follows: virtual panel reactive antibody >85% and participating for 2 years in Eurotransplant Acceptable Mismatch program. sHI patients were given priority, and ABO blood group incompatible (ABOi) and/or HLA incompatible (HLAi) matching with donor-specific antigen-mean fluorescence intensity (MFI) <8000 were allowed. For long-waiting blood group O or B patients, ABOi matches were allowed. RESULTS In reality, 90 alternative program transplantations were carried out: 73 compatible, 16 ABOi, and 1 both ABOi and HLAi combination. Simulation with CIAT resulted in 95 hypothetical transplantations: 83 compatible (including 1 sHI) and 5 ABOi combinations. Eight sHI patients were matched: 1 compatible, 6 HLAi with donor-specific antigen-MFI <8000 (1 also ABOi), and 1 ABOi match. Six/eight combinations for sHI patients were complement-dependent cytotoxicity cross-match negative. CONCLUSIONS CIAT led to 8 times more matches for difficult-to-match sHI patients. This offers them better chances because of a more favorable MFI profile against the new donor. Besides, more ABO compatible matches were found for ABOi couples, while total number of transplantations was not hampered. Prioritizing difficult-to-match patients improves their chances without affecting the chances of regular patients.
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Affiliation(s)
- Marry de Klerk
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - Marcia L Kho
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Michiel G H Betjes
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Willij C Zuidema
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Dave Roelen
- Department of Immunohaematology and Blood Transfusion LUMC, Leiden, The Netherlands
| | - Kristiaan Glorie
- Erasmus Q-Intelligence, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Joke I Roodnat
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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Verbesey J, Thomas AG, Ronin M, Beaumont J, Waterman A, Segev DL, Flechner SM, Cooper M. Early graft losses in paired kidney exchange: Experience from 10 years of the National Kidney Registry. Am J Transplant 2020; 20:1393-1401. [PMID: 31922651 PMCID: PMC7183872 DOI: 10.1111/ajt.15778] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/03/2019] [Accepted: 12/30/2019] [Indexed: 01/25/2023]
Abstract
Cooperative kidney paired donation (KPD) networks account for an increasing proportion of all living donor kidney transplants in the United States. There are sparse data on the rate of primary nonfunction (PNF) losses and their consequences within KPD networks. We studied National Kidney Registry (NKR) transplants (February 14, 2009 to December 31, 2017) and quantified PNF, graft loss within 30 days of transplantation, and graft losses in the first-year posttransplant and assessed potential risk factors. Of 2364 transplants, there were 38 grafts (1.6%) lost within the first year, 13 (0.5%) with PNF. When compared to functioning grafts, there were no clinically significant differences in blood type compatibility, degree of HLA mismatch, number of veins/arteries, cold ischemia, and travel times. Of 13 PNF cases, 2 were due to early venous thrombosis, 2 to arterial thrombosis, and 2 to failure of desensitization and development of antibody-mediated rejection (AMR). Given the low rate of PNF, the NKR created a policy to allocate chain-end kidneys to recipients with PNF following event review and attributable to surgical issues of donor nephrectomy. It is expected that demonstration of low incidence of poor early graft outcomes and the presence of a "safety net" would further encourage program participation in national KPD.
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Affiliation(s)
| | - Alvin G. Thomas
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Amy Waterman
- Terasaki Research Institute, Los Angeles, CA
- Department of Nephrology, University of California, Los Angeles, CA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Scientific Registry of Transplant Recipients, Minnesota, MN
| | - Stuart M. Flechner
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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Affiliation(s)
- Bushra Syed
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Joshua J Augustine
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
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Leeser DB, Thomas AG, Shaffer AA, Veale JL, Massie AB, Cooper M, Kapur S, Turgeon N, Segev DL, Waterman AD, Flechner SM. Patient and Kidney Allograft Survival with National Kidney Paired Donation. Clin J Am Soc Nephrol 2020; 15:228-237. [PMID: 31992572 PMCID: PMC7015097 DOI: 10.2215/cjn.06660619] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 11/14/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the United States, kidney paired donation networks have facilitated an increasing proportion of kidney transplants annually, but transplant outcome differences beyond 5 years between paired donation and other living donor kidney transplant recipients have not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using registry-linked data, we compared National Kidney Registry (n=2363) recipients to control kidney transplant recipients (n=54,497) (February 2008 to December 2017). We estimated the risk of death-censored graft failure and mortality using inverse probability of treatment weighted Cox regression. The parsimonious model adjusted for recipient factors (age, sex, black, race, body mass index ≥30 kg/m2, diabetes, previous transplant, preemptive transplant, public insurance, hepatitis C, eGFR, antibody depleting induction therapy, year of transplant), donor factors (age, sex, Hispanic ethnicity, body mass index ≥30 kg/m2), and transplant factors (zero HLA mismatch). RESULTS National Kidney Registry recipients were more likely to be women, black, older, on public insurance, have panel reactive antibodies >80%, spend longer on dialysis, and be previous transplant recipients. National Kidney Registry recipients were followed for a median 3.7 years (interquartile range, 2.1-5.6; maximum 10.9 years). National Kidney Registry recipients had similar graft failure (5% versus 6%; log-rank P=0.2) and mortality (9% versus 10%; log-rank P=0.4) incidence compared with controls during follow-up. After adjustment for donor, recipient, and transplant factors, there no detectable difference in graft failure (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77 to 1.18; P=0.6) or mortality (adjusted hazard ratio, 0.86; 95% confidence interval, 0.70 to 1.07; P=0.2) between National Kidney Registry and control recipients. CONCLUSIONS Even after transplanting patients with greater risk factors for worse post-transplant outcomes, nationalized paired donation results in equivalent outcomes when compared with control living donor kidney transplant recipients.
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Affiliation(s)
- David B Leeser
- Department of Surgery, East Carolina University, Greenville, North Carolina;
| | - Alvin G Thomas
- Department of Surgery and.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Ashton A Shaffer
- Department of Surgery and.,Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Sandip Kapur
- Department of Surgery, Cornell University, New York, New York
| | - Nicole Turgeon
- Department of Surgery, Dell School of Medicine, University of Texas at Austin, Austin, Texas
| | - Dorry L Segev
- Department of Surgery and.,Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Amy D Waterman
- Department of Nephrology, University of California, Los Angeles, Los Angeles, California.,Terasaki Research Institute, Los Angeles, California; and
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Holscher CM, Jackson KR, Segev DL. Transplanting the Untransplantable. Am J Kidney Dis 2020; 75:114-123. [DOI: 10.1053/j.ajkd.2019.04.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 04/22/2019] [Indexed: 12/27/2022]
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11
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Favi E, James A, Puliatti C, Whatling P, Ferraresso M, Rui C, Cacciola R. Utility and safety of early allograft biopsy in adult deceased donor kidney transplant recipients. Clin Exp Nephrol 2019; 24:356-368. [PMID: 31768863 DOI: 10.1007/s10157-019-01821-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Delayed graft function (DGF) is considered a risk factor for rejection after kidney transplantation (KTx). Clinical guidelines recommend weekly allograft biopsy until DGF resolves. However, who may benefit the most from such an aggressive policy and when histology should be evaluated remain debated. METHODS We analyzed 223 biopsies in 145 deceased donor KTx treated with basiliximab or anti-thymocyte globulin (rATG) and calcineurin inhibitor-based maintenance. The aim of the study was to assess the utility and safety of biopsies performed within 28 days of transplant. Relationships between transplant characteristics, indication, timing, and biopsy-related outcomes were evaluated. RESULTS Main indication for biopsy was DGF (87.8%) followed by lack of improvement in graft function (9.2%), and worsening graft function (3.1%). Acute tubular necrosis was the leading diagnosis (89.8%) whereas rejection was detected in 8.2% specimens. Rejection was more frequent in patients biopsied due to worsening graft function or lack of improvement in graft function than DGF (66.7% vs. 3.5%; P = 0.0075 and 33.3% vs. 3.5%; P = 0.0104, respectively) and in biopsies performed between day 15 and 28 than from day 0 to 14 (31.2% vs. 3.7%; P = 0.0002). Complication rate was 4.1%. Management was affected by the information gained with histology in 12.2% cases (7% considering DGF). CONCLUSIONS In low-immunological risk recipients treated with induction and calcineurin inhibitors maintenance, protocol biopsies obtained within 2 weeks of surgery to rule out rejection during DGF do not necessarily offer a favourable balance between risks and benefits. In these patients, a tailored approach may minimize complications thus optimizing results.
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Affiliation(s)
- Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy.
| | - Ajith James
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Carmelo Puliatti
- Organ Transplantation, Parma University Hospital, Via A. Gramsci 14, 43126, Parma, Italy
| | - Phil Whatling
- Nephrology, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB, UK
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Chiara Rui
- Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza n. 35, 20122, Milan, Italy
| | - Roberto Cacciola
- HPB and Transplant Unit, Department of Surgery, Tor Vergata University, Viale Oxford 81, 00133, Rome, Italy
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