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Assfalg V, Miller G, Stocker F, Hüser N, Hartmann D, Heemann U, Tieken I, Zanen W, Vogelaar S, Rosenkranz AR, Schneeberger S, Függer R, Berlakovich G, Ysebaert DR, Jacobs-Tulleneers-Thevissen D, Mikhalski D, van Laecke S, Kuypers D, Mühlfeld AS, Viebahn R, Pratschke J, Melchior S, Hauser IA, Jänigen B, Weimer R, Richter N, Foller S, Schulte K, Kurschat C, Harth A, Moench C, Rademacher S, Nitschke M, Krämer BK, Renders L, Koliogiannis D, Pascher A, Hoyer J, Weinmann-Menke J, Schiffer M, Banas B, Hakenberg O, Schwenger V, Nadalin S, Lopau K, Piros L, Nemes B, Szakaly P, Bouts A, Bemelman FJ, Sanders JS, de Vries APJ, Christiaans MHL, Hilbrands L, van Zuilen AD, Arnol M, Stippel D, Wahba R. Rescue Allocation Modes in Eurotransplant Kidney Transplantation: Recipient Oriented Extended Allocation Versus Competitive Rescue Allocation-A Retrospective Multicenter Outcome Analysis. Transplantation 2024; 108:1200-1211. [PMID: 38073036 DOI: 10.1097/tp.0000000000004878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Whenever the kidney standard allocation (SA) algorithms according to the Eurotransplant (ET) Kidney Allocation System or the Eurotransplant Senior Program fail, rescue allocation (RA) is initiated. There are 2 procedurally different modes of RA: recipient oriented extended allocation (REAL) and competitive rescue allocation (CRA). The objective of this study was to evaluate the association of patient survival and graft failure with RA mode and whether or not it varied across the different ET countries. METHODS The ET database was retrospectively analyzed for donor and recipient clinical and demographic characteristics in association with graft outcomes of deceased donor renal transplantation (DDRT) across all ET countries and centers from 2014 to 2021 using Cox proportional hazards methods. RESULTS Seventeen thousand six hundred seventy-nine renal transplantations were included (SA 15 658 [89%], REAL 860 [4.9%], and CRA 1161 [6.6%]). In CRA, donors were older, cold ischemia times were longer, and HLA matches were worse in comparison with REAL and especially SA. Multivariable analyses showed comparable graft and recipient survival between SA and REAL; however, CRA was associated with shorter graft survival. Germany performed 76% of all DDRTs after REAL and CRA and the latter mode reduced waiting times by up to 2.9 y. CONCLUSIONS REAL and CRA are used differently in the ET countries according to national donor rates. Both RA schemes optimize graft utilization, lead to acceptable outcomes, and help to stabilize national DDRT programs, especially in Germany.
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Affiliation(s)
- Volker Assfalg
- TransplanTUM Munich Transplant Center, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Gregor Miller
- Department of Mathematics, Technical University of Munich, Garching, Germany
| | - Felix Stocker
- TransplanTUM Munich Transplant Center, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Norbert Hüser
- TransplanTUM Munich Transplant Center, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Daniel Hartmann
- TransplanTUM Munich Transplant Center, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Surgery, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Uwe Heemann
- TransplanTUM Munich Transplant Center, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Nephrology, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, München, Germany
| | - Ineke Tieken
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - Wouter Zanen
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - Serge Vogelaar
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - Alexander R Rosenkranz
- Department of Internal Medicine, Division of Nephrology, Medical University of Graz, Graz, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Reinhold Függer
- Department of Surgery, Krankenhaus der Elisabethinen and Johannes Kepler University, Linz, Austria
| | | | - Dirk R Ysebaert
- Department of HPB and Transplantation Surgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | | | - Dimitri Mikhalski
- Department of Abdominal Surgery and Transplantation, Hôpital Erasme, ULB, Brussels, Belgium
| | | | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Anja S Mühlfeld
- Department of Nephrology, Uniklinik RWTH Aachen, Aachen, Germany
| | - Richard Viebahn
- Chirurgische Klinik, Universitätsklinikum Knappschaftskrankenhaus, Bochum, Germany
| | - Johann Pratschke
- Chirurgische Klinik CCM/CVK, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Ingeborg A Hauser
- Department of Nephrology, University Clinic Frankfurt, Frankfurt am Main, Germany
| | - Bernd Jänigen
- Department of General and Digestive Surgery, Transplant Unit, Freiburg, Germany
| | - Rolf Weimer
- Department of Internal Medicine, Nephrology/Renal Transplantation, University of Giessen, Giessen, Germany
| | - Nicolas Richter
- Medizinische Hochschule Hannover, Allgemein-, Viszeral- und Transplantationschirurgie, Hannover, Germany
| | - Susan Foller
- Department of Urology, Jena University Hospital, Jena, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertensiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Christine Kurschat
- Department II of Internal Medicine and Cologne Excellence Cluster on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Ana Harth
- Medizinische Klinik I Merheim, Kliniken der Stadt Köln, Klinikum der Universität Witten/Herdecke, Köln, Germany
| | - Christian Moench
- General-, Visceral- and Transplantation Surgery, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Thoracic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Martin Nitschke
- Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Bernhard K Krämer
- Vth Department of Medicine, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Lutz Renders
- TransplanTUM Munich Transplant Center, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, Munich, Germany
- Department of Nephrology, Technical University of Munich, TUM School of Medicine, Klinikum rechts der Isar, München, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral, and Transplant Surgery, LMU University of Munich, Munich, Germany
| | - Andreas Pascher
- Department of General, Visceral, and Transplant Surgery, UKM Muenster, Münster, Germany
| | - Joachim Hoyer
- Department of Internal Medicine and Nephrology, University Medical Center, Philipps University Marburg, Marburg, Germany
| | - Julia Weinmann-Menke
- I. Department of Medicine, Division of Nephrology, Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Mario Schiffer
- Nephrology and Hypertension, Friedrich-Alexander-University Erlangen, Erlangen, Germany
| | - Bernhard Banas
- Abteilung für Nephrologie, Universitäres Transplantationszentrum, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Oliver Hakenberg
- Department of Urology, Rostock University Medical Centre, Rostock, Germany
| | - Vedat Schwenger
- Department of Nephrology and Transplant Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Kai Lopau
- Department of Internal Medicine, Division of Nephrology, University of Wuerzburg-Kidney Transplant Program, Wuerzburg, Germany
| | - Laszlo Piros
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Balazs Nemes
- Department of Organ Transplantation, Institute of Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Peter Szakaly
- Department of Surgery, Medical School, University of Pécs, Pécs, Hungary
| | - Antonia Bouts
- Pediatric Nephrology Department, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Frederike J Bemelman
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jan S Sanders
- Departement of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Aiko P J de Vries
- Department of Medicine, Division of Nephrology, Leiden University Medical Center and Transplant Center, Leiden, the Netherlands
| | - Maarten H L Christiaans
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology and Hypertension, UMC Utrecht, Utrecht, the Netherlands
| | - Miha Arnol
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dirk Stippel
- Department of Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roger Wahba
- Department of Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Kilambi V, Barah M, Formica RN, Friedewald JJ, Mehrotra S. Evaluation of Opening Offers Early for Deceased Donor Kidneys at Risk of Nonutilization. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00287. [PMID: 37943856 PMCID: PMC10861110 DOI: 10.2215/cjn.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Reducing nonutilization of kidneys recovered from deceased donors is a current policy concern for kidney allocation in the United States. The likelihood of nonutilization is greater with a higher kidney donor risk index (KDRI) offer. We examine how opening offers for organs with KDRI >1.75 to the broader waitlist at varying points of time affects usage rates. METHODS We simulate kidney allocation using data for January 2018 to June 2019 from Organ Procurement and Transplantation Network. For the simulation experiment, allocation policy is modified so that KDRI >1.75 organs are offered to all local candidates (same donation service area) after a set amount of cold time simultaneously. Open offers to candidates nationally are similarly examined. RESULTS Simulation results ( n =50 replications) estimate that opening offers locally for KDRI >1.75 after 10 hours yields a nonutilization rate of 38% (range: 35%-42%), less than the prevailing rate of 55% of KDRI >1.75 kidneys. Opening offers after 5 hours yields 30% (range: 26%-34%), reducing the prevailing nonutilization rate by 45%. Opening offers nationally after 10 and 5 hours yields nonutilization rates of 11% (range: 8%-15%) and 6% (range: 4%-9%) for KDRI >1.75 kidneys, respectively. CONCLUSIONS Simulation findings indicate that opening offers and adjusting their timing can significantly reduce nonutilization of high-KDRI kidneys.
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Affiliation(s)
- Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Richard N. Formica
- Department of Nephrology, Yale School of Medicine, New Haven, Connecticut
| | - John J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Barah M, Kilambi V, Friedewald JJ, Mehrotra S. Implications of Accumulated Cold Time for US Kidney Transplantation Offer Acceptance. Clin J Am Soc Nephrol 2022; 17:1353-1362. [PMID: 35868843 PMCID: PMC9625102 DOI: 10.2215/cjn.01600222] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Reducing discard is important for the US transplantation system because nearly 20% of the deceased donor kidneys are discarded. One cause for the discards is the avoidance of protracted cold ischemia times. Extended cold ischemia times at transplant are associated with additional risk of graft failure and patient mortality. A preference for local (within the same donor service area) or low-Kidney Donor Risk Index organs, the endogeneity of cold ischemia time during organ allocation, and the use of provisional offers all complicate the analysis of cold ischemia times' influence on kidney acceptance decision making. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using January 2018 to June 2019 Organ Procurement and Transplantation Network data, we modeled the probability of accepting an offer for a kidney after provisional acceptance. We use logistic regression that includes cold ischemia time, Kidney Donor Risk Index, and other covariates selected from literature. Endogeneity of cold ischemia time was treated by a two-stage instrumental variables approach. RESULTS Logistic regression results for 3.33 million provisional acceptances from 12,369 donors and 108,313 candidates quantify trade-offs between cold ischemia time at the time of offer acceptance and donor-recipient characteristics. Overall, each additional 2 hours of cold ischemia time affected acceptance for nonlocal and local recipients (odds ratio, 0.75; 95% confidence interval, 0.73 to 0.77, odds ratio, 0.88; 95% confidence interval, 0.86 to 0.91; P<0.001). For Kidney Donor Risk Index >1.75 (Kidney Donor Profile Index >85) kidneys, an additional 2 hours of cold ischemia time for nonlocal and local recipients was associated with acceptance with odds ratio, 0.58; 95% confidence interval, 0.54 to 0.63 (nonlocal) and odds ratio, 0.65; 95% confidence interval, 0.6 to 0.7 (local); P<0.001. The effect of an additional 2 hours of cold ischemia time on acceptance of kidneys with Kidney Donor Risk Index ≤1.75 (Kidney Donor Profile Index ≤85) was less pronounced for nonlocal offers (odds ratio, 0.82; 95% confidence interval, 0.80 to 0.85; P<0.001) and not significant for local offers. CONCLUSIONS The acceptability of marginal organs was higher when placements were nearer to the donor and when cold ischemia time was shorter.
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Affiliation(s)
- Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - John J Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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King KL, Husain SA, Cohen DJ, Schold JD, Mohan S. The role of bypass filters in deceased donor kidney allocation in the United States. Am J Transplant 2022; 22:1593-1602. [PMID: 35090080 DOI: 10.1111/ajt.16967] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
Kidney transplant centers set organ offer filters enabling all candidates at their center to be bypassed during allocation of deceased donor kidneys from the UNOS Organ Center. These filters aim to increase allocation efficiency by preemptively screening out offers unlikely to be accepted. National data were used to compare filter settings of 175 centers in 2007 and in 2019. We examined characteristics of centers whose settings became increasingly restrictive over time, and associations between filter settings and organ offer acceptance. Overall, centers became more open to receiving offers over time, from a median 62% of filters open to receiving national offers in 2007 to 73% in 2019. Intravenous drug use filter settings changed most, from 63 to 153 willing centers. Centers with more open filter settings had higher transplant volume and offer acceptance ratios across all risk categories despite preemptively screening out fewer offers compared to centers with less open settings, but similar transplant rates. There was significant geographic heterogeneity in the distribution of centers with more open filter settings. Current center bypass filters may impact patients' access to transplantation without achieving their full potential for improving allocation efficiency.
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Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Husain SA, King KL, Robbins-Juarez S, Adler JT, McCune KR, Mohan S. Number of Donor Renal Arteries and Early Outcomes after Deceased Donor Kidney Transplantation. KIDNEY360 2021; 2:1819-1826. [PMID: 35373010 PMCID: PMC8785844 DOI: 10.34067/kid.0005152021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/07/2021] [Indexed: 02/07/2023]
Abstract
Background Anatomic abnormalities increase the risk of deceased donor kidney discard, but their effect on transplant outcomes is understudied. We sought to determine the effect of multiple donor renal arteries on early outcomes after deceased donor kidney transplantation. Methods For this retrospective cohort study, we identified 1443 kidneys from 832 deceased donors with ≥1 kidney transplanted at our center (2006-2016). We compared the odds of delayed graft function and 90-day graft failure using logistic regression. To reduce potential selection bias, we then repeated the analysis using a paired-kidney cohort, including kidney pairs from 162 donors with one single-artery kidney and one multiartery kidney. Results Of 1443 kidneys included, 319 (22%) had multiple arteries. Multiartery kidneys experienced longer cold ischemia time, but other characteristics were similar between groups. Delayed graft function (50% multiartery versus 45% one artery, P=0.07) and 90-day graft failure (3% versus 3%, P=0.83) were similar between groups before and after adjusting for donor and recipient characteristics. In the paired kidney analysis, cold ischemia time was significantly longer for multiartery kidneys compared with single-artery kidneys from the same donor (33.5 versus 26.1 hours, P<0.001), but delayed graft function and 90-day graft failure were again similar between groups. Conclusions Compared with single-artery deceased donor kidneys, those with multiple renal arteries are harder to place, but experience similar delayed graft function and early graft failure.
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Affiliation(s)
- S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Shelief Robbins-Juarez
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
| | - Joel T Adler
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, Massachusetts
| | - Kasi R McCune
- Department of Surgery, Kidney and Pancreas Transplant Program, Columbia University College of Physicians & Surgeons, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, New York, New York
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