1
|
Offerni JCM, Ai Li E, Matti D, Luke G, Luke PP, Sener A. Can We Predict Kidney Graft Function and Graft Survival Using Hypothermic Machine Perfusion Parameters From Donors After Circulatory Death? Transplant Direct 2024; 10:e1601. [PMID: 38464425 PMCID: PMC10923389 DOI: 10.1097/txd.0000000000001601] [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: 09/22/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 03/12/2024] Open
Abstract
Background Hypothermic machine perfusion (HMP) reduces renal injury in donation after circulatory death donors with a high Kidney Donor Profile Index (KDPI). This study aims to characterize the correlation between KDPI, HMP parameters, and donor vitals during the withdrawal period in predicting short- and long-term graft outcomes. Methods ANOVA with Tukey's honestly significant difference tests compared the relationship between average flow, average resistance, peak resistance, flow slope, and resistance slope on day 30, 1-y, and 3-y eGFR, and days of delayed graft function. Graft and recipient survival rates were assessed using Kaplan-Meier analysis. Results The data for 72 grafts were suitable for analysis. Kidneys with KDPI >50% had a significantly higher day 30, and 1-y posttransplant eGFR, if HMP average flow was >150 mL/min, or the average resistance was <0.15 mm Hg/mL/min, compared with kidneys with also KDPI >50% but had not achieved the same pump parameters. There were no significant differences in the Kaplan-Meier analysis, considering recipient or graft survival, regardless of the KPDI score with 3- or 5-y outcomes. Conclusions Use of average resistance and average flow from a HMP, in conjunction with KDPI, may be predictive of the short- and long-term function of donation after circulatory death kidney transplants.
Collapse
Affiliation(s)
- Juliano C. M. Offerni
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
- Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada
- Division of Urology, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Erica Ai Li
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Danny Matti
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
| | - Grant Luke
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Patrick P. Luke
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
- Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada
| | - Alp Sener
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
- Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada
- Department of Microbiology and Immunology, Western University, London, ON, Canada
| |
Collapse
|
2
|
Hydrick TC, Zhang C, Ruch B, Wagler J, Kumm K, Harbell JW, Hewitt WR, Jadlowiec CC, Katariya NN, Moss AA, Nguyen MC, Reddy KS, Singer AL, Mathur AK. Declining Medicare reimbursement in abdominal transplantation from 2000 to 2021. Surgery 2023; 173:1484-1490. [PMID: 36894411 DOI: 10.1016/j.surg.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services is a major payer for abdominal transplant services. Reimbursement reductions could have a major impact on the transplant surgical workforce and hospitals. Yet government reimbursement trends in abdominal transplantation have not been fully characterized. METHODS We performed an economic analysis to characterize changes in inflation-adjusted trends in Medicare surgical reimbursement for abdominal transplant procedures. Using the Medicare Fee Schedule Look-Up Tool, we performed a procedure code-based surgical reimbursement rate analysis. Reimbursement rates were adjusted for inflation to calculate overall changes in reimbursement, overall year-over-year, 5-year year-over-year, and compound annual growth rate from 2000 to 2021. RESULTS We observed declines in adjusted reimbursement of common abdominal transplant procedures, including liver (-32.4%), kidney with and without nephrectomy (-24.2% and -24.1%, respectively), and pancreas transplant (-15.2%) (all, P < .05). Overall, the yearly average change for liver, kidney with and without nephrectomy, and pancreas transplant were -1.54%, -1.15%, -1.15%, and -0.72%. Five-year annual change averaged -2.69%, -2.35%, -2.64%, and -2.43%, respectively. The overall average compound annual growth rate was -1.27%. CONCLUSION This analysis depicts a worrisome reimbursement pattern for abdominal transplant procedures. Transplant surgeons, centers, and professional organizations should note these trends to advocate sustainable reimbursement policy and to preserve continued access to transplant services.
Collapse
Affiliation(s)
| | - Chi Zhang
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic, Rochester, MN. https://twitter.com/ChiZhang_MD
| | - Brianna Ruch
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ. https://twitter.com/BriannaCRuch
| | - Josiah Wagler
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Kayla Kumm
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Jack W Harbell
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Winston R Hewitt
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Caroline C Jadlowiec
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ. https://twitter.com/CarrieJadlowiec
| | - Nitin N Katariya
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Adyr A Moss
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | | | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Andrew L Singer
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, AZ; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic, Rochester, MN.
| |
Collapse
|
3
|
Delaura IF, Gao Q, Anwar IJ, Abraham N, Kahan R, Hartwig MG, Barbas AS. Complement-targeting therapeutics for ischemia-reperfusion injury in transplantation and the potential for ex vivo delivery. Front Immunol 2022; 13:1000172. [PMID: 36341433 PMCID: PMC9626853 DOI: 10.3389/fimmu.2022.1000172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/05/2022] [Indexed: 01/21/2023] Open
Abstract
Organ shortages and an expanding waitlist have led to increased utilization of marginal organs. All donor organs are subject to varying degrees of IRI during the transplant process. Extended criteria organs, including those from older donors and organs donated after circulatory death are especially vulnerable to ischemia-reperfusion injury (IRI). Involvement of the complement cascade in mediating IRI has been studied extensively. Complement plays a vital role in the propagation of IRI and subsequent recruitment of the adaptive immune elements. Complement inhibition at various points of the pathway has been shown to mitigate IRI and minimize future immune-mediated injury in preclinical models. The recent introduction of ex vivo machine perfusion platforms provides an ideal window for therapeutic interventions. Here we review the role of complement in IRI by organ system and highlight potential therapeutic targets for intervention during ex vivo machine preservation of donor organs.
Collapse
Affiliation(s)
- Isabel F. Delaura
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Qimeng Gao
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Imran J. Anwar
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Nader Abraham
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Riley Kahan
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, United States
| | - Andrew S. Barbas
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| |
Collapse
|
4
|
Molinari M, Kaltenmeier C, Liu H, Ashwat E, Jorgensen D, Puttarajappa C, Wu CM, Mehta R, Sood P, Shah N, Sharma A, Thompson A, Reddy D, Hariharan S. Function and longevity of renal grafts from high-KDPI donors. Clin Transplant 2022; 36:e14759. [PMID: 35778369 PMCID: PMC9786736 DOI: 10.1111/ctr.14759] [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: 12/22/2021] [Revised: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND High kidney-donor profile index (KDPI) kidneys have a shorter survival than grafts with lower KDPI values. It is still unclear, however, whether their shorter longevity depends on an inferior baseline function, faster functional decline, or the combination of both. METHODS We analyzed the estimated glomerular filtration rate (eGFR) of 605 consecutive recipients of deceased donor kidney transplants (KT) at 1, 3, 6, 12, 18, 24, 36, 48, and 60 months. Comparisons were performed among four groups based on KDPI quartile: Group I-KDPI ≤ 25% (n = 151), Group II-KDPI 26-50% (n = 182), Group III-KDPI 51-75% (n = 176), and Group IV-KDPI 〉 75% (n = 96). Linear mixed model analysis was subsequently used to assess whether KDPI was independently associated with the decline in eGFR during the first 5-years after KT. We also analyzed the incidence of delayed graft function (DGF), rejection within the first year after KT, patient survival, graft survival, and death censored graft survival based on KDPI group. FINDINGS High-KDPI grafts had lower eGFR immediately after KT, had a higher incidence of DGF and rejection. However, there were no signifcant differences in the adjusted rate (slope) of decline in eGFR among the four KDPI groups (P = .06). Although patient survival was signigicantly lower for recipients of high-KDPI grafts, death-censored graft survival was similar among the four KDPI groups (P = .33). CONCLUSIONS The shorter functional survival of high-KDPI grafts seems to be due to their lower baseline eGFR rather than a more rapid functional decline after KT.
Collapse
Affiliation(s)
- Michele Molinari
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Christof Kaltenmeier
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Hao Liu
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Eishan Ashwat
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Dana Jorgensen
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA,Biostatistics, Division of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Chethan Puttarajappa
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Christine M. Wu
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Rajil Mehta
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Puneet Sood
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Nirav Shah
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Akhil Sharma
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Ann Thompson
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Dheera Reddy
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Sundaram Hariharan
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| |
Collapse
|
5
|
Ott L, Vakili K, Cuenca AG. Organ allocation in pediatric abdominal transplant. Semin Pediatr Surg 2022; 31:151180. [PMID: 35725055 PMCID: PMC9333194 DOI: 10.1016/j.sempedsurg.2022.151180] [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] [Indexed: 11/18/2022]
Abstract
Pediatric patients constitute an important group within the general transplant population, given the opportunity to significantly extend their lives with successful transplantation. Children have historically received special consideration under the various abdominal solid organ allocation algorithms, but matching patients with size and weight restrictions with appropriate donors remains an ongoing issue. Here, we describe the historical trends in pediatric organ allocation policies for liver, kidney, intestine, and pancreas transplantation. We also review recent changes to these allocation policies, with particular attention to recent amendments to geographical prioritization, with the dissolution of donor service areas and United Network for Organ Sharing (UNOS) regions and the subsequent creation of acuity circles.
Collapse
Affiliation(s)
- Leah Ott
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Khashayar Vakili
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Alex G Cuenca
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States.
| |
Collapse
|