Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk?

An Anatomically Complicated Living Donor Kidney Transplantation from Hepatitis B Surface Antigen-Positive Donor to Negative Recipient With Size Discrepancy

The deficiency of organ donors remains a barrier to kidney transplantation. Living donor kidney transplantation (LDKT) can overcome graft shortage, resulting in better outcomes. Many efforts are being made to expand the donor pool, such as hepatitis B surface antigen (HBsAg)-positive donors to negative recipients and anatomically complicated donor kidneys with size discrepancies. We report a case in which we overcame various problems in LDKT. The recipient was a 56-year-old, 106-kg, HBsAg negative male with diabetic nephropathy. The donor was a 63-year-old female, 56-kg, hepatitis B virus (HBV) carrier with dual renal arteries. Preoperative antiviral medication was provided to the donor for negative conversion of HBV-DNA. The recipient was given HBV vaccination (antihepatitis B antibody: 2.25-36.16 mIU/mL). Anti-HBV immunoglobulin was intraoperatively administered to prevent transmission. The donor and recipient had an absolute weight difference (50 kg). In addition, the donor's kidney had a main and an accessory artery in the upper pole, which were anastomosed to the recipient's right external iliac and inferior epigastric artery, respectively. Follow-up serum creatinine levels decreased. Doppler ultrasonography showed good vascular flow within the reference range of the resistive index. The recipient's follow-up HBV-DNA titer was negative with antiviral medication. We successfully performed LDKT from an HBV-positive donor to a negative recipient by perioperative antiviral treatment and overcame a significant size discrepancy and anatomic challenges by preserving even a small portion of the kidney graft.

Age Disparities in Access to First and Repeat Kidney Transplantation

BACKGROUND

Evidence suggests that older patients are less frequently placed on the waiting list for kidney transplantation (KT) than their younger counterparts. The trends and magnitude of this age disparity in access to first KT and repeat KT (re-KT) remain unclear.

METHODS

Using the US Renal Data System, we identified 2 496 743 adult transplant-naive dialysis patients and 110 338 adult recipients with graft failure between 1995 and 2018. We characterized the secular trends of age disparities and used Cox proportional hazard models to compare the chances of listing and receiving first KT versus re-KT by age (18-64 y versus ≥65 y).

RESULTS

Older transplant-naive dialysis patients were less likely to be listed (adjusted hazard ratio [aHR] = 0.18; 95% confidence interval [CI], 0.17-0.18) and receive first KT (aHR = 0.88; 95% CI, 0.87-0.89) compared with their younger counterparts. Additionally, older patients with graft failure had a lower chance of being listed (aHR = 0.40; 95% CI, 0.38-0.41) and receiving re-KT (aHR = 0.76; 95% CI, 0.72-0.81). The magnitude of the age disparity in being listed for first KT was greater than that for re-KT ( Pinteraction  < 0.001), and there were no differences in the age disparities in receiving first KT or re-KT ( Pinteraction  = 0.13). Between 1995 and 2018, the age disparity in listing for first KT reduced significantly ( P  < 0.001), but the age disparities in re-KT remained the same ( P  = 0.16).

CONCLUSIONS

Age disparities exist in access to both first KT and re-KT; however, some of this disparity is attenuated among older adults with graft failure. As the proportion of older patients with graft failure rises, a better understanding of factors that preclude their candidacy and identification of appropriate older patients are needed.

COVID-19 and Access to Kidney Transplantation for Older Candidates in the United States: A National Registry Study

Rationale & Objective

Coronavirus disease (COVID)-19 has likely impacted accessibility to transplantation services among older adults (age ≥65 years). We quantified the impact of COVID-19 on kidney transplantation access for older kidney-only candidates registered on the United States (US) kidney waitlist.

Study Design

Retrospective analysis of registry data.

Setting & Participants

57,222 older adults who were part of or added to the US kidney waitlist between January 1, 2016 and February 28, 2022, identified using the Scientific Registry of Transplant Recipients (SRTR).

Exposures

Four COVID-19 waves and one nonwave period based on the national incidence of COVID-19 in the US (initial: March 15-May 30, 2020; winter 2020-2021: December 1, 2020-January 31, 2021; delta: August 1, 2021-September 30, 2021; omicron: December 1, 2021-February 28, 2022; nonwave: inter-wave periods).

Outcomes

Waitlist registrations, deceased-donor kidney transplants, living-donor kidney transplants, waitlist mortality, and waitlist removals due to deteriorating condition (hereafter referred to as removals).

Analytical Approach

Poisson regression for the adjusted incidence rate ratio (aIRR) of each outcome during the COVID-19 waves and the nonwave period relative to reference (January 1, 2016-December 31, 2019), adjusted for seasonality and secular trends.

Results

Waitlist registrations initially declined and increased henceforth. Deceased-donor kidney transplants and living-donor kidney transplants remained below-expected levels during all waves. Waitlist mortality peaked during the winter 2020-2021 wave (aIRR: 1.701.982.30) and has declined since; mortality rates were 139%, 107%, and 251% above expected for Black candidates, men, and candidates aged ≥75 years, respectively, during the winter 2020-2021 wave. Removals increased from 22% below expected levels (initial wave) to 26% above expected levels (omicron wave); removals were nonsignificantly higher than expected during the omicron wave for older Black and Hispanic candidates.

Limitations

The findings are not generalizable to those listed at earlier ages with prolonged waitlist times. Additionally, using national COVID-19 incidence does not consider local policy and health care variations. Lastly, aIRRs must be interpreted cautiously due to smaller daily event counts.

Conclusions

COVID-19 was associated with fewer transplants and increased mortality and removals in older kidney transplant candidates. Transplant providers should consider this impact and implement policies and practices to ensure the continuity of care.

Plain-Language Summary

The proportion of older adults on the kidney transplant waitlist is increasing, but the impact of COVID-19 on this population is not well characterized. In this study, we looked at incident waitlist registrations, deceased- and living-donor kidney transplants, and waitlist mortality and removals due to deteriorating condition over 4 waves of COVID-19. We found that transplantation services did not fully recover to prepandemic levels as of March 2022. Notably, racial/ethnic minorities and older men experienced lower rates of kidney transplants and higher rates of waitlist mortality, respectively, relative to White candidates and older women. Identifying vulnerable subpopulations affected by COVID-19 and its long-term impact is crucial for creating strategies to ensure the continuity of care in this population during public health emergencies.

Survival after kidney transplantation compared with ongoing dialysis for people over 70 years of age: A matched-pair analysis

Kidney transplantation offers improved survival and quality of life compared to dialysis for most recipients; however, benefits for elderly patients (>70 years) remain uncertain. Using the Australia and New Zealand Dialysis and Transplant Registry (2009-2019), elderly transplant recipients were matched to a waitlisted dialysis patient by age, cause of end-stage kidney disease, and dialysis duration (paired controls). We censored dialysis patients at the time of transplant. Survival was compared using stratified Cox regression. Elderly transplant recipients (KTRs) (n = 465) were matched to waitlisted pairs. Transplant group mortality initially exceeded dialysis due to excess infection-related deaths (1.9 transplant versus 0.3 dialysis/100 patient-years, P = .03). Beyond month 9, a progressive survival benefit in favor of transplantation was apparent. Over a median follow-up of 1.7 years, mortality was 38% lower for KTRs (95% confidence interval 0.41-0.94, P = .02), and 5-year survival was 80% KTRs vs 53% dialysis (P < .001). Recipients of living and standard criteria donor kidneys acquired immediate survival advantage compared with dialysis, while recipients of expanded criteria donor's kidneys experienced elevated risk of death for the first 17 months. Compared with remaining on dialysis, elderly KTRs incur an increased risk of early posttransplant mortality but thereafter may anticipate progressively superior survival rates.

Kidney transplant in the next decade: Strategies, challenges and vision of the future

Although the results of kidney transplantation (KT) have improved substantially in recent years, a chronic and inexorable loss of grafts mainly due to the death of the patient and chronic dysfunction of the KT, continues to be observed. The objectives, thus, to optimize this situation in the next decade are fundamentally focused on minimizing the rate of kidney graft loss, improving patient survival, increasing the rate of organ procurement and its distribution, promoting research and training in health professionals and the development of scientific registries providing clinical and reliable information that allow us to optimize our clinical practice in the field of KT. With this perspective, this review will deep into: (1) strategies to avoid chronic dysfunction and graft loss in the medium and long term; (2) to prolong patient survival; (3) strategies to increase the donation, maintenance and allocation of organs; (4) promote clinical and basic research and training activity in KT; and (5) the analysis of the results in KT by optimizing and merging scientific registries.

Complement Binding Anti-HLA Antibodies and the Survival of Kidney Transplantation

Background: Antibody-mediated rejection (AMR) is one of the most important challenges in the context of renal transplantation, because the binding of de novo donor-specific antibodies (dnDSA) to the kidney graft triggers the activation of the complement, which in turn leads to loss of transplant. In this context, the objective of this study was to evaluate the association between complement-fixing dnDSA antibodies and graft loss as well as the possible association between non-complement-fixing antibodies and transplanted organ survival in kidney transplant recipients. Methods: Our study included a cohort of 245 transplant patients over a 5-year period at Virgen de las Nieves University Hospital (HUVN) in Granada, Spain. Results: dnDSA was observed in 26 patients. Of these patients, 17 had non-complement-fixing dnDSA and 9 had complement-fixing dnDSA. Conclusions: Our study demonstrated a significant association between the frequency of rejection and renal graft loss and the presence of C1q-binding dnDSA. Our results show the importance of the individualization of dnDSA, classifying them according to their ability to activate the complement, and suggest that the detection of complement-binding capacity by dnDSA could be used as a prognostic marker to predict AMR outcome and graft survival in kidney transplant patients who develop dnDSA.

Living Donor Kidney Transplantation in Older Individuals: An Ethical Legal and Psychological Aspects of Transplantation (ELPAT) View

Living donor transplantation is the optimal treatment for suitable patients with end-stage kidney disease. There are particular advantages for older individuals in terms of elective surgery, timely transplantation, and early graft function. Yet, despite the superiority of living donor transplantation especially for this cohort, older patients are significantly less likely to access this treatment modality than younger age groups. However, given the changing population demographic in recent decades, there are increasing numbers of older but otherwise healthy individuals with kidney disease who could benefit from living donor transplantation. The complex reasons for this inequity of access are explored, including conscious and unconscious age-related bias by healthcare professionals, concerns relating to older living donors, ethical anxieties related to younger adults donating to aging patients, unwillingness of potential older recipients to consider living donation, and the relevant legislation. There is a legal and moral duty to consider the inequity of access to living donor transplantation, recognising both the potential disparity between chronological and physiological age in older patients, and benefits of this treatment for individuals as well as society.

Kidney Transplant Outcomes in Recipients Over the Age of 70

BACKGROUND

Patients older than 70 years are the fastest-growing age group of patients requiring renal replacement therapy. This has resulted in a corresponding increase in the number of elderly transplant recipients. We hypothesized that graft survival in this population would be comparable to that seen in the literature on kidney transplant recipients under 70 years of age.

METHODS

This was a retrospective, single-center review of outcomes of kidney transplant recipients aged ≥70 years. Patients were dichotomized based on whether their allograft originated from a living or deceased donor.

RESULTS

A total of 59 recipients aged ≥70 years underwent kidney transplantation. Of these, five (8.5%) were lost to follow-up within the first year post transplant and excluded from the analysis. History of cerebrovascular accident (p = 0.003), coronary artery disease (p = 0.03), postoperative return to the operating room (p = 0.03), and readmission within one year of transplant were predictive of graft loss (p = 0.003). Overall graft survival in our cohort declined from 92.6% at one year to 53.8% at five years. Death-censored graft survival was 100% at one year and decreased to 80.8% at five years. There were no differences seen in patient, graft, or death-censored graft survival based on donor type.

CONCLUSIONS

Kidney transplant patients over 70 years, as seen in our cohort, had good short-term outcomes. Graft survival is similar to rates seen in younger cohorts but the decline in this rate over time is steeper in the older age group, possibly due to decreased patient survival. These findings could be validated further in larger multi-center studies.

Prehabilitation in Adult Solid Organ Transplant Candidates

Purpose of Review

To highlight the importance of biological age in the context of prehabilitation and to present relevant research regarding prehabilitation prior to solid organ transplantation.

Recent Findings

Studies on the effect of prehabilitation have been performed in kidney-, lung-, liver-, and heart transplant patient populations. Prior to kidney transplantation, exercise interventions have been shown to improve cardiopulmonary- and physical fitness and result in a decreased length of hospital stay postoperatively. Among lung transplant candidates, various methods of prehabilitation have been studied including home-based, outpatient and in-patient programs, consisting of physical training, psychological support, education, and nutritional interventions. Overall, prehabilitation seems to improve or maintain quality of life and exercise capacity in this patient population. Patients undergoing liver transplantation seem to benefit from prehabilitation as well. Not only does it seem safe and feasible, but significant improvements in aerobic and functional capacity have also been found. Regarding heart transplant candidates, both inpatient and outpatient, supervised prehabilitation programs show promising results with improvements in exercise capacities and quality of life.

Summary

Prehabilitation is an effective and safe intervention for improving functional outcomes of solid organ transplant patients. Future studies should evaluate whether prehabilitation translates into improved pre- and post-transplant clinical outcomes.

Utility of geriatric assessments in evaluation of older adults for kidney transplantation

BACKGROUND

While kidney transplantation has favorable outcomes in patients aged 65 years and older, many are not referred for evaluation despite having no contraindications. We wanted to determine whether incorporating geriatrics and geriatric assessments (GA), as part of kidney transplant evaluation at the University of Chicago Medicine, would help identify suitable candidates and improve transplantation outcomes among older adults.

METHODS

Between 2012 and 2016, as part of their multi-disciplinary transplant evaluation, 171 patients underwent an initial GA with the study geriatrician, who rated them on a five-point scale from "poor" to "excellent," and presented their cases to multidisciplinary transplant review meetings. Patients were followed until June 1st, 2021. Predictor variables included geriatric recommendation, clinical characteristics, and demographics. Outcomes of interest were mortality, receipt of transplant, and waitlist placement.

RESULTS

Compared to patients rated "poor," "marginal," or "fair," we found that patients that the geriatrician recommended as "good" or "excellent" were more likely to be waitlisted and receive a transplant. Favorably rated patients were also less likely to be removed from the waitlist due to becoming medically unfit, meaning worsening medical morbidity, frailty, and cognitive status.

CONCLUSION

Including geriatricians to perform GAs as part of the transplant evaluation process can help identify suitable elderly candidates.

Exploring Transplant Medication-Taking Behaviours in Older Adult Kidney Transplant Recipients: A Qualitative Study of Semi-Structured Interviews

Background

Today, older adult patients routinely undergo kidney transplantation. To support graft survival, patients must take immunosuppressant medicines for the rest of their lives. The post-transplant medication regimen is complex, and barriers to medication taking are likely confounded by both functional and intrinsic changes associated with advancing age. To develop diverse and innovative approaches to support best health outcomes in this vulnerable age group, it is imperative that the degree to which patients’ needs are currently being met, be identified.

Aim

The aim of this study was to examine medication-taking behaviours of kidney transplant recipients transplanted at 60 years of age or older.

Methods

This qualitative study used semi-structured patient interviews to explore how kidney transplant recipients currently manage their immunosuppressant regimen and how they cope after transplantation with the complex routine. Data were themed using the principles of Grounded Theory methodology; with interviews conducted until data saturation was reached.

Results

Quantitative information was collected from 14 participants who ranged in age from 66 to 77 years (at time of interview), and were prescribed a median of 13 (min: 10, max: 26) medicines. The main themes that emerged from the interview were variability in health literacy toward medicines, the importance of support networks, the need to adjust health expectations, factors that were motivators for self-care, different approaches to medication management, and different approaches to medication taking. Overall, it was found that patients prioritised medication taking above all else, and gratitude to their donor was a powerful motivator to adhere. However, strategies to support medication taking were sometimes ineffective when patients’ routine changed.

Conclusions

Future interventions should consider approaches to foster adaptable medication taking behaviours that stand up to changes in the day-to-day routine.

Medication taking is complicated in transplant recipients, due to the number of medicines that need to be taken and the complex nature of the treatment regimen. Challenges in older transplant recipients may be more pronounced and varied compared with younger adults. There are multiple factors that may impact medication taking in older adults and each requires consideration, including level of dependence, living arrangements, level of mobility and manual dexterity, vision and memory, and social situation. To better identify the gaps in support, patients’ current perspectives around medication taking and how they cope after transplantation must be explored. Therefore, this study aimed to identify how older adult transplant recipients currently manage their anti-rejection medicine regimen. Participants described several strategies around how they manage a complex medication regimen. These included cues such as an alarm and linking the time they should take their medication to already established habits such as eating meals. Most participants discussed at length their relationships, and it seems that these relationships are often crucial to post-transplant positivity. Additionally, extreme gratitude to the donor, relative improvement in their life quality (compared with the rapid deterioration in their health when on dialysis), and fear of consequences (particularly graft failure) were important facilitators of self-care and served as timely reminders to prioritise one’s own health. To foster more robust medication-taking habits, future education needs to be tailored to each individual patient and include details about how to link medication taking to already established routines (coined ‘habit stacking’).

Risk factors for graft loss and death among kidney transplant recipients: A competing risk analysis

INTRODUCTION

Kidney transplantation is the best therapeutical option for CKD patients. Graft loss risk factors are usually estimated with the cox method. Competing risk analysis could be useful to determine the impact of different events affecting graft survival, the occurrence of an outcome of interest can be precluded by another. We aimed to determine the risk factors for graft loss in the presence of mortality as a competing event.

METHODS

A retrospective cohort of 1454 kidney transplant recipients who were transplanted between July 1, 2008, to May 31, 2019, in Colombiana de Trasplantes, were analyzed to determine risk factors of graft loss and mortality at 5 years post-transplantation. Kidney and patient survival probabilities were estimated by the competing risk analysis. The Fine and Gray method was used to fit a multivariable model for each outcome. Three variable selection methods were compared, and the bootstrapping technique was used for internal validation as split method for resample. The performance of the final model was assessed calculating the prediction error, brier score, c-index and calibration plot.

RESULTS

Graft loss occurred in 169 patients (11.6%) and death in 137 (9.4%). Cumulative incidence for graft loss and death was 15.8% and 13.8% respectively. In a multivariable analysis, we found that BKV nephropathy, serum creatinine and increased number of renal biopsies were significant risk factors for graft loss. On the other hand, recipient age, acute cellular rejection, CMV disease were risk factors for death, and recipients with living donor had better survival compared to deceased-donor transplant and coronary stent. The c-index were 0.6 and 0.72 for graft loss and death model respectively.

CONCLUSION

We developed two prediction models for graft loss and death 5 years post-transplantation by a unique transplant program in Colombia. Using a competing risk multivariable analysis, we were able to identify 3 significant risk factors for graft loss and 5 significant risk factors for death. This contributes to have a better understanding of risk factors for graft loss in a Latin-American population. The predictive performance of the models was mild.

Defining the ethical considerations surrounding kidney transplantation for frail and cognitively impaired patients: a Delphi study of geriatric transplant experts

Background

Among adult kidney transplant (KT) candidates, 21% are frail and 55% have cognitive impairment, increasing the risk of pre- and post-KT mortality. Centers often assess frailty status and cognitive function during transplant evaluation to help identify appropriate candidate. Yet, there are no ethical guidelines regarding the use of frailty and cognitive function during this evaluation. We seek to develop a clinical consensus on balancing utility and justice in access to KT for frail and cognitively impaired patients.

Methods

Twenty-seven experts caring for ESRD patients completed a two-round Delphi panel designed to facilitate consensus (> 80% agreement).

Results

Experts believed that denying patients transplantation based solely on expected patient survival was inequitable to frail or cognitively impaired candidates; 100% agreed that frailty and cognitive impairment are important factors to consider during KT evaluation. There was consensus that health related quality of life and social support are important to consider before waitlisting frail or cognitively impaired patients. Experts identified important factors to consider before waitlisting frail (likely to benefit from KT, frailty reversibility, age, and medical contraindications) and cognitively impaired (degree of impairment and medication adherence) patients.

Conclusions

Clinical experts believed it was ethically unacceptable to allocate organs solely based on patients’ expected survival; frailty and cognitive impairment should be measured at evaluation when weighed against other clinical factors. Ethical guidelines regarding the use of frailty and cognitive function during KT evaluation ought to be developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03209-x.

Quality indicators in hemodialysis: A 5-year experience of national campaigns in France

BACKGROUND

End stage kidney disease (ESKD) is associated with increased morbidity and mortality. Hemodialysis (HD) is the main technique used for kidney replacement therapy. Dialyzed patients are expected to live less than one half as long as their counterparts without ESKD. Improving quality of care may help to improve mortality in this population.

METHODS

The French National Authority for Health has carried out three consecutive national campaigns over 5 years for the assessment of quality indicators (QCI) during HD. QCI included anemia management, iron status evaluation, nutritional status assessment, and annual transplantation access.

RESULTS

From 2013 to 2017, 227 health facilities participated, and 33,319 files were analyzed. Median age was 72 years old (IQR_25-75  = 61-81), and 58.25% of patients were men. Median time in HD was 39.4 months (IQR_25-75  = 20.7-72.7). Most of the patients underwent in-center HD (85.41%). Overweight and obese patients accounted, respectively, for 28.39% and 21.32%, and malnutrition was present in 38.61%. A contra-indication for renal transplantation was found in 68.3% of patients. All QCI improved over 5 years.

CONCLUSION

Developing QCI based on guidelines is crucial to assure appropriate care of HD patients. Repeating campaigns over 5 years in France improves the quality of care among physicians.

The use of polytetrafluoroethylene graft for damaged renal artery in ABO-incompatible living donor kidney transplantation: a case report

Short donor renal vessels during donor nephrectomy represent a technical challenge. The allograft of vessels from deceased donors can be an option for reconstruction; however, cryopreserved vessels are not routinely prepared for living donor kidney transplantation (LDKT). We report a reconstruction of the damaged short renal artery (RA) in LDKT using a polytetrafluoroethylene (PTFE) graft. A 45-year-old male patient underwent ABO-incompatible LDKT from his wife. After donor nephrectomy, we detected a hematoma surrounding the proximal RA of the allograft. The injured segment of the RA was transected, and the short RA was connected to the right external artery of the recipient; however, the blood flow was interrupted by the graft location. Once the arterial anastomosis was removed, the graft was flushed with cold saline, and a PTFE graft was used for the reconstruction of the short RA. Immediate blood flow to the renal graft was excellent without sign of parenchymal infarction until fascial closure. Renal graft Doppler on postoperative day 7 and 3 months showed good blood flow. In this patient, the use of PTFE graft presented no additional morbidity to the kidney transplantation, and no postoperative complications related to its use were noted.

Desenlaces a largo plazo en pacientes trasplantados renales con donantes de criterios expandidos: experiencia de 10 años

Introducción. El trasplante renal es el tratamiento de elección para la enfermedad renal crónica. Debido a la brecha con la disponibilidad de donantes, el uso de criterios expandidos es una opción que busca mejorar la tasa de donación mundial. El objetivo de este estudio fue comparar la sobrevida del injerto y del paciente trasplantado con donante de criterios expandidos versus el donante estándar. Métodos. Cohorte retrospectiva de 1002 pacientes con trasplante renal donde se determinó la sobrevida del injerto renal y del receptor a 10 años después del trasplante. La sobrevida del injerto renal y el receptor fueron estimadas por el método de Kaplan-Meier. Una regresión de Cox fue realizada ajustando el modelo multivariado. Resultados. El análisis incluyó 1002 receptores, con un 18,8 % (n=189) que correspondían al uso de donante de criterios expandidos. El grupo de trasplante renal con donante de criterios expandidos tuvo menor sobrevida del paciente (48,1 % versus 63,8 %) y del injerto (63,3 % versus 74,7 %) en comparación con el grupo de trasplante renal con donantes con criterios estándar a los 10 años después del trasplante. La asociación de trasplante renal con donante de criterios expandidos y muerte o pérdida del injerto renal no fueron significativas cuando se ajustaron las variables en el modelo multivariado. Conclusión. El trasplante renal con donante de criterios expandidos tiene menor sobrevida del receptor y del injerto frente al grupo de trasplante renal con donante estándar. No hubo diferencias estadísticamente significativas en cuanto al trasplante renal con donante de criterios expandidos frente a la pérdida del injerto renal o muerte.

Suggested Patient Selection Criteria for Initial Clinical Trials of Pig Kidney Xenotransplantation in the United States

There is a critical shortage of kidneys for transplantation into patients with kidney failure. Genetically-engineered pigs could provide an additional source. Increasing success is being reported of the transplantation of pig kidneys in nonhuman primates. Consideration is now being given to the selection of patients for the first clinical trial of pig kidney transplantation. In some US states, patients aged 55–65, particularly if of blood group O, may wait >5 years for a donor organ, by which time >50% are likely to have died or removed from the wait-list because they are no longer acceptable for transplantation. We suggest these patients, if otherwise healthy, might accept the opportunity of early pig kidney transplantation.

Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication

Peripheral vascular disease (PVD) is highly prevalent in patients on the waiting list for kidney transplantation (KT) and after transplantation and is associated with impaired transplant outcomes. Multiple traditional and nontraditional risk factors, as well as uremia- and transplant-related factors, affect 2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD. Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD. Early detection of PVD before and after KT, better understanding of the mechanisms of vascular damage, and application of suitable therapeutic approaches could all minimize the impact of PVD on transplant outcomes. This review focuses on the following issues: (1) definition, epidemiological data, diagnosis, risk factors, and pathogenic mechanisms in KT candidates and recipients; (2) adverse clinical consequences and outcomes; and (3) classical and new therapeutic approaches.

Expanding the Deceased Donor Pool in Manitoba Using Hepatitis C-Viremic Donors: Program Report

Purpose of program:

The ongoing shortage of organs for transplant combined with Manitoba having the highest prevalence of end-stage renal disease (ESRD) in Canada has resulted in long wait times on the deceased donor waitlist. Therefore, the Transplant Manitoba Adult Kidney Program has ongoing quality improvement initiatives to expand the deceased donor pool. This clinical transplant protocol describes the use of prophylactic pan-genotypic direct-acting anti-viral agents (DAA) for transplanting hepatitis C (HCV)-viremic kidneys (HCV antibody positive/nucleic acid [nucleic acid amplification testing, NAT] positive) to HCV-naïve recipients as routine standard of care. We will evaluate the provincial implementation of this protocol as a prospective observational cohort study.

Sources of information:

Scoping literature review and key stakeholder engagement with interdisciplinary health care providers and health system leaders/decision markers.

Methods:

Patients will be screened pre-transplant for eligibility and undergo a multilevel education and consent process to participate in this expanded donor program. Incident adult HCV-naïve recipients of an HCV-viremic kidney transplant will be treated prophylactically with glecaprevir-pibrentasvir with the first dose administered on call to the operation. Glecaprevir-pibrentasvir will be used for 8 weeks with viral monitoring and hepatology follow-up. Primary outcomes are sustained virologic response (SVR) at 12 weeks and the tolerability of DAA therapy. Secondary outcomes within the first year post-transplant are patient and graft survival, graft function, biopsy-proven rejection, HCV transmission to recipient (HCV NAT positive), and HCV nonstructural protein 5A (NS5A) resistance. Safety outcomes within the first year post-transplant include fibrosing cholestatic hepatitis, acute liver failure, primary and secondary DAA treatment failure, HCV transmission to a recipient’s partner, elevated liver enzymes ≥2-fold, abnormal international normalized ratio (INR), angioedema, anaphylaxis, cirrhosis, and hepatocellular carcinoma.

Key findings:

This program successfully advocated for and obtained hospital formulary, provincial Exceptional Drug Status (EDS), and Non-Insured Health Benefits (NIHB) to provide prophylactic DAA therapy for this indication, and this information may be useful to other provincial transplant organizations seeking to establish an HCV-viremic kidney transplant program with prophylactic DAA drug coverage.

Limitations:

(1) Patient engagement was not undertaken during the program design phase, but patient-reported experience measures will be obtained for continuous quality improvement. (2) Only standard criteria donors (optimal kidney donor profile index [KDPI] ≤60) will be used. If this approach is safe and feasible, then higher KDPI donors may be included.

Implications:

The goal of this quality improvement project is to improve access to kidney transplantation for Manitobans. This program will provide prophylactic DAA therapy for HCV-viremic kidney transplant to HCV-naïve recipients as routine standard of care outside a clinical trial protocol. We anticipate this program will be a safe and effective way to expand kidney transplantation from a previously unutilized donor pool.

Kidney transplantation from living donor with monolateral renal artery fibromuscular dysplasia using a cryopreserved iliac graft for arterial reconstruction: a case report and review of the literature

Background

Aging and mortality of patients on waiting lists for kidney transplantation have increased, as a result of the shortage of organs available all over the world. Living donor grafts represent a significant source to maintain the donor pool, and resorting successfully to allografts with arterial disease has become a necessity. The incidence of renal artery fibromuscular dysplasia (FMD) in potential living renal donors is reported to be 2–6%, and up to 4% of them present concurrent extra-renal involvement.

Case presentation

We present a case of renal transplantation using a kidney from a living donor with monolateral FMD. Resection of the affected arterial segment and its subsequent replacement with a cryopreserved iliac artery graft from a deceased donor were performed. No intraoperative nor post-operative complications were reported. The allograft function promptly resumed, with satisfying creatinine clearance, and adequate patency of the vascular anastomoses was detected by Doppler ultrasounds.

Conclusion

Literature lacks clear guidelines on the eligibility of potential living renal donors with asymptomatic FMD. Preliminary assessment of the FMD living donor should always rule out any extra-renal involvement. Whenever possible, resection and reconstruction of the affected arterial segment should be taken into consideration as this condition may progress after implantation.

Logistic Regression Model in a Machine Learning Application to Predict Elderly Kidney Transplant Recipients with Worse Renal Function One Year after Kidney Transplant: Elderly KTbot

Background

Renal replacement therapy (RRT) is a public health problem worldwide. Kidney transplantation (KT) is the best treatment for elderly patients' longevity and quality of life.

Objectives

The primary endpoint was to compare elderly versus younger KT recipients by analyzing the risk covariables involved in worsening renal function, proteinuria, graft loss, and death one year after KT. The secondary endpoint was to create a robot based on logistic regression capable of predicting the likelihood that elderly recipients will develop worse renal function one year after KT.

Method

Unicentric retrospective analysis of a cohort was performed with individuals aged ≥60 and <60 years old. We analysed medical records of KT recipients from January to December 2017, with a follow-up time of one year after KT. We used multivariable logistic regression to estimate odds ratios for elderly vs younger recipients, controlled for demographic, clinical, laboratory, data pre- and post-KT, and death.

Results

18 elderly and 100 younger KT recipients were included. Pretransplant immune variables were similar between two groups. No significant differences (P > 0.05) between groups were observed after KT on laboratory data means and for the prevalences of diabetes mellitus, hypertension, acute rejection, cytomegalovirus, polyomavirus, and urinary infections. One year after KT, the creatinine clearance was higher (P = 0.006) in youngers (70.9 ± 25.2 mL/min/1.73 m²) versus elderlies (53.3 ± 21.1 mL/min/1.73 m²). There was no difference in death outcome comparison. Multivariable analysis among covariables predisposing chronic kidney disease epidemiology collaboration (CKD-EPI) equation <60 mL/min/1.73 m² presented a statistical significance for age ≥60 years (P = 0.01) and reduction in serum haemoglobin (P = 0.03). The model presented goodness-fit in the evaluation of artificial intelligence metrics (precision: 90%; sensitivity: 71%; and F ₁ score: 0.79).

Conclusion

Renal function in elderly KT recipients was lower than in younger KT recipients. However, patients aged ≥60 years maintained enough renal function to remain off dialysis. Moreover, a learning machine application built a robot (Elderly KTbot) to predict in the elderly populations the likelihood of worse renal function one year after KT.

Outcomes of Patients Suspended From the National Kidney Transplant Waiting List in the United Kingdom Between 2000 and 2010

BACKGROUND

In the United Kingdom, 1 in 3 patients on the National Kidney Transplant Waiting List (NKTWL) is suspended from the list at least once during their wait. The mortality of this large cohort of patients remains underreported and poorly described.

METHODS

We linked patient records from the UK transplant registry to mortality data from the Office of National Statistics and evaluated the impact of a clinically induced suspension event by estimating hazard ratios (HRs) that compared mortality and graft survival between those who had experienced a suspension event and those who had not.

RESULTS

Between January 1, 2000, and December 31, 2010, 16.7% (2221/13 322) of all patients registered on the NKTWL were suspended. Forty-eight percent (588/1225) of those who were suspended and who were never transplanted died, most often from cardiothoracic causes. A suspension event was associated with increased mortality from the time of listing (adjusted HR [aHR], 1.79; 1.64-1.95) and from the time of transplantation (aHR, 1.20; 1.06-1.37; P = 0.005). Graft survival was also poorer in those who had been suspended (aHR, 1.13; 1.01-1.28; P = 0.04).

CONCLUSIONS

Patients suspended on the NKTWL have a significantly higher rate of mortality both on the waiting list and following transplantation. Earlier prioritization of patients at risk of experiencing a suspension event may improve their outcomes.

[Waiting list management]

Listing a patient on the Eurotransplant waiting list for a kidney transplantation obliges transplant centers to ensure that an allocated organ can also be transplanted, as long as there are no acute recipient-specific medical or personal contraindications. Assessing the ability for transplantation over a period of up to 10 years between initiation of dialysis and an organ offer represents a major challenge in manpower and logistic efforts. The present article reviews specific aspects regarding waiting list management on the basis of current guideline recommendations and literature data.

Waiting List and Kidney Transplant Vascular Risk: An Ongoing Unmet Concern

BACKGROUND

Chronic kidney disease (CKD) is an important independent risk factor for adverse cardiovascular events in patients waitlisted for kidney transplantation (KT). Although KT reduces cardiovascular risk, these patients still have a higher all-cause and cardiovascular mortality than the general population. This concerning situation is due to a high burden of traditional and nontraditional risk factors as well as uremia-related factors and transplant-specific factors, leading to 2 differentiated processes under the framework of CKD, atherosclerosis and arteriosclerosis. These can be initiated by insults to the vascular endothelial endothelium, leading to vascular calcification (VC) of the tunica media or the tunica intima, which may coexist. Several pathogenic mechanisms such as inflammation-related endothelial dysfunction, mineral metabolism disorders, activation of the renin-angiotensin system, reduction of nitric oxide, lipid disorders, and the fibroblast growth factor 23-klotho axis are involved in the pathogenesis of atherosclerosis and arteriosclerosis, including VC.

SUMMARY

This review focuses on the current understanding of atherosclerosis and arteriosclerosis, both in patients on the waiting list as well as in kidney transplant recipients, emphasizing the cardiovascular risk factors in both populations and the inflammation-related pathogenic mechanisms. Key Message: The importance of cardiovascular risk factors and the pathogenic mechanisms related to inflammation in patients waitlisted for KT and kidney transplant recipients.

Long-Term Outcomes among Kidney Transplant Recipients and after Graft Failure: A Single-Center Cohort Study in Brazil

Background

The results of kidney transplantation are impacted by the categories of events responsible for patient death and graft failure. The objective of this study was to evaluate the causes of death and graft failure and outcomes after graft failure among kidney transplant recipients.

Methodology

A retrospective cohort study was conducted with 944 patients who underwent kidney transplantation. Outcomes were categorized in a managed and hierarchical manner.

Results

The crude mortality rate was 10.8% (n=102): in 35.3% cause of death was infection, in 30.4% cardiovascular disease, and in 15.7% neoplasia and in 6.8%, it was not possible to determine the cause of death. The rate of graft loss was 10.6%. The main causes of graft failure were chronic rejection (40%), acute rejection (18.3%), thrombosis (17.3%), and recurrence of primary disease (16.5%). Failures due to an acute rejection occurred earlier than those due to chronic rejection and recurrence (p<0.0001). As late causes of graft loss, death with the functioning kidney occurred earlier than recurrence and chronic rejection (p=0.008). The outcomes after graft failure were retransplantation in 26.1% and death in 21.4%, at a mean of 25.5 and 21.4 months, respectively.

Conclusion

It was possible to identify more than 90% of the events responsible for the deaths of transplanted patients, predominantly infectious and cardiovascular diseases. Among the causes of graft failure, chronic and acute rejections and recurrence were the main causes of graft failure which were followed more frequently by retransplantation than by death on dialysis.

Kidney transplant registries: How to optimise their utility?

The scientific Registries (RE) in renal transplantation (Tx) are very useful since they allow us to identify risk factors in this population and facilitate contrasting the information with other national and international registries, contributing to establishing strategies which improve outcomes in terms of survival. They constitute an organised and planned system that uses observational methods and standardised systematic processes, including adjusted risk models, to essentially evaluate survival outcomes. The scientific RE are complemented with clinical trials providing scientific evidence, but inexcusably need adequate statistical analysis to generate reliable clinical data that contribute to optimising the prognosis of the transplant population. In addition, scientific RE provide valuable information on the performance of Tx programmes and help generate prognostic indexes, which could contribute to improving survival. Under these prerequisites, this review will assess the following aspects related to the scientific RE in the Tx: 1) the concept and importance of implementing RE in Tx; 2) the measures that are needed for the correct execution of the scientific RE; 3) the benefits, quality and limitations of RE; 4) the statistical tools for the adequate analysis of survival; and 5) utility of RE in the evaluation of performance, quality and surveillance of transplant programmes and the generation of comorbidity índices.

Impact of Physical Function on 1-Year Kidney Transplant Outcomes

End-stage renal disease patients who have impaired physical function are denied for transplantation by clinicians concerned about graft/survival outcomes. The purpose of this study was to determine the impact of physical function on graft/survival outcomes at 1-year post-kidney transplantation. Data were analyzed from the Scientific Registry of Transplant Recipients regarding kidney transplantation patients (N = 218,657) between January 1, 2000 and September 2, 2014. The hazard ratio of 1-year graft failure for deceased donor transplantation recipients needing total assistance was 1.60 (95% confidence interval [CI] = [1.303, 1.965], p < .01). Patients needing none or some assistance did not demonstrate a significant difference in 1-year graft failure in either deceased or living donor transplantation. The hazard ratio of 1-year death for those needing total assistance was 2.52 (95% CI = [2.087, 3.045], p < .001) in deceased donor kidney transplantation.

Single-center analysis of infectious complications in older adults during the first year after kidney transplantation

Infections are among the top three causes of death of older adults in the first year after kidney transplantation (KT). Our aim was to describe infectious complications among KT recipients aged ≥ 65 during the first 12 months post-transplant. Single-center retrospective cohort study. Ninety-one KTs had been performed in patients ≥ 65 years of age between 2011 and 2015. 92.3% of the patients developed at least one infection. Infectious episodes increased the risk of future infection by 10% (p = 0.0018) with each infection portending a greater risk. At a patient level, viral (71.4%) and bacterial (70.2%) infections predominated. Urinary tract infections were the most frequent complication (30.3%), followed by cytomegalovirus infections (22.7%). Infections were the main reason for readmission. 7.7% of the patients developed rejection; and overall 3.3% lost their graft. Mortality at 1 year was 9.9%. Older KT recipients have a high incidence of infectious complications the first year after KT. Infections were the number one reason for readmission, and an infection episode predicted future infections for the individual patient. Despite these complications, the majority of older KT recipients were alive with a functioning graft at 1 year.