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Wiseman A, Alhamad T, Alloway RR, Concepcion BP, Cooper M, Formica R, Klein CL, Kumar V, Leca N, Shihab F, Taber DJ, Mulnick S, Bushnell DM, Hadi M, Bunnapradist S. Use of LCP-Tacrolimus (LCPT) in Kidney Transplantation: A Delphi Consensus Survey of Expert Clinicians. Ann Transplant 2024; 29:e943498. [PMID: 38526543 PMCID: PMC10944009 DOI: 10.12659/aot.943498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/06/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND LCPT (Envarsus XR®) is a common once-daily, extended-release oral tacrolimus formulation used in kidney transplantation. However, there are minimal evidence-based recommendations regarding optimal dosing and treatment in the de novo and conversion settings. MATERIAL AND METHODS Using Delphi methodology, 12 kidney transplantation experts with LCPT experience reviewed available data to determine potential consensus topics. Key statements regarding LCPT use were generated and disseminated to the panel in an online Delphi survey. Statements were either accepted, revised, or rejected based on the level of consensus, perceived strength of evidence, and alignment with clinical practice. Consensus was defined a priori as ≥75% agreement. RESULTS Twenty-three statements were generated: 14 focused on de novo LCPT use and 9 on general administration or LCPT conversion use. After 2 rounds, consensus was achieved for 11/14 of the former and 7/9 of the latter statements. In a de novo setting, LCPT was recognized as a first-line option based on its safety and efficacy compared to immediate-release tacrolimus. In particular, African Americans and rapid metabolizer populations were identified as preferred for first-line LCPT therapy. In a conversion setting, full consensus was achieved for converting to LCPT to address neurological adverse effects related to immediate-release tacrolimus and for the time required (approximately 7 days) for steady-state LCPT trough levels to be reached. CONCLUSIONS When randomized clinical trials do not replicate current utilization patterns, the Delphi process can successfully generate consensus statements by expert clinicians to inform clinical decision-making for the use of LCPT in kidney transplant recipients.
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Affiliation(s)
- Alexander Wiseman
- AdventHealth Transplant Institute, Porter Adventist Hospital, Denver, CO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA
| | - Rita R. Alloway
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Matthew Cooper
- Transplant Center – Center for Advanced Care – Froedtert Hospital, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard Formica
- Yale New Haven Transplantation Center, Yale University School of Medicine, New Haven, CT, USA
| | - Christina L. Klein
- Department of Transplant Nephrology, Piedmont Transplant Institute, Atlanta, GA, USA
| | - Vineeta Kumar
- Renal Transplant Program, University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Nicolae Leca
- Kidney Care and Transplantation Services, University of Washington, Seattle, WA, USA
| | - Fuad Shihab
- Kidney and Liver Clinic, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - David J. Taber
- Transplant Immunobiology Laboratory, Medical University of South Carolina, Charleston, SC, USA
| | - Sarah Mulnick
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | | | - Monica Hadi
- Patient-Centered Research, Evidera, London, United Kingdom
| | - Suphamai Bunnapradist
- Division of Nephrology and Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
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Bestard O, Augustine J, Wee A, Poggio E, Mannon RB, Ansari MJ, Bhati C, Maluf D, Benken S, Leca N, La Manna G, Samaniego-Picota M, Shawar S, Concepcion BP, Rostaing L, Alberici F, O'Connell P, Chang A, Salem F, Kattan MW, Gallon L, Donovan MJ. Prospective observational study to validate a next-generation sequencing blood RNA signature to predict early kidney transplant rejection. Am J Transplant 2024; 24:436-447. [PMID: 38152017 DOI: 10.1016/j.ajt.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/20/2023] [Accepted: 09/30/2023] [Indexed: 12/29/2023]
Abstract
The objective of this study was to validate the performance of Tutivia, a peripheral blood gene expression signature, in predicting early acute rejection (AR) post-kidney transplant. Recipients of living or deceased donor kidney transplants were enrolled in a nonrandomized, prospective, global, and observational study (NCT04727788). The main outcome was validation of the area under the curve (AUC) of Tutivia vs serum creatinine at biopsy alone, or Tutivia + serum creatinine at biopsy. Of the 151 kidney transplant recipients, the mean cohort age was 53 years old, and 64% were male. There were 71% (107/151) surveillance/protocol biopsies and 29% (44/151) for-cause biopsies, with a 31% (47/151) overall rejection rate. Tutivia (AUC 0.69 [95% CI: 0.59-0.77]) and AUC of Tutivia + creatinine at biopsy (0.68 [95% CI: 0.59-0.77]) were greater than the AUC of creatinine at biopsy alone (0.51.4 [95% CI: 0.43-0.60]). Applying a model cut-off of 50 (scale 0-100) generated a high- and low-risk category for AR with a negative predictive value of 0.79 (95% CI: 0.71-0.86), a positive predictive value of 0.60 (95% CI: 0.45-0.74), and an odds ratio of 5.74 (95% CI: 2.63-12.54). Tutivia represents a validated noninvasive approach for clinicians to accurately predict early AR, beyond the current standard of care.
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Affiliation(s)
- Oriol Bestard
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Alvin Wee
- Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | | | | | - Daniel Maluf
- University of Maryland, Baltimore, Maryland, USA
| | - Scott Benken
- University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nicolae Leca
- University of Washington, Seattle, Washington, USA
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | - Saed Shawar
- Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | | | | | - Fadi Salem
- Mayo Medical, Jacksonville, Florida, USA
| | | | - Lorenzo Gallon
- Northwestern University, Evanston, Illinois, USA; Verici Dx, Franklin, Tennessee, USA.
| | - Michael J Donovan
- Verici Dx, Franklin, Tennessee, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Singh N, Anand PM, Gupta G, Sawinski D, Fix O, Adey D, Akalin E, Zayas C, Dadhania D, Doshi M, Cibrik D, Gupta M, Parsons R, Leca N, Santos RD, Concepcion BP, Nishio Lucar AG, Ong S, Sridhar VS, Parajuli S, Zachariah M, Mehta S, Soliman K, Shawar S, Husain SA, Preczewski L, Friedewald J, Mohan S, Wiseman A, Samaniego M, Kumar V, Tanriover B, Bloom R. Should Transplant Nephrology pursue recognition from the Accreditation Council for Graduate Medical Education (ACGME)? Clin J Am Soc Nephrol 2024:01277230-990000000-00352. [PMID: 38319649 DOI: 10.2215/cjn.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024]
Abstract
Kidney transplant is not only the best treatment for patients with advanced kidney disease, but it also reduces health-care expenditure. The management of transplant patients is complex as they require special care by transplant nephrologists who have expertise in assessing transplant candidates, understand immunology and organ rejection, have familiarity with peri-operative complications, and have the ability to manage the long-term effects of chronic immunosuppression. This skill set at the intersection of multiple disciplines necessitates additional training in Transplant Nephrology. Currently, there are more than 250,000 patients with a functioning kidney allograft and over 100,000 waitlisted patients awaiting kidney transplant, with a burgeoning number added to the kidney transplant wait list every year. In 2022, more than 40,000 patients were added to the kidney wait list and more than 25,000 received a kidney transplant. The Advancing American Kidney Health Initiative (AAKHI), passed in 2019, is aiming to double the number of kidney transplants by 2030 creating a need for additional transplant nephrologists to help care for them. Over the last decade there has been a decline in the Nephrology- as well Transplant Nephrology- workforce due to a multitude of reasons. The American Society of Transplantation (AST) Kidney Pancreas Community of Practice (KPCOP) created a workgroup to discuss the Transplant Nephrology workforce shortage. In this paper, we discuss the scope of the problem and how ACGME accreditation of Transplant Nephrology Fellowship could at least partly mitigate the Transplant Nephrology work-force crisis.
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Affiliation(s)
| | - Prince M Anand
- Medical University of South Carolina, Lancaster Medical Center, Lancaster, SC
| | | | - Deirdre Sawinski
- Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY
| | - Oren Fix
- University of North Carolina, Chapel Hill, NC
| | - Deborah Adey
- University of California San Francisco, San Francisco, CA
| | | | | | - Darshana Dadhania
- Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY
| | | | | | | | | | | | | | | | | | - Song Ong
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Shikha Mehta
- University of Alabama at Birmingham, Birmingham, AL
| | - Karim Soliman
- Medical University of South Carolina, Charleston, SC
- Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Saed Shawar
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | | | | | | | | | - Bekir Tanriover
- University of Arizona, College of Medicine-Tucson, Tucson, AZ
| | - Roy Bloom
- University of Pennsylvania, Philadelphia, PA
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Murakami N, Reich AJ, He K, Gelfand SL, Leiter RE, Sciacca K, Adler JT, Lu E, Ong SC, Concepcion BP, Singh N, Murad H, Anand P, Ramer SJ, Dadhania DM, Lentine KL, Lakin JR, Alhamad T. Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study. Am J Kidney Dis 2024; 83:173-182.e1. [PMID: 37726050 DOI: 10.1053/j.ajkd.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/03/2023] [Accepted: 07/09/2023] [Indexed: 09/21/2023]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population. STUDY DESIGN National explanatory sequential mixed methods study including an online survey and semistructured interviews. SETTING & PARTICIPANTS Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022. ANALYTICAL APPROACH Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data. RESULTS A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care. LIMITATIONS Potential selection bias. CONCLUSIONS Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them. PLAIN-LANGUAGE SUMMARY Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine He
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samantha L Gelfand
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joel T Adler
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Emily Lu
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Song C Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | - Haris Murad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Prince Anand
- Medical University of South Carolina, Greenville, South Carolina
| | | | | | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St Louis, Missouri
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri.
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Binari LA, Thorne P, Rega SA, Feurer ID, Shawar S, Naik R, Birdwell KA, Helderman JH, Langone A, Sarrell BA, Schaefer H, DuBray BJ, Eid K, Hickman L, Shaffer D, Concepcion BP, Forbes RC. Twelve-month kidney and liver outcomes of kidney transplantation from Hepatitis C Viremic deceased donors to aviremic recipients. Transpl Infect Dis 2024; 26:e14213. [PMID: 38112078 PMCID: PMC10922352 DOI: 10.1111/tid.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Utilization of hepatitis C viremic (HCV+) deceased donor kidneys (DDKT) for aviremic recipients increases opportunities for transplantation with excellent short-term outcomes. Our primary aim was to understand longer-term outcomes, specifically assessing kidney and liver function in the first year posttransplant. METHODS This was a retrospective single-center study of adult DDKT recipients of HCV+ kidneys (cases) matched 1:1 to recipients of HCV- kidneys (comparators). Between-group outcomes were analyzed using comparisons of means and proportions, survival analysis methods, and multivariable mixed effects models. RESULTS Sixty-five cases and 65 comparators had statistically comparable demographic and clinical characteristics. There were no between-group differences in serum creatinine or estimated glomerular filtration rate at month 12 (p = .662) or in their trajectories over months 1-12 (p > .292). Within the first 60 days, rates of liver function values >3 times upper limit of normal among cases were comparable to comparators for aspartate aminotransferase (AST) (14% vs. 6%, p = .242) and higher for alanine transaminase (ALT) (23% vs. 6%, p = .011). AST declined during the first 8 weeks (p = .005) and stabilized for both groups (p = .406) during the following 10 months. ALT declined during the first 8 weeks (p < .001), continued to decline over months 3-12 (p = .016), and the trajectory was unrelated to antiviral therapy initiation among cases. CONCLUSIONS Aviremic recipients of HCV+ kidneys had comparable kidney outcomes to matched recipients of HCV- kidneys. Despite more HCV+ recipients having an elevation in ALT within the first 60 days, ALT values normalized with no identified liver complications attributed to HCV.
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Affiliation(s)
- Laura A Binari
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter Thorne
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Irene D Feurer
- Department of Surgery, Department of Biostatistics, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Saed Shawar
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ruchi Naik
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kelly A Birdwell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Harold Helderman
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony Langone
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie Ann Sarrell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heidi Schaefer
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bernard John DuBray
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kareem Eid
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura Hickman
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Shaffer
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Casey MJ, Murakami N, Ong S, Adler JT, Singh N, Murad H, Parajuli S, Concepcion BP, Lubetzky M, Pavlakis M, Woodside KJ, Faravardeh A, Basu A, Tantisattamo E, Aala A, Gruessner AC, Dadhania DM, Lentine KL, Cooper M, Parsons RF, Alhamad T. Medical and Surgical Management of the Failed Pancreas Transplant. Transplant Direct 2024; 10:e1543. [PMID: 38094134 PMCID: PMC10715788 DOI: 10.1097/txd.0000000000001543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 02/22/2024] Open
Abstract
Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers.
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Affiliation(s)
- Michael J. Casey
- Division of Nephrology, Medical University of South Carolina, Charleston, SC
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women Hospital, Boston, MA
| | - Song Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Joel T. Adler
- Division of Transplant Surgery, University of Texas at Austin, Austin, TX
| | | | - Haris Murad
- Section of Nephrology, The Aga Khan University, Medical College, Pakistan
| | | | | | | | | | | | | | - Arpita Basu
- Division of Renal Medicine, Emory University, Atlanta, GA
| | | | - Amtul Aala
- Division of Nephrology, Beth Israel Deaconess, Boston, MA
| | | | | | - Krista L. Lentine
- Division of Nephrology, SSM Health Saint Louis University Transplant Center, St. Louis, MO
| | - Matthew Cooper
- Division of Transplant Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ronald F. Parsons
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St Louis, St. Louis, MO
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7
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Forbes RC, Johnson WR, D'Souza N, Dreher A, Rega SA, Feurer ID, Concepcion BP. Disparities in telemedicine utilization among kidney transplant patients during the COVID-19 pandemic: Barriers and opportunities. Clin Transplant 2023; 37:e15136. [PMID: 37715601 DOI: 10.1111/ctr.15136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION The COVID-19 pandemic allowed for the rapid implementation of telemedicine for kidney transplant patients; however, widespread adoption may worsen existing health care inequities among vulnerable populations. This study aimed to characterize telemedicine utilization by kidney transplant patients during the early pandemic with particular attention to healthcare equity. METHODS A retrospective analysis of kidney transplant patients interacting with telemedicine was performed. Patient demographic data and distance to the transplant center were obtained. The National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties and Brokamp Neighborhood Deprivation Index (NDI) score were used to characterize patients' counties of residence. Multivariable logistic regression evaluated associations between patient and community characteristics and the likelihood of an encounter being telemedicine. RESULTS This study included 1033 patients who participated in 3727 encounters from March 11 through October 2020. Characteristics associated with decreased likelihood of telemedicine use were increased age (OR = .993; 95% CI = .986-.999, P = .022), non-White vs. White race (OR = .826, 95% CI = .697-.979; P = .028), male vs. female sex (OR = .746, 95% CI = .632-.880; P < .001), and a higher Brokamp Neighborhood Deprivation Index score (OR = .159; 95% CI = .029-.873; P = .034). The effect of distance to the transplant center on the likelihood of a telemedicine encounter differed by NCHS Urban-Rural designation (interaction P = .018), with its likelihood increasing by 2%-3% with each 10-mile increment among persons residing in medium-, small-, and non-metropolitan counties compared to those residing in the most rural counties. CONCLUSIONS Telemedicine visits were less often completed by patients of older age, non-white race, male sex, and those residing in counties having higher NDI scores. While telemedicine has the potential to improve healthcare access and decrease costs, proactive efforts need to be taken to mitigate disparities in vulnerable populations.
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Affiliation(s)
- Rachel C Forbes
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wali R Johnson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nigel D'Souza
- Mercer University School of Medicine, Macon, Georgia, USA
| | | | - Scott A Rega
- Vanderbilt Transplant Center, Nashville, Tennessee, USA
| | - Irene D Feurer
- Department of Surgery, Department of Biostatistics, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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8
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Long JJ, Motter JD, Jackson KR, Chen J, Orandi BJ, Montgomery RA, Stegall MD, Jordan SC, Benedetti E, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Verbesey JE, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Wellen JR, Bozorgzadeh A, Gaber AO, Heher EC, Weng FL, Djamali A, Helderman JH, Concepcion BP, Brayman KL, Oberholzer J, Kozlowski T, Covarrubias K, Massie AB, McAdams-DeMarco MA, Segev DL, Garonzik-Wang JM. Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients. Am J Transplant 2023; 23:1980-1989. [PMID: 37748554 PMCID: PMC10767749 DOI: 10.1016/j.ajt.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/26/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
Older compatible living donor kidney transplant (CLDKT) recipients have higher mortality and death-censored graft failure (DCGF) compared to younger recipients. These risks may be amplified in older incompatible living donor kidney transplant (ILDKT) recipients who undergo desensitization and intense immunosuppression. In a 25-center cohort of ILDKT recipients transplanted between September 24, 1997, and December 15, 2016, we compared mortality, DCGF, delayed graft function (DGF), acute rejection (AR), and length of stay (LOS) between 234 older (age ≥60 years) and 1172 younger (age 18-59 years) recipients. To investigate whether the impact of age was different for ILDKT recipients compared to 17 542 CLDKT recipients, we used an interaction term to determine whether the relationship between posttransplant outcomes and transplant type (ILDKT vs CLDKT) was modified by age. Overall, older recipients had higher mortality (hazard ratio: 1.632.072.65, P < .001), lower DCGF (hazard ratio: 0.360.530.77, P = .001), and AR (odds ratio: 0.390.540.74, P < .001), and similar DGF (odds ratio: 0.461.032.33, P = .9) and LOS (incidence rate ratio: 0.880.981.10, P = 0.8) compared to younger recipients. The impact of age on mortality (interaction P = .052), DCGF (interaction P = .7), AR interaction P = .2), DGF (interaction P = .9), and LOS (interaction P = .5) were similar in ILDKT and CLDKT recipients. Age alone should not preclude eligibility for ILDKT.
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Affiliation(s)
- Jane J Long
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jennifer D Motter
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Kyle R Jackson
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Jennifer Chen
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Babak J Orandi
- Department of Surgery, University of Alabama, Birmingham, Alabama, USA
| | - Robert A Montgomery
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mark D Stegall
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Stanley C Jordan
- Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, California, USA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois-Chicago, Chicago, Illinois, USA
| | - Ty B Dunn
- Department of Surgery, University of Pennsylvania, Philadelphia, Philadelphia, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Sandip Kapur
- Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, New York, USA
| | - Ronald P Pelletier
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - John P Roberts
- Department of Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Marc L Melcher
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Pooja Singh
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Philadelphia, USA
| | - Debra L Sudan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Marc P Posner
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jose M El-Amm
- Integris Baptist Medical Center, Transplant Division, Oklahoma City, Oklahoma, USA
| | - Ron Shapiro
- Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA
| | - Jennifer E Verbesey
- Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA
| | - George S Lipkowitz
- Department of Surgery, Baystate Medical Center Springfield, Massachusetts, Massachusetts, USA
| | - Michael A Rees
- Department of Urology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Christopher L Marsh
- Department of Surgery, Scripps Clinic and Green Hospital, La Jolla, California, USA
| | | | - David A Gerber
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jason R Wellen
- Department of Surgery, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Adel Bozorgzadeh
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Eliot C Heher
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francis L Weng
- Renal and Pancreas Transplant Division, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - J Harold Helderman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kenneth L Brayman
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jose Oberholzer
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Tomasz Kozlowski
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Karina Covarrubias
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Allan B Massie
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
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9
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Davis AL, Kapp ME, Concepcion BP. Lung Nodule and AKI in a Kidney Transplant Patient. Kidney360 2023; 4:1657-1658. [PMID: 38032768 PMCID: PMC10697473 DOI: 10.34067/kid.0000000000000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Alyssa L. Davis
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan E. Kapp
- Department of Pathology, University Hospitals and Case Western Reserve University, Cleveland, Ohio
| | - Beatrice P. Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
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10
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Shawar S, Concepcion BP. A Gut-Wrenching Infection: Norovirus in a Kidney Transplant Recipient. Clin J Am Soc Nephrol 2023; 18:1231-1233. [PMID: 37382971 PMCID: PMC10564365 DOI: 10.2215/cjn.0000000000000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Saed Shawar
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
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11
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Hernandez A, Concepcion BP. Disseminated histoplasmosis with central nervous system involvement in a kidney transplant recipient. Transpl Infect Dis 2023; 25:e14033. [PMID: 36744781 DOI: 10.1111/tid.14033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/07/2023]
Affiliation(s)
- Antonette Hernandez
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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12
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Cabeza Rivera FH, Concepcion BP, Levea SLL. Chronic Kidney Disease After Liver Transplantation. Adv Kidney Dis Health 2023; 30:368-377. [PMID: 37657883 DOI: 10.1053/j.akdh.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Chronic kidney disease among liver transplant recipients is common and associated with an increased mortality risk. Several risk factors and causes for the development of chronic kidney disease have been identified. They can be divided into perioperative factors, such as unresolved acute kidney injury; donor-related factors, such as the use of extended criteria liver allografts; and recipient-related factors, such as the use of calcineurin inhibitors and the presence of metabolic syndrome, diabetes, and obesity. There is a bimodal progression, more prominent during the initial post-transplant months, followed by a gradual but progressive decline over the subsequent years. Management strategies to prevent and treat chronic kidney disease in the general population can be reasonably applied to the liver transplant population and include addressing comorbidities such as hypertension and diabetes. Strategies to minimize or withdraw calcineurin inhibitors from the immunosuppressive regimen can slow progression of kidney dysfunction. Patients with advanced chronic kidney disease should be considered for kidney transplantation due to its survival advantage. Allocation policy in the United States confers safety-net allocation priority for liver transplant recipients who develop advanced chronic kidney disease within the first year of liver transplantation.
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Affiliation(s)
- Franco H Cabeza Rivera
- Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL
| | | | - Swee-Ling L Levea
- Division of Nephrology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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13
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Alhamad T, Murad H, Dadhania DM, Pavlakis M, Parajuli S, Concepcion BP, Singh N, Murakami N, Casey MJ, Ji M, Lubetzky M, Tantisattamo E, Alomar O, Faravardeh A, Blosser CD, Basu A, Gupta G, Adler JT, Adey D, Woodside KJ, Ong SC, Parsons RF, Lentine KL. The Perspectives of General Nephrologists Toward Transitions of Care and Management of Failing Kidney Transplants. Transpl Int 2023; 36:11172. [PMID: 37456682 PMCID: PMC10348051 DOI: 10.3389/ti.2023.11172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
The management of failing kidney allograft and transition of care to general nephrologists (GN) remain a complex process. The Kidney Pancreas Community of Practice (KPCOP) Failing Allograft Workgroup designed and distributed a survey to GN between May and September 2021. Participants were invited via mail and email invitations. There were 103 respondents with primarily adult nephrology practices, of whom 41% had an academic affiliation. More than 60% reported listing for a second kidney as the most important concern in caring for patients with a failing allograft, followed by immunosuppression management (46%) and risk of mortality (38%), while resistant anemia was considered less of a concern. For the initial approach to immunosuppression reduction, 60% stop antimetabolites first, and 26% defer to the transplant nephrologist. Communicating with transplant centers about immunosuppression cessation was reported to occur always by 60%, and sometimes by 29%, while 12% reported making the decision independently. Nephrologists with academic appointments communicate with transplant providers more than private nephrologists (74% vs. 49%, p = 0.015). There are heterogeneous approaches to the care of patients with a failing allograft. Efforts to strengthen transitions of care and to develop practical practice guidelines are needed to improve the outcomes of this vulnerable population.
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Affiliation(s)
- Tarek Alhamad
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Haris Murad
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Darshana M. Dadhania
- Department of Transplantation Medicine, Weill Cornel Medicine - New York Presbyterian Hospital, New York, NY, United States
| | - Martha Pavlakis
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard University, Boston, MA, United States
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin - Madison, Madison, WI, United States
| | | | - Neeraj Singh
- John C. McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, LA, United States
| | - Naoka Murakami
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Michael J. Casey
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Mengmeng Ji
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Michelle Lubetzky
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Ekamol Tantisattamo
- Department of Medicine, University of California, Irvine, Orange, CA, United States
| | - Omar Alomar
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, CA, United States
| | - Christopher D. Blosser
- Department of Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Arpita Basu
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Gaurav Gupta
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Joel T. Adler
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Deborah Adey
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | | | - Song C. Ong
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ronald F. Parsons
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University, Saint Louis, MO, United States
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14
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Triozzi JL, Rodriguez JV, Velagapudi R, Fallahzadeh MK, Binari LA, Paueksakon P, Fogo AB, Concepcion BP. Malakoplakia of the Kidney Transplant. Kidney Int Rep 2023; 8:680-684. [PMID: 36938075 PMCID: PMC10014369 DOI: 10.1016/j.ekir.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Affiliation(s)
- Jefferson L. Triozzi
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Ramya Velagapudi
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mohammad Kazem Fallahzadeh
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Nephrology Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura A. Binari
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paisit Paueksakon
- Division of Renal Pathology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Agnes B. Fogo
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Renal Pathology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P. Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Correspondence: Beatrice P. Concepcion, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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15
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Concepcion BP, Harhay M, Ruterbories J, Finn J, Wiseman A, Cooper M, Mohan S, Doshi MD. Current landscape of kidney allocation: Organ procurement organization perspectives. Clin Transplant 2023; 37:e14925. [PMID: 36715287 DOI: 10.1111/ctr.14925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/21/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
Organ procurement organizations (OPOs) play a central role in the recovery, preservation, and distribution of deceased donor kidneys for transplantation in the United States. We conducted a national survey to gather information on OPO practices and perceived barriers to efficient organ placement in the face of the new circle-based allocation and asked for suggestions to overcome them. Of the 57 OPOs, 44 responded (77%). The majority of OPOs (61%) reported barriers to obtaining a kidney biopsy, including lack of an available pathologist. Most OPOs (55%) indicated barriers to pumping owing to a lack of available staff and transportation. Respondents agreed or strongly agreed that the new allocation system has worsened transportation challenges (85%), increased provisional acceptances of kidneys (66%), increased communication challenges with transplant centers (68%), and worsened the efficiency of organ allocation (83%). OPO-suggested solutions include making transplant centers more accountable for inefficient selection practices, developing reliable transportation options, and removing the requirement for national sharing. These findings underscore the need to examine closely the trade-offs of the new allocation system with respect to costs, organ ischemia, and discard. These findings may help inform practice and policy for overcoming transportation barriers and improving the efficiency of organ placement.
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Affiliation(s)
- Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meera Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania, USA.,Penn Transplant Institute, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Jan Finn
- Midwest Transplant Network, Westwood, Kansas, USA
| | | | | | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, 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
| | - Mona D Doshi
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
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16
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Binari LA, Kiehl AL, Jackson JC, Feurer ID, Rega SA, Altuhaifi TM, Yankyera RP, Reed M, Sika M, Van J, Collar EM, Forbes RC, Concepcion BP. Neurocognitive Function Changes Following Kidney Transplant: A Prospective Study. Kidney Med 2022; 4:100560. [PMID: 36507052 PMCID: PMC9732409 DOI: 10.1016/j.xkme.2022.100560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Rationale & Objective Patients with advanced kidney disease are at risk for cognitive impairment, which may persist after kidney transplantation. We sought to understand changes in neurocognitive function domains utilizing comprehensive cognitive assessments. Study Design Prospective cohort study. Setting & Population Single-center study of patients undergoing kidney transplantation. Exposure Kidney transplantation. Outcomes Changes in neurocognitive function as measured by the Repeatable Battery for Assessment of Neuropsychological Status (RBANS) and the Trail Making Test Parts A and B (TRAIL A and B) before transplantation (baseline) and compared to 3 months and 12 months posttransplant. Analytical Approach Wilcoxon signed-rank and linear mixed effect models were utilized to assess changes in neurocognitive scores at 3 months and 12 months compared to baseline. Results Thirty-two patients were included with a mean age of 45 years, 47% female, 85% White, and 62% with at least some college education. Hypertension and diabetes were etiologies of kidney disease in 31% and 25% of patients, respectively. Baseline RBANS and TRAIL A and B scores averaged 84.7 ± 14, 40.4 ± 9.9, and 41 ± 11.5, respectively. Although there were posttransplant improvements in immediate and delayed memory at 3 months, these were not sustained at 12 months. There were no significant differences from baseline at 3 months and 12 months in RBANS index scores for language, visuospatial/constructional abilities, and attention. Compared to baseline, TRAIL A scores were not significantly different at 3 months but were significantly improved at 12 months, whereas TRAIL B scores improved significantly at both 3 months and 12 months. Limitations Single-center design and small sample size. Conclusions Utilizing comprehensive cognitive assessments, we found improvements in attention and executive function in the first posttransplant year as measured by TRAIL A and B. However, there was no significant change in global cognition as measured by RBANS. These findings identify cognitive domains for potential intervention in the posttransplant population.
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Affiliation(s)
- Laura A. Binari
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy L. Kiehl
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - James C. Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - Irene D. Feurer
- Department of Surgery, Department of Biostatistics, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - Scott A. Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - Tareq M. Altuhaifi
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Rita P. Yankyera
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Malia Reed
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mohammed Sika
- Nephrology Clinical Trials Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Julie Van
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Psychology, Neuroscience Center, Brigham Young University, Provo, UT
| | - Erin M. Collar
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - Rachel C. Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Beatrice P. Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Address for Correspondence: Beatrice P. Concepcion, MD, MS, 1313 21st Avenue S, Oxford House 912F, Nashville, TN 37232.
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17
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Al Ammary F, Motter JD, Sung HC, Lentine KL, Sharfuddin A, Kumar V, Yadav A, Doshi MD, Virmani S, Concepcion BP, Grace T, Sidoti CN, Yahya Jan M, Muzaale AD, Wolf J. Telemedicine services for living kidney donation: A US survey of multidisciplinary providers. Am J Transplant 2022; 22:2041-2051. [PMID: 35575439 PMCID: PMC9543040 DOI: 10.1111/ajt.17093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/13/2022] [Accepted: 05/08/2022] [Indexed: 01/25/2023]
Abstract
Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine can facilitate healthcare access/care coordination. Yet difficulties exist in telemedicine implementation and sustainability. We sought to examine centers' practices and providers' attitudes toward telemedicine to improve services for donors. We surveyed multidisciplinary providers from 194 active adult US living donor kidney transplant centers; 293 providers from 128 unique centers responded to the survey (center representation rate = 66.0%), reflecting 83.9% of practice by donor volume and 91.5% of US states/territories. Most centers (70.3%) plan to continue using telemedicine beyond the pandemic for donor evaluation/follow-up. Video was mostly used by nephrologists, surgeons, and psychiatrists/psychologists. Telephone and video were mostly used by social workers, while video or telephone was equally used by coordinators. Half of respondent nephrologists and surgeons were willing to accept a remote completion of physical exam; 68.3% of respondent psychiatrists/psychologists and social workers were willing to accept a remote completion of mental status exam. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation. However, providers (65.5%) perceived out-of-state licensing as a key policy/regulatory barrier. These findings help inform practice and underscore the instigation of policies to remove barriers using telemedicine to increase living kidney donation.
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Affiliation(s)
- Fawaz Al Ammary
- Department of MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Hannah C. Sung
- Department of SurgeryJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Asif Sharfuddin
- Department of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Vineeta Kumar
- Department of MedicineUniversity of AlabamaBirminghamAlabamaUSA
| | - Anju Yadav
- Department of MedicineThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Mona D. Doshi
- Department of MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Sarthak Virmani
- Department of MedicineYale UniversityNew HavenConnecticutUSA
| | | | - Terry Grace
- Department of MedicineWake Forest Baptist HealthWinston‐SalemNorth CarolinaUSA
| | | | | | | | - Joshua Wolf
- Piedmont Transplant InstituteAtlantaGeorgiaUSA
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18
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Molnar MZ, Potluri VS, Schaubel DE, Sise ME, Concepcion BP, Forbes RC, Blumberg E, Bloom RD, Shaffer D, Chung RT, Strohbehn IA, Elias N, Azhar A, Shah M, Sawinski D, Binari LA, Talwar M, Balaraman V, Bhalla A, Eason JD, Besharatian B, Trofe-Clark J, Goldberg DS, Reese PP. Association of donor hepatitis C virus infection status and risk of BK polyomavirus viremia after kidney transplantation. Am J Transplant 2022; 22:599-609. [PMID: 34613666 PMCID: PMC8968853 DOI: 10.1111/ajt.16834] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/01/2021] [Accepted: 09/03/2021] [Indexed: 02/03/2023]
Abstract
Kidney transplantation (KT) from deceased donors with hepatitis C virus (HCV) into HCV-negative recipients has become more common. However, the risk of complications such as BK polyomavirus (BKPyV) remains unknown. We assembled a retrospective cohort at four centers. We matched recipients of HCV-viremic kidneys to highly similar recipients of HCV-aviremic kidneys on established risk factors for BKPyV. To limit bias, matches were within the same center. The primary outcome was BKPyV viremia ≥1000 copies/ml or biopsy-proven BKPyV nephropathy; a secondary outcome was BKPyV viremia ≥10 000 copies/ml or nephropathy. Outcomes were analyzed using weighted and stratified Cox regression. The median days to peak BKPyV viremia level was 119 (IQR 87-182). HCV-viremic KT was not associated with increased risk of the primary BKPyV outcome (HR 1.26, p = .22), but was significantly associated with the secondary outcome of BKPyV ≥10 000 copies/ml (HR 1.69, p = .03). One-year eGFR was similar between the matched groups. Only one HCV-viremic kidney recipient had primary graft loss. In summary, HCV-viremic KT was not significantly associated with the primary outcome of BKPyV viremia, but the data suggested that donor HCV might elevate the risk of more severe BKPyV viremia ≥10 000 copies/ml. Nonetheless, one-year graft function for HCV-viremic recipients was reassuring.
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Affiliation(s)
- Miklos Z. Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vishnu S. Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, Philadelphia, PA
| | - Meghan E. Sise
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Beatrice P. Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Rachel C. Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Emily Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Roy D. Bloom
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - David Shaffer
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Raymond T. Chung
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA
| | - Ian A. Strohbehn
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Nahel Elias
- Department of Surgery, Transplant Center, Massachusetts General Hospital, Boston MA
| | - Ambreen Azhar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mital Shah
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Deirdre Sawinski
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Laura A. Binari
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D. Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Behdad Besharatian
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
| | | | - David S. Goldberg
- Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, FL
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, PA
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19
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Sarrell BA, Bloch K, El Chediak A, Kumm K, Tracy K, Forbes RC, Langone A, Thomas L, Schlendorf K, Trindade AJ, Perri R, Wright P, Concepcion BP. Monoclonal antibody treatment for COVID-19 in solid organ transplant recipients. Transpl Infect Dis 2021; 24:e13759. [PMID: 34787345 PMCID: PMC8646855 DOI: 10.1111/tid.13759] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/24/2021] [Accepted: 10/21/2021] [Indexed: 12/17/2022]
Abstract
Solid organ transplant (SOT) recipients are at high risk for severe coronavirus disease 2019 (COVID‐19). Studies suggest that early intervention with monoclonal antibody (MAB) treatment directed against the SARS‐CoV‐2 spike protein may reduce the risk of emergency department visits or hospitalization for COVID‐19, especially in high‐risk patients. Herein, we describe our single‐center experience of 93 SOT (50 kidney, 17 liver, 11 lung, nine heart, and six dual‐organ) recipients with mild to moderate COVID‐19 who were treated with bamlanivimab or casirivimab‐imdevimab per emergency use authorization guidelines. Median age of recipients was 55 [(Interquartile range) 44–63] years, and 41% were diabetic. Median time from transplant to MAB was 64 (IQR 24–122) months and median time from the onset of COVID‐19 symptoms to the infusion was 6 (IQR 4–7) days. All patients had a minimum 30 days of study follow‐up. The 30‐day hospitalization rate for COVID‐19‐directed therapy was 8.7%. Infusion‐related adverse events were rare and generally mild. Biopsy‐proven organ rejection occurred in two patients, and there were no graft losses or deaths. A comparator group of 72 SOT recipients diagnosed with COVID‐19 who were eligible but did not receive MAB treatment had a higher 30‐day hospitalization rate for COVID‐19‐directed therapy (15.3%), although this difference was not statistically significant, after adjustment for age (Odds Ratio 0.49 [95% Confidence Interval 0.18–1.32], p = 0.16). Our experience suggests that MAB treatment, with respect to the available MAB formulations and circulating viral variants present during our study period, may provide favorable outcomes for mild to moderate COVID‐19 in SOT recipients.
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Affiliation(s)
- Bonnie Ann Sarrell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen Bloch
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alissar El Chediak
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kayla Kumm
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kaitlyn Tracy
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony Langone
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lora Thomas
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly Schlendorf
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anil J Trindade
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Roman Perri
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patty Wright
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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20
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Al Ammary F, Concepcion BP, Yadav A. The Scope of Telemedicine in Kidney Transplantation: Access and Outreach Services. Adv Chronic Kidney Dis 2021; 28:542-547. [PMID: 35367022 DOI: 10.1053/j.ackd.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/29/2021] [Accepted: 10/12/2021] [Indexed: 12/23/2022]
Abstract
Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor.
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21
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Binari LA, Kapp ME, Schaefer HM, Concepcion BP. Polyomavirus nephropathy with crescent formation. Kidney Int 2021; 100:953. [PMID: 34556306 DOI: 10.1016/j.kint.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Laura A Binari
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meghan E Kapp
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heidi M Schaefer
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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22
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Azhar A, Binari LA, Joglekar K, Tsujita M, Talwar M, Balaraman V, Bhalla A, Eason JD, Hall IE, Rofaiel G, Forbes RC, Shaffer D, Concepcion BP, Molnar MZ. Association between ezetimibe usage and hepatitis C RNA levels in uninfected kidney transplant recipients who received hepatitis C infected kidneys. Clin Transplant 2021; 35:e14485. [PMID: 34523744 DOI: 10.1111/ctr.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/24/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022]
Abstract
Kidney transplantation (KT) from hepatitis C virus infected (HCV+) donors to HCV negative recipients achieve excellent graft function but have relatively higher rates of post-KT co-infections presumably due to prolonged HCV viremia in transmission-and-treat approach. Ezetimibe acts as an antagonist of Niemann-Pick C1-Like 1 receptor required for HCV entry and theoretically can reduce HCV viremia. However, no data is available to examine the role of ezetimibe as a bridge therapy between KT surgery and direct acting antiviral (DAA) initiation. A retrospective cohort study including 70 HCV+ to HCV negative KT recipients from Methodist University Hospital and Vanderbilt University Medical Center was performed to determine the association between ezetimibe usage and HCV viremia. Twenty patients received ezetimibe daily while 50 patients did not. Primary outcome of study was mean HCV RNA level at 1-2 weeks post-KT and before initiation of DAA. Median (IQR) viral load (VL) in log copies/ml was one log lower in ezetimibe group versus non-ezetimibe group (4.1 [3.7-5.3] vs. 5.1 [4.4-5.5], P = .01), and highest VL was also lower in ezetimibe group (4.2 [3.7-5.4] vs. 5.4 [4.7-5.9], P = .006). We concluded that ezetimibe bridge therapy might be associated with reduction in HCV VL while waiting for DAA initiation in HCV+ to HCV negative KT recipients.
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Affiliation(s)
- Ambreen Azhar
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Laura A Binari
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kiran Joglekar
- Division of Gastroenterology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Makoto Tsujita
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Isaac E Hall
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - George Rofaiel
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Shaffer
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
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23
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Edmonds C, Carver A, DeClercq J, Choi L, Peter M, Schlendorf K, Perri R, Forbes RC, Concepcion BP. Access to hepatitis C direct-acting antiviral therapy in hepatitis C-positive donor to hepatitis C-negative recipient solid-organ transplantation in a real-world setting. Am J Surg 2021; 223:975-982. [PMID: 34548142 DOI: 10.1016/j.amjsurg.2021.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Emerging data supports expanding the solid organ donor pool with transplantation from hepatitis C virus (HCV)-positive donors into HCV-negative recipients. However, concerns exist regarding the ability to access direct-acting antivirals (DAAs) post-transplant in a real-world setting. METHODS This single-center, retrospective study evaluated DAA access rates, time to first dose, and patient cost in donor-derived HCV solid-organ transplant recipients utilizing an integrated specialty pharmacy process. RESULTS Among 91 patients, all accessed DAAs through prescription insurance (97%) or patient assistance programs (3%). Of those who received DAAs through insurance, only 65% received approval on initial insurance submission. Median time from transplant to first dose was 45d [IQR 34-66]. The on-site specialty pharmacy was used by 69% of patients. Copay assistance programs reduced the median monthly patient cost from $1914 [range $7-7536] to $0 [range $0-5]. CONCLUSION Our findings indicate that access to DAAs in donor-derived HCV post-transplant is achievable and affordable; however, significant added administrative efforts may be required for insurance approval as well as obtaining copay assistance, which is a limited resource.
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Affiliation(s)
- Cori Edmonds
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Alicia Carver
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Megan Peter
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Kelly Schlendorf
- Section of Heart Failure and Cardiac Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Roman Perri
- Department of Medicine, Division of Hepatology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA.
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24
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Alhamad T, Lubetzky M, Lentine KL, Edusei E, Parsons R, Pavlakis M, Woodside KJ, Adey D, Blosser CD, Concepcion BP, Friedewald J, Wiseman A, Singh N, Chang SH, Gupta G, Molnar MZ, Basu A, Kraus E, Ong S, Faravardeh A, Tantisattamo E, Riella L, Rice J, Dadhania DM. Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers. Am J Transplant 2021; 21:3034-3042. [PMID: 33559315 DOI: 10.1111/ajt.16523] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 01/25/2023]
Abstract
Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.
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Affiliation(s)
- Tarek Alhamad
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Michelle Lubetzky
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Emmanuel Edusei
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Deborah Adey
- University of California San Francisco, San Francisco, California, USA
| | | | | | | | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - Su-Hsin Chang
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Gaurav Gupta
- Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | | | - Song Ong
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California, USA
| | | | | | - Jim Rice
- Scripps Heath, San Diego, California, USA
| | - Darshana M Dadhania
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
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25
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Lubetzky M, Tantisattamo E, Molnar MZ, Lentine KL, Basu A, Parsons RF, Woodside KJ, Pavlakis M, Blosser CD, Singh N, Concepcion BP, Adey D, Gupta G, Faravardeh A, Kraus E, Ong S, Riella LV, Friedewald J, Wiseman A, Aala A, Dadhania DM, Alhamad T. The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients. Am J Transplant 2021; 21:2937-2949. [PMID: 34115439 DOI: 10.1111/ajt.16717] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/23/2021] [Accepted: 05/20/2021] [Indexed: 01/25/2023]
Abstract
The return to dialysis after allograft failure is associated with increased morbidity and mortality. This transition is made more complex by the rising numbers of patients who seek repeat transplantation and therefore may have indications for remaining on low levels of immunosuppression, despite the potential increased morbidity. Management strategies vary across providers, driven by limited data on how to transition off immunosuppression as the allograft fails and a paucity of randomized controlled trials to support one approach over another. In this review, we summarize the current data available for management and care of the failing allograft. Additionally, we discuss a suggested plan for immunosuppression weaning based upon the availability of re-transplantation and residual allograft function. We propose a shared-care model in which there is improved coordination between transplant providers and general nephrologists so that immunosuppression management and preparation for renal replacement therapy and/or repeat transplantation can be conducted with the goal of improved outcomes and decreased morbidity in this vulnerable patient group.
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Affiliation(s)
- Michelle Lubetzky
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Ekamol Tantisattamo
- Division of Nephrology, University of California Irvine, Orange, California, USA
| | - Miklos Z Molnar
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Krista L Lentine
- Internal Medicine-Nephrology, Saint Louis University, St. Louis, Missouri, USA
| | - Arpita Basu
- Division of Transplantation, Emory University, Atlanta, Georgia, USA
| | - Ronald F Parsons
- Division of Transplantation, Emory University, Atlanta, Georgia, USA
| | - Kenneth J Woodside
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, Michigan, USA
| | - Martha Pavlakis
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher D Blosser
- Division of Nephrology, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Neeraj Singh
- Division of Nephrology, Willis Knighton Health System, Shreveport, Louisiana, USA
| | | | - Deborah Adey
- Division of Nephrology, University of California San Francisco, San Francisco, California, USA
| | - Gaurav Gupta
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California, USA
| | - Edward Kraus
- Department of Medicine, Johns Hopkins, Baltimore, Maryland, USA
| | - Song Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Leonardo V Riella
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John Friedewald
- Division of Medicine and Surgery, Northwestern University, Chicago, Illinois, USA
| | - Alex Wiseman
- Division of Nephrology, University of Colorado, Denver, Colorado, USA
| | - Amtul Aala
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Darshana M Dadhania
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Michigan, USA
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26
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Sarrell BA, Laurenzano J, Freitas J, Concepcion BP. Q fever presenting with hepatic and splenic lesions in a kidney transplant recipient. Transpl Infect Dis 2021; 23:e13699. [PMID: 34324786 DOI: 10.1111/tid.13699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Bonnie Ann Sarrell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Laurenzano
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jared Freitas
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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27
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Motter JD, Jackson KR, Long JJ, Waldram MM, Orandi BJ, Montgomery RA, Stegall MD, Jordan SC, Benedetti E, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Verbesey JE, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Wellen JR, Bozorgzadeh A, Gaber AO, Heher EC, Weng FL, Djamali A, Helderman JH, Concepcion BP, Brayman KL, Oberholzer J, Kozlowski T, Covarrubias K, Massie AB, Segev DL, Garonzik-Wang JM. Delayed graft function and acute rejection following HLA-incompatible living donor kidney transplantation. Am J Transplant 2021; 21:1612-1621. [PMID: 33370502 PMCID: PMC8016719 DOI: 10.1111/ajt.16471] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/17/2020] [Accepted: 12/08/2020] [Indexed: 02/05/2023]
Abstract
Incompatible living donor kidney transplant recipients (ILDKTr) have pre-existing donor-specific antibody (DSA) that, despite desensitization, may persist or reappear with resulting consequences, including delayed graft function (DGF) and acute rejection (AR). To quantify the risk of DGF and AR in ILDKT and downstream effects, we compared 1406 ILDKTr to 17 542 compatible LDKT recipients (CLDKTr) using a 25-center cohort with novel SRTR linkage. We characterized DSA strength as positive Luminex, negative flow crossmatch (PLNF); positive flow, negative cytotoxic crossmatch (PFNC); or positive cytotoxic crossmatch (PCC). DGF occurred in 3.1% of CLDKT, 3.5% of PLNF, 5.7% of PFNC, and 7.6% of PCC recipients, which translated to higher DGF for PCC recipients (aOR = 1.03 1.682.72 ). However, the impact of DGF on mortality and DCGF risk was no higher for ILDKT than CLDKT (p interaction > .1). AR developed in 8.4% of CLDKT, 18.2% of PLNF, 21.3% of PFNC, and 21.7% of PCC recipients, which translated to higher AR (aOR PLNF = 1.45 2.093.02 ; PFNC = 1.67 2.403.46 ; PCC = 1.48 2.243.37 ). Although the impact of AR on mortality was no higher for ILDKT than CLDKT (p interaction = .1), its impact on DCGF risk was less consequential for ILDKT (aHR = 1.34 1.621.95 ) than CLDKT (aHR = 1.96 2.292.67 ) (p interaction = .004). Providers should consider these risks during preoperative counseling, and strategies to mitigate them should be considered.
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Affiliation(s)
- Jennifer D. Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jane J. Long
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Madeleine M. Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Babak J. Orandi
- Department of Surgery, University of Alabama, Birmingham, AL
| | - Robert A. Montgomery
- The NYU Transplant Institute, New York University Langone Medical Center, New York, NY
| | | | - Stanley C. Jordan
- Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, CA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois-Chicago, Chicago, IL
| | - Ty B. Dunn
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Lloyd E. Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Sandip Kapur
- Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, NY
| | - Ronald P. Pelletier
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - John P. Roberts
- Department of Surgery, University of California-San Francisco, San Francisco, CA
| | | | - Pooja Singh
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia. PA
| | - Debra L. Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Marc P. Posner
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Jose M. El-Amm
- Integris Baptist Medical Center, Transplant Division, Oklahoma City, OK
| | - Ron Shapiro
- Recanti Miller Transplantation Institute, Mount Sinai Hospital, New York, NY
| | | | | | | | - Michael A. Rees
- Department of Urology, University of Toledo Medical Center, Toledo, OH
| | | | | | - David A. Gerber
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jason R. Wellen
- Department of Surgery, Barnes-Jewish Hospital, St. Louis, MO
| | - Adel Bozorgzadeh
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - A. Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Eliot C. Heher
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Francis L. Weng
- Renal and Pancreas Transplant Division, Saint Barnabas Medical Center, Livingston, NJ
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin, Madison, WI
| | | | | | | | - Jose Oberholzer
- Department of Surgery, University of Virginia, Charlottesville, VA
| | | | - Karina Covarrubias
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - 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, Minneapolis, MN
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Jackson KR, Long J, Motter J, Bowring MG, Chen J, Waldram MM, Orandi BJ, Montgomery RA, Stegall MD, Jordan SC, Benedetti E, Dunn TB, Ratner LE, Kapur S, Pelletier RP, Roberts JP, Melcher ML, Singh P, Sudan DL, Posner MP, El-Amm JM, Shapiro R, Cooper M, Verbesey JE, Lipkowitz GS, Rees MA, Marsh CL, Sankari BR, Gerber DA, Wellen J, Bozorgzadeh A, Gaber AO, Heher E, Weng FL, Djamali A, Helderman JH, Concepcion BP, Brayman KL, Oberholzer J, Kozlowski T, Covarrubias K, Desai N, Massie AB, Segev DL, Garonzik-Wang J. Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes. Transplantation 2021; 105:436-442. [PMID: 32235255 PMCID: PMC8080262 DOI: 10.1097/tp.0000000000003254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these, as well as other practice variations, on ILDKT outcomes remains unknown. METHODS We sought to quantify center-level variation in mortality and graft loss following ILDKT using a 25-center cohort of 1358 ILDKT recipients with linkage to Scientific Registry of Transplant Recipients for accurate outcome ascertainment. We used multilevel Cox regression with shared frailty to determine the variation in post-ILDKT outcomes attributable to between-center differences and to identify any center-level characteristics associated with improved post-ILDKT outcomes. RESULTS After adjusting for patient-level characteristics, only 6 centers (24%) had lower mortality and 1 (4%) had higher mortality than average. Similarly, only 5 centers (20%) had higher graft loss and 2 had lower graft loss than average. Only 4.7% of the differences in mortality (P < 0.01) and 4.4% of the differences in graft loss (P < 0.01) were attributable to between-center variation. These translated to a median hazard ratio of 1.36 for mortality and 1.34 of graft loss for similar candidates at different centers. Post-ILDKT outcomes were not associated with the following center-level characteristics: ILDKT volume and transplanting a higher proportion of highly sensitized, prior transplant, preemptive, or minority candidates. CONCLUSIONS Unlike most aspects of transplantation in which center-level variation and volume impact outcomes, we did not find substantial evidence for this in ILDKT. Our findings support the continued practice of ILDKT across these diverse centers.
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Affiliation(s)
- Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jane Long
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madeleine M. Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Babak J Orandi
- Department of Surgery, University of Alabama, Birmingham, AL
| | - Robert A. Montgomery
- The NYU Transplant Institute, New York University Langone Medical Center, New York, NY
| | | | - Stanley C. Jordan
- Department of Medicine, Cedars-Sinai Comprehensive Transplant Center, Los Angeles, CA
| | - Enrico Benedetti
- Department of Surgery, University of Illinois-Chicago, Chicago, IL
| | - Ty B. Dunn
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Lloyd E. Ratner
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Sandip Kapur
- Department of Surgery, New York Presbyterian/Weill Cornell Medical Center, New York, NY
| | - Ronald P. Pelletier
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - John P. Roberts
- Department of Surgery, University of California-San Francisco, San Francisco, CA
| | | | - Pooja Singh
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia. PA
| | - Debra L. Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Marc P. Posner
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Jose M. El-Amm
- Integris Baptist Medical Center, Transplant Division, Oklahoma City, OK
| | - Ron Shapiro
- Recanti Miller Transplantation Institute, Mount Sinai Hospital, New York, NY
| | | | | | | | - Michael A. Rees
- Department of Urology, University of Toledo Medical Center, Toledo, OH
| | | | | | - David A. Gerber
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jason Wellen
- Department of Surgery, Barnes-Jewish Hospital, St. Louis, MO
| | - Adel Bozorgzadeh
- Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - A. Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Eliot Heher
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Francis L. Weng
- Renal and Pancreas Transplant Division, Saint Barnabas Medical Center, Livingston, NJ
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin, Madison, WI
| | | | | | | | - Jose Oberholzer
- Department of Surgery, University of Virginia, Charlottesville, VA
| | | | - Karina Covarrubias
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - 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, Minneapolis, MN
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29
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DuBray BJ, Shawar SH, Rega SA, Smith KM, Centanni KM, Warmke K, Concepcion BP, Edwards GC, Schaefer HM, Feurer ID, Forbes RC. Impact of Social Media on Self-Referral Patterns for Living Kidney Donation. Kidney360 2020; 1:1419-1425. [PMID: 35372891 DOI: 10.34067/kid.0003212020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/16/2020] [Indexed: 01/10/2023]
Abstract
Background As the organ-shortage crisis continues to worsen, many patients in need of a kidney transplant have turned to social media to find a living donor. The effect of social media on living kidney donation is not known. The goal of this study is to investigate the influence of social media on those interested in donating a kidney. Methods Self-referrals for living kidney donation from December 2016 to March 2019 were retrospectively reviewed. Age, sex, race, and relationship of individuals petitioned through social media (SM) were compared with those petitioned through verbal communication (VC). Data were analyzed using chi-squared tests, with z tests of column proportions, and multivariable logistic regression. Results A total of 7817 individuals (53% SM, 36% VC, and 10% other) were self-referred for living kidney donation. The analysis sample included 6737 adults petitioned through SM (n=3999) or VC (n=2738). Half (n=3933) of the individuals reported an altruistic relationship, and 94% of these respondents were petitioned through SM. Although univariate analyses indicated that SM respondents were younger, more likely female, more likely White, and more likely to have directed altruistic intent than those petitioned through VC (all P<0.05), multivariable logistic regression demonstrated that only decreased age, female sex, and relationship were significantly related to likelihood of SM use (all P<0.001). Conclusions The use of SM to petition living kidney donors is prevalent and accounts for a greater proportion of respondents compared with VC. SM respondents tend to be younger, female, and altruistic compared with VC. Directed altruistic interest in kidney donation is almost exclusively generated through SM.
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Affiliation(s)
- Bernard J DuBray
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Saed H Shawar
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott A Rega
- Vanderbilt Transplant Center, Nashville, Tennessee
| | | | | | - Kara Warmke
- Vanderbilt Transplant Center, Nashville, Tennessee
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gretchen C Edwards
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Heidi M Schaefer
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Irene D Feurer
- Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Vanderbilt Transplant Center, Nashville, Tennessee
| | - Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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30
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Lentine KL, Peipert JD, Alhamad T, Caliskan Y, Concepcion BP, Forbes R, Schnitzler M, Chang SH, Cooper M, Bloom RD, Mannon RB, Axelrod DA. Survey of Clinician Opinions on Kidney Transplantation from Hepatitis C Virus Positive Donors: Identifying and Overcoming Barriers. ACTA ACUST UNITED AC 2020; 1:1291-1299. [PMID: 33251523 DOI: 10.34067/kid.0004592020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Transplant practices related to use of organs from Hepatitis C virus infected donors (DHCV+) is evolving rapidly. Methods We surveyed U.S. kidney transplant programs by email and professional society listserv postings between 7/19-1/20 to assess attitudes, management strategies, and barriers related to use of viremic (nucleic acid testing (NAT)+) donor organs in HCV uninfected recipients. Results Staff at 112 unique programs responded, representing 54% of U.S. adult kidney transplant programs and 69% of adult deceased donor kidney transplant volume in 2019. Most survey respondents were transplant nephrologists (46%) or surgeons (43%). Among responding programs, 67% currently transplant DHCV antibody+/NAT- organs under a clinical protocol or as standard of care. By comparison, only 58% offer DHCV NAT+ kidney transplant to HCV- recipients, including 35% under clinical protocols, 14% as standard of care, and 9% under research protocols. Following transplant of DHCV NAT+ organs to uninfected recipients, 53% start direct acting antiviral agent (DAA) therapy after discharge and documented viremia. Viral monitoring protocols after DHCV NAT+ to HCV uninfected recipient kidney transplantation varied substantially. 56% of programs performing these transplants report having an institutional plan to provide DAA treatment if declined by the recipient's insurance. Respondents felt a mean decrease in waiting time of ≥18 months (range 0-60) justifies the practice. Program concerns related to use of DHCV NAT+ kidneys include insurance coverage concerns (72%), cost (60%), and perceived risk of transmitting resistant infection (44%). Conclusions Addressing knowledge about safety and logistical/financial barriers related to use of DHCV NAT+ kidney transplantation for HCV uninfected recipients may help reduced discards and expand the organ supply.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | - John D Peipert
- Northwestern University, Feinberg School of Medicine, Chicago, IL.,Northwestern University Transplant Outcomes Research Core, Chicago, IL
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | | | | | - Mark Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | | | | | - Roy D Bloom
- University of Pennsylvania, Philadelphia, PA
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31
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Edwards GC, Shipe ME, Smith L, Gamble C, Shaffer D, Concepcion BP, Forbes R. Exploring patient willingness to accept hepatitis C-infected kidneys for transplantation. BMC Nephrol 2020; 21:473. [PMID: 33172408 PMCID: PMC7653701 DOI: 10.1186/s12882-020-02114-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 10/20/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND As organs infected with Hepatitis C virus (HCV) provide an opportunity to expand the donor pool, the primary aim of this study is to explore patient willingness to accept a kidney from HCV-infected donors compared to other high-risk donors. METHODS An anonymous, electronic survey was sent to all active kidney transplant waitlist patients at a single large volume transplant center. Patients were asked to respond to three hypothetical organ offers from the following: 1) HCV-infected donor 2) Donor with active intravenous drug use and 3) Donor with longstanding diabetes and hypertension. RESULTS The survey was sent to 435 patients of which 125 responded (29% response rate). While 86 out of 125 patients (69%) were willing to accept an HCV-infected kidney, only a minority of respondents were willing to accept a kidney from other high-risk donors. In contrast to other studies, by multivariable logistic regression, age and race were not associated with willingness to accept an HCV-infected kidney. CONCLUSIONS In this exploratory study, utilization of kidneys from HCV-infected donors to expand the donor pool appears to be an acceptable option to patients.
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Affiliation(s)
- Gretchen C Edwards
- Department of General Surgery, Vanderbilt University Medical Center, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN, 37232-2730, USA.
| | - Maren E Shipe
- Department of General Surgery, Vanderbilt University Medical Center, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN, 37232-2730, USA
| | - Lindsay Smith
- Vanderbilt University Medical Center Transplant Center, Nashville, USA
| | | | - David Shaffer
- Department of General Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, USA
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, USA
| | - Rachel Forbes
- Department of General Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, USA
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32
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Chang RS, Hu JR, Beckman JA, Forbes RC, Shawar SH, Concepcion BP. High Output Heart Failure Associated With Arteriovenous Fistula in the Setting of Kidney Transplantation. Kidney Int Rep 2020; 6:544-551. [PMID: 33615082 PMCID: PMC7879118 DOI: 10.1016/j.ekir.2020.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/30/2020] [Accepted: 11/04/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Rachel S Chang
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Jiun-Ruey Hu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joshua A Beckman
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Saed H Shawar
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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33
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Thorne P, Arroyo JP, Concepcion BP. Fever and Gross Hematuria in a Kidney Transplant Recipient. Kidney360 2020; 1:712-713. [PMID: 35372939 PMCID: PMC8815547 DOI: 10.34067/kid.0000732020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 03/10/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Peter Thorne
- Vanderbilt University Medical Center, Nashville, Tennessee
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34
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Concepcion BP, Alasfar S, Levea SL, Singh P, Wiseman A. The Transplant Nephrology Workforce in the United States: Current State and Future Directions. Adv Chronic Kidney Dis 2020; 27:336-343.e1. [PMID: 33131647 DOI: 10.1053/j.ackd.2020.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/02/2020] [Accepted: 05/04/2020] [Indexed: 11/11/2022]
Abstract
The population of patients with kidney transplants in the United States is growing. The delivery of transplant care is complex, involves a multidisciplinary transplant team, and care coordination between transplant and community providers. The transplant nephrologist is central to the delivery of this care and assumes a multitude of clinical and nonclinical roles and responsibilities. With a growing population of patients requiring transplant care that spans a continuum from pretransplant referral to long-term posttransplant management, an understanding of the current state of the transplant nephrology workforce in the United States and the future that it faces is important in ensuring that current and future needs of both patients and physicians are met. In this article, we (1) review the scope of practice of the transplant nephrologist, (2) discuss the state of training in the field of transplant nephrology, (3) review the role of the referring primary nephrologist in the care of patients undergoing kidney transplant, and (4) discuss challenges and opportunities facing the transplant nephrology workforce.
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35
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Forbes RC, Concepcion BP, Clapper D, DuBray BJ, Shawar S, Schaefer HM, Langone A, Shaffer D, Johnson K. The effect of pulsatile pump perfusion on hepatitis C transmission in kidney transplantation: A prospective pilot study. Clin Transplant 2020; 34:e13987. [PMID: 32441791 DOI: 10.1111/ctr.13987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/15/2020] [Indexed: 11/30/2022]
Abstract
With increasing utilization of hepatitis C (HCV) viremic donor organs, there may be a role for kidney pump perfusion to reduce viral load and prevent HCV transmission. We performed a prospective pilot study of HCV viremic donors; one kidney from each donor pair was pumped with perfusate exchanges and viral load testing at least every 4 hours. Donor, recipient, and transplant characteristics were obtained with clinical outcomes. Linear regression was performed to quantify the association between pump time and perfusate viral load. Six HCV viremic donors for six pairs of aviremic recipients were included. Perfusate of the pumped kidneys showed detectable virus throughout the pump cycles. Although perfusate viral levels decreased with increasing pump times, this was not statistically significant (β = -.48, P = .36). All recipients had detectable HCV RNA postoperatively. The pumped cohort had an insignificantly reduced mean viral load compared to pumped recipients (1352 ± 2006 vs 26 170 ± 61 211, P = .09). Time to initiation of direct-acting antiviral was 32 ± 12 vs 26 ± 7 days (P = .17) and to undetectable levels was 66 ± 27 vs 55 ± 22 days (P = .82) for the pumped and unpumped cohorts, respectively. Pulsatile perfusion alone does not appear adequate to decrease HCV transmission. Future studies will need to explore additional ex vivo interventions to pumping.
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Affiliation(s)
- Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Deana Clapper
- Tennessee Donor Services, Dialysis Clinics, Inc., Nashville, TN, USA
| | - Bernard J DuBray
- Division of Kidney and Pancreas Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Saed Shawar
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heidi M Schaefer
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony Langone
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Shaffer
- Tennessee Donor Services, Dialysis Clinics, Inc., Nashville, TN, USA
| | - Keith Johnson
- Tennessee Donor Services, Dialysis Clinics, Inc., Nashville, TN, USA
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36
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37
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38
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Forbes RC, Solorzano CC, Concepcion BP. Surgical telemedicine here to stay: More support from a randomized controlled trial on postoperative surgery visits. Am J Surg 2020; 219:880-881. [PMID: 32265012 PMCID: PMC7194890 DOI: 10.1016/j.amjsurg.2020.03.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 11/09/2022]
Abstract
Telemedicine and their studied elements. Reference to large review articles including numerous surgical studies reviewing telemedicine. •Association of Telemedicine adoption and COVID-19.
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Affiliation(s)
- Rachel C Forbes
- Vanderbilt University Medical Center, Department of General Surgery, 1313 21st Avenue South, Oxford House, Suite 912, Nashville, TN, 37232, USA.
| | - Carmen C Solorzano
- Vanderbilt University Medical Center, Department of General Surgery, 1313 21st Avenue South, Oxford House, Suite 912, Nashville, TN, 37232, USA
| | - Beatrice P Concepcion
- Vanderbilt University Medical Center, Department of Medicine, 1313 21st Avenue South, Oxford House, Suite 912, Nashville, TN, 37232, USA
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39
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Forbes RC, Feurer ID, LaNeve D, Concepcion BP, Gamble C, Rega SA, Pinson CW, Shaffer D. Increasing kidney donor profile index sequence does not adversely affect medium-term health-related quality of life after kidney transplantation. Clin Transplant 2018; 32:e13212. [PMID: 29377273 DOI: 10.1111/ctr.13212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The United Network for Organ Sharing system allocates deceased donor kidneys based on the kidney donor profile index (KDPI), stratified as sequences (A ≤ 20%, B > 20-<35%, C ≥ 35-≤85%, and D > 85%), with increasing KDPI associated with decreased graft survival. While health-related quality of life (HRQOL) may improve after transplantation, the effect of donor kidney quality, reflected by KDPI sequence, on post-transplant HRQOL has not been reported. METHODS Health-related quality of life was measured using the eight scales and physical and mental component summaries (PCS, MCS) of the SF-36® Health Survey. Multivariable mixed effects models that adjusted for age, gender, rejection, and previous transplant and analysis of variance methods tested the effects of time and KDPI sequence on post-transplant HRQOL. RESULTS A total of 141 waitlisted adults and 505 recipients (>1700 observations) were included. Pretransplant PCS and MCS averaged, respectively, slightly below and within general population norms (GPN; 40-60). At 31 ± 26 months post-transplant, average PCS (41 ± 11) and MCS (51 ± 11), overall and within each KDPI sequence, were within GPN. KDPI sequence was not related to post-transplant HRQOL (P > .134) or its trajectory (interaction P > .163). CONCLUSION Increasing KDPI does not adversely affect the medium-term values and trajectories of HRQOL after kidney transplantation. This may reassure patients and centers when considering using high KDPI kidneys.
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Affiliation(s)
- Rachel C Forbes
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Irene D Feurer
- Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David LaNeve
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Beatrice P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianna Gamble
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott A Rega
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Wright Pinson
- Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Shaffer
- Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
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40
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Anand M, Arroyo JP, Alhalabi H, Thayer T, Lusco M, Langone A, Concepcion BP. IgA-Dominant Acute Postinfectious Glomerulonephritis Presenting as Acute Renal Failure in a Kidney Transplant Recipient. Kidney Int Rep 2018; 2:766-769. [PMID: 29318221 PMCID: PMC5720536 DOI: 10.1016/j.ekir.2017.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Affiliation(s)
- Manish Anand
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Juan Pablo Arroyo
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hassan Alhalabi
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Timothy Thayer
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Lusco
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony Langone
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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41
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Arroyo JP, Zhu L, Dee K, Concepcion BP. Painful erythematous skin nodules in a kidney transplant recipient. Am J Transplant 2018; 18:268-270. [PMID: 29267997 DOI: 10.1111/ajt.14551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/16/2017] [Accepted: 10/16/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Juan Pablo Arroyo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lilly Zhu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin Dee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Beatrice P Concepcion
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
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Al Nimri O, Rajput A, Martinez E, Fahrenholz JM, Paueksakon P, Langone A, Concepcion BP. Acute Rejection of a Kidney Transplant in a Patient With Common Variable Immunodeficiency: A Case Report. Transplant Proc 2017; 49:380-385. [PMID: 28219603 DOI: 10.1016/j.transproceed.2016.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
Abstract
Common variable immunodeficiency is a primary immunodeficiency characterized by hypogammaglobulinemia and recurrent bacterial infections. We report a case of a 44-year-old male patient with end-stage renal disease and an established diagnosis of common variable immunodeficiency who underwent a living unrelated kidney transplant. He remained nearly infection free on maintenance immunoglobulin replacement. However, his posttransplant course was complicated by acute rejection that ultimately led to allograft loss. This case illustrates the challenge of transplantation in this patient population because of the delicate balance that must be achieved between maintaining adequate immunosuppression and minimizing the risk of infection.
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Affiliation(s)
- O Al Nimri
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - A Rajput
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - E Martinez
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J M Fahrenholz
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - P Paueksakon
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - A Langone
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - B P Concepcion
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Forbes RC, DeMers A, Concepcion BP, Moore DR, Schaefer HM, Shaffer D. A2 to B Blood Type Incompatible Deceased Donor Kidney Transplantation in a Recipient Infected with the Human Immunodeficiency Virus: A Case Report. Transplant Proc 2017; 49:206-209. [PMID: 28104138 DOI: 10.1016/j.transproceed.2016.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/22/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND With the introduction of the Kidney Allocation System in the United States in December 2014, transplant centers can list eligible B blood type recipients for A2 organ offers. There have been no prior reports of ABO incompatible A2 to B deceased donor kidney transplantation in human immunodeficiency virus-positive (HIV+) recipients to guide clinicians on enrolling or performing A2 to B transplantations in HIV+ candidates. We are the first to report a case of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results. METHODS AND RESULTS We describe an HIV+ 39-year-old African American man with end-stage renal disease who underwent A2 to B blood type incompatible deceased donor kidney transplantation. Prior to transplantation, he had an undetectable HIV viral load. The patient was unsensitized, with his most recent anti-A titer data being 1:2 IgG and 1:32 IgG/IgM. Induction therapy of basiliximab and methylprednisolone was followed by a postoperative regimen of plasma exchange, intravenous immunoglobulin, and rituximab with maintenance on tacrolimus, mycophenolate mofetil, and prednisone. He had delayed graft function without rejection on allograft biopsy. Nadir serum creatinine was 2.0 mg/dL. He continued to have an undetectable viral load on the same antiretroviral therapy adjusted for renal function. CONCLUSIONS To our knowledge, this is the first report of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results, suggesting that A2 donor kidneys may be considered for transplantation into HIV+ B-blood type wait list candidates.
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Affiliation(s)
- R C Forbes
- Department of General Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - A DeMers
- Department of General Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - B P Concepcion
- Department of Internal Medicine, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - D R Moore
- Department of General Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - H M Schaefer
- Department of Internal Medicine, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - D Shaffer
- Department of General Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Concepcion BP, Forbes RC, Schaefer HM. Older candidates for kidney transplantation: Who to refer and what to expect? World J Transplant 2016; 6:650-657. [PMID: 28058214 PMCID: PMC5175222 DOI: 10.5500/wjt.v6.i4.650] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/22/2016] [Accepted: 09/22/2016] [Indexed: 02/05/2023] Open
Abstract
The number of older end-stage renal disease patients being referred for kidney transplantation continues to increase. This rise is occurring alongside the continually increasing prevalence of older end-stage renal disease patients. Although older kidney transplant recipients have decreased patient and graft survival compared to younger patients, transplantation in this patient population is pursued due to the survival advantage that it confers over remaining on the deceased donor waiting list. The upper limit of age and the extent of comorbidity and frailty at which transplantation ceases to be advantageous is not known. Transplant physicians are therefore faced with the challenge of determining who among older patients are appropriate candidates for kidney transplantation. This is usually achieved by means of an organ systems-based medical evaluation with particular focus given to cardiovascular health. More recently, global measures of health such as functional status and frailty are increasingly being recognized as potential tools in risk stratifying kidney transplant candidates. For those candidates who are deemed eligible, living donor transplantation should be pursued. This may mean accepting a kidney from an older living donor. In the absence of any living donor, the choice to accept lesser quality kidneys should be made while taking into account the organ shortage and expected waiting times on the deceased donor list. Appropriate counseling of patients should be a cornerstone in the evaluation process and includes a discussion regarding expected outcomes, expected waiting times in the setting of the new Kidney Allocation System, benefits of living donor transplantation and the acceptance of lesser quality kidneys.
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Wheless L, Concepcion BP. A 71-year-old kidney transplant recipient with hemorrhagic mucocutaneous lesions. Am J Transplant 2015; 15:3008-10. [PMID: 26484841 DOI: 10.1111/ajt.13498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- L Wheless
- Division of Dermatology, Vanderbilt University, Nashville, TN
| | - B P Concepcion
- Division of Nephrology, Vanderbilt University, Nashville, TN
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