SO032THE DISCARD AND DECLINE OF HEPATITIS C VIRUS POSITIVE DONOR KIDNEYS IN THE UNITED STATES

Background and Aims

With more transplant centers in the United States are accepting hepatitis C virus infected (HCV+) deceased donor kidneys (dHCV+), the trend of non-utilization and decline of these organs have not been re-examined.

Method

We used data from the national Organ Procurement and Transplantation Network on deceased donor kidneys between Jan 2000 and Dec 2018 in the United States. Kidney non-utilization for HCV+ was defined as a positive donor HCV status and positive hepatitis as the reason for non-utilization. dHCV+ kidney decline was defined as a donor HCV+ status among kidneys recovered for transplantation but not transplanted. We assessed associations of a dHCV+ status with kidney non-utilization or decline, adjusted for donor characteristics (age, race, sex, body mass index, diabetes, hypertension, kidney donor profile index), using multivariable logistic regression.

Results

A total of 274,570 deceased donor kidneys procured for transplantation between 2000 and 2018 were identified. Among these kidneys, 4.1% were from dHCV+. Proportion of dHCV+ non-utilization among all non-utilized kidneys increased from 2000-2005 (3.9%) and then subsequently declined. This proportion increased slightly to 1.1% in 2014 and decreased to 0.5, 0.8, 0.4, 0.6% in 2015-2018, respectively. Multivariable-adjusted odds ratios for dHCV+ non-utilization and decline by year demonstrate consistently an increasing trend from 2000-2006 followed by a decreasing trend from 2006-2011 (Fig A-B). Multivariable-adjusted odds ratios for dHCV+ (compared to dHCV-) non-utilization and decline increased to 6.56 (95% CI 5.30-8.12) and 6.66 (95% CI 5.39-8.24), respectively, in 2012, and decreased to 2.32 (95% CI 2.01-2.69) and 2.28 (95% CI 1.98-2.64), respectively, in 2018.

Conclusion

dHCV+ non-utilization and decline have decreased in the last few years, particularly after 2014. 2018 had a historic lowest odds ratio for non-utilization and decline of dHCV+ organs, which reflects the increased acceptability of transplant centers to these kidneys. Overall, since 2014, the odds ratios for dHCV+ non-utilization and decline decreased by half. Yet, there is more room for decreasing the non-utilization and decline for these potentially life-saving organs.

Assessing variation in the costs of care among patients awaiting liver transplantation

Previous economic analyses of liver transplantation have focused on the cost of the transplant and subsequent care. Accurate characterization of the pretransplant costs, indexed to severity of illness, is needed to assess the economic burden of liver disease. A novel data set linking Medicare claims with transplant registry data for 15,710 liver transplant recipients was used to determine average monthly waitlist spending (N = 249,434 waitlist months) using multivariable linear regression models to adjust for recipient characteristics including Model for End-Stage Liver Disease (MELD) score. Characteristics associated with higher spending included older age, female gender, hepatocellular carcinoma, diabetes, hypertension and increasing MELD score (p < 0.05 for all). Spending increased exponentially with severity of illness: expected monthly spending at a MELD score of 30 was 10 times higher than at MELD of 20 ($22,685 vs. $2030). Monthly spending within MELD strata also varied geographically. For candidates with a MELD score of 35, spending varied from $19,548 (region 10) to $36,099 (region 7). Regional variation in waitlist costs may reflect the impact of longer waiting times on greater pretransplant hospitalization rates among high MELD score patients. Reducing the number of high MELD waitlist patients through improved medical management and novel organ allocation systems could decrease total spending for end-stage liver care.

Living kidney donor follow-up: state-of-the-art and future directions, conference summary and recommendations

In light of continued uncertainty regarding postkidney donation medical, psychosocial and socioeconomic outcomes for traditional living donors and especially for donors meeting more relaxed acceptance criteria, a meeting was held in September 2010 to (1) review limitations of existing data on outcomes of living kidney donors; (2) assess and define the need for long-term follow-up of living kidney donors; (3) identify the potential system requirements, infrastructure and costs of long-term follow-up for living kidney donor outcomes in the United States and (4) explore practical options for future development and funding of United States living kidney donor data collection, metrics and endpoints. Conference participants included prior kidney donors, physicians, surgeons, medical ethicists, social scientists, donor coordinators, social workers, independent donor advocates and representatives of payer organizations and the federal government. The findings and recommendations generated at this meeting are presented.

Application of diagnostic classification algorithms to identify the most common causes of post-transplant complications

ICD-9-CM diagnoses for hospitalizations occurring during the first 6 post-transplant months were summarized into Clinical Classifications System (CCS) categories. Of the 28,900 patients examined, 54% had at least one hospitalization. There were 2.39 hospitalizations per patient-year at risk. The total Medicare inpatient costs were $339 million and mean length of stay was 8.3 days. The most common and costly CCS diagnosis was complications of a kidney transplant followed by infections, circulatory system disease, gastrointestinal disease and endocrine complications. The CCS is a useful tool to summarize the complexity of claims information in the USRDS and could prove useful in further claims research.

New insights into protein intake and progression of renal disease

PURPOSE OF REVIEW

For several decades, dietary protein restriction has been considered as a strategy to slow renal disease progression. Recently, a National Kidney Foundation advisory board incorporated recommendations for supervised low-protein diets into guidelines for the care of non-dialyzed patients with chronic kidney failure. Despite this consensus statement, the clinical utility of dietary modification remains controversial. This article reviews new investigations of protein intake as a mediator of renal function and physiology published since 1 October 2002.

RECENT FINDINGS

Population-level data indicate graded risk for progressive renal functional decline with increasing protein intake among women with mild renal insufficiency, and support a possible association of higher protein consumption with the risk of microalbuminuria in people with concomitant diabetes and hypertension. A link between the quantity of protein intake and the rate of renal deterioration is suggested by preliminary prospective studies among incident peritoneal dialysis patients, renal transplant recipients, and animal models of kidney disease. Varied renal consequences based on protein composition were reported in population-based studies, animal-model experiments, and animal studies of in-utero protein exposure. Clinical trial experience raises concern for the feasibility of dietary interventions in practice.

SUMMARY

New research supports the view that high-protein diets accelerate renal disease progression, suggests differential consequences based on protein source, and explores risk among defined sub-populations. Topics for future exploration include the renal impact of high-protein weight-loss regimens, implications of dietary protein quantity and type across the stages of chronic kidney disease, and translation of animal studies of prenatal nutrition to humans.

A developmentally regulated chromosomal origin of replication uses essential transcription elements

Only one of the two chromosomes in the asymmetric Caulobacter predivisional cell initiates replication in the progeny cells. Transcription from a strong promoter within the origin occurs uniquely from the replication-competent chromosome at the stalked pole of the predivisional cell. This regulated promoter has an unusual sequence organization, and transcription from this promoter is essential for regulated (cell type-specific) replication. Our analysis defines a new class of bacterial origins and suggests a coupling between transcription and replication that is consistent with the phylogenetic relationship of Caulobacter to the ancestral mitochondrion.