1
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Forman LM, Jackson WE, Arrigain S, Lopez R, Schold JD. Socioeconomic deprivation is associated with worse patient and graft survival following adult liver transplantation. Liver Transpl 2024:01445473-990000000-00380. [PMID: 38767448 DOI: 10.1097/lvt.0000000000000400] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/05/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The impact of social determinants of health (SDOH) on adult liver transplant recipient outcomes is not clear at a national level. Further understanding of the impact of SDOH on patient outcomes can inform effective equitable healthcare delivery. METHODS Unadjusted and multivariable models were used to analyze the Scientific Registry of Transplant Recipients to evaluate the association between the Social Deprivation Index (SDI) based on liver transplant recipient's residential location and patient and graft survival. We included adult recipients between 1/1/2008-12/1/2021. RESULTS Patient and graft survival were lower in adults living in areas with deprivation scores above the median. Five-year patient and graft survival were 78.7% and 76.5% respectively in the cohort above median SDI compared to 80.5% and 78.3% below median SDI. Compared to the recipients in low deprivation residential areas, recipients residing in highest deprivation (SDI quintile=5) cohort had 6% higher adjusted risk of mortality (Adjusted Hazard Ratio [AHR]=1.06,95%C.I. 1.01-1.13) and 6% higher risk of graft failure (AHR=1.06,95% C.I. 1.001-1.11). The increased risks for recipients residing in more vulnerable residential areas were higher (AHR=1.11,95% CI 1.03-1.20 for both death and graft loss) following the first-year post-transplantation. Importantly, overall risk for graft loss associated with SDI was not linear but instead accelerated above the median level of deprivation. DISCUSSION In the United States, SDOH, as reflected by residential distress, significantly impact 5-year patient and graft survival. The overall effect of residential deprivation are modest, but importantly, results illustrate they are more strongly associated with longer-term follow up and accelerate at higher deprivation levels. Further research is needed to evaluate effective interventions and policies to attenuate disparities in outcomes among recipients in highly disadvantaged areas.
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Affiliation(s)
- Lisa M Forman
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Gastroenterology and Hepatology
- Colorado Center for Transplantation Care, Research and Education (CCTCARE)
| | - Whitney E Jackson
- University of Colorado Anschutz Medical Campus, Department of Medicine, Division of Gastroenterology and Hepatology
- Colorado Center for Transplantation Care, Research and Education (CCTCARE)
| | - Susana Arrigain
- Colorado Center for Transplantation Care, Research and Education (CCTCARE)
- University of Colorado Anschutz Medical Campus, Department of Surgery, Division of Transplant Surgery
| | - Rocio Lopez
- Colorado Center for Transplantation Care, Research and Education (CCTCARE)
- University of Colorado Anschutz Medical Campus, Department of Surgery, Division of Transplant Surgery
| | - Jesse D Schold
- Colorado Center for Transplantation Care, Research and Education (CCTCARE)
- University of Colorado Anschutz Medical Campus, Department of Surgery, Division of Transplant Surgery
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2
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Brahmania M, Rogal S, Serper M, Patel A, Goldberg D, Mathur A, Wilder J, Vittorio J, Yeoman A, Rich NE, Lazo M, Kardashian A, Asrani S, Spann A, Ufere N, Verma M, Verna E, Simpson D, Schold JD, Rosenblatt R, McElroy L, Wadwhani SI, Lee TH, Strauss AT, Chung RT, Aiza I, Carr R, Yang JM, Brady C, Fortune BE. Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease. Hepatol Commun 2024; 8:e0413. [PMID: 38696374 PMCID: PMC11068141 DOI: 10.1097/hc9.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 01/05/2024] [Indexed: 05/04/2024] Open
Abstract
Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.
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Affiliation(s)
- Mayur Brahmania
- Department of Medicine, Division of Gastroenterology and Transplant Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shari Rogal
- Department of Medicine, Division of Gastroenterology, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arpan Patel
- Department of Medicine, Division of Gastroenterology, University of California Los Angeles, Los Angeles, California, USA
| | - David Goldberg
- Department of Medicine, Division of Gastroenterology, University of Miami, Miami, Florida, USA
| | - Amit Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Julius Wilder
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Division of Pediatric Gastroenterology, NYU Langone Health, New York, New York, USA
| | - Andrew Yeoman
- Department of Medicine, Gwent Liver Unit, Aneurin Bevan University Health Board, Newport, Wales, UK
| | - Nicole E. Rich
- Department of Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mariana Lazo
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ani Kardashian
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Sumeet Asrani
- Department of Medicine, Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Ashley Spann
- Department of Medicine, Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nneka Ufere
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Elizabeth Verna
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Dinee Simpson
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - Jesse D. Schold
- Department of Surgery and Epidemiology, University of Colorado, Aurora, Colorado, USA
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Lisa McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sharad I. Wadwhani
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Tzu-Hao Lee
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Alexandra T. Strauss
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond T. Chung
- Department of Medicine, Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ignacio Aiza
- Department of Medicine, Liver Unit, Hospital Ángeles Lomas, Mexico City, Mexico
| | - Rotonya Carr
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Jin Mo Yang
- Department of Medicine, Division of Gastroenterology, Catholic University of Korea, Seoul, Korea
| | - Carla Brady
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Hepatology, Montefiore Einstein Medical Center, Bronx, New York, USA
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3
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Schold JD, Conzen KD, Cooper J, Arrigain S, Lopez R, Mohan S, Husain SA, Huml AM, Kennealey PT, Kaplan B, Pomfret EA. Quantifying the Effect of Consent for High-Kidney Donor Profile Index Deceased Donor Transplants in the United States. J Am Soc Nephrol 2024; 35:630-641. [PMID: 38347668 DOI: 10.1681/asn.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/19/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Key Points
Nationally, 41% of kidney transplant candidates consented to receive high–Kidney Donor Profile Index (KDPI) donor offers in the United States.There was wide variation in consent proportion for high-KDPI donors on the basis of individual characteristics and transplant centers.Consent for high-KDPI kidneys was associated with 15% higher adjusted rates of deceased donor transplantation.
Background
Despite known benefits of kidney transplantation, including transplantation from donors with increased risk factors, many waitlisted candidates die before transplantation. Consent to receive donor kidneys with lower expected survival (e.g., Kidney Donor Profile Index [KDPI] >85%) is typically obtained at waitlist placement. The presumed benefit of consent to receive high-KDPI donor kidneys is higher likelihood and timeliness of donor offers for transplantation. However, the specific effect of consent on access to transplantation is unclear. Our aims were to evaluate the characteristics of candidates consenting to high-KDPI donor kidneys and the likelihood of receiving a deceased donor transplant over time on the basis of consent.
Methods
We used national Scientific Registry of Transplant Recipients data between 2015 and 2022 (n=213,364). We evaluated the likelihood of consent using multivariable logistic models and time to deceased donor transplant with cumulative incidence plots accounting for competing risks and multivariable Cox models.
Results
Overall, high-KDPI consent was 41%, which was higher among candidates who were older, were Black or Hispanic, had higher body mass index, had diabetes, had vascular disease, and had 12–48 months prelisting dialysis time, with significant center-level variation. High-KDPI consent was associated with higher rates of deceased donor transplant (adjusted hazard ratio=1.15; 95% confidence interval, 1.13 to 1.17) with no difference in likelihood of deceased donor transplant from donors with KDPI <85%. The effect of high-KDPI consent on higher rates of deceased donor transplantation was higher among candidates older than 60 years and candidates with diabetes and variable on the basis of center characteristics.
Conclusions
There is significant variation of consent for high-KDPI donor kidneys and higher likelihood of transplantation associated with consent.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kendra D Conzen
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James Cooper
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Susana Arrigain
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rocio Lopez
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York
- Department of Epidemiology, Columbia University, New York, New York
| | - Syed Ali Husain
- Department of Medicine, Columbia University, New York, New York
| | - Anne M Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Peter T Kennealey
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth A Pomfret
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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4
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King KL, Yu M, Huml AM, Schold JD, Husain SA, Mohan S. Allocation and Utilization Patterns of Deceased Donor Kidneys for Preemptive Transplantation in the United States. J Am Soc Nephrol 2024; 35:642-645. [PMID: 38284887 DOI: 10.1681/asn.0000000000000317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/20/2024] [Indexed: 01/30/2024] Open
Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Anne M Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, Colorado
| | - Syed Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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5
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Zubkov MR, Moore HB, Lopez R, Brosi D, Choudhury RA, Arrigain S, Saben J, Conzen KD, Pomposelli JJ, Pomfret EA, Schold JD. Prognostic value of body mass index is highly modified by sex among liver transplant recipients. Liver Transpl 2024:01445473-990000000-00370. [PMID: 38687166 DOI: 10.1097/lvt.0000000000000389] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/22/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Micaella R Zubkov
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Rocio Lopez
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - Deena Brosi
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - Rashikh A Choudhury
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - Susana Arrigain
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - Jessica Saben
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - Kendra D Conzen
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - James J Pomposelli
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - Elizabeth A Pomfret
- University of Colorado Department of Surgery
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
| | - Jesse D Schold
- University of Colorado Department of Surgery
- University of Colorado Department of Epidemiology
- Colorado Center for Transplantation Care, Research, and Education, University of Colorado Anschutz Medical Campus, Aurora
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6
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Yu M, King KL, Maclay LM, Husain SA, Schold JD, Mohan S. Incomplete reporting of clinically significant acute rejection episodes in the national kidney transplant registry. Am J Transplant 2024:S1600-6135(24)00277-6. [PMID: 38636806 DOI: 10.1016/j.ajt.2024.04.006] [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: 12/12/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Administrative claims data could provide a unique opportunity to identify acute rejection (AR) events using specific antirejection medications and to validate rejected data reported to the Organ Procurement and Transplantation Network. This retrospective cohort study examined differences in registry-reported events and those identified using claims data among adult kidney transplant recipients from 2012 to 2017 using Standard Analysis Files from the US Renal Data System. Rejection rates, survival estimates, and center-level differences were assessed using each approach. Among 45 880 first-time kidney transplant recipients, we identified 3841 AR events within 12 months of transplant reported by centers in the registry; claims data yielded 2945 events. Of all events occurring within 12 months of transplant, 48.5% were reported using registry only, 32.9% were identified using claims only, and 18.6% were identified using both approaches. A 3-year death-censored graft survival probability was 90.0%, 88.4%, and 81.2% (P < .001) for ARs identified using registry only, claims data only, and both approaches, respectively. The large discordance between registry-reported and claims-based events suggests incomplete and potentially inaccurate reporting of events in the Organ Procurement Transplant Network registry. These findings have important implications for analyses that use AR data and underscore the need for improved capture of clinically meaningful events.
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Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Lindsey M Maclay
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.
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7
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Yu M, King KL, Husain SA, Schold JD, Mohan S. Use of Offer Bypass Filters Under the Updated Kidney Allocation System. Kidney360 2024:02200512-990000000-00367. [PMID: 38568866 DOI: 10.34067/kid.0000000000000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/19/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY
- Columbia University Renal Epidemiology Group, New York, NY
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY
- Columbia University Renal Epidemiology Group, New York, NY
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY
- Columbia University Renal Epidemiology Group, New York, NY
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, CO
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY
- Columbia University Renal Epidemiology Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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8
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Amdani S, Dewey EN, Schold JD. Public Reporting of Heart Transplant Center Performance: Promoting Clarity or Causing Confusion? JACC Heart Fail 2024:S2213-1779(24)00160-4. [PMID: 38613559 DOI: 10.1016/j.jchf.2024.01.021] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/07/2023] [Accepted: 01/22/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Transplant center report cards are publicly available and used by regulators, insurance payers, and importantly patients and families. OBJECTIVES In this study, the authors sought to evaluate the variability in reported public performance ratings of pediatric and adult heart transplant centers. METHODS Program-specific reports from the Scientific Registry of Transplant Recipients from 2017-2021 were used to evaluate stability, volatility, and reliability of 3 publicly reported ratings: waitlist survival (WS), getting to a faster transplant (FT), and post-transplantation graft failure (GF). RESULTS There were 112 adult and 55 pediatric centers. Over the study period, nearly all centers (98%) had at least 1 change in rating in at least 1 of the tiers. The average time to the first rating change of any magnitude was 12-18 months for all tiers and centers. For adult centers, the most volatile rating was WS (SD: 0.77), followed by GF (SD: 0.76) and then FT (SD: 0.57). For pediatric centers, the most volatile rating was WS (SD: 0.79), followed by both GF (SD: 0.66) and FT (SD: 0.68), which were equally volatile. All tiers except adult FT had an estimated Fleiss's kappa <0.20, indicating poor agreement/consistency across the study period. In addition, the intraclass correlation coefficient for all tiers was <0.50, indicating poor reliability. CONCLUSIONS The current 5-tier reporting of transplant center performance is highly volatile and has poor reliability and consistency. Given the unintended and significant negative consequences these reports can have, critical revision of these ratings is warranted.
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Affiliation(s)
- Shahnawaz Amdani
- Children's Institute Department of Heart, Vascular & Thoracic, Division of Cardiology & Cardiovascular Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA.
| | - Elizabeth N Dewey
- Center for Populations Health Research, Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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9
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Buchalter RB, Mohan S, Schold JD. Geospatial Modeling Methods in Epidemiological Kidney Research: An Overview and Practical Example. Kidney Int Rep 2024; 9:807-816. [PMID: 38765574 PMCID: PMC11101776 DOI: 10.1016/j.ekir.2024.01.017] [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] [Received: 10/25/2023] [Revised: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 05/22/2024] Open
Abstract
Geospatial modeling methods in population-level kidney research have not been used to full potential because few studies have completed associative spatial analyses between risk factors and exposures and kidney conditions and outcomes. Spatial modeling has several advantages over traditional modeling, including improved estimation of statistical variation and more accurate and unbiased estimation of coefficient effect direction or magnitudes by accounting for spatial data structure. Because most population-level kidney research data are geographically referenced, there is a need for better understanding of geospatial modeling for evaluating associations of individual geolocation with processes of care and clinical outcomes. In this review, we describe common spatial models, provide details to execute these analyses, and perform a case-study to display how results differ when integrating geographic structure. In our case-study, we used U.S. nationwide 2019 chronic kidney disease (CKD) data from Centers for Disease Control and Prevention's Kidney Disease Surveillance System and 2006 to 2010 U.S. Environmental Protection Agency environmental quality index (EQI) data and fit a nonspatial count model along with global spatial models (spatially lagged model [SLM]/pseudo-spatial error model [PSEM]) and a local spatial model (geographically weighted quasi-Poisson regression [GWQPR]). We found the SLM, PSEM, and GWQPR improved model fit in comparison to the nonspatial regression, and the PSEM model decreased the positive relationship between EQI and CKD prevalence. The GWQPR also revealed spatial heterogeneity in the EQI-CKD relationship. To summarize, spatial modeling has promise as a clinical and public health translational tool, and our case-study example is an exhibition of how these analyses may be performed to improve the accuracy and utility of findings.
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Affiliation(s)
- R. Blake Buchalter
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
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10
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Husain SA, Khanna S, Yu M, Adler JT, Cron DC, King KL, Schold JD, Mohan S. Cold Ischemia Time and Delayed Graft Function in Kidney Transplantation: A Paired Kidney Analysis. Transplantation 2024:00007890-990000000-00713. [PMID: 38557641 DOI: 10.1097/tp.0000000000005006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND We aimed to understand the association between cold ischemia time (CIT) and delayed graft function (DGF) after kidney transplantation and the impact of organ pumping on that association. METHODS Retrospective cohort study using US registry data. We identified kidney pairs from the same donor where both kidneys were transplanted but had a CIT difference >0 and ≤20 h. We determined the frequency of concordant (both kidneys with/without DGF) or discordant (only 1 kidney DGF) DGF outcomes. Among discordant pairs, we computed unadjusted and adjusted relative risk of DGF associated with longer-CIT status, when then repeated this analysis restricted to pairs where only the longer-CIT kidney was pumped. RESULTS Among 25 831 kidney pairs included, 71% had concordant DGF outcomes, 16% had only the longer-CIT kidney with DGF, and 13% had only the shorter-CIT kidney with DGF. Among discordant pairs, longer-CIT status was associated with a higher risk of DGF in unadjusted and adjusted models. Among pairs where only the longer-CIT kidney was pumped, longer-CIT kidneys that were pumped had a lower risk of DGF than their contralateral shorter-CIT kidneys that were not pumped regardless of the size of the CIT difference. CONCLUSIONS Most kidney pairs have concordant DGF outcomes regardless of CIT difference, but even small increases in CIT raise the risk of DGF. Organ pumping may mitigate and even overcome the adverse consequences of prolonged CIT on the risk of DGF, but prospective studies are needed to better understand this relationship.
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Affiliation(s)
- Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Sohil Khanna
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Jesse D Schold
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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11
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Schold JD, Tambur AR, Mohan S, Kaplan B. Calibration of Priority Points for Sensitization Status of Kidney Transplant Candidates in the United States. Clin J Am Soc Nephrol 2024:01277230-990000000-00366. [PMID: 38509037 DOI: 10.2215/cjn.0000000000000449] [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: 09/28/2023] [Accepted: 03/14/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND A primary change to the national organ allocation system in 2014 for deceased donor kidney offers was to weight candidate priority based on sensitization (i.e. calculated panel reactive antibody percentage [CPRA%]) using a sliding scale. Increased priority for sensitized patients could improve equity in access to transplantation for disadvantaged candidates. We sought to evaluate the effect of these weights using a contemporary cohort of adult US kidney transplant candidates. METHODS We used the national Scientific Registry of Transplant Recipients to evaluate factors associated with sensitization using multivariable logistic models and rates of deceased donor transplantation using cumulative incidence models accounting for competing risks and multivariable Cox models. RESULTS We examined 270,912 adult candidates placed on the waiting list between Jan,2016-September,2023. Six-year cumulative incidence of deceased donor transplantation for candidates with cPRA%=[80-85) and [90-95) was 48% and 53% respectively, as compared to 37% for candidates with cPRA%=[0-20). In multivariable models, candidates with high cPRA% had the highest adjusted hazards for deceased donor transplantation. There was significant effect modification such that the association of high cPRA% with adjusted rates of deceased donor transplantation varied by region of the country, gender, race/ethnicity, prior dialysis time and blood type. CONCLUSIONS Results indicate that the weighting algorithm for highly sensitized candidates may overinflate the need for prioritization and lead to higher rates of transplantation. Findings suggest re-calibration of priority weights for allocation is needed to facilitate overall equity in access to transplantation for prospective kidney transplant candidates. However, priority points should also account for subgroups of candidates who are disadvantaged for access to donor offers.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anat R Tambur
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York
- Department of Epidemiology, Columbia University, New York, New York
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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12
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Bakhtiyar SS, Maksimuk TE, Gutowski J, Park SY, Cain MT, Rove JY, Reece TB, Cleveland JC, Pomposelli JJ, Bababekov YJ, Nydam TL, Schold JD, Pomfret EA, Hoffman JRH. Association of procurement technique with organ yield and cost following donation after circulatory death. Am J Transplant 2024:S1600-6135(24)00237-5. [PMID: 38521350 DOI: 10.1016/j.ajt.2024.03.027] [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: 01/13/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024]
Abstract
Donation after circulatory death (DCD) could account for the largest expansion of the donor allograft pool in the contemporary era. However, the organ yield and associated costs of normothermic regional perfusion (NRP) compared to super-rapid recovery (SRR) with ex-situ normothermic machine perfusion, remain unreported. The Organ Procurement and Transplantation Network (December 2019 to June 2023) was analyzed to determine the number of organs recovered per donor. A cost analysis was performed based on our institution's experience since 2022. Of 43 502 donors, 30 646 (70%) were donors after brain death (DBD), 12 536 (29%) DCD-SRR and 320 (0.7%) DCD-NRP. The mean number of organs recovered was 3.70 for DBD, 3.71 for DCD-NRP (P < .001), and 2.45 for DCD-SRR (P < .001). Following risk adjustment, DCD-NRP (adjusted odds ratio 1.34, confidence interval 1.04-1.75) and DCD-SRR (adjusted odds ratio 2.11, confidence interval 2.01-2.21; reference: DBD) remained associated with greater odds of allograft nonuse. Including incomplete and completed procurement runs, the total average cost of DCD-NRP was $9463.22 per donor. By conservative estimates, we found that approximately 31 donor allografts could be procured using DCD-NRP for the cost equivalent of 1 allograft procured via DCD-SRR with ex-situ normothermic machine perfusion. In conclusion, DCD-SRR procurements were associated with the lowest organ yield compared to other procurement methods. To facilitate broader adoption of DCD procurement, a comprehensive understanding of the trade-offs inherent in each technique is imperative.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA.
| | - Tiffany E Maksimuk
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - John Gutowski
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Sarah Y Park
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - T Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - James J Pomposelli
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Yanik J Bababekov
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Trevor L Nydam
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Jesse D Schold
- Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Elizabeth A Pomfret
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
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13
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Schold JD, Lopez R, Mohan S. Are the Centers for Medicare & Medicaid Services metrics evaluating organ procurement organization performance too fragile? Am J Transplant 2024:S1600-6135(24)00222-3. [PMID: 38519005 DOI: 10.1016/j.ajt.2024.03.025] [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: 02/13/2024] [Revised: 03/04/2024] [Accepted: 03/18/2024] [Indexed: 03/24/2024]
Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Rocio Lopez
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Department of Medicine, Columbia University, New York, New York, USA; Department of Epidemiology, Columbia University, New York, New York, USA
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14
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Adams AB, Blumberg EA, Gill JS, Katz E, Kawai T, Schold JD, Sykes M, Tector A, Sachs DH. Enhancing Kidney Transplantation and the Role of Xenografts: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2024:S0272-6386(24)00629-2. [PMID: 38452918 DOI: 10.1053/j.ajkd.2023.12.025] [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: 07/26/2023] [Revised: 12/10/2023] [Accepted: 12/30/2023] [Indexed: 03/09/2024]
Abstract
Chronic kidney disease affects an estimated 37 million people in the United States; of these,>800,000 have end-stage renal disease requiring chronic dialysis or a kidney transplant to survive. Despite efforts to increase the donor kidney supply, approximately 100,000 people are registered on the kidney transplant wait-list with no measurable decrease over the past 2 decades. The outcomes of kidney transplantation are significantly better than for chronic dialysis: kidney transplant recipients have lower rates of mortality and cardiovascular events and better quality of life, but wait-list time matters. Time on dialysis waiting for a deceased-donor kidney is a strong independent risk factor for outcomes after a kidney transplant. Deceased-donor recipients with wait-list times on dialysis of<6 months have graft survival rates equivalent to living-donor recipients with waitlist times on dialysis of>2 years. In 2021,>12,000 people had been on the kidney transplant waitlist for ≥5 years. As the gap between the demand for and availability of donor kidneys for allotransplantation continues to widen, alternative strategies are needed to provide a stable, sufficient, and timely supply. A strategy that is gaining momentum toward clinical application is pig-to-human kidney xenotransplantation. This report summarizes the proceedings of a meeting convened on April 11-12, 2022, by the National Kidney Foundation to review and assess the state of pig-to-human kidney xenotransplantation as a potential cure for end-stage renal disease.
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Affiliation(s)
- Andrew B Adams
- Department of Surgery, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Emily A Blumberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John S Gill
- Division of Nephrology, University of British Columbia, British Columbia, Vancouver, Canada
| | | | - Tatsuo Kawai
- Massachusetts General Hospital, Harvard University, Boston, Massachusetts; Center for Transplantation Sciences, Harvard University, Boston, Massachusetts
| | - Jesse D Schold
- Department of Surgery and Epidemiology, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Megan Sykes
- Department of Medicine, Columbia Center for Translational Immunology, and Department of Medicine, Department of Microbiology and Immunology, and Department of Surgery; Columbia University, New York, New York
| | - Alfred Tector
- DeWitt Daughtry Family Department of Surgery, School of Medicine, University of Miami, Miami, Florida
| | - David H Sachs
- Massachusetts General Hospital, Harvard University, Boston, Massachusetts; Medical School, Harvard University, Boston, Massachusetts; Columbia University Medical Center, New York, New York.
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15
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Schold JD, Mohan S, Jackson WE, Stites E, Burton JR, Bababekov YJ, Saben JL, Pomposelli JJ, Pomfret EA, Kaplan B. Differential in Kidney Graft Years on the Basis of Solitary Kidney, Simultaneous Liver-Kidney, and Kidney-after-Liver Transplants. Clin J Am Soc Nephrol 2024; 19:364-373. [PMID: 37962880 PMCID: PMC10937020 DOI: 10.2215/cjn.0000000000000353] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The number of simultaneous liver-kidney (SLK) transplants has significantly increased in the United States. There has also been an increase in kidney-after-liver transplants associated with 2017 policy revisions aimed to fairly allocate kidneys after livers. SLK and kidney-after-liver candidates are prioritized in allocation policy for kidney offers ahead of kidney-alone candidates. METHODS We compared kidney graft outcomes of kidney-alone transplant recipients with SLK and kidney-after-liver transplants using paired kidney models to mitigate differences among donor risk factors. We evaluated recipient characteristics between transplant types and calculated differential graft years using restricted mean survival estimates. RESULTS We evaluated 3053 paired donors to kidney-alone and SLK recipients and 516 paired donors to kidney-alone and kidney-after-liver recipients from August 2017 to August 2022. Kidney-alone recipients were younger, more likely on dialysis, and Black race. One-year and 3-year post-transplant kidney graft survival for kidney-alone recipients was 94% and 86% versus SLK recipients 89% and 80%, respectively, P < 0.001. One-year and 3-year kidney graft survival for kidney-alone recipients was 94% and 84% versus kidney-after-liver recipients 93% and 87%, respectively, P = 0.53. The additional kidney graft years for kidney-alone versus SLK transplants was 21 graft years/100 transplants (SEM=5.0) within 4 years post-transplantation, with no significant difference between kidney-after-liver and kidney-alone transplants. CONCLUSIONS Over a 5-year period in the United States, SLK transplantation was associated with significantly lower kidney graft survival compared with paired kidney-alone transplants. Most differences in graft survival between SLK and kidney-alone transplants occurred within the first year post-transplantation. By contrast, kidney-after-liver transplants had comparable graft survival with paired kidney-alone transplants.
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Affiliation(s)
- Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Whitney E. Jackson
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Erik Stites
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James R. Burton
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Yanik J. Bababekov
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jessica L. Saben
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James J. Pomposelli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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16
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Saben JL, Kaplan B, Burton JR, Cooper JE, Pomposelli JJ, Schold JD, Pomfret EA. Highlights From Controversies in Transplantation 2023 Conference. Transplantation 2024; 108:598-600. [PMID: 37314449 DOI: 10.1097/tp.0000000000004699] [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: 06/15/2023]
Affiliation(s)
- Jessica L Saben
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Bruce Kaplan
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James R Burton
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James E Cooper
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James J Pomposelli
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Jesse D Schold
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Elizabeth A Pomfret
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
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17
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Cooper M, Wiseman AC, Doshi MD, Hall IE, Parsons RF, Pastan S, Reddy KS, Schold JD, Mohan S, Hippen BE. Understanding Delayed Graft Function to Improve Organ Utilization and Patient Outcomes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2024; 83:360-369. [PMID: 37844725 DOI: 10.1053/j.ajkd.2023.08.018] [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: 05/24/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 10/18/2023]
Abstract
Delayed graft function (DGF) is a common complication after kidney transplant. Despite extensive literature on the topic, the extant definition of DGF has not been conducive to advancing the scientific understanding of the influences and mechanisms contributing to its onset, duration, resolution, or long-term prognostic implications. In 2022, the National Kidney Foundation sponsored a multidisciplinary scientific workshop to comprehensively review the current state of knowledge about the diagnosis, therapy, and management of DGF and conducted a survey of relevant stakeholders on topics of clinical and regulatory interest. In this Special Report, we propose and defend a novel taxonomy for the clinical and research definitions of DGF, address key regulatory and clinical practice issues surrounding DGF, review the current state of therapies to reduce and/or attenuate DGF, offer considerations for clinical practice related to the outpatient management of DGF, and outline a prospective research and policy agenda.
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Affiliation(s)
- Matthew Cooper
- Department of Surgery, Division of Transplantation, Medical College of Wisconsin, Milwaukee, WI.
| | | | - Mona D Doshi
- Department of Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Isaac E Hall
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah
| | | | - Stephen Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse D Schold
- Departments of Surgery and Epidemiology, University of Colorado Anschutz Medical College, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Benjamin E Hippen
- Global Medical Office, Fresenius Medical Care, Charlotte, North Carolina
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18
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McElroy LM, Schold JD. Moving toward Racial Equity in Preemptive Listing for Kidney Transplant in the United States. Clin J Am Soc Nephrol 2024; 19:278-279. [PMID: 38265767 PMCID: PMC10937013 DOI: 10.2215/cjn.0000000000000426] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Lisa M. McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Jesse D. Schold
- Department of Surgery, University of Colorado University Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado University Anschutz Medical Campus, Aurora, Colorado
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19
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Noreen SM, Patzer RE, Mohan S, Schold JD, Lyden GR, Miller J, Verbeke S, Stewart D, Fritz AR, McBride M, Snyder JJ. Augmenting the Unites States transplant registry with external mortality data: A moving target ripe for further improvement. Am J Transplant 2024; 24:190-212. [PMID: 37704059 DOI: 10.1016/j.ajt.2023.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 04/12/2023] [Revised: 08/13/2023] [Accepted: 09/03/2023] [Indexed: 09/15/2023]
Abstract
The Organ Procurement and Transplantation Network conducts a robust death verification process when augmenting the United States transplant registry with external sources of data. Process enhancements added over 35,000 externally verified deaths across waitlist candidates and transplant recipients for all organs beginning in April 2022. Ninety-four percent of added posttransplant deaths occurred beyond 5 years posttransplant, and over 74% occurred beyond 10 years. Deceased donor solid organ recipients transplanted from January 1, 2010, through October 31, 2020, were analyzed from January and July 2022 Organ Procurement and Transplantation Network Standard Transplant Analysis and Research and the Scientific Registry of Transplant Recipients Standard Analysis Files to quantify the impact of including vs excluding unverified deaths (not releasable to researchers) on posttransplant patient survival estimates. Across all organs, 1- and 5-year posttransplant survival rates were not substantially impacted; meaningful differences were observed in 10-year survival among kidney recipients. These findings bear important implications for anyone who utilized transplant registry data to examine long-term outcomes prior to the updated verification process. Users of transplant surveillance data should interpret results of long-term outcomes cautiously, particularly differences across subpopulations, and the transplant community should identify ways to improve data quality and minimize the reporting burden on transplant institutions.
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Affiliation(s)
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz, Aurora, Colorado, USA
| | - Grace R Lyden
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Jonathan Miller
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Scott Verbeke
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York, USA
| | - Amber R Fritz
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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20
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Cholin LK, Ramos EF, Yahr J, Schold JD, Poggio ED, Delvalle CL, Huml AM. Psychosocial characteristics of potential and actual living kidney donors. BMC Nephrol 2024; 25:31. [PMID: 38267875 PMCID: PMC10807153 DOI: 10.1186/s12882-023-03375-z] [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: 10/20/2022] [Accepted: 10/19/2023] [Indexed: 01/26/2024] Open
Abstract
The psychosocial assessment is an essential component of the living kidney donor (LKD) evaluation. However, it remains uncertain how specific psychosocial factors impact LKD eligibility. We performed a retrospective chart review of LKD candidates who initiated the evaluation process and who had completed a required, in-person licensed social work (LSW) visit. LSW notes were reviewed for frequency of psychosocial factors that may impact the success of LKD candidate approval by the selection committee. 325 LKD candidates were included in the study: 104 not-approved and 221 approved. Not-approved LKD candidates were more likely to receive a negative family reaction to wanting to donate than approved LKD candidates (8.7% vs 1.4%, p < 0.01). On multivariate analysis, Black race, history of psychiatric illness, highest level of education being high school, and high psychosocial risk score assignment were all associated with a lower odds ratio of being approved. The majority of not-approved LKD candidates were disqualified for medical reasons (N = 76, 73.1%). In conclusion, psychosocial factors impact donation even after LKD candidates make it to an in-person evaluation.
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Affiliation(s)
- Liza K Cholin
- Department of Nephrology, The Ohio State University Wexner Medical Center, 300 W 10Th Ave, Columbus, OH, #1150, USA.
| | - Everly F Ramos
- Department of Internal Medicine, Cleveland Clinic, Cleveland, USA
| | - Jordana Yahr
- Department of Internal Medicine, Cleveland Clinic, Cleveland, USA
| | - Jesse D Schold
- Department of Surgery and Transplant, University of CO Anschutz Medical Campus, Aurora, CO,, USA
| | - Emilio D Poggio
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, OH, USA
- Department of Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | | | - Anne M Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, OH, USA
- Department of Transplantation, Cleveland Clinic, Cleveland, OH, USA
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21
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Abidi MZ, Schold JD, Kaplan B, Weinberg A, Erlandson KM, Malamon JS. Patient years lost due to cytomegalovirus serostatus mismatching in the scientific registry of transplant recipients. Front Immunol 2024; 14:1292648. [PMID: 38264645 PMCID: PMC10803440 DOI: 10.3389/fimmu.2023.1292648] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024] Open
Abstract
Background The cytomegalovirus (CMV) mismatch rate in deceased donor kidney transplant (DDKT) recipients in the US remains above 40%. Since CMV mismatching is common in DDKT recipients, the cumulative effects may be significant in the context of overall patient and graft survival. Our primary objective was to describe the short- and long-term risks associated with high-risk CMV donor positive/recipient negative (D+/R-) mismatching among DDKT recipients with the explicit goal of deriving a mathematical mismatching penalty. Methods We conducted a retrospective, secondary analysis of the Scientific Registry of Transplant Recipients (SRTR) database using donor-matched DDKT recipient pairs (N=105,608) transplanted between 2011-2022. All-cause mortality and graft failure hazard ratios were calculated from one year to ten years post-DDKT. All-cause graft failure included death events. Survival curves were calculated using the Kaplan-Meier estimation at 10 years post-DDKT and extrapolated to 20 years to provide the average graft days lost (aGDL) and average patient days lost (aPDL) due to CMV D+/R- serostatus mismatching. We also performed an age-based stratification analysis to compare the relative risk of CMV D+ mismatching by age. Results Among 31,518 CMV D+/R- recipients, at 1 year post-DDKT, the relative risk of death increased by 29% (p<0.001), and graft failure increased by 17% (p<0.001) as compared to matched CMV D+/R+ group (N=31,518). Age stratification demonstrated a significant increase in the risk associated with CMV mismatching in patients 40 years of age and greater. The aGDL per patient due to mismatching was 125 days and the aPDL per patient was 100 days. Conclusion The risks of CMV D+/R- mismatching are seen both at 1 year post-DDKT period and accumulated throughout the lifespan of the patient, with the average CMV D+/R- recipient losing more than three months of post-DDKT survival time. CMV D+/R- mismatching poses a more significant risk and a greater health burden than previously reported, thus obviating the need for better preventive strategies including CMV serodirected organ allocation to prolong lifespans and graft survival in high-risk patients.
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Affiliation(s)
- Maheen Z. Abidi
- Department of Medicine, Division of Infectious Diseases, University of Colorado, Aurora, CO, United States
| | - Jesse D. Schold
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora, CO, United States
- Colorado Center for Transplantation Care (CCTCARE), Research and Education, Division of Transplant Surgery, Department of Surgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
| | - Bruce Kaplan
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora, CO, United States
- Colorado Center for Transplantation Care (CCTCARE), Research and Education, Division of Transplant Surgery, Department of Surgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
| | - Adriana Weinberg
- Department of Medicine, Division of Infectious Diseases, University of Colorado, Aurora, CO, United States
- Department of Pediatrics and Pathology, University of Colorado, Aurora, CO, United States
| | - Kristine M. Erlandson
- Department of Medicine, Division of Infectious Diseases, University of Colorado, Aurora, CO, United States
| | - John S. Malamon
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora, CO, United States
- Colorado Center for Transplantation Care (CCTCARE), Research and Education, Division of Transplant Surgery, Department of Surgery, Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
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22
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Amdani S, Lopez R, Schold JD, Tang WHW. 30- and 60-Day Readmission Rates for Children With Heart Failure in the United States. JACC Heart Fail 2024; 12:83-96. [PMID: 37943220 DOI: 10.1016/j.jchf.2023.08.029] [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] [Received: 03/28/2023] [Revised: 08/07/2023] [Accepted: 08/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Studies on readmission for pediatric heart failure (HF) patients is sparse. OBJECTIVES This study evaluated 30- and 60-day readmission rates in pediatric HF patients from 2010 to 2019. METHODS The authors used data from the Nationwide Readmission Database to evaluate trends in 30- and 60-day hospital readmissions among pediatric patients with HF and compare them with adults with HF. Readmissions were also stratified by sex, diagnosis, neighborhood income, and hospital volume. RESULTS There were 84,731 hospital admissions for HF. Compared with children without HF, those with HF were older, had Medicare/Medicaid insurance, and resided in micropolitan areas and low-income neighborhoods. The 30- (19.5% vs 3.1%) and 60-day (27.5% vs 4.3%) all-cause readmission rates were higher for children with HF compared with those without HF. Compared with children without HF, lengths of stay, deaths, and costs related to their readmission were higher for children readmitted with HF (P < 0.05 for all). There was no significant decline in pediatric HF-related 30- or 60- day readmissions during the study period overall, or for those with congenital heart disease (P > 0.05), unlike adult HF readmissions (P < 0.01). Infants were at highest risk, and readmission rates for teenagers are rising. CONCLUSIONS The 30- and 60-day readmission rates for pediatric patients with HF in the current era is high (∼20% and 30%, respectively). Unlike adult HF, pediatric HF readmission rates have not declined. Pediatric HF patients readmitted to the hospital have higher death rates and greater resource utilization than patients without HF. National measures to decrease readmissions for pediatric patients with HF is warranted.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA.
| | - Rocio Lopez
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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23
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Augustine JJ, Liaqat A, Arrigain S, Schold JD, Poggio ED. Performance of estimated glomerular filtration rate equations in Black living kidney donor candidates. Clin Transplant 2024; 38:e15198. [PMID: 37964662 DOI: 10.1111/ctr.15198] [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: 06/03/2023] [Revised: 10/18/2023] [Accepted: 11/08/2023] [Indexed: 11/16/2023]
Abstract
INTRODUCTION New estimated glomerular filtration rate (eGFR) equations using serum creatinine and/or cystatin C have been derived to eliminate adjustment by perceived Black ancestry. We sought to analyze the performance of newer eGFR equations among Black living kidney donor candidates. METHODS Black candidates (n = 64) who had measured iothalamate GFR between January 2015 and October 2021 were included, and eGFR was calculated using race adjusted (eGFRcr2009 and eGFRcr-cys2012) and race unadjusted (eGFRcys2012, eGFRcr2021, and eGFRcr-cys2021) CKD-EPI equations. Bias and accuracy were calculated. RESULTS The eGFRcr2021 equation had a negative bias of 9 mL/min/1.73 m2 , while other equations showed a modest positive bias. Accuracy within 10% and 30% was greatest using the eGFRcr-cys2021 equation. With the eGFRcr2021 equation, 9.4% of donors with an mGFR > 80 mL/min/1.73 m2 were misclassified as having an eGFR < 80 mL/min/1.73 m2 . eGFR was also compared among 18 kidney donors at 6-24 months post-donation. Post-donation, the percentage of donors with an eGFR < 60 mL/min/1.73 m2 was 44% using the eGFRcr2021 equation compared to 11% using the eGFRcr-cys2021 equation. CONCLUSION The CKD-EPICr2021 equation appears to underestimate true GFR in Black living donor candidates. Alternatively, compared to CKD-EPICr2021, the CKD-EPICr-CysC2021 equation appears to perform with less bias and improved accuracy.
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Affiliation(s)
- Joshua J Augustine
- Department of Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Aimen Liaqat
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Susana Arrigain
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Emilio D Poggio
- Department of Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
BACKGROUND The Organ Procurement Transplant Network (OPTN)/United Network for Organ Sharing (UNOS) registry is an important national registry in the field of solid organ transplantation. Data collected are mission critical, given its role in organ allocation prioritization, program performance monitoring by both the OPTN and the Centers for Medicare & Medicaid Services, and countless observational analyses that helped to move the field forward. Despite the multifaceted importance of the OPTN/UNOS database, there are clear indications that investments in the database to ensure the quality and reliability of the data have been lacking. METHODS This analysis outlines 2 examples: (1) primary diagnosis for patients who are receiving a second transplant and (2) reporting peripheral vascular disease in kidney transplantation to illustrate the extensive challenges facing the veracity and integrity of the OPTN/UNOS database today. RESULTS Despite guidance that repeat kidney transplant patients should be coded as "retransplant/graft failure" rather than their native kidney disease, only 59% of new incident patients are coded in this manner. Peripheral vascular disease prevalence more than doubled in a 20-y span when the variable became associated with risk adjustment. CONCLUSIONS This article summarizes critical gaps in the OPTN/UNOS database, and we bring forward ideas and proposals for consideration as a path toward improvement.
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Affiliation(s)
- Demetra S Tsapepas
- Department of Transplant Analytics, New York Presbyterian Hospital, New York, NY
- Department of Transplant Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kristen King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Miko E Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | | | - Jesse D Schold
- Departments of Surgery and Epidemiology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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25
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Schold JD, Huml AM, Husain SA, Poggio ED, Buchalter RB, Lopez R, Kaplan B, Mohan S. Deceased donor kidneys from higher distressed communities are significantly less likely to be utilized for transplantation. Am J Transplant 2023; 23:1723-1732. [PMID: 37001643 DOI: 10.1016/j.ajt.2023.03.019] [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: 11/01/2022] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
The proportion of kidneys procured for transplantation but not utilized exceeds 20% in the United States. Factors associated with nonutilization are complex, and further understanding of novel causes are critically important. We used the national Scientific Registry of Transplant Recipients data (2010-2022) to evaluate associations of Distressed Community Index (DCI) of deceased donor residence and likelihood of kidney nonutilization (n = 209 413). Deceased donors from higher distressed communities were younger, had an increased history of hypertension and diabetes, were CDC high-risk, and had higher terminal creatinine and donation after brain death. Mechanisms and circumstances of death varied significantly by DCI. The proportion of kidney nonutilization was 19.9%, which increased by DCI quintile (Q1 = 18.1% to Q5 = 21.6%). The adjusted odds ratio of nonutilization from the highest quintile DCI communities was 1.22 (95% CI = 1.16-1.28; reference = lowest DCI), which persisted stratified by donor race. Donors from highly distressed communities were highly variable by the donor service area (range: 1%-51%; median = 21%). There was no increased risk for delayed graft function or death-censored graft loss by donor DCI but modest increased adjusted hazard for overall graft loss (high DCI = 1.05; 95% CI = 1.01-1.10; reference = lowest DCI). Results indicate that donor residential distress is associated with significantly higher rates of donor kidney nonutilization with notable regional variation and minimal impact on recipient outcomes.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Anne M Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - S Ali Husain
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Emilio D Poggio
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Blake Buchalter
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Epidemiology, Columbia University, New York, New York, USA
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26
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Yu M, King KL, Husain SA, Huml AM, Patzer RE, Schold JD, Mohan S. Discrepant Outcomes between National Kidney Transplant Data Registries in the United States. J Am Soc Nephrol 2023; 34:1863-1874. [PMID: 37535362 PMCID: PMC10631598 DOI: 10.1681/asn.0000000000000194] [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: 12/14/2022] [Accepted: 07/03/2023] [Indexed: 08/04/2023] Open
Abstract
SIGNIFICANCE STATEMENT Effects of reduced access to external data by transplant registries to improve accuracy and completeness of the collected data are compounded by different data management processes at three US organizations that maintain kidney transplant-related datasets. This analysis suggests that the datasets have large differences in reported outcomes that vary across different subsets of patients. These differences, along with recent disclosure of previously missing outcomes data, raise important questions about completeness of the outcome measures. Differences in recorded deaths seem to be increasing in recent years, reflecting the adverse effects of restricted access to external data sources. Although these registries are invaluable sources for the transplant community, discrepancies and incomplete reporting risk undermining their value for future analyses, particularly when used for developing national transplant policy or regulatory measures. BACKGROUND Central to a transplant registry's quality are accuracy and completeness of the clinical information being captured, especially for important outcomes, such as graft failure or death. Effects of more limited access to external sources of death data for transplant registries are compounded by different data management processes at the United Network for Organ Sharing (UNOS), the Scientific Registry of Transplant Recipients (SRTR), and the United States Renal Data System (USRDS). METHODS This cross-sectional registry study examined differences in reported deaths among kidney transplant candidates and recipients of kidneys from deceased and living donors in 2000 through 2019 in three transplant datasets on the basis of data current as of 2020. We assessed annual death rates and survival estimates to visualize trends in reported deaths between sources. RESULTS The UNOS dataset included 77,605 deaths among 315,346 recipients and 61,249 deaths among 275,000 nonpreemptively waitlisted candidates who were never transplanted. The SRTR dataset included 87,149 deaths among 315,152 recipients and 60,042 deaths among 259,584 waitlisted candidates. The USRDS dataset included 89,515 deaths among 311,955 candidates and 63,577 deaths among 238,167 waitlisted candidates. Annual death rates among the prevalent transplant population show accumulating differences across datasets-2.31%, 4.00%, and 4.03% by 2019 from UNOS, SRTR, and USRDS, respectively. Long-term survival outcomes were similar among nonpreemptively waitlisted candidates but showed more than 10% discordance between USRDS and UNOS among transplanted patients. CONCLUSIONS Large differences in reported patient outcomes across datasets seem to be increasing, raising questions about their completeness. Understanding the differences between these datasets is essential for accurate, reliable interpretation of analyses that use these data for policy development, regulatory oversight, and research. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_10_24_JASN0000000000000194.mp3.
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Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
- Department of Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - Rachel E. Patzer
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
- Department of Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Jesse D. Schold
- Department of Surgery, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora, Colorado
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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27
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Husain SA, Yu ME, King KL, Adler JT, Schold JD, Mohan S. Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities. JAMA Intern Med 2023; 183:1238-1246. [PMID: 37782509 PMCID: PMC10546295 DOI: 10.1001/jamainternmed.2023.5013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 08/07/2023] [Indexed: 10/03/2023]
Abstract
Importance Disparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear. Objective To examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant. Design, Setting, and Participants This retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023. Main Outcome(s) and Measure(s) Kidney transplant waitlisting after dialysis initiation. Results Of 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56). Conclusions and Relevance This retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.
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Affiliation(s)
- S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Miko E. Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin
| | - Jesse D. Schold
- Department of Surgery, University of Colorado–Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado–Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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28
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Saben JL, Schold JD, Kaplan B. The Use of In Silico and Mathematical Modeling to Create More Accurate and Efficient Clinical Trial Design. Transplantation 2023; 107:2292-2293. [PMID: 37870881 DOI: 10.1097/tp.0000000000004733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Affiliation(s)
- Jessica L Saben
- Department of Surgery, Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jesse D Schold
- Department of Surgery, Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Bruce Kaplan
- Department of Medicine, Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, CO
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29
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Lopez R, Mohan S, Schold JD. Population Characteristics and Organ Procurement Organization Performance Metrics. JAMA Netw Open 2023; 6:e2336749. [PMID: 37787992 PMCID: PMC10548299 DOI: 10.1001/jamanetworkopen.2023.36749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/25/2023] [Indexed: 10/04/2023] Open
Abstract
Importance In 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating the Organ Procurement Organization (OPO) Conditions for Coverage. This rule evaluates OPO performance based on an unadjusted donation rate and an age-adjusted transplant rate; however, neither considers other underlying population differences. Objective To evaluate whether adjusting for age and/or area deprivation index yields the same tier assignments as the cause, age, and location consistent (CALC) tier used by CMS. Design, Setting, and Participants This retrospective cross-sectional study examined the performance of 58 OPOs from 2018 to 2020 across the entire US. A total of 12 041 778 death records were examined from the 2017 to 2020 National Center for Health Statistics' Restricted Vital Statistics Detailed Multiple Cause of Death files; 399 530 of these met the definition of potential deceased donor. Information about 42 572 solid organ donors from the Scientific Registry of Transplant Recipients was also used. Statistical analysis was performed from January 2017 to December 2020. Exposure Area deprivation of donation service areas and age of potential donors. Main Outcome and Measures OPO performance as measured by donation and transplant rates. Results A total of 399 530 potential deceased donors and 42 572 actual solid donor organs were assigned to 1 of 58 OPOs. Age and ADI adjustment resulted in 19.0% (11 of 58) to 31.0% (18 of 58) reclassification of tier ratings for the OPOs, with 46.6% of OPOs (27 of 58) changing tier ranking at least once during the 3-year period. Between 6.9% (4 of 58) and 12.1% (7 of 58) moved into tier 1 and up to 8.6% (5 of 58) moved into tier 3. Conclusions and Relevance This cross-sectional study of population characteristics and OPO performance metrics found that adjusting for area deprivation and age significantly changed OPO measured performance and tier classifications. These findings suggest that underlying population characteristics may alter processes of care and characterize donation and transplant rates independent of OPO performance. Risk adjustment accounting for population characteristics warrants consideration in prospective policy and further evaluation of quality metrics.
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Affiliation(s)
- Rocio Lopez
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Jesse D. Schold
- Division of Transplant Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora
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30
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Lehr CJ, Schold JD, Arrigain S, Valapour M. New OPTN/UNOS data demonstrates higher than previously reported waitlist mortality for lung transplant candidates supported with ECMO. J Heart Lung Transplant 2023; 42:1399-1407. [PMID: 37150472 PMCID: PMC10524253 DOI: 10.1016/j.healun.2023.04.017] [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: 07/20/2022] [Revised: 04/05/2023] [Accepted: 04/30/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) is not currently incorporated into US allocation models due to the historical lack of complete data in the national US registry which changed in 2016 to include ECMO at the time of waitlist removal and more granular timing and configuration data. METHODS We studied adult lung transplant candidates from May 1, 2016 to June 1, 2020 with data abstracted from multiple sources in the US Scientific Registry of Transplant Recipients. Waitlist analyses included cumulative incidence functions and Cox proportional hazards models considering ECMO as a time-dependent variable. Post-transplant analyses included Kaplan Meier, Cox proportional hazards models, and observed to expected survival ratios. RESULTS A total of 867 candidates were on ECMO prior to transplant; 247 were identified using new sources of data. Candidates on ECMO had a 23.9 increased adjusted likelihood of waitlist removal for being too sick or death, but only a 4.08 increased adjusted likelihood of transplant. Candidates bridged with ECMO who underwent lung transplant (N = 587) experienced an increased overall hazard of post-transplant mortality with veno-arterial and veno-venous configurations conferring hazard ratio (HR) = 1.67 (95% CI, 1.16, 2.40), HR = 1.45 (95% CI, 1.15, 1.82), respectively. CONCLUSIONS We identified an additional 28.5% of candidates bridged with ECMO prior to transplant using new data. This study of the newly identified full cohort of ECMO candidates demonstrates higher utilization of ECMO as well as an underestimation of waitlist mortality risk factors that should inform strategies to provide timely access to transplants for this population.
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Affiliation(s)
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Maryam Valapour
- Respiratory Institute, Cleveland Clinic. https://twitter.com/@MValapour
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Schold JD, Huml AM, Husain SA, Mohan S. Why the National Academies Got it Wrong about Changing Preemptive Listing Priority for Kidney Transplantation. J Am Soc Nephrol 2023; 34:1615-1617. [PMID: 37782624 PMCID: PMC10561815 DOI: 10.1681/asn.0000000000000209] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 07/26/2023] Open
Affiliation(s)
- Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Malamon JS, Kaplan B, Jackson WE, Saben JL, Schold JD, Pomfret EA, Pomposelli JJ. Reassessing the survival benefit of deceased donor liver transplantation: retrospective cohort study. Int J Surg 2023; 109:2714-2720. [PMID: 37226874 PMCID: PMC10498891 DOI: 10.1097/js9.0000000000000498] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/14/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Currently in the United States, deceased donor liver transplant (DDLT) allocation priority is based on the model for end-stage liver disease including sodium (MELD-Na) score. The United Network for organ sharing's 'Share-15' policy states that candidates with MELD-Na scores of 15 or greater have priority to receive local organ offers compared to candidates with lower MELD-Na scores. Since the inception of this policy, major changes in the primary etiologies of end-stage liver disease have occurred and previous assumptions need to be recalibrated. METHODS The authors retrospectively analyzed the Scientific Registry of Transplant Recipients database between 2012 and 2021 to determine life years saved by DDLT at each interval of MELD-Na score and the time-to-equal risk and time-to-equal survival versus remaining on the waitlist. The authors stratified our analysis by MELD exception points, primary disease etiology, and MELD score. RESULTS On aggregate, compared to remaining on the waitlist, a significant 1-year survival advantage of DDLT at MELD-Na scores as low as 12 was found. The median life years saved at this score after a liver transplant was estimated to be greater than 9 years. While the total life years saved were comparable across all MELD-Na scores, the time-to-equal risk and time-to-equal survival decreased exponentially as MELD-Na scores increased. CONCLUSION Herein, the authors challenge the perception as to the timing of DDLT and when that benefit occurs. The national liver allocation policy is transitioning to a continuous distribution framework and these data will be instrumental to defining the attributes of the continuos allocation score.
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Affiliation(s)
- John S. Malamon
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | - Bruce Kaplan
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Whitney E. Jackson
- Department of Medicine, University of Colorado Anschutz Medical Campus
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Jessica L. Saben
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | - Jesse D. Schold
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Elizabeth A. Pomfret
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
| | - James J. Pomposelli
- Department of Surgery
- Department of Medicine, University of Colorado Anschutz Medical Campus
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Davis RA, Branagan T, Schneck CD, Schold JD, Thant T, Kaplan B. Lithium and the living kidney donor: Science or stigma? Am J Transplant 2023; 23:1300-1306. [PMID: 37236400 DOI: 10.1016/j.ajt.2023.05.022] [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: 04/29/2023] [Revised: 05/16/2023] [Accepted: 05/21/2023] [Indexed: 05/28/2023]
Abstract
Nearly 10 000 people are removed from the kidney transplant waiting list each year either due to becoming too ill for transplant or due to death. Live donor kidney transplant (LDKT) provides superior outcomes and survival benefit relative to deceased donor transplant, but the number of LDKT has decreased over the past few years. Therefore, it is of paramount importance that transplant centers employ evaluation processes that safely maximize LDKT. Decisions about donor candidacy should be based on the best available data, rather than on processes prone to bias. Here, we examine the common practice of declining potential donors based solely on treatment with lithium. We conclude that the risk of end-stage renal disease related to lithium treatment is comparable to other generally accepted risks in LDKT. We present this viewpoint to specifically challenge the carte blanche exclusion of individuals taking lithium and highlight the importance of using the best available data relevant to any risk factor, rather than relying on biases, when evaluating potential living kidney donors.
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Affiliation(s)
- Rachel A Davis
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA; Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA.
| | - Tyler Branagan
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Christopher D Schneck
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz, Aurora, Colorado, USA
| | - Thida Thant
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education, Aurora, Colorado, USA; Department of Medicine, University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
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34
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Matas AJ, Montgomery RA, Schold JD. The Organ Shortage Continues to Be a Crisis for Patients With End-stage Kidney Disease. JAMA Surg 2023; 158:787-788. [PMID: 37223921 DOI: 10.1001/jamasurg.2023.0526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This Viewpoint describes the organ shortage for patients with end-stage kidney disease despite increases in kidney donations between 2000 and 2021.
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Affiliation(s)
- Arthur J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis
| | | | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora
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35
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Fadel R, Taliercio JJ, Daou R, Layoun H, Bassil E, Fawaz A, Arrigain S, Schold JD, Herlitz L, Simon JF, Mehdi A, Nakhoul G. Urine Sediment Examination: Comparison Between Laboratory-Performed Versus Nephrologist-Performed Microscopy and Accuracy in Predicting Pathologic Diagnosis in Patients with Acute Kidney Injury. Kidney360 2023; 4:918-923. [PMID: 36810426 PMCID: PMC10371296 DOI: 10.34067/kid.0000000000000081] [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] [Received: 11/02/2022] [Accepted: 01/17/2023] [Indexed: 02/23/2023]
Abstract
Key Points A nephrologist is more likely to recognize the presence of pathologic casts and dysmorphic red blood cells. Nephrologist-performed urine sediment analysis is also highly accurate in diagnosing acute tubular injury or glomerulonephritis when compared with kidney biopsy. Introduction Automated urine technology is becoming the standard for urinalysis microscopy. We sought to compare urine sediment analysis performed by a nephrologist with the analysis performed by the laboratory. When available, we also compared the suggested diagnosis per nephrologists' sediment analysis with the biopsy diagnosis. Methods We identified patients with AKI who had urine microscopy with sediment analysis performed by the laboratory (Laboratory-UrSA) and by a nephrologist (Nephrologist-UrSA) within 72 hours of each other. We collected data to determine the following: number of red blood cells (RBCs) and white blood cells (WBCs) per high-power field, presence and types of casts per low-power field, and presence of dysmorphic RBCs. We evaluated agreement between the Laboratory-UrSA and the Nephrologist-UrSA using cross-tabulation and the Kappa statistic. When available, we categorized the nephrologist sediment findings into four categories: (1) bland, (2) suggestive of acute tubular injury (ATI), (3) suggestive of glomerulonephritis (GN), and (4) suggestive of acute interstitial nephritis (AIN). In a group of patients with kidney biopsy within 30 days of the Nephrologist-UrSA, we assessed agreement between the nephrologist diagnosis and the biopsy diagnosis. Results We included 387 patients with both Laboratory-UrSA and Nephrologist-UrSA. The agreement was moderate for the presence of RBCs (Kappa, 0.46; 95% CI, 0.37 to 0.55) and fair for WBCs (Kappa, 0.36; 95% CI, 0.27 to 0.45). There was no agreement for casts (Kappa, 0.026; 95% CI, −0.04 to 0.07). Eighteen dysmorphic RBCs were detected on Nephrologist-UrSA compared with zero on Laboratory-UrSA. Among the 33 patients with kidney biopsy, 100% ATI and 100% GN suggested per Nephrologist-UrSA were confirmed on the biopsy. Of the five patients with bland sediment on the Nephrologist-UrSA, 40% showed ATI pathologically while the other 60% demonstrated GN. Conclusion A nephrologist is more likely to recognize the presence of pathologic casts and dysmorphic RBCs. Correct identification of these casts carries important diagnostic and prognostic value when evaluating kidney disease.
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Affiliation(s)
- Remy Fadel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jonathan J. Taliercio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Ohio
| | - Remy Daou
- Department of Family Medicine, Saint Joseph University, Beirut, Lebanon
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Elias Bassil
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Ohio
| | - Adam Fawaz
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Leal Herlitz
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio
| | - James F. Simon
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Ohio
| | - Ali Mehdi
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Ohio
| | - Georges Nakhoul
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Ohio
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36
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Schold JD. The promise and reality of machine-learning models in kidney transplantation. Kidney Int 2023; 103:835-836. [PMID: 37085256 DOI: 10.1016/j.kint.2023.02.008] [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: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 04/23/2023]
Abstract
There have been numerous advances in statistical methods and computing technologies over the past decades, including the use of machine-learning models. In the current study, Truchot et al. rigorously evaluated the performance of different machine-learning models compared with traditional Cox proportional hazard models. Results of the study indicated that a Cox model had equivalent or superior performance than machine-learning models and can be relied on for predicting graft survival in kidney transplantation.
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Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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37
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Schold JD, Hoffman J, Cleveland J. Developing a System for Best Performance for Cardiac Transplantation. JACC Heart Fail 2023; 11:520-522. [PMID: 37137659 DOI: 10.1016/j.jchf.2023.01.025] [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] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Jordan Hoffman
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joseph Cleveland
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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38
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Malamon JS, Jackson WE, Saben JL, Conzen K, Schold JD, Pomposelli JJ, Pomfret EA, Kaplan B. A model for calculating the long-term estimated post-transplant survival of deceased donor liver transplant patients. EBioMedicine 2023; 90:104505. [PMID: 36870199 PMCID: PMC9996349 DOI: 10.1016/j.ebiom.2023.104505] [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: 11/01/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND The estimated long-term survival (EPTS) score is used for kidney allocation. A comparable prognostic tool to accurately quantify EPTS benefit in deceased donor liver transplant (DDLT) candidates is nonexistent. METHODS Using the Scientific Registry of Transplant Recipients (SRTR) database, we developed, calibrated, and validated a nonlinear regression equation to calculate liver-EPTS (L-EPTS) for 5- and 10-year outcomes in adult DDLT recipients. The population was randomly split (70:30) into two discovery (N = 26,372 and N = 46,329) and validation cohorts (N = 11,288 and N = 19,859) for 5- and 10-year post-transplant outcomes, respectively. Discovery cohorts were used for variable selection, Cox proportional hazard regression modeling, and nonlinear curve fitting. Eight clinical variables were selected to construct the L-EPTS formula, and a five-tiered ranking system was created. FINDINGS Tier thresholds were defined and the L-EPTS model was calibrated (R2 = 0.96 [5-year] and 0.99 [10-year]). Patients' median survival probabilities in the discovery cohorts for 5- and 10-year outcomes ranged from 27.94% to 89.22% and 16.27% to 87.97%, respectively. The L-EPTS model was validated via calculation of receiver operating characteristic (ROC) curves using validation cohorts. Area under the ROC curve was 82.4% (5-year) and 86.5% (10-year). INTERPRETATION L-EPTS has high applicability and clinical utility because it uses easily obtained pre-transplant patients characteristics to accurately discriminate between those who are likely to receive a prolonged survival benefit and those who are not. It is important to evaluate medical urgency alongside survival benefit and placement efficiency when considering the allocation of a scarce resource. FUNDING There are no funding sources related to this project.
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Affiliation(s)
- John S Malamon
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA.
| | - Whitney E Jackson
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA; Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jessica L Saben
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA
| | - Kendra Conzen
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA; Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - James J Pomposelli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA
| | - Elizabeth A Pomfret
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA
| | - Bruce Kaplan
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, CO, USA; Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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King KL, Yu M, Husain SA, Patzer RE, Sandra V, Reese PP, Schold JD, Mohan S. Contribution of Estimates of Glomerular Filtration to the Extensive Disparities in Preemptive Listing for Kidney Transplant. Kidney Int Rep 2023; 8:442-454. [PMID: 36938099 PMCID: PMC10014377 DOI: 10.1016/j.ekir.2022.12.021] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction The use of race coefficients in equations for estimated glomerular filtration rate (eGFR) may have contributed to racial disparities in access to preemptive (without dialysis exposure) kidney transplantation (Ktx). Methods In this retrospective national cohort study of incident kidney transplant candidates in the United States from 2001 to 2019, we describe temporal trends and racial disparities in preemptive listing and the distribution of eGFR at listing, using eGFR as reported and after removing the race coefficient for Black candidates. Results Among 511,686 candidates, preemptive listing increased over time, from 18% in 2001 to 33% in 2019. Non-Black candidates were listed preemptively nearly twice as frequently as Black candidates in 2019 (38% vs. 21% preemptive) and at higher eGFR values (median 15.6 vs. 15.0 ml/min per 1.73 m2). After adjusting for candidate characteristics, including listing eGFR without the race coefficient, preemptive Black candidates still had significantly lower odds of preemptive deceased donor (DD) kidney transplantation compared to non-Black candidates (odds ratio 0.87, 95% confidence interval: 0.78-0.98). Conclusions Over the last 2 decades, Black patients were consistently less likely to be listed preemptively and were listed at lower eGFR values. Adjusting for listing eGFR with the race coefficient computationally removed did not eliminate the racial disparity, suggesting that additional efforts are needed to achieve equity in preemptive transplantation beyond adopting race-free eGFR equations.
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Affiliation(s)
- Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vanessa Sandra
- Columbia University Renal Epidemiology Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse D. Schold
- Department of Surgery, University of Colorado–Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, School of Public Health, University of Colorado–Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- Correspondence: Sumit Mohan, Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, Ph4-124, New York, New York 10032, USA.
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40
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Stites E, Cooper JE, Schold JD. Untangling the Clinical and Methodological Assessment of Risks Associated With BK Nephropathy. Kidney Int Rep 2023; 8:401-402. [PMID: 36938076 PMCID: PMC10014429 DOI: 10.1016/j.ekir.2023.01.027] [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: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 01/30/2023] Open
Affiliation(s)
- Erik Stites
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Correspondence: Erik Stites, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Floor 7, Aurora, Colorado 80045, USA.
| | - James E. Cooper
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Sawinski D, Lai JC, Pinney S, Gray AL, Jackson AM, Stewart D, Levine DJ, Locke JE, Pomposelli JJ, Hartwig MG, Hall SA, Dadhania DM, Cogswell R, Perez RV, Schold JD, Turgeon NA, Kobashigawa J, Kukreja J, Magee JC, Friedewald J, Gill JS, Loor G, Heimbach JK, Verna EC, Walsh MN, Terrault N, Testa G, Diamond JM, Reese PP, Brown K, Orloff S, Farr MA, Olthoff KM, Siegler M, Ascher N, Feng S, Kaplan B, Pomfret E. Addressing sex-based disparities in solid organ transplantation in the United States - a conference report. Am J Transplant 2023; 23:316-325. [PMID: 36906294 DOI: 10.1016/j.ajt.2022.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 05/02/2022] [Revised: 10/17/2022] [Accepted: 11/04/2022] [Indexed: 01/15/2023]
Abstract
Solid organ transplantation provides the best treatment for end-stage organ failure, but significant sex-based disparities in transplant access exist. On June 25, 2021, a virtual multidisciplinary conference was convened to address sex-based disparities in transplantation. Common themes contributing to sex-based disparities were noted across kidney, liver, heart, and lung transplantation, specifically the existence of barriers to referral and wait listing for women, the pitfalls of using serum creatinine, the issue of donor/recipient size mismatch, approaches to frailty and a higher prevalence of allosensitization among women. In addition, actionable solutions to improve access to transplantation were identified, including alterations to the current allocation system, surgical interventions on donor organs, and the incorporation of objective frailty metrics into the evaluation process. Key knowledge gaps and high-priority areas for future investigation were also discussed.
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Affiliation(s)
- Deirdre Sawinski
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois, USA
| | - Alice L Gray
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Annette M Jackson
- Department of Surgery, Duke University, Department of Surgery, Durham, Carolina, USA
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | - Jayme E Locke
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama, USA
| | - James J Pomposelli
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | | | | | - Darshana M Dadhania
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA
| | - Rebecca Cogswell
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Richard V Perez
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jon Kobashigawa
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
| | - John S Gill
- Division of Nephrology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Gabriel Loor
- Baylor College of Medicine Lung Institute, Houston, Texas, USA
| | | | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mary Norine Walsh
- Ascension St Vincent Heart Center, Indianapolis, Indianapolis, Indiana, USA
| | - Norah Terrault
- Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - Guiliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Division of Renal, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Susan Orloff
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Portland, Oregon, USA
| | - Maryjane A Farr
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kim M Olthoff
- Department of Surgery, Penn Transplant Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Siegler
- University of Chicago Medicine, Chicago, Illinois, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Nancy Ascher
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Kaplan
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Elizabeth Pomfret
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
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Schold JD, Turgeon NA. Erratum to ‘Words matter: adding rigor to our definition of waiting time’ [American Journal of Transplantation 23 (2023) 163–164]. Am J Transplant 2023:S1600-6135(23)00362-3. [PMID: 37005110 DOI: 10.1016/j.ajt.2023.03.018] [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: 03/31/2023]
Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz, Aurora, Colorado, USA.
| | - Nicole A Turgeon
- Department of Surgery, University of Texas Dell Medical School, Austin, Texas, USA
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Schold JD, Turgeon NA. Words matter: adding rigor to our definition of waiting time. Am J Transplant 2023; 23:163-164. [PMID: 36725426 DOI: 10.1016/j.ajt.2023.01.004] [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: 12/16/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Affiliation(s)
- Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz, Aurora, Colorado, USA.
| | - Nicole A Turgeon
- Department of Surgery, University of Texas Dell Medical School, Austin, Texas, USA
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Amdani S, Tang A, Schold JD. Children from socioeconomically disadvantaged communities present in more advanced heart failure at the time of transplant listing. J Heart Lung Transplant 2023; 42:150-155. [PMID: 36270922 DOI: 10.1016/j.healun.2022.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 04/04/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 01/18/2023] Open
Abstract
Transplant registries in the US do not collect information about community level risk factors. We utilized a community level socio-economic risk indicator, the distressed communities' index to understand its association with clinical presentation among children listed for heart transplant (HT). We found that currently, majority (40%) of children listed from distressed communities are Black. On multivariable analysis, compared to children from prosperous communities, those from distressed communities listed for HT were significantly more likely to be Status 1A (adjusted odds ratio [aOR] 1.39) and on a ventricular assist device (aOR 1.44). Compared to White children from prosperous communities, both Black and White children from distressed communities were more likely to be listed Status 1A (aOR 2.1 and 1.36 respectively) and have renal dysfunction (aOR 1.71 and 1.52 respectively). In conclusion, heart failure severity at listing appears more likely associated with community-level risk factors and less so with child's race/ethnicity.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Ohio.
| | - Anne Tang
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Formica RN, Schold JD. The Unintended Consequences of Changes to the Organ Allocation Policy. J Am Soc Nephrol 2023; 34:14-16. [PMID: 36719146 PMCID: PMC10101628 DOI: 10.1681/asn.0000000000000009] [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] [Indexed: 01/22/2023] Open
Affiliation(s)
| | - Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Tsuang WM, Lopez R, Tang A, Budev M, Schold JD. Place-based heterogeneity in lung transplant recipient outcomes. Am J Transplant 2022; 22:2981-2989. [PMID: 35962587 DOI: 10.1111/ajt.17170] [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: 02/17/2022] [Revised: 07/14/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
Place is defined as a social or environmental area of residence with meaning to a patient. We hypothesize there is an association between place and the clinical outcomes of lung transplant recipients in the United States. In a retrospective cohort study of transplants between January 1, 2010, and December 31, 2019, in the Scientific Registry of Transplant Recipients, multivariable Cox regression models were used to test the association between place (through social and environmental factors) with readmission, lung rejection, and survival. Among 18,465 recipients, only 20% resided in the same county as the transplant center. Recipients from the most socially vulnerable counties when compared to the least vulnerable were more likely to have COPD as a native disease, Black or African American race, and travel long distances to reach a transplant center. Higher local life expectancy was associated with lower likelihood for readmission (odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.84, 0.98, p = .01). Higher social vulnerability was associated with a higher likelihood of lung rejection (OR = 1.37, [CI]: 1.07, 1.76, p = .01). There was no association of residence with posttransplant survival. Recipient place-based factors were associated with complications and processes of care after transplant and warrant further investigation.
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Affiliation(s)
- Wayne M Tsuang
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anne Tang
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marie Budev
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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Hassanein M, Arrigain S, Schold JD, Nakhoul GN, Navaneethan SD, Mehdi A, Sekar A, Tabbara J, Taliercio JJ. Dysnatremias, Mortality, and Kidney Failure in CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Kidney Med 2022; 4:100554. [PMID: 36483992 PMCID: PMC9722469 DOI: 10.1016/j.xkme.2022.100554] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Rationale & Objective Dysnatremias have been associated with an increased risk of mortality in the chronic kidney disease (CKD) population. Our objective is to identify the prevalence of and risk factors associated with dysnatremias in a CKD population and assess the association of dysnatremias with kidney failure and mortality among patients with CKD enrolled in the Chronic Renal Insufficiency Cohort Study. Study Design Analysis of prospective cohort study. Setting & Participants Adult patients aged 21-74 years with CKD from the Chronic Renal Insufficiency Cohort study. Predictors Baseline and time-dependent hyponatremia and hypernatremia. Outcomes All-cause mortality and kidney failure. Analytical Approach Baseline characteristics were compared using χ2 tests for categorical variables, analysis of variance for age, and Kruskal-Wallis tests for laboratory variables. Cox proportional hazards models and competing risk models were used to evaluate the association between baseline sodium level and overall mortality. Results Of a total of 5,444 patients with CKD, 486 (9%) had hyponatremia and 53 (1%) had hypernatremia. Altogether, 1,508 patients died and 1,206 reached kidney failure. In adjusted Cox models, time-dependent dysnatremias were strongly associated with mortality for both hyponatremia (HR, 1.38; 95% CI, 1.16-1.64) and hypernatremia (HR, 1.54; 95% CI, 1.04-2.29). Factors associated with hyponatremia included female sex, diabetes, and hypertension. Regardless of age, time-dependent hypernatremia was associated with an increased risk of kidney failure (HR, 1.64; 95% CI, 1.06-2.53). Baseline and time-dependent hyponatremia were associated with an increased risk of kidney failure in patients younger than 65 (baseline hyponatremia HR, 1.30; 95% CI, 1.03-1.64 and time-dependent hyponatremia HR, 1.36; 95% CI, 1.09-1.70) but not among patients aged >65 years. Limitations Inability to establish causality and lack of generalizability to hospitalized patients. Conclusions Dysnatremias are prevalent among ambulatory CKD patients and are associated with mortality and kidney failure. Time-dependent dysnatremias were significantly associated with mortality in patients with CKD. Time-dependent hypernatremia was associated with progression to kidney failure. Baseline and time-dependent hyponatremia were associated with an increased risk of progression to kidney failure in those younger than 65 years.
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Affiliation(s)
| | - Susana Arrigain
- Department of Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D. Schold
- Department of Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio
| | - Georges N. Nakhoul
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | | | - Ali Mehdi
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | | | - Jad Tabbara
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jonathan J. Taliercio
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - CRIC Investigators
- University of Mississippi Medical Center, Jackson, Mississippi
- Department of Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
- Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
- Associates in Kidney Care, Des Moines, Iowa
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Buchalter RB, Huml AM, Poggio ED, Schold JD. Geographic hot spots of kidney transplant candidates wait-listed post-dialysis. Clin Transplant 2022; 36:e14821. [PMID: 36102154 PMCID: PMC10078213 DOI: 10.1111/ctr.14821] [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: 07/16/2022] [Revised: 08/16/2022] [Accepted: 09/09/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Preemptive wait-listing of deceased donor kidney transplant (DDKT) candidates before maintenance dialysis increases the likelihood of transplantation and improves outcomes among transplant patients. Previous studies have identified substantial disparities in rates of preemptive listing, but a gap exists in examining geographic sources of disparities, particularly for sub-regional units. Identifying small area hot spots where delayed listing is particularly prevalent may more effectively inform both health policy and regionally appropriate interventions. METHODS We conducted a retrospective cohort study utilizing 2010-2020 Scientific Registry of Transplant Recipients (SRTR) data for all DDKT candidates to examine overall and race-stratified geospatial hot spots of post-dialysis wait-listing in U.S. zip code tabulation areas (ZCTA). Three geographic clustering methods were utilized to identify robust statistically significant hot spots of post-dialysis wait-listing. RESULTS Novel sub-regional hot spots were identified in the southeast, southwest, Appalachia, and California, with a majority existing in the southeast. Race-stratified results were more nuanced, but broadly reflected similar patterns. Comparing transplant candidates in hot spots to candidates in non-clusters indicated a strong association between residence in hot spots and high area deprivation (OR: 6.76, 95%CI: 6.52-7.02), indicating that improving access healthcare in these areas may be particularly beneficial. CONCLUSION Our study identified overall and race-stratified hot spots with low rates of preemptive wait list placement in the U.S., which may be useful for prospective healthcare policy and interventions via targeting of these narrowly defined geographical areas.
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Affiliation(s)
- R. Blake Buchalter
- Department of Quantitative Health Sciences, Lerner Research InstituteCleveland ClinicClevelandOhioUSA
- Center for Populations Health Research, Lerner Research InstituteCleveland ClinicClevelandOhioUSA
| | - Anne M. Huml
- Department of Kidney Medicine, Glickman Urological and Kidney InstituteCleveland ClinicClevelandOhioUSA
| | - Emilio D. Poggio
- Department of Kidney Medicine, Glickman Urological and Kidney InstituteCleveland ClinicClevelandOhioUSA
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Lerner Research InstituteCleveland ClinicClevelandOhioUSA
- Center for Populations Health Research, Lerner Research InstituteCleveland ClinicClevelandOhioUSA
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Koval CE, Eltemamy M, Poggio ED, Schold JD, Wee AC. Comparative outcomes for over 100 deceased donor kidney transplants from SARS-CoV-2 positive donors: A single-center experience. Am J Transplant 2022; 22:2903-2911. [PMID: 36176236 PMCID: PMC9538585 DOI: 10.1111/ajt.17203] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/03/2022] [Accepted: 09/16/2022] [Indexed: 01/25/2023]
Abstract
Emerging data support the safety of transplantation of extra-pulmonary organs from donors with SARS-CoV-2-detection. Our center offered kidney transplantation (KT) from deceased donors (DD) with SARS-CoV-2 with and without COVID-19 as a cause of death (CoV + COD and CoV+) to consenting candidates. No pre-emptive antiviral therapies were given. We retrospectively compared outcomes to contemporaneous DDKTs with negative SARS-CoV-2 testing (CoVneg). From February 1, 2021 to January 31, 2022, there were 220 adult KTs, including 115 (52%) from 35 CoV+ and 33 CoV + COD donors. Compared to CoVneg and CoV+, CoV + COD were more often DCD (100% vs. 40% and 46%, p < .01) with longer cold ischemia times (25.2 h vs. 22.9 h and 22.2 h, p = .02). At median follow-up of 5.7 months, recipients of CoV+, CoV + COD and CoVneg kidneys had similar rates of delayed graft function (10.3%, 21.8% and 21.9%, p = .16), rejection (5.1%, 0% and 8.5%, p = .07), graft failure (1.7%, 0% and 0%, p = .35), mortality (0.9%, 0% and 3.7%; p = .29), and COVID-19 diagnoses (13.6%, 7.1%, and 15.2%, p = .33). Though follow-up was shorter, CoV + COD was associated with lower but acceptable eGFR on multivariable analysis. KT from DDs at various stages of SARS-CoV-2 infection appears safe and successful. Extended follow-up is required to assess the impact of CoV + COD donors on longer term graft function.
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Affiliation(s)
- Christine E. Koval
- Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA,Correspondence Christine E. Koval, Department of Infectious Diseases, Cleveland Clinic Foundation, 500 Euclid Avenue, G-21, Cleveland, Ohio 44195, USA.
| | - Mohamed Eltemamy
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emilio D. Poggio
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alvin C. Wee
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Isaacson D, Schold JD, Gmeiner MW, Copley HC, Kosmoliaptsis V, Tambur AR. HLA-DQ Mismatches Lead to More Unacceptable Antigens, Greater Sensitization, and Increased Disparities in Repeat Transplant Candidates. J Am Soc Nephrol 2022; 33:2293-2305. [PMID: 36450598 PMCID: PMC9731640 DOI: 10.1681/asn.2022030296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/12/2022] [Accepted: 07/25/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In single-center studies, HLA-DQ mismatches stimulate the most pathogenic donor-specific antibodies. However, because of limitations of transplant registries, this cannot be directly confirmed with registry-based analyses. METHODS We evaluated patients in the Scientific Registry of Transplant Recipients who were relisted after renal graft failure with new, unacceptable antigens corresponding to the HLA typing of their previous donor (UA-PD) as a proxy for donor-specific antibodies. Linear regression was applied to estimate the effects of HLA mismatches on UA-PD and the effects of UA-PD on calculated panel reactive antibody (cPRA) values for 4867 kidney recipients from 2010 to 2021. RESULTS Each additional HLA-DQ mismatch increased the probability of UA-PD by 25.2% among deceased donor transplant recipients and by 28.9% among living donor transplant recipients, significantly more than all other HLA loci (P<0.05). HLA-DQ UA-PD increased cPRA by 29.0% in living donor transplant recipients and by 23.5% in deceased donor transplant recipients, significantly more than all loci except for HLA-A in deceased donor transplant recipients (23.1%). African American deceased donor transplant recipients were significantly more likely than Hispanic and White recipients to develop HLA-DQ UA-PD; among living donor transplant recipients, African American or Hispanic recipients were significantly more likely to do so compared with White recipients. Models evaluating interactions between HLA-DR/DQ mismatches revealed largely independent effects of HLA-DQ mismatches on HLA-DQ UA-PD. CONCLUSIONS HLA-DQ mismatches had the strongest associations with UA-PD, an effect that was greatest in African American and Hispanic recipients. cPRA increases with HLA-DQ UA-PD were equivalent or larger than any other HLA locus. This suggests a need to consider the effects of HLA-DQ in kidney allocation.
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Affiliation(s)
- Dylan Isaacson
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael W. Gmeiner
- Department of Economics, London School of Economics, London, United Kingdom
| | - Hannah C. Copley
- Department of Surgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, United Kingdom
- National Institute for Health Research Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Cambridge, United Kingdom
| | - Anat R. Tambur
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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