Deceased Donor Kidney Recipients Research Articles

#2822 Can KDPI estimate long-term graft survival in a cohort of Portuguese patients?

Abstract Background and Aims The Kidney Donor Profile Index (KDPI) was introduced in the United States in 2014 to support clinicians' decision-making regarding the acceptance or decline of potential donors. In Portugal, there is no valid stratification score to assist physicians in accepting or declining an organ offer. Our study aims to characterize a cohort of Portuguese kidney transplant recipients and donors and evaluate the correlation between KDPI and long-term graft survival. The results are interpreted considering the nuances of the Portuguese allocation system, which favors an age-matched donor-recipient allocation. Method We conducted an observational single-center retrospective cohort study, which included patients who received a deceased donor kidney transplant at our unit between January 2013 and December 2015. We excluded patients for whom the donor KDPI index was unavailable for retrieval. Besides the KDPI index, we collected data regarding the receptor's demographic, clinical, and immunological characteristics, as well as graft and recipient survival. The primary outcome was death-censored survival, and follow-up ended on the 31st of December 2023. The secondary outcome was survival with a functioning graft. Survival estimates were obtained using Kaplan-Meier curves. We performed univariate and multivariate survival analysis with log-rank tests and Cox proportional-hazards regression models. Results We selected 364 deceased-donor kidney recipients and 212 kidney donors. The mean KDPI was 60% and 53.3% of donors were classified as expanded criteria. The kidney recipients were predominantly male (68.4%), with a mean age of 50.16 years and an average of 4 HLA mismatches. Median follow-up was 102 months. Considering recipient characteristics according to pre-defined KDPI strata (≤ 20%, 21-85%, > 85%), recipients from higher KDPI were significantly older, with a mean age of 40.6, 48.8, and 61.1 years, respectively (p < 0.001), and had a higher average body mass index (p = 0.041). There were no significant differences regarding the number of HLA mismatches (p = 0.624) or the proportion of hypersensitized patients (p = 0.253) between classes. During follow-up, 16.8% patients presented graft failure and 9.9% died with a functioning graft. Cumulative death-censored graft survival at 5, 8, and 10 years was 87.7%, 87.1%, and 84.4% respectively. The cumulative percentage of patients living with a functioning graft at 5, 8, and 10 years was 83.6%, 76.7%, and 68.6%. Death-censored graft survival was lower in recipients of donors with higher KDPI (Fig. 1), although it did not reach statistical significance (p-value = 0.166). The number of HLA mismatches (p = 0.592) or the recipient's age (p = 0.513) did not significantly impact death-censored graft survival, whereas delayed graft function (DGF) was the variable with the strongest association in univariate analysis (p < 0.001). In a multivariate Cox regression model, KDPI (HR 1.02, p = 0.005) and DGF (HR 3.2, p < 0.001) correlated with graft loss, while older recipients (HR 0.971, p = 0.019) seemed to have a protective effect over death-censored survival. Patient survival with a functioning graft was significantly associated with KDPI strata (p = 0.008; Fig. 2), the recipient's age (p = 0.006), and DGF (p < 0.001) in univariate analysis. Considering KDPI kidneys ≥ 90%, 10-year cumulative death-censored survival was 67.9%. Conclusion In our sample, despite not reaching statistical significance, there was a trend for improved death-censored graft survival in patients with lower KDPI, which further emulates the results of other European cohorts. Nevertheless, the 10-year cumulative death-censored survival of higher KDPI kidneys (≥ 90%) was remarkable, showing that long-term acceptable outcomes can be achieved. The impact of KDPI on patient survival with a functioning graft is probably overestimated, given the bias introduced by the Portuguese matching system, which rewards an “old-for-old” donor-recipient allocation.

Time trends in preemptive kidney transplantation in Europe: an era registry study.

Preemptive kidney transplantation has better outcomes when compared to transplantation after dialysis. We aimed to examine trends in preemptive kidney transplantation between 2000 and 2019 in Europe and to provide an overview of associated policies, barriers and initiatives. Adult patients from 12 European countries who received a preemptive kidney transplant were included. The representatives of the registries providing these data were questioned on the policies, barriers and initiatives around preemptive kidney transplantation. Between 2000 and 2019, 20251 adults underwent preemptive kidney transplantation (11169 from living donors, 8937 from deceased donors). The proportion of first kidney transplantations that were preemptive more than doubled from 7% in 2000 to 18% in 2019, reflecting a similar relative increase for living donor kidney recipients (from 21% to 43%) and deceased donor kidney recipients (from 4% to 11%). Large international differences were found. The increase in preemptive kidney transplantation was observed across all age, sex and primary renal disease groups. Countries had similar criteria for preemptive waitlisting. Barriers mentioned included donor shortage, late referral to the transplant center and long donor or recipient work-up. Suggested initiatives included raising awareness on the possibility of preemptive kidney transplantation, earlier start and shorter work-up time for recipient and living donor. Over the last two decades the proportion of patients receiving a first kidney transplant preemptively has more than doubled, reflecting a similar relative increase for living and deceased donor kidney recipients.

Transplant Candidates of 70+ Years Have Superior Survival If Receiving Pre-Emptively a Living Donor Kidney.

Background: The number of kidney transplant recipients over 70 years of age is increasing but detailed data on patient and graft survival in the modern era of immune suppression are few. Methods: A single-center cohort of patients of 70 years and older (n = 349) at time of kidney transplantation from 2010-2020 were followed until January 2023. Results: The median age was 73 years with a median follow-up of 4.3 years. Fifty percent of recipients of a living donor kidney (LDK, n = 143) received their graft pre-emptively. Cumulative death-censored graft survival was excellent in the LDK group and reached 98% at 5 years vs. 85% in the deceased donor kidney (DDK) group. Primary non-function (38%) and rejection (43%) were the major causes of graft loss in the first year after DDK transplantation. Rejection-related graft loss was 4.6% during follow-up. Median recipient survival was superior in the subgroup of pre-emptively transplanted LDK patients compared to non-pre-emptively LDK transplanted patients (11.1 versus 6.2 years). Non-pre-emptively transplanted patients had a significantly increased incidence of infection (HR 3.81, 1.46-9.96) and cardiovascular-related causes of death (HR 3.35, 1.16-9.71). Pre-emptive transplantation was also associated with a significantly improved graft survival in the DDK recipients but this result was confounded by significantly better HLA matching and younger donor age in this group. Conclusions: Pre-emptive LDK transplantation in patients of 70 years or older confers superior graft and recipient survival.

Prevention of Delayed Graft Function in Kidney Transplant Recipients through a Continuous Infusion of the Prostaglandin Analogue Iloprost: A Single-Center Prospective Study.

Delayed graft function (DGF) is common after kidney transplantation from deceased donors and may significantly affect post-transplant outcomes. This study aimed to evaluate whether an innovative approach, based on the administration of the intravenous prostaglandin analogue iloprost, could be beneficial in reducing the incidence of DGF occurring after kidney transplantation from deceased donors. This prospective, randomized (1:1), placebo-controlled study enrolled all consecutive patients who received a kidney transplant from a deceased donor from January 2000 to December 2012 and who were treated in the peri-transplant period with the prostaglandin analogue iloprost at 0.27 μg/min through an elastomeric pump (treatment group) or with a placebo (control group). A total of 476 patients were included: DGF was reported in 172 (36.1%) patients in the entire cohort. The multivariate analysis showed that the donor's age > 70 years (OR 2.50, 95% confidence interval (CI): 1.40-3.05, p < 0.001), cold ischemia time > 24 h (OR 2.60, 95% CI: 1.50-4.51, p < 0.001), the donor's acute kidney injury (OR 2.71, 95% CI: 1.61-4.52, p = 0.021) and, above all, the recipient's arterial hypotension (OR 5.06, 95% CI: 2.52-10.1, p < 0.0001) were the strongest risk factors for developing post-transplant DGF. The incidence of DGF was 21.4% in the treatment group and 50.9% in the control group (p < 0.001). Interestingly, among patients who developed DGF, those who received iloprost had a shorter duration of post-transplant DGF (10.5 ± 8.3 vs. 13.4 ± 6.7, days, p = 0.016). This study showed that the use of a continuous infusion of iloprost could safely and effectively reduce the incidence of DGF in recipients of deceased-donor kidneys, allowing a better graft functionality as well as a better graft survival.

The Association Between Kidney Donor Profile Index and 1-y Graft Function.

This single-center, retrospective cohort study analyzed data from 3059 consecutive deceased donor kidney transplant recipients with a 1-y follow-up from January 2013 to December 2017. The aim was to determine the association between the KDPI strata (0%-35%, 36%-50%, 51%-85%, 86%-100%) and 1-y eGFR estimated by the CKD-EPI equation. The incidence of delayed graft function (50.6% versus 59.3% versus 62.7% versus 62.0%; P < 0.001) and cytomegalovirus infection (36.7% versus 36.6% versus 43.3% versus 57.8%; P < 0.001) increased with increasing KDPI strata but not biopsy-proven acute rejection (9.1% versus 9.8% versus 8.4% versus 9.1%; P = 0.736). The median 1-y eGFR decreased with increasing KDPI strata (64.8 versus 53.5 versus 46.9 versus 39.1 mL/min/1.73 m2; P < 0.001). In the Cox regression, the higher the KDPI was, the lower the probability of a lower 1-y eGFR was. Assuming the 0%-35% strata as the reference, the likelihood of eGFR <50 mL/min/1.73 m2 was increased by 76.6% (hazard ratio [HR] = 1.767, 95% confidence interval [CI] = 1.406-2.220), 2.24- and 2.87-fold higher for KDPI higher >35%-50% (HR = 2.239, 95% CI = 1.862-2.691), and >51%-85% (HR = 2.871, 95% CI = 2.361-3.491), respectively. Other variables associated with a lower graft function were donor sex (HR male versus female = 0.896, 95% CI = 0.813-0.989) and cold ischemia time (HR for each hour = 1.011, 95% CI = 1.004-1.019). This association was sustained after the Poisson mediation analysis, including delayed graft function, cytomegalovirus, and acute rejection as mediators. In this cohort of deceased donor kidney recipients, KDPI, and cold ischemia time were the major independent risk factors associated with lower 1-y kidney function.

MP31-12 ASSOCIATION OF INITIAL POST-TRANSPLANT DONOR-DERIVED CELL-FREE DNA LEVELS WITH PERI-TRANSPLANT OUTCOMES AND DONOR CHARACTERISTICS IN DECEASED DONOR KIDNEY TRANSPLANT RECIPIENTS: A SINGLE-CENTER RETROSPECTIVE STUDY

You have accessJournal of UrologyCME1 Apr 2023MP31-12 ASSOCIATION OF INITIAL POST-TRANSPLANT DONOR-DERIVED CELL-FREE DNA LEVELS WITH PERI-TRANSPLANT OUTCOMES AND DONOR CHARACTERISTICS IN DECEASED DONOR KIDNEY TRANSPLANT RECIPIENTS: A SINGLE-CENTER RETROSPECTIVE STUDY Conner Lombardi, Jacob Lang, Emile Garcia, Mary Lee Brown, Dinkar Kaw, Deepak Malhotra, Shobha Ratnam, Michael Rees, and Obi Ekwenna Conner LombardiConner Lombardi More articles by this author , Jacob LangJacob Lang More articles by this author , Emile GarciaEmile Garcia More articles by this author , Mary Lee BrownMary Lee Brown More articles by this author , Dinkar KawDinkar Kaw More articles by this author , Deepak MalhotraDeepak Malhotra More articles by this author , Shobha RatnamShobha Ratnam More articles by this author , Michael ReesMichael Rees More articles by this author , and Obi EkwennaObi Ekwenna More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Donor-derived cell-free DNA has been demonstrated as an accurate biomarker and risk predictor for acute rejection in kidney transplantation, but it’s association with other clinical variables implicated in rejection have been mixed. The aim of this study was to assess the clinical association of dd-cfDNA levels that have been associated with peri-transplant outcomes including development of delayed graft function, cold ischemia time (CIT), use of machine perfusion, and donor characteristics, including deceased donor mode of death, kidney donor profile index (KDPI), and donor age. METHODS: Retrospective data from a cohort of 84 deceased donor kidney recipients transplanted from November 2019 to December 2020 with initial dd-cfDNA (ProsperaÔ, Natera, Inc.) levels collected within six months (Median date of collection 19 days; IQR 16-31 days) of undergoing transplantation were included in the study. Pearson’s C2, Wilcoxon rank-sum tests, and linear regression with Pearson’s correlation coefficient were used to measure association with significance determined at p<0.05. RESULTS: When examining peri-transplant characteristics, mean levels of dd-cfDNA were significantly higher in those with DGF (n=20) than non-DGF (n=64) [1.02% (95% CI 0.65-1.39%) vs. 0.65 (95% CI 0.42-0.88%); p=0.002]. Dd-cfDNA levels were not significantly associated with CIT (mean p=.744, r=.036), or machine perfusion (n=45) versus no machine perfusion(n=39) (0.85% (95% CI 0.52%-1.19%) vs. 0.60% (95% CI 0.41%-0.78%); p=.32). When examining donor characteristics, dd-cfDNA levels in were significantly higher in recipients with donation after cardiac death (DCD) kidneys versus donation after brainstem death (DBD) kidneys [1.26% (95% CI 0.75%-1.76%) vs. 0.53% (95% CI 0.36%-0.69%); p=0.000]. Donor age (p=.271, r=0.12) and KDPI (p=0.15, r=0.16) were not significantly associated with dd-cfDNA levels. CONCLUSIONS: Dd-cfDNA levels were significantly elevated in patients who had DGF and in recipients of DCD kidneys in our single center cohort. Notably, machine perfusion, donor age, KDPI, and CIT were not associated with increased levels with of dd-cfDNA. As associations of these variables in the literature are thus far varied, studies with increased sample size are necessary to determine the true associations. Source of Funding: The authors declare no sources of funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e434 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Conner Lombardi More articles by this author Jacob Lang More articles by this author Emile Garcia More articles by this author Mary Lee Brown More articles by this author Dinkar Kaw More articles by this author Deepak Malhotra More articles by this author Shobha Ratnam More articles by this author Michael Rees More articles by this author Obi Ekwenna More articles by this author Expand All Advertisement PDF downloadLoading ...

Back on track: outcomes of deceased donor kidney recipients at national kidney and transplant institute during the COVID-19 pandemic

Back on track: outcomes of deceased donor kidney recipients at national kidney and transplant institute during the COVID-19 pandemic

Apheresis of Deceased Donors as a New Source of Mobilized Peripheral Blood Hematopoietic Stem Cells for Transplant Tolerance.

Solid organ transplantation is the therapy of choice for many patients with end-stage organ failure; however, recipients must remain on lifelong immunosuppression, leaving them susceptible to infections and cancer. The study of transplant tolerance to prolong graft survival in the absence of immunosuppression has been restricted to recipients of living donor allografts; however, deceased donors significantly outnumber living donors. Mobilization of hematopoietic stem cells (HSCs) from the bone marrow to peripheral blood (PB) could allow PB-HSCs to be used to induce tolerance in deceased donor kidney recipients; however, a major concern is the well-known concomitant mobilization of immune cells into the liver. We mobilized HSCs to the PD using a protocol of 2 doses of granulocyte colony-stimulating factor and 1 dose of plerixafor, followed by the collection of mobilized cells via apheresis in 3 deceased donors. The physiological, laboratory, and radiographic parameters were monitored throughout the procedure. Longitudinal biopsies were performed to assess the potential for ectopic liver mobilization. The use of both agents led to the successful mobilization of peripheral blood CD34+ cells, demonstrating the potential for use in transplant tolerance protocols. Increased immune cell trafficking into the liver was not observed, and apheresis of mobilized cells resulted in a uniform decrease in all liver leukocyte subsets. HSCs can be mobilized and collected from the PB of brain-dead donors. This new approach may facilitate the dissemination of immune tolerance trials beyond living-donor kidney transplantation to deceased-donor transplantation, without sacrificing the transplantability of the liver.

Preoperative blood pressure and risk of delayed graft function in deceased donor kidney transplantation.

In kidney transplantation, delayed graft function (DGF) is associated with increased morbidity and a higher risk of graft failure. Prior research suggests that chronic hypotension increases DGF risk, but the relationship of preoperative blood pressure to DGF is unclear. In this single center study of adult deceased donor kidney transplant recipients transplanted between 2015 and 2019, we evaluated the question of whether preoperative mean arterial pressure (MAP) affected DGF risk. Additionally, we investigated whether the risk of DGF was moderated by certain donor and recipient characteristics. For recipient characteristics associated with increased DGF risk and preoperative MAP, we performed a mediation analysis to estimate the proportion of DGF risk mediated through preoperative MAP. Among 562 deceased donor kidney recipients, DGF risk decreased as preoperative MAP increased, with a 2% lower risk per 1mmHg increase in MAP. This increased risk was similar, with no statistically significant interaction effect between preoperative MAP and donor (donation after circulatory death) and recipient characteristics (diabetes, body mass index, and use of anti-hypertensive medications). Preoperative MAP was negativity correlated with recipient BMI and duration of pre transplant dialysis. On mediation analysis, MAP accounted for 12% and 16% of the DGF risk associated with recipient BMI and pre-transplant dialysis duration, respectively. In deceased donor kidney transplantation, each 1mmHg increase in preoperative MAP was associated with 2% lower DGF risk. Preoperative MAP was influenced by recipient BMI and dialysis duration, and likely contributes to some of the high DGF risk from obesity and long dialysis vintage.

Access to kidney transplantation among pediatric candidates with prior solid organ transplants in the United States.

Pediatric kidney transplant candidates require timely access to transplant to optimize growth and neurodevelopmental outcomes. We studied access to transplant for pediatric candidates with prior organ transplants. We used US registry data to identify pediatric kidney transplant candidates added to the waiting list 2015-2019 and used competing risk regression to study the association between prior transplant status and probability of receiving a kidney transplant, treating wait-list removal and death as competing events. Of 4962 pediatric kidney transplant candidates included, 89% had no prior transplant and 11% had received a prior organ transplant (kidney 87%, liver 5%, heart 5%). Prior transplant recipients were older at listing (median 15 vs. 12 years) and more likely to have PRA≥98% (22% vs. 0.3%) (both p < .001). There was no significant difference in the proportion of candidates from each group who were preemptively wait-listed. Unadjusted competing risk regression showed a lower risk of kidney transplant after wait-listing among candidates with prior organ transplant (HR 0.52, 95%CI 0.47-0.59, p < .001). This association remained significant after adjusting for candidate characteristics (HR 0.73, 95%CI 0.63-0.83, p < .001). Among deceased donor kidney recipients, median KDPI was similar between groups, but recipients with prior transplants were more likely to receive kidneys from donors with hypertension (4% vs. 1%, p=.01) and donors after cardiac death (11% vs. 4%, p < .001). Pediatric kidney transplant candidates with prior organ transplants have reduced access to transplant after wait-listing. Allocation system changes are needed to improve timely access to transplant for this vulnerable group.

Deep Learning Algorithms for the Prediction of Posttransplant Renal Function in Deceased-Donor Kidney Recipients: A Preliminary Study Based on Pretransplant Biopsy.

BackgroundPosttransplant renal function is critically important for kidney transplant recipients. Accurate prediction of graft function would greatly help in deciding acceptance or discard of allocated kidneys.Methods: Whole-slide images (WSIs) of H&E-stained donor kidney biopsies at × 200 magnification between January 2015 and December 2019 were collected. The clinical characteristics of each donor and corresponding recipient were retrieved. Graft function was indexed with a stable estimated glomerular filtration rate (eGFR) and reduced graft function (RGF). We used convolutional neural network (CNN)-based models, such as EfficientNet-B5, Inception-V3, and VGG19 for the prediction of these two outcomes.ResultsIn total, 219 recipients with H&E-stained slides of the donor kidneys were included for analysis [biopsies from standard criteria donor (SCD)/expanded criteria donor (ECD) was 191/28]. The results showed distinct improvements in the prediction performance of the deep learning algorithm plus the clinical characteristics model. The EfficientNet-B5 plus clinical data model showed the lowest mean absolute error (MAE) and root mean square error (RMSE). Compared with the clinical data model, the area under the receiver operating characteristic (ROC) curve (AUC) of the clinical data plus image model for eGFR classification increased from 0.69 to 0.83. In addition, the predictive performance for RGF increased from 0.66 to 0.80. Gradient-weighted class activation mappings (Grad-CAMs) showed that the models localized the areas of the tubules and interstitium near the glomeruli, which were discriminative features for RGF.ConclusionOur results preliminarily show that deep learning for formalin-fixed paraffin-embedded H&E-stained WSIs improves graft function prediction accuracy for deceased-donor kidney transplant recipients.

Donor rhabdomyolysis, acute kidney injury, and kidney transplant outcomes.

Donor rhabdomyolysis may constrain kidney utilization due to anticipated unfavorable graft outcomes-especially in combination with acute kidney injury (AKI). There is a paucity of empiric data to inform organ acceptance decision-making. A single-center retrospective cohort study of adult transplant recipients of deceased-donor kidneys with reported donor creatine phosphokinase (CPK) levels was conducted between 2014 and 2020. Recipients of CPK ≥ 1000U/L kidneys were propensity matched to CPK<1000 recipients according to outcome-predictive baseline covariates, except AKI. A total of 254 kidney transplants were propensity matched into CPK ≥ 1000 (n=90) versus CPK<1000 (n=90) groups. Transplant outcomes with high versus low CPK kidneys were similar in terms of delayed graft function (P=0.64), 1-year estimated glomerular filtration rate<25th percentile (P=0.69) and mean (P=0.58), and time to all-cause graft failure (P=0.58). There was no interaction between AKI and high CPK for these outcomes. Extreme CPK thresholds as high as>8672U/L were not associated with overall graft survival in the unmatched sample (P=0.81). In a single center study, donor rhabdomyolysis was not associated with short-term kidney transplant graft outcomes, nor was there an additive effect of AKI. However, studies with greater CPK and AKI severity and longer follow-up are warranted.

COVID-19 Infection in Kidney Transplant Recipients From a Single Center in Iran.

COVID-19 has been spreading rapidly throughout the world, with nearly every country thus far documenting this infection. In this study, our aim was to evaluate the risk factors for increased mortality in deceased donor kidney transplant recipients with COVID-19 at a single center in Iran. This was a retrospective study in a single center. During the 17-month ongoing COVID19 pandemic in Iran, there were 153 deceased donor kidney recipients at our center with suspected COVID19 symptoms. Of these patients, 138 had positive COVID-19 tests, and thus a therapeutic regimen was commenced for these patients. Data were analyzed with SPSS version 16 software. The patients were predominantly male (83, 60.1%) with a median age of 47.09 ± 13.75 years and a median time since transplant of 51 months (IQR, 1-276 months). Among these patients, 84 (60.8%) had hypertension and 43 (31.2%) had diabetes mellitus. We observed a significant relationship between disease severity and mortality (P < .001). After risk adjustments for age, presence of diabetes mellitus and hypertension and blood group type were factors that showed a significantly higher risk of death. Deceased donor kidney transplant recipients with confirmed COVID-19 experienced less fever as an initial symptom. However, recipients with COVID-19 and an underlying disease had a higher rate of mortality, severity of infection, and progression of disease. Appropriate management of renal complications and vaccinations in deceased donor kidney transplant recipients may help lead to more favorable outcomes.

Efficacy of Low-Dose Trimethoprim/Sulfamethoxazole for the Treatment of Pneumocystis jirovecii Pneumonia in Deceased Donor Kidney Recipients.

BackgroundTrimethoprim/sulfamethoxazole (TMP-SMX) is considered the first-choice treatment for Pneumocystis jirovecii pneumonia (PJP) in recipients of solid organ transplantation. However, this treatment is associated with various severe adverse events that might not be tolerable for some renal transplant recipients, and the optimal dose remains elusive. The present study assessed the efficacy of low-dose TMP-SMX in recipients of a deceased donor kidney.MethodsA total of 37 adult deceased donor kidney recipients who suffered PJP between January 2015 and June 2020 were included. The survival rates of the patients and grafts, the rate of invasive ventilation, and adverse events, including gastrointestinal discomfort, hematologic side effects, hyperkalemia, and renal function impairments, were assessed.ResultsThe patient and graft survival rates were both 100%. Two patients (5.4%) required invasive ventilation. Eight patients (21.6%) reported gastrointestinal discomfort, but none required dose reduction or discontinued treatment. The frequencies of hematologic side effects, hyperkalemia and impaired kidney function were 5.4% (2/37), 2.7% (1/37), and 2.7% (1/37), respectively.ConclusionOptimization of TMP-SMX dose may reduce the risk of adverse events without compromising efficacy for the treatment of PJP in deceased donor kidney recipients.

The Sum of Kidney Donor Profile Index and Estimated Post-Transplant Survival Scale and Their Correlation with eGFR Decline in Deceased Donor Kidney Recipients.

The impact of donor quality on post-kidney transplant survival may vary by candidate condition. Analyzing the combined use of the Kidney Donor Profile Index (KDPI) and the estimated post-transplant survival (EPTS) scale and their correlation with the estimated glomerular filtration rate (eGFR) decline in deceased-donor kidney recipients (DDKR). This was a retrospective, observational cohort study. We included DDKRs between 2015 and 2017 at a national third-level hospital. We analyzed 68 DDKR. The mean age at transplant was 41 ± 14 years, 47 (69%) had sensitization events, 18 (26%) had delayed graft function, and 16 (23%) acute rejection. The graft survival at 12 and 36 months was 98.1% (95% CI 94-100) and 83.7% (95% CI 65-100), respectively. The Pearson correlation coefficient between the percentage reduction in the annual eGFR and the sum of EPTS and KDPI scales was r = 0.61, p < 0.001. The correlation coefficient between the percentage reduction in the annual eGFR and the EPTS and KDPI scales separately was r = 0.55, p < 0.001, and r = 0.53, p < 0.001, respectively. The sum of EPTS and KDPI scales can provide a better donor-recipient relationship and has a moderately positive correlation with the decrease in eGFR in DDKR.

Trends and impact on cold ischemia time and clinical outcomes using virtual crossmatch for deceased donor kidney transplantation in the United States

For assessing human leukocyte antigen compatibility in deceased donor kidney transplantation, virtual crossmatch is used as an alternative to physical crossmatch and has potential to reduce cold ischemia time. The 2014 United States kidney allocation system prioritized highly sensitized candidates but led to increased shipping of kidneys. Using data from the Scientific Registry of Transplant Recipients, we evaluated changes in virtual crossmatch use with the new allocation policy and the impact of virtual crossmatch use on cold ischemia time and transplant outcomes. This was a retrospective cohort study of adult deceased donor kidney recipients in the United States (2011-2018) transplanted with either 9,632 virtual or 71,839 physical crossmatches. Before allocation change, only 9% of transplants were performed relying on a virtual crossmatch. After the 2014 allocation change, this increased by 2.4%/year so that 18% transplants in 2018 were performed with just a virtual crossmatch. There was significant variation in virtual crossmatch use among transplant regions (range 0.7-36%) and higher use was noted among large volume centers. Compared to physical crossmatches, virtual crossmatches were significantly associated with shorter cold ischemia times (mean 15.0 vs 16.5 hours) and similar death-censored graft loss and mortality (both hazard ratios HR 0.99) at a median follow-up of 2.9 years. Thus, our results show that virtual crossmatch is an attractive strategy for shortening cold ischemia time without negatively impacting transplant outcomes. Hence, strategies to optimize use and reduce practice variation may allow for maximizing benefits from virtual crossmatch.

Primary pediatric deceased-donor kidney transplant recipients outcomes by immunosuppression induction received in the United States.

We studied the association of induction immunosuppression and pediatric deceased-donor kidney recipient and graft survival. We utilized the SRTR to evaluate all primary pediatric deceased-donor kidney transplants from January 1st, 2000, through December 2018. We included only recipients who were maintained on tacrolimus and mycophenolate. Recipients were grouped by induction type: alemtuzumab n=320, r-ATG n=2091 and IL-2RA n=2165. Recipient and allograft survival, and their predictors, were examined. Models were adjusted for age, sex, ethnicity, HLA-antigen mismatches, transplant year, steroid maintenance, pre-emptive transplantation and payor type, with the transplant center included as a random effect. Rejection rates at 6months (alemtuzumab 8.6% vs r-ATG 7.8% vs IL2-RA 9.2%; P=.30) and 12months (alemtuzumab 17.2% vs r-ATG 15.7% vs IL2-RA 16.5%; P=.70) were not significantly different between induction groups. In the multivariable models, compared to IL-2RA neither alemtuzumab nor r-ATG was associated with improved recipient [alemtuzumab (HR 1.06, P=.88); r-ATG (HR 1.03, P=.84)] or graft survival [alemtuzumab (HR 1.18, P=.32); r-ATG (HR 1.10, P=.21)]. In this large cohort of standard immunological risk primary pediatric deceased-donor kidney recipients on tacrolimus and mycophenolate maintenance, depletional induction regimens were not associated with better rejection rates, recipient, or graft survival compared to IL-2RA induction. Racial, payor type, and sex-related outcome disparities were significant in this group independent of the induction choice.

P1721PERI-OPERATIVE HYPERKALAEMIA IN DECEASED-DONOR KIDNEY TRANSPLANT RECIPIENTS

Abstract Background Hyperkalaemia is a common and life-threatening medical emergency present in up to 10% of acute hospital admissions. End-stage Kidney Disease (ESKD) patients undergoing transplantation are at increased risk of hyperkalaemia and although the prevalence of hyperkalaemia in ESKD is well described, few studies have assessed the incidence and treatment of hyperkalaemia in kidney transplant recipients. Here, we describe the results from a retrospective review of peri-operative hyperkalaemia in incident deceased-donor kidney transplant recipients. Methods We conducted a retrospective electronic health record review of 172 consecutive deceased-donor kidney recipients at Addenbrooke’s Hospital, Cambridge between November 2018 and November 2019. Patients receiving simultaneous pancreas/kidney transplants, simultaneous liver/kidney or multi-visceral transplants were excluded as were living-donor kidney recipients. Variables abstracted included demographics, the type of organ received, pre-transplant renal replacement modality, treatments received for hyperkalaemia, serum potassium values and admission and discharge dates. Data were summarised as frequency (%), mean ± standard deviation (SD) or median with interquartile range (IQR) as appropriate. Categorical variables were compared by Chi-squared test and continuous variables by Student's t-test or Mann–Whitney U-test based on their distribution. Results 172 patients received a deceased-donor kidney during the study period and the median age of all recipients was 56 (IQR 46-64.5) years. 110 (64%) patients received a DCD (donation after circulatory death) kidney with the remaining 62 (36%) receiving DBD (donation after brainstem death) kidneys. 110 (64%) of recipients received haemodialysis prior to transplant. Mean serum potassium prior to transplant was 4.22±0.61 mmol/L and immediately post-operatively was 4.69±0.61 mmol/L. 85 (49%) recipients required emergency treatment for hyperkalaemia post-operatively. The median serum potassium prior to treatment was 5.98mmol/L (IQR 5.7-6.2) with median time to treatment of 6.8 hours (IQR 2.4-9.6) after kidney reperfusion. Of these patients 64% underwent emergency haemodialysis as the first line treatment for hyperkalaemia, whilst 24 of the 31 patients treated with insulin/dextrose for hyperkalaemia went on to receive haemodialysis for hyperkalaemia. Median length of stay was longer in those receiving treatment for hyperkalaemia (9 days (7-13) vs 7 days (6-10), p=0.005). Additional data is described in the figure below. Conclusion Hyperkalaemia amongst kidney transplant recipients is common, particularly in the peri-operative period. Current management strategies contribute to morbidity, with haemodialysis in the first week also independently associated with increased healthcare costs per patient in the first year following transplantation. New oral potassium binders may offer an alternative or adjunct to current management but there is a lack of data for their use in transplant patients. Clinical trials in the transplant peri-operative setting are warranted.

Contemporary patterns in kidney graft survival from donors after circulatory death in the United States.

Kidney transplants from donors after circulatory death (DCD) make up an increasing proportion of all deceased donor kidney transplants in the United States (US). However, DCD grafts are considered to be of lower quality than kidneys from donors after brain death (DBD). It is unclear whether graft survival is different for these two types of donor kidneys. We conducted a retrospective cohort study of US deceased donor kidney recipients using data from the United Network of Organ Sharing from 12/4/2014 to 6/30/2018. We employed a Cox proportional hazard model with mixed effects to compare all-cause graft loss and death-censored graft loss for DCD versus DBD deceased donor kidney transplant recipients. We used transplant center as the random effects term to account for cluster-specific random effects. In the multivariable analysis, we adjusted for recipient characteristics, donor factors, and transplant logistics. Our cohort included 27,494 DBD and 7,770 DCD graft recipients transplanted from 2014 to 2018 who were followed over a median of 1.92 years (IQR 1.08-2.83). For DCD compared with DBD recipients, we did not find a significant difference in all-cause graft loss (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.87-1.05 in univariable and HR 1.03 [95% CI 0.95-1.13] in multivariable analysis) or for death-censored graft loss (HR 0.97 (95% CI 0.91-1.06) in univariable and 1.05 (95% CI 0.99-1.11) in multivariable analysis). For a contemporary cohort of deceased donor kidney transplant recipients, we did not find a difference in the likelihood of graft loss for DCD compared with DBD grafts. These findings signal a need for additional investigation into whether DCD status independently contributes to other important outcomes for current kidney transplant recipients and indices of graft quality.

Small donor size does not negatively impact outcomes after deceased-donor renal transplantation.

Higher body mass index (BMI) of deceased-donors is associated with poorer outcomes in transplant recipients. The effect of low donor BMI on recipient graft function is not clear. Scientific Registry of Transplant Recipients data on recipients of deceased-donor kidneys from 2000 to 2019 were categorized by donor BMI (donor BMI<18, 18-27, and >27). Primary outcome was death-censored graft survival. The impact of multiple recipient and donor variables, including low donor BMI and the difference between donor and recipient BMI, was evaluated using a multivariate Cox proportional-hazards model. Low BMI donors (LBD) were more likely to be younger, female, and white (all P<.05). LBD were less likely to be Hispanic, diabetic, or have hypertension (all P<.001). LBD recipients were more likely to be younger and female (both P<.001). Low donor BMI was not significantly associated with recipient graft survival. Donor-recipient BMI difference did not correlate with an increased risk of graft failure. Similar results were obtained when donors were classified using body surface area (BSA). Small donor size in terms of BMI or BSA or a large discrepancy between donor and recipient size should not necessarily preclude transplantation of an otherwise acceptable kidney.