Deceased-donor Recipients Research Articles

Long-Term Survival (>25 Years) of Deceased Donor Kidney Transplant Recipients: A Single-Center Experience

IntroductionThe aim of this preliminary work is to analyze the clinical features of 52 patients with a functional transplanted kidney for >25 years (all first transplant and all deceased donor recipients) and to compare with a similar though more complete study from Hôpital Necker-Paris 2012. MethodsThe mean graft survival at 25 years is 12.7% and at 30 years is 10%. The actual mean serum creatinine concentration is 1.3 mg/L. We analyzed recipient age (mean, 35.9 years) and gender (29 men and 23 women). Donor age was 26.7 ± 10.3 years. Seven patients (13.4%) were transplanted with 1 HLA mismatch, 42.3% with 2 mismatches, and 44.2% with 3 mismatches. Mean cold ischemia time was 15.45 ± 7.7 hours. Of the recipients, 76% had immediate graft function; 38% experienced 1 acute rejection episode and 4 patients had 2 rejection crises. The initial immunosuppressive regimen was azathioprine (AZA) + prednisolone (Pred) in 14 patients, cyclosporin (CSA) + Pred in 13 patients, and CSA + AZA + Pred in 25 patients. Of these patients, 19% maintained their initial regimen, and 54% (28 patients) were very stable on a mixed CSA regimen for >25 years. ResultsWe present the major complications (diabetes, neoplasia, and hepatitis C virus positivity). ConclusionOur results in deceased donor kidney recipients for >25 years are similar to the mixed population (deceased donors and living donors) presented by the Necker group, although 54% of our patients remain on CSA immunosuppression, contradicting the idea that its use is not compatible with good long-term kidney function in transplant recipients.

Frailty, mycophenolate reduction, and graft loss in kidney transplant recipients.

Mycophenolate mofetil (MMF) side effects often prompt dose reduction or discontinuation, and this MMF dose reduction (MDR) can lead to rejection and possibly graft loss. Unfortunately, little is known about what factors might cause or contribute to MDR. Frailty, a measure of physiologic reserve, is emerging as an important, novel domain of risk in kidney transplantation recipients. We hypothesized that frailty, an inflammatory phenotype, might be associated with MDR. We measured frailty (shrinking, weakness, exhaustion, low physical activity, and slowed walking speed), other patient and donor characteristics, longitudinal MMF doses, and graft loss in 525 kidney transplantation recipients. Time-to-MDR was quantified using an adjusted Cox proportional hazards model. By 2 years after transplantation, 54% of frail recipients and 45% of nonfrail recipients experienced MDR; by 4 years, incidence was 67% and 51%. Frail recipients were 1.29 times (95% confidence interval [95% CI], 1.01-1.66; P = 0.04) more likely to experience MDR, as were deceased donor recipients (adjusted hazard ratio [aHR], 1.92; 95% CI, 1.44-2.54, P < 0.001) and older adults (age ≥ 65 vs <65; aHR, 1.47; 95% CI, 1.10-1.96, P = 0.01). Mycophenolate mofetil dose reduction was independently associated with a substantially increased risk of death-censored graft loss (aHR, 5.24; 95% CI, 1.97-13.98, P = 0.001). A better understanding of risk factors for MMF intolerance might help in planning alternate strategies to maintain adequate immunosuppression and prolong allograft survival.

OPTN/SRTR 2013 Annual Data Report: kidney.

A new kidney allocation system, expected to be implemented in late 2014, will characterize donors on a percent scale (0%-100%) using the kidney donor profile index (KDPI). The 20% of deceased donor kidneys with the greatest expected posttransplant longevity will be allocated first to the 20% of candidates with the best expected posttransplant survival; kidneys that are not accepted will then be offered to remaining 80% of candidates. Waiting time will start at the time of maintenance dialysis initiation (even if before listing) or at the time of listing with an estimated glomerular filtration rate of 20 mL/min/1.73 m(2) or less. Under the current system, the number of candidates on the waiting list continues to increase, as each year more candidates are added than are removed. Median waiting times for adults increased from 3 years in 2003 to more than 4.5 years in 2009. Donation rates have not increased. Short-term outcomes continue to improve; death-censored graft survival at 90 days posttransplant was 97% or higher for deceased donor transplants and over 99% for living donor transplants. In 2013, 883 pediatric candidates were added to the waiting list; 65.8% of pediatric candidates on the list in 2013 underwent deceased donor transplant. Five-year graft survival was highest for living donor recipients aged younger than 11 years (89%) and lowest for deceased donor recipients aged 11 to 17 years (68%).

Benefits, efficacy, cost-effectiveness and infectious complications in transplant patients desensitized with intravenous immunoglobulin and anti-CD20 therapy.

Renal transplantation is the treatment of choice for end-stage renal disease (ESRD), as it offers improved quality of life and survival 1–3. Currently, there are more than 100 000 ESRD patients on the deceased donor (DD) waiting list and almost 30 000 new patients register annually, yet only 16 895 kidney transplants were performed in 2013 [Organ Procurement and Transplantation Network (OPTN) data as of August 2014] 3. Unfortunately, the growing number of patients waiting for kidney transplants exceeds our ability to provide this life-saving treatment. This is particularly true for patients who are difficult to match due to human leukocyte antigen (HLA)-specific alloantibodies (resulting from previous pregnancies, blood or blood transfusions and transplantations). The recognition of the importance of alloantibodies and B cells as mediators of acute and chronic allograft injury is not new, but the magnitude of the problem is now well recognized 4. B cells and alloantibodies were felt to be important (but less important than T cells) as mediators of allograft injury. The deleterious effects of antibodies to HLA antigens that result from exposure to human tissues or blood are well known and prohibitive to transplantation. Patients who receive transplants across these incompatibilities show hyperacute rejection with rapid loss of graft function 4. Therefore, the presence of donor-specific anti-HLA antibodies (DSA) is considered a contraindication to transplantation 4,5. Sensitization to HLA antigens is long-lived and associated with memory B cells and plasma cells. Without modification, the opportunities for transplantation are minimal 6. Because of this, desensitization protocols have emerged using therapies directed at antibodies and B cells 6–13. These therapies have dramatically increased the rates of transplantation for this immunologically disadvantaged population. Of additional importance is the recognition of distinct and separate pathways that facilitate antibody-mediated rejection (AMR), which is a devastating consequence of DSA production after transplantation, with a more chronic form, transplant glomerulopathy, now recognized as a probable consequence of long-term exposure to DSA 14–17. Thus, alloantibody and allospecific B cells have emerged as major pathogenic factors for prevention of successful transplantation and a major cause for the decreased half-life of kidney transplants 18,19. B cells probably contribute to the pathogenesis of T cell-mediated rejection (CMR) and AMR through multiple pathways. B cells play a key role in presenting antigen to CD4+ T cells in collaboration with dendritic cells and other antigen-presenting cells (APC) 20–23. B cells express a number of co-stimulatory molecules (B7, CD40) that aid in co-stimulation of activated T cells and in their progression to full effector and cytotoxic functions. This is, of course, in addition to the role of B cells and plasma cells in producing DSA that has the capacity to activate complement and induce antibody-dependent cellular cytotoxicity (ADCC). B cells also produce a number of cytokines that are proinflammatory and promote cell injury directly or through activation of cytotoxic effector cells. B effector cells produce proinflammatory cytokines such as lymphotoxin-α, interferon (IFN)-γ and interleukin (IL)-6 21–23. IL-6 was identified as a critical B cell cytokine responsible for relapse of multiple sclerosis 24. In this study, patients treated with B cell depletion with rituximab showed elimination of IL-6-producing B cells and developed remission from disease. IFN-γ-producing B cells have been identified in active systemic lupus erythematosus (SLE) and are felt responsible for increased T helper type 1 (Th1) cytokine production with concomitant reductions in regulatory T cells (Tregs). In addition, B regulatory subsets also exist, and have the capacity to modify inflammation and autoimmunity in animal models 20. In an effort to optimize the availability of compatible donors, several transplant centers have developed desensitization protocols aimed at modification of alloantibodies and B cells to reduce HLA sensitization and AMR. There are two widely accepted desensitization protocols: low-dose intravenous immunoglobulin with plasma exchange (IVIg/PLEX) and high-dose IVIg (HD-IVIg). IVIg/PLEX has been used successfully in ABO-incompatible and in positive cross-match (+CMX) renal transplantation 8,9, while HD-IVIg has been used to desensitize both living-donor +CMX and highly sensitized (HS) DD recipients on the waiting list 6,7,10–13. HD-IVIg (2 g/kg) in multiple-dosing regimens is considered a reasonable approach for desensitization 25. The B cell-depleting agent, rituximab, is used frequently in combination with HD-IVIg and IVIg/PLEX protocols 8–12. Experience with the IVIg/rituximab protocol has shown that rituximab has a critical role in modifying alloreactive B cells and prevention of DSA rebound 26,27. Here, we will discuss data regarding the safety, efficacy and economic aspects of current desensitization protocols.

Trends in kidney transplant outcomes in older adults.

To estimate mortality and death-censored graft loss according to year of kidney transplant (KT) between 1990 and 2011. Cohort study. The Scientific Registry of Transplant Recipients (SRTR). KT recipients aged 65 and older at the time of transplantation (N = 30,207). Mortality and death-censored graft loss ascertained through center report and linkage to Social Security Death Master File and to Medicare. Older adults currently account for 18.4% of KT recipients, up from 3.4% in 1990; similar increases were noted for deceased donor (5.4 times percentage increase) and live donor (9.1 times percentage increase) transplants. Current recipients are not only older, but also more likely to be female and African American, have lengthier pretransplant dialysis, have diabetes mellitus or hypertension, and receive marginal kidneys. Mortality for older deceased donor recipients between 2009 and 2011 was 57% lower (hazard ratio (HR) = 0.43, 95% confidence interval (CI) = 0.33-0.56, P < .001) than between 1990 and 1993; mortality for older live donor recipients was 50% lower (HR = 0.50, 95% CI = 0.36-0.68, P < .001). Death-censored graft loss for older deceased donor recipients between 2009 and 2011 was 65% lower (HR = 0.35, 95% CI = 0.29-0.42, P < .001) than between 1990 and 1993; death-censored graft loss for older live donor recipients was 59% lower (HR = 0.41, 95% CI = 0.24-0.70, P < .001). Despite a major increase in number of older adults transplanted and an expanding window of transplant eligibility, mortality and graft loss have decreased substantially for this recipient population. These trends are important to understand for patient counseling and transplant referral.

Changes in geographic disparity in kidney transplantation since the final rule.

The national organ allocation system for deceased-donor kidney transplant will endure increased burden as the waitlist expands and organ shortage persists. The Department of Health and Human Services issued the "Final Rule" in 1998 that states "Organs and tissues ought to be distributed on the basis of objective priority criteria and not on the basis of accidents of geography." However, it has not been addressed whether the rule was effective in encouraging regions to share the additional burden equitably. To assess the significance of changes of geographic disparities for four metrics since the rule's adoption: waiting times, transplant rates, pretransplant mortality, and organ quality. Using Organ Procurement and Transplant Network data from 1988 through 2009, annual ranges of the metrics were calculated for all donor service areas and United Network for Organ Sharing regions. Time series analyses were used to compare the metrics before and after the enactment of the Final Rule. A total of 412,127 kidney transplant candidates and 178,163 deceased-donor recipients were analyzed. Demographics varied significantly by region. The ranges of the four metrics have worsened by approximately 30% or more after the Final Rule at both the regional and donor service area levels. Increasing geographic disparity in allocation procedures may yield diverging outcomes and experiences in different locations for otherwise similar candidates. Consensus for measuring allocation discrepancies and policy interventions are required to mitigate the inequities.

Efficacy and safety of conversion from cyclosporine to everolimus in living-donor kidney transplant recipients: an analysis from the ZEUS study.

Conversion of living-donor kidney transplant patients from calcineurin inhibitor therapy to an mTOR inhibitor is poorly documented. In the prospective, multicentre ZEUS study, 300 kidney transplant recipients without prior rejection (Banff grade >1) and serum creatinine ≤265μmol/l were randomized to continue cyclosporine or convert to everolimus at 4.5months post-transplant. In a post hoc analysis of 80 living-donor recipients, adjusted estimated GFR (Nankivell) at month 12 (the primary endpoint) was 74.3 (95% CI [70.7, 77.9]) ml/min/1.73m(2) with everolimus versus 63.8 (95% CI [60.0, 67.7]) ml/min/1.73m(2) ) with cyclosporine, a difference of 10.5ml/min/1.73m(2) in favour of everolimus (P<0.001). From randomization to month 12, adjusted estimated GFR increased by a mean of 9.8 (95% CI [6.2, 13.4]) ml/min/1.73m(2) with everolimus versus -0.7 (95% CI [-4.6, 3.1]) ml/min/1.73m(2) ) (P<0.001) with cyclosporine. There were six biopsy-proven acute rejection episodes in everolimus-treated patients (five Banff grade I) and one episode in cyclosporine-treated patients (Banff grade 1). Overall safety profile was similar between groups. Discontinuation due to adverse events occurred in three everolimus patients (7.1%) and five cyclosporine patients (13.2%) between randomization and month 12. Initiation of everolimus with early elimination of calcineurin therapy is associated with a significant renal benefit at 12months post-transplant that is observed in both living and deceased-donor recipients. (clinicaltrials.gov NCT00154310).

Vascular access for chronic hemodialysis in children: arteriovenous fistula or central venous catheter?

The choice of vascular access (VA) for hemodialysis (HD) in end-stage renal disease (ESRD) is arteriovenous fistula (AVF) or central venous catheter (CVC). Whereas clinical practice guidelines suggest AVF to preserve the vascular bed, pediatric nephrologists tend to favor CVC for shorter-term dialysis. Our objective was to determine whether pediatric priority allocation policies for deceased-donor kidneys affect VA planning. Pediatric priority for deceased-donor kidneys was instituted in Quebec in 2004. We retrospectively compared clinical practice on AVF, CVC, wait time on transplant list, HD duration in pre-policy (group A) and post-policy (group B) from 1997-2011. We identified 78 patients with a median age of 14.7 years (range, 0.7-20.5 years) and weight of 46 kg (12.5-95 kg); AVF decreased from 76 % in group A to 41 % in group B (p = 0.002). Wait times on transplant list were significantly reduced: median 413.5 days (range, 2-1,910 days) in group A vs. 89 days (range, 18-692 days) in group B (p = 0.003). Time on HD for deceased-donor recipients was shorter: 705 (range, 51-1,965 days) group A vs. 349.5 days (range, 158-1,060 days) group B (p = 0.01). This is the first study to document VA changes related to pediatric priority allocation policy. Our fistula-first center saw a shift toward CVC-first.

Health Literacy of Living Kidney Donors and Kidney Transplant Recipients

Health literacy (HL) may be a mediator for known socioeconomic and racial disparities in living kidney donation. We evaluated the associations of patient and demographic characteristics with HL in living kidney donors (LD), living donor kidney transplant recipients (LDR), and deceased donor recipients (DDR) in a single-center retrospective review of patients undergoing kidney donation or transplantation from September 2010 to July 2012. HL and demographic data were collected. HL was assessed via the Short Literacy Survey (SLS) comprising three self-reported screening questions scored using the five-point Likert scale (low, moderate, high). Chi-square and logistic regression were used to test factors associated with lower HL. The sample included 360 adults (105 LD, 103 LDR, and 152 DDR; 46±14 years; 70% white; 56% male; 14±3 years of education). HL scores were skewed (49% high, 41% moderate, and 10% low). The distribution of HL categories differed significantly among groups (P=0.019). After controlling for age, race, sex, education, and a race-education interaction term, DDR was more likely to have moderate or low HL than LDR (OR, 1.911; 95% CI, 1.096-3.332; P=0.022). Overall, living donors had high HL. The distribution of low, moderate, and high HL differed significantly between LD, DDR, and LDR. DDR had a higher likelihood of having low HL than LDR. Screening kidney transplant candidates and donors for lower HL may identify barriers to living donation. Future interventions addressing HL may be important to increase living donation and reduce disparities.

Post-Operative Infectious Complications among Renal Transplant Recipients in the Multi-Drug Resistant Era: A Single Institutional Study from a High Volume Renal Transplant Center (2008-2012).

Purpose: To analyze the impact of ESCAPE pathogens on post-operative infectious complications in a large contemporary renal transplant (RT) population. Methods: 1,012 RT recipients (2008-2012) from a single, large transplant center formed the study population. Demographic and clinical data was abstracted. Standard statistical methods were employed. Results: Post-operative infections were seen in 16.4% of RT patients (166/1,012). Resistant ESCAPE pathogens were seen in 5.4% (11) in 2008, 1.8% (4) in 2009, 4.8% (9) in 2010, 3.6% (7) in 2011 and 4.2% (9) in 2012 (p=0.31). UTI (7.2%) and surgical site infection (3.9%) were the most common infection sites followed by blood stream infection (1.5%). RT patients with early post-operative infection were 5 years older than those without infection, p=0.003. No significant gender differences was observed (p=0.112). African Americans (21.2%), deceased donor recipients (21%), those receiving thymoglobulin induction (18.5%), those with delayed graft function (16.8%), diabetes (19.3%) and leukopenia (18.6%) had higher infection rates (p<0.05 in each case). Patients with infection had shorter mean antibiotic administration to incision time (19 versus 22 minutes), p=0.041, but longer hospital stay (8 versus 5 days), p<0.001.Table: No Caption available.Conclusions: ESCAPE organisms accounted for only 3 -5% of the organisms isolated from post-operative infections in a modern large single-center RT population. African Americans, deceased donor recipients, thymoglobulin, diabetes and leukopenia were associated with increased rate of post-operative infection, and highlight a group of patients in whom rigid attention to aseptic technique, hemostasis and infection control practices maybe impactful and worthy of additional study.

Thymoglobulin 5 mg/kg Is as Effective as 6 mg/kg and Costs Less: Largest Report to Date.

Background: The agent, dose, and duration used for induction post-renal transplantation (RT) are controversial and center-specific. Approximately 50% of RT patients receive induction with rATG nationwide. Cumulative target doses in small, retrospective studies have ranged from 3-10.5 mg/kg. A recent retrospective study of 188 patients showed that acute rejection (AR) is more frequent if the cumulative rATG dose is <6 mg/kg of actual body weight (ABW). We adjusted our induction protocol with rATG by lowering the cumulative dose from 6 mg/kg ABW to 5 mg/kg ABW. Methods: We performed a retrospective cohort study of adult RT recipients transplanted 2006-2012 who received rATG for induction. The primary outcome was the incidence of acute cellular rejection (ACR) at 1 year. Secondary outcomes were AR (ACR or AMR) and time to ACR. A multivariate analysis was performed to determine predictors of ACR at 1 year post-transplant. Results: 1,096 patients were identified and groups were compared based on total induction dose of rATG [low dose <5 mg/kg (n=683) vs high dose >5 mg/kg (n=413)]. 60% were male, 23% AA race, 64% deceased donor recipients, and average of 3.8 HLA mismatches. Baseline characteristics were well matched, with the exception of the low dose group being slightly older (51 vs 50 years). The mean dose of rATG in the low dose group was 4.87 mg/kg vs 5.86 mg/kg in the high dose group, p<0.001. There were no differences in the incidence of ACR (4.7% low dose vs 5.1% high dose, p=0.76) or AR (5.3% low dose vs 5.7% high dose, p=0.81) at 1 year post-transplant.Figure: No Caption available.In a multivariate model including HLA mismatches, AA race, age, and rATG dosing, only older age was associated with a significant reduction in risk of ACR (HR 0.967, CI 0.948 - 0.987 for each year). Conclusions: This large retrospective analysis suggests that induction immunosuppression with rATG <5 mg/kg is as effective as higher doses for preventing AR at 1 year post-transplant, and can save over $2,000 per patient without compromising graft outcomes. DISCLOSURES:Brennan, D.: Speaker's Bureau, Sanofi.

Modified Frailty Index Is Associated With 30-Day Mortality in Liver Recipients.

Background The current liver transplant (LT) allocation scheme, transplanting the sickest waitlist patients first, raises interest in better identifying patients at increased risk of mortality post-transplant. In practice, the decision to offer LT is largely related to subjective assessment of global health, however tools used to identify risk factors for early postoperative mortality are lacking. We hypothesized that a modified frailty index (MFI) may be a predictor of 30-day mortality in this patient population. Methods Adult first-time liver-only, deceased donor recipients from Scientific Registry of Transplant Recipients from 2002-2012 [n=47,605] were studied. The MFI was derived from the International Classification of Primary Care and the Canadian Study of Health and Aging, and defined as the proportion of deficits present at the time of transplant. Deficits examined included albumin <3, BMI <18.5, functional status, angina, COPD, PVD, hypertension, peptic ulcer disease, diabetes and stroke. The adjusted relative risk (aRR) for mortality within 30-days of transplant was estimated using modified Poisson regression with robust error variance, adjusting for age, gender, race and MELD. Results The distribution of frailty is described in figure A, with 12.4% of liver recipients with no deficits, 83% with one to three deficits, and 4.6% with four or more deficits. 30-day mortality increased as the MFI increased, ranging from 2% mortality with those who had no deficits to 12.5% for those with 7 deficits (B) In adjusted analysis, frailty was associated with a 1.25-fold increased risk of mortality with 1-3 deficits (aRR 1.25, 95% CI 1.03-1.51, p=0.02) and a 1.76 fold increased risk with > 4 deficits (aRR 1.76, 95% CI 1.35-2.30 p<0.0001).Figure: No Caption available.Conclusion The MFI was associated with a 30-day mortality following liver transplantation in this retrospective analysis. Pre-transplant quantification of individual patient risk using the MFI may aid in guiding risk assessment, patient counseling and informed consent.

Clinical Outcomes in Renal Transplant Recipients With Fabry Disease.

Introduction:Fabry disease consists of an X-linked metabolic disorder characterized by a deficiency of the enzyme alpha-galactosidase A. The resulting accumulation of glycosphingolipids in several cells is the cause of organ dysfunction. Kidney transplantation is an alternative renal replacement therapy for such patients, but its impact on long-term outcomes are not yet based on robust evidences. The aim of this study was describe the clinical and epidemiological profiles of patients with end-stage renal disease (ESRD) caused by Fabry disease submitted to renal transplantation and evaluate their long-term outcomes. Methods: This is a case-control study with case:control ratio of 1:2. The cases consisted of all kidney recipients transplanted in a single center from 2004 to 2012 which etiology of ESRD was Fabry disease. The controls were matched for gender, age and time of transplantation. Results: In mentioned period, 6 patients with Fabry disease were submitted to renal transplantation. The mean follow-up was 1,665 ± 992 days. The study population (6 cases and 12 controls) was composed predominantly of male (100%), young (44 years), Caucasian (78%), deceased donor recipients (55%), and at low immunological risk (mean panel reactive antibodies = 3.4%). There were no difference between groups regarding acute rejection incidence (55%), number of hospital readmissions (3.3 times), 1 year- serum creatinine (1.4 mg/dL), 1 year-creatinine clearance (64 mL/min), and 1 year-proteinuria (0.19 mg/24h). The 4-year patient and graft survivals were 89% and 78%, respectively, and there were no difference between groups. Conclusion: Renal transplantation appears to be an effective strategy for the treatment of ESRD in patients with Fabry disease and provides similar long-term outcomes when compared to patients with ESRD due to other causes.

Quantifying Prognostic Impact of Prescription Narcotics Use Before Kidney Transplantation through Linked Registry and Pharmaceutical Claims Data.

Concern for an epidemic of complications related to prescription opioids has not spared the kidney transplant (KT) population. We examined a novel database wherein OPTN identifiers for KT recipients were linked to records from a U.S. pharmaceutical claims clearinghouse (2005 to 2010). Adult KT recipients with 1yr of captured pre-transplant pharmacy fill records were included (N=29,882). Narcotics fills in the year prior to KT were normalized to Morphine Equivalents (ME), and expressed as average mg/kg/d exposures. Associations of ME with post-transplant graft and patient survival (adjusted hazards ratio, aHR) were quantified by Cox regression adjusted for recipient, donor and transplant factors as well as propensity for narcotics use. 28.9% of the sample filled narcotics in the year before KT. Among narcotics users, the 25th, 50th and 75th percentiles of ME were: 0.01, 0.02, and 0.06 mg/kg/d, respectively. 3-yr survival of deceased donor (DD) recipients declined with higher quartiles of ME exposure, from 88.9% among non-users to 87.6% (Q2), 85.3% (Q3), 83.2% (Q4) (P<0.0001). After multivariate adjustment, the risks of post-transplant death and graft loss in DD recipients with the highest quartile ME exposure were 1.6-times and 1.4-times that of narcotic non-users, respectively (Table). Patterns were similar among live donor KT recipients, with the upper quartile of pre-transplant narcotics exposure predicting 2.4 times the risk of death (P<0.0001) and 1.8 times the risk of all-cause graft loss (P<0.0001) (Table).Table: No Caption available.Table: No Caption available.While observed associations may in part reflect underlying conditions that require pain management, KT recipients who use chronic narcotics should be identified as a high-risk group warranting focused clinical attention before and after KT.

Renal Transplantations in African Americans: A Single-center Experience of Outcomes and Innovations to Improve Access and Results

To report a single-center 10-year experience of outcomes of kidney transplantation in African Americans (AAs) vs Caucasian Americans (CA) and to propose ways in which to improve kidney transplant outcomes in AAs, increased access to kidney transplantation, prevention of kidney disease, and acceptance of organ donor registration rates in AAs. We compared outcomes of deceased donor (DD) and living donor (LD) renal transplantation in AAs vs CAs in 772 recipients of first allografts at our transplant center from January 1995 to March 2004. For DD and LD transplants, no significant differences in gender, age, body mass index, or transplant panel reactive antibody (PRA) existed between AA and CA recipients. Primary diagnosis of hypertension was more common in AA, DD, and LD recipients. Significant differences for DD transplants included Medicaid insurance in 23% AA compared with 7.0% CA (P<.0001) and more frequent diabetes mellitus type 2 in AAs (15% vs 4.1%, P=.0009). Eighty-three percent of AAs had received hemodialysis compared with 72% of CAs (P=.02). AAs endured significantly longer pretransplant dialysis (911±618 vs 682±526 days CA, P=.0006) and greater time on the waiting list (972±575 vs 637±466 days CA, P<0001). In DD renal transplants, AAs had more human leukocyte antigen (HLA) mismatches than CAs (4.1±1.4 vs 2.7±2.1, P<.0001). Mean follow-up for survivors was 7.1±2.5 years. Among LD transplants, graft survival and graft function were comparable for AAs and CAs; however, among DD transplants, graft function and survival were substantially worse for AAs (P=.0003). In both LD and DD transplants, patient survival was similar for AAs and CAs. Our data show that AAs receiving allografts from LDs have equivalent short- and long-term outcomes to CAs, but AAs have worse short- and long-term outcomes after DD transplantation. As such, we conclude that AAs should be educated about prevention of kidney disease, the importance of organ donor registration, the merits of LD over DD, and encouraged to seek LD options.

PUK19 - Costs Of Delayed Graft Function After Kidney Transplantation In Living And Deceased Donor Recipients

PUK19 - Costs Of Delayed Graft Function After Kidney Transplantation In Living And Deceased Donor Recipients

MP72-17 SCREENING FOR ASYMPTOMATIC BACTERURIA AT ONE MONTH AFTER ADULT KIDNEY TRANSPLANTATION : CLINICAL FACTORS AND IMPLICATIONS

You have accessJournal of UrologyTransplantation & Vascular Surgery II1 Apr 2014MP72-17 SCREENING FOR ASYMPTOMATIC BACTERURIA AT ONE MONTH AFTER ADULT KIDNEY TRANSPLANTATION : CLINICAL FACTORS AND IMPLICATIONS Yen Seow Benjamin Goh, Zhao Long Deng, Pei Shan, Cassandra Cheong, Bee Choo Tai, Ting Hui, Angeline Goh, Vathsala Anatharaman, and Ho Yee Tiong Yen Seow Benjamin GohYen Seow Benjamin Goh More articles by this author , Zhao Long DengZhao Long Deng More articles by this author , Pei ShanPei Shan More articles by this author , Cassandra CheongCassandra Cheong More articles by this author , Bee Choo TaiBee Choo Tai More articles by this author , Ting HuiTing Hui More articles by this author , Angeline GohAngeline Goh More articles by this author , Vathsala AnatharamanVathsala Anatharaman More articles by this author , and Ho Yee TiongHo Yee Tiong More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2256AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary tract infections (UTI) are a significant cause of morbidity after kidney transplantation. Screening for asymptomatic bacteruria (AB) has proven beneficial in certain adults like pregnant women; but it is poorly studied in the transplant population. We reviewed the clinical features and implications of AB one month after kidney transplantation. METHODS A review of 176 adult kidney transplant patients (87(51%) male, 86(50%) living, mean age 47) from 2005-2012 was performed. Protocol urine cultures were taken at 1 month after transplantation for all patients, regardless of symptoms. Five patients were excluded with missing results. Bacteruria was defined as 10⁵ CFUs of pathogenic organism per millilitre of voided urine specimen. All patients with positive cultures were treated with appropriate antibiotics. Patients were analysed according to culture positivity for associated factors and outcomes including hospitalizations, graft and patient survival. RESULTS Among the 171 urine cultures, 41(24%) were positive for AB. Klebsiella penumoniae, E. coli and Enterococcus faecalis were the most common organisms, accounting for 34.1%, 26.8% and 22.0% of the isolates. Multi-resistant organisms accounted for 43.9% of the infections. Bacteruria was associated with deceased donor transplants (P=0.001) and female recipients (P=0.014). It was not associated (P=NS) with recipient age, race, native kidney disease, donor demographics, and regimen of induction or maintenance immunosuppression, delayed graft function and duration of ureteric stent. Logistic regression confirms female sex (RR 2.6 95% CI 1.2-5.6, P<0.001) and deceased donor recipients (RR 7.7 95% CI 1.9-3.1, P=0.02) were independent predictors of AB at 30 days. Patients with AB were significantly more likely to be hospitalized subsequently for symptomatic UTI (RR 4.6 95% CI 2.1-9.9, P=0.001). However, there was no significant difference in 1-year patient (100% vs. 97%) and graft survival (95.1% vs. 95.4%) between the groups with positive and negative culture. CONCLUSIONS AB 30 days post transplant can be predicted in deceased donor and female recipients, reflecting functional and anatomical differences in voiding function. It is predictive of increased morbidity of subsequent hospitalization for symptomatic UTI and high risk groups may warrant targeted prophylaxis. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e829-e830 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Yen Seow Benjamin Goh More articles by this author Zhao Long Deng More articles by this author Pei Shan More articles by this author Cassandra Cheong More articles by this author Bee Choo Tai More articles by this author Ting Hui More articles by this author Angeline Goh More articles by this author Vathsala Anatharaman More articles by this author Ho Yee Tiong More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effects of Cardiovascular Comorbidity Adjustment on SRTR Risk-Adjusted Cox Proportional Hazard Models of Graft Survival

The Scientific Registry of Transplant Recipients (SRTR) and the Centers for Medicare and Medicaid Services (CMS) determine expected graft survivals to identify potentially underperforming transplant centers. There has been recent interest in evaluating adjustments for comorbidities when performing these calculations. This study was performed to determine the influence that adjustment for pre-transplant cardiovascular disease comorbidity can have on risk-adjusted Cox models, such as those used by SRTR and CMS. We analyzed Cox proportional hazards models for 1-year and 3-year graft survival for kidney recipients from a single center where cardiovascular disease covariates were added to a baseline model derived by using the SRTR calculated risk scores and including all standard SRTR parameters. Living and deceased donor recipient 1-year and living donor 3-year Cox models that included all seven covariates demonstrated 8% to 13% improved discrimination. Only the 1-year deceased donor recipient Cox model demonstrated significantly improved calibration (likelihood ratio test P=0.038). The expected graft losses increased by >30% for living donor recipients at 1 and 3 years and decreased by 2% to 4% for deceased donor recipients at 1 and 3 years. SRTR and CMS use of pre-transplant cardiovascular comorbidity adjustment might impact center performance evaluations.

Transplantation Results of Completely HLA-Mismatched Living and Completely HLA-Matched Deceased-Donor Kidneys Are Comparable

Human leukocyte antigen (HLA) mismatches are known to influence graft survival in deceased-donor kidney transplantation. We studied the effect of HLA mismatches in a population of recipients of deceased-donor or living-donor kidney transplantations. All 1998 transplantations performed in our center between 1990 and 2011 were included in this retrospective cohort study. Four different multivariable Cox proportional hazard analyses were performed with HLA mismatches as continuous variable, as categorical variable (total number of HLA mismatches), as binary variable (zero vs. nonzero HLA mismatches), and HLA-A, -B, and -DR mismatches included separately. Nine hundred ninety-one patients received a deceased-donor kidney and 1007 received a living-donor kidney. In multivariable Cox analysis, HLA mismatches, recipient age, current panel-reactive antibodies, transplant year, donor age, calcineurin inhibitor treatment, and donor type were found to have a significant and independent influence on the risk of graft failure, censored for death. Variables representing the total number of HLA-A, -B, and -DR mismatches had a significant and comparable influence in all analyses. The influence of HLA mismatches on death-censored graft survival holds true for both deceased- and living-donor kidney transplantation. However, the relative risk of death-censored graft failure of a 2-2-2 mismatched living-donor kidney is comparable with that of a 0-0-0 mismatched deceased-donor kidney.

Sequelae of Early Hospital Readmission After Kidney Transplantation

We recently elucidated risk factors for early hospital readmission (EHR) following kidney transplantation (KT). We now sought to quantify the independent associations between EHR and post-KT outcomes, including late hospital readmission (LHR: 1 year after EHR window), death-censored graft loss and mortality, among Medicare-primary KT recipients (2000-2005). Of 32961 KT recipients, 7.7% had at least one readmission within 3 days of discharge, 14.8% within 7 days, 22.4% within 14 days and 30.5% within 30 days of discharge after the initial KT hospitalization. KT recipients who experienced EHR within 30 days of discharge after the initial KT hospitalization were more likely to have experienced LHR (29.6% vs. 9.0%, p<0.001) and were at 3.02 times higher (95% CI: 2.82-3.23, p<0.001) risk of LHR. Additionally, EHR was associated with death-censored graft loss (deceased donor recipients hazard ratio [HR]: 1.43, 95% CI: 1.36-1.51, p<0.001 and live donor recipients HR: 1.54, 95% CI: 1.40-1.70, p<0.001) and mortality (deceased donor recipients HR: 1.50, 95% CI: 1.43-1.58, p<0.001 and live donor recipients HR: 1.45, 95% CI: 1.32-1.60, p<0.001). Thirty days posttransplant represents a high-risk window for KT recipients and the readmissions during this window are strong predictors of adverse sequelae, particularly LHRs. Efforts should be made to implement and improve systems to reduce LHR and subsequent graft loss and mortality among recipients with EHR.