Deceased Kidney Transplantation Research Articles

229.2: The impact of female sex and intersectional disadvantage on access to deceased kidney transplantation in australia: A 15 year national cohort study.

229.2: The impact of female sex and intersectional disadvantage on access to deceased kidney transplantation in australia: A 15 year national cohort study.

A Survey of United States Transplant Center Donation After Circulatory Death Kidney Transplant Practices in the Modern Era

IntroductionThe mismatch between the number of patients awaiting kidney transplantation and the supply of donor organs has in part resulted in a rise in kidney transplantation from donors after circulatory death (DCD). Persistently long waiting times have led the transplant community to continue to explore the use of expanded criteria DCD kidneys. In parallel, advances in organ preservation strategies have contributed to an overall increase in DCD organ transplantation and are altering the transplant landscape. Some of these techniques may improve kidney allograft outcomes and affect how DCD kidneys are utilized. We aimed to better understand practices in accepting DCD kidney offers in the modern era. MethodsDirectors of 196 U.S. kidney transplant centers were emailed a link to an online survey over a 5-week period. Results48 (13%) out of the 364 directors responded with all UNOS regions represented. Definitions of warm ischemia time (WIT) used in DCD kidney evaluation varied widely amongst respondents. The maximum total WIT limit varied with 19 (39.6%) less than 60 minutes responses, followed by 16 (33%) less than 90 minutes responses, and 10 (20.8%) less than 120 minutes responses. ConclusionDespite increasing DCD kidney transplantation volumes in the U.S. there are no standardized procurement biopsy practices, OPO pre-operative protocols, or consensus definition or limits of WIT. Agreement upon terminology may facilitate rapid clinical communication, efficiency of organ allocation and utilization, recording of data, research, and improvements in policy.

Impact of Warm Ischemia Time on Donation After Circulatory Death Kidney Transplant Outcomes.

Efforts to address the shortage of donor organs include increasing the use of renal allografts from donors after circulatory death (DCD). While warm ischemia time (WIT) is thought to be an important factor in DCD kidney evaluation, few studies have compared the relationship between WIT and DCD kidney outcomes, and WIT acceptance practices remain variable. We conducted a single-center retrospective review of all adult patients who underwent deceased donor kidney transplantation from 2000 to 2021. We evaluated the impact of varied functional warm ischemia time (fWIT) in controlled DCD donors by comparing donor and recipient characteristics and posttransplant outcomes between high fWIT (>60min), low fWIT (≤60min), and kidneys transplanted from donors after brain death (DBD). Two thousand eight hundred eleven patients were identified, 638 received low fWIT DCD, 93 received high fWIT DCD, and 2080 received DBD kidneys. There was no significant difference in 5-year graft survival between the DCD low fWIT, high fWIT, and DBD groups, with 84%, 83%, and 83% of grafts functioning, respectively. Five-year patient survival was 91% in the low fWIT group, 92% in the high fWIT group, and 90% in the DBD group. An increase in kidney donor risk index (KDRI) (HR 3.37, 95% CI=2.1-5.7) and high CIT compared to low CIT (HR 2.12, 95% CI=1.4-3.1) have higher hazard ratios for 1-year graft failure. Increased acceptance of kidneys from selected DCD donors with prolonged fWIT may present an opportunity to increase kidney utilization while preserving outcomes. Our group specifically prioritizes the use of kidneys from younger donors, with lower KDPI, and without acute kidney injury, or risk factors for underlying chronic kidney disease.

The early outcomes of two separate anastomosis procedures in deceased kidney transplantation with double arteries: A retrospective comparative study

BackgroundKidneys with double renal arteries are used on a routine basis nowadays, and separate anastomosis in situ is one of the suitable arterial anastomosis procedures. The commonly used methods are parallel end-to-side anastomoses of double arteries to the external iliac artery, and end-to-end anastomosis to the internal iliac artery combined with end-to-side anastomosis to the external iliac artery. No studies have compared the prognoses of the two procedures in deceased kidney transplantation. MethodsWe retrospectively analyzed 35 consecutive deceased kidney transplantations with double arterial anastomoses in the urology department of China–Japan Friendship Hospital from January 2018 to April 2021. Group I comprised recipients with double parallel end-to-side anastomoses to the external iliac artery; Group II comprised the others. Their prognoses were then compared. ResultsThere were no significant differences between Group I and II in characteristics of recipients and donors. The mean eGFRs at 1, 3, 6 and 12 months post-transplant in Group I and II were 36.4 vs 54.1 (P = 0.009), 40.4 vs 54.4 (P = 0.02), 40.4 vs 56.9 (P = 0.02) and 39.8 vs 57.9 (P = 0.007) mL/min respectively. There was no difference in early postoperative complications and 1-year survival rates between the two groups (P = 1.00). ConclusionSeparate anastomosis is a reliable procedure for deceased kidney transplantation with double arteries. Double separate anastomoses to the external and internal iliac arteries have better graft function compared with double parallel anastomoses to the external iliac artery during the first year after transplantation.

Deceased-Donor Kidney Transplant Outcome Prediction Using Artificial Intelligence to Aid Decision-Making in Kidney Allocation.

In kidney transplantation, pairing recipients with the highest longevity with low-risk allografts to optimize graft-donor survival is a complex challenge. Current risk prediction models exhibit limited discriminative and calibration capabilities and have not been compared to modern decision-assisting tools. We aimed to develop a highly accurate risk-stratification index using artificial intelligence (AI) techniques. Using data from the UNOS database (156,749 deceased kidney transplants, 2007-2021), we randomly divided transplants into training (80%) and validation (20%) sets. The primary measure was death-censored graft survival. Four machine learning models were assessed for calibration (integrated Brier score [IBS]) and discrimination (time-dependent concordance [CTD] index), compared with existing models. We conducted decision curve analysis and external validation using UK Transplant data. The Deep Cox mixture model showed the best discriminative performance (area under the curve [AUC] = 0.66, 0.67, and 0.68 at 6, 9, and 12 years post-transplant), with CTD at 0.66. Calibration was adequate (IBS = 0.12), while the kidney donor profile index (KDPI) model had lower CTD (0.59) and AUC (0.60). AI-based D-TOP outperformed the KDPI in evaluating transplant pairs based on graft survival, potentially enhancing deceased donor selection. Advanced computing is poised to influence kidney allocation schemes.

Pros and cons of live kidney donation in prediabetics: A critical review and way forward.

There is shortage of organs, including kidneys, worldwide. Along with deceased kidney transplantation, there is a significant rise in live kidney donation. The prevalence of prediabetes (PD), including impaired fasting glucose and impaired glucose tolerance, is on the rise across the globe. Transplant teams frequently come across prediabetic kidney donors for evaluation. Prediabetics are at risk of diabetes, chronic kidney disease, cardiovascular events, stroke, neuropathy, retinopathy, dementia, depression and nonalcoholic liver disease along with increased risk of all-cause mortality. Unfortunately, most of the studies done in prediabetic kidney donors are retrospective in nature and have a short follow up period. There is lack of prospective long-term studies to know about the real risk of complications after donation. Furthermore, there are variations in recommendations from various guidelines across the globe for donations in prediabetics, leading to more confusion among clinicians. This increases the responsibility of transplant teams to take appropriate decisions in the best interest of both donors and recipients. This review focuses on pathophysiological changes of PD in kidneys, potential complications of PD, other risk factors for development of type 2 diabetes, a review of guidelines for kidney donation, the potential role of diabetes risk score and calculator in kidney donors and the way forward for the evaluation and selection of prediabetic kidney donors.

Arteriolar hyalinization at 0-hour biopsy predicts long-term graft function in deceased kidney transplantation.

Regarding the relationship between donor kidney quality and renal graft function after deceased kidney transplantation (KTx) following donation after cardiac death (DCD), the evaluation timing varies depending on the study. Evaluation of histology and changes in long-term renal graft function is limited. A retrospective single-center study included 71 recipients who underwent 0-hour biopsy for KTx from DCD. The recipients were divided into two groups to evaluate factors related to renal graft function (study1). The two groups were categorized as stable graft function and poor graft function with the change of estimated glomerular filtration rate (eGFR) after KTx. The recipients were then divided into four groups to assess whether the factors identified in study1 were related to the change in long-term renal graft function (study2). They were categorized as follows: Improved, Stable, Deteriorated, and Primary non-function with the change of eGFR after KTx. In study1, donor age ≥ 50 years (29.5% vs. 65.2%; p = 0.09), banff arteriolar hyalinosis (ah) score (0.66 ± 0.78 vs. 1.2 ± 1.0; p = 0.018), and presence of glomerulosclerosis (43.2% vs. 76.2%; p = 0.017) were significant risk factors for poor long-term graft function. When the recipients were divided into four groups, the severity of ah correlated well with changes in long-term renal function. We can predict the shift in long-term renal graft function after KTx from DCD according to the severity of ah by 0-hour biopsy.

Clinical characteristics of 15 cases of renal transplantation with pre-exsiting donor-specific antibody.

Currently, patients with pre-exsiting donor-specific antibody (DSA) are prone to antibody-mediated rejection (AMR) after surgery and are at a relatively high risk of postoperative complications and graft failure. The risk of postoperative complications and graft failure is relatively high. This study aims to discuss the clinical outcome of DSA-positive kidney transplantation and analyze the role and safety of preoperative pretreatment in DSA-positive kidney transplantation, providing single-center treatment experience for DSA-positive kidney transplantation. We retrospectively analyzed the clinical data of 15 DSA-positive kidney transplants in the Department of Renal Transplantation of First Affiliated Hospital of Zhengzhou University from August 2017 to July 2022. Eight cases were organ donation after citizen's death (DCD) kidney transplant recipients, of which 3 cases in the early stage were not treated with preoperative desensitisation therapy (DCD untreated group, n=3), and 5 recipients were treated with preoperative rituximab desensitisation (DCD preprocessing group, n=5). The remaining 7 cases were living related donors recipients (LRD) who received preoperative desensitisation treatment with rituximab and plasma exchange (LRD preprocessing group, n=7). We observed and recorded the incidence of complications with changes in renal function and DSA levels in the recipients and the survival of the recipients and transplanted kidneys at 1, 3 and 5 years, and to compare the differences in recovery and postoperative complications between 3 groups. All 15 recipients were positive for preoperative panel reactive antibody (PRA) and DSA and were treated with methylprednisolone+rabbit anti-human thymocyte immunoglobulin induction before kidney transplantation. DCD untreated group all suffered from DSA level rebound, delayed renal graft function (DGF) and rejection reaction after surgery. After the combined treatment, DSA level was reduced and the graft renal function returned to normal. The DCD preprocessing group were all without antibody rebound, 1 recipient developed DGF and the renal function returned to normal after plasmapheresis, and the remaining 4 recipients recovered their renal function to normal within 2 weeks after the operation. In the LRD preprocessing group, 2 cases had antibody rebound and 1 case had rejection, but all of them recovered to normal after treatment, and DSA was maintained at a low level or even disappeared. The incidence of DGF and rejection in the DCD untreated group were significantly higher than that in the DCD preprocessing group and the LRD preprocessing group; and there were no significant difference in the incidence of postoperative haematuria, proteinuria, bacterial and fungal infections, and BK virus infection between the 3 groups (all P>0.05). A total of 11 of the 15 recipients were followed up for more than 1 year, 6 for more than 3 years, and 1 for more than 5 years, and the survival rates of both the recipients and the transplanted kidneys were 100%. Effective preoperative pretreatment with desensitization therapy can effectively prevent antibody rebound in DSA-positive kidney transplantation and reduce perioperative complications.

The toll of COVID-19 on organ donation and kidney transplantation in Europe: Do legislative defaults matter?

This study investigates the cascading effects of COVID-19 pandemic on organ donation and transplantation in Europe. We also check whether legislative defaults for organ donation have a role in these outcomes. For this purpose, we used data from 32 European countries, between 2010 and 2021, and estimated pooled OLS regressions. We find that COVID-19 pandemic reduced deceased organ donation rates by 23.4%, deceased kidney transplantation rates by 27.9% and live kidney transplantation rates by 31.1% after accounting for health system capacity indicators. While our study finds that presumed consent legislation under normal circumstances leads to notable benefits in terms of deceased kidney transplantation and organ donation rates, the legislative defaults did not have a significant impact during the pandemic. Additionally, our findings indicate a trade-off between living and deceased transplantation that is influenced by the legislative default.

Urinary Kidney Injury Biomarkers Are Associated with Ischemia-Reperfusion Injury Severity in Kidney Allograft Recipients.

We explored the potential of emerging and conventional urinary kidney injury biomarkers in recipients of living donor (LD) or donation after circulatory death (DCD) kidney transplantation, patients with chronic kidney disease (CKD), and individuals from the general population. Urine samples from kidney allograft recipients with mild (LD; n = 199) or severe (DCD; n = 71) ischemia-reperfusion injury (IRI) were analyzed for neutrophil gelatinase-associated lipocalin (NGAL), insulin-like growth factor-binding protein 7 (IGFBP7), tissue inhibitor of metalloproteinases 2 (TIMP2), kidney injury molecule-1 (KIM-1), chemokine C-X-C motif (CXCL9), solute carrier family 22 member 2 (SLC22A2), nephrin, and uromodulin (UMOD) by quantitative multiplex LC-MS/MS analysis. The fold-change in biomarker levels was determined in mild and severe IRI and in patients with CKD stage 1-2 (n = 127) or stage ≥3 (n = 132) in comparison to the general population (n = 1438). Relationships between the biomarkers and total protein, β2-microglobulin (B2M), creatinine, and osmolality were assessed. NGAL, IGFBP7, TIMP2, KIM-1, CXCL9, and UMOD were quantifiable, whereas nephrin and SLC22A2 were below the limit of detection. Kidney injury biomarkers were increased up to 6.2-fold in allograft recipients with mild IRI and 8.3-fold in recipients with severe IRI, compared to the reference population, with the strongest response observed for NGAL and B2M. In CKD stage 1-2, B2M, NGAL, IGFBP7, TIMP2, KIM-1, UMOD, and CXCL9 were not altered, but in individuals with CKD stage ≥3, B2M, NGAL, and KIM-1 were increased up to 1.3-fold. IGFBP7, TIMP2, NGAL, and CXCL9 were strongly correlated (all r ≥ 0.8); correlations with B2M and TP were smaller (all r ≤ 0.6). IRI, but not stable CKD, was associated with increased urinary levels of kidney injury biomarkers determined by LC-MS/MS. Absolute and multiplexed protein quantitation by LC-MS/MS is an effective strategy for biomarker panel evaluation for translation toward the clinical laboratory.

Normothermic machine perfusion versus static cold storage in donation after circulatory death kidney transplantation: a randomized controlled trial

Kidney transplantation is the optimal treatment for end-stage renal disease, but it is still severely limited by a lack of suitable organ donors. Kidneys from donation after circulatory death (DCD) donors have been used to increase transplant rates, but these organs are susceptible to cold ischemic injury in the storage period before transplantation, the clinical consequence of which is high rates of delayed graft function (DGF). Normothermic machine perfusion (NMP) is an emerging technique that circulates a warmed, oxygenated red-cell-based perfusate through the kidney to maintain near-physiological conditions. We conducted a randomized controlled trial to compare the outcome of DCD kidney transplants after conventional static cold storage (SCS) alone or SCS plus 1-h NMP. A total of 338 kidneys were randomly allocated to SCS (n = 168) or NMP (n = 170), and 277 kidneys were included in the final intention-to-treat analysis. The primary endpoint was DGF, defined as the requirement for dialysis in the first 7 d after transplant. The rate of DGF was 82 of 135 (60.7%) in NMP kidneys versus 83 of 142 (58.5%) in SCS kidneys (adjusted odds ratio (95% confidence interval) 1.13 (0.69–1.84); P = 0.624). NMP was not associated with any increase in transplant thrombosis, infectious complications or any other adverse events. A 1-h period of NMP at the end of SCS did not reduce the rate of DGF in DCD kidneys. NMP was demonstrated to be feasible, safe and suitable for clinical application. Trial registration number: ISRCTN15821205.

Successful Kidney Transplantation of Two Patients with Donors Positive for Severe Acute Respiratory Syndrome Coronavirus Infection

Despite preventative measures, including vaccination, severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection may result in severe illness, particularly in immunosuppressed transplant recipients. This has had a negative impact on organ donation and transplantation rates. However, the risk of transmission from SARS-CoV-2 positive donors to kidney transplant recipients is unknown. We describe 2 cases of successful kidney transplantation from SARS-CoV-2 positive donors. Case 1: 38-year old unvaccinated female, established on haemodialysis for 1 year, with underlying reflux nephropathy. Donor tested SARS-CoV-2 positive on polymerase chain reaction testing with a cycle threshold (CT) value of 29 initially. Sequential testing demonstrated a rise in CT value (37.8), aiding the decision to proceed. The recipient was high immunological risk and received a controlled category 3 donation after circulatory death (DCD) kidney transplant. She had immediate graft function and did not develop SARS-CoV-2 infection. Case 2: 63-year old female, with diabetes mellitus and hypertension. She was low immunological risk and for pre-emptive transplantation. The donor was SARS-CoV-2 positive with a CT value of 41.5 and was subsequently negative. Decision was made to proceed with a donation after brainstem death (DBD) transplant. The recipient had immediate graft function and did not develop SARS-CoV-2 infection. We report 2 cases of successful transplantation from SARS-CoV-2 positive donors, without severe infection, with no transmission seen in the recipients post-operatively. Decisions to proceed were primarily made on clinical grounds with assistance from RT-PCR CT values, making this a useful additional tool in determining suitability of organ donation in people who are SARS-CoV-2 positive.

Total Cell-Free DNA as a Noninvasive Biomarker of a Delayed Graft Function After Kidney Transplantation From Donors After Cardiac Death

Because of the organ shortage, donation after cardiac death (DCD) kidney transplantation (KTx) is an alternative way of achieving KTx using brain-dead donors (BDs). Although the prognosis of DCD-KTx is improving, the graft suffers from delayed graft function (DGF), the management of which is essential. With progress in understanding the characteristics of cell-free DNA (CF-DNA), we consider plasma total CF-DNA (tCF-DNA) to be a useful biomarker for predicting DGF in DCD-KTx. Consecutive patients from living donors (LDs; n=9), BDs (n=8), or DCD donors (n=13) were enrolled. Plasma samples were collected after KTx and on postoperative days 3 and 5. CF-DNA was isolated, and tCF-DNA was quantified using the TapeStation 2200 software program. The tCF-DNA levels after BD-KTx and DCD-KTx were higher than those after LD-KTx (LD, 78 ± 27 (ng/mL); BD, 99 ± 20; DCD, 150 ± 23); the difference between DCD-KTx and LD-KTx was statistically significant (P < .05). The tCF-DNA levels declined at postoperative day 5 (LD, 45 ± 10; BD, 51 ± 11; DCD, 66 ± 13). tCF-DNA levels were significantly increased in patients with DGF after KTx (DGF, 139 ± 22; immediate function, 91 ± 18; P < .05). The tCF-DNA level was correlated with the duration of DGF (r=0.5825, P < .05). Although the mechanism underlying DNA release from transplanted grafts into the recipient circulation remains unclear, cell death by apoptosis or necrosis and the active secretion of the immune system may play important roles in DGF. These data suggest that monitoring tCF-DNA may help predict graft recovery after DCD-KTx.

Uncontrolled donation after cardiac death kidney transplantation: Opportunity to expand the donor pool?

BackgroundCompared to controlled donation after cardiac death (cDCD), uncontrolled DCD (uDCD) kidney transplantation remains an underutilized resource in the United States. However, it is unclear whether long-term allograft outcomes following uDCD are inferior to that of cDCD kidney transplantation. MethodsFrom January 1995 to January 2018, the OPTN/UNOS database was queried to discover all reported cases of uDCD and cDCD kidney transplantation. Primary non-function, delayed graft function, ten-year graft and patient survival were compared among uDCD and cDCD patients. ResultsRates of primary non-function (4.0% [uDCD] vs. 1.8% [cDCD], P < 0.001) and delayed graft function (51.1% [uDCD] vs. 41.7% [cDCD], P < 0.001) were higher following uDCD transplant. However, ten-year graft survival (47.5% [uDCD] vs. 48.4% [cDCD], P = 0.21) and patient survival were similar to cDCD transplantation (59.4% [uDCD] vs. 59.2% [cDCD], P = 0.32). ConclusionAlthough initial allograft outcomes are inferior following uDCD, long-term durability of uDCD kidney allografts is on par to cDCD transplantation. Kidney allografts derived by uDCD may be a viable and durable option to increase the donor pool.

Anastomosis Time and Outcomes after Donation after Circulatory Death Kidney Transplantation: The Elimination of Warm Ischemic Time with the Ice Bag Technique.

Anastomosis Time and Outcomes after Donation after Circulatory Death Kidney Transplantation: The Elimination of Warm Ischemic Time with the Ice Bag Technique.

416.1: Impact of HLA-A,B DR and DQ on Deceased Kidney Transplant Outcomes in the Tacrolimus/MMF Era: An Artificial Intelligence Approach

Introduction: One of the biological barriers that can impact outcomes in kidney transplantation is HLA mismatch. Several immunotherapy protocols were implemented to reduce this detrimental effect. The aim of our study is to assess the effect of HLA mismatches on acute rejection rates and graft survival in the Tacrolimus era. Moreover, to determine the most important factors affecting survival. Methodology: All kidney transplant patients registered in UNOS database between 01/01 2005 and 01/12/2019 were retrospectively reviewed. Inclusion criteria: deceased donor transplants that were discharged on Tacrolimus/Mycophenolate Mofetil. Exclusion criteria: multiple organ transplants, previous kidney transplants, recipient age<18 years old, living donor transplants, missing data about induction therapy, missing HLA mismatch or ABO incompatible transplant. We used double-selection lasso (least absolute shrinkage and selection operator) logistic regression model to assess for the effect of HLA-A, B, DR, and DQ on acute rejection rates at one-year post-transplant. Variables of interest were HLA-A,B,DR and DQ mismatch. Variables Lasso selected from were: recipient characteristics (age, sex, BMI, ethnicity, diabetes, recipient/donor CMV status, pre-transplant dialysis), donor characteristics (KDPI score) and transplant characteristics (induction therapy, steroid intake, cold ischemia time, delayed graft function, PRA). Acute rejection was defined as biopsy proven or clinically suspected rejection. For survival analysis, we fit a penalised Cox model after choosing best alpha. Cross-validated grid-search was used to evaluate the best alpha. The variables included in the penalised cox model: donor, recipient and transplant factors. We visualised the coefficients variations across different α using ridge regression model in figure 1. Results: 66,021 were included. Worse acute rejection rates at one-year post-transplant were noted with incremental increase in HLA-DQ (Two HLA-DQ: OR=1.24, P=0.005,95%CI:1.10-1.40; One HLA DQ:OR=1.19,P=0.01,95%CI:1.06-1.33), HLA-DR mismatches (Two HLA-DR: OR=1.41, P<0.01, 95%CI:1.25-1.61; One HLA-DR: OR=1.27,p<0.01, 95%CI:1.13-1.43),Two HLA-B (OR=1.19,P=0.049) and HLA-A(Two HLA-A: OR=1.18, P=0.01; One HLA-A: OR=1.16,P=0.02). In the penalized cox regression model, only Two HLA-DR mismatch was associated with worse survival (HR=1.13, P<0.01, 95%CI: 1.05-1.21). KDPI was the most important factor affecting graft survival (KDPI>80%: HR=2.3, P<0.01; KDPI 60-80%: HR=1.57, P<0.01; KDPI 40-60%: HR=1.23, P<0.01). Delayed graft function affected graft survival by HR=1.50 (P<0.01). Mean follow-up time was 3.79 years. Conclusion: HLA-DQ, DR,B and A mismatches play a vital role in the occurrence of acute rejection in the Tacrolimus/MMF era. However, only 2-HLA-DR mismatch has significant effect on graft survival. KDPI>40% and delayed graft function play the most important role in determining graft survival.

A renal transplant patient with COVID-19 presented with acute cellular rejection

A 27-year-old man underwent a deceased kidney transplant. Three days after transplantation, COVID-19 was diagnosed for our patient. Immunosuppressants were reduced and a renal biopsy was conducted, which showed acute T cell-mediated rejection. We intened to share a case to help clinicians to understand the risks that kidney transplant recipients face.

Pediatric Kidney Transplantation in the Middle East: Challenges and Solutions.

Pediatric kidney transplant is the best option for treating children with end-stage renal disease. Poor economics and paucity of renal replacement therapy and transplant facilities are the most important challenges of pediatric kidney transplantation in the Middle East. The aim of the study was to collect data on the rates of pediatric kidney transplant during a recent year from the Middle East countries. All well-known kidney transplant centers from the Middle East were contacted to answer specified questions related to adult and pediatric kidney transplant volume from both living and deceased donors that was performed in each country during a recent year (preferably 2021, or, if not available, 2020 or 2019). In the single recent year, 8772 kidney transplants were performed for adult and pediatric patients in Middle East countries, making a total kidney transplant rate per million populations per year of 10.9 (ranging from 1.2 in Yemen and Pakistan to 39.7 in Turkey). Of these, 1399 transplants were from deceased donors (rate of deceased donor kidney transplants of 15.9%, ranging from 0% in 10 countries to 64.2% in Iran). Of 8772 total kidney transplants, 746 were pediatric recipients (<18 years old), with 166 pediatric kidney transplants from deceased donors (percent of deceased donor pediatric kidney transplant of 22.2%, ranging from 0% in 11 countries to 100% in Tunisia). Average pediatric kidney transplant rate per million populations per year was 0.93 (ranging from <0.1 in Pakistan to 3.2 in Syria). Average pediatric kidney transplant share was about 8.5% of total kidney transplants (ranging from 3.2 in Iraq to 20% in Algeria). The deceased kidney transplant program is currently available in only 8 of the 18 Middle Eastern countries included in this study. However, a deceased program is active in some Middle East countries (ie, Iran, Turkey, Kingdom of Saudi Arabia, Kuwait, and United Arab Emirates). Of note, Turkey had the highest kidney transplant rate per million populations per year (39.7), Syria had the highest pediatric kidney transplant rate per million populations per year (3.2), and Iran had the highest deceased donor kidney transplant percent of the total kidney transplants (64.2%). In the Middle East, Iran alone performed 63.5% (888/1399) of all deceased donor kidney transplants and 63.9% (106/166) of all deceased donor pediatric kidney transplants. Algeria had the highest pediatric kidney transplant share of the total transplants (20%). Low health spending, poorly developed infrastructures, delayed referral of children with chronic kidney disease, comorbidities, lack of technical expertise, inadequate pediatric dialysis programs, extended dialysis time, organ shortage, commercial transplantation, and posttransplant infections are the main pre- and posttransplant challenges. The community-government partnership model from the Sindh Institute of Urology and Transplantation in Karachi Pakistan showed that pediatric renal replacement therapy and transplant can be successfully established in a developing country. Although pediatric kidney transplant is active in many parts of the Middle East, it is still inactive in others, mostly relying on living donors. The lack of deceased donor programs in most Middle Eastern countries is a main issue to be addressed to adequately responding to the increasing demand for organs.

Proteinuria in Deceased Kidney Transplant Donors for Prediction of Chronic Lesions in Pretransplant Biopsies: A Prospective Observational Study.

Pretransplant kidney graft biopsies have been suggested for organ quality assessment. Data on the association between donor proteinuria and organ quality of deceased donors are not available. In this prospective study, we analyzed 147 pretransplant kidney biopsies from 88 deceased adult donors procured and transplanted consecutively at the Medical University Vienna between July 2017 and May 2020. Lesions in each renal compartment were scored from 0 to 5 with each ascending score representing a 20% increase in organ damage. A chronic lesions score was calculated including glomerulosclerosis, intima fibrosis, hyalinosis, interstitial fibrosis, and tubular atrophy. The median chronic lesion score was 2 (interquartile range [IQR] 1-4) and the median donor urinary protein to creatinine ratio (UPCR) was 382 mg/dL (IQR 222-703). There was a positive correlation between UPCR and number of chronic lesions (β 0.15, 95% confidence interval, 0.03-0.28; P = 0.019). Biopsies with 2 or more lesions had a median UPCR of 486 mg/dL (IQR 251-717) compared with 274 mg/dL (IQR 211-556; P = 0.016) in biopsies with <2 lesions. The risk for detection of 2 or more lesions rose by 18% for every log increase in UPCR (risk ratio 1.18, 95% confidence interval, 1.03-1.25; P = 0.017). Multivariable and sensitivity analysis revealed an independent and robust association between chronic lesions and UPCR. Donor UPCR is associated with chronic lesions in pretransplant deceased donor kidney graft biopsies. This finding justifies further investigation of donor proteinuria for the assessment of organ quality and outcome.

Post-transplant Lymphoproliferative Disorder Following Kidney Transplantation,

Posttransplant lymphoproliferative diseases are complications that develop after solid organ transplantation. Primary EBV infection is one of the most important risk factors. After deceased kidney transplantation, we presented a young male patient diagnosed with diffuse large B-cell lymphoma.