Kidney Transplant Program Research Articles

Reducing disparities in kidney transplantation for Spanish-speaking patients through creation of a dedicated center

IntroductionHispanic Americans receive disproportionately fewer organ transplants than non-Hispanic whites. In 2018, the Hispanic Kidney Transplant Program (HKTP) was established as at the University of Colorado Hospital (UCH). The purpose of this quality improvement study was to examine the effect of this culturally sensitive program in reducing disparities in kidney transplantation.MethodsWe performed a mixed-methods analysis of data from 436 Spanish-speaking patients referred for transplant to UCH between 2015 and 2020. We compared outcomes for patients referred between 2015–2017 (n = 156) to those referred between 2018–2020 (n = 280). Semi-structured phone interviews were conducted with 6 patients per time period and with 6 nephrology providers in the Denver Metro Area. Patients and providers were asked to evaluate communication, transplant education, and overall experience.ResultsWhen comparing the two time periods, there was a significant increase in the percentage of patients being referred (79.5% increase, p-0.008) and evaluated for transplant (82.4% increase, p = 0.02) during 2018–2020. While the number of committee reviews and number waitlisted increased during 2018–2020, it did not reach statistical significance (82.9% increase, p = 0.37 and 79.5% increase, p = 0.75, respectively. During patient and provider interviews, we identified 4 themes reflecting participation in the HKTP: improved communication, enhanced patient education, improved experience and areas for advancement. Overall, patients and providers reported a positive experience with the HKTP and noted improved patient understanding of the transplantation process.ConclusionsThe establishment of the HKTP is associated with a significant increase in Spanish-speaking Hispanic patients being referred and evaluated for kidney transplantation.

Trends, Social Context, and Transplant Implications of Obesity Among Incident Dialysis Patients in the United States.

Kidney transplant programs have variable thresholds to accept obese candidates. This study aimed to examine trends and the social context of obesity among United States dialysis patients and implications for kidney transplant access. We performed a retrospective cohort study of 1 084 816 adults who initiated dialysis between January 2007 and December 2016 using the United States Renal Data System data. We estimated national body mass index (BMI) trends and 1-y cumulative incidence of waitlisting and death without waitlisting by BMI category (<18.5 kg/m 2 , ≥18.5 and <25 kg/m 2 [normal weight], ≥25 and <30 kg/m 2 [overweight], ≥30 and <35 kg/m 2 [class 1 obesity], ≥35 and <40 kg/m 2 [class 2 obesity], and ≥40 kg/m 2 [class 3 obesity]). We then used Fine-Gray subdistribution hazard regression models to examine associations between BMI category and 1-y waitlisting with death as a competing risk and tested for effect modification by End Stage Renal Disease (ESRD) network, patient characteristics, and neighborhood social deprivation index. The median age was 65 (interquartile range 54-75) y, 43% were female, and 27% were non-Hispanic Black. From 2007 to 2016, the adjusted prevalence of class 1 obesity or higher increased from 31.9% to 38.2%. Class 2 and 3 obesity but not class 1 obesity were associated with lower waitlisting rates relative to normal BMI, especially for younger individuals, women, those of Asian race, or those living in less disadvantaged neighborhoods ( pinteraction < 0.001 for all). Obesity prevalence is rising among US incident dialysis patients. Relative to normal BMI, waitlisting rates with class 2 and 3 obesity were lower and varied substantially by region, patient characteristics, and socioeconomic context.

Kidney Donation and Transplant Outcomes in Trinidad and Tobago: A 15-Year Experience of the National Organ Transplant Unit.

Trinidad and Tobago is the only English- speaking Caribbean country with an established kidney transplant program from living and deceased donors. The program is managed by the National OrganTransplant Unit.This study analyzed the 15-year experience of the public program in terms of transplant outcomes and procurement quality at the main deceased donor procurement hospital using some DOPKI and ODEQUS quality indicators. We collected data from 2006 through 2020 from the National OrganTransplantUnit database, surveyedhospital staffonorgandonationand transplant after face-to-face education activities on these subjects, and provided an online survey to religious leaders.DOPKI and ODEQUS quality indicators from 1 procurement center were also recorded. During the data collection period, 195 transplants were achieved, with 23.6% from deceased donors. Deceased donation and deceased donor kidney transplant rates ranged from 0.71 to 3.6 and from 0.71 to 7.1 per million population, respectively. Since 2011, deceased donor registry and actual deceased donors increased 6-fold and 14-fold, respectively, while living donor transplants doubled and deceased donor transplants increased 15-fold. Quality parameters revealed major gaps in deceased donor critical pathway, with limited transplant budget, absence of hospital budget for deceased donor organ retrieval processes, important deficiencies in deceased donor registry and waiting lists, refusal of expanded criteria donors, and missed donation opportunities from poor HLA reagent supply chain management. Religious leaders and health care workers showed supportive positive attitudes toward organ donation and transplant. The public organ donation and transplant program of Trinidad and Tobago has performed reasonably well over a 15-year period. Enhancing quality performance and donation effectiveness requires rebalancing and improving resource allocation from renal dialysis to kidney transplant, funding deceased organ procurement, and facilitating education of religious leaders and health care professionals for end-of-life care and change of community values in organ transplant decisions.

Implementation and modification of an organizational-level intervention: a prospective analysis

BackgroundModifications to interventions can jeopardize intervention outcomes. Pre-existing perceived barriers and facilitators to the intervention arising in the implementation preparation phase may help explain why modifications to the intervention may occur during the implementation phase. This two-site comparative case study describes modifications made to a complex organizational-level intervention and examines how known implementation science factors may have enabled such changes to occur.MethodsNorthwestern Medicine’sTM Hispanic Kidney Transplant Program (HKTP) is a culturally competent transplant center-based intervention designed to reduce disparities in living donor kidney transplantation among Hispanics. In-depth qualitative interviews and discussions were longitudinally conducted with transplant stakeholders (i.e., physicians, administrators, clinicians) at two kidney transplant programs with large Hispanic populations during implementation preparation and implementation phases. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis, and Stirman’s Framework for Reporting Adaptations and Modifications-Expanded (FRAME) guided modification classification.ResultsAcross sites, 57 stakeholders participated in an interview, group discussion, and/or learning collaborative discussion. Site-B made more modifications than Site-A (n = 29 versus n = 18). Sites differed in the proportions of delaying/skipping (Site-A 50% versus Site-B 28%) and adding (Site-A 11% versus Site-B 28%) but had comparable substituting (Site-A 17% versus Site-B 17%) and tweaking (Site-A 17% versus Site-B 14%) modification types. Across sites, the transplant team consistently initiated the most modifications (Site-A 66%; Site-B 62%). While individuals initiated slightly more modifications at Site-B (21% versus Site-A 17%), institutions instigated proportionately slightly more modifications at Site-A (17% versus Site-B 10%). CFIR inner setting factors (i.e., structural characteristics, culture, available resources, implementation climate) that prominently emerged during the implementation preparation phase explained similarities and differences in sites’ modification numbers, types, and agents in the implementation phase.ConclusionOrganizations implementing a culturally competent care intervention made modifications. CFIR inner setting factors emerging in the implementation preparation phase largely explained similarities and differences in study sites’ modifications. Identifying factors contributing to modifications may help institutions become better prepared to implement an intervention by addressing known factors in advance, which may foster greater fidelity leading to desired outcomes.Trial registrationClinicalTrials.govNCT03276390. We registered the study retrospectively on 9-7-17.

Impact of COVID-19 on living donor liver and kidney transplantation programs in Japan in 2020.

BackgroundAlthough many transplant programs have been forced to suspend living donor transplants due to the emergence of coronavirus disease (COVID‐19), there are relatively few real‐time databases to assess center‐level transplant activities. We aimed to delineate the actual impact of COVID‐19 on living donor transplant programs and the resumption process in Japan.MethodsIn a nationwide survey, questionnaires were sent to 32 liver transplant programs that had performed at least more than one case of living donor liver transplantation in 2019 and 132 kidney transplant programs that had performed more than one living donor kidney transplantation in 2018.ResultsThirty‐one (96.9%) and 125 (94.7%) liver and kidney transplant programs responded, respectively. In the early pandemic period, 67.7% (21/31) of liver programs and 29.8% (37/125) of kidney programs were able to maintain transplant activities similar to those during the pre‐pandemic period. After temporal suspension, 58.1% of kidney programs resumed their transplant activity after the number of local COVID‐19 cases peaked. Establishing institutional COVID‐19 screening, triage, and therapeutic management protocols was mandatory to resume transplant activity for 64.5% and 67.7% of liver and kidney programs, respectively. In the future wave of COVID‐19, 67.7% of liver programs would be affected by institutional COVID‐19 intensive care unit‐bound patient numbers, and 55.7% of kidney programs would stop if hospital‐acquired severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) infection spreads.Conclusions: This nationwide survey revealed for the first time how living donor liver and kidneytransplant programs changed in response to the COVID‐19 pandemic in a country where living donor transplantations are predominant.

MO991: Covid-19 Infection After Kidney Transplantation in Spain: Comparable Impact Throughout Six Epidemic Waves

BACKGROUND AND AIMSThe successive COVID-19 epidemic waves have significantly influenced kidney transplantation (KT) programs. Contact protection together with vaccination are the principal protective tools for KT recipients. We reviewed the impact of COVID-19 infection in KT recipients throughout the different epidemic waves.METHODOf 900 active KT recipients in our program, 160 (17.8%) have suffered COVID-19 infection during the six epidemic waves: first (March–August 2020), second (September–December2020), third (January–March 2021), fourth (April–May 2021), fifth (June–September 2021) and sixth (October–December 2021, preliminary data). We compared the clinical evolution and the impact of vaccination.RESULTSInfected KT recipients were younger in the third and fourth waves (P < 0.001). We observed a higher percentage of pneumonia and hospital admission in the first and fifth waves (P = 0.045, P = 0.016) (Table 1), without differences in ICU admission, and with the disappearance of asymptomatic cases after the third wave. The highest mortality was observed in KT recipients >65 years old infected within the first 6 months after KT (P = 0.006) and overall mortality was higher in the first wave (P = 0.033). Mortality in hospitalized KT recipients and those admitted in the ICU were similar along the 5 waves, without clear impact of vaccination (P = 0.251). On the 5 January 2022, we have already accumulated an incidence of COVID in KT of 3.1% (sixth wave, 77% with booster vaccination), similar to the first wave (3.8%), with 12.5% mortality, similar to second, third and fifth waves, in patients with outcome (53.3%).CONCLUSIONThe incidence of COVID-19 in KT recipients has been high in all the waves of the pandemic in Spain. Global mortality has diminished after the first wave, and the time until outcome has increased. The highest mortality occurs in the subgroup of old KT recipients early after KT. Vaccination has not significantly reduced the mortality in KT with Covid who require hospital or ICU admission.

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.

MP023 - Implanting a robot-assisted kidney transplant program

MP023 - Implanting a robot-assisted kidney transplant program

Effect of the COVID-19 Pandemic on Organ Donation and Transplantation in São Paulo, Brazil

The COVID-19 pandemic has affected donation and transplantation activities in São Paulo, Brazil, as well as the patients receiving these organs. In this study, information from the database of the São Paulo Organ Allocation System was analyzed and compared 2 periods—before the pandemic and during the pandemic—to identify this effect. The COVID-19 pandemic interfered in the mortality rate and the time on the waiting list for heart, liver, pancreas, lung, and kidney transplants; the number of effective donors; and the use or disposal of available organs from deceased donors. It also reduced the transplant activity with living donors. Regarding the activity of eye tissue transplantation, the time on the waiting list increased and the number of transplant procedures decreased. The kidney transplant program was the most affected in our study. There was an increase in waiting time and mortality in the waiting list for this organ and also a decrease in kidney utilization rates.

Kidney transplantation versus dialysis in Zimbabwe

In Zimbabwe, the population of patients with chronic kidney disease is rising, putting a strain on the nation's few dialysis treatment centers, whether government or private. The government covers the whole expense of delivering dialysis in the government facilities, increasing the financial burden. Patients from both public and private dialysis units opting for kidney transplantation (KT) are referred abroad at high foreign currency costs. The goal of this study focused on reviewing the economic advantage of KT in relation to renal dialysis as a means of establishing a KT program in Zimbabwe. Economic advantage studies on KT versus renal dialysis were obtained using various digital resources. The search strategy was based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations. Economic assessment tools such as the Markov model, cost–utility analysis, cost-effective analysis were utilized to substantiate the relevance of KT in improving survival of end-stage renal disease patients at a lower expenditure. In studies where cost-effectiveness between KT and dialysis was compared, it was shown that KT is a cheaper solution with a higher quality of life than dialysis. It was also shown in most of the studies that among the dialysis modalities, hemodialysis (HD) was more expensive than peritoneal dialysis (PD). In one of the studies, the cost values were Euro 36 000 for HD, Euro 26 000 for PD, and Euro 11 000 for KT. The quality-adjusted life years per patient were 0.46 for HD, 0.49 for PD, and 0.61 for KT. As far as cost-effectiveness and raising the health status, wellness level, good living, and survival, KT is rated highly and a better modality than dialysis. It is a more appropriate renal treatment for introduction in Zimbabwe to save on the scarce foreign currency. The barriers to the commencement of KT were identified, and the solutions were enumerated.

Deceased Donor Procurement Biopsy Practices, Interpretation, and Histology-Based Decision-Making: A Survey of US Kidney Transplant Centers

IntroductionThe utility of kidney procurement biopsies is controversial. Understanding the current landscape of how clinicians obtain and use biopsies in organ evaluation may help inform consensus-building efforts.MethodsAn electronic survey was distributed to clinicians at US kidney transplant programs (April 22, 2021–June 30, 2021) to evaluate donor biopsy indications, frequency, processing and interpretation, and impact of findings on practices.ResultsResponses from staff involved in organ acceptance (73% surgeons, 20% nephrologists, 6% coordinators) at 95 transplant centers were analyzed, representing 40% of US transplant centers and 50% of recent deceased donor kidney transplant volume. More than a third of centers (35%) reported obtaining procurement biopsies on most-to-all kidneys. Most clinicians decided when to biopsy jointly with the Organ Procurement Organization (OPO) (82%) based on formal criteria for the decision (72%), although 41% reported having requested a biopsy outside of the criteria. Most respondents used a semiquantitative scoring system for interpretation (57%). Many respondents reported rarely or never having access to renal specialty pathologists (37%) or to telepathology (59%). Most respondents reported that a favorable biopsy result would encourage them to accept a "marginal" donor kidney (72%); nearly half (46%) indicated that an unfavorable biopsy result would lead to decline of a standard criteria kidney.ConclusionProcurement biopsies are commonly used in organ acceptance decisions despite inconsistent access to experienced renal pathologists and heterogeneous approaches to criteria, scoring, and interpretation. Ongoing study and consensus building are needed to direct procurement biopsy practice toward increasing organ utilization and reducing allocation inefficiency.

Trends in Cost Attributable to Kidney Transplantation Evaluation and Waiting List Management in the United States, 2012-2017

While recent policy reforms aim to improve access to kidney transplantation for patients with end-stage kidney disease, the cost implications of kidney waiting list expansion are not well understood. The Organ Acquisition Cost Center (OACC) is the mechanism by which Medicare reimburses kidney transplantation programs, at cost, for costs attributable to kidney transplantation evaluation and waiting list management, but these costs have not been well described to date. To describe temporal trends in mean OACC costs per kidney transplantation and to identify factors most associated with cost. This economic evaluation included all kidney transplantation waiting list candidates and recipients in the United States from 2012 to 2017. A population-based study of cost center reports was conducted using data from all Center of Medicare & Medicaid-certified transplantation hospitals. Data analysis was conducted from June to August 2021. Year, local price index, transplantation and waiting list volume of transplantation program, and comorbidity burden. Mean OACC costs per kidney transplantation. In 1335 hospital-years from 2012 through 2017, Medicare's share of OACC costs increased from $0.95 billion in 2012 to $1.32 billion in 2017 (3.7% of total Medicare End-Stage Renal Disease program expenditure). Median (IQR) OACC costs per transplantation increased from $81 000 ($66 000 to $103 000) in 2012 to $100 000 ($82 000 to $125 000) in 2017. Kidney organ procurement costs contributed to 36% of mean OACC costs per transplantation throughout the study period. During the study period, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, kidney transplantation volume, and comorbidity burden. For a median-sized transplantation program, mean OACC costs per transplantation decreased with more transplants (-$3500 [95% CI, -$4300 to -$2700] per 10 transplants; P < .001) and increased with year ($4400 [95% CI, $3500 to $5300] per year; P < .001), local price index ($1900 [95% CI, $200 to $3700] per 10-point increase; P = .03), patients listed active on the waiting list ($3100 [95% CI, $1700 to $4600] per 100 patients; P < .001), and patients on the waiting list with high comorbidities ($1500 [9% CI, $600 to $2500] per 1% increase in proportion of waitlisted patients with the highest comorbidity score; P = .002). In this study, OACC costs increased at 4% per year from 2012 to 2017 and were not solely attributable to the cost of organ procurement. Expanding the waiting list will likely contribute to further increases in the mean OACC costs per transplantation and substantially increase Medicare liability.

Kidney allocation rules simulator

The greatest challenge of any kidney transplant program lies in finding enough organ donors (in number and quality) for all waitlisted transplant candidates. Unfortunately, we must resign ourselves to a manifestly insufficient supply of organs for the current demand. Furthermore we must be able to predict kidney transplant success at organ allocation if we want to minimize the number of patients who return to an already overcrowded waiting list for transplantation. Therefore, the definition of deceased donors' kidney allocation rules on transplantation must be supported by simulations that allow foreseeing, as much as possible, the consequences of these rules.Here we present the Kidney Allocation Rules Simulator (KARS) application that enables testing different kidney transplant allocation’ systems with different donors and transplant candidates' datasets. In this application, it is possible to simulate allocation rules implemented in Portugal, in the United Kingdom, in countries within Eurtotransplant, and a previously suggested color priority system. As inputs, this application needs three data files: a file with transplant candidates' information, a file with candidates' anti-HLA antibodies, and a file with donors' information. As output, we will have a file with donor-recipient pairs selected according to the kidney allocation system simulated.When seeking waste reduction while ensuring a fair distribution of organs from deceased donors, the definition of rules selecting donor-recipient pairs in renal transplantation must be based on evidence supported by data. On the continuously changing process for a better distribution of an increasingly scarce resource must, we must be able to predict transplant outcomes when defining the best allocation rules.

Pediatric Versus Adult Kidney Transplant Activity in Arab Countries.

This study aimed to evaluate current activities of pediatric versus adult kidney transplant in the Arab world. A questionnaire was mailed to all kidney transplant centers in Arab countries to collect the most recent data on kidney transplant activity. There were 3309 kidney transplants performed over a single year, with a transplant rate of 9.5 per million population; 298 of these were pediatric kidney transplant procedures, with a rate of 0.87 per million population, which is much lower than that shown in developed countries where it ranges from 5 to 10 per million population. Of all kidney transplants, the pediatric share is 9%, a rate that is twice as high as that shown among European children. Kidney transplant programs in most Arab countries rely exclusively on living donors, as there is a severe shortage of deceased donors. Of all transplants (that is, combined adult and pediatric), 93.5% were from living donors. Deceased donor pediatric kidney transplant is only available in the Kingdom of Saudi Arabia, Tunisia, and Kuwait. In these 3 Arab countries, which have stable deceased donor transplant programs, deceased donor transplant procedures ranged from 14% to 31% of all transplants. Of the 212 adult and pediatric transplant procedures that were performed from deceased donors in the 8 countries that perform deceased donor transplant, only 29 were for pediatric recipients. Surprisingly, the share of pediatric kidney transplant procedures was not better in the countries with higher overall kidney transplant rate or in those where deceased donor transplant was available. In general, pediatric kidney transplant procedures are still inactive in most Arab countries and mostly relies on living donors. The lack of well-developed deceased donor programs is the main issue to be addressed.

Long-Term Outcomes of Kidney Transplant Recipients with Glomerulonephritides by Induction Type and Steroid Avoidance

Kidney transplant programs have different approaches to induction immunosuppression, and conflicting data exist on the role of steroid maintenance in recipients with glomerulonephritis (GN). GN patients are unique because of a higher risk for immune system exhaustion due to prior exposure to immunosuppressants to treat their GN; this raises questions regarding the optimal immunosuppression needed for transplant success and reduction of complications. We sought to assess the effect of induction type and steroid maintenance on the recipient and kidney graft survival in those with IgA nephropathy (IgAN), systemic lupus erythematosus related GN (SLE), small-vessel vasculitis (SVV), and anti-glomerular basement membrane disease (anti-GBM). We analyzed the Scientific Registry of Transplant Recipients (SRTR) database for adult, primary kidney recipients with the above glomerulonephritides through September 2019. Kaplan–Meier curves were generated to examine kidney graft and recipient survival. We used multivariable Cox proportional hazard models to investigate the impact of induction type and steroid maintenance in each group separately. Our study included 9176 IgAN, 5355 SLE, 1189 SVV, and 660 anti-GBM recipients. Neither induction type nor steroid maintenance therapy influenced recipient or death-censored graft survival in this cohort of recipients. Our findings provide an opportunity for recipients with a history of one of the studied glomerulonephritides to receive a more tailored immunosuppression regimen, considering their previous exposure to immunosuppressants.

POS-811 A RETROSPECTIVE STUDY TO ASSESS DROPOUT RATE AND ITS CAUSES IN LIVING DONOR TRANSPLANT PROGRAM IN INDIA

Kidney transplant programs in developing countries rely heavily on living donor programs. Though increasing, deceased donor programs are still in infancy due to resource constraints and social or cultural barriers against deceased organ donation. As the burden of end-stage kidney disease (ESKD) is rising, the waiting times for transplants in living donor kidney transplant programs in public sector hospitals are increasing. A significant proportion of patients who do register with provisionally eligible living kidney donors ultimately do not receive transplants. Therefore, we decided to explore the reasons for dropout from the living donor kidney transplant program at a large public sector hospital in India. The study was done at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. At PGIMER, living kidney donors are provisionally registered in the program after ruling out kidney disease and its risk factors. Thereafter, the recipient-donor pairs are extensively evaluated. The priority is decided by the date of donor registration. Retrospectively, we looked at all the provisionally eligible recipient-donor pairs registered between 1stJanuary 2018 and 31stDecember 2019. Pairs who did not undergo a kidney transplant at our center were contacted and reasons for the same were noted. A total of 576 eligible recipient-donor pairs were registered between 2018 and 2019. 252 (43.8%) underwent a living donor kidney transplant at our center (figure 1). The median waiting period from the time of registration to the date of the transplant was 246 days (IQR 133 days). 130 (22.6%) pairs could not be reached despite repeated attempts. Out of the remaining 194 (33.7%), 33 underwent a kidney transplant with the same donor at a private center due to long delays at our center. In the remaining 161 pairs, reasons for not getting the transplant were as follows: 73 (12.7%) recipients died while they were waiting for the transplant, donors were detected to be medically or surgically unfit in 44 (7.6%) pairs at subsequent evaluation, 12 (2%) had a positive crossmatch and 15 (2.6%) recipients changed their mind and continued hemodialysis. Other reasons included poor finances, legal issues in approval of donor, and death of other kidney paired donation (KPD) recipients thereby leaving the first recipient without an eligible living donor. 56.2% of living kidney recipient-donor pairs dropped out of living donor kidney transplant program at a large public sector hospital in India. 22.5% could not be contacted while 5.7% went on to get the transplant at a private center. 12.7% died while waiting to get a slot for surgery. Despite the availability of living kidney donors, 36% (161/446) failed to get a transplant. It is likely that the outcomes would be at least similar in the group that could not be contacted. The data suggest an urgent need for upscaling living donor kidney transplant programs, laying the foundation for quality improvement (QI) initiatives to optimize resource utilization and hence, improve accessibility in living donor transplant programs.

Effectiveness of a culturally competent care intervention in reducing disparities in Hispanic live donor kidney transplantation: A hybrid trial

Hispanic patients receive disproportionately fewer living donor kidney transplants (LDKTs) than non-Hispanic Whites (NHWs). The Northwestern Medicine Hispanic Kidney Transplant Program (HKTP), designed to increase Hispanic LDKTs, was evaluated as a nonrandomized, implementation-effectiveness hybrid trial of patients initiating transplant evaluation at two intervention and two similar control sites. Using a mixed method, observational design, we evaluated the fidelity of the HKTP implementation at the two intervention sites. We tested the impact of the HKTP intervention by evaluating the likelihood of receiving LDKT comparing pre-intervention (January 2011-December 2016) and postintervention (January 2017-March 2020), across ethnicity and centers. The HKTP study included 2063 recipients. Intervention Site A exhibited greater implementation fidelity than intervention Site B. For Hispanic recipients at Site A, the likelihood of receiving LDKTs was significantly higher at postintervention compared with pre-intervention (odds ratio [OR]=3.17 95% confidence interval [1.04, 9.63]), but not at the paired control Site C (OR=1.02 [0.61, 1.71]). For Hispanic recipients at Site B, the likelihood of receiving an LDKT did not differ between pre- and postintervention (OR=0.88 [0.40, 1.94]). The LDKT rate was significantly lower for Hispanics at paired control Site D (OR=0.45 [0.28, 0.90]). The intervention significantly improved LDKT rates for Hispanic patients at the intervention site that implemented the intervention with greater fidelity. Registration: ClinicalTrials.gov registered (retrospectively) on September 7, 2017 (NCT03276390).

Willingness to change diet and exercise behavior is associated with better lifestyle in dialysis patients close to a kidney transplant.

Evidence suggests that multiple-behavior interventions (with a specialist) have a greater impact on public health than single-behavior interventions, particularly in a chronic patient. However, there is little understanding of some very basic principles concerning multiple health behavior change, especially in situations such as kidney transplantation, which requires a great willingness to change negative lifestyle behaviors to achieve intermediate and long-term success. We compared healthy lifestyles and nutritional status according to the willingness to change dietary and exercise behavior in dialysis patients from a living donor kidney transplant program. 400 dialysis patients had a dietetic, anthropometric, protein-energy wasting [subjective global assessment (SGA)] and biochemical evaluation. Lifestyle was evaluated with an adapted instrument to measure lifestyle in chronic disease. Willingness to change behaviors was evaluated by the trans-theoretical model; 2 groups were formed: willingness to change dietary and exercise behaviors and unwillingness to change. Willingness to change dietary behavior was 50% and exercise 25%. Patients with willingness to change dietary and exercise behaviors had better healthy lifestyle scores, and higher frequency of healthy food consumption. Healthy lifestyle score (R2=0.37, p<0.0001) was predicted by older age, higher educational degree, shorter time on dialysis, and the highest willingness to change dietary and exercise behaviors. Willingness to change dietary and exercise behaviors was associated with healthy lifestyle, as well as with higher frequency of healthy food consumption and with lower frequency of unhealthy food consumption.

Perspectives of Kidney Transplant Recipients, Transplant Candidates, and Living Kidney Donors on the Role of Patients' Self-Narratives and Experiences of Creative Writing Workshops: A Qualitative Study.

Kidney transplantation is the best treatment for kidney failure but is associated with medical, psychological, and existential challenges for patients. Patients' experiential knowledge can help other patients facing these challenges. Patients' self-narratives and creative writings are ways to operationalize this experiential knowledge. Creative writing has been described as a therapeutic tool for patients with chronic disease. Over the past year, we conducted creative writing workshops with kidney transplant recipients (KTRs), living kidney donors (LKDs), kidney transplant candidates (KTCs), and professional writers. During these workshops, patients were invited to explore different aspects of their experiences of their transplant or donation journey through narrative-writing, poetry, comic art, and screenwriting. The objectives of this study were to gather the perspectives of KTRs, KTCs, and LKDs on the role of patients' self-narratives and creative writing, and to collect patients' experiences of the creative writing workshops. Focus groups and individual interviews. The Center hospitalier de l'Université de Montréal (CHUM) kidney transplant program. KTRs, LKDs, and KTCs attending the CHUM kidney transplant clinic between February 2020 and January 2021. We conducted 2 focus groups and 8 semi-structured individual interviews with 7 KTRs, 8 LKDs, and 5 KTCs from the CHUM between June and November 2020, before the creative writing workshops. We also conducted 10 semi-structured interviews with 5 KTRs, 1 KTC, and 4 LKDs in March 2021, after their participation in the creative writing workshops. The interviews were recorded and transcribed. Thematic and content analyses were conducted. KTRs, LKDs, and KTCs had multiple significant moments to share from their transplant/donation journey. These moments were highly emotional and marked by uncertainty. The creative writing workshops were described as therapeutic by participants, because they offered a safe space for group-facilitated reflection, including a discovery and learning process, and normalization, relativization, and appreciation of the transplant/donation experience. The creative writing workshops also provided an opportunity to give back to others (helping other patients, promoting kidney donation and continuing this process in the future through the web platform). Our participants came from a single French-speaking urban transplant center in Quebec and were highly educated. The study set out to capture the perspectives of KTRs, LKDs, and KTCs through the sharing of self-narratives and their participation in creative writing workshops related to their transplant or donation journey. A website was set up to publish patients' creative writings (https://recitsdudonetdelavie.lorganon.ca/les-recits/). Further study is needed to assess the website's impact on other patients. Not registered.

Kidney Transplantation during the First Year of COVID-19 Pandemic in Our Center.

SARS-CoV2 pandemic has altered the normal activity in our day-to-day life. During the most critical moments of the pandemic at the hospital, attendance and programmed activities had to be reduced to a minimum, including kidney transplants. Hospitals with this kind of activity had to suspend or restructure it due to the decrease in the number of donors with a solid organ donation profile, the lack of knowledge as to whether the disease could be transmitted through transplantation or the risk that was believed to be associated with the admission of patients with end-stage chronic kidney disease or immunosuppressive treatment. A retrospective review of all patients who had received a kidney transplant at Doctor Peset University Hospital in Valencia was performed from March 2020 to March 2021. The objective was to study the safety of kidney transplantation and the incidence of COVID-19 disease in kidney transplant patients during this pandemic period. 56 cases of kidney transplantation were included, most of them male with an average age of 56 years old, and variable comorbidity such as hypertension, dyslipidemia, an average body mass index of 26 and undergoing renal replacement therapy by hemodialysis. Regarding the organ donors, more than 50% were male patients and the donation was in encephalic death. The average cold ischemia time was 15 hours. Postoperative complications were mostly graded I and II in the Clavien-Dindo classification. 5.4% of the recipients had passed the SARS-CoV2 infection prior to the transplant and 5.4% were infected with COVID-19 after the transplant. In our experience, the current kidney transplant program seems viable and safe, even during periods of health emergencies.