Living Donor Kidney Transplantation Research Articles

Sociodemographic Drivers of Donor and Recipient Gender Disparities in Living Kidney Donation in Australia

Females account for 60% of all living kidney donors worldwide. We defined the proportion of female to male donors for living donor kidney transplantation stratified by recipient gender, and explored the factors associated with female kidney donation. Data from the ANZDATA (Australian and New Zealand Dialysis and Transplantation) and ANZOD (Australian and New Zealand Organ Donor) registries (2002-2019) were used to identify the sociodemographic characteristics and their interactions associated with living donation from female donors. We derived the predicted probabilities from adjusted logistic models using marginal means. Of 3523 living donor pairs, 2203 (63%) recipients were male, and 2012 (57%) donors were female. Male recipients were more likely to receive kidneys from female donors than male donors. Donor and recipient sex association was modified by donor-recipient relationship (P< 0.01), with sensitivity analysis suggesting that spousal donor-recipient pairs drive this interaction. Older recipients residing in regional or remote areas were more likely to receive kidneys from female donors compared with those from major cities (aged≥60 years: 0.67 [0.63-0.71] vs. aged<60 years: 0.57 [0.53-0.60]). Factors associated with female donation include recipient sex, with spousal donors contributing to the interaction between recipient gender and donor-recipient relationship. Recipient age and location of residence have interactive effects on the likelihood of living donor transplantation from female donors.

Outcomes of thymoglobulin versus basiliximab induction therapies in living donor kidney transplant recipients with mild to moderate immunological risk – a retrospective analysis of UNOS database

Introduction The aim of this study is to assess the outcomes of different induction therapies among mild to moderate immunological risk kidney transplants in the era tacrolimus and mycophenolate-derivate based maintenance. Methods This was a retrospective cohort study using data from the United States Organ Procurement and Transplantation Network among mild to moderate immunological risk living-donor KTRs, defined as having first transplant and panel reactive antibodies less than 20% but with two HLA-DR mismatches. KTRs were divided into two groups based on induction therapy with either thymoglobulin or basiliximab. Instrumental variable regression models were used to assess the effect of induction therapy on acute rejection episodes, serum creatinine levels and graft survival. Results Of the entire cohort, 788 patients received basiliximab while 1727 patients received thymoglobulin induction. There were no significant differences between basiliximab versus thymoglobulin induction in acute rejection episodes at one-year post-transplant (coefficient= −0.229, p value = .106), serum creatinine levels at one-year post-transplant (coefficient= −0.024, p value = .128) or death-censored graft survival (coefficient: − <0.001, p value = .201). Conclusion This study showed no significant difference in acute rejection episodes or graft survival when using thymoglobulin or basiliximab in mild to moderate immunological risk living donor KTRs, maintained on tacrolimus and mycophenolate-based immunosuppressive regimen.

Lithium and the living kidney donor: Science or stigma?

Nearly 10 000 people are removed from the kidney transplant waiting list each year either due to becoming too ill for transplant or due to death. Live donor kidney transplant (LDKT) provides superior outcomes and survival benefit relative to deceased donor transplant, but the number of LDKT has decreased over the past few years. Therefore, it is of paramount importance that transplant centers employ evaluation processes that safely maximize LDKT. Decisions about donor candidacy should be based on the best available data, rather than on processes prone to bias. Here, we examine the common practice of declining potential donors based solely on treatment with lithium. We conclude that the risk of end-stage renal disease related to lithium treatment is comparable to other generally accepted risks in LDKT. We present this viewpoint to specifically challenge the carte blanche exclusion of individuals taking lithium and highlight the importance of using the best available data relevant to any risk factor, rather than relying on biases, when evaluating potential living kidney donors.

Preemptive living donor kidney transplantation: Access, fate, and review of the status in Egypt.

Preemptive living donor kidney transplantation (PLDKT) is recommended as the optimal treatment for end-stage renal disease. To assess the rate of PLDKT among patients who accessed KT in our center and review the status of PLDKT in Egypt. We performed a retrospective review of the patients who accessed KT in our center from November 2015 to November 2022. In addition, the PLDKT status in Egypt was reviewed relative to the literature. Of the 304 patients who accessed KT, 32 patients (10.5%) had preemptive access to KT (PAKT). The means of age and estimated glomerular filtration rate were 31.7 ± 13 years and 12.8 ± 3.5 mL/min/1.73 m2, respectively. Fifty-nine patients had KT, including 3 PLDKTs only (5.1% of total KTs and 9.4% of PAKT). Twenty-nine patients (90.6%) failed to receive PLDKT due to donor unavailability (25%), exclusion (28.6%), regression from donation (3.6%), and patient regression on starting dialysis (39.3%). In multivariate analysis, known primary kidney disease (P = 0.002), patient age (P = 0.031) and sex (P = 0.001) were independent predictors of achievement of KT in our center. However, PAKT was not significantly (P = 0.065) associated with the achievement of KT. Review of the literature revealed lower rates of PLDKT in Egypt than those in the literature. Patient age, sex, and primary kidney disease are independent predictors of achieving living donor KT. Despite its non-significant effect, PAKT may enhance the low rates of PLDKT. The main causes of non-achievement of PLDKT were patient regression on starting regular dialysis and donor unavailability or exclusion.

Rapid Diagnosis of Disseminated Tuberculosis Using Cell-free DNA Sequencing in a Kidney Transplant Recipient.

Here, we report a case of smear-negative disseminated tuberculosis (TB) in a kidney transplant recipient diagnosed using plasma cell-free DNA (cfDNA). A 68-y-old woman presented with 2 mo of fevers and a 15-pound weight loss. Six years earlier, she received a living donor kidney transplant from her husband for adult polycystic kidney disease. She received standard induction with antithymocyte globulin and maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and low-dose prednisone. Her posttransplant course was uncomplicated. She was born and lived in Massachusetts and had not traveled internationally in many years. She worked in finance until she retired a few years prior. She had no history of incarceration or homelessness. Her hobbies included volunteering at a local food bank. On presentation, she was febrile to 38.8 °C and diaphoretic but otherwise appeared well. Her laboratory values were notable for a leukocytosis of 16 000 K/µL and a urinalysis with >100 white blood cells per high power field. There was no growth in the urine or blood cultures. Her nasopharyngeal multiplex polymerase chain reaction (PCR) was negative for common respiratory viruses. She had negative test results for Epstein-Barr virus DNA, cytomegalovirus DNA, HIV 1/2 antigen/antibody, cryptococcal and Histoplasma antigens. Chest computed tomography showed innumerable 1- to 3-mm bilateral nodules (Figure 1A) and lytic lesions of the T6 and T7 vertebral bodies. Spine magnetic resonance imaging demonstrated enhancing lesions involving the entire T6 and T7 bodies (Figure 1B).FIGURE 1.: Abnormal imaging findings. A, Chest CT scan with diffuse bilateral pulmonary nodules in a miliary pattern. B, MRI of the thoracic spine with enhancing lesions of the T6 and T7 vertebral bodies. CT, computed tomography.Further workup included bronchoalveolar lavage with multiple negative studies: bacterial cultures, Pneumocystis direct fluorescent antibody, galactomannan antigen, acid-fast bacilli (AFB) and modified AFB smear, and Mycobacterium tuberculosis PCR. Transbronchial biopsy was nondiagnostic, with negative AFB and fungal stains. Mycobacterial blood and urine cultures were also obtained. A biopsy of her T7 vertebral body noted chronic inflammation and 1 nonnecrotizing granuloma. On hospital day (HD) 13, while she remained febrile and without a definitive diagnosis, we sent a quantitative cfDNA test (Karius, Inc, Redwood City, CA). On HD 15, the Karius cfDNA test returned positive for M tuberculosis. Subsequently, the mycobacterial blood, urine, and bronchoalveolar lavage cultures grew M tuberculosis on HD 17, 17, and 21, respectively. Bone cultures grew M tuberculosis at 34 d after biopsy after the patient had been discharged from the hospital. Cell-free DNA tests have become increasingly prevalent in recent years, including donor-derived cfDNA, which is routinely used to detect allograft rejection. The Karius cfDNA test uses metagenomic next-generation sequencing to specifically detect microbial nucleic acid from over a thousand clinically relevant species in plasma.1 This was the first case of TB diagnosed by plasma cfDNA sequencing in our institution. The turnaround time of 48 h is a promising characteristic of this test, especially when slow-growing pathogens are suspected. Had it been obtained earlier in the course, this test would have not only expedited diagnosis and treatment initiation but also eliminated the need for invasive diagnostics. Nevertheless, like other molecular tests, cfDNA sequencing does not provide antimicrobial susceptibilities to guide antimicrobial therapy and thus does not eliminate the need for cultures. In a recent meta-analysis, cfDNA sequencing showed excellent specificity but poor pooled sensitivity for the diagnosis of TB.2 The very low-risk epidemiologic history for TB and disease onset in the late posttransplant period were other interesting features of this case. Her pretransplant T spot TB was negative. We considered donor-derived TB, but this was deemed unlikely because her donor was her husband, who was healthy and had a negative TB screening. She had no known exposures to TB, and her exposure to higher-risk populations via volunteerism was her only epidemiologic risk factor.

Lactated Ringer as Preservation Solution in Living Donor Renal Transplantation

Optimal organ preservation remains a critical hallmark event in renal transplantation as it is the supply line. Previous studies have shown that the choice of preservation solution may affect transplant outcomes. In this study, we aimed to present the early follow-up results of the graft and patients, using lactated Ringer to preserve kidney allografts with living donors. The results of 97 living donor transplant operations performed in Sanko University Hospital were evaluated retrospectively. The patient's evaluation included demographics, dialysis time duration, renal replacement method, primary disease, comorbidity, surgical and clinical complications in the acute period, graft functions, blood levels of calcineurin inhibitor drugs, anastomotic renal artery, warm ischemia, and cold ischemia times. Donor (49 men, 50.5%) and recipient (58 men, 59.7%) demographics, HLA compatibility (mismatch), hospitalization days, and length of warm and cold ischemic time are summarized in Table 1. Primary nonfunction was not defined in any patients, but delayed graft function was observed during the follow-up of 3 patients (3.09%), who were all hypotensive in the post-transplantation period, and positive inotropic infusion was needed for hemodynamic stability. Lactated Ringer demonstrated efficacy in terms of patient and graft survival, and its lower cost represents a financial advantage, so it can be used in living donor kidney transplantation because it is safe, effective, and inexpensive. Standard preservation solutions may still be recommended in cases with long cold ischemia times, such as paired exchange transplants and cadaveric transplants. Thus, randomized controlled studies are needed for further investigation.

Standardization of Laparoscopic Donor Nephrectomy Technique in Minimizing Ureteral Complications in Renal Transplant Recipients: 10-Year Experience of a Single Center

BackgroundLaparoscopic donor nephrectomy (LDN) is the preferred method for kidney retrieval in live donor kidney transplantation. The surgical technique of LDN has improved over the years, but ureteral complications are still common after kidney transplantation. The relationship between the surgical technique in LDN and ureteral complications has been debated. This study aims to discuss ureteral complications and risk factors in kidney transplantation in a group of patients performed with a standard technique. Materials and MethodsA total of 751 live donor kidney transplantations were included in the study. Age, sex, body mass index, concomitant metabolic diseases, nephrectomy side, multiple renal arteries, and several complete or incomplete duplicated ureters of donors were recorded. The recipient's age, sex, body mass index, duration of dialysis, the daily volume of urine before transplantation, accompanying metabolic diseases, and postoperative ureteral complications were also recorded. ResultsOf the 751 patient donors included in the study, 433 (57.7%) were female, and 318 (42.3%) were male. Of the 751 recipients, 291 (38.7%) were female, and 460 (61.3%) were male. In the 751 recipients, there were 8 (1.0%) ureteral complications, all of which were ureteral strictures. No ureteral leaks or urinomas were noted in this series. There was no statistically significant relation between donor age, donor body mass index, donor side, presence of hypertension in the donor, presence of diabetes mellitus in the donor, or ureteral complications. The mean duration of dialysis and preoperative daily urine volume were associated with increased ureteral complications with statistical significance. ConclusionRecipient factors may affect ureteral complication rates in live donor kidney transplantation, donor nephrectomy technique, and gonadal vein preservation.

The Impact of Intraoperative Graft Blood Flow Measurement on Early Graft Function

The aim of this study is to evaluate the impact of intraoperative allograft vascular flow on early kidney graft function. A total of 159 patients underwent kidney transplantation from January 2017 to March 2022 at Linkou Chang Gung Memorial Hospital. Graft arterial and venous blood flow was measured separately with a transient time flowmeter (Transonic HT353; Transonic Systems, Inc, Ithaca, NY, United States) after ureteroneocystostomy. The early outcomes, including the postoperative creatinine level, were analyzed accordingly. There were 83 males and 76 females, with a mean age of 44.5 years. The mean graft arterial flow measured was 480.6 mL/min, and the mean venous flow was 506.2 mL/min. Delayed graft function (DGF) incidence was 36.5%, 32.5%, and 40.8% in total, living, and deceased donor groups, respectively. Living donor and deceased donor kidney transplantation were analyzed separately. In the DGF subgroup, there were lower graft venous flows, higher body mass index (BMI), and more male patients in the living kidney transplant group. Similarly, the deceased donor kidney transplantation group with delayed graft function tended to have higher body height, higher body weight, higher BMI, and more diabetes mellitus. The multivariate analysis showed that lower graft venous blood flow (odds ratio [OR]=0.995, P=.008) and higher BMI (OR=1.144, P=.042) were significantly correlated with delayed graft function in living donor kidney transplantations. In the deceased donor group, a multivariate analysis of risk factors showed that BMI had a significant correlation with delayed graft function (OR=1.41, P=.039). Graft venous blood flow was significantly associated with delayed graft function in living donor kidney transplantation, and high BMI was correlated with DGF in all patients receiving kidney transplantation.

A Case Report of Successful Kidney Transplantation in a Patient With Chronic Myelogenous Leukemia (CML) Who Has Been in Remission for 15 Years on Imatinib

For chronic myeloid leukemia (CML), a Philadelphia chromosome-positive myeloproliferative neoplasm, the introduction of tyrosine kinase inhibitors has transformed CML from a lethal disease into a manageable chronic disease with a close-to-normal life expectancy. Active malignancy is an absolute contraindication to kidney transplantation. However, it is controversial whether kidney transplantation can be safely performed in patients with a history of CML who are in remission. We describe the clinical course of a 64-year-old male patient with chronic kidney disease from diabetic nephropathy (DMN) who underwent living donor kidney transplantation. The patient was diagnosed with CML 15 years ago and promptly achieved cytogenetic and molecular biological remission after starting imatinib. After that, he continued imatinib treatment for 15 years and was in remission, but his chronic kidney disease from DMN gradually worsened. A preemptive living donor kidney transplant was performed in July 2020. Imatinib for CML was discontinued because the patient maintained deep molecular remission (DMR) of major molecular response for more than 15 years before kidney transplantation. After kidney transplantation, the transplanted kidney function remained good at approximate serum creatinine levels of 1.1 mg/dL without histopathologic rejection, and the 3 monthly BCR-ABL1 measurement results were negative and are in progress. Thus, he continues to maintain treatment-free remission status without imatinib for 26 months after renal transplantation. In conclusion, this result suggests that CML with long-lasting DMR on imatinib therapy can be considered an inactive malignancy and therefore a relative indication for kidney transplantation.

Antidonor T-Cell Responses Are Not Attenuated in Elderly Kidney Transplant Recipients.

Although the number of kidney transplants among elderly patients has been steadily increasing, no specific recommendations have been established for treatment of elderly patients. In general, elderly recipients are considered to be at lower risk of cell rejection and require less intense immunosuppression than younger recipients. However, a recent report from Japan reported that chronic T-cell-mediated rejection was more frequent in elderly living-donor kidney transplant recipients. In this study, we investigated the effects of aging on antidonor T-cell responses in living-donor kidney transplantrecipients. We retrospectively evaluated 70 adultliving-donor kidney transplantrecipients with negative crossmatches and cyclosporine-based immunosuppressive regimens. To evaluate antidonor T-cell responses, serial mixed lymphocyte reaction assays were performed.We compared results in elderly (≥65 years) versus nonelderly recipients. Regarding donor characteristics, elderly recipients were more likely than nonelderly recipients to receive a transplant from their spouse. The number of mismatches at the HLA-DRB1 loci was significantly higher in the elderly group than in the nonelderly group. As a result, the proportion of patients with antidonor hyporesponsiveness in the elderly group did not increase over the postoperative course. Antidonor T-cell responses in elderly living-donor kidney transplant recipients were not attenuated over time. Thus, caution is required regarding the imprudent reduction of immunosuppressants in elderly living-donor kidney transplant recipients. A rigorously designed, large-scale, prospective study is required to validate these results.

Evaluation of Antithymocyte Globulin Efficacy in Reversing Refractory Graft Rejection Using Retrospective Event-Based Sequential Graft Biopsy Analysis in Living Related Donor Renal Transplant.

The main risk factor for poor graft outcomes is refractory acute rejection and its consequences. In this study, we compared the efficacy of antithymocyte globulins versus other antirejection strategies in reversing refractory acute graft rejection after living donor renal transplant. We retrospectively reviewed the records of 745 patients who received living-donor kidney transplants and experienced acute rejection episodes at Mansoura Urology and Nephrology Center in Egypt over the past 20 years. Based on the type of antirejection medication that they received, we divided patients into 2 groups, with 80 patients in the antithymocyte globulin group and 665 patients who had other antirejection strategies. By using event-based sequential graft biopsy histopathology analysis, we compared the efficacy of antithymocyte globulins in reversing refractory rejection in terms of graft and patient complications and survival. Patient survival was comparable in both groups; however, graft survival was better in the antithymocyte globulin group than in the other group; in addition, event-based sequential graft biopsies revealed a lower incidence of acute and chronic rejection episodes after treatment of severe acute rejection in the antithymocyte globulin group compared with the other group. Incidence of posttreatment complications, particularly infection and malignancy, was comparable in both groups. Our retrospective analysis of event-based sequential graft biopsy allowed us to track graft rejection resolution or worsening. Antithymocyte globulins are highly effective in reversing acute graft rejection when compared with other approaches, with no increased risk of infection or malignancy.

Comparison of Bipolar Electrocautery-Based Vascular Sealers with Conventional Ligation in Iliac Vessel Preparation of Renal Transplant Recipients

Post-transplant lymphocele is a common complication with a potentially severe course and may require percutaneous drainage or open/percutaneous surgical intervention. Closure of the lymphatics around the iliac vessels is paramount in avoiding lymphocele formation. This study aimed to evaluate the effectiveness of bipolar electrocautery-based vascular sealers (BSD) in the dissection and/or ligation of lymphatic vessels in terms of the development of lymphoceles and postoperative kidney functions in live donor kidney transplants at our center. A total of 63 patients who underwent kidney transplantation (KTx) between January and December 2021 were included in the study. Data, including postoperative creatinine values and postoperative ultrasonography follow-up, were recorded. Thirty-seven patients who were operated on using conventional ligation for iliac vessel preparation were included in group 1. Twenty-six patients treated using BSD for iliac vessel preparation were included in group 2. Statistical analysis was performed to compare these groups. This study complied with The Helsinki Congress and The Declaration of Istanbul. There was no significant difference between the groups in terms of postoperative first-week creatinine values (1.176 mg/dL vs 1.203 mg/dL), first-month creatinine values (1.061 mg/dL vs 1.091 mg/dL), first-week collection volume (33.240 mL vs 33.430 mL), and third-month collection volume (23.120 mL vs 23.430 mL) (P > .05). In KTx surgery, BSD is as safe as and faster than conventional ligation in preparation of the recipient's iliac vessels.

Outcome of ABO-Incompatible Living Donor Kidney Transplantation: A Single Center Observational Study from Nepal

Introduction: Kidney transplantation is the most effective treatment for end-stage renal disease (ESRD) patients. However, the increasing number of ESRD patients and the limited availability of living and cadaveric donors has led to a growing waiting list for kidney transplantation. ABO-incompatible transplantation has emerged as an alternative for these patients in Nepal. Methods: This was an observational study of all the patients who underwent kidney transplantation from March 2017-Feb 2019. Data on demography of recipients and donor, blood group, human leukocyte antigen mismatch, induction agent, post-operative complications and creatinine clearance at discharge and one-year post-transplant were collected and analysed. Then we compared patient and kidney graft survival at one year between ABO incompatible and ABO compatible recipients. Results: During the study period, there were total of 124 kidney transplant recipients among them 12 were ABO incompatible and 112 were ABO compatible recipients. The study showed slightly lower patient and graft survival in ABO-incompatible recipients than ABO compatible recipients (83.3% vs 99.2%, p&lt;0.001). However, death-censored graft survival were similar in both groups (100%,p&lt;0.001). The graft function at one year measured by creatinine clearance was better in ABO-incompatible recipients than ABO-compatible recipients (67.1±11.75 vs 61.87±12.82, p&lt;0.001). Postoperative complications were slightly higher, however, complications at one year were lower in ABO-incompatible recipients. Conclusion: The study showed that living donor ABO-incompatible kidney transplant recipients have a good outcome at one year but is associated with greater risks of patient and graft loss at early transplant period compared to ABO-compatible recipients.

Impact of ABO incompatibility and early antibody-mediated rejection on chronic antibody-mediated rejection in kidney transplant patients.

Early antibody-mediated rejection has been reported to increase chronic antibody-mediated rejection and decrease graft survival in kidney transplantation. However, the impact of early antibody-mediated rejection in ABO-incompatible kidney transplantation remains unclear. We retrospectively analyzed living-donor kidney transplantation patients from two Korean centers. Patients were categorized based on ABO compatibility and early antibody-mediated rejection within 1 year. The primary outcome was chronic antibody-mediated rejection. The secondary outcomes were production of de novo donor-specific antibody and composite kidney outcome, defined as graft loss or a decline in estimated glomerular filtration rate to below 30mL/min/1.73 m2. A total of 1639 patients were analyzed, including 1292 patients who underwent ABO-compatible kidney transplantation and 347 patients who underwent ABO-incompatible kidney transplantation. ABO-incompatible kidney transplantation had a lower risk of de novo donor-specific antibody production (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.48-0.95) and chronic antibody-mediated rejection (HR 0.33, 95% CI 0.12-0.92) with a comparable risk of the composite kidney outcome (HR 1.06, 95% CI 0.71-1.59) compared to ABO-compatible kidney transplantation. When outcomes of ABO-incompatible kidney transplantation were analyzed according to early antibody-mediated rejection, ABO-incompatible kidney transplantation without antibody-mediated rejection had a lower risk of de novo donor-specific antibody production (HR 0.60, 95% CI 0.41-0.88) and chronic antibody-mediated rejection (HR 0.28, 95% CI 0.09-0.91) than ABO-compatible kidney transplantation without antibody-mediated rejection. However, ABO-incompatible kidney transplantation with antibody-mediated rejection showed a higher risk of de novo donor-specific antibody production and similar risk of chronic antibody-mediated rejection compared to ABO-compatible kidney transplantation without antibody-mediated rejection. ABO-incompatible kidney transplantation showed a lower risk of de novo donor-specific antibody production and chronic antibody-mediated rejection compared to ABO-compatible kidney transplantation; however, early antibody-mediated rejection abrogated these beneficial effects of ABO-incompatible kidney transplantation.

A Case Report of Successful Kidney Transplantation in a Patient With Autosomal Dominant Polycystic Kidney Disease Who Underwent Thoracic Endovascular Aortic Repair for Type B Aortic Dissection

Autosomal dominant polycystic kidney disease (ADPKD) is associated with several cardiovascular disorders, including aortic dissection, which preferentially occurs at the thoracic or abdominal level. Because there are few case reports describing surgical repair for aortic dissection followed by renal transplantation in patients with ADPKD, kidney transplantation performed after repair for aortic dissection remains challenging. A 34-year-old Japanese man with end-stage renal disease secondary to ADPKD underwent thoracic endovascular aortic repair for complicated acute type B aortic dissection 12 months earlier. A contrast computed tomography scan before transplantation revealed an aortic dissection involving the descending aorta proximal to the common iliac arteries and confirmed multiple large bilateral renal cysts. After simultaneous right native nephrectomy, the patient underwent preemptive living-donor kidney transplantation obtained from his mother. Intraoperatively, we noted that dissection of the external iliac vessels was difficult because of dense adhesions. Arterial clamping was performed immediately below the bifurcation of the internal iliac artery to prevent further aortic dissection of the external iliac artery. After end-to-end anastomosis to the internal iliac artery was completed and the vascular clamp was released, the kidney began to produce urine immediately. This case suggests that kidney transplantation in patients undergoing endovascular aortic repair for aortic dissection can be performed by adequately applying a vascular clamp proximal to the internal iliac artery during vascular anastomosis.

Access to the Kidney Transplant Waitlist for People With HIV.

The Advisory Committee on Blood and Tissue Safety and Availability recently voted to remove the statutory National Institutes of Health research criteria and institutional review board requirements for performing kidney transplantation using kidneys from donors with HIV. This policy change may subsequently increase utilization of such organs.1 Despite excellent kidney transplant outcomes, single-center studies have demonstrated significantly lower kidney transplant waitlist addition rates for people with HIV (PWH) in the United States as compared with those without HIV, a requisite step for deceased donor kidney transplantation.2-4 Should adoption of transplantation using kidneys from donors with HIV increase following the implementation of this policy, understanding waitlist addition nationally is imperative. Acknowledging the lack of granularity in HIV-specific data, we used the United States Renal Data System and accompanying Medicare claims data to identify a cohort of PWH (January 1, 2007–December 31, 2016) with end-stage kidney disease (ESKD) and compared waitlist addition rates among PWH with ESKD patients without HIV. This study was approved by the Institutional Review Board at the University of Alabama at Birmingham. Among 602 006 incident patients whose primary payer was Medicare,5 HIV status was defined using the Chronic Conditions Data Warehouse algorithm (sensitivity: 93.2%; specificity: 99.4%). PWH with claims for an opportunistic infection within 90 d of dialysis initiation were excluded. Cox proportional hazards and Fine and Gray competing risks regressions were used to examine the likelihood of waitlist addition. The 6250 PWH were younger, more commonly African American, and more commonly reported alcohol dependence, drug dependence, and tobacco use. Cumulative incidence of waitlist addition within 5 y of dialysis initiation was 11.1% among PWH and 15.3% among ESKD patients without HIV. Following adjustment for demographics, comorbid conditions, and geography, HIV was associated with 52% lower likelihood of waitlist addition (adjusted hazard ratio: 0.48; 95% confidence interval, 0.43-0.52; P < 0.001; Table 1). After accounting for competing risks of death and living donor kidney transplantation before waitlist addition, a similar inequity was observed (adjusted subdistribution hazard ratio: 0.45; 95% confidence interval, 0.42-0.49; P < 0.001). TABLE 1. - Unadjusted and adjusted likelihood of waitlist addition among ESKD patients within 5 y and within all observed time following dialysis initiation 5 y, HR (95% CI) a Full follow-up, HR (95% CI) a Unadjusted PWH (ref: HIV–) 0.90 (0.83-0.98) 0.64 (0.54-0.75) PWH (ref: HIV–) b 0.93 (0.86-0.99) 0.62 (0.58-0.68) aHR (95% CI) b aHR (95% CI) b Adjusted PWH (ref: HIV–) 0.48 (0.43-0.52) 0.27 (0.21-0.35) PWH (ref: HIV–) b 0.45 (0.42-0.49) 0.25 (0.20-0.32) Bold values indicate significance at P < 0.05.aAdjusted for age, race, ethnicity, sex, WHO obesity class, alcohol abuse, drug abuse, diabetes, hypertension, cancer, peripheral vascular disease, nonambulatory status, assistance needed for daily activities, atherosclerotic heart disease, cerebrovascular disease, amputation, coronary obstructive pulmonary disease, institutionalized (yes/no), functional status, tobacco use, rurality, ESKD network, and year of dialysis initiation.bCompeting risk model.aHR, adjusted HR; CI, confidence interval; ESKD, end-stage kidney disease; HIV–, HIV negative; HR, hazard ratio; PWH, people with HIV; WHO, World Health Organization. This disparity in waitlist addition experienced by PWH has been described in single-center data,2-4 and commonly attributed to clinical factors, specifically severity of HIV infection as defined by CD4 counts, HIV viral loads, presence of opportunistic infections, substance use, and failure to complete transplant evaluation. Reported substance use was included in our analysis, but, despite attempts to account for HIV-specific characteristics through the exclusion of PWH with opportunistic infections, we were unable to completely account for such, nor could we assess where this disparity manifests, including referral rates or evaluation completions. Reliance upon Medicare claims data also resulted in an older cohort, potentially resulting in lower waitlist addition rates. Thus, the magnitude of the disparity between PWH and ESKD patients with HIV may have been overestimated or developed earlier at referral or evaluation. Despite these limitations, this observed inequity is confirmed by studies that collected HIV-specific characteristics, referral, and evaluation data. Given advances in transplantation for PWH, national data collection should be revised to capture early steps in transplantation and HIV-specific characteristics to ensure equitable access to and outcomes of transplantation.2-4

Living Donor Kidney Transplantation in Older Individuals: An Ethical Legal and Psychological Aspects of Transplantation (ELPAT) View.

Living donor transplantation is the optimal treatment for suitable patients with end-stage kidney disease. There are particular advantages for older individuals in terms of elective surgery, timely transplantation, and early graft function. Yet, despite the superiority of living donor transplantation especially for this cohort, older patients are significantly less likely to access this treatment modality than younger age groups. However, given the changing population demographic in recent decades, there are increasing numbers of older but otherwise healthy individuals with kidney disease who could benefit from living donor transplantation. The complex reasons for this inequity of access are explored, including conscious and unconscious age-related bias by healthcare professionals, concerns relating to older living donors, ethical anxieties related to younger adults donating to aging patients, unwillingness of potential older recipients to consider living donation, and the relevant legislation. There is a legal and moral duty to consider the inequity of access to living donor transplantation, recognising both the potential disparity between chronological and physiological age in older patients, and benefits of this treatment for individuals as well as society.

Using Laser Speckle Contrast Imaging to Quantify Perfusion Quality in Kidney and Pancreas Grafts on Vascular Reperfusion: A Proof-of-Principle Study.

This study was registered in ClinicalTrials.gov (NCT04202237). The Moor FLPI-2 blood flow imager was used in 4 patients (1 Simultaneous Pancreas and Kidney, 2 deceased, and 1 living donor kidney transplants) during reperfusion to capture reperfusion data. The following parameters were measured: flux (average speed × concentration of moving red blood cells in the sample volume), doppler centroid, total and valid pixels, valid rate, and total and valid area. Flux data were analyzed with Moor FLPI analysis software. The perfusion characteristics and flux images correlated with initial graft function. LSCI is a safe, noncontact imaging modality that provides real-time, accurate, high-resolution, full field blood flow images and a wide range of flux data to objectively quantify organ reperfusion intraoperatively in kidney/kidney-pancreas transplantation. This modality could be used to develop a robust numerical quantification system for the evaluation and reporting of intraoperative organ perfusion, and aid intraoperative decision-making. Perfusion data could be combined with biomarkers and immunological parameters to more accurately predict graft outcomes.

Upside-Down Kidney Transplantation in a Recipient with Severe Arteriosclerosis: A Case Report

Recently, the number of patients with significant arteriosclerosis has been increasing owing to the aging of kidney transplant patients, an increase in the number of patients with kidney failure with diabetes as the primary disease, and an increase in the number of patients undergoing long-term dialysis. Severe atherosclerosis in kidney transplant recipients makes it difficult to determine the site of vascular anastomosis and increases the technical difficulty of the surgical procedure. This study presents a case of upside-down kidney transplantation in a recipient with severe arteriosclerosis. The patient was a 58-year-old male with diabetic nephropathy. He received an ABO-compatible living donor kidney transplant from his wife. Preoperative computed tomography revealed a mild calcification of the external iliac artery. However, during surgery, more than half of the external iliac artery was found to be calcified, making vascular anastomosis difficult. The peripheral side of the external iliac artery showed mild atherosclerosis. Therefore, the vessel could be anastomosed to the peripheral side of the external iliac artery by turning the kidney graft upside-down for use as the anastomosis site. The postoperative course was uneventful, and the kidney function was good at the last follow-up. Upside-down kidney transplantation is safe in patients with severe arteriosclerosis.

A Case of Chronic Active Antibody-Mediated Rejection Caused by a Pre-Existing Anti-DQ Donor-Specific Antibody in a Systemic Lupus Erythematosus Recipient Without History of Sensitization: A Case Report

Systemic lupus erythematosus (SLE) is reported to produce anti-HLA antibodies. We report a case of chronic active antibody-mediated rejection caused by pre-existing donor-specific antibody (DSA) in a patient with SLE without a history of sensitization. The case was a 29-year-old man with end-stage renal disease due to lupus nephritis. Cross-match with the mother was negative, but low titer anti-DQ DSA was detected, although he had no prior history of sensitization. After desensitization with rituximab and mycophenolate mofetil, a living donor kidney transplant was undergone, and his early postoperative period was uneventful. However, his renal function started to decline at 2 years post-transplant. Although there was no rejection on the biopsy at 2.5 years post-transplant, his renal function continued to decline after that. At 7 years, he had failed his graft due to chronic active antibody-mediated rejection. Retrospective analysis of human leukocyte antigen antibody tests revealed that anti-DQ DSA had disappeared at 1 year post-transplant, but high titer DSA was detected again with complement-binding capacity at 2 years and after that. Careful monitoring might be warranted in an SLE patient with pre-existing DSA, even though the titer was low and without any prior histories of sensitization events.