Living Donor Kidney Transplant Program Research Articles

Impact of single centre kidney-exchange transplantation to increase living donor pool in India: A cohort study involving non-anonymous allocation.

In India, 85% of organ donations are from living donors and 15% are from deceased donors. One-third of living donors were rejected because of ABO or HLA incompatibility. Kidney exchange transplantation (KET) is a cost-effective and legal strategy to increase living donor kidney transplantation (LDKT) by 25%-35%. We report our experience with 539 KET cases and the evolution of a single-centre program to increase the use of LDKT. Between January 2000 and 13 March, 2024, 1382 deceased donor kidney transplantations and 5346 LDKT were performed at our centre, including 10% (n = 539) from KET. Of the 539 KET, 80.9% (n = 436) were ABO incompatible pairs, 11.1% (n = 60) were compatible pairs, and 8% (n = 43) were sensitized pairs. There were 75% 2-way (n = 2 × 202 = 404), 16.2% 3-way (n = 3 × 29 = 87), 3% 4-way (n = 4 × 4 = 16), 1.8% 5-way (n = 5 × 2 = 10), 2.2% 6-way (n = 6 × 2 = 12), and 1.8% 10-way KET (n = 10 × 1 = 10). Of the recipients 81.2% (n = 438) were male and 18.8% (n = 101) were female, while of the donors, 78.5% (n = 423) were female and 21.5% (n = 116) were male. All donors were near relatives; wives (54%, n = 291) and mothers (20%, n = 108) were the most common donors. At a median follow-up of 8.2 years, patient survival, death censored graft survival, acute rejection, and median serum creatinine levels of functioning grafts were 81.63% (n = 440), 91% (n = 494), 9.8% (n = 53) and 1.3 mg/dL respectively. We credited the success to maintaining a registry of incompatible pairs, high-volume LDKT programs, non-anonymous allocation and teamwork. This is the largest single-centre KET program in Asia. We report the challenges and solutions to replicate our success in other KET programs.

246.11: Establishing a living donor kidney transplant program in Rwanda.

246.11: Establishing a living donor kidney transplant program in Rwanda.

Outcomes of ABO-Incompatible Living Donor Kidney Transplantation Compared to Waiting or Deceased Donor Kidney Transplantation.

ABO-incompatible (ABOi) living donor kidney transplantation (LDKT) is considered only for patients who do not have an ABO-compatible (ABOc) LD. Therefore, a clinically practical question is whether to proceed with ABOi LDKT or remain on dialysis while waiting for ABOc deceased donor kidney transplantation (DDKT). However, this issue has not been addressed in Asian countries, where ABOi LDKT programs are more active than DDKT programs. A total of 426 patients underwent ABOi-LDKT between 2010 and 2020 at Seoul National University Hospital and Severance Hospital, Korea. We compared outcomes between the ABOi-LDKT and the propensity-matched control groups (waiting-list-only group, n = 1,278; waiting-list-or-ABOc-DDKT group, n = 1,278). The ABOi-LDKT group showed a significantly better patient survival rate than the waiting-list-only group (p = 0.001) and the waiting-list-or-ABOc-DDKT group (p = 0.048). When the ABOi-LDKT group was categorized into a high-titer group (peak anti-ABO titer ≥1:128) and a low-titer group (peak anti-ABO titer ≤1:64), the low-titer group showed better patient survival rates than those of the waiting-list-or-ABOc-DDKT group (p = 0.046) or the waiting-list-only group (p = 0.004). In contrast, the high-titer ABOi-LDKT group showed no significant benefit in patient survival compared to the waiting-list-or-ABOc-DDKT group. Death-censored graft survival in the ABOi-LDKT group was not significantly different from that in the ABOc-DDKT group (p = 0.563). The ABOi-LDKT group has better outcomes than the waiting-list-or-ABOc-DDKT group in a country with a long waiting time.

Interpersonal Connections Are Important for Virtual Kidney Transplant Educational Program Development.

Introduction: The Living Donor Navigator program is designed to mitigate disparities in living donor kidney transplantation, although geographic disparities in program participation were observed in the initial years of implementation. The purpose of this study was to understand participant perspectives regarding the use of a virtual option/alternative to expand program participation. Methods: Previous participants of the in-person navigator program were purposively sampled. Using the nominal group technique, a well-structured formative methodology to elicit participant perspectives, 2 meetings were conducted among transplant recipients and advocates (N = 13) to identify and prioritize responses to the question "What things would concern you about participating in a virtual and remote Living Donor Navigator program?" Findings: Mean participant age was 59.3 (9.3) years, and participants were 54% male and 62% white. Education levels varied from less than high school to master's degrees. Participants generated 70 unique responses, of which 36 (51.4%) received prioritization. The top 5 ranked responses of each nominal group technique meeting received approximately 50 percent (47.6% vs. 66.7%, respectively) of the total votes and described the potentially limited interpersonal connections, time conflicts, and differing content in a virtual navigator program compared to the in-person model. Discussion: These data suggest that previous participants were concerned with upholding the original design of the program, thus, virtual living donor kidney transplantation programs should aim to maintain interpersonal connections and consistency of content to ensure adequate programmatic engagement. Future research will focus on program fidelity independent of delivery modality.

Many a Slip Twixt the Intake Form and the Living Donation.

Many a Slip Twixt the Intake Form and the Living Donation.

Coping with alack of evidence: living-donor kidney transplantation in the initial phase of the SARS-CoV-2 pandemic.

Due to immunosuppressive therapy, transplant patients are more susceptible to viral and bacterial infections. A potentially deadly new virus haunted us in 2020: SARS-CoV‑2, causing coronavirus disease 19 (COVID-19). We analyzed the consequences of this previously unknown risk for our living-donor transplant program in the first year of the pandemic. After the complete lockdown in spring 2020, our transplant center in Linz resumed the living-donor kidney transplantation program from June to September 2020, between the first and second waves of COVID-19 in Austria. We compared the outcomes of these living-donor kidney transplantations with the transplant outcomes of the corresponding periods of the three previous years. From June 4 to September 9, 2020, five living-donor kidney transplantations were performed. All donors and recipients were screened for COVID 19 infection by PCR testing the day before surgery. Kidney transplant recipients remained isolated in single rooms until discharge from hospital. All recipients and donors remained SARS-CoV‑2 negative during the follow-up of 10 months and have been fully vaccinated to date. The number of living transplants in the studied period of 2020 was constant compared to the same months of 2017, 2018, and 2019. Living-donor kidney transplantation can be continued using testing for SARS-CoV‑2 and meticulous hygienic precautions in epidemiologically favorable phases of the SARS-CoV‑2 pandemic. Donors and recipients should be carefully selected and informed about risks and benefits.

Progression of histological lesions after ABO incompatible kidney transplantation.

Recent large meta-analyses suggested a poorer long-term patients’ and grafts’ outcomes after ABO incompatible (ABOi) living-donor kidney transplantation (LDKT) compared to ABO compatible LDKT. However, little is known about the long-term histological pattern after ABOi LDKT. We compared the histological features observed on protocol biopsies from 03/11 to 11/19 in 94 ABOi LDKT (including 14 with preformed Donor Specific Antibodies, pDSAs), 27 LDKT ABO compatible (ABOc) with pDSAs, and 21 ABOc without pDSAs) during the first five years post transplantation. During the first 5 years post-transplantation, a progression of chronic lesions (patients with a ci >0 raised from 11% to 65%, p<0.0001, patients with a ct >0 raised from 29% to 78%, p<0.0001) was observed in ABOi LDKT without pDSAs. Histological patterns of evolution were comparable to those observed in ABOc kidney transplant patients. Microvascular inflammation was lower in ABOi LDKT without pDSAs compared to those with pDSAs (ABOi or ABOc). At last follow-up, 28 months, IQR (15-48) post-transplantation, 29 patients (36%) had a severe graft dysfunction (defined by a CKD-epi eGFR < 30 mL/min/1.73m²). The donor age was a predictive factor for the development of severe kidney allograft dysfunction at last follow-up (HR= 1.05, 95% CI [1.05-1.10], p= 0.03).Hence, long-term histological analysis of ABOi LDKT shows only an increase of chronic interstitial and tubular atrophy changes, without active lesions. These data confirm that ABOi LDKT programs can be securely developed.

423.7: Impact of Single Centre 440 Kidney Exchange Transplantation Over 20 Years to Increase Living Donor Pool in India: A Cohort Study

Introduction: In a living donor kidney transplantation (LDKT) dominated transplant program, kidney exchange may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages. There is a data scarcity of challenges and solutions for kidney exchange in the developing world. Here, we report our experience of 440 single-center kidney exchange transplantation to increase LDKT in India. Methods: The study has been reviewed by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards laid down in the Declaration of Helsinki as well as the Declaration of Istanbul. All donor-recipient pairs (DRP) gave their informed consent prior to their inclusion in the study. All pairs exchange kidneys of similar quality. Results: Between January 2000 and February 2020, 6050 LDKT and 925 DDKT were performed at our single-center, 440 using kidney exchanges (8.5%) (350 male, 90 female recipients, and 345 female and 95 male donors). The reasons for joining kidney exchange among transplanted patients were ABO incompatibility (n = 313), sensitization (n = 88), and better HLA matching (n = 39). All donors were near relatives [wife (n=236), husband (n=58), mother (n=93), father (n=25), sister (n=11), brother (n=8), grand-parents (n=2), son (n=1) and others (n=6)]. There were 164 two-way (n =328), 23 three-way (n = 69), 4 four-way (n = 16), 1 five-way (n=5), 2 six-way and one ten-way kidney exchange (n = 12). The state of residence of DRP was our state (Gujarat=246), and other states (n=144). There was an overwhelming preponderance of female donors (wife and mother) but similar to our LDKT program. The graft survival, patient survival, biopsy-proven rejection rate, and graft function was similar to other LDKT outcomes. It is important to recognize that over the 20 years our kidney exchange program has evolved into a large, advanced program with innovative approaches to further increase LDKT. We credit the success of our kidney exchange program to maintaining a registry of incompatible pairs, counseling on kidney exchange, a high-volume LDKT program, and teamwork. Conclusions: Kidney exchange is legal, cost-effective, and rapidly growing for facilitating LDKT with incompatible donors. This study provides large-scale evidence for the expansion of single-center LDKT via kidney exchange when national programs do not exist.

244.2: 18-Year Follow-up of Kidney Donation in the Living Donor Transplant Program at a Reference Pediatric Hospital

Introduction: The frequency of living donor transplant has recently increased for several reasons. On one hand, due to the increased prevalence of advanced chronic kidney disease and the decrease in the number of suitable brain-dead donors, and on the other hand, due to the improvement in the safety of the procedure for the donor. Since the primary objective of living-donor kidney transplantation is to guarantee the safety of the donor, the scientific community has recently become interested in the possible long-term complications of kidney donation, since follow-up information on the health of donors is essential for understanding the risks and consequences of donation, support donation selection and provide informed consent. The objective of this study is to evaluate the evolution after nephrectomy of the living donor population in a reference pediatric hospital. Methods: A cross-sectional study of the living donor’s outpatient database was carried out from October 2002 to December 2021. All donors who completed donation in this period of time were included. Surgical time, transoperative incidents, hospital stay, post-surgical complications and long-term behavior of creatinine clearance and proteinuria were analyzed. Results: A total of 1332 patients who entered the living donor kidney transplant program were analyzed, 796 completed donation (59.75%) and 43 lost follow-up (5.4%). Of the remaining 753 donors, 409 were women (54.31%) and 344 men (45.68%). A total of 702 patients underwent left nephrectomy (93.22%), 50 right nephrectomy (6.64%), and one patient was suspended before completing surgery (0.13%). The median age at nephrectomy was 37.068 years (r=18-56 yrs). The mean surgical time was 128.77 minutes (r=25-170 min). Among transoperative incidents, 125 pleural and/or peritoneum openings (16.60%), 10 kidney decapsulations (1.32%), 9 tearings of different vessels (1.19%), 1 adrenal vessel avulsion (0.13%), and 1 ureteral injury (0.13%) were described. There was one case of cardiorespiratory arrest in the recovery area. The mean days of hospital stay were 2.64 days (r=1-32 days). Creatinine clearance and proteinuria levels were analyzed during a follow-up period of up to 18 years. 96 patients (12.74%) had a sustained decrease in creatinine clearance and proteinuria (>150 mg/d) was found in 16 patients (2.12%). There were 2 donor deaths, none of theme related to renal failure. Conclusions: Although some increases in urinary protein levels and decreases in creatinine clearance were described, none of our living donors developed kidney failure. Of the 2 reported deaths, one was attributed to colon cancer and the other to alcoholic pancreatitis consequences, none of them related to donation. We can conclude that nephrectomy for donation purposes is a safe procedure since we found no decrease in long-term survival or progressive renal dysfunction.

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.

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.

Live donor kidney transplantation. Situation analysis and roadmap

Living donor kidney transplantation (LDKT) is the best treatment option for end stage renal disease in terms of both patient and graft survival. However, figures on LDKT in Spain that had been continuously growing from 2005 to 2014, have experienced a continuous decrease in the last five years.One possible explanation for this decrease is that the significant increase in the number of deceased donors in Spain during the last years, both brain death and controlled circulatory death donors, might have generated the false idea that we have coped with the transplant needs. Moreover, a greater number of deceased donor kidney transplants have caused a heavy workload for the transplant teams.Furthermore, the transplant teams could have moved on to a more conservative approach to the information and assessment of patients and families considering the potential long-term risks for donors in recent papers. However, there is a significant variability in the LDKT rate among transplant centers and regions in Spain independent of their deceased donor rates. This fact and the fact that LDKT is usually a preemptive option for patients with advanced chronic renal failure, as time on dialysis is a negative independent factor for transplant outcomes, lead us to conclude that the decrease in LDKT depends on other factors.Thus, in the kidney transplant annual meeting held at ONT site in 2018, a working group was created to identify other causes for the decrease of LDKT in Spain and its relationship with the different steps of the process. The group was formed by transplant teams, a representative of the transplant group of the Spanish Society of Nephrology (SENTRA), a representative of the Spanish Society of Transplants (SET) and representatives of the Spanish National Transplant Organization (ONT).A self-evaluation survey that contains requests about the phases of the LDKT processes (information, donor work out, informed consent, surgeries, follow-up and human resources) were developed and sent to 33 LDKT teams. All the centers answered the questionnaire. The analysis of the answers has resulted in the creation of a national analysis of strengths, weaknesses, opportunities, threats (SWOT) of the LDKT program in Spain and the development of recommendations targeted to improve every step of the donation process. The work performed, the conclusions and recommendations provided, have been reflected in the following report: Spanish living donor kidney transplant program assessment: recommendations for optimization. This document has also been reviewed by a panel of experts, representatives of the scientific societies (Spanish Society of Urology (AEU), Spanish Society of Nephrology Nursery (SEDEN), Spanish Society of Immunology (SEI/GETH)) and the patient association ALCER. Finally, the report has been submitted to public consultation, reaching ample consensus. In addition, the transplant competent authorities of the different regions in Spainhave adopted the report at institutional level.The work done and the recommendations to optimize LDKT are summarized in the present manuscript, organized by the different phases of the donation process.

Trasplante renal de donante vivo. Análisis de situación y hoja de ruta

Living donor kidney transplantation (LDKT) is the best treatment option for end stage renal disease in terms of both patient and graft survival. However, figures on LDKT in Spain that had been continuously growing from 2005 to 2014, have experienced a continuous decrease in the last five years.One possible explanation for this decrease is that the significant increase in the number of deceased donors in Spain during the last years, both brain death and controlled circulatory death donors, might have generated the false idea that we have coped with the transplant needs. Moreover, a greater number of deceased donor kidney transplants have caused a heavy workload for the transplant teams.Furthermore, the transplant teams could have moved on to a more conservative approach to the information and assessment of patients and families considering the potential long-term risks for donors in recent papers. However, there is a significant variability in the LDKT rate among transplant centers and regions in Spain independent of their deceased donor rates. This fact and the fact that LDKT is usually a preemptive option for patients with advanced chronic renal failure, as time on dialysis is a negative independent factor for transplant outcomes, lead us to conclude that the decrease in LDKT depends on other factors.Thus, in the kidney transplant annual meeting held at ONT site in 2018, a working group was created to identify other causes for the decrease of LDKT in Spain and its relationship with the different steps of the process. The group was formed by transplant teams, a representative of the transplant group of the Spanish Society of Nephrology (SENTRA), a representative of the Spanish Society of Transplants (SET) and representatives of the Spanish National Transplant Organization (ONT).A self-evaluation survey that contains requests about the phases of the LDKT processes (information, donor work out, informed consent, surgeries, follow-up and human resources) were developed and sent to 33 LDKT teams. All the centers answered the questionnaire.The analysis of the answers has resulted in the creation of a national analysis of strengths, weaknesses, opportunities, threats (SWOT) of the LDKT program in Spain and the development of recommendations targeted to improve every step of the donation process. The work performed, the conclusions and recommendations provided, have been reflected in the following report: Spanish living donor kidney transplant program assessment: recommendations for optimization. This document has also been reviewed by a panel of experts, representatives of the scientific societies (Spanish Society of Urology (AEU), Spanish Society of Nephrology Nursery (SEDEN), Spanish Society of Immunology (SEI/GETH)) and the patient association ALCER. Finally, the report has been submitted to public consultation, reaching ample consensus. In addition, the transplant competent authorities of the different regions in Spain have adopted the report at institutional level.The work done and the recommendations to optimize LDKT are summarized in the present manuscript, organized by the different phases of the donation process.

Practicing With Uncertainty: Kidney Transplantation During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic required transplant nephrologists, surgeons, and care teams to make decisions about the full spectrum of transplant program operations and clinical practices in the absence of experience or data. Initially, across the country, there was a reduction in kidney transplant procedures and a striking pause in the conduct of living donation and living-donor transplant surgeries. Aspects of candidate evaluation and follow-up rapidly converted to telehealth. Months into the pandemic, much has been learned from experiences worldwide, yet many questions remain. In this Perspective, we reflect on some of the practice decisions made by the transplant community in the initial response to the pandemic and consider lessons learned, including those related to the risks, benefits, and logistical considerations of proceeding with versus delaying deceased-donor transplantation, living donation, and living-donor transplantation during the pandemic. We review the evolution of therapeutic strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their use in transplant recipients, current consensus related to immunosuppression management in infected transplant recipients, and emerging information on vaccination against SARS-CoV-2. We share our thoughts on research priorities, discuss the areas in which we are still practicing with uncertainty, and look ahead to the next phase of the pandemic response.

An International survey on living kidney donation and transplant practices during the COVID-19 pandemic.

The scope of the impact of the Coronavirus disease 19 (COVID‐19) pandemic on living donor kidney transplantation (LDKT) practices across the world is not well‐defined. We received survey responses from 204 transplant centers internationally from May to June 2020 regarding the impact of the COVID‐19 pandemic on LDKT practices. Respondents represented 16 countries on five continents. Overall, 75% of responding centers reported that LDKT surgery was on hold (from 67% of North American centers to 91% of European centers). The majority (59%) of centers reported that new donor evaluations were stopped (from 46% of North American centers to 86% of European centers), with additional 23% of centers reporting important decrease in evaluations. Only 10% of centers reported slight variations on their evaluations. For the centers that continued donor evaluations, 40% performed in‐person visits, 68% by video, and 42% by telephone. Center concerns for donor (82%) and recipient (76%) safety were the leading barriers to LDKT during the pandemic, followed by patients concerns (48%), and government restrictions (46%). European centers reported more barriers related to staff limitations while North and Latin American centers were more concerned with testing capacity and insufficient resources including protective equipment. As LDKT resumes, 96% of the programs intend to screen donor and recipient pairs for coronavirus infection, most of them with polymerase chain reaction testing of nasopharyngeal swab samples. The COVID‐19 pandemic has had broad impact on all aspects of LDKT practice. Ongoing research and consensus‐building are needed to guide safe reopening of LDKT programs.

Intraoperative Fluid Restriction is Associated with Functional Delayed Graft Function in Living Donor Kidney Transplantation: A Retrospective Cohort Analysis.

Background: In 2016 we observed a marked increase in functional delayed graft function (fDGF) in our living donor kidney transplantation (LDKT) recipients from 8.5% in 2014 and 8.8% in 2015 to 23.0% in 2016. This increase coincided with the introduction of a goal-directed fluid therapy (GDFT) protocol in our kidney transplant recipients. Hereupon, we changed our intraoperative fluid regimen to a fixed amount of 50 mL/kg body weight (BW) and questioned whether the intraoperative fluid regimen was related to this increase in fDGF. Methods: a retrospective cohort analysis of all donors and recipients in our LDKT program between January 2014–February 2017 (n = 275 pairs). Results: Univariate analysis detected various risk factors for fDGF. Dialysis dependent recipients were more likely to develop fDGF compared to pre-emptively transplanted patients (p < 0.001). Recipients developing fDGF received less intraoperative fluid (36 (25.9–50.0) mL/kg BW vs. 47 (37.3–55.6) mL/kg BW (p = 0.007)). The GDFT protocol resulted in a reduction of intraoperative fluid administration on average by 850 mL in total volume and 21% in mL/kg BW compared to our old protocol (p < 0.001). In the unadjusted analysis, a higher intraoperative fluid volume in mL/kg BW was associated with a lower risk for the developing fDGF (OR 0.967, CI (0.941–0.993)). After adjustment for the confounders, prior dialysis and the use of intraoperative noradrenaline, the relationship of fDGF with fluid volume was still apparent (OR 0.970, CI (0.943–0.998)). Conclusion: Implementation of a GDFT protocol led to reduced intraoperative fluid administration in the LDKT recipients. This intraoperative fluid restriction was associated with the development of fDGF.

Mitigating Racial and Sex Disparities in Access to Living Donor Kidney Transplantation: Impact of the Nation's Longest Single-center Kidney Chain.

In this study, we sought to assess likelihood of living donor kidney transplantation (LDKT) within a single-center kidney transplant waitlist, by race and sex, after implementation of an incompatible program. Disparities in access to LDKT exist among minority women and may be partially explained by antigen sensitization secondary to prior pregnancies, transplants, or blood transfusions, creating difficulty finding compatible matches. To address these and other obstacles, an incompatible LDKT program, incorporating desensitization and kidney paired donation, was created at our institution. A retrospective cohort study was performed among our kidney transplant waitlist candidates (n = 8895). Multivariable Cox regression was utilized, comparing likelihood of LDKT before (era 1: 01/2007-01/2013) and after (era 2: 01/2013-11/2018) implementation of the incompatible program. Candidates were stratified by race [white vs minority (nonwhite)], sex, and breadth of sensitization. Program implementation resulted in the nation's longest single-center kidney chain, and likelihood of LDKT increased by 70% for whites [adjusted hazard ratio (aHR) 1.70; 95% confidence interval (CI), 1.46-1.99] and more than 100% for minorities (aHR 2.05; 95% CI, 1.60-2.62). Improvement in access to LDKT was greatest among sensitized minority women [calculated panel reactive antibody (cPRA) 11%-49%: aHR 4.79; 95% CI, 2.27-10.11; cPRA 50%-100%: aHR 4.09; 95% CI, 1.89-8.82]. Implementation of an incompatible program, and the resulting nation's longest single-center kidney chain, mitigated disparities in access to LDKT among minorities, specifically sensitized women. Extrapolation of this success on a national level may further serve these vulnerable populations.

Developing a Sustainable Renal Transplant Program in Low- and Middle-Income Countries: Outcome, Challenges, and Solutions.

The initiation of a kidney transplant program, in a low- and middle-income country, while striving to maintain excellent outcomes and adhere to high ethical, legal standards, is a formidable task. Herein, we review the outcomes and challenges of a living donor kidney transplant program from its inception to sustainability, in Guyana, South America. This is a retrospective review of a living donor kidney transplant program instituted in Guyana in 2008. Data included recipient and donor demographics, cause of renal failure, donor-recipient matching and relationship, perioperative complications, timing and cause of death, graft failure, surgical technique, and laterality of organ procured. Patient and donor data were compared by phases and additionally compared to United States Renal Data Base System. Survival outcomes were compared by phases and by Kaplan-Meier curves. To date, 45 kidney transplants have been completed. Phase I (2007-2008) was the initiation of the program, which was comprised of upgrading hospital and operating rooms, obtaining antirejection medications, educating local providers, fostering a relationship with the government, and screening patients and living donors. We also began vascular access and peritoneal dialysis in the country, as well as introduced the companion public health service initiative: the SEVAK program. Phase II (2008-2014) involved completion of 25 living donor kidney transplants, of which there have been 11 confirmed deaths and 10 lost to follow-up. In Phase III (2015-present), 20 transplants have been completed to date, of whom only 1 died and none were lost to follow-up. In the third phase, we also introduced corneal transplantation to Guyana and have performed over 100 transplants. Kidney transplantation can be safely and ethically performed in a low- and middle-income country. We applied lessons learnt from the first two phases to improve follow-up by appointing a local coordinator who goes to patient's homes in remote villages. Currently, there is a stable local team that is performing transplants and following the patients. We believe that our model of public-private partnership can sustain kidney, as well as corneal, transplantation and could be replicated in other countries.

Living Unrelated Kidney Transplantation: Does It Prevent Deceased-Donor Kidney Transplantation Growth?

It is usually assumed that an active livingdonor transplant program inhibits the growth of a deceased-donor kidney transplant program. In our 33-year experience, we found the contrary to be true. From 1984 until 2017, we performed a total of 4966 kidney transplant procedures. All cases were registered through the Collaborating Transplant Study (Heidelberg, Germany). During the first 16 years, only living-donor kidney transplant procedures were done. Our first unrelated living-donor kidney transplant procedure was in 1986 and involved a wife to husband donation. This breakthrough in our country was the first in our unrelated living-donor kidney transplant program. In 2000, the Iranian Parliament passed the deceased-donor transplant act, and we have started deceased-donor kidney transplants since then. Despite a jam-packed living-donor kidney transplant program, our deceased-donor kidney transplant program has grown steadily since then and now comprises more than 50% of our kidney transplant procedures. When we compared the outcome of these programs, the 5-year survival from Collaborating Transplant Study report of 3527 cases of 114 living-related donor procedures was 90%. The 5-year survival rates for living unrelated-donor (n = 2689) and deceased-donor (n = 724) transplant procedures were 88% and 83%, respectively (P = .001). Our data showed that deceased-donor kidney transplant procedures have steadily increased despite an active unrelated living-donor kidney transplant program. Wait lists for kidney transplant can be significantly reduced by following our model, both in developed and in developing countries.

Patient Characteristics and Outcomes Following Establishment of a Living Donor Kidney Transplant Program in Sub-Saharan Africa

Background End-stage renal disease (ESRD) is one of the most common non-communicable causes of death. ESRD’s effects are significantly worse in the economically underprivileged parts of African society where renal replacement therapy such as dialysis or kidney transplantation is not available, as it is both scarce and unaffordable for most patients and families. About 2 years ago, we established Ethiopia’s first living donor kidney transplant program. Herein, we sought to describe the patient characteristics and outcomes of our living donor kidney program. Methods We retrospectively analyzed all ESRD patients who received kidney transplantation at the Ethiopian Ministry of Health National Kidney Transplant Center, located at St. Paul’s Hospital Millennium Medical College in Addis Ababa. All patients underwent living donor kidney engraftment from September 2015 to August 2017. Results After about 3 years of planning prior to human transplants, a total of 52 living donor kidney transplants were performed, of which 20 were performed in the first year. Of these, 40 recipients (76.9%) were male. Recipient age ranged from 16 to 60 years, with a mean of 34.5 years, and a mean BMI of 20.1 (range 15.3-30.6). Geographically, the majority of patients were from Addis Ababa (71.2%). Due to a relative lack of access for pre-transplant biopsy, the cause of ESRD was unknown in many patients (63.5%). All patients received left donor kidneys, and the majority was placed on the recipient’s left external iliac artery (88.5%). The mean operation time and blood loss were 148 minutes and 120 mL, respectively. The mean length of stay was 8.1 days (SD=4.1). There were a total of 9 surgical complications (6 early and 3 late) in 7 patients, with superficial surgical site infection (SSI) being the most common (4). There were no patient deaths during the immediate postoperative period. Conclusions We have successfully established the first kidney transplant center in Ethiopia. While training for faculty and staff are ongoing, our results so far are comparable to other international centers. Key words: ESRD, Kidney Transplant, Outcomes