National Kidney Registry Research Articles

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

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

400.2: Family Voucher Programs: An Ethical Way to Increase Nondirected Kidney Donation

Kidney transplant “vouchers” were created in 2014 as a means to overcome the “chronological incompatibility” that arises when a potential donor wants or needs to donate before the relative or friend who is to receive the kidney is ready to have a transplant. In exchange for the donor giving a kidney now, the prospective recipient is provided with what the National Kidney Registry (NKR) calls a “Standard Voucher” (SV), which can be redeemed when the recipient is ready for a transplant. In this paper, we describe the benefits of extending this innovation to altruistic donation and examine preliminary data on the effects. The kidneys supplied by altruistic donors are critical to the success of transplant chains because they typically serve as a non-directed donation that sets in motion a chain of many biologically incompatible donor-recipient pairs. Well-designed chains make possible a large number of transplants which would otherwise not have occurred or would have taken much longer to arrange, especially for highly sensitized or O blood-type recipients. The innovation—termed “Family Vouchers” (FVs) by the NKR— overcomes the “sentimental incompatibility” that leads some potential altruistic donors to back away from donating when they realize that giving a kidney to a stranger now will preclude them from providing a kidney should a loved one need a transplant in the future. FVs differ from SVs because donors are permitted to list up to five intended recipients, though only one may redeem the FV, and the intended recipients do not then have terminal kidney disease and may not develop it in the future. Like SVs, FV-based donors initiate kidney chains, which end with a recipient who lacks a donor. Likewise, the transplant network that issues the voucher will provide a suitable kidney at the end of a future chain when the designated recipient redeems the voucher.The expectation that FVs will attract new donors as well as provide assurance to people who develop doubts about their plan to make an altruistic donation is supported by current data. For example, voucher-based donation, which accounted for a tiny fraction of nondirected donation in the U.S. when it began in 2014 had surpassed altruistic donation by 2019, and its rapid growth helped nondirected donation to triple by 2021 (Figure 1). The Covid-19 pandemic interrupted this steady rise, but the decrease in nondirected donation was much smaller than for living kidney donation generally (Table 1). While altruistic donation went down, the rise in FV-based donations meant that in 2021 the percentage of living donors who were nondirected was the highest ever. Family Voucher programs, which are aligned with a central goal of transplant professionals—shortening the wait for transplants—need to broaden their outreach in minority communities and to carefully self-monitor their ability always to fulfill their moral commitment to provide all voucher-holders with a kidney from a suitable living donor.

Matching in Dynamic Imbalanced Markets

Abstract We study dynamic matching in exchange markets with easy- and hard-to-match agents. A greedy policy, which attempts to match agents upon arrival, ignores the positive externality that waiting agents provide by facilitating future matchings. We prove that the trade-off between a “thicker” market and faster matching vanishes in large markets; the greedy policy leads to shorter waiting times and more agents matched than any other policy. We empirically confirm these findings in data from the National Kidney Registry. Greedy matching achieves as many transplants as commonly used policies (1.8$\%$ more than monthly batching) and shorter waiting times (16 days faster than monthly batching).

MP36-04 THE “CANNIBALIZATION” OF ALTRUISTIC KIDNEY DONATION BY VOUCHER-BASED KIDNEY TRANSPLANTATION

You have accessJournal of UrologyCME1 May 2022MP36-04 THE “CANNIBALIZATION” OF ALTRUISTIC KIDNEY DONATION BY VOUCHER-BASED KIDNEY TRANSPLANTATION Nima Nassiri, Torey Averick, and Jeffrey Veale Nima NassiriNima Nassiri More articles by this author , Torey AverickTorey Averick More articles by this author , and Jeffrey VealeJeffrey Veale More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002590.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Barriers to living kidney donation are multi-factorial, and may include logistic, financial, familial, cultural, and religious factors. Less discussed but impactful barriers involve: (1) a reluctance to donate because a present-day donation prohibits future one, and (2) chronological incompatibility. Voucher-based kidney donation seeks to address these latter two barriers. Herein, we sought to evaluate how voucher-based donations have impacted standard altruistic kidney donation. METHODS: Subjects were all patients participating in standard altruistic donation and voucher-based donation through the National Kidney Registry from 2014 to present. Demographic and clinical factors were considered. The impact on downstream chains of transplantation were also evaluated. Both voucher-based and standard altruistic donation were considered “non-directed”. RESULTS: Since 2014, the total number of non-directed donations, either from standard altruistic donation or through the voucher program, has risen by over 3-fold (Figure 1). The number standard altruistic donations has declined since 2018, coinciding with an uptick in the number of voucher-based donations from 22 in 2018 to 113 in 2020. Voucher-based donations continued to grow throughout the pandemic. The following trends have been seen: (1) a steady rise in FV-based donation from the inception of the voucher program to present; (2) a steady shift in the percent involvement from standard altruistic donation to voucher-based donation; and (3) an annual decline in number of standard altruistic donors over the past 3 years. CONCLUSIONS: The following trends have been seen: (1) a steady rise in FV-based donation from the inception of the voucher program to present; (2) a steady shift in the percent involvement from standard altruistic donation to voucher-based donation; and (3) an annual decline in number of standard altruistic donors over the past 3 years. Though greater follow up is required, the short term trends suggest that voucher-based donation may be “cannibalizing” donation. Despite this, the overall number of non-directed donations, and the chains of transplants they spark, have expanded, delivering more high-quality kidneys and shortening the waiting time for kidney-paired exchange. Source of Funding: OneLegacy Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e597 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nima Nassiri More articles by this author Torey Averick More articles by this author Jeffrey Veale More articles by this author Expand All Advertisement PDF DownloadLoading ...

Motivations and outcomes of compatible living donor–recipient pairs in paired exchange

Increasing numbers of compatible pairs are choosing to enter paired exchange programs, but motivations, outcomes, and system-level effects of participation are not well described. Using a linkage of the Scientific Registry of Transplant Recipients and National Kidney Registry, we compared outcomes of traditional (originally incompatible) recipients to originally compatible recipients using the Kaplan-Meier method. We identified 154 compatible pairs. Most pairs sought to improve HLA matching. Compared to the original donor, actual donors were younger (39 vs. 50years, p<.001), less often female (52% vs. 68%, p<.01), higher BMI (27 vs. 25kg/m², p=.03), less frequently blood type O (36% vs. 80%, p<.001), and had higher eGFR (99 vs. 94ml/min/1.73m², p=.02), with a better LKDPI (median 7 vs. 22, p<.001). We observed no differences in graft failure or mortality. Compatible pairs made 280 additional transplants possible, many in highly sensitized recipients with long wait times. Compatible pair recipients derived several benefits from paired exchange, including better donor quality. Living donor pairs should receive counseling regarding all options available, including kidney paired donation. As more compatible pairs choose to enter exchange programs, consideration should be given to optimizing compatible pair and hard-to-transplant recipient outcomes.

Wages, Travel, and Lodging Reimbursement by the National Kidney Registry: An Important Step Toward Financial Neutrality for Living Kidney Donors in the United States.

Since 2007, the National Living Donor Assistance Center has provided the most financial support to US living donors meeting specific income criteria by reimbursing travel, meal, and lodging expenses. In 2019, the National Kidney Registry started providing lost wages, travel, and lodging reimbursement via their Donor Shield program. Donor Shield is automatically provided to donors who participate in kidney paired donation through the National Kidney Registry or who donate at a Donor Shield Direct center, without any income restrictions. The support donors across the United States received from the Donor Shield program between January 2019 and February 2020 was studied. During the study period, 326 (25.9%) of the 1260 donors covered by Donor Shield, from 46 programs received reimbursements amounting to a total of $647 384.45, with $472 389.97 (73.0%) covering lost wages. Median reimbursement per donor was $1813.80 (range, $44.0-$165.63). Eighty-one percent of 108 reimbursed donors who were surveyed reported that the lack of these reimbursements would have posed a financial hardship, and 4% said they would have been unable to donate without this support. Expansion of lost wages reimbursement programs to all donors in the United States would be an important step toward achieving financial neutrality for this unique population and could also help meet the growing demand for transplantable organs by increasing living donation rates.

Discrepant subtyping of blood type A2 living kidney donors: Missed opportunities in kidney transplantation.

Despite the institution of a new Kidney Allocation System in 2014, A2/A2B to B transplantation has not increased as expected. The current Organ Procurement and Transplantation Network policy requires subtyping on two separate occasions, and in the setting of discrepant results, defaulting to the A1 subtype. However, there is significant inherent variability in the serologic assays used for blood group subtyping and genotyping is rarely done. The National Kidney Registry, a kidney paired donation (KPD) program, performs serological typing on all A/AB donors, and in cases of non-A1/non-A1B donors, confirmatory genotyping is performed. Between 2/18/2018 and 9/15/2020, 13.0% (145) of 1,111 type A donors registered with the NKR were ultimately subtyped as A2 via genotyping. Notably, 49.6% (72) of these were subtyped as A1 at their donor center, and in accordance with OPTN policy, ineligible for allocation as A2. Inaccurate A2 subtyping represents a significant lost opportunity in transplantation, especially in KPD where A2 donors can not only facilitate living donor transplantation for O and highly sensitized candidates, but can also facilitate additional living donor transplants. This study highlights the need for improved accuracy of subtyping technique, and the need for policy changes encouraging optimal utilization of A2 donor kidneys.

Voucher-Based Kidney Donation and Redemption for Future Transplant

Policy makers, transplant professionals, and patient organizations agree that there is a need to increase the number of kidney transplants by facilitating living donation. Vouchers for future transplant provide a means of overcoming the chronological incompatibility that occurs when the ideal time for living donation differs from the time at which the intended recipient actually needs a transplant. However, uncertainty remains regarding the actual change in the number of living kidney donors associated with voucher programs and the capability of voucher redemptions to produce timely transplants. To examine the consequences of voucher-based kidney donation and the capability of voucher redemptions to provide timely kidney allografts. This multicenter cohort study of 79 transplant centers across the US used data from the National Kidney Registry from January 1, 2014, to January 31, 2021, to identify all family vouchers and patterns in downstream kidney-paired donations. The analysis included living kidney donors and recipients participating in the National Kidney Registry family voucher program. A voucher was provided to the intended recipient at the time of donation. Vouchers had no cash value and could not be sold, bartered, or transferred to another person. When a voucher was redeemed, a living donation chain was used to return a kidney to the voucher holder. Deidentified demographic and clinical data from each kidney donation were evaluated, including the downstream patterns in kidney-paired donation. Voucher redemptions were separately evaluated and analyzed. Between 2014 and 2021, 250 family voucher-based donations were facilitated. Each donation precipitated a transplant chain with a mean (SD) length of 2.3 (1.6) downstream kidney transplants, facilitating 573 total transplants. Of those, 111 transplants (19.4%) were performed in highly sensitized recipients. Among 250 voucher donors, the median age was 46 years (range, 19-78 years), and 157 donors (62.8%) were female, 241 (96.4%) were White, and 104 (41.6%) had blood type O. Over a 7-year period, the waiting time for those in the National Kidney Registry exchange pool decreased by more than 3 months. Six vouchers were redeemed, and 3 of those redemptions were among individuals with blood type O. The time from voucher redemption to kidney transplant ranged from 36 to 155 days. In this study, the family voucher program appeared to mitigate a major disincentive to living kidney donation, namely the reluctance to donate a kidney in the present that could be redeemed in the future if needed. The program facilitated kidney donations that may not otherwise have occurred. All 6 of the redeemed vouchers produced timely kidney transplants, indicating the capability of the voucher program.

Dissolving Disincentives to Living Kidney Donation

Despite barriers and disincentives to living kidney donation, a record-setting number of living donor transplants (6,867) were performed in 2019. Additionally, there was a 24% increase in living donor kidney transplants from 2014-2019. These increases are welcome, yet the supply has not kept up with the demand, and the kidney transplant waiting list continues to grow. Innovative solutions are necessary to overcome disincentives to living kidney donation and increase the number of donors. The authors propose changing laws and rules to reimburse donors for all expenses related to donating a kidney; informing them of all the options of donation, including directed, non-directed, paired exchange, remote, and advanced donation; informing them of programs that transplant centers provide, including whether or not the center participates in the National Kidney Registry Donor Shield program; educating each donor about their personal risk; and dispelling misinformation they may have about living kidney donation. Implementing these measures will require a national, standard approach because there is variability between the states in relation to work leave and financial incentives for living donation.

Trends in US Kidney Transplantation During the COVID-19 Pandemic.

Solid organ transplants have been impacted significantly during the COVID-19 pandemic in the United States. Limited data exist regarding changes in living donor kidney transplants. The aim of this study was to describe national trends in kidney transplantation during COVID-19. This descriptive cross-sectional study used publicly available data from the United Network for Organ Sharing (UNOS) and the National Kidney Registry (NKR). Plots of national waitlist inactivations, waitlist additions, deceased donor transplants and living donor transplants were created. An Auto Regressive Integrated Moving Average (ARIMA) model with interrupted time series analysis adjusting for first-order autocorrelation was used to evaluate for significant changes in outcome trends every four-week period during the COVID-19 era between March 15 and August 1, 2020. A statistical significance of 0.05 (𝛼) was established for analysis. Changes in kidney transplant volumes during the COVID-19 outbreak were registered. Density mapping and linear regression with interrupted time series analysis were used to characterize changes over time nationwide. Kidney transplants were affected significantly in recent months due to COVID-19. Deceased donor and living donor kidney transplant trends are described in this paper in addition to operative recommendations.

Editorial introductions

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Didier A. MandelbrotDidier A. MandelbrotDr Mandelbrot is currently Medical Director of Kidney and Pancreas Transplantation at UW Health and Professor of Medicine at the University of Wisconsin School of Medicine. He was an undergraduate at Harvard College, medical student at the University of Pennsylvania, resident in Medicine at the Hospital of the University of Pennsylvania, and renal fellow at Brigham and Women's Hospital. He has a background in basic transplant immunology and a longstanding interest in the diagnosis and treatment of solid organ rejection. He has participated in numerous single and multi-center clinical trials in kidney transplantation, and has published almost 200 papers and chapters. He has made important contributions on the role of donor-specific antibodies in the context of kidney transplantation, pancreas transplantation and simultaneous liver-kidney transplantation. He also has a particular interest in living kidney donation, and has been active in describing and improving practices in the US. He was co-PI of the NIH-funded Kidney Donor Outcomes Cohort study and recently finished serving as Chair of the American Society of Transplantation's Living Donor Community of Practice. He is currently a member of the United Network of Organ Sharing Medical and Professional Standards Committee, the American Transplant Congress Program Planning Committee, and the Medical Board of the National Kidney Registry. He is an Associate Editor of Clinical Transplantation. Maria SiemionowMaria SiemionowDr Siemionow, a world-renowned scientist and microsurgeon, is Professor of Orthopedics and Director of Microsurgery Research at The University of Illinois at Chicago. She specializes in microsurgery, hand surgery, peripheral nerve surgery, transplantation, and microsurgery research. She is pioneering development of new technology for minimal immunosuppression in transplantation and enhancement of nerve and muscle regeneration. She served as a President of the American Society for Reconstructive Transplantation, President of the International Hand and Composite Tissue Allotransplantation Society and President of the American Society for Peripheral Nerve. She is a member of the academic-industry team, Warrior Restoration Consortium, focusing on development of clinical therapies and new technologies for wounded soldiers as part of the second phase of the Armed Forces Institute for Regenerative Medicine (AFIRM II). She has received numerous honors, including high praise as Principal Investigator for the world's first IRB approval for Facial Allograft Transplantation protocol; in 2008, she led the team that performed the first near-total face transplantation in the United States. Dr Siemionow has over 330 scientific publications. She has edited three plastic surgery textbooks, two popular science books, and has contributed to over 120 published book chapters. Dr Siemionow received numerous awards including the Polish Order of Merit (2009), the Commander's Cross Polonia Restituta Award from the President of Poland (2009), the Outstanding Achievement in Clinical Research Award from the Plastic Surgery Educational Foundation (2010); the 2011 American Society of Plastic Surgeons’ Board of Trustees Special Achievement Award and Casimir Funk National Science Award (2013). In 2014 she received the Great Immigrants Award from the Carnegie Foundation of New York. In 2016 Dr Siemionow was awarded the Heritage Award granted by the Polish American Congress. In 2019 she received Golden Otis Award. Prior to her UIC appointment, she was Director of Plastic Surgery Research and Head of Microsurgical Training for Cleveland Clinic's Department of Plastic Surgery. Jeffery A. KahnJeffery A. KahnDr Jeffrey A. Kahn completed his undergraduate training at the University at Albany, State University of New York, medical school training at the State University of New York, Upstate Medical University and internal medicine residency at Emory University. He then went on to fellowship training in gastroenterology at the University of Southern California and transplant hepatology training at Cedars Sinai-Sinai Medical Center. He has been the medical director of the Keck School of Medicine of USC Liver Transplant Program since 2011, with a special interest in living donor liver transplantation and transfusion-free liver transplantation. His research interests include liver transplant waitlist disparities, liver transplant outcomes and has ongoing translational research related to occult hepatitis C infection.

Living Donor Nephrectomy Using a Right Malrotated Kidney: A Case Report

A 46-year-old woman was approved as a living kidney donor in our center for paired donation working with the National Kidney Registry. The imaging revealed a malrotated right kidney with the hilum oriented cephalad. We selected that kidney for donation, and an uneventful laparoscopic donor nephrectomy was performed. To our knowledge, this is the first case of laparoscopic living donor nephrectomy using a sagittally malrotated kidney.

Deceased donors as nondirected donors in kidney paired donation.

As proof of concept, we simulate a revised kidney allocation system that includes deceased donor (DD) kidneys as chain-initiating kidneys (DD-CIK) in a kidney paired donation pool (KPDP), and estimate potential increases in number of transplants. We consider chains of length 2 in which the DD-CIK gives to a candidate in the KPDP, and that candidate's incompatible donor donates to theDD waitlist. In simulations, we vary initial pool size, arrival rates of candidate/donor pairs and (living) nondirected donors (NDDs), and delay time from entry to the KPDP until a candidate is eligible to receive a DD-CIK. Using data on candidate/donor pairs and NDDs from the Alliance for Paired Kidney Donation, and the actual DDs from the Scientific Registry of Transplant Recipients (SRTR) data, simulations extend over 2years. With an initial pool of 400, respective candidate and NDD arrival rates of 2 per day and 3 per month, and delay times for access to DD-CIK of 6months or less, including DD-CIKs increases the number of transplants by at least 447 over 2years, and greatly reduces waiting times of KPDP candidates. Potential effects on waitlist candidates are discussed as are policy and ethical issues.

Early Experiences With COVID-19 Testing in Transplantation.

Background.The early effects of coronavirus disease 2019 (COVID-19) on transplantation are dramatic: >75% of kidney and liver programs are either suspended or operating under major restrictions. To resume transplantation, it is important to understand the prevalence of COVID-19 among transplant recipients, donors, and healthcare workers (HCWs) and its associated mortality.Methods.To investigate this, we studied severe acute respiratory syndrome coronavirus 2 diagnostic test results among patients with end-stage renal disease or kidney transplants from the Johns Hopkins Health System (n = 235), and screening test results from deceased donors from the Southwest Transplant Alliance Organ Procurement Organization (n = 27), and donors, candidates, and HCWs from the National Kidney Registry and Viracor-Eurofins (n = 253) between February 23 and April 15, 2020.Results.We found low rates of COVID-19 among donors and HCWs (0%–1%) who were screened, higher rates of diagnostic tests among patients with end-stage renal disease or kidney transplant (17%–20%), and considerable mortality (7%–13%) among those who tested positive.Conclusions.These findings suggest the threat of COVID-19 for the transplant population is significant and ongoing data collection and reporting is critical to inform transplant practices during and after the pandemic.

Ensuring the need is met: A 50-year simulation study of the National Kidney Registry's family voucher program.

The National Kidney Registry (NKR) Advanced Donation Program enables living donors the opportunity to donate altruistically, or in advance of a potential recipient's transplant, and to receive a voucher that can be redeemed for a future transplant facilitated by the NKR. Family vouchers allow a donor to identify multiple individuals within their immediate family, with the first person in that group in need of a transplant being prioritized to receive a kidney. An increase in vouchers introduces concerns that demand for future voucher redemptions could exceed the supply of available donors and kidneys. A Monte Carlo simulation model was constructed to estimate the annual number of voucher redemptions relative to the number of kidneys available over a 50‐year time horizon under several projected scenarios for growth of the program. In all simulated scenarios, the number of available kidneys exceeded voucher redemptions every year. While not able to account for all real‐life scenarios, this simulation study found that the NKR should be able to satisfy the likely redemption of increasing numbers of vouchers under a range of possible scenarios over a 50‐year time horizon. This modeling exercise suggests that a donor family's future needs can be satisfied through the voucher program.

The effect of the National Kidney Registry on the kidney-exchange market

We assess the causal effect of the National Kidney Registry (NKR), the largest national kidney-exchange network in the U.S., on kidney-exchange outcomes. Analyzing a unique database hosted by the Scientific Registry of Transplant Recipients (SRTR) that contains information on all kidney donors, wait-listed candidates, and transplant recipients in the U.S., we find that patients in an NKR hospital are 2.5–3 times more likely than their counterparts in a non-NKR hospital to receive a transplant from a living donor, conditional on wait-time. At the same time, NKR participation does not have a significant effect on the desirability of donors and the health status of recipients. We employ various approaches to ensure our finding is robust in addressing the non-random sorting of patients and donors. As far as the outcomes we study, the expansion of the NKR brings about an overall positive impact on the kidney exchange market.

Early graft losses in paired kidney exchange: Experience from 10years of the National Kidney Registry.

Cooperative kidney paired donation (KPD) networks account for an increasing proportion of all living donor kidney transplants in the United States. There are sparse data on the rate of primary nonfunction (PNF) losses and their consequences within KPD networks. We studied National Kidney Registry (NKR) transplants (February 14, 2009 to December 31, 2017) and quantified PNF, graft loss within 30days of transplantation, and graft losses in the first-year posttransplant and assessed potential risk factors. Of 2364 transplants, there were 38 grafts (1.6%) lost within the first year, 13 (0.5%) with PNF. When compared to functioning grafts, there were no clinically significant differences in blood type compatibility, degree of HLA mismatch, number of veins/arteries, cold ischemia, and travel times. Of 13 PNF cases, 2 were due to early venous thrombosis, 2 to arterial thrombosis, and 2 to failure of desensitization and development of antibody-mediated rejection (AMR). Given the low rate of PNF, the NKR created a policy to allocate chain-end kidneys to recipients with PNF following event review and attributable to surgical issues of donor nephrectomy. It is expected that demonstration of low incidence of poor early graft outcomes and the presence of a "safety net" would further encourage program participation in national KPD.

Patient and Kidney Allograft Survival with National Kidney Paired Donation.

In the United States, kidney paired donation networks have facilitated an increasing proportion of kidney transplants annually, but transplant outcome differences beyond 5 years between paired donation and other living donor kidney transplant recipients have not been well described. Using registry-linked data, we compared National Kidney Registry (n=2363) recipients to control kidney transplant recipients (n=54,497) (February 2008 to December 2017). We estimated the risk of death-censored graft failure and mortality using inverse probability of treatment weighted Cox regression. The parsimonious model adjusted for recipient factors (age, sex, black, race, body mass index ≥30 kg/m2, diabetes, previous transplant, preemptive transplant, public insurance, hepatitis C, eGFR, antibody depleting induction therapy, year of transplant), donor factors (age, sex, Hispanic ethnicity, body mass index ≥30 kg/m2), and transplant factors (zero HLA mismatch). National Kidney Registry recipients were more likely to be women, black, older, on public insurance, have panel reactive antibodies >80%, spend longer on dialysis, and be previous transplant recipients. National Kidney Registry recipients were followed for a median 3.7 years (interquartile range, 2.1-5.6; maximum 10.9 years). National Kidney Registry recipients had similar graft failure (5% versus 6%; log-rank P=0.2) and mortality (9% versus 10%; log-rank P=0.4) incidence compared with controls during follow-up. After adjustment for donor, recipient, and transplant factors, there no detectable difference in graft failure (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77 to 1.18; P=0.6) or mortality (adjusted hazard ratio, 0.86; 95% confidence interval, 0.70 to 1.07; P=0.2) between National Kidney Registry and control recipients. Even after transplanting patients with greater risk factors for worse post-transplant outcomes, nationalized paired donation results in equivalent outcomes when compared with control living donor kidney transplant recipients.

Intraperitoneal Antibiotic Utilization among Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients with Peritonitis at a Tertiary Hospital Setting in Malaysia.

ABSTRACTIntroduction:Patients receiving continuous ambulatory peritoneal dialysis (CAPD) are commonly associated with peritonitis. However, little is known about the utilization of antibiotics for the treatment of peritonitis in these patients.Objectives:This study aimed to evaluate the patterns of intraperitoneal (IP) antibiotic utilization for the treatment of peritonitis in CAPD patients.Materials and Methods:This is a retrospective study conducted at a tertiary hospital setting in Malaysia. Medical records of CAPD patients who were diagnosed with peritonitis and registered with National Kidney Registry from 2013 to 2018 were reviewed. Types of antibiotics used and its dose and duration were recorded and reported using the anatomical therapeutic chemical/defined daily dose (ATC/DDD) system.Results:A total of 105 peritonitis episodes were recorded from 72 patients. The most common first-line empirical antibiotic combinations used were ceftazidime/cefazolin (40%, n = 42), followed by cefepime/cefazolin (30.5%, n = 32) and ceftazidime/cloxacillin (25.7%, n = 27). The definitive therapy for culture-proven CAPD-related peritonitis (CAPD-P) showed that vancomycin was the most frequently prescribed antibiotic (31.7%, n = 26/82), followed by amikacin (14.6%, n = 12/82), meropenem (11%, n = 9/82) and ampicillin (11%, n = 9/82). Ciprofloxacin was among the least prescribed definitive antibiotics for CAPD-P (2.4%, n = 2/82) but the DDD/100 patient-days estimates showed that it had the highest therapeutic intensity.Conclusion:There are various IP antibiotics used for CAPD-P and the most common empirical therapy was the combination of ceftazidime and cefazolin while vancomycin is predominantly used for definitive therapy. Future studies to evaluate the clinical outcomes of the antibiotic use should be conducted to have a better insight on the efficacy of the peritonitis treatment.

Garet Hil, MBA: Entrepreneur, Kidney Donor, and Founder/CEO of the National Kidney Registry.

Garet Hil, MBA: Entrepreneur, Kidney Donor, and Founder/CEO of the National Kidney Registry.