Potential Kidney Transplant Recipients Research Articles

#1836 Post-transplant evolution of kidney grafts from expanded criteria donors with diabetes

Abstract Background and Aims The increase in the number of potential kidney transplant (KT) recipients has led to efforts to increase the donor pool, including organs from expanded criteria donors (ECD) with diabetes mellitus (DM). However, doubts persist about their viability, especially with DM donors. Our aim is to analyze the post-transplant evolution of KT patients who have received kidney grafts from ECD with or without DM. Method Retrospective observational study of KT who received ECD kidney graft in our center between January 2014 and November 2023. We divided KT patients into two groups based on donor DM; ECD with DM and ECD without DM. We analyzed baseline characteristics and post-KT evolution. Univariate and multivariate statistical analysis was performed using Cox regression (SPSS Statistics 29.0). Results During the study period, 161 patients received grafts from ECD at our center. Pre-implant biopsies were performed on all grafts, with 15 discarded due to high histological score. Of these, 13 (86%) were diabetic donors (p < 0.001). The mean age of donors was 66 years, and that of recipients was 61. Forty-three (26%) KT recipients had a diabetic donor. Clinical characteristics of patients are reflected in Table 1. Conclusion Donors with DM showed adequate survival in our experience, similar to that of other ECD. This may be due to a more stringent pre-transplant clinical selection or pre-KT histological assessment. The development of new techniques is necessary to more precisely asses the viability of these grafts pre-KT, allowing for an increased utilization.

Left-Sided Pneumothorax in a Potential Kidney Transplant Recipient—A Surprise in the Surgical Ward: Case Report

The risk of morbidity and mortality in the group of people qualified for kidney transplantation is high. Although currently, the qualification for kidney transplantation is very extensive and detailed, the final examination and assessment at the transplant center is crucial for the success of the transplantation. A 50-year-old woman with end-stage kidney disease was admitted to the Department of General, Vascular, and Transplant Surgery on July 21, 2023, for kidney transplantation. A month earlier, she had undergone surgery to create an arteriovenous fistula on the left forearm. The regional anesthesia was performed. Apart from temporary pain and cough, the postoperative course was uncomplicated. Upon admission to the Department, the patient was in good general condition, and only a dry cough was noted during the physical examination. Chest X-ray revealed pneumothorax on the left side with partial lung atelectasis. The patient was temporarily disqualified from kidney transplantation and the pneumothorax was cured. She is currently on the active list waiting for a kidney transplant. The analysis of the above case emphasizes the importance of a physical examination and final qualification at the transplant center. Detailed examination and evaluation at the above center can improve patients' quality of life and survival.

Successful administration of eltrombopag in preparation for peritoneal dialysis catheter placement in a girl with MYH9-related disease.

MYH9-related disease is an autosomal dominant disorder characterized by macrothrombocytopenia, nephropathy, inclusion bodies in leukocytes, sensorineural hearing loss, and cataract. Severe cases require kidney replacement therapy in the patient's second decade of life; thrombocytopenia constitutes a major risk factor for hemorrhagic complications during dialysis initiation or kidney transplantation. Prophylactic platelet transfusion prior to surgery is commonly administered to affected patients in these cases. However, transfusion in such patients has limitations other than the general risk of allergic reactions and blood-borne infections; it may also trigger alloimmunization, leading to platelet transfusion resistance or the development of anti-donor antibodies in potential kidney transplant recipients. Here, we describe prophylactic administration of eltrombopag, an oral thrombopoietin receptor agonist, prior to laparoscopic peritoneal dialysis catheter placement in a 15-year-old girl with MYH9-related disease. Her platelet count was approximately 30 × 103/μL at baseline; it increased to 61 × 103/μL on the day before surgery, thereby avoiding the need for platelet transfusions. There were no major bleeding or adverse events associated with eltrombopag administration. Thus, eltrombopag may be a safe and effective alternative to prophylactic platelet transfusions in patients with MYH9-related disease.

Latent Tuberculosis Infection in Potential Renal Transplant Recipients and Live Donors in a Tertiary Level Transplant Center in Nepal

Background: Active tuberculosis in transplant recipients can result from latent infection with Mycobacterium Tuberculosis in the transplant recipients, donor tissue, or de novo post-transplant infection. This study aimed to determine the prevalence of latent tuberculosis infection in potential renal transplant recipients and live donors at a tertiary-level transplant center.
 Materials and Methods: This observational study was conducted from July to October 2020 among 72 potential kidney transplant recipients and their potential donors from the Department of Nephrology, Tribhuvan University Teaching Hospital. The biochemical parameters and health behaviors were measured to find the association with latent tuberculosis infection.
 Results: The prevalence of latent tuberculosis infection according to Mycobacterium tuberculosis-specific interferon-gamma release assays was 20.8% in potential recipients and 16.6% in potential donors, whereas the prevalence with tuberculin skin test was 9.7% in potential recipients and 33.3% in potential donors. Low levels of hemoglobin, calcium, albumin, vitamin D and history of smoking were associated with the development of latent tuberculosis infection among potential recipients. Alcohol drinking was significantly associated with the development of latent tuberculosis infection among donors.
 Conclusion: Potential renal transplant recipients and donors have a significant burden of latent tuberculosis in the pre-transplantation phase. Diagnosis and treatment of latent tuberculosis before transplantation can prevent ominous complications.

Kidney Transplantation in Patients With the History of SARS-CoV-2 Infection

Background. The aim of this study is to present the experience and results of kidney transplantation in patients with the history of SARS-CoV-2 infection.Methods. We retrospectively analyzed waitlisted patients who had a history of SARS-CoV-2 infection and offered a kidney transplant between March 2020 and December 2021.Results. Of the 97 waitlisted potential kidney transplant recipients who were offered a kidney, 13 (13.4%) had a history of SARS-CoV-2 infection. All patients were tested negative for SARS-CoV-2 at the time of the kidney offer. Successful transplantation was performed in 9 patients (5 male; average age was 40.8 years), with the average time between SARS-CoV-2 infection and transplantation of 8 months. Four of 13 patients with a history of SARS-CoV-2 infection were finally not transplanted, with 2 patients not eligible for transplantation due to significant post-COVID findings in routine pretransplant chest CT scans, and 2 patients were not transplanted because of poor donor organ quality.Conclusions. Kidney transplantation after SARS-CoV-2 infection is possible in a setting of full recovery from acute infection, negative PCR test, and no pneumonic infiltrates on chest CT scan. A growing number of waitlisted patients with a history of SARS-CoV-2 infection imposes the need for decision-making tools and guidelines for risk/benefit assessment in these patients.

340.6: Variability in Workup and Eligibility Criteria for Adult Kidney Transplantation Among Canadian Transplant Centres

Introduction: All potential kidney transplant recipients undergo rigorous evaluation to rule out or ensure appropriate treatment of conditions that may increase risk of post-transplant complications, but specific recommendations regarding workup and kidney transplant candidacy vary across published guidelines. We assessed current pre-transplant evaluation practices and eligibility criteria for adult kidney transplantation across Canada to elucidate differences in guideline interpretation and identify areas of most uncertainty. Methods: We compared published guidelines on kidney transplant workup and eligibility in order to create a focused digital survey that included both undisputed and controversial domains. The survey was divided into: referral process, history/physical exam, multidisciplinary assessments, laboratory/imaging, and contraindications. Given the many cancers and different staging for each, malignancy-related inquiries were simplified. The medical directors of all 18 Canadian adult kidney transplant programs were invited to complete the survey. We defined consensus and uncertainty, respectively, as >90% and <65% agreement between centers. Results: Survey completion rate was 78% (14/18). There was consensus on mandatory pre-transplant viral serology testing, tuberculosis screening, and dental evaluation, while cardiac evaluation protocols varied considerably. Of 28 questioned conditions, 6 were considered absolute contraindications by >90% of centers (active bacterial infection/malignancy, non-healing ulcer, COVID-19, severe lung/liver disease). Moderate uncertainty existed for: medication non-adherence (57%), symptomatic heart failure (50%), recent myocardial infarction (57%), and frailty (35%). Other parameters demonstrating wide variability included latent tuberculosis treatment protocols, and exclusion thresholds for parathyroid hormone, body mass index, left ventricular ejection fraction, and blood pressure. Centers used several guidelines to determine eligibility for patients with treated cancer. Conclusion: There is marked variability in evaluation requirements and eligibility criteria for kidney transplantation across Canada. National harmonization of evaluation processes and eligibility criteria may help to ensure more equitable and transparent access to kidney transplantation for Canadian patients with end-stage kidney disease.

Pretransplant characteristics of kidney transplant recipients that predict posttransplant outcome.

Better characterization of the potential kidney transplant recipient using novel biomarkers, for example, pretransplant plasma endotrophin, will lead to improved outcome after transplantation. This mini-review will focus on current knowledge about pretransplant recipients’ characteristics, biomarkers, and immunology. Clinical characteristics of recipients including age, obesity, blood pressure, comorbidities, and estimated survival scores have been introduced for prediction of recipient and allograft survival. The pretransplant immunologic risk assessment include histocompatibility leukocyte antigens (HLAs), anti-HLA donor-specific antibodies, HLA-DQ mismatch, and non-HLA antibodies. Recently, there has been the hope that pretransplant determination of markers can further improve the prediction of posttransplant complications, both short-term and long-term outcomes including rejections, allograft loss, and mortality. Higher pretransplant plasma endotrophin levels were independently associated with posttransplant acute allograft injury in three prospective European cohorts. Elevated numbers of non-synonymous single-nucleotide polymorphism mismatch have been associated with increased allograft loss in a multivariable analysis. It is concluded that there is a need for integration of clinical characteristics and novel molecular and immunological markers to improve future transplant medicine to reach better diagnostic decisions tailored to the individual patient.

Evaluation of Deceased Donor Kidney Transplantation in the Eurotransplant Senior Program in Comparison to Standard Allocation.

BackgroundThe organ shortage and long waiting times have dramatically increased the age of potential kidney transplant recipients. The Eurotransplant Senior Program (ESP) was initiated to allocate kidneys from deceased donors aged ≥65 years to recipients with a comparable age independent of pre-transplant human leucocyte antigen (HLA) matching; however, parameters affecting the long-term benefits of this strategy remain poorly defined.Material/MethodsWe retrospectively evaluated outcome and risk factors for mortality in kidney recipients aged ≥65 years that were transplanted according to the ESP protocol relative to patients aged >50 years transplanted according to the Eurotransplant kidney allocation system (ETKAS) criteria at the University Freiburg Medical Center, Germany, between 2008 and 2018.ResultsGraft survival, graft function, the maintenance immunosuppressive therapy, and the incidence of rejections and infections did not differ between groups. Infectious diseases were the main cause of death in both groups; however, infection-associated mortality was more than double in the ESP group, and 5-year patient survival was 61.4% in the ESP group compared to 83.2% in the ETKAS group. Multivariate analysis identified age, the number of HLA mismatches, and the CMV serostatus with a seropositive donor and negative recipient as the main risk factors for mortality.ConclusionsA comparable immunosuppressive regimen used in ESP and ETKAS patients was associated with similar rejection rates and infectious disease complications, and infections were the most common cause of death in both groups. CMV-negative patients receiving an organ from a CMV-positive donor and patients with a high number of HLA mismatches require close follow-up to reduce mortality.

Risk Factors Associated With New-Onset Myocardial Perfusion Abnormalities in Kidney Transplant Candidates

The optimal coronary artery disease surveillance strategy for end-stage renal disease patients being evaluated for kidney transplantation is unknown. It is unclear what risk factors are associated with the development of new-onset perfusion abnormalities on serial myocardial perfusion imaging. Potential kidney transplant recipients who underwent 2 myocardial perfusion imaging studies at Emory University Hospital between January 2010 and December 2019 were identified. We assessed the frequency of development of any new perfusion defect and development of moderate to severe ischemia (reversible perfusion defect >10%) on serial imaging. Finally, we identified the clinical and imaging factors associated with new perfusion defects and explored the association between new perfusion defects and all-cause mortality. History of myocardial infarction (MI) and peripheral artery disease was associated with an increased risk of developing a new perfusion defect. History of MI was also associated with the risk of developing moderate-severe ischemia. Female patients were less likely to develop new perfusion defects or moderate-severe ischemia. There was no association between either outcome and all-cause mortality. In conclusion, a history of MI, peripheral artery disease, and male gender are risk factors for developing new perfusion defects, although only the history of MI and male gender predict moderate to severe ischemia. Interval development of any abnormal perfusion is not associated with increased mortality.

Should Thorax Thin-Section Computed Tomography Be a Standard Diagnostic Procedure in the Evaluation of Potential Kidney Transplant Recipients? Lessons Learned From the COVID-19 Pandemic

BackgroundKidney transplant is the preferred treatment for most patients with end-stage renal disease. Because dialyzed patients often have significant comorbidities or multimorbidities, they should be carefully evaluated before being waitlisted for transplant. The COVID-19 pandemic presents a major challenge for surgery, including transplant surgery. Owing to a fear of COVID-19 symptoms occurring in lungs, thin-section computed tomography (TSCT) became a standard evaluation technique in potential kidney transplant recipients before surgery.MethodsThe aim of the study was to evaluate the rationale and usefulness of TSCT in deceased donor kidney transplant during the COVID‐19 pandemic. All adult patients who underwent deceased donor kidney transplant between May 1, 2020, and December 15, 2021, were included in the study. Potential kidney transplant recipients who were admitted to the Department of General, Vascular, and Transplant Surgery at the Medical University of Warsaw in Warsaw, Poland, were tested for COVID-19 (CovGenX rapid test); blood chemistries were performed; dialysis was performed (if needed); and, on a negative reverse transcriptase polymerase chain reaction test, HRCT was performed.ResultsFrom May 2020 until the end of December 2021, 54 patients were transplanted; however, 7 patients were disqualified after TSCT and consulted with a pulmonary specialist. Disqualification from kidney transplant accounted for 13% of the potential kidney allograft recipients.ConclusionsDespite the possibility of overdiagnosis by TSCT, TSCT should be considered a standard evaluation technique in potential kidney transplant recipients. Potential kidney transplant recipients must be periodically reassessed given the prolonged wait time for a donor kidney and the significant number of comorbid conditions in this patient population. However, more data with longer follow‐ups are needed to prove or disprove the rationale to use TSCT in transplant surgery.

Malignancy Prevalence in the Dialyzed Population and in Waitlisted Potential Kidney Transplant Recipients

Malignancy is the second cause of death in the dialyzed population. However, data on the prevalence of cancer are very scarce. Kidney transplantation improves quality of life, prolongs survival, and is cost-effective but bears some serious complications including malignancy. Therefore, active screening for cancer is of utmost importance. The aim of this study was to assess the prevalence of malignancy in dialyzed patients in relation to status on the on the waiting list and type of dialysis. This cross-sectional study was conducted in 108 hemodialyzed patients (mean age 65 years, 47 women) and 47 peritoneally dialyzed patients (mean age 51 years, 25 women). Among the population studied, 20 patients were actively waitlisted, including 14 peritoneal dialysis patients. Patients who had been active on the cadaver kidney waiting list and not listed did not differ in regard to sex, dialysis vintage, and causes of end-stage renal failure, but were significantly younger. Among hemodialysis patients, 24 of them had a history of malignancy and 10 in the peritoneal dialysis population. The most common were renal cell carcinoma in 6, breast cancer in 4, lung cancer in 3, prostate cancer in 3, hepatocellular cancer in 2, colorectal cancer in 2, esophageal cancer in 2, and others 14. In waitlisted patients, only 2 hemodialysis patients had a history of malignancy. Waitlisted patients represent a very selected and healthier dialyzed population. Malignancy has become a more common comorbidity in dialyzed patients, which may have important clinical implication regarding therapy. Guidelines for cancer screening in potential transplant recipients should be developed, as nowadays there are scarcity of data in this matter.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient’s needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

The Scope of Telemedicine in Kidney Transplantation: Access and Outreach Services.

Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor.

S1143 Noninvasive Assessment of NAFLD in Potential Kidney Transplant Recipients

Introduction: Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease among US adults. Risk factors (RF) for NAFLD including diabetes mellitus (DM) and hypertension (HTN), also increase the risk of chronic kidney disease (CKD). Our aim is to assess the prevalence of NAFLD and identify RF and predictors for NAFLD in patients listed for Kidney Transplant (KT). We also use noninvasive tests (NITs) to assess the prevalence of at least significant fibrosis in the NAFLD group. Methods: We performed a retrospective chart review on patients listed for KT. We included all adult patients listed for KT between 03/2015-08/2019. Exclusion criteria included a history of prior liver transplant, listed for simultaneous liver kidney transplant, and lack of available liver imaging in the past 5 years. We excluded patients with a history of either nonNAFLD liver disease or excessive alcohol use from the NAFLD group, but included them in the nonNAFLD analysis. We collected data on demographics, comorbidities, etiology of CKD, liver chemistries, and imaging of the liver. Most patients listed for KT after 2018 had a LE. FIB-4 score was calculated for all NAFLD patients. Results: 204 patients were included. 22.5% of patients were found to have NAFLD based on imaging describing an echogenic liver or hepatic steatosis. See table 1. On univariate analysis, a history of DM, metabolic syndrome (MS), DM as cause of CKD, and BMI were significantly associated with NAFLD (all p< 0.05). On multivariate analysis, ALT level was the only independent predictor of NAFLD (p< 0.05). The mean FIB4 score in the NAFLD group was 1.43. 67% of the NAFLD group had a FIB-4 < 1.45. 28.3% of the NAFLD group had an indeterminate FIB-4 score of >1.45 but < 3.25. 4.3% of the NAFLD group had a FIB-4 score >3.25, likely having advanced fibrosis. 56% of NAFLD patients had an available liver stiffness (LS) score. Of the NAFLD patients with LS scores, 11.5% was consistent with F2 fibrosis and 11.5% with ≥F3 fibrosis. Conclusion: NAFLD prevalence in patients listed for KT is similar to that of US adults, but this patient group may have a higher prevalence of at least significant fibrosis. Patients listed for KT who have a high BMI or history of MS or DM, especially if they have an abnormal ALT, should be evaluated for NAFLD. Potential KT recipients with NAFLD should have NITs such as a FIB-4 score or LE to assess for advanced fibrosis. Further studies are required to confirm these findings.Table 1.: Percentage of patients meeting inclusion criteria as compared by whether they were accepted for full assessment or not.

Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal?

ABSTRACT Screening for occult coronary artery disease in potential kidney transplant recipients has become entrenched in current medical practice as the standard of care and is supported by national and international clinical guidelines. However, there is increasing and robust evidence that such an approach is out-dated, scientifically and conceptually flawed, ineffective, potentially directly harmful, discriminates against ethnic minorities and patients from more deprived socioeconomic backgrounds, and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. Herein we review the available evidence in the light of recently published randomized controlled trials and major observational studies. We propose ways of moving the field forward to the overall benefit of patients with advanced kidney disease.

Current possibilities of improving the results of kidney transplantation in patients of the older age group, including those with an aggravated urological history

Introduction. All over the world and in Russia, the number of patients requiring dialysis therapy and kidney transplantation for chronic renal failure in the end-stage of the renal disease is increasing. In many countries of the world, the number of dialysis patients over 60 years of age accounts for 30 to 45% of all patients with chronic renal failure. Meantime, taking into account the improved methods for early diagnosis of chronic renal failure and the treatment methods for chronic kidney disease, including the renal replacement therapy, we can expect an increase in the number of elderly potential kidney transplant recipients. The likelihood of receiving a renal graft in elderly patients is significantly lower than in young recipients. Elderly patients are known to have a higher risk of death while waiting for a kidney transplant due to higher morbidity and lethality on dialysis. For this reason, the urgency of increasing the availability of kidney transplantation in elderly patients is growing over time. One of the solutions can be the use of kidneys from suboptimal donors with a far from ideal graft quality, but which could meet the needs for transplant care of the older age group of patients. The older age of a recipient entails a certain risk of developing a graft dysfunction due to the presence of concomitant diseases, and the potential risk increases even more with kidney transplants from expanded criteria donors. If a reduced functional reserve of kidneys removed from donors with extended criteria is identified, two-kidney transplantation is possible, which provides fairly good long-term results. To reduce the risk of a kidney graft loss, a careful selection of recipients is necessary, taking into account their co-morbidities, including the presence of urological diseases that impair the function of the upper and lower urinary tract. Their timely identification and correction makes it possible to raise the availability of kidney transplantation for elderly patients and improve its results. This review presents the results of the studies conducted in various world transplant centers, covers the mortality rates, kidney graft and recipient survival rates.The study purpose was to summarize the actual data and the results of the study on kidney transplantation in elderly patients with urological pathology.

Abstract 16810: Myocardial Perfusion Abnormalities, Ejection Fraction, and Coronary Calcium Score Are Not Associated With All-Cause Mortality Among Potential Kidney Transplant Recipients at Emory University Hospital

Introduction: Screening for coronary artery disease in patients being considered for kidney transplant is common to stratify morbidity and mortality risk, but the optimal strategy, and its impact on outcomes, remains unclear. Here we test the hypothesis that myocardial perfusion imaging (MPI) abnormalities, left ventricular ejection fraction (LVEF), or coronary artery calcium (CAC) score are associated with all-cause mortality in potential kidney transplant recipients at Emory University Hospital (EUH). Methods: In a retrospective chart review, we assessed the relationship between patient demographics, single-photon emission MPI results, and CAC scoring with post-evaluation outcomes at 5 years in consecutive patients referred for pre-transplant stress testing at EUH in 2015. Mann-Whitney U and Chi-Square tests assessed between-group differences in continuous and categorical variables, respectively. Multivariate analysis was performed using logistic regression models. Results: During the study period, 589 patients (mean age 54 years; SEM 0.512, 58% male, 65% African American) underwent MPI and 424 also underwent CAC scoring. Overall, 90 patients (15%) had abnormal MPI (defined as any fixed or reversible defect) and 54 (9%) died during follow up. Age (mean 53.2 years; SEM 0.533 vs. 57.7 years; SEM 1.73, p=0.008), previous coronary artery bypass graft (CABG) (2.06% vs. 7.41%, p=0.017), and myocardial infarction (MI) post-evaluation (4.11% vs. 18.5%, p&lt;0.001) were associated with all-cause mortality. Age (p=0.032) and MI post-evaluation (p&lt;0.001) remained significant in multivariate analysis. MPI abnormalities, LVEF, and CAC score were not associated with all-cause mortality. Conclusions: Age and MI post-evaluation are associated with increased mortality in potential kidney transplant recipients referred for stress testing at EUH. We found no association between MPI abnormalities, LVEF, or CAC score and all-cause mortality.

Frailty and the Potential Kidney Transplant Recipient: Time for a More Holistic Assessment?

Frailty is an age-related clinical syndrome characterized by a decline in physiologic reserve and an associated decreased ability to respond to stressor events (1). Importantly, frailty is associated with an increased risk of adverse outcomes, including falls, hospitalization, poorer health-related quality of life (HRQOL), and ultimately earlier than expected death (1). Frailty is a significant health burden for patients with advanced CKD (2). The decline from fitness to frailty is influenced by an array of factors, such as sarcopenia, infection and inflammation, cognitive impairment, reduced physical exercise threshold, vitamin D deficiency, metabolic acidosis, and cellular senescence (2⇓⇓⇓⇓–7). Pathophysiologic processes inherent to CKD exacerbate this decline (2). Although the concept of frailty has received more attention in recent years within nephrology, there remain uncertainties as to how it should be best used to inform shared decision making around RRT, including transplantation. Research has been performed on frailty in solid organ (other than kidney) and stem cell transplantation. A recent consensus conference sponsored by the American Society of Transplantation concluded that the optimal methods by which frailty should be measured in each organ group are yet to be determined, and that interventions to reverse frailty vary among organ groups and appear promising if unproven (8). Frailty is generally well accepted as a predictor of short-term mortality with surgery (9) and after admission to critical care environments (10). One may wonder about the relevance of frailty in lung transplantation in what is perhaps the most vulnerable group of patients pre- and post-transplant. An earlier study suggested increased risk of death and delisting in lung transplant candidates living with frailty (11). We also know that frailty is common at discharge after lung transplantation (12). Somewhat surprisingly, frailty does not seem to correlate with length of hospital stay nor …

A randomized, controlled trial comparing the immunogenecity and safety of a 23‐valent pneumococcal polysaccharide vaccination to a repeated dose 13‐valent pneumococcal conjugate vaccination in kidney transplant recipients

The risk of invasive pneumococcal disease is significant among solid organ transplant (SOT) recipients. The optimal pneumococcal vaccination strategy for SOT patients is not known. The potential kidney transplant recipients in dialysis were randomized into two arms: to receive a 23-valent pneumococcal polysaccharide vaccine (PPV23) before transplantation or to receive a 13-valent pneumococcal conjugate vaccine (PCV13) before transplantation and a second dose of PCV13 six months after the transplantation. Serotype-specific antibody concentrations and opsonophagocytic activity (OPA) were measured before and after the first vaccination (visits V1,V2) and six and seven months after the transplantation, for example, before and after the second PCV13 (visits V3,V4). Out of 133 participants, 48 (PCV13 arm) and 46 (PPV23 arm) received a kidney transplant, and 37+37 in both arms completed the study. After the first vaccination, the geometric mean concentrations (GMCs) in the PCV13 arm were significantly higher for 9/13 serotypes and the OPA geometric mean titers (GMTs) were significantly higher for 4/13 serotypes. At V3, the antibody levels had declined but OPA remained significantly higher for 7/13 (PCV13) vs 4/13 (PPV23) serotypes. At V4, the GMCs for 9/13 serotypes and the GMTs for 12/13 serotypes were significantly higher in the PCV13 arm. The GMCs but not GMTs were lower than at V2. There was no difference in adverse effects. No vaccine-related allograft rejection was detected. The immunogenicity of PCV13 was better in dialysis patients, and revaccination with PCV13 was immunogenic and safe.

Malignancy Prevalence in Waitlisted Potential Kidney Transplant Recipients Is Very Low Relative to Patients After Kidney Transplantation

Kidney transplantation improves quality of life, prolongs survival, and is cost-effective, but bears some serious complications including malignancy.The aim of this study was to assess the prevalence of malignancy in dialyzed patients on the waiting list and in kidney allograft recipients.The cross-sectional study was conducted in 50 prevalent patients on the waiting list and 300 kidney allograft recipients. Patients who had been registered in the cadaver kidney waiting list and kidney allograft recipients did not differ in regard to age, sex, dialysis vintage, and causes of end-stage renal failure. In waitlisted patients, only 3 had a history of malignancy. In kidney allograft recipients, 52 patients developed malignancy. The leading malignancy was skin cancer with 9 cases, followed by post-transplant lymphoproliferative disorder in 5 cases, Kaposi sarcoma in 2 cases, brain cancer in 2 cases, Merkel carcinoma in 2 cases, lung cancer (small cell and non--small cell), unknown origin in 2 cases, and the other 22 malignancies were in single patients (including 1 leukemia and 1 multiple myeloma). Seventeen deaths were recorded in kidney allograft recipients with malignancy mainly in post-transplant lymphoproliferative disorder, Kaposi sarcoma, Merkel carcinoma, sarcoma, and brain cancer.Concluding, waitlisted patients represent a very selected and healthier dialyzed population. Guidelines for cancer screening in both potential transplant recipients and kidney allograft recipients should be developed as nowadays a scarcity of data exists in this matter. Minimization of immunosuppressive regimen should be considered, in particular, in high-risk patients.