Rate Of Graft Loss Research Articles

Renal allograft torsion, is sirolimus a culprit– Case series and review of literature

BackgroundTorsion is defined as rotation of allograft around its renal pedicle. It is a rare complication with high rate of graft loss. The nonspecific presentation and inability to provide definitive diagnosis by imaging in cases of partial torsion may delay the diagnosis and treatment. MethodsWe present two patients who were diagnosed with kidney allograft torsion (KAT) and underwent surgical exploration with varying outcomes. We also included the review of literature on KAT, highlighting the clinical presentation, investigation modality, intervention, and outcome. We identified reports of KAT in PubMed and Cochrane from 1990 through January 2021. Results22 manuscripts with 30 intraperitoneal and 6 extraperitoneal cases of KAT were identified. Most common presenting symptom was oliguria/anuria (11 cases) and abdomen pain (11 cases). Acute kidney injury was reported in almost all cases. Diagnosis of KAT by imaging was diagnosed in 7 cases before exploration. Surgical exploration led to graft salvage in 25 (69.4%) of cases and immediate transplant nephrectomy was performed in 11 (30.5%) of cases. Recurrence was documented in 3 cases and none of them had recurrence after surgical intervention ConclusionRenal torsion presents with various non-specific symptoms that could often be misdiagnosed. Since early suspicion and diagnosis is critical to prompt therapy and better graft outcome, including KAT as a possible cause of allograft dysfunction of unclear etiology particularly in patients with intraperitoneally placed allograft and sirolimus use, will be crucial.

Impact of delayed graft function on clinical outcomes in highly sensitized patients after deceased-donor kidney transplantation.

BackgroundWe investigated whether the development of delayed graft function (DGF) in pre-sensitized patients affects the clinical outcomes after deceased-donor kidney transplantation (DDKT).MethodsThe study included 709 kidney transplant recipients (KTRs) from three transplant centers. We divided KTRs into four subgroups (highly sensitized DGF, highly sensitized non-DGF, low-sensitized DGF, and low-sensitized non-DGF) according to panel reactive antibody level of 50%, or DGF development. We compared post-transplant clinical outcomes among the four subgroups.ResultsIncidence of biopsy-proven acute rejection (BPAR) was higher in two highly sensitized subgroups than in low-sensitized subgroups. It tended to be higher in highly sensitized DGF subgroups than in the highly sensitized non-DGF subgroups. In addition, the highly sensitized DGF subgroup showed the highest risk for BPAR (hazard ratio, 3.051; P=0.005) and independently predicted BPAR. Allograft function was lower in the two DGF subgroups than in the non-DGF subgroup until one month after transplantation, but thereafter it was similar. Death-censored graft loss rates and patient mortality tended to be low when DGF developed, but it did not reach statistical significance.ConclusionsDGF development in highly sensitized patients increases the risk for BPAR in DDKT compared with patients without DGF, suggesting the need for strict monitoring and management of such cases.

Factors associated with graft survival in South African adolescent renal transplant patients at CMJAH over a 20-year period (GRAFT-SAT Study).

In the developed world, studies on transition of adolescent renal transplant patients have noted high rates of rejection, non-adherence and graft loss. There is a paucity of data in developing countries and none from South Africa. We evaluated patient and graft outcomes during adolescence (10-19years), of patients who received a renal transplant over a 20-year period (1990-2010), at a tertiary hospital in Johannesburg. Cox proportional hazards models and Kaplan-Meier curves were used to analyse graft and patient survival. A total of 213kidney transplants were done in 162 patients during the study period, 165 transplants occurred during the adolescent period. Factors associated with graft failure on multivariate analysis included non-white race, transplant during the adolescent period ([aHR] 3.94; 95% [CI], 2.25-6.91), non-compliance with follow-up (aHR 3.89; 95% CI, 1.76-8.60) and receipt of a DD graft (aHR 2.10; 95% CI, 1.27-3.48). Patient survival rates at 1-, 3-, 5- and 10-years were 98.8%, 97.6%, 95.1% and 93.9% respectively. High rates of graft rejection and loss occurred in South African renal transplant recipients in the adolescent period, especially in those retained in paediatric care. Establishment of transition clinics may improve the graft outcomes of this vulnerable group and warrant further research.

Recurrent Renal Allograft Torsion After Simultaneous Kidney and Pancreas Transplantation: Is it Still Possible to Salvage the Graft? A Case Report

Kidney allograft torsion (KAT) is defined as a rotation of the renal allograft around its vascular pedicle. It is a rare complication with high rate of graft loss. The nonspecific presentation and inability to provide a definitive diagnosis by imaging, mainly in cases of partial torsion, often delay the diagnosis and treatment. We report a case of recurrent complete torsion of the renal allograft after simultaneous kidney and pancreas transplantation, requiring 2 emergency exploratory laparotomies. A 38-year-old woman with a history of intraperitoneal simultaneous kidney and pancreas transplantation underwent 2 separate emergency exploratory laparotomies secondary to complete renal allograft torsion, respectively, 7 and 11 months after the transplant. In both episodes, no adhesions were encountered. During the first operation, nephropexy was performed. During the second operation, an abdominal wall mesh was placed and fixed to the abdominal wall. Acute kidney injury related to KAT recovered in both occasions with a creatinine of 1.3 mg/dL at 4 months follow-up. Renal torsion always should be suspected in intraperitoneally placed kidneys presenting with nonspecific symptoms, abdominal pain, oliguria, and worsening kidney function. Surgical exploration should be considered to salvage the renal graft. This case illustrates the reversibility of a severe injury related to this vascular complication with an adequate return to baseline kidney function even when diagnosis and surgical treatment of KAT might be delayed secondary to its misleading clinical presentation.

Comparison of standard versus low-dose valganciclovir regimens for cytomegalovirus prophylaxis in high-risk liver transplant recipients.

The purpose of this study was to compare the safety and efficacy of two valganciclovir (VGCV) institutional dosing protocols for cytomegalovirus (CMV) prophylaxis in liver transplant (LT) recipients with CMV serotype donor +/recipient- (D+/R-). This was a single-center review of CMV D+/R- adult LT recipients who received VGCV 450mg/day for 90 days (low-dose) or VGCV 900mg/day for 180 days (standard-dose). The primary outcome was incidence of CMV disease at 1 year. Secondary outcomes included rates of CMV syndrome, end-organ disease, breakthrough infection, and resistance. Neutropenia, early discontinuation of VGCV, growth colony stimulating factors use (G-CSF), biopsy-proven rejection (BPAR), graft loss, and death at 1 year were analyzed. Ninety-six CMV D+/R- LT recipients were included. Although no difference in CMV disease was observed (low-dose 26%vs. standard-dose 23%, p=0.71), 75% of CMV infections in the low-dose group presented with end-organ disease. Ganciclovir (GCV) resistance was observed only in the low-dose group (n=2). Significantly more patients in the standard-dose group developed neutropenia (low-dose 10%vs 60% standard-dose, p<0.001). In the standard-dose group, 29% required early discontinuation of VGCV (vs. 5% in the low-dose group, p<0.001), and 20% were treated with G-CSF. Both cohorts had similar rates of BPAR, graft loss, and death at 1 year. VGCV 900mg/day for 180 days had higher rates of hematologic adverse effects resulting in frequent treatment interruptions. However, the occurrence of two cases of GCV-resistant CMV disease raises concerns about routinely using low-dose VGCV prophylaxis.

Impact of risk-stratified mycophenolate dosing in heart transplantation.

Mycophenolate mofetil (MMF), the prodrug of mycophenolic acid, is a highly effective immunosuppressive agent in heart transplant therapy. While the FDA approved dose is 1500 mg twice daily, dosing is often reduced due to dose-dependent adverse effects. However, empiric MMF dose reductions may lead to sub-therapeutic dosing and impair clinical outcomes. Our single center protocolized a risk-stratified approach based on age and weight to dose 500 mg twice daily or 1000 mg twice daily to patients after heart transplantation. This retrospective single-center study analyzed 140 consecutive heart transplant patients who were initiated on our risk-stratified MMF protocol post-transplant. The analysis revealed that the composite rate of biopsy-proven rejection, graft loss, or mortality at 1-year post-transplantation was similar between the two groups. Incidence of neutropenia, thrombocytopenia, infection, cardiac allograft vasculopathy, or acute kidney injury by 1-year also showed similar results between the two groups. Risk-stratification of MMF dosing appears to be a safe and effective strategy after heart transplantation.

Pancreas transplant with enteric drainage at a single institute in Asia

This study is to assess immunological and graft survival outcomes after pancreas transplant at a single institute in Asia. Patients undergoing pancreas transplant with enteric drainage were included. Clinical data and outcomes were evaluated and compared between each subgroup. There were 165 cases of pancreas transplant, including 38 (23%) simultaneous pancreas-kidney transplant (SPK), 24 (15%) pancreas after kidney transplant (PAK), 75 (46%) pancreas transplant alone (PTA), and 28 (17%) pancreas before kidney transplant (PBK). The overall surgical complication rate was 46.1%, with highest (62.5%) in PAK and lowest (32.0%) in PTA, P=0.008. The late complications included 32.7% infection and 3.6% malignancy. Overall rejection of pancreas graft was 24.8% including 18.2% acute and 9.7% chronic rejection. Rejection was highest in PTA group (36.0%) and lowest in PBK (3.6%). There were 56 cases (33.9%) with graft loss in total, with highest graft loss rate in PTA (38.7%). The 1-year, 5-year and 10-year pancreas graft survivals for total patients were 98.0%, 87.7% and 70.9% respectively. Enteric drainage in pancreas transplant could be applied safely not only in SPK but also in other subgroups. Enteric drainage itself would not compromise the immunological and graft survival outcomes.

Transplantation of kidneys after normothermic perfusion: A single center experience.

In order to expand the pool of usable donors from circulatory death (DCD) there is increasing interest in normothermic regional perfusion (NRP) to assess and improve liver viability.1,2 NRP may also improve outcomes in kidney transplantation.We present our single center experience of outcomes in imported kidneys following NRP. Data was obtained from a prospectively maintained database between December 2012 and September 2018. Primary endpoints were incidence of delayed graft function (DGF) and estimated glomerular filtration rate (eGFR). Six-hundred and thirty-two decease donor kidneys were transplanted, 229 from DCD donors, 29 of which had NRP. The DGF rate was lower for NRP versus DCD (six of 29, 20.7% vs. 70 of 200, 35.0%) with reduced duration of DGF. Multivariate analysis demonstrated transplant type to be a statistically significant independent predictor of eGFR at 7 and 14 days. Early transplant function in NRP kidneys was comparable to DBD. There were no graft losses within 30 days in the NRP group. One-year graft loss rate was 3.4% for NRP and 6.0% for standard DCD. This data suggests NRP is safe, and reduces rates of DGF and improves early renal transplant function.

Simultaneous heart-kidney transplantation results in respectable long-term outcome but a high rate of early kidney graft loss in high-risk recipients \u2013 a European single center analysis

BackgroundIn spite of renal graft shortage and increasing waiting times for transplant candidates, simultaneous heart and kidney transplantation (HKTx) is an increasingly performed procedure established for patients with combined end-stage cardiac and renal failure. Although data on renal graft outcome in this setting is limited, reports on reduced graft survival in comparison to solitary kidney transplantation (KTx) have led to an ongoing discussion of adequate organ utilization.MethodsThis retrospective study was conducted to evaluate prognostic factors and outcomes of 27 patients undergoing HKTx in comparison to a matched cohort of 27 patients undergoing solitary KTx between September 1987 and October 2019 in one of Europe’s largest transplant centers.ResultsMedian follow-up was 100.33 (0.46–362.09) months. Despite lower five-year kidney graft survival (62.6% versus 92.1%; 111.73 versus 183.08 months; p = 0.189), graft function and patient survival (138.90 versus 192.71 months; p = 0.128) were not significantly inferior after HKTx in general. However, in case of prior cardiac surgery requiring sternotomy we observed significantly reduced early graft and patient survival (57.00 and 94.09 months, respectively) when compared to patients undergoing solitary KTx (183.08 and 192.71 months; p < 0.001, respectively) or HKTx without prior cardiac surgery (203.22 and 203.22 months; p = 0.016 and p = 0.019, respectively), most probably explained by the significantly increased rate of primary nonfunction (33.3%) and in-hospital mortality (25.0%).ConclusionsOur data demonstrates the increased rate of early kidney graft loss and thus significantly inferior graft survival in high-risk patients undergoing HKTx. Thus, we advocate for a “kidney-after-heart” program in such patients to ensure responsible and reasonable utilization of scarce resources in times of ongoing organ shortage crisis.

Post-transplant allograft outcomes according to mismatch between donor kidney volume and body size of recipients with pre-transplant diabetes mellitus

AimsThe aim of this study was to investigate allograft outcomes when relatively small kidneys were donated to patients with pre-transplant diabetes mellitus (DM). MethodsFrom January 2010 to December 2018, 788 cases of non-sensitized living donor kidney transplant recipient and donor pairs were enrolled. The subjects were divided into four groups according to the relative size of kidney and pre-transplant DM status: non-DM large kidney, non-DM small kidney, DM large kidney, and DM small kidney. We compared allograft outcomes between these four groups. ResultsThe four groups did not show differences in the development of de novo donor-specific antibody and acute rejection. However, a significantly greater decline of allograft function and increased proteinuria were observed in the DM small kidney group. The highest death-censored graft loss rate (P = 0.008) was also observed in this group and the combination of relatively small kidney size and pre-transplant DM was an independent risk factor for death-censored graft loss. In addition, the relatively small kidney and pre-transplant DM showed significant interaction with each other. ConclusionsThe size mismatch between donated kidney volume and recipient body size should be considered in donor selection of patients with pre-transplant DM.

Evolution of Monoclonal Gammopathy of Undetermined Significance in Kidney Transplant Recipients at the CHUM (Centre Hospitalier de l'Université de Montréal) — a Single-Institution Retrospective Study

IntroductionRecommendations guiding the care of patients with monoclonal gammopathy of undetermined significance (MGUS) in the setting of kidney transplant are scarce. Nevertheless, monoclonal gammopathies carry a risk of neoplastic progression to hematologic malignancies and may induce renal injury from their deposition in the kidney (monoclonal gammopathy of renal significance - MGRS). However, it remains largely uncertain if these considerations translate into adverse outcomes in the setting of transplantation, as immunosuppression might favor malignant evolution of MGUS or, alternatively, a nephrotoxic paraprotein could lead to graft loss.MethodsWe conducted a retrospective review of the medical records of patients who received a kidney transplant at our institution between Jan 1, 2000 and Jan 1, 2016. We included patients with at least one available serum protein electrophoresis at any time before or after transplantation. Exclusion criteria consisted of age < 18 years at the time of transplant, no follow-up at our center, multiorgan transplant (liver, lung, pancreas, heart), as well as first transplant prior to study period or presence of any plasma cell malignancy before transplant. Outcomes of interest included paraprotein evolution, appearance of hematologic malignancy, graft rejection and loss. Chi-square tests and Fischer's exact probability test for categorical data and Student's t test for continuous variables were used to assess statistical significance.ResultsOut of 1009 eligible transplant recipients, 755 patients were included in our study based on our inclusion and exclusion criteria. Thirteen patients were found to have MGUS prior to transplant and a monoclonal gammopathy appeared in 43 patients after transplant corresponding to a 5-year incidence rate of 2.7%. Median patient follow-up was 7.5 years. Of the patients with MGUS prior to transplant, 2 developed light chain deposition disease (LCDD) after a follow-up of 1 and 2 years and 2 evolved to smoldering multiple myeloma (SMM) at 1 month and 4 years post-transplant. Of the 43 patients who developed MGUS after transplant, 1 transformed into multiple myeloma (MM) 8 years later and 1 progressed to LCDD 2 months after transplant. None of the 6 patients who evolved to malignancy after transplantation had a systematic hematologic workup prior to allograft implantation questioning whether SMM or MGRS may have already been present before transplant. Figure 1 summarizes the evolution of monoclonal gammopathies in our study population. Of monoclonal gammopathies appearing after transplantation, most remained stable (n=26, 60%) and 9 (21%) were found to be transient. Median size was 0.76 g/L (range 0.1 - 21.6 g/L). Twenty-two (74%) were of IgG isotype and an abnormal kappa/lambda ratio was present in 6 cases (14%). We conducted a univariate analysis to compare allograft outcomes between patients who developed post-transplant MGUS (n=43) and patients who did not (n=699). No differences in induction immunosuppression, occurrence of graft loss (18% and 11%, p=0.14) and acute rejection rates (26% and 27%, p=0.866) were observed between these two groups, respectively. However, the former were found to have an increased risk of CMV (26% and 12%, p=0.01) and polyoma BK virus (26% and 14%, p=0.04). Of note, 7 cases of post-transplant lymphoproliferative disorder (PTLD) were identified in our study population and none was preceded by MGUS.ConclusionOur study suggests a reassuring evolution of true MGUS in the setting of renal transplantation. Indeed, the cases of plasma cell malignancies diagnosed in transplant recipients may have already been present before transplant, yet undetected from lack of systematic investigation. We therefore highlight the importance of identifying and diligently investigating monoclonal immunoglobulins in transplant candidates. If a paraprotein is found before transplant, further investigations with bone marrow biopsy and review of native kidney biopsy appear warranted in order to identify cases of plasma cell dyscrasias (such as SMM) and MGRS prior to transplant. Additionally, MGUS arising after transplant appear to carry a favorable evolution. They also tend to be transient and their appearance may be related to prior CMV and BK virus infections. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

US deceased kidney transplantation: Estimated GFR, donor age and KDPI association with graft survival.

BackgroundDespite a significant shortage of kidneys for transplantation in the US, kidneys from older deceased donors are infrequently transplanted. This is primarily over concern of graft quality and transplant durability.MethodsThe US national transplant database (2000–2018) was assessed for deceased donor kidney transplant patient and graft survival, graft durability and stratified by donor age (<65 years>), Kidney Donor Profile Index (KDPI) and estimated glomerual filtration rate (GFR) one year post-transplantation (eGFR-1) were calculated.FindingsRecipients of kidneys transplanted from deceased donors >65 years had a lower eGFR-1, (median 39 ml/min) than recipients of younger donor kidneys (median 54 ml/min). However, death-censored graft survival, stratified by eGFR-1, demonstrated similar survival, irrespective of donor age or KDPI. The durability of kidney survival decreases as the achieved eGFR-1 declines. KDPI has a poor association with eGFR-1 and lesser for graft durability. While recipients of kidneys > 65 years had a higher one year mortality than younger kidney recipients, recipients of kidneys > 65 years and an eGFR-1 <30 ml/min, had a lower survival than an untransplanted waitlist cohort (p<0.001).InterpretationThe durability of kidney graft survival after transplantation was associated with the amount of kidney function gained through the transplant (eGFR-1) and the rate of graft loss (return to dialysis) was not significantly associated with donor age. 24.9% of recipients of older donor kidneys failed to achieve sufficient eGFR-1 providing a transplant survival benefit. While there is significant benefit from transplanting older kidneys, better decision-making tools are required to avoid transplanting kidneys that provide insufficient renal function.FundingNone.

MO927IMPACT OF DONOR AGE ON LIVING DONOR KIDNEY TRANSPLANTATION

Abstract Background and Aims Although elderly living donors are recognized as a marginal donor for kidney transplantation, the number of elderly living donors are increasing because of insufficiency. We investigated the impact of donor age on living donor kidney transplantation. Method A total 858 adult living donor kidney transplantation (LDKT) between January 2008 and December 2018 was included in this study and followed up until September 2020. LDKTs were stratified into 3 groups according to the donor age; 157 LDKTs from donors aged 30 – 49, 592 LDKTs from donors aged 50 – 69, and 109 LDKTs from donors aged 70 – 89. To investigate the impact of donor age on living donors, postoperative estimated glomerular filtration rates (eGFR), mortality rate and incidence of end stage renal disease were compared between 3 donor age groups. To investigate the impact of donor age on recipients, postoperative eGFR was compared between 3 donor age groups and the risk factors of graft loss were analyzed using Cox regression hazard model. Results The eGFRs of donors demonstrated a decline with increased donor age and significant differences at all time points among 3 donor age groups. (Figure 1) Mortality rate and incidence of end stage renal disease of donors were similar among 3 donor age groups. (Figure 2) The eGFRs of recipients demonstrated a decline with increased donor age and significant differences at all time points among 3 donor age groups. (Figure 3) Multivariate analysis using Cox regression hazard model demonstrated donor aged 70 – 89 as a significant risk of graft loss (P = 0.024, hazard ratio 3.053, 95% confidence interval 1.160 – 8.040). Conclusion The prognosis of living donors after donation were not affected by the donor age except for the lower eGFR with increased donor age. The eGFRs of recipients and graft loss rates were the worst in the recipients transplanted from donors aged 70 – 89.

Early Detection Strategy of BK Polyomavirus Nephropathy in Patients undergoing Renal Transplant: A Single-Center Retrospective Study

Introduction: BK polyoma virus nephropathy represents one of the non-immunological causes of renal graft loss with a cumulative incidence between 5 and 10 percent, and a graft loss rate on BK virus nephropathy patients that ranges from 30 to 90 percent depending on the nephropathy status at the time of diagnosis (1). Objective: To determine the outcomes regarding the kidney graft survival and kidney function of an early detection strategy for BK Polyomavirus nephropathy which is drawn upon urinary cytology in order to look for Decoy cells. Methodology: Descriptive, retrospective study type. Adult renal transplant recipients/patients from the Interdisciplinary Renal Transplant program of the Colombia University Clinic were included in a time period from 2012 to 2018, in whom monthly post-transplant monitoring with positive urinary cytology was performed. Results: 303 patients were transplanted in the program, 107 patients with positive urinary cytology were included, wherein, men predominated with 72% and 45 years old being the average age (IQR: 18–72). The cumulative incidence of polyomavirus nephropathy, under this early detection strategy, was 9.2%, thus preserving the graft survival at 24 months in a 100% of the patients with the management strategies employed. Conclusions: This early detection and monitoring study utilizing post-transplant urinary cytology proved to be useful for the early diagnosis of BK Polyomavirus nephropathy with a favorable impact on the graft livelihood.

Risk factors and consequences of delayed graft function in renal transplantation

Background/Aim: Delayed graft function (DGF) continues to be an important complication in patients who underwent kidney transplantation. Our study aimed to determine the rate of DGF and risk factors after renal transplantation at our center and explore DGF-related complications and outcomes. Methods: Patients over 18 years of age who underwent kidney transplantation between January 2015 and January 2020 were evaluated. DGF was defined as the need for at least one dialysis session within the first week after renal transplantation. The factors affecting DGF were analyzed as the primary outcome, and discharge and additional complications, as the secondary outcomes. Results: Data of 206 patients who underwent renal transplantation were analyzed, and delayed graft function (the need for at least one dialysis session within the first week after renal transplantation) was observed at a rate of 20.9%. A statistically significant relationship was observed between DGF and presence of diabetes mellitus, cadaver graft transplantation, higher cold ischemia time, need for postoperative erythrocyte suspension and fresh frozen plasma transfusion (P<0.05 for all). Graft loss was significantly higher in patients with DGF (P=0.001). Conclusion: After renal transplantation, delayed graft function continues to occur at a high rate. Prevention of delayed graft function development will reduce graft loss rates.

Impact of high body mass index on allograft outcomes in kidney transplant recipients with presensitization to human leukocyte antigen.

BackgroundThis study aimed to investigate whether high body mass index (BMI) and presensitization to human leukocyte antigen (HLA) in kidney transplant recipients (KTRs) affected allograft outcomes.MethodsFrom January 2010 to December 2018, 1,290 kidney transplantations (KTs) were performed at the Seoul St Mary’s Hospital. Of these, 682 cases of ABO-compatible living donor KT patients were enrolled. They were divided into four groups (low BMI-non-sensitized, high BMI-non-sensitized, low BMI-sensitized, and high BMI-sensitized) according to the median BMI value (22.7 kg/m2) and HLA presensitization status (anti-HLA antibody mean fluorescence intensity > 3,000). Short-term and long-term allograft outcomes were compared between groups.ResultsIn the high BMI-sensitized group, the decline in allograft function was higher than that in the other three groups. Death-censored graft loss (DCGL) rates were highest in the high BMI-sensitized group (4 of 21 [19.0%], p = 0.04). In the multivariable Cox regression hazard regression model analysis, the hazard ratio (HR) for DCGL was intensified when high BMI and presensitization statuses were combined (HR, 3.75; p = 0.03); these statuses significantly interacted with each other (p-value for interaction = 0.008).ConclusionOur results suggest that presensitization to HLA and high BMI might have an interactive adverse impact on allograft outcomes in KTRs.

POS-520 EPIDEMIOLOGY OF KIDNEY TRANSPLANTS IN KAZAKHSTAN: DATA FROM UNIFIED NATIONAL ELECTRONIC HEALTH SYSTEM 2014-2018

The epidemiology of kidney transplant recipients (KTR) in Kazakhstan, nationally haven not previously been evaluated. We examined the prevalence, incidence, patient and renal graft survival rates of KTR using a large-scale administrative healthcare data from the Unified National Electronic Health System (UNEHS) for 2014-2018. Data of 1,142 KTR registered between 2014-2018 years were extracted from the UNEHS encompassing available retrospective records starting from 2009. Data included date of birth, sex, ethnicity, address by region, date of kidney transplantation (KT), donor source (deceased or living) and date of first dialysis after KT (considered as a graft lost). Descriptive statistics of demographic, epidemiology and transplant related outcome characteristics were provided. There was a predominance of male recipients (63.3%), of Kazakh ethnicity (79.5%), of urban residents (79.5%) and of living donors KT (92.5%). The crude all-cause mortality rate was 11.5 per 1000 patient-years (PY) (95%CI: 8.8-15.0) (Table 1). Tabled 1VariableN=1142 (%)Mortality rate per 1000 PY [95% CI]Gender: FemaleMale419 (36.7%)723 (63.3%)6.25 [3.46-11.27]14.55 [10.83-19.55]Age groups:<1818-3435-50>5185 (7.4%)508 (44.5%)381 (33.4%)168 (14.7%)8.3 [2.7 -25.6]6.3 [3.8 -10.7]15.6 [10.5 -23.3]20.7 [12.3 -35.0]Ethnicity:KazakhRussianOthers908 (79.5%) 91 (8.0%)143 (12.5%)11.2 [8.2 - 15.1]15.9 [7.1 - 35.4]10.9 [5.2 - 22.9]Residency:RuralUrban250 (21.8%)892 (78.2%)16.0 [9.5 - 27.0]10.8 [7.9 - 14.6]Donor source:DeceasedLiving86 (7.5%)1,056 (92.5%)28.4 [15.3-52.8]10.2 [7.6-13.6] Open table in a new tab The median follow-up time was 3.59 (Interquartile range (IQR) 2.27- 5.22) years. The prevalent and incident cases, and the rate of graft loss for the period 2014-2018 are present in Figure 1. Males had 2.3-fold higher risk of death (Hazard ratio (HR): 2.30 [95%CI: 1.19-4.4], p=0.008) compared with females (Figure 2a), while KTR of living donors had 65% lower risk of death (HR: 0.35 [95%CI: 0.18-0.71], p=0.009) compared with KTR from cadaveric donations (Figure 2b).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The median graft survival time during the follow-up period was 2.12 (IQR 0.96-3.47) years. In life-table analysis (Figure 3) the 1-, 5-, and 10-year cumulative survival probability of KTR were 98.5% (95%CI: 97.5-99.0), 94.3% (95%CI: 92.4-95.7) and 92% (95%CI: 88.1-94.6) respectively. At the end of 1-, 5- and 10-years the cumulative death-censored graft survival were 80.8% (95%CI: 78.3-83.0), 27.9% (95%CI: 24.6-31.3) and 10% (95%CI: 7.4-13.1) respectively (Figure 3). For the first time in Kazakhstan, we analyzed and described data of kidney transplant patients utilizing a large-scale records from UNEHS. We observed decrease in the annual number of kidney transplantations starting from 2017 with overall extremely low rate of transplantations from deceased donors. The male recipients and cadaveric graft had statistically significant higher mortality rates. Although the patient survival rate was comparable with other countries, the rate of graft loss remained high. This information is of great consequence to the national public health authorities involved in planning of renal replacement therapies, considering the increasing number of patients who need dialysis or returned to dialysis after the graft failure. Further healthcare and organizational efforts are needed to improve the graft survival and to increase the number of deceases donor transplants.

57 Safety and Cost Effectiveness of Outpatient Surgery in Acute Burn Care

Abstract Introduction Outpatient burn surgery is increasingly utilized for delivery of acute burn care. Reports of its safety and efficacy are limited. The purpose of our study was to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our centre’s experience. Methods This was a single centre, retrospective cohort study of consecutive patients who underwent outpatient acute burn surgery requiring split thickness skin graft or dermal regenerative template from January 2010 - December 2018. Patients with insufficient follow up to evaluate operative site healing were excluded. Patient demographics, comorbidities, burn etiologies, operative data and postoperative care were reviewed. The primary outcome is complication involving major graft loss requiring reoperation. Results 165 patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. The number of annual outpatient procedures increased 48% from 23 to 34 cases over the 9-year period. The mean grafted total body surface area was 1.0 ± 0.9%. Rate of major graft loss requiring reoperation was 5.2% (9/172). Greater than 95% graft take was achieved in 80.9% of patients. Age, sex, co-morbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rate. Outpatient burn surgery model was estimated to save CA$7,875 per patient from inpatient costs. This extrapolates to a total of over CA$1.36 million in savings over the 9-year study period. Conclusions Acute burn care at our centre is increasingly being delivered through an outpatient day surgery model. Our demonstration of its safety and considerable cost savings is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

POS-711 GRAFT FUNCTION AND ACUTE REJECTION AFTER G-CSF USE IN KIDNEY TRANSPLANT PATIENTS: A RETROSPECTIVE COHORT STUDY

Neutropenia is a commonly seen complication following kidney transplantation1,2 and is often managed with granulocyte colony-stimulating factor (G-CSF) which stimulates white blood cell (WBC) proliferation. Published data on solid organ graft outcomes following G-CSF treatment is limited and reports on the rates of graft rejection following treatment are contradictory2-5. The records of 310 consecutive kidney-only transplants between 2011 and 2019 were examined. From this a cohort of patients who received G-CSF for neutropenia was identified and matched 1:1 with patients from the same era who did not receive G-CSF. Variables including donor type, HLA mismatch, CMV status, induction agent and immunosuppressive regimen were matched as closely as possible. Outcome data was recorded including eGFR at 12 and 18 months post-transplantation, episodes of rejection at 12 and 18 months (biopsy-proven), graft loss at 12 and 18 months, or death. Fifty-two patients were included in the analysis, with twenty-six patients in each group (G-CSF vs. non G-CSF). Median eGFR in the G-CSF group was 42mL/min/1.73 m2 vs 51mL/min/1.73 m2 in the non G-CSF group at 12 months (p=0.25) and 42mL/min/1.73 m2 vs 48 mL/min/1.73 m2 at 18 months (p=0.33). There were 2/26 patients who had an episode of rejection in the G-CSF group vs 6/26 patients with an episode of rejection in the non G-CSF group at 12 months (p=0.24), and 2/26 patients with an episode of rejection vs 8/26 patients with an episode of rejection at 18 months (p=0.08). In the G-CSF group 1/26 patient had graft loss vs 2/26 patients in the non G-CSF group at 12 months (p=0.55), and 1/26 graft losses vs 2/26 graft losses at 18 months (p=0.55). 1 patient in each group died due to unrelated causes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) In this small cohort of patients, treatment with G-CSF was not associated with any significant increase in rates of rejection or graft loss, with comparable graft function at 12 and 18 months. While other studies have had relatively short periods of follow up and no comparator, this study is strengthened by its long follow-up and the presence of a control group. Nonetheless, while these results are reassuring, larger prospective studies are needed in order to provide greater certainty that there is no association between G-CSF use and rates of acute rejection in kidney transplant recipients.

POS-685 STRUCTURE OF RENAL REPLACEMENT THERAPY IN THE KINGDOM OF SAUDI ARABIA

Renal replacement therapy (RRT) is the mainstay in the clinical management and treatment of patients with chronic renal disease and end-stage renal disease (ESRD) aimed to support, maintain and improved the quality of life and may even decreased the mortality of patients having the disease, and with the increasing demand on renal replacement therapy in Kingdom it is imperative to improve the facilities, patient quality care and even types of RRT in the Kingdom. A review of renal replacement therapy in the Kingdom of Saudi Arabia published by Saudi Center for Organ Transplantation (SCOT) data in 2019; based on the cross-sectional study of annual questionnaires from all the dialysis centers in the Kingdom and annual post-transplantation follow-up from the accredited renal transplant centers in KSA. Renal replacement therapy (RRT) in the Kingdom were composed of 3 modalities: hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KTx). In 2019, a total of 28,256 patients were on RRT with 19,522 patients on HD, 1,546 on PD and, 7,188 patients with post-renal transplant follow-up. The prevalence and incidence rate of patients on dialysis were 631 and 142 per million population (PMP) respectively. Mortality rate on patients on dialysis were 8.2% this year. Kidney transplantation from deceased and living donors was the highest kidney transplants performed with a total of 1,121 kidneys transplanted, 140 (12%) from deceased and 981 (88%) kidneys from living donation making the Saudi Arabia the 2nd highest kidney transplant from living donor rate worldwide 29.37 pmp and 3rd highest living organ donors rate worldwide with 36.59 pmp (IRODAT: 2019). Graft loss and mortality rate on the same year were also recorded on living kidney recipients with 6 (0.6%) recipients loss their graft and 2 (0.2%) recipients died on the same year, while recipients from deceased donors, graft loss were 4 (2.8%) and a mortality rate were 2 (1.4%). Renal replacement therapy is the cornerstone in clinical management of patients with end-stage renal disease. Hemodialysis is the most common modality of renal replacement therapy providing greater convenience and accessibility, followed by peritoneal dialysis which needs to be encouraged, other modality such as home hemodialysis should be explored and considered. While, the Kingdom has reached a milestone in kidney transplantation making it one of the highest living organ donors rate worldwide, Saudi Arabia is still working on to improve its deceased organ donation which has a great potential in buffering the increasing demand of kidney transplant. Mortality rate post-renal transplant at one year was also considerably low with 4 deaths (0.3%) from both living and deceased kidney transplant at the same year.