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Durand CM, Halpern SE, Bowring MG, Bismut GA, Kusemiju OT, Doby B, Fernandez RE, Kirby CS, Ostrander D, Stock PG, Mehta SG, Turgeon NA, Wojciechowski D, Huprikar S, Florman S, Ottmann S, Desai NM, Cameron A, Massie AB, Tobian AA, Redd AD, Segev DL. Organs from deceased donors with false-positive HIV screening tests: An unexpected benefit of the HOPE act. Am J Transplant 2018; 18:2579-2586. [PMID: 29947471 PMCID: PMC6160348 DOI: 10.1111/ajt.14993] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 01/25/2023]
Abstract
Organs from deceased donors with suspected false-positive HIV screening tests were generally discarded due to the chance that the test was truly positive. However, the HIV Organ Policy Equity (HOPE) Act now facilitates use of such organs for transplantation to HIV-infected (HIV+) individuals. In the HOPE in Action trial, donors without a known HIV infection who unexpectedly tested positive for anti-HIV antibody (Ab) or HIV nucleic acid test (NAT) were classified as suspected false-positive donors. Between March 2016 and March 2018, 10 suspected false-positive donors had organs recovered for transplant for 21 HIV + recipients (14 single-kidney, 1 double-kidney, 5 liver, 1 simultaneous liver-kidney). Median donor age was 24 years; cause of death was trauma (n = 5), stroke (n = 4), and anoxia (n = 1); three donors were labeled Public Health Service increased infectious risk. Median kidney donor profile index was 30.5 (IQR 22-58). Eight donors were HIV Ab+/NAT-; two were HIV Ab-/NAT+. All 10 suspected false-positive donors were confirmed to be HIV-noninfected. Given the false-positive rates of approved assays used to screen > 20 000 deceased donors annually, we estimate 50-100 HIV false-positive donors per year. Organ transplantation from suspected HIV false-positive donors is an unexpected benefit of the HOPE Act that provides another novel organ source.
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Konel JM, Warsame F, Ying H, Haugen CE, Mountford A, Chu NM, Crews DC, Desai NM, Garonzik-Wang JM, Walston JD, Norman SP, Segev DL, McAdams-DeMarco MA. Depressive symptoms, frailty, and adverse outcomes among kidney transplant recipients. Clin Transplant 2018; 32:e13391. [PMID: 30152107 DOI: 10.1111/ctr.13391] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 12/30/2022]
Abstract
Depressive symptoms and frailty are each independently associated with morbidity and mortality in kidney transplant (KT) recipients. We hypothesized that having both depressive symptoms and frailty would be synergistic and worse than the independent effect of each. In a multicenter cohort study of 773 KT recipients, we measured the Fried frailty phenotype and the modified 18-question Center for Epidemiologic Studies-Depression Scale (CES-D). Using adjusted Poisson regression and survival analysis, we tested whether depressive symptoms (CES-D score > 14) and frailty were associated with KT length of stay (LOS), death-censored graft failure (DCGF), and mortality. At KT admission, 10.0% of patients exhibited depressive symptoms, 16.3% were frail, and 3.6% had both. Recipients with depressive symptoms were more likely to be frail (aOR = 3.97, 95% CI: 2.28-6.91, P < 0.001). Recipients with both depressive symptoms and frailty had a 1.88 times (95% CI: 1.70-2.08, P < 0.001) longer LOS, 6.20-fold (95% CI:1.67-22.95, P < 0.01) increased risk of DCGF, and 2.62-fold (95% CI:1.03-6.70, P = 0.04) increased risk of mortality, compared to those who were nonfrail and without depressive symptoms. There was only evidence of synergistic effect of frailty and depressive symptoms on length of stay (P for interaction < 0.001). Interventions aimed at reducing pre-KT depressive symptoms and frailty should be explored for their impact on post-KT outcomes.
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Durand CM, Bowring MG, Thomas AG, Kucirka LM, Massie AB, Cameron A, Desai NM, Sulkowski M, Segev DL. The Drug Overdose Epidemic and Deceased-Donor Transplantation in the United States: A National Registry Study. Ann Intern Med 2018; 168:702-711. [PMID: 29710288 PMCID: PMC6205229 DOI: 10.7326/m17-2451] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The epidemic of drug overdose deaths in the United States has led to an increase in organ donors. OBJECTIVE To characterize donors who died of overdose and to analyze outcomes among transplant recipients. DESIGN Prospective observational cohort study. SETTING Scientific Registry of Transplant Recipients, 1 January 2000 to 1 September 2017. PARTICIPANTS 138 565 deceased donors; 337 934 transplant recipients at 297 transplant centers. MEASUREMENTS The primary exposure was donor mechanism of death (overdose-death donor [ODD], trauma-death donor [TDD], or medical-death donor [MDD]). Patient and graft survival and organ discard (organ recovered but not transplanted) were compared using propensity score-weighted standardized risk differences (sRDs). RESULTS A total of 7313 ODDs and 19 897 ODD transplants (10 347 kidneys, 5707 livers, 2471 hearts, and 1372 lungs) were identified. Overdose-death donors accounted for 1.1% of donors in 2000 and 13.4% in 2017. They were more likely to be white (85.1%), aged 21 to 40 years (66.3%), infected with hepatitis C virus (HCV) (18.3%), and increased-infectious risk donors (IRDs) (56.4%). Standardized 5-year patient survival was similar for ODD organ recipients compared with TDD organ recipients (sRDs ranged from 3.1% lower to 3.9% higher survival) and MDD organ recipients (sRDs ranged from 2.1% to 5.2% higher survival). Standardized 5-year graft survival was similar between ODD and TDD grafts (minimal difference for kidneys and lungs, marginally lower [sRD, -3.2%] for livers, and marginally higher [sRD, 1.9%] for hearts). Kidney discard was higher for ODDs than TDDs (sRD, 5.2%) or MDDs (sRD, 1.5%); standardization for HCV and IRD status attenuated this difference. LIMITATION Inability to distinguish between opioid and nonopioid overdoses. CONCLUSION In the United States, transplantation with ODD organs has increased dramatically, with noninferior outcomes in transplant recipients. Concerns about IRD behaviors and hepatitis C among donors lead to excess discard that should be minimized given the current organ shortage. PRIMARY FUNDING SOURCE National Institutes of Health.
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Durand CM, Bowring MG, Brown DM, Chattergoon MA, Massaccesi G, Bair N, Wesson R, Reyad A, Naqvi FF, Ostrander D, Sugarman J, Segev DL, Sulkowski M, Desai NM. Direct-Acting Antiviral Prophylaxis in Kidney Transplantation From Hepatitis C Virus-Infected Donors to Noninfected Recipients: An Open-Label Nonrandomized Trial. Ann Intern Med 2018; 168:533-540. [PMID: 29507971 PMCID: PMC6108432 DOI: 10.7326/m17-2871] [Citation(s) in RCA: 232] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Given the high mortality rate for patients with end-stage kidney disease receiving dialysis and the efficacy and safety of hepatitis C virus (HCV) treatments, discarded kidneys from HCV-infected donors may be a neglected public health resource. OBJECTIVE To determine the tolerability and feasibility of using direct-acting antivirals (DAAs) as prophylaxis before and after kidney transplantation from HCV-infected donors to non-HCV-infected recipients (that is, HCV D+/R- transplantation). DESIGN Open-label nonrandomized trial. (ClinicalTrials.gov: NCT02781649). SETTING Single center. PARTICIPANTS 10 HCV D+/R- kidney transplant candidates older than 50 years with no available living donors. INTERVENTION Transplantation of kidneys from deceased donors aged 13 to 50 years with positive HCV RNA and HCV antibody test results. All recipients received a dose of grazoprevir (GZR), 100 mg, and elbasvir (EBR), 50 mg, immediately before transplantation. Recipients of kidneys from donors with genotype 1 infection continued receiving GZR-EBR for 12 weeks after transplantation; those receiving organs from donors with genotype 2 or 3 infection had sofosbuvir, 400 mg, added to GZR-EBR for 12 weeks of triple therapy. MEASUREMENTS The primary safety outcome was the incidence of adverse events related to GZR-EBR treatment. The primary efficacy outcome was the proportion of recipients with an HCV RNA level below the lower limit of quantification 12 weeks after prophylaxis. RESULTS Among 10 HCV D+/R- transplant recipients, no treatment-related adverse events occurred, and HCV RNA was not detected in any recipient 12 weeks after treatment. LIMITATION Nonrandomized study design and a small number of patients. CONCLUSION Pre- and posttransplantation HCV treatment was safe and prevented chronic HCV infection in HCV D+/R- kidney transplant recipients. If confirmed in larger studies, this strategy should markedly expand organ options and reduce mortality for kidney transplant candidates without HCV infection. PRIMARY FUNDING SOURCE Merck Sharp & Dohme.
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Fan CJ, Hirose K, Walsh CM, Quartuccio M, Desai NM, Singh VK, Kalyani RR, Warren DS, Sun Z, Hanna MN, Makary MA. Laparoscopic Total Pancreatectomy With Islet Autotransplantation and Intraoperative Islet Separation as a Treatment for Patients With Chronic Pancreatitis. JAMA Surg 2017; 152:550-556. [PMID: 28241234 DOI: 10.1001/jamasurg.2016.5707] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Pain management of patients with chronic pancreatitis (CP) can be challenging. Laparoscopy has been associated with markedly reduced postoperative pain but has not been widely applied to total pancreatectomy with islet autotransplantation (TPIAT). Objective To examine the feasibility of using laparoscopic TPIAT (L-TPIAT) in the treatment of CP. Design, Setting, and Participants Thirty-two patients with CP presented for TPIAT at a tertiary hospital from January 1, 2013, through December 31, 2015. Of the 22 patients who underwent L-TPIAT, 2 patients converted to an open procedure because of difficult anatomy and prior surgery. Pain and glycemic outcomes were recorded at follow-up visits every 3 to 6 months postoperatively. Main Outcomes and Measures Operative outcomes included operative time, islet isolation time, warm ischemia time, islet equivalent (IE) counts, estimated blood loss, fluid resuscitation, and blood transfusions. Postoperative outcomes included length of stay, all-cause 30-day readmission rate, postoperative complications, mortality rate, subjective pain measurements, opioid use, random C-peptide levels, insulin requirements, and glycated hemoglobin level. Results Of the 32 patients who presented for TPIAT, 20 underwent L-TPIAT (8 men and 12 women; mean [SD] age, 39 [13] years; age range, 21-58 years). Indication for surgery was CP attributable to genetic mutation (n = 9), idiopathic pancreatitis (n = 6), idiopathic pancreatitis with pancreas divisum (n = 3), and alcohol abuse (n = 2). Mean (SD) operative time was 493 (78) minutes, islet isolation time was 185 (37) minutes, and warm ischemia time was 51 (62) minutes. The mean (SD) IE count was 1325 (1093) IE/kg. The mean (SD) length of stay was 11 (5) days, and the all-cause 30-day readmission rate was 35% (7 of 20 patients). None of the patients experienced postoperative surgical site infection, hernia, or small-bowel obstruction, and none died. Eighteen patients (90%) had a decrease or complete resolution of pain, and 12 patients (60%) no longer required opioid therapy at a median follow-up period of 6 months. Postoperative random insulin C-peptide levels were detectable in 19 patients (95%) at a median follow-up of 10.4 months. At a median follow-up of 12.5 months, 5 patients (25%) were insulin independent, whereas 9 patients (45%) required 1 to 10 U/d, 5 patients (25%) required 11 to 20 U/d, and 1 patient (5%) required greater than 20 U/d of basal insulin. The mean (SD) glycated hemoglobin level was 7.4% (0.5%). Conclusions and Relevance This study represents the first series of L-TPIAT, demonstrating its safety and feasibility. Our approach enables patients to experience shorter operative times and the benefits of laparoscopy, including reduced length of stay and quicker opioid independence.
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Lonze BE, Bae S, Kraus ES, Holechek MJ, King KE, Alachkar N, Naqvi FF, Dagher NN, Sharif A, Desai NM, Segev DL, Montgomery RA. Outcomes and risk stratification for late antibody-mediated rejection in recipients of ABO-incompatible kidney transplants: a retrospective study. Transpl Int 2017; 30:874-883. [DOI: 10.1111/tri.12969] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/20/2016] [Accepted: 03/27/2017] [Indexed: 12/29/2022]
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Houp JA, Schillinger KP, Eckstein AJ, Vega RM, Desai NM, Lonze BE, Jackson AM. Casting a smaller net into a bigger donor pool: A single center's experience with the new kidney allocation system. Hum Immunol 2016; 78:49-53. [PMID: 27890719 DOI: 10.1016/j.humimm.2016.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/14/2016] [Accepted: 11/17/2016] [Indexed: 12/27/2022]
Abstract
The new kidney allocation system (KAS) provides additional allocation points for candidates with broad HLA sensitization in an effort to increase transplant rates for this underserved population. Following the implementation of KAS, our center lowered the HLA antibody threshold for listing unacceptable antigens from a cytotoxicity crossmatch level to a flow cytometric crossmatch level increasing Calculated Panel Reactive Antibody (CPRA) values and allocation points, yet restricting acceptable donor HLA phenotypes. As a result, many sensitized candidates were transitioned from 50% to 98% CPRA categories into the 99% CPRA regional share and 100% CPRA national share categories. Exposure to these larger donor pools significantly increased transplantation with compatible donors for 100% CPRA candidates, but regional sharing was not sufficient to increase transplantation rates for our 99% CPRA candidates. Competition within the 100% CPRA cohort identified inequities for 99.99-100.0% CPRA candidates and highlighted the continued need for desensitization therapies to reduce immunological barriers and provide transplant opportunities for the most highly sensitized candidates.
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Massie AB, Leanza J, Fahmy LM, Chow EKH, Desai NM, Luo X, King EA, Bowring MG, Segev DL. A Risk Index for Living Donor Kidney Transplantation. Am J Transplant 2016; 16:2077-84. [PMID: 26752290 PMCID: PMC6114098 DOI: 10.1111/ajt.13709] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/20/2015] [Accepted: 12/13/2015] [Indexed: 01/25/2023]
Abstract
Choosing between multiple living kidney donors, or evaluating offers in kidney paired donation, can be challenging because no metric currently exists for living donor quality. Furthermore, some deceased donor (DD) kidneys can result in better outcomes than some living donor kidneys, yet there is no way to compare them on the same scale. To better inform clinical decision-making, we created a living kidney donor profile index (LKDPI) on the same scale as the DD KDPI, using Cox regression and adjusting for recipient characteristics. Donor age over 50 (hazard ratio [HR] per 10 years = 1.15 1.241.33 ), elevated BMI (HR per 10 units = 1.01 1.091.16 ), African-American race (HR = 1.15 1.251.37 ), cigarette use (HR = 1.09 1.161.23 ), as well as ABO incompatibility (HR = 1.03 1.271.58 ), HLA B (HR = 1.03 1.081.14 ) mismatches, and DR (HR = 1.04 1.091.15 ) mismatches were associated with greater risk of graft loss after living donor transplantation (all p < 0.05). Median (interquartile range) LKDPI score was 13 (1-27); 24.2% of donors had LKDPI < 0 (less risk than any DD kidney), and 4.4% of donors had LKDPI > 50 (more risk than the median DD kidney). The LKDPI is a useful tool for comparing living donor kidneys to each other and to deceased donor kidneys.
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Bae S, Massie AB, Luo X, Anjum S, Desai NM, Segev DL. Changes in Discard Rate After the Introduction of the Kidney Donor Profile Index (KDPI). Am J Transplant 2016; 16:2202-7. [PMID: 26932575 PMCID: PMC4925251 DOI: 10.1111/ajt.13769] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 02/19/2016] [Accepted: 02/22/2016] [Indexed: 01/25/2023]
Abstract
Since March 26, 2012, the Kidney Donor Profile Index (KDPI) has been provided with all deceased-donor kidney offers, with the goal of improving the expanded criteria donor (ECD) indicator. Although an improved risk index may facilitate identification and transplantation of marginal yet viable kidneys, a granular percentile system may reduce provider-patient communication flexibility, paradoxically leading to more discards ("labeling effect"). We studied the discard rates of the kidneys recovered for transplantation between March 26, 2010 and March 25, 2012 ("ECD era," N = 28 636) and March 26, 2012 and March 25, 2014 ("KDPI era," N = 29 021) using Scientific Registry of Transplant Recipients (SRTR) data. There was no significant change in discard rate from ECD era (18.1%) to KDPI era (18.3%) among the entire population (adjusted odds ratio [aOR] = 0.97 1.041.10 , p = 0.3), or in any KDPI stratum. However, among kidneys in which ECD and KDPI indicators were discordant, "high risk" standard criteria donor (SCD) kidneys (with KDPI > 85) were at increased risk of discard in the KDPI era (aOR = 1.07 1.421.89 , p = 0.02). Yet, recipients of these kidneys were at much lower risk of death (adjusted Risk Ratio [aRR] = 0.56 0.770.94 at 2 years posttransplant) compared to those remaining on dialysis waiting for low-KDPI kidneys. Our findings suggest that there might be an unexpected, harmful labeling effect of reporting a high KDPI for SCD kidneys, without the expected advantage of providing a more granular risk index.
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Abstract
Substantial ischemia-reperfusion injury (IRI) to the transplanted kidney occurs in 30% to 50% of transplantation patients who receive the organ from a deceased donor. IRI usually manifests as delayed graft function (DGF) and, in severe cases, results in primary nonfunction. Previous studies, primarily experimental, have demonstrated sex-specific susceptibility to IRI in kidney and other organs. In this issue of the JCI, Aufhauser Jr., Wang, and colleagues further demonstrate the importance of donor and recipient sex in IRI and elucidate the role of estrogen receptors in a murine model. Furthermore, analysis of data from 46,691 renal transplant patients in the United Network for Organ Sharing (UNOS) database revealed that sex affects DGF outcomes in humans. Manipulation of sex-driven molecular pathways offers a fertile opportunity to increase the number of organs available for transplantation and to reduce IRI in kidney and, likely, other organs.
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Massie AB, Luo X, Lonze BE, Desai NM, Bingaman AW, Cooper M, Segev DL. Early Changes in Kidney Distribution under the New Allocation System. J Am Soc Nephrol 2015; 27:2495-501. [PMID: 26677865 DOI: 10.1681/asn.2015080934] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/11/2015] [Indexed: 11/03/2022] Open
Abstract
The Kidney Allocation System (KAS), a major change to deceased donor kidney allocation, was implemented in December 2014. Goals of KAS included directing the highest-quality organs to younger/healthier recipients and increasing access to deceased donor kidney transplantation (DDKT) for highly sensitized patients and racial/ethnic minorities. Using national registry data, we compared kidney distribution, DDKT rates for waitlist registrants, and recipient characteristics between January 1, 2013, and December 3, 2014 (pre-KAS) with those between December 4, 2014, and August 31, 2015 (post-KAS). Regional imports increased from 8.8% pre-KAS to 12.5% post-KAS; national imports increased from 12.7% pre-KAS to 19.1% post-KAS (P<0.001). The proportion of recipients >30 years older than their donor decreased from 19.4% to 15.0% (P<0.001). The proportion of recipients with calculated panel-reactive antibody =100 increased from 1.0% to 10.3% (P<0.001). Overall DDKT rate did not change as modeled using exponential regression adjusting for candidate characteristics (P=0.07). However, DDKT rate (incidence rate ratio, 95% confidence interval) increased for black (1.19; 1.13 to 1.25) and Hispanic (1.13; 1.05 to 1.20) candidates and for candidates aged 18-40 (1.47; 1.38 to 1.57), but declined for candidates aged >50 (0.93; 0.87 to 0.98 for aged 51-60 and 0.90; 0.85 to 0.96 for aged >70). Delayed graft function in transplant recipients increased from 24.8% pre-KAS to 29.9% post-KAS (P<0.001). Thus, in the first 9 months under KAS, access to DDKT improved for minorities, younger candidates, and highly sensitized patients, but declined for older candidates. Delayed graft function increased substantially, possibly suggesting poorer long-term outcomes.
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Berli JU, Montgomery JR, Segev DL, Ratner LE, Maley WR, Cooper M, Melancon JK, Burdick J, Desai NM, Dagher NN, Lonze BE, Nazarian SM, Montgomery RA. Surgical management of early and late ureteral complications after renal transplantation: techniques and outcomes. Clin Transplant 2014; 29:26-33. [PMID: 25312804 DOI: 10.1111/ctr.12478] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND In this study, we present our experience with ureteral complications requiring revision surgery after renal transplantation and compare our results to a matched control population. METHODS We performed a retrospective analysis of our database between 1997 and 2012. We divided the cases into early (<60 d) and late repairs. Kaplan-Meier and Cox proportional hazards models were used to compare graft survival between the intervention cohort and controls generated from the Scientific Registry of Transplant Recipients data set. RESULTS Of 2671 kidney transplantations, 51 patients were identified as to having undergone 53 ureteral revision procedures; 43.4% of cases were performed within 60 d of the transplant and were all associated with urinary leaks, and 49% demonstrated ureteral stenosis. Reflux allograft pyelonephritis and ureterolithiasis were each the indication for intervention in 3.8%; 15.1% of the lesions were located at the anastomotic site, 37.7% in the distal segment, 7.5% in the middle segment, 5.7% proximal ureter, and 15.1% had a long segmental stenosis. In 18.9%, the location was not specified. Techniques used included ureterocystostomy (30.2%), ureteroureterostomy (34%), ureteropyelostomy (30.1%), pyeloileostomy (1.9%), and ureteroileostomy (3.8%). No difference in overall graft survival (HR 1.24 95% CI 0.33-4.64, p = 0.7) was detected when compared to the matched control group. CONCLUSION Using a variety of techniques designed to re-establish effective urinary flow, we have been able to salvage a high percentage of these allografts. When performed by an experienced team, a ureteric complication does not significantly impact graft survival or function as compared to a matched control group.
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Gupta N, Salter ML, Garonzik-Wang JM, Reese PP, Wickliffe CE, Dagher NN, Desai NM, Segev DL. Actual and perceived knowledge of kidney transplantation and the pursuit of a live donor. Transplantation 2014; 98:969-73. [PMID: 24837542 PMCID: PMC4218880 DOI: 10.1097/tp.0000000000000161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Live donor kidney transplantation (LDKT) remains underutilized, partly resulting from the challenges many patients face in asking someone to donate. Actual and perceived kidney transplantation (KT) knowledge are potentially modifiable factors that may influence this process. Therefore, we sought to explore the relationships between these constructs and the pursuit of LDKT. METHODS We conducted a cross-sectional survey of transplant candidates at our center to assess actual KT knowledge (5-point assessment) and perceived KT knowledge (5-point Likert scale, collapsed empirically to 4 points); we also asked candidates if they had previously asked someone to donate. Associations between participant characteristics and having asked someone to donate were quantified using modified Poisson regression. RESULTS Of 307 participants, 45.4% were female, 56.4% were non-white race, and 44.6% had previously asked someone to donate. In an adjusted model that included both actual and perceived knowledge, each unit increase in perceived knowledge was associated with 1.21-fold (95% CI: 1.03-1.43, P=0.02) higher likelihood of having asked someone to donate, whereas there was no statistically significant association with actual knowledge (RR=1.08 per unit increase, 95% CI: 0.99-1.18, P=0.10). A conditional forest analysis confirmed the importance of perceived but not actual knowledge in predicting the outcome. CONCLUSIONS Our results suggest that perceived KT knowledge is more important to a patient's pursuit of LDKT than actual knowledge. Educational interventions that seek to increase patient KT knowledge should also focus on increasing confidence about this knowledge.
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Massie AB, Luo X, Chow EKH, Alejo JL, Desai NM, Segev DL. Survival benefit of primary deceased donor transplantation with high-KDPI kidneys. Am J Transplant 2014; 14:2310-6. [PMID: 25139729 DOI: 10.1111/ajt.12830] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 01/25/2023]
Abstract
The Kidney Donor Profile Index (KDPI) has been introduced as an aid to evaluating deceased donor kidney offers, but the relative benefit of high-KDPI kidney transplantation (KT) versus the clinical alternative (remaining on the waitlist until receipt of a lower KDPI kidney) remains unknown. Using time-dependent Cox regression, we evaluated the mortality risk associated with high-KDPI KT (KDPI 71-80, 81-90 or 91-100) versus a conservative, lower KDPI approach (remain on waitlist until receipt of KT with KDPI 0-70, 0-80 or 0-90) in first-time adult registrants, adjusting for candidate characteristics. High-KDPI KT was associated with increased short-term but decreased long-term mortality risk. Recipients of KDPI 71-80 KT, KDPI 81-90 KT and KDPI 91-100 KT reached a "break-even point" of cumulative survival at 7.7, 18.0 and 19.8 months post-KT, respectively, and had a survival benefit thereafter. Cumulative survival at 5 years was better in all three high-KDPI groups than the conservative approach (p < 0.01 for each comparison). Benefit of high-KDPI KT was greatest in patients age >50 years and patients at centers with median wait time ≥33 months. Recipients of high-KDPI KT can enjoy better long-term survival; a high-KDPI score does not automatically constitute a reason to reject a deceased donor kidney.
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Glebova NO, Brooke BS, Desai NM, Lum YW. Endovascular interventions for managing vascular complication of renal transplantation. Semin Vasc Surg 2014; 26:205-12. [PMID: 25220328 DOI: 10.1053/j.semvascsurg.2014.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Renal transplantation is a well-established treatment for patients with end-stage renal disease. Although the procedure is commonly undertaken with a high rate of initial technical success, a low but significant risk of vascular complications can develop and ultimately threaten the transplanted kidney. Complications include transplant renal artery stenosis, extraparenchymal and intraparenchymal pseudoaneurysm and arteriovenous fistula formation, and stenosis of native iliac arteries due to aortoiliac occlusive disease. Historically, open surgical correction of these complications has been associated with high morbidity and the risk of graft loss. Endovascular approaches are better tolerated by renal transplantation patients and are used increasingly for management of vascular complications associated with kidney transplantation. We review the contemporary diagnosis and treatment of these complications using endovascular techniques.
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McAdams-DeMarco MA, Grams ME, King E, Desai NM, Segev DL. Sequelae of early hospital readmission after kidney transplantation. Am J Transplant 2014; 14:397-403. [PMID: 24447652 PMCID: PMC3998748 DOI: 10.1111/ajt.12563] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 09/30/2013] [Accepted: 10/27/2013] [Indexed: 01/25/2023]
Abstract
We recently elucidated risk factors for early hospital readmission (EHR) following kidney transplantation (KT). We now sought to quantify the independent associations between EHR and post-KT outcomes, including late hospital readmission (LHR: 1 year after EHR window), death-censored graft loss and mortality, among Medicare-primary KT recipients (2000-2005). Of 32961 KT recipients, 7.7% had at least one readmission within 3 days of discharge, 14.8% within 7 days, 22.4% within 14 days and 30.5% within 30 days of discharge after the initial KT hospitalization. KT recipients who experienced EHR within 30 days of discharge after the initial KT hospitalization were more likely to have experienced LHR (29.6% vs. 9.0%, p<0.001) and were at 3.02 times higher (95% CI: 2.82-3.23, p<0.001) risk of LHR. Additionally, EHR was associated with death-censored graft loss (deceased donor recipients hazard ratio [HR]: 1.43, 95% CI: 1.36-1.51, p<0.001 and live donor recipients HR: 1.54, 95% CI: 1.40-1.70, p<0.001) and mortality (deceased donor recipients HR: 1.50, 95% CI: 1.43-1.58, p<0.001 and live donor recipients HR: 1.45, 95% CI: 1.32-1.60, p<0.001). Thirty days posttransplant represents a high-risk window for KT recipients and the readmissions during this window are strong predictors of adverse sequelae, particularly LHRs. Efforts should be made to implement and improve systems to reduce LHR and subsequent graft loss and mortality among recipients with EHR.
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Lonze BE, Zachary AA, Magro CM, Desai NM, Orandi BJ, Dagher NN, Singer AL, Carter-Monroe N, Nazarian SM, Segev DL, Streiff MB, Montgomery RA. Eculizumab prevents recurrent antiphospholipid antibody syndrome and enables successful renal transplantation. Am J Transplant 2014; 14:459-65. [PMID: 24400968 DOI: 10.1111/ajt.12540] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/16/2013] [Accepted: 09/30/2013] [Indexed: 01/25/2023]
Abstract
Renal transplantation in patients with antiphospholipid antibodies has historically proven challenging due to increased risk for thrombosis and allograft failure. This is especially true for patients with antiphospholipid antibody syndrome (APS) and its rare subtype, the catastrophic antiphospholipid antibody syndrome (CAPS). Since a critical mechanism of thrombosis in APS/CAPS is one mediated by complement activation, we hypothesized that preemptive treatment with the terminal complement inhibitor, eculizumab, would reduce the extent of vascular injury and thrombosis, enabling renal transplantation for patients in whom it would otherwise be contraindicated. Three patients with APS, two with a history of CAPS, were treated with continuous systemic anticoagulation together with eculizumab prior to and following live donor renal transplantation. Two patients were also sensitized to human leukocyte antigens (HLA) and required plasmapheresis for reduction of donor-specific antibodies. After follow-up ranging from 4 months to 4 years, all patients have functioning renal allografts. No systemic thrombotic events or early graft losses were observed. While the appropriate duration of treatment remains to be determined, this case series suggests that complement inhibitors such as eculizumab may prove to be effective in preventing the recurrence of APS after renal transplantation.
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Hall EC, James NT, Garonzik Wang JM, Berger JC, Montgomery RA, Dagher NN, Desai NM, Segev DL. Center-level factors and racial disparities in living donor kidney transplantation. Am J Kidney Dis 2012; 59:849-57. [PMID: 22370021 DOI: 10.1053/j.ajkd.2011.12.021] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 12/19/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND On average, African Americans attain living donor kidney transplantation (LDKT) at decreased rates compared with their non-African American counterparts. However, center-level variations in this disparity or the role of center-level factors is unknown. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 247,707 adults registered for first-time kidney transplants from 1995-2007 as reported by the Scientific Registry of Transplant Recipients. PREDICTORS Patient-level factors (age, sex, body mass index, insurance status, education, blood type, and panel-reactive antibody level) were adjusted for in all models. The association of center-level characteristics (number of candidates, transplant volume, LDKT volume, median time to transplant, percentage of African American candidates, percentage of prelisted candidates, and percentage of LDKT) and degree of racial disparity in LDKT was quantified. OUTCOMES Hierarchical multivariate logistic regression models were used to derive center-specific estimates of LDKT attainment in African American versus non-African American candidates. RESULTS Racial parity was not seen at any of the 275 transplant centers in the United States. At centers with the least racial disparity, African Americans had 35% lower odds of receiving LDKT; at centers with the most disparity, African Americans had 76% lower odds. Higher percentages of African American candidates (interaction term, 0.86; P = 0.03) and prelisted candidates (interaction term, 0.80; P = 0.001) at a given center were associated with increased racial disparity at that center. Higher rates of LDKT (interaction term, 1.25; P < 0.001) were associated with less racial disparity. LIMITATIONS Some patient-level factors are not captured, including a given patient's pool of potential donors. Geographic disparities in deceased donor availability might affect LDKT rates. Center-level policies and practices are not captured. CONCLUSIONS Racial disparity in attainment of LDKT exists at every transplant center in the country. Centers with higher rates of LDKT attainment for all races had less disparity; these high-performing centers might provide insights into policies that might help address this disparity.
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Bagnasco SM, Subramanian AK, Desai NM. Fungal infection presenting as giant cell tubulointerstitial nephritis in kidney allograft. Transpl Infect Dis 2011; 14:288-91. [PMID: 22093412 DOI: 10.1111/j.1399-3062.2011.00676.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 07/06/2011] [Accepted: 07/23/2011] [Indexed: 01/16/2023]
Abstract
Giant cell tubulointerstitial nephritis in the kidney allograft caused by infection is rare, and donor-transmitted infection in transplanted kidneys is also rare. In this case report, we describe an unusual histological manifestation of Candida albicans in the graft biopsy of a 53-year-old male kidney transplant recipient with decreased renal function 12 days post transplant. Several giant cells were present in the tubulointerstitial inflammation, as well as yeasts, with no evidence of rejection, and the histological diagnosis was confirmed by urine culture. Donor urine culture was positive for C. albicans, suggestive of a possible donor-transmitted infection. Prompt antifungal treatment eradicated the infection, and averted systemic spread. To our knowledge, there are no previous reports of Candida infection with giant cell tubulointerstitial nephritis in human renal allograft.
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Kaja S, Duncan RS, Longoria S, Hilgenberg JD, Payne AJ, Desai NM, Parikh RA, Burroughs SL, Gregg EV, Goad DL, Koulen P. Novel mechanism of increased Ca2+ release following oxidative stress in neuronal cells involves type 2 inositol-1,4,5-trisphosphate receptors. Neuroscience 2010; 175:281-91. [PMID: 21075175 DOI: 10.1016/j.neuroscience.2010.11.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 11/04/2010] [Accepted: 11/05/2010] [Indexed: 12/14/2022]
Abstract
Dysregulation of Ca(2+) signaling following oxidative stress is an important pathophysiological mechanism of many chronic neurodegenerative disorders, including Alzheimer's disease, age-related macular degeneration, glaucomatous and diabetic retinopathies. However, the underlying mechanisms of disturbed intracellular Ca(2+) signaling remain largely unknown. We here describe a novel mechanism for increased intracellular Ca(2+) release following oxidative stress in a neuronal cell line. Using an experimental approach that included quantitative polymerase chain reaction, quantitative immunoblotting, microfluorimetry and the optical imaging of intracellular Ca(2+) release, we show that sub-lethal tert-butyl hydroperoxide-mediated oxidative stress result in a selective up-regulation of type-2 inositol-1,4,5,-trisphophate receptors. This oxidative stress mediated change was detected both at the transcriptional and translational level and functionally resulted in increased Ca(2+) release into the nucleoplasm from the membranes of the nuclear envelope at a given receptor-specific stimulus. Our data describe a novel source of Ca(2+) dysregulation induced by oxidative stress with potential relevance for differential subcellular Ca(2+) signaling specifically within the nucleus and the development of novel neuroprotective strategies in neurodegenerative disorders.
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Massie AB, Stewart DE, Dagher NN, Montgomery RA, Desai NM, Segev DL. Center-level patterns of indicated willingness to and actual acceptance of marginal kidneys. Am J Transplant 2010; 10:2472-80. [PMID: 20977638 DOI: 10.1111/j.1600-6143.2010.03294.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNet(SM) , the UNOS data collection and electronic organ allocation system, allows centers to specify organ offer acceptance criteria for patients on their kidney waiting list. We hypothesized that the system might not be fully utilized and that the criteria specified by most transplant centers would be much broader than the characteristics of organs actually transplanted by those centers. We analyzed the distribution of criteria values among waitlist patients (N = 304 385) between January 2000 and February 2009, mean criteria values among listed candidates on February 19, 2009 and differences between a center's specified criteria and the organs it accepted for transplant between July 2005 and April 2009. We found wide variation in use of criteria variables, with some variables mostly or entirely unused. Most centers specified very broad criteria, with little within-center variation by patient. An offer of a kidney with parameters more extreme than the maximum actually transplanted at that center was designated a 'surplus offer' and indicated a potentially avoidable delay in distribution. We found 7373 surplus offers (7.1% of all offers), concentrated among a small number of centers. The organ acceptance criteria system is currently underutilized, leading to possibly avoidable inefficiencies in organ distribution.
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Massie AB, Desai NM, Montgomery RA, Singer AL, Segev DL. Improving distribution efficiency of hard-to-place deceased donor kidneys: Predicting probability of discard or delay. Am J Transplant 2010; 10:1613-20. [PMID: 20642686 DOI: 10.1111/j.1600-6143.2010.03163.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We recently showed that DonorNet 2007 has reduced the efficiency of kidney distribution in the United States, particularly for those with prolonged cold ischemia time (CIT), by requiring systematic allocation of all kidneys regardless of quality. Reliable early identification of those most likely to be discarded or significantly delayed would enable assigning them to alternate, more efficient distribution strategies. Based on 39 035 adult kidneys recovered for possible transplantation between 2005 and 2008, we created a regression model that reliably (AUC 0.83) quantified the probability that a given kidney was either discarded or delayed beyond 36 h of CIT (Probability of Discard/Delay, PODD). We then analyzed two PODD cutoffs: a permissive cutoff that successfully flagged over half of those kidneys that were discarded/delayed, while only flagging 7% of kidneys that were not eventually discarded/delayed, and a more stringent cutoff that erroneously flagged only 3% but also correctly identified only 34%. Kidney transplants with high PODD were clustered in a minority of centers. Modifications of the kidney distribution system to more efficiently direct organs with high PODD to the centers that actually use them may result in reduced CIT and fewer discards.
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Sinha SN, Desai NM, Patel GM, Mansuri MM, Shivgotra V. Concentration of nitrite in respirable particulate matter of ambient air in Vadodara, Gujarat, India. JOURNAL OF ENVIRONMENTAL BIOLOGY 2010; 31:375-378. [PMID: 21047014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Water extract of respirable particulate matter (RPM) was analyzed by Ion chromatography technique to investigate the presence of nitrite (NO2) as secondary aerosol in ambient environment. The nitrite particulates undergo photo hydroxyl radical reaction in environment produce nitrous acid, which reacts with metal and absorbs on RPM as water-soluble metal salt. The mean concentration of nitrite was 20.86 microg m(-3) in ambient environment. Regression analysis showed that the relationship for respirable particulate matter and nitrite (RPM-NO2, R2 = 0.742) was positively significant. We are reporting the presence of nitrite as an aerosol in ambient environment.
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Boothpur R, Hardinger KL, Skelton RM, Lluka B, Koch MJ, Miller BW, Desai NM, Brennan DC. Serum sickness after treatment with rabbit antithymocyte globulin in kidney transplant recipients with previous rabbit exposure. Am J Kidney Dis 2009; 55:141-3. [PMID: 19628314 DOI: 10.1053/j.ajkd.2009.06.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 06/15/2009] [Indexed: 11/11/2022]
Abstract
Serum sickness after rabbit antithymocyte globulin administration has a reported incidence of 7% to 27% in kidney transplant recipients. We describe 4 patients with previous exposure to rabbits who developed serum sickness after primary rabbit antithymocyte globulin induction. All patients presented with jaw pain. Three of 4 patients treated with plasmapheresis and steroids had prompt recovery, and 1 patient treated with steroids had slower recovery. We performed a telephone interview of 214 patients who contemporaneously underwent transplantation between November 2006 and July 2008 regarding rabbit exposure. More than half the patients had some type of previous rabbit exposure. There was a suggestion that patients with serum sickness were exposed more frequently to rabbits than those without. Jaw pain appears to be a hallmark symptom, and treatment with plasmapheresis and steroids relieves symptoms more rapidly than steroids alone.
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Desai NM, Schnitzler M, Jendrisak MD, Brennan DC. Maintenance steroid therapy for kidney recipients--not ready for relegation. Am J Transplant 2009; 9:1263-4. [PMID: 19459824 DOI: 10.1111/j.1600-6143.2009.02629.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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