Renal Transplantations in African Americans: A Single-center Experience of Outcomes and Innovations to Improve Access and Results

The Impact of Recipient Demographics on Outcomes from Living Donor Kidneys: Systematic Review and Meta-Analysis

Background and Aims: Recipient demographics affect outcomes after kidney transplantation. The aim of this study was to assess, for kidneys retrieved from living donors, the effect of recipient sex, ethnicity, and body mass index (BMI) on delayed graft function (DGF) and one-year graft function, incidence of acute rejection (AR), and recipient and graft survivals. Methods: A systematic review and meta-analysis was performed. EMBASE and MEDLINE databases were searched using algorithms through Ovid. Web of Science collection, BIOSIS, CABI, Korean Journal database, Russian Science Citation Index, and SciELO were searched through Web of Science. Cochrane database was also searched. Risk of bias was assessed using the NHBLI tools. Data analysis was performed using Revman 5.4. Mean difference (MD) and risk ratio (RR) were used in analysis. Results: A total of 5129 studies were identified; 24 studies met the inclusion criteria and were analysed. Female recipients were found to have a significantly lower serum creatinine 1-year-post renal transplantation (MD: −0.24 mg/dL 95%CI: −0.18 to −0.29 p < 0.01) compared to male recipients. No significant difference in survival between male and female recipients nor between Caucasians and Africans was observed (p = 0.08). However, Caucasian recipients had a higher 1-year graft survival compared to African recipients (95% CI 0.52−0.98) with also a lower incidence of DGF (RR = 0.63 p < 0.01) and AR (RR = 0.55 p < 0.01). Recipient obesity (BMI > 30) was found to have no effect on 1-year recipient (p = 0.28) and graft survival (p = 0.93) compared to non-obese recipients although non-obese recipients had a lower rate of DGF (RR = 0.65 p < 0.01) and AR (RR = 0.81 p < 0.01) compared to obese recipients. Conclusions: Gender mismatch between male recipients and female donors has negative impact on graft survival. African ethnicity and obesity do not to influence recipient and graft survival but negatively affect DGF and AR rates.

Consistent improvements in short- and long-term survival following heart transplantation over the past three decades

BACKGROUND

Despite noted improvements in short-term survival outcomes following orthotopic heart transplantation (OHT), review of the relevant literature suggests little improvement in long-term outcomes for patients surviving beyond 1 year.

METHODS

All OHT cases performed between 1989 and 2019 within the United Network for Organ Sharing (UNOS) database were reviewed. Adults who underwent isolated OHT were included in a 1-year survival analysis. Those who survived at least 1 year post-transplant were included in a long-term survival analysis. Demographic factors were assessed using Students' t test and chi-square analysis. Survival trends and risk factors were assessed using the Kaplan-Meier and the Cox regression analysis, respectively.

RESULTS

A total of 53 265 and 46 372 recipients were included in the short-term and long-term cohorts, respectively. In an adjusted analysis, the reference implant era 2014-2019 had significantly better short-term survival outcomes when compared with earlier implant eras: 1989-1993 (HR: 2.92), 1994-1998 (HR: 1.53), 1999-2003 (HR: 1.27), 2004-2008 (HR: 1.11), and 2009-2013 (HR: 1.02). The same trend was recognized for long-term outcomes: 1989-1993 (HR: 1.87), 1994-1998 (HR: 1.27), 1999-2003 (HR: 1.09), and 2004-2008 (HR: 1.03).

CONCLUSIONS

Despite increases in multiple traditional risk factors, both short-term and long-term survival outcomes have consistently improved over the past 30 years, suggesting other factors are contributing to improved outcomes in recent eras.

Posttransplantation Hypomagnesemia as a Predictor of Better Graft Function after Transplantation

BACKGROUND

Hypomagnesemia is frequently seen after transplantation and is particularly associated with the use of calcineurin inhibitors (CNIs).

METHODS

We conducted a retrospective, single-center analysis (2000-2013, N = 726) to explore the relationship between hypomagnesemia and long-term allograft outcome in kidney transplant recipients. For this study, a median serum magnesium (Mg) level of all measured Mg levels from 1 month to 1 year after renal transplantation was calculated.

RESULTS

For every increase in Mg by 0.1 mg/dL, the GFR decreased by 1.1 mL/min at 3 years posttransplant (p < 0.01) and by 1.5 mL/min at 5 years posttransplant. A median blood Mg level of ≥1.7 was found to be an independent predictor of a GFR <60 mL/min at 3 years posttransplant. The odds of having a GFR <60 mL/min 3 years posttransplant was almost 2-fold higher in the high Mg group than in the low Mg group.

CONCLUSIONS

Hypomagnesemia from 1 to 12 months after renal transplantation is associated with a better allograft function up to 5 years posttransplant. This relationship was found to hold true after accounting for baseline allograft function and the presence of slow graft function.

Development and preliminary evaluation of ilearnKAS: An animated video about kidney allocation to support transplant decision-making

BACKGROUND

We aimed to develop and feasibility test an educational video culturally targeted to African American (AA) patients regarding kidney allocation.

METHODS

We iteratively refined an animated video for AAs with multiple stakeholder input and conducted a one-group, pre-post study with 50 kidney transplant candidates to assess video feasibility and acceptability. A mixed population was chosen to obtain race-specific acceptability data and efficacy estimates for a larger study.

RESULTS

Median participant age was 56 years, and 50% were AA. Comparing pre-post video scores, large knowledge effect sizes were found for the cohort (r = 0.7) and in the context of AA race (r = 0.8), low health literacy (r = 0.6), low educational achievement (r = 0.7), age >55 years (r = 0.6), dialysis vintage ≥1 year (r = 0.8), low income (r = 0.7) and low technology access (r = 0.8). Over 87% of participants provided positive ratings on each of the seven acceptability items. The frequency of positive responses increased pre-post video for kidney allocation understanding (78% vs 94%, P = 0.008), decisional self-efficacy (64% vs 88%, P < 0.001) and belief in fairness (76% vs 90%, P = 0.02).

CONCLUSIONS

In collaboration with key stakeholders, a culturally targeted educational video was developed that was well received. Results are promising to impact kidney allocation knowledge among AA and non-AA kidney transplant candidates.

Enabling Conversations: African American Patients' Changing Perceptions of Kidney Transplantation

BACKGROUND

Racial disparities in access to kidney transplantation (KTX) among African Americans (AAs) have been attributed in part to insufficient patient education. Interventions are needed to provide AAs with culturally sensitive, understandable information that increases their capacity to pursue KTX. Research about the factors that activated patients to pursue KTX is necessary to inform such interventions; however, few studies have yielded this type of information.

METHODS

We conducted focus groups and one-on-one interviews with 26 AA referred, listed, or transplanted patients and 3 nephrologists to explore decisional factors that foster pursuit of KTX. Interviews were recorded and transcribed, and qualitative analytic methods to identify themes and subthemes were applied in an effort to inform message content for a future educational video intervention.

RESULTS

Three themes emerged from thematic content analysis: (1) healthcare provider communication, (2) exposure to peer transplant success, and (3) family encouragement. Enabling provider communication techniques include repetition about the KTX option, optimistic messaging about KTX access, and comforting conversations about the KTX process.

CONCLUSION

We identified information based on patient views and experiences to help inspire and develop animated videos designed to activate patients towards KTX. Interventions are needed that address informational gaps and focus on emotion to improve patients' experiences and ability to understand transplant opportunities.

A Contemporary Analysis of Outcomes and Modifiable Risk Factors of Ethnic Disparities in Kidney Transplantation

OBJECTIVE

The aim of this study was to provide a contemporary analysis of longitudinal kidney transplant outcomes and to evaluate potential causes of ethnic disparities among African American (AA) and Caucasian American (CA) patients undergoing kidney transplantation at our institution.

PATIENTS AND METHODS

1400 patients were identified who underwent kidney transplantation from 2003 to 2013 from a large, academic institution in Cleveland, OH. Relevant recipient and donor demographic and clinical covariates were obtained from an institutional transplant database. Simple descriptive statistics and comparative survival analyses were performed to assess overall survival and graft survival.

RESULTS

The final cohort was comprised of 341 AA and 1059 CA patients. AAs were less likely to receive a living donor transplant (27.6% vs. 57.2%, p < 0.001) compared to CAs. Overall patient survival did not significantly differ between the two groups even when stratified by ethnicity. However, AAs had a significantly lower rate of graft survival (p < 0.001). On stratified analysis, there was no difference in the rate of graft survival among AAs and CAs who received living donor grafts. On univariate analysis, AAs demonstrated higher rates of immunosuppression non-compliance and chronic rejection (both p < 0.05). On multivariate analysis, AA recipient ethnicity (HR 1.56, p = 0.047), recipient history of diabetes (HR 1.67, p < 0.001), and AA donor ethnicity (HR 1.56, p = 0.047) were significantly associated with graft failure.

CONCLUSION

AAs undergoing deceased donor renal transplantation demonstrated lower graft survival compared to CAs. Conversely, this disparity did not exist among AAs undergoing living donor transplantation. AAs had higher rates of deceased donor transplantation, immunosuppression non-compliance, chronic rejection, and diabetes. Opportunities exist to use patient education, alternative immunosuppression regimens, and living transplantation to close the ethnic disparity in renal allograft survival.

Kidney transplantation in the Hispanic population

Hispanic race and low socioeconomic status are established predictors of disparity in access to kidney transplantation. This single-center retrospective review was undertaken to determine whether Hispanic race predicted kidney transplant outcomes. A total of 720 patients underwent kidney transplantation from January 1, 2004 to December 31, 2013, including 398 Hispanic patients and 322 non-Hispanic patients. Hispanic patients were significantly younger (p < 0.0001), on hemodialysis for longer (p = 0.0018), had a greater percentage with public insurance (p < 0.0001), more commonly had diabetes as the cause of end-stage renal disease (p = 0.0167), and had a lower percentage of living donors (p = 0.0013) compared to non-Hispanic patients. There was no difference in one-, five-, and 10-yr graft (97%, 81%, and 61% vs. 95%, 76%, and 42% p = 0.18) or patient survival (98%, 90%, and 84% vs. 97%, 87%, and 69% p = 0.11) between the Hispanic and non-Hispanic recipients. Multivariate analysis identified increased recipient age and kidney donor profile index to be predictive of lower graft survival and increasing recipient age to be predictive of lower patient survival. In the largest single-center study on kidney transplantation outcomes in Hispanic patients, there is no difference in graft and recipient survival between Hispanic and non-Hispanic kidney transplant patients, and in multivariate analysis, Hispanic race is not a risk factor for graft or patient survival.

'Suspended in a paradox'-patient attitudes to wait-listing for kidney transplantation: systematic review and thematic synthesis of qualitative studies

Patients on waiting lists for kidney transplantation have higher mortality rates and have specific anxieties about their eligibility, process, and outcomes of wait-listing. We aimed to describe patient experiences and attitudes to wait-listing for kidney transplantation. Electronic databases were searched to September 2014. Thematic synthesis was used to analyze the findings. From 22 studies (n = 795 patients), we identified six themes: accepting the only option (chance to regain normality, avoiding guilt, impulsive decision-making); maintaining hope (determined optimism, appreciating a fortuitous gift, enduring for optimal outcomes, trust in clinical judgment); burden of testing (strenuous commitment, losing the battle, medical mistrust); permeating vulnerability (eligibility enigma, being threatened, angst of timing uncertainty, desperate urgency, living in limbo, spiraling doubt and disappointment, residual ambivalence); deprived of opportunity (unfairly dismissed, unexpected disqualification, self-resignation and acceptance, jealousy, suspicious of inequity); and moral guilt (awaiting someone's death, questioning deservingness). The waiting list offered hope of restored normality. However, the demands of workup, uncertainty about eligibility, and waiting times that exceeded expectations impelled patients to disillusionment, despair, and suspicion of inequity. Managing patient expectations and ensuring transparency of wait-listing and allocation decisions may allay patient disappointment and skepticism, to improve patient satisfaction and treatment outcomes.