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Gonzalez FM, Gonzalez Cohens FDR. Kidney transplantation outcomes: Is it possible to improve when good results are falling down? World J Transplant 2024; 14:91214. [DOI: 10.5500/wjt.v14.i3.91214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 07/31/2024] Open
Abstract
Famure et al describe that close to 50% of their patients needed early or very early hospital readmissions after their kidney transplantation. As they taught us the variables related to those outcomes, we describe eight teaching capsules that may go beyond what they describe in their article. First two capsules talk about the ideal donors and recipients we should choose for avoiding the risk of an early readmission. The third and fourth capsules tell us about the reality of cadaveric donors and recipients with comorbidities, and the way transplant physicians should choose them to maximize survival. Fifth capsule shows that any mistake can result in an early readmission, and thus, in poorer outcomes. Sixth capsule talks about economic losses of early readmissions, cost-effectiveness of transplantation, and how to improve outcomes and reduce costs by managing a risky patient-portfolio. Seventh capsule argues about knowing your risk behavior to better manage your portfolio; and Eighth capsule about the importance of the center experience in transplanting complex patients. We finish with some lessons of the importance of the transplantation process and the collaboration with other disciplines in order to prevent the conditions that lead to early readmissions.
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Affiliation(s)
- Fernando M Gonzalez
- Department of Nephrology, Faculty of Medicine, Universidad de Chile, Santiago 7500922, Chile
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Nemeth DV, Iannelli L, Gangitano E, D’Andrea V, Bellini MI. Energy Metabolism and Metformin: Effects on Ischemia-Reperfusion Injury in Kidney Transplantation. Biomedicines 2024; 12:1534. [PMID: 39062107 PMCID: PMC11275143 DOI: 10.3390/biomedicines12071534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Metformin (MTF) is the only biguanide included in the World Health Organization's list of essential medicines; representing a widespread drug in the management of diabetes mellitus. With its accessibility and affordability being one of its biggest assets, it has become the target of interest for many trying to find alternative treatments for varied pathologies. Over time, an increasing body of evidence has shown additional roles of MTF, with unexpected interactions of benefit in other diseases. Metformin (MTF) holds significant promise in mitigating ischemia-reperfusion injury (IRI), particularly in the realm of organ transplantation. As acceptance criteria for organ transplants expand, IRI during the preservation phase remain a major concern within the transplant community, prompting a keen interest in MTF's effects. Emerging evidence suggests that administering MTF during reperfusion may activate the reperfusion injury salvage kinase (RISK) pathway. This pathway is pivotal in alleviating IRI in transplant recipients, potentially leading to improved outcomes such as reduced rates of organ rejection. This review aims to contextualize MTF historically, explore its current uses, pharmacokinetics, and pharmacodynamics, and link these aspects to the pathophysiology of IRI to illuminate its potential future role in transplantation. A comprehensive survey of the current literature highlights MTF's potential to recondition and protect against IRI by attenuating free radical damage, activating AMP-activated protein kinase to preserve cellular energy and promote repair, as well as directly reducing inflammation and enhancing microcirculation.
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Affiliation(s)
- Denise V. Nemeth
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX 78235, USA
| | - Leonardo Iannelli
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Elena Gangitano
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Vito D’Andrea
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
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Becker F, Pollmann NS, Funke-Kaiser R, Görlich D, Katou S, Morgül H, Kneifel F, Reuter S, Pascher A, Houben P. Effect of Donor Cigarette Smoking in Kidney Transplantation: Re-Evaluation of Long-Term Outcomes. Transpl Int 2024; 37:12955. [PMID: 38979119 PMCID: PMC11228151 DOI: 10.3389/ti.2024.12955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/07/2024] [Indexed: 07/10/2024]
Abstract
Cigarette smoking is a common risk factor associated with negative long-term outcomes in kidney transplant recipients. However, whether donor smoking decreases graft longevity or negatively impacts recipient survival after kidney transplantation remains unknown. Therefore, this study aims to investigate the long-term outcome in patients who received a kidney graft from a deceased smoking or non-smoking donor. A total of 580 patients were divided into two groups: patients who received a graft from a smoking donor (n = 276) and those who received a graft from a non-smoking donor (n = 304). Analysis of demographic factors showed that the non-smoking cohort was older, had more extended criteria donors and longer warm ischemia times. The primary composite endpoint of patient and graft survival was better in the smoking donor cohort when analyzed using Kaplan-Meier method but not when controlled for covariates in multivariate analyses. These findings do not support a previously reported negative impact of deceased donor smoking on kidney transplant recipients. Thus, the underlying results should not be interpreted in favor of a positive donor smoking history, but rather remind the transplant community that donor smoking should not be considered as a deciding factor in refusing an otherwise acceptable kidney graft.
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Affiliation(s)
- Felix Becker
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Nicola Sariye Pollmann
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Ricarda Funke-Kaiser
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University Hospital Münster, Münster, Germany
| | - Shadi Katou
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Haluk Morgül
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Felicia Kneifel
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Philipp Houben
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
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Rompianesi G, Montalti R, Vrakas G, Zarrinpar A, Warren C, Loiaco G, Rubba F, Troisi RI. Benchmark Outcomes in Deceased Donor Kidney Transplantation: A Multicenter Analysis of 80 996 Transplants From 126 Centers. Transplant Direct 2024; 10:e1618. [PMID: 38606349 PMCID: PMC11005896 DOI: 10.1097/txd.0000000000001618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 04/13/2024] Open
Abstract
Background We defined clinically relevant benchmark values in deceased donor kidney transplantation (KT), to assess the best achievable results in low-risk patient cohorts from experienced centers. Methods We identified the "ideal" cases from the United Network for Organ Sharing Standard Transplant Analysis and Research files from centers performing ≥50 KT per year between 2010 and 2018. Cases have been selected based on the kidney donor profile index values (<35%), a cold ischemia time (CIT) ≤18 h, a HLA mismatch ≤4, and excluding blood group (ABO) incompatible, dual and combined transplants. The outcomes of the benchmark cohort have been compared with a group of patients excluded from the benchmark cohort because but not meeting 1 or more of the abovementioned criteria. Results The 171 424 KT patients in the United Network for Organ Sharing Standard Transplant Analysis and Research files were screened and 8694 benchmark cases of a total of 80 996 KT (10.7%) from 126 centers meeting the selection criteria were identified. The benchmarks for 1-, 3-, and 5-y patient survival are ≥97%, ≥92.5%, and ≥86.7%, and ≥95.4%, ≥87.8%, and ≥79.6% for graft survival. Benchmark cutoff for hospital length of stay is ≤5 d, ≤23.6% for delayed graft function, and ≤7.5% and ≤9.1% for 6-mo and 1-y incidence of acute rejection. Overall 1-, 3-, and 5-y actuarial graft survivals were 96.6%, 91.1%, and 84.2% versus 93.5%, 85.4%, and 75.5% in the benchmark and comparison groups, respectively (P < 0.001). Overall 1-, 3-, and 5-y actuarial patient survivals were 98.1%, 94.8%, and 90.0% versus 96.6%, 91.1%, and 83.0% in the benchmark and comparison groups, respectively (P < 0.001). Conclusions For the first time, we quantified the best achievable postoperative results in an ideal scenario in deceased donor KT, aimed at improving the clinical practice guided by the comparison of center performances with the ideal outcomes defined.
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Affiliation(s)
- Gianluca Rompianesi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Roberto Montalti
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Georgios Vrakas
- Department of Surgery, University of Florida, Gainesville, FL
| | - Ali Zarrinpar
- Department of Surgery, University of Florida, Gainesville, FL
| | - Curtis Warren
- Department of Surgery, University of Florida, Gainesville, FL
| | - Giuseppe Loiaco
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Fabiana Rubba
- Public Health Department, Federico II University Hospital, Naples, Italy
| | - Roberto I. Troisi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
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Ergisi M, Ooi B, Salim O, Papalois V. Post-transplant lymphoproliferative disorders following kidney transplantation: A literature review with updates on risk factors, prognostic indices, screening strategies, treatment and analysis of donor type. Transplant Rev (Orlando) 2024; 38:100837. [PMID: 38430887 DOI: 10.1016/j.trre.2024.100837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) is a devastating complication of kidney transplantation with an insidious presentation and potential to disseminate aggressively. This review delineates the risk factors, prognostic indexes, screening, current management algorithm and promising treatment strategies for PTLD. Kidneys from both extended criteria donors (ECD) and living donors (LD) are being increasingly used to expand the donor pool. This review also delineates whether PTLD outcomes vary based on these donor sources. While Epstein-Barr virus (EBV) is a well-known risk factor for PTLD development, the use of T-cell depleting induction agents has been increasingly implicated in aggressive, monomorphic forms of PTLD. Research regarding maintenance therapy is sparse. The international prognostic index seems to be the most validate prognostic tool. Screening for PTLD is controversial, as annual PET-CT is most sensitive but costly, while targeted monitoring of EBV-seronegative patients was more economically feasible, is recommended by the American Society of Transplantation, but is limited to a subset of the population. Other screening strategies such as using Immunoglobulin/T-cell receptor require further validation. A risk-stratified approach is taken in the treatment of PTLD. The first step is the reduction of immunosuppressants, after which rituximab and chemotherapy may be introduced if unsuccessful. Some novel treatments have also shown potential benefit in studies: brentuximab vedotin, chimeric antigen receptor T-cell therapy and EBV-specific cytotoxic T lymphocytes. Analysis of LD v DD recipients show no significant difference in incidence and mortality of PTLD but did reveal a shortened time to development of PTLD from transplant. Analysis of SCD vs ECD recipients show a higher incidence of PTLD in the ECD group, which might be attributed to longer time on dialysis for these patients, age, and the pro-inflammatory nature of these organs. However, incidence of PTLD overall is still extremely low. Efforts should be focused on optimising recipients instead. Minimising the use of T-cell depleting therapy while encouraging research on the effect of new immunosuppressants on PTLD, screening for EBV status are essential, while enabling shared decision-making during counselling when choosing kidney donor types and individualised risk tailoring are strongly advocated.
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Affiliation(s)
- Mehmet Ergisi
- Norfolk and Norwich University Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Department of Medicine, Norwich, United Kingdom.
| | - Bryan Ooi
- Department of Medicine, Imperial College London, London, United Kingdom.
| | - Omar Salim
- Isle of Wight NHS Trust, Parkhurst Road, Newport, United Kingdom
| | - Vassilios Papalois
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, Department of Transplant and General Surgery, London, United Kingdom.
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Offerni JCM, Ai Li E, Matti D, Luke G, Luke PP, Sener A. Can We Predict Kidney Graft Function and Graft Survival Using Hypothermic Machine Perfusion Parameters From Donors After Circulatory Death? Transplant Direct 2024; 10:e1601. [PMID: 38464425 PMCID: PMC10923389 DOI: 10.1097/txd.0000000000001601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 03/12/2024] Open
Abstract
Background Hypothermic machine perfusion (HMP) reduces renal injury in donation after circulatory death donors with a high Kidney Donor Profile Index (KDPI). This study aims to characterize the correlation between KDPI, HMP parameters, and donor vitals during the withdrawal period in predicting short- and long-term graft outcomes. Methods ANOVA with Tukey's honestly significant difference tests compared the relationship between average flow, average resistance, peak resistance, flow slope, and resistance slope on day 30, 1-y, and 3-y eGFR, and days of delayed graft function. Graft and recipient survival rates were assessed using Kaplan-Meier analysis. Results The data for 72 grafts were suitable for analysis. Kidneys with KDPI >50% had a significantly higher day 30, and 1-y posttransplant eGFR, if HMP average flow was >150 mL/min, or the average resistance was <0.15 mm Hg/mL/min, compared with kidneys with also KDPI >50% but had not achieved the same pump parameters. There were no significant differences in the Kaplan-Meier analysis, considering recipient or graft survival, regardless of the KPDI score with 3- or 5-y outcomes. Conclusions Use of average resistance and average flow from a HMP, in conjunction with KDPI, may be predictive of the short- and long-term function of donation after circulatory death kidney transplants.
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Affiliation(s)
- Juliano C. M. Offerni
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
- Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada
- Division of Urology, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Erica Ai Li
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Danny Matti
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
| | - Grant Luke
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Patrick P. Luke
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
- Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada
| | - Alp Sener
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Matthew Mailing Center for Translational Transplant Studies, London, ON, Canada
- Division of Urology, Department of Surgery, London Health Sciences Center, London, ON, Canada
- Multi-Organ Transplant Program, London Health Sciences Center, London, ON, Canada
- Department of Microbiology and Immunology, Western University, London, ON, Canada
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PARIKH CHIRAGR, HERNANDEZ JEANINE. PHENOTYPING REPAIR AFTER ACUTE KIDNEY INJURY: PRECISION MEDICINE TO CLINICAL TRIALS. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2024; 134:37-46. [PMID: 39135588 PMCID: PMC11316880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Acute kidney injury (AKI) is common during hospitalization and is associated with long-term risk of readmissions and chronic kidney disease (CKD). Preclinical studies and novel urine biomarkers have demonstrated that subclinical inflammation and repair continue for several months after AKI. We conducted three clinical and translational studies to alleviate long-term sequelae after AKI. First, we assessed repair in deceased donor kidneys which can assist with organ allocation and reduce discard. In an ongoing study, organ procurement organizations are measuring repair biomarkers via lateral flow devices to assess organ quality and adding it to their workflow. Second, we performed research biopsies during AKI to interrogate kidney tissue with novel transcriptomic and proteomic techniques to advance therapeutic development. Third, we initiated pragmatic clinical trials to reduce readmissions after an episode of AKI by providing nurse navigator and pharmacist support to optimize blood pressure, fluid, and medication management.
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Rodrigues AM, Tanno MT, Contti MM, Nga HS, Valiatti MF, Costa SD, de Sandes-Freitas TV, Esmeraldo RDM, Assunção CM, Tassi JBC, Ferreira GF, Felipe CR, Medina Pestana JO, Silva HT, de Andrade LGM. Renal function at 12 months of kidney transplantation comparing tacrolimus and mycophenolate with tacrolimus and mTORi in donors with different KDPI ranges. A multicenter cohort study using propensity scoring. FRONTIERS IN TRANSPLANTATION 2023; 2:1279940. [PMID: 38993903 PMCID: PMC11235318 DOI: 10.3389/frtra.2023.1279940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/28/2023] [Indexed: 07/13/2024]
Abstract
Introduction The combination of tacrolimus/mTORi compared to tacrolimus/mycophenolate (MMF) was shown to be safe in the TRANSFORM trial. For donors with a high KDPI (Kidney Donor Profile Index), however, there are no data to support the effectiveness of this regimen. The main objective of this study was to explore the influence of the KDPI on 12-month renal function (eGFR) in patients receiving mTORi or MMF. Methods Multicenter cohort study of four Brazilian services that use the tacrolimus with mTORi as a protocol. Data from 2008 to 2018 of the tacrolimus/mycophenolate (MMF) and tacrolimus/mTORi (mTORi) regimens in renal transplant recipients over 18 years old were collected. For better homogeneity, the propensity score was used. Afterward, the method used for group selection ("match") was the K-nearest neighbor (KNN) method. New analyses were performed on this new balanced sample, and two different subsamples were constituted based on the median KDPI. Results The global analysis (n = 870) showed that the major determinant of worse kidney function was high KDPI. Afterward, the three strata were analyzed. In the first stratum (KDPI up to 50), 242 patients were evaluated, with 121 in each group. The eGFR was 64 ml/min/1.73 m2 in the mTORi group compared to 63 in the MMF group, p = 0.4, and when imputed eGFR was evaluated, 61 in the mTORi and 53 in the MMF, p = 0.065. In the second stratum (KDPI from 50 to 85), 282 patients were evaluated, with 141 in each group. eGFR was 46 ml/min/1.73 m2 in mTORi compared to 48 in MMF, p = 0.4, and when imputed eGFR was evaluated, 40 mTORi and 41 MMF, p = 0.8. In the last stratum (KDPI higher than 85) with n = 126 and 63 cases per group, eGFR was 36 ml/min/1.73 m2 in mTORi compared to 39 in MMF, p = 0.2, and when imputed eGFR was evaluated, 30 mTORi and 34 MMF, p = 0.2. Discussion The regimen using mTOR inhibitor is an effective and safe regimen when compared to the standard regimen. In addition, the scheme seems to offer additional protection against infections and may be an important ally in cases of high risk for these pathologies.
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Affiliation(s)
- Arlisson Macedo Rodrigues
- Division of Nephrology, Department of Internal Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Mariana Tavares Tanno
- Division of Nephrology, Department of Internal Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Mariana Moraes Contti
- Division of Nephrology, Department of Internal Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Hong Si Nga
- Division of Nephrology, Department of Internal Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Mariana Farina Valiatti
- Division of Nephrology, Department of Internal Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | | | | | | | | | | | | | - Claudia Rosso Felipe
- Division of Nephrology, Universidade Federal de São Paulo, Hospital do Rim, São Paulo, Brazil
| | | | - Helio Tedesco Silva
- Division of Nephrology, Universidade Federal de São Paulo, Hospital do Rim, São Paulo, Brazil
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Comai G, Corradetti V, Bini C, Tondolo F, Hu L, Valente S, Pasquinelli G, Malvi D, Vasuri F, Ravaioli M, Provenzano M, La Manna G. Histological findings of diabetic kidneys transplanted in non-diabetic recipients: a case series. Int Urol Nephrol 2023; 55:2611-2619. [PMID: 36940004 PMCID: PMC10499976 DOI: 10.1007/s11255-023-03552-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/09/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Diabetic donors are recognized as a reliable source of organs, although the discard rate of kidneys is still high. Few data are available on the histological evolution of these organs especially on kidneys transplanted into non-diabetic patients who remain euglycemic. METHODS We describe the histological evolution of ten kidney biopsies performed on non-diabetic recipients of diabetic donors. RESULTS Mean donor age was 69 ± 7 years, 60% were males. Two donors were treated with insulin, eight with oral antidiabetic drugs. Mean recipient age was 59.9 ± 7 years, 70% were males. The pre-existing diabetic lesions identified in the pre-implantation biopsies, encompassed all histological classes, and were associated with mild IF/TA and vascular damages. The median follow-up was 59.5 [IQR 32.5-99.0] months; at follow-up, 40% of cases did not change histologic classification, two patients with class IIb downgraded to IIa or I and one with class III downgraded to IIb. Conversely, three cases showed a worsening, from class 0 to I, I to IIb or from IIa to IIb. We also observed a moderate evolution of IF/TA and vascular damages. At follow-up visit, estimated GFR was stable (50.7 mL/min vs. 54.8 at baseline) and proteinuria was mild (51.1 ± 78.6 mg/day). CONCLUSIONS Kidneys from diabetic donors show variable evolution of the histologic features of diabetic nephropathy after transplant. This variability may be associated to recipients characteristics such as euglycemic milieu, in case of improvement, or obesity and hypertension, in case of worsening of histologic lesions.
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Affiliation(s)
- Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Valeria Corradetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Francesco Tondolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Lilio Hu
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Sabrina Valente
- Biotechnology and Methods in Laboratory Medicine, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gianandrea Pasquinelli
- Biotechnology and Methods in Laboratory Medicine, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
- Pathology Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Deborah Malvi
- Pathology Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Francesco Vasuri
- Pathology Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Matteo Ravaioli
- General Surgery and Transplantation Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Mas-Sarenti 9, 40138, Bologna, Italy
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy.
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS - Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Alma Mater Studiorum, University of Bologna, 40138, Bologna, Italy.
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Patel K, Brotherton A, Chaudhry D, Evison F, Nieto T, Dabare D, Sharif A. All Expanded Criteria Donor Kidneys are Equal But are Some More Equal Than Others? A Population-Cohort Analysis of UK Transplant Registry Data. Transpl Int 2023; 36:11421. [PMID: 37727380 PMCID: PMC10505656 DOI: 10.3389/ti.2023.11421] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023]
Abstract
Survival outcomes for kidney transplant candidates based on expanded criteria donor (ECD) kidney type is unknown. A retrospective cohort study was undertaken of prospectively collected registry data of all waitlisted kidney failure patients receiving dialysis in the United Kingdom. All patients listed for their first kidney-alone transplant between 2000-2019 were included. Treatment types included; living donor; standard criteria donor (SCD); ECD60 (deceased donor aged ≥60 years); ECD50-59 (deceased donor aged 50-59 years with two from the following three; hypertension; raised creatinine and/or death from stroke) or remains on dialysis. The primary outcome was all-cause mortality, with time-to-death from listing analyzed using time-dependent non-proportional Cox regression models. The study cohort comprised 47,917 waitlisted kidney failure patients, of whom 34,558 (72.1%) received kidney transplantation. ECD kidneys (n = 7,356) were stratified as ECD60 (n = 7,009) or ECD50-59 (n = 347). Compared to SCD, both ECD60 (Hazard Ratio 1.126, 95% CI 1.093-1.161) and ECD50-59 (Hazard Ratio 1.228, 95% CI 1.113-1.356) kidney recipients have higher all-cause mortality. However, compared to dialysis, both ECD60 (Hazard Ratio 0.194, 95% CI 0.187-0.201) and ECD50-59 (Hazard Ratio 0.218, 95% CI 0.197-0.241) kidney recipients have lower all-cause mortality. ECD kidneys, regardless of definition, provide equivalent and superior survival benefits in comparison to remaining waitlisted.
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Affiliation(s)
- Kamlesh Patel
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Anna Brotherton
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Daoud Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Felicity Evison
- Data Science Team, Research Development and Innovation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Thomas Nieto
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Dilan Dabare
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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11
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Foresto RD, Hazin MAA, Cassão BC, de Morais APA, Felipe CR, Requião-Moura LR, Medina Pestana J, Tedesco-Silva H. The Association Between Kidney Donor Profile Index and 1-y Graft Function. Transplant Direct 2023; 9:e1476. [PMID: 37090122 PMCID: PMC10118325 DOI: 10.1097/txd.0000000000001476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/16/2023] [Indexed: 04/25/2023] Open
Abstract
The association between Kidney Donor Profile Index (KDPI) and 1-y estimated glomerular filtration rate (eGFR) with long-term kidney graft survival is well known. Yet, the association between KDPI and 1-y eGFR remains uncertain considering the several concurrent competing risk factors. Methods This single-center, retrospective cohort study analyzed data from 3059 consecutive deceased donor kidney transplant recipients with a 1-y follow-up from January 2013 to December 2017. The aim was to determine the association between the KDPI strata (0%-35%, 36%-50%, 51%-85%, 86%-100%) and 1-y eGFR estimated by the CKD-EPI equation. Results The incidence of delayed graft function (50.6% versus 59.3% versus 62.7% versus 62.0%; P < 0.001) and cytomegalovirus infection (36.7% versus 36.6% versus 43.3% versus 57.8%; P < 0.001) increased with increasing KDPI strata but not biopsy-proven acute rejection (9.1% versus 9.8% versus 8.4% versus 9.1%; P = 0.736). The median 1-y eGFR decreased with increasing KDPI strata (64.8 versus 53.5 versus 46.9 versus 39.1 mL/min/1.73 m2; P < 0.001). In the Cox regression, the higher the KDPI was, the lower the probability of a lower 1-y eGFR was. Assuming the 0%-35% strata as the reference, the likelihood of eGFR <50 mL/min/1.73 m2 was increased by 76.6% (hazard ratio [HR] = 1.767, 95% confidence interval [CI] = 1.406-2.220), 2.24- and 2.87-fold higher for KDPI higher >35%-50% (HR = 2.239, 95% CI = 1.862-2.691), and >51%-85% (HR = 2.871, 95% CI = 2.361-3.491), respectively. Other variables associated with a lower graft function were donor sex (HR male versus female = 0.896, 95% CI = 0.813-0.989) and cold ischemia time (HR for each hour = 1.011, 95% CI = 1.004-1.019). This association was sustained after the Poisson mediation analysis, including delayed graft function, cytomegalovirus, and acute rejection as mediators. Conclusions In this cohort of deceased donor kidney recipients, KDPI, and cold ischemia time were the major independent risk factors associated with lower 1-y kidney function.
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Affiliation(s)
- Renato Demarchi Foresto
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Maria Amelia Aguiar Hazin
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Bianca Cristina Cassão
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Claudia Rosso Felipe
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Lucio R. Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - José Medina Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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12
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Darema M, Athanasopoulou D, Bellos I, Tsoumbou I, Vittoraki AG, Bokos J, Marinaki S, Boletis IN. Evaluation of Kidney Donor Risk Index/Kidney Donor Profile Index as Predictor Tools of Deceased-Donor Kidney Transplant Outcomes in a Greek Cohort. J Clin Med 2023; 12:jcm12062439. [PMID: 36983440 PMCID: PMC10054426 DOI: 10.3390/jcm12062439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
The Kidney Donor Risk Index (KDRI) and Kidney Donor Profile Index (KDPI) have been developed to assess deceased-donor graft quality, although validation of their utility outside the USA remains limited. This single-center retrospective cohort study evaluated the ability of KDRI and KDPI to predict transplant outcomes in a Greek cohort. The efficacy of KDRI, KDPI, and donor's age in predicting death-censored graft failure was primarily assessed. Overall, 394 donors and 456 recipients were included. Death-censored graft survival was significantly worse with increasing KDRI (hazard ratio-HR: 2.21, 95% confidence intervals-CI: 1.16-4.22), KDPI (HR: 1.01, 95% CI: 1.00-1.02), and donor's age (HR: 1.03, 95% CI: 1.00-1.05). The unadjusted discriminative ability was similar for KDPI (C-statistic: 0.54) and donor's age (C-statistic: 0.52). The KDPI threshold of 85 was not predictive of graft failure (p-value: 0.19). Higher KDPI was linked to delayed graft function and worse kidney function, but not among expanded-criteria donor transplantations. No significant association was found between KDRI, KDPI, and patient survival. In conclusion, increasing KDRI and KDPI are linked to worse graft function, although their ability to discriminate long-term graft failure remains limited.
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Affiliation(s)
- Maria Darema
- Department of Nephrology and Kidney Transplantation, Medical School, Laiko General Hospital of Athens, National and Kapodistrian University, 11527 Athens, Greece
| | - Diamanto Athanasopoulou
- Department of Nephrology and Kidney Transplantation, Medical School, Laiko General Hospital of Athens, National and Kapodistrian University, 11527 Athens, Greece
| | - Ioannis Bellos
- Department of Nephrology and Kidney Transplantation, Medical School, Laiko General Hospital of Athens, National and Kapodistrian University, 11527 Athens, Greece
| | - Ioanna Tsoumbou
- Department of Nephrology and Kidney Transplantation, Medical School, Laiko General Hospital of Athens, National and Kapodistrian University, 11527 Athens, Greece
| | - Angeliki G Vittoraki
- Immunology Department & National Tissue Typing Center, General Hospital of Athens "G. Gennimatas", 11527 Athens, Greece
| | - John Bokos
- Transplantation Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Smaragdi Marinaki
- Department of Nephrology and Kidney Transplantation, Medical School, Laiko General Hospital of Athens, National and Kapodistrian University, 11527 Athens, Greece
| | - Ioannis N Boletis
- Department of Nephrology and Kidney Transplantation, Medical School, Laiko General Hospital of Athens, National and Kapodistrian University, 11527 Athens, Greece
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13
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Merzkani M, Chang SH, Murad H, Lentine KL, Mattu M, Wang M, Hu V, Wang B, Al-Hosni Y, Alzahabi O, Alomar O, Wellen J, Alhamad T. The association of center volume with transplant outcomes in selected high-risk groups in kidney transplantation. BMC Nephrol 2023; 24:61. [PMID: 36941609 PMCID: PMC10029277 DOI: 10.1186/s12882-023-03099-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 02/27/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND In context of increasing complexity and risk of deceased kidney donors and transplant recipients, the impact of center volume (CV) on the outcomes of high-risk kidney transplants(KT) has not been well determined. METHODS We examined the association of CV and outcomes among 285 U.S. transplant centers from 2000-2016. High-risk KT were defined as recipient age ≥ 70 years, body mass index (BMI) ≥ 35 kg/m2, receiving kidneys from donors with kidney donor profile index(KDPI) ≥ 85%, acute kidney injury(AKI), hepatitisC + . Average annual CV for the specific-high-risk KT categorized in tertiles. Death-Censored-Graft-Loss(DCGL) and death at 3 months, 1, 5, and 10 years were compared between CV tertiles using Cox-regression models. RESULTS Two hundred fifty thousand five hundred seventy-four KT were analyzed. Compared to high CV, recipients with BMI ≥ 35 kg/m2 had higher risk of DCGL in low CV(aHR = 1.11,95%CI = 1.03-1.19) at 10 years; recipients with age ≥ 70 years had higher risk of death in low CV(aHR = 1.07,95%CI = 1.01-14) at 10 years. There was no difference of DCGL or death in low CV for donors with KDPI ≥ 85%, hepatitisC + , or AKI. CONCLUSIONS Recipients of high-risk KT with BMI ≥ 35 kg/m2 have higher risk of DCGL and recipients age ≥ 70 years have higher risk of death in low CV, compared to high CV. Future studies should identify care practices associated with CV that support optimal outcomes after KT.
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Affiliation(s)
- Massini Merzkani
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Haris Murad
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, MO, USA
| | - Munis Mattu
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Mei Wang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Vangie Hu
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Bolin Wang
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Yazen Al-Hosni
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Obadah Alzahabi
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Omar Alomar
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA
| | - Jason Wellen
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, 4523 Clayton Ave. CB 8126, St. Louis, MO, 63110, USA.
- Transplant Epidemiology Research Collaboration (TERC), Institute of Public Health, Washington University School of Medicine, St. Louis, MO, USA.
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14
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Miller G, Ankerst DP, Kattan MW, Hüser N, Vogelaar S, Tieken I, Heemann U, Assfalg V. Kidney Transplantation Outcome Predictions (KTOP): A Risk Prediction Tool for Kidney Transplants from Brain-dead Deceased Donors Based on a Large European Cohort. Eur Urol 2023; 83:173-179. [PMID: 35000822 DOI: 10.1016/j.eururo.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND European kidney donation shortages mandate efficient organ allocation by optimizing the prediction of success for individual recipients. OBJECTIVE To develop the first European online risk tool for kidney transplant outcomes on the basis of recipient-only and recipient plus donor characteristics. DESIGN, SETTING, AND PARTICIPANTS We used individual recipient and donor risk factors and three outcomes (death, death with functioning graft [DWFG], and graft loss) for 32 958 transplants within the Eurotransplant kidney allocation system and the Eurotransplant senior program between January 2006 and May 2018 in eight European countries to develop and validate a risk tool. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cox proportional-hazards models were used to analyze the association of risk factors with overall patient mortality, and proportional subdistribution hazard regression models for their association with graft loss and DWFG. Prediction models were developed with recipient-only and recipient-donor risk factors. Sensitivity analyses based on time-specific area under the receiver operating characteristic curve (AUC) with leave-one-country-out validation were performed and calibration plots were generated. RESULTS AND LIMITATIONS The 10-yr cumulative incidence rate was 37% for mortality, 12% for DWFG, and 41% for graft loss. In recipient-donor models the leading risk factors for mortality were recipient diabetes (hazard ratio [HR] 10.73), retransplantation (HR 3.08 per transplant), and recipient age (HR 1.08). Effects were similar for DWFG. For graft loss, diabetes (subdistributional HR [SHR] 1.32), increased donor age (SHR 1.02), and prolonged cold ischemia time (SHR 1.02) had increased SHRs. All p values were <0.001. CONCLUSIONS Previously identified risk factors for outcomes following kidney transplants allow for outcome prediction with 10-yr AUC values of up to 0.81. PATIENT SUMMARY Using European data, we estimated individual risks to predict the success of kidney transplants and support physicians in decision-making. An online tool is now available (https://riskcalc.org/ktop/) for predicting kidney transplant outcomes both before and after a donor has been identified.
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Affiliation(s)
- Gregor Miller
- Department of Mathematics, Technical University of Munich, Garching, Germany.
| | - Donna P Ankerst
- Department of Mathematics, Technical University of Munich, Garching, Germany; Department of Life Science Systems, Munich Data Science Institute, Technical University of Munich, Freising, Germany
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Norbert Hüser
- TransplanTUM - Munich Transplant Center, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Serge Vogelaar
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Ineke Tieken
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Uwe Heemann
- TransplanTUM - Munich Transplant Center, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Volker Assfalg
- TransplanTUM - Munich Transplant Center, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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15
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Comparison of Survival in Recipients of Marginal and Standard Cadaveric Donor Kidneys. Transplant Proc 2023; 55:87-92. [PMID: 36517286 DOI: 10.1016/j.transproceed.2022.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/08/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Renal transplantation is the main treatment for end-stage renal disease and has rapidly increased in number over the past 3 decades, leading to an increasing need for organs. The disparity between organ access and the number of patients on the waiting list has led transplant surgeons to use marginal cadaveric donors. As a consequence, the concept of "marginal cadaveric kidney donor" has been developed. METHODS We retrospectively evaluated 120 patients who received kidneys from cadaveric donors between September 2009 and August 2021. The donors were divided into standard and marginal cadaveric donors, and their age, sex, cause of death, criteria of acceptance as marginal donors, and Kidney Donor Profile Index (KDPI) were recorded RESULTS: The donors included 69 men and 51 women, with a mean age of 52.9 ± 16.8 years. There were 52 standard donors and 68 marginal donors. Graft and donor survival were compared based on the KDPI values of the donors, and were respectively found to be higher in those with a KDPI of 0 to 60 than in those with a KDPI of 81 to 100 (P = .011 and .039, respectively). There was no significant difference between those with a KDPI of 61 to 80 and the other groups. CONCLUSIONS Expanded criteria donor organs, which offer greater survival benefits than hemodialysis, can be used safely to meet the increasing need for donors. Expanded criteria donor organs should thus be considered a valuable alternative in this patient group.
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16
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Characteristics of Kidney Recipients of High Kidney Donor Profile Index Kidneys as Identified by Machine Learning Consensus Clustering. J Pers Med 2022; 12:jpm12121992. [PMID: 36556213 PMCID: PMC9782675 DOI: 10.3390/jpm12121992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Our study aimed to characterize kidney transplant recipients who received high kidney donor profile index (KDPI) kidneys using unsupervised machine learning approach. Methods: We used the OPTN/UNOS database from 2010 to 2019 to perform consensus cluster analysis based on recipient-, donor-, and transplant-related characteristics in 8935 kidney transplant recipients from deceased donors with KDPI ≥ 85%. We identified each cluster’s key characteristics using the standardized mean difference of >0.3. We compared the posttransplant outcomes among the assigned clusters. Results: Consensus cluster analysis identified 6 clinically distinct clusters of kidney transplant recipients from donors with high KDPI. Cluster 1 was characterized by young, black, hypertensive, non-diabetic patients who were on dialysis for more than 3 years before receiving kidney transplant from black donors; cluster 2 by elderly, white, non-diabetic patients who had preemptive kidney transplant or were on dialysis less than 3 years before receiving kidney transplant from older white donors; cluster 3 by young, non-diabetic, retransplant patients; cluster 4 by young, non-obese, non-diabetic patients who received dual kidney transplant from pediatric, black, non-hypertensive non-ECD deceased donors; cluster 5 by low number of HLA mismatch; cluster 6 by diabetes mellitus. Cluster 4 had the best patient survival, whereas cluster 3 had the worst patient survival. Cluster 2 had the best death-censored graft survival, whereas cluster 4 and cluster 3 had the worst death-censored graft survival at 1 and 5 years, respectively. Cluster 2 and cluster 4 had the best overall graft survival at 1 and 5 years, respectively, whereas cluster 3 had the worst overall graft survival. Conclusions: Unsupervised machine learning approach kidney transplant recipients from donors with high KDPI based on their pattern of clinical characteristics into 6 clinically distinct clusters.
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17
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Lung Transplantation Advanced Prediction Tool: Determining Recipient's Outcome for a Certain Donor. Transplantation 2022; 106:2019-2030. [PMID: 35389371 PMCID: PMC9521589 DOI: 10.1097/tp.0000000000004131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many risk-prediction models for lung transplantation are centered on recipient characteristics and do not account for impact of donor and transplant-related factors or only examine short-term outcomes (eg, predicted 1-y survival). We sought to develop a comprehensive model guiding recipient-donor matching. METHODS We identified double lung transplant recipients (≥12 y old) in the United Network for Organ Sharing Registry (2005-2020) to develop a risk scoring tool. Cohort was divided into derivation and validation sets. A total of 42 recipient, donor, and transplant factors were included in the analysis. Lasso method was used for variable selection. Survival was estimated using Cox-proportional hazard models. An interactive web-based tool was developed for clinical use. RESULTS A derivation cohort (n = 10 660) informed the model with 13-recipient, 4-donor, and 2-transplant variables. Adjusted risk scores were computed for every transplant and grouped into 3 clusters. Model-estimated survival probabilities were similar to the observed in the validation cohort (n = 4464) for all clusters. The mortality increases for medium- and high-risk groups was similar in both derivation and validation cohorts (C statistics for 1-, 5-, and 10-y survival were 0.67, 0.64, and 0.72, respectively). The web-based application estimated 1-, 5-, 10-y survival and half-life for low- (92%, 73%, 52%; 10.5 y), medium- (89%, 62%, 38%; 7.3 y), and high-risk clusters (85%, 52%, 26%; 5.2 y). CONCLUSIONS Advanced methods incorporating machine/deep learning led to a risk scoring model (including recipient, donor, and transplant factors) and a web-based clinical tool providing short- and long-term survival probabilities for recipient-donor matches. This will enable risk-based matching that could improve utilization of and benefit from a limited donor pool.
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18
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Dynamic Parameters of Hypothermic Machine Perfusion-An Image of Initial Graft Function in Adult Kidney Transplantation? J Clin Med 2022; 11:jcm11195698. [PMID: 36233566 PMCID: PMC9571023 DOI: 10.3390/jcm11195698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/16/2022] Open
Abstract
Kidney allografts are subjected to ischemia reperfusion injury during the process of transplantation. Hypothermic machine perfusion (HMP) of deceased donor kidneys from organ procurement until transplantation is associated with a superior outcome when compared to static cold storage (SCS). Nevertheless, cold ischemia time (CIT) remains an independent risk factor for delayed graft function (DGF) in HMP-preserved kidney allografts as well. We performed a retrospective single-center study including all adult recipients who underwent deceased donor kidney-only transplantation at our center between January 2019 and December 2020. Beside the clinicopathological donor and recipient data, flow and resistance data during HMP were assessed. Short- and long-term kidney allograft outcome after end-ischemic HMP and SCS were analyzed and compared. Organ preservation consisted of either SCS (n = 88) or HMP (n = 45). There were no differences in recipient demographics and donor details between groups. CIT was significantly longer in the HMP group (16.5 [8.5−28.5] vs. 11.3 [5.4−24.1], p < 0.0001). The incidence of DGF as well as serum creatinine at discharge and at 1 year post transplant were comparable between groups. Duration of SCS prior to HMP was comparable among grafts with and without DGF. Flow rate and organ resistance at the start of HMP were significantly worse in DGF-kidney grafts (arterial flow 22.50 [18.00−48.00] vs. 51.83 [25.50−92.67] ml/min, p = 0.0256; organ resistance 123.33 [57.67−165.50] vs. 51.33 [28.17−111.50] mmHg/mL/min, p = 0.0050). Recipients with DGF had significantly worse creatinine levels at discharge (2.54 [1.08−7.64] vs. 1.67 [0.90−6.56], p < 0.0001) and at 1 year post transplant (1.80 [1.09−7.95] vs. 1.59 [0.87−7.40], p = 0.0105). In conclusion, baseline HMP parameters could be applied as a predictive tool for initial graft function, which in turn determines long-term outcome.
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Molinari M, Kaltenmeier C, Liu H, Ashwat E, Jorgensen D, Puttarajappa C, Wu CM, Mehta R, Sood P, Shah N, Sharma A, Thompson A, Reddy D, Hariharan S. Function and longevity of renal grafts from high-KDPI donors. Clin Transplant 2022; 36:e14759. [PMID: 35778369 PMCID: PMC9786736 DOI: 10.1111/ctr.14759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND High kidney-donor profile index (KDPI) kidneys have a shorter survival than grafts with lower KDPI values. It is still unclear, however, whether their shorter longevity depends on an inferior baseline function, faster functional decline, or the combination of both. METHODS We analyzed the estimated glomerular filtration rate (eGFR) of 605 consecutive recipients of deceased donor kidney transplants (KT) at 1, 3, 6, 12, 18, 24, 36, 48, and 60 months. Comparisons were performed among four groups based on KDPI quartile: Group I-KDPI ≤ 25% (n = 151), Group II-KDPI 26-50% (n = 182), Group III-KDPI 51-75% (n = 176), and Group IV-KDPI 〉 75% (n = 96). Linear mixed model analysis was subsequently used to assess whether KDPI was independently associated with the decline in eGFR during the first 5-years after KT. We also analyzed the incidence of delayed graft function (DGF), rejection within the first year after KT, patient survival, graft survival, and death censored graft survival based on KDPI group. FINDINGS High-KDPI grafts had lower eGFR immediately after KT, had a higher incidence of DGF and rejection. However, there were no signifcant differences in the adjusted rate (slope) of decline in eGFR among the four KDPI groups (P = .06). Although patient survival was signigicantly lower for recipients of high-KDPI grafts, death-censored graft survival was similar among the four KDPI groups (P = .33). CONCLUSIONS The shorter functional survival of high-KDPI grafts seems to be due to their lower baseline eGFR rather than a more rapid functional decline after KT.
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Affiliation(s)
- Michele Molinari
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Christof Kaltenmeier
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Hao Liu
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Eishan Ashwat
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Dana Jorgensen
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA,Biostatistics, Division of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Chethan Puttarajappa
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Christine M. Wu
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Rajil Mehta
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Puneet Sood
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Nirav Shah
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Akhil Sharma
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Ann Thompson
- Department of SurgeryDivision of TransplantationUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Dheera Reddy
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Sundaram Hariharan
- Department of MedicineDivision of NephrologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
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20
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Sharif A. Deceased Donor Characteristics and Kidney Transplant Outcomes. Transpl Int 2022; 35:10482. [PMID: 36090778 PMCID: PMC9452640 DOI: 10.3389/ti.2022.10482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the therapy of choice for people living with kidney failure who are suitable for surgery. However, the disparity between supply versus demand for organs means many either die or are removed from the waiting-list before receiving a kidney allograft. Reducing unnecessary discard of deceased donor kidneys is important to maximize utilization of a scarce and valuable resource but requires nuanced decision-making. Accepting kidneys from deceased donors with heterogenous characteristics for waitlisted kidney transplant candidates, often in the context of time-pressured decision-making, requires an understanding of the association between donor characteristics and kidney transplant outcomes. Deceased donor clinical factors can impact patient and/or kidney allograft survival but risk-versus-benefit deliberation must be balanced against the morbidity and mortality associated with remaining on the waiting-list. In this article, the association between deceased kidney donor characteristics and post kidney transplant outcomes for the recipient are reviewed. While translating this evidence to individual kidney transplant candidates is a challenge, emerging strategies to improve this process will be discussed. Fundamentally, tools and guidelines to inform decision-making when considering deceased donor kidney offers will be valuable to both professionals and patients.
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Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Adnan Sharif,
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21
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Molecular Markers of Kidney Transplantation Outcome: Current Omics Tools and Future Developments. Int J Mol Sci 2022; 23:ijms23116318. [PMID: 35682996 PMCID: PMC9181061 DOI: 10.3390/ijms23116318] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
Purpose of review: The emerging field of molecular predictive medicine is aiming to change the traditional medical approach in renal transplantation. Many studies have explored potential biomarker molecules with predictive properties in renal transplantation, issued from omics research. Herein, we review the biomarker molecules of four technologies (i.e., Genomics, Transcriptomics, Proteomics, and Metabolomics) associated with favorable kidney transplant outcomes. Recent findings: Several panels of molecules have been associated with the outcome that the majority of markers are related to inflammation and immune response; although. other molecular ontologies are also represented, such as proteasome, growth, regeneration, and drug metabolism. Throughout this review, we highlight the lack of properly validated statistical demonstration. Indeed, the most preeminent molecular panels either remain at the limited size study stage or are not confirmed during large-scale studies. At the core of this problem, we identify the methodological shortcomings and propose a comprehensive workflow for discovery and validation of molecular biomarkers that aims to improve the relevance of these tools in the future. Summary: Overall, adopting a patient management through omics approach could bring remarkable improvement to transplantation success. An increased effort and investment between scientists, medical biologists, and clinicians seem to be the path toward a proper solution.
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22
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Romann S, Wagner T, Katou S, Reuter S, Vogel T, Becker F, Morgul H, Houben P, Wahl P, Pascher A, Radunz S. Hyperspectral Imaging for Assessment of Initial Graft Function in Human Kidney Transplantation. Diagnostics (Basel) 2022; 12:diagnostics12051194. [PMID: 35626349 PMCID: PMC9139834 DOI: 10.3390/diagnostics12051194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 01/27/2023] Open
Abstract
The aim of our study was to evaluate hyperspectral imaging (HSI) as a rapid, non-ionizing technique for the assessment of organ quality and the prediction of delayed graft function (DGF) in kidney transplantation after static cold storage (SCS, n = 20), as well as hypothermic machine perfusion (HMP, n = 18). HSI assessment of the kidney parenchyma was performed during organ preservation and at 10 and 30 min after reperfusion using the TIVITA® Tissue System (Diaspective Vision GmbH, Am Salzhaff, Germany), calculating oxygen saturation (StO2), near-infrared perfusion index (NIR), tissue haemoglobin index (THI), and tissue water index (TWI). Recipient and donor characteristics were comparable between organ preservation groups. Cold ischemic time was significantly longer in the HMP group (14.1 h [3.6–23.1] vs. 8.7h [2.2–17.0], p = 0.002). The overall presence of DGF was comparable between groups (HMP group n = 10 (55.6%), SCS group n = 10 (50.0%)). Prediction of DGF was possible in SCS and HMP kidneys; StO2 at 10 (50.00 [17.75–76.25] vs. 63.17 [27.00–77.75]%, p = 0.0467) and 30 min (57.63 [18.25–78.25] vs. 65.38 [21.25–83.33]%, p = 0.0323) after reperfusion, as well as NIR at 10 (41.75 [1.0–58.00] vs. 48.63 [12.25–69.50], p = 0.0137) and 30 min (49.63 [8.50–66.75] vs. 55.80 [14.75–73.25], p = 0.0261) after reperfusion were significantly lower in DGF kidneys, independent of the organ preservation method. In conclusion, HSI is a reliable method for intraoperative assessment of renal microperfusion, applicable after organ preservation through SCS and HMP, and predicts the development of DGF.
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Affiliation(s)
- Sophie Romann
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Tristan Wagner
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Shadi Katou
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Stefan Reuter
- Department of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, 48149 Münster, Germany;
| | - Thomas Vogel
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Felix Becker
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Haluk Morgul
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Philipp Houben
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Philip Wahl
- Diaspective Vision GmbH, 18233 Am Salzhaff, Germany;
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
| | - Sonia Radunz
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Münster, Germany; (S.R.); (T.W.); (S.K.); (T.V.); (F.B.); (H.M.); (P.H.); (A.P.)
- Correspondence: ; Tel.: +49-2151-8351765
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23
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Bachmann Q, Haberfellner F, Büttner-Herold M, Torrez C, Haller B, Assfalg V, Renders L, Amann K, Heemann U, Schmaderer C, Kemmner S. The Kidney Donor Profile Index (KDPI) Correlates With Histopathologic Findings in Post-reperfusion Baseline Biopsies and Predicts Kidney Transplant Outcome. Front Med (Lausanne) 2022; 9:875206. [PMID: 35573025 PMCID: PMC9100560 DOI: 10.3389/fmed.2022.875206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background The increasing organ shortage in kidney transplantation leads to the necessity to use kidneys previously considered unsuitable for transplantation. Numerous studies illustrate the need for a better decision guidance rather than only the classification into kidneys from standard or expanded criteria donors referred to as SCD/ECD-classification. The kidney donor profile index (KDPI) exhibits a score utilizing a much higher number of donor characteristics. Moreover, graft biopsies provide an opportunity to assess organ quality. Methods In a single center analysis 383 kidney transplantations (277 after deceased and 106 after living donation) performed between January 1st, 2006, and December 31st, 2016, retrospectively underwent SCD/ECD and KDPI scoring. Thereby, the quality of deceased donor kidneys was assessed by using the KDPI and the living donor kidneys by using the living KDPI, in the further analysis merged as (L)KDPI. Baseline biopsies taken 10 min after the onset of reperfusion were reviewed for chronic and acute lesions. Survival analyses were performed using Kaplan-Meier analysis and Cox proportional hazards analysis within a 5-year follow-up. Results The (L)KDPI correlated with glomerulosclerosis (r = 0.30, p < 0.001), arteriosclerosis (r = 0.33, p < 0.001), interstitial fibrosis, and tubular atrophy (r = 0.28, p < 0.001) as well as the extent of acute tubular injury (r = 0.20, p < 0.001). The C-statistic of the (L)KDPI concerning 5-year death censored graft survival was 0.692. Around 48% of ECD-kidneys were classified as (L)KDPI<85%. In a multivariate Cox proportional hazard analysis including (preformed) panel reactive antibodies, cold ischemia time, (L)KDPI, and SCD/ECD-classification, the (L)KDPI was significantly associated with risk of graft loss (hazard ratio per 10% increase in (L)KDPI: 1.185, 95% confidence interval: 1.033–1.360, p = 0.025). Survival analysis revealed decreased death censored (p < 0.001) and non-death censored (p < 0.001) graft survival in kidneys with an increasing (L)KDPI divided into groups of <35, 35–85, and >85%, respectively. Conclusion With a higher granularity compared to the SCD/ECD-classification the (L)KDPI is a promising tool to judge graft quality. The correlation with chronic and acute histological lesions in post-reperfusion kidney biopsies underlines the descriptive value of the (L)KDPI. However, its prognostic value is limited and underlines the urgent need for a more precise prognostic tool adopted to European kidney transplant conditions.
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Affiliation(s)
- Quirin Bachmann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Flora Haberfellner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Carlos Torrez
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- School of Medicine, Institute of AI and Informatics in Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Volker Assfalg
- Department of Surgery, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephan Kemmner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- *Correspondence: Stephan Kemmner
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24
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Beyond Graft Survivl: A National Cohort Study Quantifying the Impact of Increasing Kidney Donor Profile Index on Recipient Outcomes 1 Year Post-transplantation. Transplant Direct 2022; 8:e1308. [PMID: 35474655 PMCID: PMC9029898 DOI: 10.1097/txd.0000000000001308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 01/29/2022] [Indexed: 11/26/2022] Open
Abstract
Background. The reporting of a locally validated kidney donor profile index (KDPI) began in Australia in 2016. Across diverse populations, KDPI has demonstrated utility in predicting allograft survival and function. A metric that incorporates both elements may provide a more comprehensive picture of suboptimal recipient outcomes. Methods. A retrospective cohort study of adult kidney transplant recipients in Australia (January 2009 to December 2014) was conducted. Conventional recipient outcomes and a composite measure of suboptimal outcome (1-y allograft failure or estimated glomerular filtration rate [eGFR] <30 mL/min) were evaluated across KDPI intervals (KDPI quintiles and 5-point increments in the KDPI 81–100 cohort). The impact of increasing KDPI on allograft function (1-y eGFR) and a suboptimal outcome was explored using multivariable regression models, adjusting for potential confounding factors. Results. In 2923 donor kidneys eligible for analysis, median KDPI was 54 (interquartile range [IQR], 31–77), and Kidney Donor Risk Index was 1.39 (IQR, 1.03–1.67). The median 1-y eGFR was 52.74 mL/min (IQR, 40.79–66.41 mL/min). Compared with the first quintile reference group, progressive reductions in eGFR were observed with increasing KDPI and were maximal in the fifth quintile (adjusted β-coefficient: −27.43 mL/min; 95% confidence interval, –29.44 to –25.42; P < 0.001). A suboptimal outcome was observed in 359 recipients (12.3%). The adjusted odds for this outcome increased across quintiles from a baseline of odds ratio of 1.00 (first quintile) to odds ratio of 11.68 (95% confidence interval, 6.33-21.54, P < 0.001) in the fifth quintile cohort. Conclusions. Increases in donor KDPI were associated with higher probabilities of a suboptimal outcome and poorer baseline allograft function, particularly in the KDPI > 80 cohort. These findings may inform pretransplant discussions with potential recipients of high-KDPI allografts.
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25
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A Review of Current and Emerging Trends in Donor Graft-Quality Assessment Techniques. J Clin Med 2022; 11:jcm11030487. [PMID: 35159939 PMCID: PMC8836899 DOI: 10.3390/jcm11030487] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 02/07/2023] Open
Abstract
The number of patients placed on kidney transplant waiting lists is rapidly increasing, resulting in a growing gap between organ demand and the availability of kidneys for transplantation. This organ shortage has forced medical professionals to utilize marginal kidneys from expanded criteria donors (ECD) to broaden the donor pool and shorten wait times for patients with end-stage renal disease. However, recipients of ECD kidney grafts tend to have worse outcomes compared to those receiving organs from standard criteria donors (SCD), specifically increased risks of delayed graft function (DGF) and primary nonfunction incidence. Thus, representative methods for graft-quality assessment are strongly needed, especially for ECDs. Currently, graft-quality evaluation is limited to interpreting the donor’s recent laboratory tests, clinical risk scores, the visual evaluation of the organ, and, in some cases, a biopsy and perfusion parameters. The last few years have seen the emergence of many new technologies designed to examine organ function, including new imaging techniques, transcriptomics, genomics, proteomics, metabolomics, lipidomics, and new solutions in organ perfusion, which has enabled a deeper understanding of the complex mechanisms associated with ischemia-reperfusion injury (IRI), inflammatory process, and graft rejection. This review summarizes and assesses the strengths and weaknesses of current conventional diagnostic methods and a wide range of new potential strategies (from the last five years) with respect to donor graft-quality assessment, the identification of IRI, perfusion control, and the prediction of DGF.
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26
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Li X, Davis RC, Xu Y, Wang Z, Souma N, Sotolongo G, Bell J, Ellis M, Howell D, Shen X, Lafata KJ, Barisoni L. Deep learning segmentation of glomeruli on kidney donor frozen sections. J Med Imaging (Bellingham) 2021; 8:067501. [PMID: 34950750 PMCID: PMC8685284 DOI: 10.1117/1.jmi.8.6.067501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/08/2021] [Indexed: 10/15/2023] Open
Abstract
Purpose: Recent advances in computational image analysis offer the opportunity to develop automatic quantification of histologic parameters as aid tools for practicing pathologists. We aim to develop deep learning (DL) models to quantify nonsclerotic and sclerotic glomeruli on frozen sections from donor kidney biopsies. Approach: A total of 258 whole slide images (WSI) from cadaveric donor kidney biopsies performed at our institution ( n = 123 ) and at external institutions ( n = 135 ) were used in this study. WSIs from our institution were divided at the patient level into training and validation datasets (ratio: 0.8:0.2), and external WSIs were used as an independent testing dataset. Nonsclerotic ( n = 22767 ) and sclerotic ( n = 1366 ) glomeruli were manually annotated by study pathologists on all WSIs. A nine-layer convolutional neural network based on the common U-Net architecture was developed and tested for the segmentation of nonsclerotic and sclerotic glomeruli. DL-derived, manual segmentation, and reported glomerular count (standard of care) were compared. Results: The average Dice similarity coefficient testing was 0.90 and 0.83. And the F 1 , recall, and precision scores were 0.93, 0.96, and 0.90, and 0.87, 0.93, and 0.81, for nonsclerotic and sclerotic glomeruli, respectively. DL-derived and manual segmentation-derived glomerular counts were comparable, but statistically different from reported glomerular count. Conclusions: DL segmentation is a feasible and robust approach for automatic quantification of glomeruli. We represent the first step toward new protocols for the evaluation of donor kidney biopsies.
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Affiliation(s)
- Xiang Li
- Duke University, Department of Electrical and Computer Engineering, Durham, North Carolina, United States
| | - Richard C. Davis
- Duke University, Department of Pathology, Division of AI and Computational Pathology, Durham, North Carolina, United States
| | - Yuemei Xu
- Duke University, Department of Pathology, Division of AI and Computational Pathology, Durham, North Carolina, United States
- Nanjing Drum Tower Hospital, Department of Pathology, Nanjing, China
| | - Zehan Wang
- Duke University, Department of Biomedical Engineering, Durham, North Carolina, United States
| | - Nao Souma
- Duke University, Department of Medicine, Division of Nephrology, Durham, North Carolina, United States
| | - Gina Sotolongo
- Duke University, Department of Pathology, Division of AI and Computational Pathology, Durham, North Carolina, United States
| | - Jonathan Bell
- Duke University, Department of Pathology, Division of AI and Computational Pathology, Durham, North Carolina, United States
| | - Matthew Ellis
- Duke University, Department of Medicine, Division of Nephrology, Durham, North Carolina, United States
- Duke University, Department of Surgery, Durham, North Carolina, United States
| | - David Howell
- Duke University, Department of Pathology, Division of AI and Computational Pathology, Durham, North Carolina, United States
| | - Xiling Shen
- Duke University, Department of Biomedical Engineering, Durham, North Carolina, United States
| | - Kyle J. Lafata
- Duke University, Department of Electrical and Computer Engineering, Durham, North Carolina, United States
- Duke University, Department of Radiation Oncology, Durham, North Carolina, United States
- Duke University, Department of Radiology, Durham, North Carolina, United States
| | - Laura Barisoni
- Duke University, Department of Pathology, Division of AI and Computational Pathology, Durham, North Carolina, United States
- Duke University, Department of Medicine, Division of Nephrology, Durham, North Carolina, United States
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Thölking G, Filensky B, Jehn U, Schütte-Nütgen K, Koch R, Kurschat C, Pavenstädt H, Suwelack B, Reuter S, Kuypers D. Increased renal function decline in fast metabolizers using extended-release tacrolimus after kidney transplantation. Sci Rep 2021; 11:15606. [PMID: 34341448 PMCID: PMC8329201 DOI: 10.1038/s41598-021-95201-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/20/2021] [Indexed: 11/09/2022] Open
Abstract
Fast metabolism of immediate-release tacrolimus (IR-Tac) is associated with decreased kidney function after renal transplantation (RTx) compared to slow metabolizers. We hypothesized, by analogy, that fast metabolism of extended-release tacrolimus (ER-Tac) is associated with worse renal function. We analyzed data from patients who underwent RTx at three different transplant centers between 2007 and 2016 and received an initial immunosuppressive regimen with ER-Tac, mycophenolate, and a corticosteroid. Three months after RTx, a Tac concentration to dose ratio (C/D ratio) < 1.0 ng/ml · 1/mL defined fast ER-Tac metabolism and ≥ 1.0 ng/ml · 1/mL slow metabolism. Renal function (estimated glomerular filtration rate, eGFR), first acute rejection (AR), conversion from ER-Tac, graft and patient survival were observed up to 60-months. 610 RTx patients were divided into 192 fast and 418 slow ER-Tac metabolizers. Fast metabolizers showed a decreased eGFR at all time points compared to slow metabolizers. The fast metabolizer group included more patients who were switched from ER-Tac (p < 0.001). First AR occurred more frequently (p = 0.008) in fast metabolizers, while graft and patient survival rates did not differ between groups (p = 0.529 and p = 0.366, respectively). Calculation of the ER-Tac C/D ratio early after RTx may facilitate individualization of immunosuppression and help identify patients at risk for an unfavorable outcome.
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Affiliation(s)
- Gerold Thölking
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, 48565, Steinfurt, Germany.
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital of Münster, Münster, Germany.
| | - Brigitte Filensky
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, 48565, Steinfurt, Germany
| | - Ulrich Jehn
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital of Münster, Münster, Germany
| | - Katharina Schütte-Nütgen
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital of Münster, Münster, Germany
| | - Raphael Koch
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Christine Kurschat
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - Hermann Pavenstädt
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital of Münster, Münster, Germany
| | - Barbara Suwelack
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital of Münster, Münster, Germany
| | - Stefan Reuter
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital of Münster, Münster, Germany
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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28
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Raghavan D, Tomacruz IDV, Hall IE. Deceased-Donor Kidneys: Is Past Performance an Indicator of Future Transplant Success? Kidney Int Rep 2021; 6:2025-2027. [PMID: 34386650 PMCID: PMC8344110 DOI: 10.1016/j.ekir.2021.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/07/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Divya Raghavan
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Isabelle Dominique V. Tomacruz
- Division of Nephrology, Department of Medicine, Philippine General Hospital, University of the Philippines Manila, Metro Manila, Philippines
| | - Isaac E. Hall
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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29
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Impaired renal function before kidney procurement has a deleterious impact on allograft survival in very old deceased kidney donors. Sci Rep 2021; 11:12226. [PMID: 34108573 PMCID: PMC8190122 DOI: 10.1038/s41598-021-91843-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/24/2021] [Indexed: 11/16/2022] Open
Abstract
As the use of elderly kidney donors for transplantation is increasing with time, there is a need to understand which factors impact on their prognosis. No data exist on the impact of an impaired renal function (IRF) in such population. 116 kidney recipients from deceased kidney donors over 70 years were included from 2005 to 2015 in a single-center retrospective study. IRF before organ procurement was defined as a serum creatinine above 1.0 mg/dl or a transient episode of oligo-anuria. Mean ages for donors and recipients were respectively 74.8 ± 3.5 and 66.7 ± 8.0. Graft survival censored for death at 5 years was of 77%. Using a multivariate analysis by Cox model, the only predictor of graft loss present in the donor was IRF before organ procurement (HR 4.2 CI95[1.8–9.7]). IRF was also associated with significant lower estimated glomerular filtration rates up to 1 year post-transplantation. By contrast, KDPI score (median of 98 [96–100]), was not associated with the risk of graft failure. Then, IRF before kidney procurement may define a risk subgroup among very-old deceased kidney donors, in whom pre-implantatory biopsies, dual kidney transplantation or calcineurin inhibitor-free immunosuppressive regimen could help to improve outcomes.
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30
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Tumor Recurrence and Graft Survival in Renal Transplant Recipients with a History of Pretransplant Malignancy: A Matched Pair Analysis. J Clin Med 2021; 10:jcm10112349. [PMID: 34071904 PMCID: PMC8199231 DOI: 10.3390/jcm10112349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/15/2022] Open
Abstract
Organ scarcity demands critical decision-making regarding eligible transplant candidates and graft allocation to ensure best benefit from renal transplantation (RTx). Among the controversial relative contraindications is a history of pretransplant malignancy (PTM). While oncological outcomes of PTM-RTx recipients are well described, data on graft-specific outcome are scarce. A retrospective double case control matched pair analysis (60 months follow-up) was carried out and RTx-recipients were stratified for history of PTM. First, PTM-RTx recipients were matched according to age, sex and duration of immunosuppressive therapy. Next, PTM-RTx recipients were matched 1:1 for age, sex and cause of end-stage renal disease. Five-year patient and graft survival as well as oncological outcomes were analyzed. A total of 65 PTM-RTx recipients were identified. Post-RTx recurrence rate was 5%, while 20% developed second de novo malignancy, comparable to 14% in the control group. PTM-RTx recipients had a noticeable lower five-year death-censored as well as overall graft survival and Cox proportional hazard modeling showed a correlation between PTM and inferior graft survival. Although underlying reasons remain not fully understood, this study is the first to show inferior graft survival in PTM-RTx recipients and advocates necessity to focus on more meticulous graft monitoring in PTM recipients in addition to heightened surveillance for cancer recurrence.
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Homkrailas P, Sampaio M, Datta N, Danovitch GM, Bunnapradist S. Impact of donor obesity on allograft outcomes after kidney transplantation adjusted for kidney donor profile index - a national cohort study. Transpl Int 2021; 34:681-688. [PMID: 33475204 DOI: 10.1111/tri.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/06/2020] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
Obesity in deceased kidney donors is a known risk factor for poor allograft outcomes. The Kidney Donor Profile Index (KDPI) has been introduced to predict graft survival in deceased donor kidney transplantation (DDKT). Obesity, however, is not included in KDPI. We study the impact of donor obesity on DDKT outcomes after adjusting for organ quality by KDPI. The Organ Procurement Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) data of DDKT from 2005 to 2017, with donor BMI ≥ 18.5 kg/m2 and weight >80 kg were included. There was a total of 66 382 DDKTs with 10 917 death-censored graft failures. For KDPI ≤ 30%, the 10-year death-censored graft survival (DCGS) rates among donor BMI < 30, 30-35, 35-40, 40-45 and ≥45 kg/m2 groups were 75.9%, 75.4%, 76.1%, 74.9% and 79.6%, respectively. For KDPI > 30%, 10-year DCGS rates were 67.5%, 66.1%, 65.9%, 62.6% and 63.2%, respectively. After adjusting for known confounding factors including KDPI, donor obesity was not independently associated with an increased risk for graft failure. In DDKT with donor weight >80 kg, donor obesity was not associated with a lower long term DCGS compared to non-obesity when KDPI ≤ 30%.
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Affiliation(s)
- Piyavadee Homkrailas
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Marcelo Sampaio
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nakul Datta
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gabriel M Danovitch
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, Kidney and Pancreas Transplant Research Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Kuhn C, Lang BM, Lörcher S, Karolin A, Binet I, Beldi G, Golshayan D, Hadaya K, Mueller TF, Schaub S, Immer F, Stampf S, Koller M, Sidler D. Outcome of kidney transplantation from very senior donors in Switzerland - a national cohort study. Transpl Int 2021; 34:689-699. [PMID: 33529392 DOI: 10.1111/tri.13836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/18/2020] [Accepted: 01/29/2021] [Indexed: 11/29/2022]
Abstract
Kidney transplantation from older and marginal donors is effective to confront organ shortage. However, limitations after transplantation of kidneys from very marginal kidney donors remain unclear. We compared patient and graft outcome, achieved allograft function and quality of life of renal transplantations from Very Senior Donors (VSD, defined as donors aged 70 years and older) with Senior Donors (SD, aged 60-70 years) and Regular Donors (RD, aged younger than 60 years) in Switzerland. We evaluated the outcome of 1554 adult recipients of deceased donor kidney transplantations from 05/2008 to 12/2019; median follow-up was 4.7 years. Failure-free survival (freedom from graft loss or death), glomerular filtration rate (eGFR), and quality of life at 12 months were analyzed for RD (reference group, n = 940), SD (n = 404), and VSD (n = 210). Failure-free survival decreased with increasing donor age, mainly attributable to premature graft loss. Still, overall 5-year failure-free survival reached 83.1%, 81.0%, and 64.0% in the RD, SD, and VSD subgroups, respectively. eGFR 12 months post-transplantation was significantly higher in RD compared with SD and VSD. The acceptance rate of donor candidates for kidney TPL was 78% for the entire cohort (87% for RD, 79% for SD, and 56% for VSD). Deceased donor kidney transplantation from donors aged 70 years or older is associated with an inferior, yet acceptable failure-free outcome, with sustained quality of life.
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Affiliation(s)
- Christian Kuhn
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
| | - Brian M Lang
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland.,Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Sylvia Lörcher
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
| | - Andrea Karolin
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
| | - Isabelle Binet
- Klinik für Nephrologie und Transplantationsmedizin, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Guido Beldi
- Klinik für Viszerale Chirurgie und Medizin, Inselspital, Bern, Switzerland
| | - Délaviz Golshayan
- Centre de Transplantation d'organes et Service de Néphrologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Karine Hadaya
- Service de Néphrologie et Hypertension, Hôpitaux Universitaires Genève, Genève, Switzerland
| | - Thomas F Mueller
- Klinik für Nephrologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Stefan Schaub
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland
| | | | - Susanne Stampf
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland.,Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Michael Koller
- Klinik für Transplantationsimmunologie und Nephrologie, Universitätsspital Basel, Basel, Switzerland
| | - Daniel Sidler
- Klinik für Nephrologie und Hypertonie, Inselspital, Bern, Switzerland
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Pearson R, Asher J, Jackson A, Mark PB, Shumeyko V, Clancy MJ. Viability assessment and utilization of declined donor kidneys with rhabdomyolysis using ex vivo normothermic perfusion without preimplantation biopsy. Am J Transplant 2021; 21:1317-1321. [PMID: 33021059 DOI: 10.1111/ajt.16329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/14/2020] [Indexed: 01/25/2023]
Abstract
The role of ex vivo normothermic perfusion (EVNP) in both organ viability assessment and reconditioning is increasingly being demonstrated. We report the use of this emerging technology to facilitate the transplantation of a pair of donor kidneys with severe acute kidney injury (AKI) secondary to rhabdomyolysis. Donor creatinine was 10.18 mg/dl with protein (30 mg/dl) present in urinalysis. Both kidneys were declined by all other transplantation units and subsequently accepted by our unit. The first kidney was perfused with red cell-based perfusate at 37°C for 75 min, mean renal blood flow was 110 ml/min/100 g and produced 85 ml of urine. Having demonstrated favorable macroscopic appearance and urine output, the kidney was transplanted into a 61-year-old peritoneal dialysis dependent without complication. Given the reassuring information from the first kidney provided by EVNP, the second kidney was not perfused with EVNP and was directly implanted to a 64-year-old patient. The first kidney achieved primary function and the second functioned well after delayed graft function. Recipient eGFR have stabilized at 88.5 and 55.3, respectively (ml/min/1.73 m2 ), at 2 months posttransplant.
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Affiliation(s)
| | - John Asher
- Queen Elizabeth University Hospital, Glasgow, UK
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Abstract
Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.
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Prevention of acute rejection after rescue with Belatacept by association of low-dose Tacrolimus maintenance in medically complex kidney transplant recipients with early or late graft dysfunction. PLoS One 2020; 15:e0240335. [PMID: 33057374 PMCID: PMC7561183 DOI: 10.1371/journal.pone.0240335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/24/2020] [Indexed: 01/23/2023] Open
Abstract
Background Increased acute rejection risk in rescue protocols with Belatacept may limit its use particularly in medically complex patients where preexisting increased risk of rejection couples with CNI toxicity. Methods Retrospective analysis was performed in 19 KTs shifted to a Belatacept-based immunosuppression with low-dose Tacrolimus (2–3 ng/mL) after evidence of allograft disfunction, including patients with primary non-function (PNF), chronic-active antibody-mediated rejection (cAMR), history of previous KTs and/or other concomitant transplants (liver, pancreas). Evaluation of CD28+ CD4+ effector memory T cell (TEM) before conversion was performed in 10/19. Results Kidney function significantly improved (median eGFR 16.5 ml/min/1.73m2 before vs 25 ml/min after; p = 0.001) at a median time after conversion of 12.5 months (9.1–17.8). Overall graft and patient survival were 89.5% and 100% respectively. Definitive weaning from dialysis in 5/5 KTs with PNF was observed, whereas 7/8 patients lost their graft within first year in a control group. eGFR significantly ameliorated in re-trasplants (p = 0.001) and stabilized in KTs with other organ transplants or cAMR. No acute rejection episodes occurred, despite the significant risk suggested by high frequency of CD28+ CD4+ TEM in most patients. Opportunistic infections were limited and most common in early vs late-converted. Conclusions Rescue association of Belatacept with low-dose Tacrolimus in medically complex KTs is a feasible option that allows prevention of acute rejection and amelioration of graft function.
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Yap YT, Ho QY, Kee T, Ng CY, Chionh CY. Impact of pre-transplant biopsy on 5-year outcomes of expanded criteria donor kidney transplantation. Nephrology (Carlton) 2020; 26:70-77. [PMID: 32986301 DOI: 10.1111/nep.13788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 01/09/2023]
Abstract
AIM Compared to Standard Criteria Donors (SCD), Expanded Criteria Donor (ECD) kidneys are associated with poorer outcomes, although pre-transplant biopsy may mitigate risks. This study assessed 5-year outcomes of deceased-donor kidney transplant recipients, comparing recipients of ECD allografts evaluated histologically to recipients of SCD and ECD kidneys assessed clinically. METHODS This is a single-centre retrospective study. From November 2005 to December 2009 (Era 1), donors were assessed clinically for suitability for kidney donation. From December 2009 to October 2017 (Era 2), kidneys from ECDs and diabetics underwent pre-transplant biopsy and were allocated based on Remuzzi score. Outcomes of Era 1 and 2 recipients were compared. RESULTS ECD kidney transplantation increased from 30.4% to 40.0% from Era 1 to 2. Univariable Cox regression, stratified by transplant era, found that 5-year graft loss was highest with Era 1 ECD (HR 2.5, 95% CI 1.1-5.5, P = .027) while graft loss for Era 2 ECD recipients was similar to SCD recipients. There was no difference in 5-year recipient survival. Amongst Era 1 ECD recipients, 51.2% experienced rejection compared to 30.8-41.5% for other subgroups. Five-year eGFR was higher with Era 2 ECD at 48.4 (33.3-60.7) ml/min/1.73 m2 compared to 42.2 (35.8-57.3) ml/min/1.73 m2 for Era 1 ECD. However, these differences were not statistically significant. CONCLUSION Introduction of pre-transplant biopsy assessment may be associated with improved outcomes of ECD kidney recipients such that they are now comparable to SCD kidney recipients, with benefits persisting over 5 years.
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Affiliation(s)
- Yun Ting Yap
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore.,Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore.,Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Chee Yong Ng
- Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore.,Department of Renal Medicine, Changi General Hospital, Singapore
| | - Chang Yin Chionh
- Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore.,Department of Renal Medicine, Changi General Hospital, Singapore
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Mehdorn AS, Reuter S, Suwelack B, Schütte-Nütgen K, Becker F, Senninger N, Palmes D, Vogel T, Bahde R. Comparison of kidney allograft survival in the Eurotransplant senior program after changing the allocation criteria in 2010-A single center experience. PLoS One 2020; 15:e0235680. [PMID: 32702005 PMCID: PMC7377418 DOI: 10.1371/journal.pone.0235680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/21/2020] [Indexed: 12/22/2022] Open
Abstract
Aims The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome. Methods Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation. Results Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards. Conclusion nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.
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Affiliation(s)
- Anne-Sophie Mehdorn
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, Münster University Hospital, Münster, Germany
- * E-mail:
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, Münster University Hospital, Münster, Germany
| | - Katharina Schütte-Nütgen
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, Münster University Hospital, Münster, Germany
| | - Felix Becker
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Norbert Senninger
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Daniel Palmes
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Thomas Vogel
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
| | - Ralf Bahde
- Department of General, Visceral and Transplant Surgery, Münster University Hospital, Münster, Germany
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Jun H, Yoon HE, Lee KW, Lee DR, Yang J, Ahn C, Han SY. Kidney Donor Risk Index Score Is More Reliable Than Kidney Donor Profile Index in Kidney Transplantation From Elderly Deceased Donors. Transplant Proc 2020; 52:1744-1748. [DOI: 10.1016/j.transproceed.2020.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/23/2020] [Accepted: 03/12/2020] [Indexed: 10/24/2022]
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Pajenda S, Rasul S, Hacker M, Wagner L, Geist BK. Dynamic 2-deoxy-2[18F] fluoro-D-glucose PET/MRI in human renal allotransplant patients undergoing acute kidney injury. Sci Rep 2020; 10:8270. [PMID: 32427878 PMCID: PMC7237443 DOI: 10.1038/s41598-020-65267-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/29/2020] [Indexed: 12/11/2022] Open
Abstract
Patients after solid organ kidney transplantation (KTX) often suffer from acute kidney injury (AKI). Parameters as serum creatinine indicate a loss of kidney function, although no distinction of the cause and prognosis can be made. Imaging tools measuring kidney function have not been widely in clinical use. In this observational study we evaluated 2-deoxy-2[18F] fluoro-D-glucose (FDG) PET/MRI in thirteen patients after KTX with AKI as a functional assessment of the graft. Twenty-four healthy volunteers served as control. General kidney performance (GKP), initial flow (IF) and renal response function (RF) were calculated by standardized uptake values (SUV) and time activity curves (TAC). The GKP measured for the total kidney and medulla was significantly higher in healthy patients compared to patients after KTX (p = 0.0002 and p = 0.0004, respectively), but no difference was found for the GKP of the cortex (p = 0.59). The IF in KTX patients correlated with renal recovery, defined as change in serum creatinine 10 days after PET/MRI (r = 0.80, p = 0.001). With regard to the RF, a negative correlation for tubular damage was found (r = -0.74, p = 0.004). In conclusion, parameters obtained from FDG PET/MRI showed a possible predictive feature for renal recovery in KTX patients undergoing AKI.
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Affiliation(s)
- Sahra Pajenda
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Sazan Rasul
- Department of Biomedical Imaging and Image- Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Marcus Hacker
- Department of Biomedical Imaging and Image- Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ludwig Wagner
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Barbara Katharina Geist
- Department of Biomedical Imaging and Image- Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna. Waehringer Guertel 18-20, 1090, Vienna, Austria
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Bisigniano L, Tagliafichi V, Antik A. Validation of the Kidney Donor Profile Index in Argentina. Transplant Proc 2020; 52:1049-1052. [PMID: 32217013 DOI: 10.1016/j.transproceed.2020.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/22/2020] [Indexed: 10/24/2022]
Abstract
Kidney Donor Profile Index (KDPI), derived from donor characteristics, was developed in the United States in an effort to devise an objective means of assessing donor organ suitability based on predicted graft survival. The objective of this study is to analyze the utility of KDPI to predict renal graft survival in Argentina. We conducted a retrospective national cohort study of adult patients who received a deceased donor renal transplantation in Argentina between January 2008 and December 2017. The graft survival was estimated according to the KDPI stratified by quartiles. A Kaplan-Meier analysis was used to calculate survival. A Cox regression was performed to estimate the probability of graft loss for each quart of the KDPI adjusted by receptor variables (age, diabetes, sex, and dialysis time) and cold ischemia time. In a Kaplan-Meier analysis, the graft survival decreases as the quartile of KDPI increases. Multivariate analysis shows that the increase in KDPI quartile and recipient's characteristics-such as age ≥60 years, diabetes, and dialysis time-were related to the probability of graft loss. In conclusion, the KDPI system could provide a guide to objectively assess the quality of organs offered for transplantation in Argentina.
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Affiliation(s)
- Liliana Bisigniano
- Department of Scientific and Technical Direction, Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Viviana Tagliafichi
- Department of Scientific and Technical Direction, Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Ariel Antik
- Department of Scientific and Technical Direction, Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina.
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