1
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Sandal S, Ahn J, Chen Y, Thompson V, Purnell TS, Cantarovich M, Clark-Cutaia MN, Wu W, Suri R, Segev DL, McAdams-DeMarco M. Differences in Racial and Ethnic Disparities Between First and Repeat Kidney Transplantation. Transplantation 2024:00007890-990000000-00761. [PMID: 38771099 DOI: 10.1097/tp.0000000000005051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Recent data suggest patients with graft failure had better access to repeat kidney transplantation (re-KT) than transplant-naive dialysis accessing first KT. This was postulated to be because of better familiarity with the transplant process and healthcare system; whether this advantage is equitably distributed is not known. We compared the magnitude of racial/ethnic disparities in access to re-KT versus first KT. METHODS Using United States Renal Data System, we identified 104 454 White, Black, and Hispanic patients with a history of graft failure from 1995 to 2018, and 2 357 753 transplant-naive dialysis patients. We used adjusted Cox regression to estimate disparities in access to first and re-KT and whether the magnitude of these disparities differed between first and re-KT using a Wald test. RESULTS Black patients had inferior access to both waitlisting and receiving first KT and re-KT. However, the racial/ethnic disparities in waitlisting for (adjusted hazard ratio [aHR] = 0.77; 95% confidence interval [CI], 0.74-0.80) and receiving re-KT (aHR = 0.61; 95% CI, 0.58-0.64) was greater than the racial/ethnic disparities in first KT (waitlisting: aHR = 0.91; 95% CI, 0.90-0.93; Pinteraction = 0.001; KT: aHR = 0.68; 95% CI, 0.64-0.72; Pinteraction < 0.001). For Hispanic patients, ethnic disparities in waitlisting for re-KT (aHR = 0.83; 95% CI, 0.79-0.88) were greater than for first KT (aHR = 1.14; 95% CI, 1.11-1.16; Pinteraction < 0.001). However, the disparity in receiving re-KT (aHR = 0.76; 95% CI, 0.72-0.80) was similar to that for first KT (aHR = 0.73; 95% CI, 0.68-0.79; Pinteraction = 0.55). Inferences were similar when restricting the cohorts to the Kidney Allocation System era. CONCLUSIONS Unlike White patients, Black and Hispanic patients with graft failure do not experience improved access to re-KT. This suggests that structural and systemic barriers likely persist for racialized patients accessing re-KT, and systemic changes are needed to achieve transplant equity.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - JiYoon Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yusi Chen
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Valerie Thompson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Wenbo Wu
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Rita Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
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2
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Nishio Lucar AG, Patel A, Mehta S, Yadav A, Doshi M, Urbanski MA, Concepcion BP, Singh N, Sanders ML, Basu A, Harding JL, Rossi A, Adebiyi OO, Samaniego-Picota M, Woodside KJ, Parsons RF. Expanding the access to kidney transplantation: Strategies for kidney transplant programs. Clin Transplant 2024; 38:e15315. [PMID: 38686443 DOI: 10.1111/ctr.15315] [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: 11/14/2023] [Revised: 03/05/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.
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Affiliation(s)
- Angie G Nishio Lucar
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Ankita Patel
- Recanati-Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shikha Mehta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anju Yadav
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mona Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan A Urbanski
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - M Lee Sanders
- Department of Internal Medicine, Division of Nephrology, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Arpita Basu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Oluwafisayo O Adebiyi
- Department of Medicine, Indiana University Health Hospital, Indianapolis, Indiana, USA
| | | | | | - Ronald F Parsons
- Department of Surgery, University of Pennsylvannia, Philadelphia, Pennsylvania, USA
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3
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Tran J, Alrajhi I, Chang D, Sherwood KR, Keown P, Gill J, Kadatz M, Gill J, Lan JH. Clinical relevance of HLA-DQ eplet mismatch and maintenance immunosuppression with risk of allosensitization after kidney transplant failure. Front Genet 2024; 15:1383220. [PMID: 38638120 PMCID: PMC11024336 DOI: 10.3389/fgene.2024.1383220] [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: 02/07/2024] [Accepted: 03/21/2024] [Indexed: 04/20/2024] Open
Abstract
The optimal immunosuppression management in patients with a failed kidney transplant remains uncertain. This study analyzed the association of class II HLA eplet mismatches and maintenance immunosuppression with allosensitization after graft failure in a well characterized cohort of 21 patients who failed a first kidney transplant. A clinically meaningful increase in cPRA in this study was defined as the cPRA that resulted in 50% reduction in the compatible donor pool measured from the time of transplant failure until the time of repeat transplantation, death, or end of study. The median cPRA at the time of failure was 12.13% (interquartile ranges = 0.00%, 83.72%) which increased to 62.76% (IQR = 4.34%, 99.18%) during the median follow-up of 27 (IQR = 18, 39) months. High HLA-DQ eplet mismatches were significantly associated with an increased risk of developing a clinically meaningful increase in cPRA (p = 0.02) and de novo DQ donor-specific antibody against the failed allograft (p = 0.02). We did not observe these associations in patients with high HLA-DR eplet mismatches. Most of the patients (88%) with a clinically meaningful increase in cPRA had both a high DQ eplet mismatch and a reduction in their immunosuppression, suggesting the association is modified by immunosuppression. The findings suggest HLA-DQ eplet mismatch analysis may serve as a useful tool to guide future clinical studies and trials which assess the management of immunosuppression in transplant failure patients who are repeat transplant candidates.
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Affiliation(s)
- Jenny Tran
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ibrahim Alrajhi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Doris Chang
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Karen R. Sherwood
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul Keown
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jagbir Gill
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Providence Health Care Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Matthew Kadatz
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Gill
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Providence Health Care Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James H. Lan
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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4
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Bathini S, Jha V. Immunosuppressive Practices in Failed Kidney Grafts in South Asia-An Investigative Survey. Kidney Int Rep 2024; 9:1107-1110. [PMID: 38765570 PMCID: PMC11101818 DOI: 10.1016/j.ekir.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Affiliation(s)
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
- School of Public Health, Imperial College, London, UK
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5
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Francis RS, Nadig SN. Should I Stay or Should I Go? The Role of Allograft Nephrectomy. Transplantation 2023; 107:2454-2455. [PMID: 37122088 DOI: 10.1097/tp.0000000000004626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- Ross S Francis
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Satish N Nadig
- Comprehensive Transplant Center, Northwestern University-Feinberg School of Medicine, Chicago, IL
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6
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Josephson MA, Becker Y, Budde K, Kasiske BL, Kiberd BA, Loupy A, Małyszko J, Mannon RB, Tönshoff B, Cheung M, Jadoul M, Winkelmayer WC, Zeier M. Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:1076-1091. [PMID: 37236423 DOI: 10.1016/j.kint.2023.05.010] [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: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.
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Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, F-75015 Paris, France; Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Roslyn B Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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7
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Sibulesky L, Leca N, Bakthavatsalam R, Perkins JD. Intention-to-treat Analysis of Patients Aged 70 Years and Older Awaiting Kidney Transplantation in Post-Kidney Allocation System Era. Transplantation 2023; 107:2510-2525. [PMID: 37322588 DOI: 10.1097/tp.0000000000004677] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The US population is aging, and so the number of patients treated for end-stage renal disease is on the rise. In the United States, 38% of people over 65 y old have chronic kidney disease. There continues to be a reluctance of clinicians to consider older candidates for transplant, including early referrals. METHODS We conducted a retrospective analysis of the Organ Procurement and Transplantation Network database of all adults ≥70 y old undergoing kidney transplants from December 1, 2014, to June 30, 2021. We compared patient and graft survival in candidates who were transplanted while on hemodialysis versus preemptive with a living versus deceased donor kidney transplant. RESULTS In 2021, only 43% of the candidates listed for transplant were preemptive. In an intention-to-treat analysis from the time of listing, candidate survival was significantly improved for those transplanted preemptively versus being on dialysis (hazard ratio 0.59; confidence interval, 0.56-0.63). All donor types, donor after circulatory death, donor after brain death, and living donor, had a significant decrease in death over remaining on the waiting list. Patients who were on dialysis or transplanted preemptively with a living donor kidney had significantly better survival than those receiving a deceased donor kidney. However, receiving a deceased donor kidney significantly decreased the chance of death over remaining on the waiting list. CONCLUSIONS Patients ≥70 y old who are transplanted preemptively, whether with a deceased donor or a living donor kidney, have a significantly better survival than those who are transplanted after initiating dialysis. Emphasis on timely referral for a kidney transplant should be placed in this population.
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Affiliation(s)
- Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Department of Surgery, Division of Transplant Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, WA
| | - Nicolae Leca
- Department of Surgery, Division of Transplant Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, WA
- Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Ramasamy Bakthavatsalam
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA
- Department of Surgery, Division of Transplant Surgery, Clinical and Bio-Analytics Transplant Laboratory, University of Washington, Seattle, WA
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8
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Tanriover C, Copur S, Basile C, Ucku D, Kanbay M. Dialysis after kidney transplant failure: how to deal with this daunting task? J Nephrol 2023; 36:1777-1787. [PMID: 37676635 DOI: 10.1007/s40620-023-01758-x] [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: 12/06/2022] [Accepted: 08/06/2023] [Indexed: 09/08/2023]
Abstract
The best treatment for patients with end-stage kidney disease is kidney transplantation, which, if successful provides both a reduction in mortality and a better quality of life compared to dialysis. Although there has been significant improvement in short-term outcomes after kidney transplantation, long-term graft survival still remains insufficient. As a result, there has been an increase in the number of individuals who need dialysis again after kidney transplant failure, and increasingly contribute to kidney transplant waiting lists. Starting dialysis after graft failure is a difficult task not only for the patients, but also for the nephrologists and the care team. Furthermore, recommendations for management of dialysis after kidney graft loss are lacking. Aim of this narrative review is to provide a perspective on the role of dialysis in the management of patients with failed kidney allograft. Although numerous studies have reported higher mortality in patients undergoing dialysis following kidney allograft failure, reports are contrasting. A patient-centered, individualized approach should drive the choices of initiating dialysis, dialysis modality, maintenance of immunosuppressive drugs and vascular access.
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Affiliation(s)
- Cem Tanriover
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Via Battisti 192, 74121, Taranto, Italy.
| | - Duygu Ucku
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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9
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McDonald M. Allograft nephrectomy vs. no nephrectomy for failed renal transplants. FRONTIERS IN NEPHROLOGY 2023; 3:1169181. [PMID: 37675360 PMCID: PMC10479781 DOI: 10.3389/fneph.2023.1169181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/13/2023] [Indexed: 09/08/2023]
Abstract
The role of allograft nephrectomy (AN) in failed renal transplants is a topic of debate, owing to controversial results reported in the literature and the fact that most of the studies are limited by a retrospective design and small numbers of participants. Allograft nephrectomy is most likely of benefit in the patient with recurrent allograft intolerance syndrome (AIS) following pulse steroids. Immunosuppression weaning in the presence of clinical signs related to a chronic inflammatory state is also reasonable grounds to pursue AN. Studies are mainly inconclusive but suggest that AN has no overall benefit for allograft survival after retransplant. This topic is still of interest in the transplant field and is particularly relevant for patients who are likely to require retransplantation within their lifetime. Further assessment is needed in the form of randomized controlled trials that control for various AN indications and immunosuppression regimens, and have clearly defined survival outcomes.
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Affiliation(s)
- Michelle McDonald
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, United States
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10
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Lam NN, Quinn RR, Clarke A, Al-Wahsh H, Knoll GA, Tibbles LA, Kamar F, Jeong R, Kiberd J, Ravani P. Progression of Kidney Disease in Kidney Transplant Recipients With a Failing Graft: A Matched Cohort Study. Can J Kidney Health Dis 2023; 10:20543581231177203. [PMID: 37313362 PMCID: PMC10259097 DOI: 10.1177/20543581231177203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/26/2023] [Indexed: 06/15/2023] Open
Abstract
Background Few studies have assessed outcomes in transplant recipients with failing grafts as most studies have focused on outcomes after graft loss. Objective To determine whether renal function declines faster in kidney transplant recipients with a failing graft than in people with chronic kidney disease of their native kidneys. Design Retrospective cohort study. Setting Alberta, Canada (2002-2019). Patients We identified kidney transplant recipients with a failing graft (2 estimated glomerular filtration rate [eGFR] measurements 15-30 mL/min/1.73 m2 ≥90 days apart). Measurements We compared the change in eGFR over time (eGFR with 95% confidence limits, LCLeGFRUCL) and the competing risks of kidney failure and death (cause-specific hazard ratios [HRs], LCLHRUCL). Methods Recipients (n = 575) were compared with propensity-score-matched, nontransplant controls (n = 575) with a similar degree of kidney dysfunction. Results The median potential follow-up time was 7.8 years (interquartile range, 3.6-12.1). The hazards for kidney failure (HR1.101.331.60) and death (HR1.211.592.07) were significantly higher for recipients, while the eGFR decline over time was similar (recipients vs controls: -2.60-2.27-1.94 vs -2.52-2.21-1.90 mL/min/1.73 m2 per year). The rate of eGFR decline was associated with kidney failure but not death. Limitations This was a retrospective, observational study, and there is a risk of bias due to residual confounding. Conclusions Although eGFR declines at a similar rate in transplant recipients as in nontransplant controls, recipients have a higher risk of kidney failure and death. Studies are needed to identify preventive measures to improve outcomes in transplant recipients with a failing graft.
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Affiliation(s)
- Ngan N. Lam
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Robert R. Quinn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Alix Clarke
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Huda Al-Wahsh
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Greg A. Knoll
- Department of Medicine (Nephrology) and The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Lee Anne Tibbles
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Fareed Kamar
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Rachel Jeong
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - James Kiberd
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Pietro Ravani
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, AB, Canada
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11
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Au EHK, Chapman JR, Teixeira-Pinto A, Craig JC, Wong G. Variations in Risk of Cancer and Death From Cancer According to Kidney Allograft Function, Graft Loss, and Return to Dialysis. Transplantation 2023; 107:1359-1364. [PMID: 36683232 DOI: 10.1097/tp.0000000000004493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cancer incidence and mortality may change with varying kidney allograft function and after graft loss. We aimed to quantify cancer incidence and mortality during periods with a functioning graft and after graft loss. METHODS We included all adult Australians aged 20 and above who commenced kidney replacement therapy between 1982 and 2014 using data from Australia and New Zealand Dialysis and Transplant Registry. We calculated the standardized incidence ratios and standardized mortality ratios (standardized against the Australian general population) for dialysis patients and transplant recipients during periods with a functioning graft and after graft loss. RESULTS A total of 44 765 dialysis patients without transplants, 13 443 with first kidney transplants, 2951 after first graft loss, 1010 with second transplants, and 279 after second graft loss were followed for 274 660 patient-years. Cancer incidence and mortality (per 100 000 patient-years) were 1564 and 760 in dialysis patients, 1564 and 689 in recipients of first transplants, 1188 and 390 after first graft loss, 1525 and 693 after second transplants, and 1645 and 779 after second graft loss. Cancer standardized incidence ratios and standardized mortality ratios (95% confidence intervals) were 1.15 (1.11-1.20) and 1.29 (1.21-1.36) for dialysis patients, 2.03 (1.94-2.13) and 2.50 (2.33-2.69) for recipients following their first transplant, 1.55 (1.29-1.85) and 1.40 (1.00-1.90) after first graft loss, 2.18 (1.79-2.63) and 3.00 (2.23-3.96) for second transplants, 2.59 (1.56-4.04) and 3.82 (1.75-7.25) after second graft loss. CONCLUSIONS In kidney transplant recipients, cancer incidence and mortality are highest during periods with a functioning graft and remained higher than in the general population even after graft loss.
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Affiliation(s)
- Eric H K Au
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Armando Teixeira-Pinto
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
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12
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Loban K, Horton A, Robert JT, Hales L, Parajuli S, McAdams-DeMarco M, Sandal S. Perspectives and experiences of kidney transplant recipients with graft failure: A systematic review and meta-synthesis. Transplant Rev (Orlando) 2023; 37:100761. [PMID: 37120965 DOI: 10.1016/j.trre.2023.100761] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Kidney transplant recipients with graft failure are a rapidly rising cohort of patients who experience high morbidity, mortality, and fragmented transitions of care between transplant and dialysis teams. Current approaches to improving care focus on medical and surgical interventions, increasing re-transplantation, and improving coordination between treating teams with little understanding of patient needs and perspectives. METHODS We undertook a systematic literature review of personal experiences of patients with graft failure. Six electronic and five grey literature databases were searched systematically. Of 4664 records screened 43 met the inclusion criteria. Six empirical qualitative studies and case studies were included in the final analysis. Thematic synthesis was used to combine data that included the perspectives of 31 patients with graft failure and 9 caregivers. RESULTS Using the Transition Model, we isolated three interconnected phases as patients transition through graft failure: shattering of lifestyle and plans associated with a successful transplant; physical and psychological turbulence; and re-alignment by learning adaptive strategies to move forward. Critical factors affecting coping included multi-disciplinary healthcare approaches, social support, and individual-level factors. While clinical transplant care was evaluated positively, participants identified gaps in the provision of information and psychosocial support related to graft failure. Graft failure had a profound impact on caregivers especially when they were living donors. CONCLUSIONS Our review reports patient-identified priorities for improving care and can help inform research and guideline development that strives to improve the care of patients with graft failure.
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Affiliation(s)
- Katya Loban
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Anna Horton
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jorane-Tiana Robert
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Lindsay Hales
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Shaifali Sandal
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
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13
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Crocerossa F, Autorino R, Derweesh I, Carbonara U, Cantiello F, Damiano R, Rubio-Briones J, Roupret M, Breda A, Volpe A, Mir MC. Management of renal cell carcinoma in transplant kidney: a systematic review and meta-analysis. Minerva Urol Nephrol 2023; 75:1-16. [PMID: 36094386 DOI: 10.23736/s2724-6051.22.04881-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION After transplantation, approximately 10% of renal cell carcinomas are detected in graft kidneys. These tumors (gRCC) present surgeons with the difficulty of finding a treatment that guarantees both oncological clearance and maintenance of function. We conducted a systematic review and an individual patient data meta-analysis on the oncology, safety and functional outcomes of the available treatments for gRCC. EVIDENCE ACQUISITION A systematic search was performed across MEDLINE, EMBASE, and Web of Science including any study reporting perioperative, functional and survival outcomes for patients undergoing graft nephrectomy (GN), partial nephrectomy (PN) or thermal ablation (TA) for gRCC. Quade's ANCOVA, Spearman Rho and Pearson χ2, Kaplan-Meier, Log-rank and Standard Cox regression and other tests were used to compare treatments. Studies' quality was evaluated using a modified version of Newcastle Ottawa Scale. EVIDENCE SYNTHESIS A number of 29 studies (357 patients) were included. No differences between TA and PN were found in terms of safety, functional and oncological outcomes for T1a gRCCs. When applied to pT1b gRCC, PN showed no difference in complications, progression or cancer-specific deaths compared to smaller lesions; PN validity for pT2 gRCCs should be considered unverified due to lack of sufficient evidence. The efficacy and safety of PN or TA for multiple gRCC remain controversial. In case of non-functioning, large (T≥2), complicated or metastatic gRCCs, GN appears to be the most reasonable choice. Quality of evidence ranged from very low to moderate. Studies with large cohorts and longer follow-up are still needed to clarify oncological and functional differences. CONCLUSIONS PN and TA might be offered as a nephron-sparing treatment in patients with T1a gRCC. There is no significant difference between these options and GN in terms of oncological outcomes and complications. PN and TA offer similar functional outcomes and graft preservation. PN for T1b gRCC seems feasible and safe, but its validity should be considered unverified.
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Affiliation(s)
- Fabio Crocerossa
- Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA.,Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | | | | | - Umberto Carbonara
- Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA.,Unit of Andrology and Kidney Transplantation, Department of Urology, University of Bari, Bari, Italy
| | - Francesco Cantiello
- Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Rocco Damiano
- Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Jose Rubio-Briones
- Department of Urology, Instituto Valenciano Oncologia (IVO) Foundation, Valencia, Spain
| | - Morgan Roupret
- Department of Urology, GRC5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France
| | - Alberto Breda
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Alessandro Volpe
- Division of Urology, Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - M Carmen Mir
- Urology Department, IMED Hospitals, Valencia, Spain -
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14
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Murakami N, Reich AJ, Pavlakis M, Lakin JR. Conservative Kidney Management in Kidney Transplant Populations. Semin Nephrol 2023; 43:151401. [PMID: 37499572 PMCID: PMC10543459 DOI: 10.1016/j.semnephrol.2023.151401] [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] [Indexed: 07/29/2023]
Abstract
Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.
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Affiliation(s)
- Naoka Murakami
- Harvard Medical School, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Amanda J Reich
- Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Martha Pavlakis
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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15
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Szabla N, Matillon X, Calves J, Branchereau J, Champy C, Neuzillet Y, Bessede T, Bouhié S, Boutin JM, Caillet K, Cognard N, Culty T, De Fortescu G, Drouin S, Bentellis I, Hubert J, Boissier R, Sallusto F, Sénéchal C, Terrier N, Thuret R, Verhoest G, Waeckel T, Tillou X. Updated National Study of Functional Graft Renal Cell Carcinomas: Are They a Different Entity? Urology 2023; 171:152-157. [PMID: 36243142 DOI: 10.1016/j.urology.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To analyze de novo graft carcinoma characteristics from our updated national multicentric retrospective cohort. METHODS Thirty-two transplant centers have retrospectively completed the database. This database concerns all kidney graft tumors including urothelial, and others type but excludes renal lymphomas over 31 years. RESULTS One hundred and fifty twokidney graft carcinomas were diagnosed in functional grafts. Among them 130 tumors were Renal Cell Carcinomas. The calculated incidence was 0.18%. Median age of the allograft at diagnosis was 45.4 years old. The median time between transplantation and diagnosis was 147.1 months. 60 tumors were papillary carcinomas and 64 were clear cell carcinomas. Median tumor size was 25 mm. 18, 64, 21 and 1 tumors were respectively Fuhrman grade 1, 2, 3 and 4. Nephron sparing surgery (NSS) was performed on 68 (52.3%) recipients. Ablative therapy was performed in 23 cases (17.7%). Specific survival rate was 96.8%. CONCLUSION This study confirmed that renal graft carcinomas are a different entity: with a younger age of diagnosis; a lower stage at diagnosis; a higher incidence of papillary subtypes.
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Affiliation(s)
- Nicolas Szabla
- CHU de Caen, Urology and Transplantation, Caen Calvados, France
| | - Xavier Matillon
- Hôpital Edouard Herriot, Urology and Transplantation, Lyon, Rhone, France
| | - Jehanne Calves
- CHU de Brest, Urology and Transplantation, Brest, Britanny, France
| | | | - Cécile Champy
- CHU Henri Mondor, Urology and Transplantation, Créteil, Val de Marne, France
| | - Yann Neuzillet
- Hôpital Foch, Urology and Transplantation, Suresnes, Huats de siene, France
| | - Thomas Bessede
- Hôpital Kremlin Bicetre, Urology and Transplantation, Paris, Paris, France
| | | | - Jean-Marie Boutin
- Hôpital Bretonneaux, Urology and Transplantation, Tours, Val de Loire, France
| | - Kevin Caillet
- CHU d'Amiens, Urology and Transplantation, Amiens, Somne, France
| | - Noelle Cognard
- CHU de Strasbourg, Urology and Transplantation, Strasbourg, Bas-Rhin, France
| | - Thibaut Culty
- CHU d'Angers, Urology and Transplantation, Angers, Maine et Loire, France
| | | | - Sarah Drouin
- Hôpital La Pitié Salpêtrière, Transplantation, Paris, Paris, France
| | - Imad Bentellis
- CHU Félix Guyon, Urology and Transplantation, La Réunion, La Reunion, France
| | - Jacques Hubert
- CHU de Nancy, Urology and Transplantation, Nancy, Meurthe-et-Moselle, France
| | - Romain Boissier
- Hôpital de la Conception, Urology and Transplantation, Marseille, Provence, France
| | - Federico Sallusto
- CHU de Toulouse, Urology and Transplantation, Toulouse ,Haute Gronnea, France
| | - Cédric Sénéchal
- CHU de Point à Pitre, Urology and Transplantation, Point à Pitre, Guadeloupe, France
| | - Nicolas Terrier
- CHU de Grenoble, Urology and Transplantation, Grenoble, Isare, France
| | - Rodolphe Thuret
- CHU de Montpellier, Urology and Transplantation, Montpellier, Herault, France
| | - Gregory Verhoest
- CHU de Rennes, Urology and Transplantation, Rennes, Ille-et-Vilaine, France
| | - Thibaut Waeckel
- CHU de Bordeaux, Urology and Transplantation, Bordeaux, Gironde, France
| | - Xavier Tillou
- CHU de Caen, Urology and Transplantation, Caen Calvados, France.
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16
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Effect of Maintaining Immunosuppression After Kidney Allograft Failure on Mortality and Retransplantation. Transplant Direct 2022; 9:e1415. [DOI: 10.1097/txd.0000000000001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022] Open
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17
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Couceiro C, Rama I, Comas J, Montero N, Manonelles A, Codina S, Favà A, Melilli E, Coloma A, Quero M, Tort J, Cruzado JM. Effect of kidney replacement therapy modality after first kidney graft failure on second kidney transplantation outcomes. Clin Kidney J 2022; 15:2046-2055. [PMID: 36325006 PMCID: PMC9613432 DOI: 10.1093/ckj/sfac155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND There is a lack of information regarding which is the best dialysis technique after kidney transplant (KT) failure. The aim of this study is to compare the effect of kidney replacement therapy modality-peritoneal dialysis (TX-PD-TX), haemodialysis (TX-HD-TX) and preemptive deceased donor retransplantation (TX-TX) on patient survival and second KT outcomes. METHODS A retrospective observational study from the Catalan Renal Registry was carried out. We included adult patients with failing of their first KT from 2000 to 2018. RESULTS Among 2045 patients, 1829 started on HD (89.4%), 168 on PD (8.2%) and 48 (2.4%) received a preemptive KT. Non-inclusion on the KT waiting list and HD were associated with worse patient survival. For patients included on the waiting list, the probability of human leucocyte antigens (HLA) sensitization and to receive a second KT was similar in HD and PD. A total of 776 patients received a second KT (38%), 656 in TX-HD-TX, 72 in TX-PD-TX and 48 in TX-TX groups. Adjusted mortality after second KT was higher in TX-HD-TX patients compared with TX-TX and TX-PD-TX groups, without differences between TX-TX and TX-PD-TX groups. Death-censored second graft survival was similar in all three groups. CONCLUSIONS Our results suggest that after first KT failure, PD is superior to HD in reducing mortality in candidates for a second KT without options for preemptive retransplantation.
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Affiliation(s)
- Carlos Couceiro
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Inés Rama
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Comas
- Department of Health, Catalan Renal Registry, Catalan Transplant Organization, Barcelona, Spain
| | - Núria Montero
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sergi Codina
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alexandre Favà
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Edoardo Melilli
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ana Coloma
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Maria Quero
- Nephrology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Biomedical Research Institute (IDIBELL), Hospital Duran i Reynals, L'Hospitalet de Llobregat, Barcelona, Spain
- Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jaume Tort
- Department of Health, Catalan Renal Registry, Catalan Transplant Organization, Barcelona, Spain
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18
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Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:jcm11195753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [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: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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19
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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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20
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Vanhove T, Elias N, Safa K, Cohen-Bucay A, Schold JD, Riella LV, Gilligan H. Long-term outcome reporting in older kidney transplant recipients and the limitations of conventional survival metrics. Kidney Int Rep 2022; 7:2397-2409. [DOI: 10.1016/j.ekir.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/14/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
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21
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Kidney Retransplantation after Graft Failure: Variables Influencing Long-Term Survival. J Transplant 2022; 2022:3397751. [PMID: 35782455 PMCID: PMC9242806 DOI: 10.1155/2022/3397751] [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: 05/11/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background There is an increasing demand for kidney retransplantation. Most studies report inferior outcomes compared to primary transplantation, consequently feeding an ethical dilemma in the context of chronic organ shortage. Objective To assess variables influencing long-term graft survival after kidney retransplantation. Material and Methods. All patients transplanted at our center between 2000 and 2016 were analyzed retrospectively. Survival was estimated with the Kaplan–Meier method, and risk factors were identified using multiple Cox regression. Results We performed 1,376 primary kidney transplantations and 222 retransplantations. The rate of retransplantation was 67.8% after the first graft loss, with a comparable 10-year graft survival compared to primary transplantation (67% vs. 64%, p=0.104) but an inferior graft survival thereafter (log-rank p=0.026). Independent risk factors for graft survival in retransplantation were age ≥ 50 years, time on dialysis ≥1 year, previous graft survival <2 years, ≥1 mild comorbidity in the Charlson–Deyo index, active smoking, and life-threatening complications (Clavien–Dindo grade IV) at first transplantation. Conclusion Graft survival is comparable for first and second kidney transplantation within the first 10 years. Risk factors for poor outcomes after retransplantation are previous graft survival, dialysis time after graft failure, recipient age, comorbidities, and smoking. Patients with transplant failure should have access to retransplantation as early as possible.
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22
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Naesens M, Loupy A, Hilbrands L, Oberbauer R, Bellini MI, Glotz D, Grinyó J, Heemann U, Jochmans I, Pengel L, Reinders M, Schneeberger S, Budde K. Rationale for Surrogate Endpoints and Conditional Marketing Authorization of New Therapies for Kidney Transplantation. Transpl Int 2022; 35:10137. [PMID: 35669977 PMCID: PMC9163307 DOI: 10.3389/ti.2022.10137] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/10/2022] [Indexed: 12/13/2022]
Abstract
Conditional marketing authorization (CMA) facilitates timely access to new drugs for illnesses with unmet clinical needs, such as late graft failure after kidney transplantation. Late graft failure remains a serious, burdensome, and life-threatening condition for recipients. This article has been developed from content prepared by members of a working group within the European Society for Organ Transplantation (ESOT) for a Broad Scientific Advice request, submitted by ESOT to the European Medicines Agency (EMA), and reviewed by the EMA in 2020. The article presents the rationale for using surrogate endpoints in clinical trials aiming at improving late graft failure rates, to enable novel kidney transplantation therapies to be considered for CMA and improve access to medicines. The paper also provides background data to illustrate the relationship between primary and surrogate endpoints. Developing surrogate endpoints and a CMA strategy could be particularly beneficial for studies where the use of primary endpoints would yield insufficient statistical power or insufficient indication of long-term benefit following transplantation.
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Affiliation(s)
- Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | | | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Marlies Reinders
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
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23
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Sageshima J, Chandar J, Chen LJ, Shah R, Al Nuss A, Vincenzi P, Morsi M, Figueiro J, Vianna R, Ciancio G, Burke GW. How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond. Transplantation 2022; 106:709-721. [PMID: 34310100 DOI: 10.1097/tp.0000000000003888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.
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Affiliation(s)
- Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rushi Shah
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ammar Al Nuss
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Paolo Vincenzi
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
- Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - George W Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
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24
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Davis S, Mohan S. Managing Patients with Failing Kidney Allograft: Many Questions Remain. Clin J Am Soc Nephrol 2022; 17:444-451. [PMID: 33692118 PMCID: PMC8975040 DOI: 10.2215/cjn.14620920] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Patients who receive a kidney transplant commonly experience failure of their allograft. Transplant failure often comes with complex management decisions, such as when and how to wean immunosuppression and start the transition to a second transplant or to dialysis. These decisions are made in the context of important concerns about competing risks, including sensitization and infection. Unfortunately, the management of the failed allograft is, at present, guided by relatively poor-quality data and, as a result, practice patterns are variable and suboptimal given that patients with failed allografts experience excess morbidity and mortality compared with their transplant-naive counterparts. In this review, we summarize the management strategies through the often-precarious transition from transplant to dialysis, highlighting the paucity of data and the critical gaps in our knowledge that are necessary to inform the optimal care of the patient with a failing kidney transplant.
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Affiliation(s)
- Scott Davis
- Department of Medicine, University of Colorado, Aurora, Colorado,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Sumit Mohan
- Department of Medicine, University of Colorado, Aurora, Colorado .,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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25
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Huml AM, Schold JD. A Second Chance at Transplant First: Preemptive Repeat Kidney Transplantation. KIDNEY360 2022; 3:11-13. [PMID: 35368554 PMCID: PMC8967608 DOI: 10.34067/kid.0007502021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Anne M. Huml
- Center for Reducing Health Disparities, Case Western Reserve University, Cleveland Clinic, Ohio
- Department of Kidney Medicine, Glickman Urological and Kidney Institute, Cleveland Clinic, Ohio
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Ohio
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Ohio
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26
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Anandh U, Deshpande P. Issues and concerns in the management of progressive allograft dysfunction: A narrative review. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_114_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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27
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Taira H, Noguchi H, Ueki K, Kaku K, Tsuchimoto A, Okabe Y, Ohya Y, Nakamura M. Initiation of dialysis for kidney graft failure: A retrospective single-center cohort study. Ther Apher Dial 2021; 26:806-814. [PMID: 34779578 DOI: 10.1111/1744-9987.13756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/22/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022]
Abstract
Few studies have focused on the outcome of dialysis for kidney graft failure. We investigated the outcomes of dialysis for graft failure. We retrospectively studied 52 patients undergoing dialysis for graft failure at our facility from January 2004 to December 2018. The mean age at initiation of dialysis was 51.8 ± 13.5 years. The patient survival rates after initiation of dialysis at 1, 3, and 5 years were 96.0%, 93.8%, and 82.4%, respectively. The rate of unplanned initiation was 44.2%. In multivariate logistic analysis, lack of follow-up by nephrologists and pre-emptive kidney transplantation (PEKT) tended to be risk factors for unplanned initiation (P = 0.065 and P = 0.014, respectively). Our study suggests that the prognosis of patients with dialysis for graft failure is acceptable. Dialysis for graft failure, especially in patients with PEKT, tends to be unplanned, and for safe initiation, early involvement of nephrologists may be necessary.
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Affiliation(s)
- Hirona Taira
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology and Neurology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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28
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Vlachopanos G, El Kossi M, Aziz D, Halawa A. Association of Nephrectomy of the Failed Renal Allograft With Outcome of the Future Transplant: A Systematic Review. EXP CLIN TRANSPLANT 2021; 20:1-11. [PMID: 34775942 DOI: 10.6002/ect.2021.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Kidney allograft failure is a significant complication in kidney transplant recipients, and the surgical decision to perform allograft nephrectomy poses a strong dilemma because it is associated with significant morbidity and mortality. There is a debate over the effect of allograft nephrectomy on the development of allosensitization and the impact on potential retransplantation. Moreover, the use of immunosuppression may contribute to antibody allosensitization as allograft nephrectomy and immunosuppression act jointly and interdependently toward antibody formation. Because more and more patients with kidney allograft failure are entering wait lists for repeat transplant procedures, a review of available evidence on the field is required. Here, we performed a literature search using multiple medical databases to identify relevant studies that assessed the effects of allograft nephrectomy on important retransplant endpoints such as allograft and patient survival; furthermore, secondary outcomes such as alloantibody sensitization were also evaluated. A total of 15 studies were identified; all were retrospective, single-center studies. The rate of allograft nephrectomy in patients with retransplant varied widely (from 20% to 80%). The average allograft nephrectomy rate in included studies was 43% (allograft nephrectomy number/number of repeat transplantations: 2351/5431). Most studies did not observe an allograft survival benefit after retransplant for patients with allograft nephrectomy with the exception of 4 studies that found worse allograft survival after allograft nephrectomy. Interestingly, 1 study found that, in the patient subgroup with early kidney allograft failure (<12 months posttransplant), allograft nephrectomy may be associated with better allograft survival. Available data suggested that allograft nephrectomy may be associated with a higher risk of increasing anti-HLA antibody levels. The quality of the included studies suffered from nonrandomized design, potential confounding, and small sample size. To conclude, further randomized controlled trials are required to delineate the role of allograft nephrectomy on retransplant outcomes.
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Affiliation(s)
- Georgios Vlachopanos
- From the Department of Nephrology, General Hospital of Nikea, Athens, Greece.,From the School of Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Science, University of Liverpool, Liverpool, United Kingdom
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29
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Lubetzky M, Tantisattamo E, Molnar MZ, Lentine KL, Basu A, Parsons RF, Woodside KJ, Pavlakis M, Blosser CD, Singh N, Concepcion BP, Adey D, Gupta G, Faravardeh A, Kraus E, Ong S, Riella LV, Friedewald J, Wiseman A, Aala A, Dadhania DM, Alhamad T. The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients. Am J Transplant 2021; 21:2937-2949. [PMID: 34115439 DOI: 10.1111/ajt.16717] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/23/2021] [Accepted: 05/20/2021] [Indexed: 01/25/2023]
Abstract
The return to dialysis after allograft failure is associated with increased morbidity and mortality. This transition is made more complex by the rising numbers of patients who seek repeat transplantation and therefore may have indications for remaining on low levels of immunosuppression, despite the potential increased morbidity. Management strategies vary across providers, driven by limited data on how to transition off immunosuppression as the allograft fails and a paucity of randomized controlled trials to support one approach over another. In this review, we summarize the current data available for management and care of the failing allograft. Additionally, we discuss a suggested plan for immunosuppression weaning based upon the availability of re-transplantation and residual allograft function. We propose a shared-care model in which there is improved coordination between transplant providers and general nephrologists so that immunosuppression management and preparation for renal replacement therapy and/or repeat transplantation can be conducted with the goal of improved outcomes and decreased morbidity in this vulnerable patient group.
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Affiliation(s)
- Michelle Lubetzky
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Ekamol Tantisattamo
- Division of Nephrology, University of California Irvine, Orange, California, USA
| | - Miklos Z Molnar
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Krista L Lentine
- Internal Medicine-Nephrology, Saint Louis University, St. Louis, Missouri, USA
| | - Arpita Basu
- Division of Transplantation, Emory University, Atlanta, Georgia, USA
| | - Ronald F Parsons
- Division of Transplantation, Emory University, Atlanta, Georgia, USA
| | - Kenneth J Woodside
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, Michigan, USA
| | - Martha Pavlakis
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher D Blosser
- Division of Nephrology, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Neeraj Singh
- Division of Nephrology, Willis Knighton Health System, Shreveport, Louisiana, USA
| | | | - Deborah Adey
- Division of Nephrology, University of California San Francisco, San Francisco, California, USA
| | - Gaurav Gupta
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California, USA
| | - Edward Kraus
- Department of Medicine, Johns Hopkins, Baltimore, Maryland, USA
| | - Song Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Leonardo V Riella
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John Friedewald
- Division of Medicine and Surgery, Northwestern University, Chicago, Illinois, USA
| | - Alex Wiseman
- Division of Nephrology, University of Colorado, Denver, Colorado, USA
| | - Amtul Aala
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Darshana M Dadhania
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Michigan, USA
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30
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Martin K, Cantwell L, Barraclough KA, Lian M, Masterson R, Hughes PD, Chow KV. Prolonged immunosuppression does not improve risk of sensitisation or likelihood of re-transplantation after kidney transplant graft failure. Transpl Int 2021; 34:2353-2362. [PMID: 34320262 DOI: 10.1111/tri.13998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimum approach toward immunosuppression withdrawal following kidney transplant failure is unclear. Prolonged weaning may be associated with reduced sensitisation, less graft nephrectomy and greater likelihood of re-transplantation, but conversely increased risk of infection, malignancy and death. METHODS We conducted a single centre retrospective analysis of patients experiencing graft failure between 2007-2017, comparing rates of sensitisation, re-transplantation, nephrectomy, infection, malignancy and death between patients who had immunosuppression weaned over <90 vs. 90-180 vs. >180 days. RESULTS Patient survival after immunosuppression withdrawal over <90 vs. 90-180 vs. >180 days was 73.3%, 72.1% and 80.4% respectively (p=0.35), with no differences in cPRA (80.06 vs. 81.21 vs. 85.42, p=0.66) or re-transplantation rate (24/31 (77.4%) vs. 21/35 (60.0%) vs. 22/36 (61.1%), p=0.13). There was significantly less nephrectomy after late immunosuppression cessation (10/42 (23.8%) vs. 7/42 (16.7%) vs. 3/43 (7.0%), p=0.01) but no differences in infections or malignancy. On competing risk regression (death as competing risk) controlling for cofactors including age, nephrectomy and rejection, prolonged immunosuppression did not predict likelihood of re-transplantation (SHR 1.000, p=0.88). CONCLUSIONS Prolonged immunosuppression withdrawal does not reduce sensitisation or improve re-transplantation rates but is associated with less nephrectomy. Immunosuppression withdrawal should be tailored to individual circumstances after graft failure.
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Affiliation(s)
- Kylie Martin
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia
| | - Linda Cantwell
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Life Blood, Victoria, Australia
| | - Katherine A Barraclough
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Michael Lian
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Peter D Hughes
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Kevin V Chow
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
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31
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Song Y, Zheng J, Guo S, Fan L. An intracapsular nephrectomy for the acquired cystic disease-associated renal cell carcinoma in renal transplant allograft: A clinical case report. Medicine (Baltimore) 2021; 100:e25858. [PMID: 34106631 PMCID: PMC8133129 DOI: 10.1097/md.0000000000025858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/21/2021] [Indexed: 01/16/2023] Open
Abstract
RATIONALE Acquired cystic disease-associated renal cell carcinoma (ACKD-RCC) is a unique subtype of renal cell carcinoma (RCC) and is found exclusively in patients with end-stage renal disease. We report a case of intracapsular nephrectomy (ICAN) of renal allograft with ACKD-RCC. To our knowledge, this is the first case in Asia of ICAN of renal allograft to treat ACKD-RCC. PATIENT CONCERNS A 51-year-old male patient with a history of allogeneic kidney transplantation (23 years previously) presented with renal cystic degeneration of the transplanted kidney over the past 2 years. DIAGNOSES ICAN was used to remove the cystic kidney. INTERVENTIONS The pathology report indicated clear cell renal cell carcinoma. OUTCOMES Two years after surgery, computed tomography showed no tumor recurrence, and the patient's creatinine level was 3.5 mg/dl under hemodialysis. LESSONS Removal of transplanted kidney with ACKD-RCC using ICAN is feasible to provide a mid-term tumor-free survival for the patient. Therefore, we consider nephrectomy as an early treatment for the nonfunctional cystic allograft kidney, in order to reduce the dosage of anti-rejection drugs, avoid the occurrence of transplanted kidney tumor, and provide the possibility for the patient an opportunity to receive a second kidney transplantation.
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Affiliation(s)
| | - Jingjing Zheng
- Department of Anesthesia, General Hospital of Northern Theater Command, Shenyang, China
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32
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Meng X, Wu W, Xu S, Cheng Z. Comparison of outcomes of peritoneal dialysis between patients after failed kidney transplant and transplant-naïve patients: a meta-analysis of observational studies. Ren Fail 2021; 43:698-708. [PMID: 33896379 PMCID: PMC8079072 DOI: 10.1080/0886022x.2021.1914659] [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] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The influence of prior failed kidney transplants on outcomes of peritoneal dialysis (PD) is unclear. Thus, we conducted a systematic review and meta-analysis to compare the outcomes of patients initiating PD after a failed kidney transplant with those initiating PD without a prior history of kidney transplantation. METHODS We searched PubMed, Embase, CENTRAL, and Google Scholar databases from inception until 25 November 2020. Our meta-analysis considered the absolute number of events of mortality, technical failures, and patients with peritonitis, and we also pooled multi-variable adjusted hazard ratios (HR). RESULTS We included 12 retrospective studies. For absolute number of events, our analysis indicated no statistically significant difference in technique failure [RR, 1.14; 95% CI, 0.80-1.61; I2=52%; p = 0.48], number of patients with peritonitis [RR, 1.13; 95% CI, 0.97-1.32; I2=5%; p = 0.11] and mortality [RR, 1.00; 95% CI, 0.67-1.50; I2=63%; p = 0.99] between the study groups. The pooled analysis of adjusted HRs indicated no statistically significant difference in the risk of technique failure [HR, 1.25; 95% CI, 0.88-1.78; I2=79%; p = 0.22], peritonitis [HR, 1.04; 95% CI, 0.72-1.50; I2=76%; p = 0.85] and mortality [HR, 1.24; 95% CI, 0.77-2.00; I2=66%; p = 0.38] between the study groups. CONCLUSION Patients with kidney transplant failure initiating PD do not have an increased risk of mortality, technique failure, or peritonitis as compared to transplant-naïve patients initiating PD. Further studies are needed to evaluate the impact of prior and ongoing immunosuppression on PD outcomes.
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Affiliation(s)
- Xiaohua Meng
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
| | - Weifei Wu
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
| | - Shuang Xu
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
| | - Zhiqun Cheng
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
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33
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Munshi VN, Saghafian S, Cook CB, Aradhyula SV, Chakkera HA. Use of Imputation and Decision Modeling to Improve Diagnosis and Management of Patients at Risk for New-Onset Diabetes After Transplantation. Ann Transplant 2021; 26:e928624. [PMID: 33723204 PMCID: PMC7980500 DOI: 10.12659/aot.928624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/06/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is a complication of solid organ transplantation. We sought to determine the extent to which NODAT goes undiagnosed over the course of 1 year following transplantation, analyze missed or later-diagnosed cases of NODAT due to poor hemoglobin A1c (HbA1c) and fasting blood glucose (FBG) collection, and to estimate the impact that improved NODAT screening metrics may have on long-term outcomes. MATERIAL AND METHODS This was a retrospective study utilizing 3 datasets from a single center on kidney, liver, and heart transplantation patients. Retrospective analysis was supplemented with an imputation procedure to account for missing data and project outcomes under perfect information. In addition, the data were used to inform a simulation model used to estimate life expectancy and cost-effectiveness of a hypothetical intervention. RESULTS Estimates of NODAT incidence increased from 27% to 31% in kidney transplantation patients, from 31% to 40% in liver transplantation patients, and from 45% to 67% in heart transplantation patients, when HbA1c and FBG were assumed to be collected perfectly at all points. Perfect screening for kidney transplantation patients was cost-saving, while perfect screening for liver and heart transplantation patients was cost-effective at a willingness-to-pay threshold of $100 000 per life-year. CONCLUSIONS Improved collection of HbA1c and FBG is a cost-effective method for detecting many additional cases of NODAT within the first year alone. Additional research into both improved glucometric monitoring as well as effective strategies for mitigating NODAT risk will become increasingly important to improve health in this population.
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Affiliation(s)
- Vidit N. Munshi
- Department of Health Policy, Harvard University, Cambridge, MA, U.S.A
| | | | - Curtiss B. Cook
- Department of Endocrinology, Mayo Clinic, Scottsdale, AZ, U.S.A
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34
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Beltrán Catalán S, Sancho Calabuig A, Molina P, Vizcaíno Castillo B, Gavela Martínez E, Kanter Berga J, González Moya M, Pallardó Mateu LM. Impact of dialysis modality on morbimortality of kidney transplant recipients after allograft failure. Analysis in the presence of competing events. Nefrologia 2021; 41:200-209. [PMID: 36165381 DOI: 10.1016/j.nefroe.2020.12.005] [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: 07/08/2020] [Accepted: 12/10/2020] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The number of patients who start dialysis due to graft failure increases every day. The best dialysis modality for this type of patient is not well defined and most patients are referred to HD. The objective of our study is to evaluate the impact of the dialysis modality on morbidity and mortality in transplant patients who start dialysis after graft failure. MATERIAL AND METHODS A multicentre retrospective observation and cohort study was performed to compare the evolution of patients who started dialysis after graft failure from January 2000 to December 2013. One group started on PD and the other on HD. The patients were followed until the change of dialysis technique, retransplantation or death. Anthropometric data, comorbidity, estimated glomerular filtration rate (eGFR) at start of dialysis, the presence of an optimal access for dialysis, the appearance of graft intolerance and retransplantation were analyzed. We studied the causes for the first 10 hospital admissions after starting dialysis. For the statistical analysis, the presence of competitive events that hindered the observation of the event of interest, death or hospital admission was analyzed. RESULTS 175 patients were included, 86 in DP and 89 in HD. The patients who started PD were younger, had less comorbidity and started dialysis with lower eGFR than those on HD. The mean follow-up was 34 ± 33 months, with a median of 24 months (IQR 7-50 months), Patients on HD had longer follow-up than patients on PD (35 vs. 18 months, p = < 0.001). The mortality risk factors were age sHR 1.06 (95% CI: 1.03-1.106, p = 0.000), non-optimal use of access for dialysis sHR 3.00 (95% CI: 1.507-5.982, p = 0.028) and the dialysis modality sHR (PD/HD) 0.36 (95% CI: 0.148-0.890, p = 0.028). Patients on PD had a lower risk of hospital admission sHR [DP/HD] 0.52 (95% CI: 0.369-0.743, p = < 0.001) and less probability of developing graft intolerance HR 0.307 (95% CI 0.142-0.758, p = 0.009). CONCLUSIONS With the limitations of a retrospective and non-randomized study, it is the first time nationwide that PD shows in terms of survival to be better than HD during the first year and a half after the kidney graft failure. The presence of a non-optimal access for dialysis was an independent and modifiable risk factor for mortality. Early referral of patients to advanced chronic kidney disease units is essential for the patient to choose the technique that best suits their circumstances and to prepare an optimal access for the start of dialysis.
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Affiliation(s)
- Sandra Beltrán Catalán
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain.
| | - Asunción Sancho Calabuig
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Pablo Molina
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Belén Vizcaíno Castillo
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Eva Gavela Martínez
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Julia Kanter Berga
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Mercedes González Moya
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
| | - Luis Manuel Pallardó Mateu
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (Fisabio), Valencia, Spain
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35
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Khan T, Kwarcinski J, Pang T, Hameed A, Boughton P, O'Grady G, Hawthorne WJ, Rogers NM, Wong G, Pleass HC. Protection From the Second Warm Ischemic Injury in Kidney Transplantation Using an Ex Vivo Porcine Model and Thermally Insulating Jackets. Transplant Proc 2021; 53:750-754. [PMID: 33581848 DOI: 10.1016/j.transproceed.2021.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Kidney transplantation is the optimum treatment for kidney failure in carefully selected patients. Technical surgical complications and second warm ischemic time (SWIT) increase the risk of delayed graft function (DGF) and subsequent short- and long-term graft outcomes including the need for post-transplant dialysis and graft failure. Intraoperative organ thermal regulation could reduce SWIT, minimizing surgical complications due to time pressure, and limiting graft ischemia-reperfusion injury. METHODS A novel ischemic-injury thermal protection jacket (iiPJ) was designed and fabricated in silicone composite and polyurethane (PU) elastomer prototypes. Both were compared with no thermal insulation as controls. Time to reach ischemic threshold (15°C) and thermal energy transfer were compared. A water bath model was used to examine the thermal protective properties of porcine kidneys, as a feasibility study prior to in vivo translation. RESULTS In both iterations of the iiPJ, the time taken to reach the warm ischemia threshold was 35.2 ± 1.4 minutes (silicone) and 38.4 ± 3.1 minutes (PU), compared with 17.2 ± 1.5 minutes for controls (n = 5, P < .001 for both comparisons). Thermal energy transfer was also found to be significantly less for both iiPJ variants compared with controls. There was no significant difference between the thermal performance of the 2 iiPJ variants. CONCLUSION Protection from SWIT by using a protective insulation jacket is feasible. With clinical translation, this novel strategy could facilitate more optimal surgical performance and reduce transplanted organ ischemia-reperfusion injury, in particular the SWIT, potentially affecting delayed graft function and long-term outcomes.
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Affiliation(s)
- Turaab Khan
- Sydney Medical School, University of Sydney, Sydney, Australia.
| | | | - Tony Pang
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ahmer Hameed
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Philip Boughton
- Sydney Medical School, University of Sydney, Sydney, Australia; Sydney Pharmacy School, University of Sydney, Sydney, Australia; Charles Perkins Centre, University of Sydney, Sydney, Australia; Global Surgical Innovations, Sydney Spine Institute, Burwood, Australia
| | - Greg O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Wayne J Hawthorne
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Surgery, Westmead Hospital, Westmead, Australia; Westmead Institute for Medical Research, Westmead, Australia
| | - Natasha M Rogers
- Department of Transplant/Renal Medicine, Westmead Hospital, Westmead, Australia
| | - Germaine Wong
- Department of Transplant/Renal Medicine, Westmead Hospital, Westmead, Australia
| | - Henry C Pleass
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Surgery, Westmead Hospital, Westmead, Australia
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36
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Kawaguchi T, Hamano T, Masakane I, Wada A, Okada E, Kadomura M, Imasawa T. Association of kidney transplantation with mortality on hemodialysis after graft failure. J Nephrol 2021; 34:521-530. [PMID: 33394343 DOI: 10.1007/s40620-020-00929-4] [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: 08/23/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although a substantial number of patients return to dialysis after kidney transplant failure, it remains controversial whether transplant-failure patients have a higher mortality risk than transplant-naïve patients on dialysis who have never undergone kidney transplantation. We compared outcomes of transplant-failure and transplant-naïve patients on hemodialysis. METHODS Data from the Japanese National Dialysis Registry (2012-2013) were analyzed, including 220,438 prevalent hemodialysis patients. Multivariable Cox models were used to compare all-cause, cardiovascular, and infection-related mortality during 1-year follow-up between transplant-failure and transplant-naïve patients. Multiple imputation and propensity score matching were utilized as sensitivity analyses. RESULTS During 209,377 patient-years of follow-up, 18,648 all-cause deaths (8.5% of all patients), 7700 cardiovascular deaths (41% of all-cause deaths), and 3806 infection-related deaths (20% of all-cause deaths) were observed. Adjusted hazard ratios [95% confidence intervals] for all-cause, cardiovascular, and infection-related deaths among transplant-failure patients were 0.81 [0.59-1.11], 0.54 [0.30-0.98], and 1.54 [0.92-2.59], respectively. Sensitivity analyses using multiple imputation and propensity score matching yielded similar results. CONCLUSIONS This Japanese cohort study suggested that a cardiovascular mortality risk of transplant-failure patients could be significantly lower than that of transplant-naïve patients, while there might be a trend toward a higher infection-related mortality risk in transplant-failure patients. However, this retrospective, single-country study can introduce an immortal time bias in transplant-failure patients, and limit the external validity. Further prospective studies are warranted to improve the comparability of outcomes between transplant-failure and transplant-naïve patients, and to examine worldwide the generalizability of the potential cardiovascular benefit of kidney transplantation even after returning to dialysis.
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Affiliation(s)
- Takehiko Kawaguchi
- Department of Nephrology, National Hospital Organization Chibahigashi National Hospital, 673 Nitona-cho, Chuo-ku, Chiba, 260-8712, Japan.
| | - Takayuki Hamano
- Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ikuto Masakane
- Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Nephrology, Yabuki Hospital, Yamagata, Japan
| | - Atsushi Wada
- Committee of Renal Data Registry, The Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Eri Okada
- Department of Nephrology, National Hospital Organization Chibahigashi National Hospital, 673 Nitona-cho, Chuo-ku, Chiba, 260-8712, Japan
| | - Moritoshi Kadomura
- Department of Nephrology, National Hospital Organization Chibahigashi National Hospital, 673 Nitona-cho, Chuo-ku, Chiba, 260-8712, Japan
| | - Toshiyuki Imasawa
- Department of Nephrology, National Hospital Organization Chibahigashi National Hospital, 673 Nitona-cho, Chuo-ku, Chiba, 260-8712, Japan
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37
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La Porta E, Conversano E, Zugna D, Camilla R, Labbadia R, Paglialonga F, Parolin M, Vidal E, Verrina E. Returning to dialysis after kidney allograft failure: the experience of the Italian Registry of Paediatric Chronic Dialysis. Pediatr Nephrol 2021; 36:3961-3969. [PMID: 34128094 PMCID: PMC8599402 DOI: 10.1007/s00467-021-05140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/19/2021] [Accepted: 05/14/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The need for dialysis after kidney allograft failure (DAGF) is among the top five reasons for dialysis initiation, making this an important topic in clinical nephrology. However, data are scarce on dialysis choice after transplantation and clinical outcomes for DAGF in children. METHODS Patients receiving chronic dialysis < 18 years were recorded from January 1991 to January 2019 by the Italian Registry of Pediatric Chronic Dialysis (IRPCD). We investigated factors influencing choice of dialysis modality, patient outcome in terms of mortality, switching dialysis modality, and kidney transplantation. RESULTS Among 118 patients receiving DAGF, 41 (35%) were treated with peritoneal dialysis (PD), and 77 (65%) with haemodialysis (HD). Significant predictors for treatment with PD were younger age at dialysis start (OR 0.85 per year increase [95%CI 0.72-1.00]) and PD use before kidney transplantation (OR 8.20 [95%CI 1.82-37.01]). Patients entering DAGF in more recent eras (OR 0.87 per year increase [95%CI 0.80-0.94]) and with more than one dialysis modality before kidney transplantation (OR 0.56 for being treated with PD [0.12-2.59]) were more likely to be initiated on HD. As compared to patients on HD, those treated with PD exhibited increased but non-significant mortality risk (HR 2.15 [95%CI 0.54-8.6]; p = 0.28) and higher prevalence of dialysis-related complications during DAGF (p = 0.002) CONCLUSIONS: Patients entering DAGF in more recent years are more likely to be initiated on HD. In this specific population of children, use of PD seems associated with a more complicated course. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Edoardo La Porta
- Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Genova, Italy
| | - Ester Conversano
- grid.418712.90000 0004 1760 7415Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Daniela Zugna
- grid.7605.40000 0001 2336 6580Department of Medical Sciences, Cancer Epidemiology Unit, University of Torino and CPO-Piemonte, Turin, Italy
| | - Roberta Camilla
- grid.415778.80000 0004 5960 9283Paediatric Nephrology Unit, Regina Margherita Children’s Hospital, CDSS, Turin, Italy
| | - Raffaella Labbadia
- grid.414125.70000 0001 0727 6809Nephrology and Dialysis Unit, Department of Pediatrics, “Bambino Gesù” Children’s Hospital-IRCCS, Rome, Italy
| | - Fabio Paglialonga
- grid.414818.00000 0004 1757 8749Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mattia Parolin
- grid.411474.30000 0004 1760 2630Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman’s and Child’s Health, University Hospital, Padova, Padua, Italy
| | - Enrico Vidal
- Division of Pediatrics, Department of Medicine (DAME), University of Udine, P.le S.M della Misericordia, 15 33100, Udine, Italy.
| | - Enrico Verrina
- Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Genova, Italy
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Hart A, Zaun D, Itzler R, Schladt D, Israni A, Kasiske B. Cost, healthcare utilization, and outcomes of antibody-mediated rejection in kidney transplant recipients in the US. J Med Econ 2021; 24:1011-1017. [PMID: 34348559 DOI: 10.1080/13696998.2021.1964267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) is one of the leading causes of graft loss in kidney transplant recipients but little is known about the associated cost and healthcare burden of AMR. METHODS We developed an algorithm to detect AMR using the 2006-2011 Centers for Medicare & Medicaid Services (CMS) using ICD-10 and billing codes as there is no specific ICD-10 or procedure code for AMR. We then compared healthcare utilization, cost, and risk of graft failure or death in AMR. patients versus matched controls. RESULTS The algorithm had a 39.4% true-positive rate (69/175) and a 4.1% false-positive rate (110/2,655). We identified 5,679/101,554 (5.6%) with AMR, who had a nearly 3-fold higher risk of graft failure (hazard ratio [HR], 2.75, 95% confidence interval [CI], 2.50 to 3.03; p < .0001) and death (HR, 2.59; 95% CI, 2.35 to 2.86; p < .0001) at 2 years, nearly 5 times the hospitalizations in the 60 d before AMR diagnosis, and increased nephrology and emergency department visits. Mean AMR attributable healthcare costs were 4 times higher than matched controls, at $13,066 more per patient in the 60 d before AMR diagnosis and $35,740 per patient per year higher in the 2 years after AMR diagnosis. CONCLUSIONS US kidney transplant recipients with AMR have substantially greater healthcare utilization and higher costs and risk of graft loss and mortality.
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Affiliation(s)
- Allyson Hart
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Zaun
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | - David Schladt
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Ajay Israni
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Bertram Kasiske
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
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39
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Ozden E, Gulsen M, Mercimek MN, Bostanci Y, Sarikaya S, Yakupoglu YK. Laparoscopic Partial Nephrectomy in Allograft Kidney. Urology 2020; 146:e5-e7. [PMID: 32882302 DOI: 10.1016/j.urology.2020.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/13/2020] [Accepted: 08/19/2020] [Indexed: 11/29/2022]
Abstract
The incidence of renal tumor on the allograft kidney is relatively rare. There is no standard treatment available for the management of such cases. However, if technically feasible nephron-sparing surgical approaches, whether open or minimally invasive, should be preferred for the management of these challenging cases. To our knowledge, there is no pure laparoscopic technique reported in the literature but only 3 cases of robot-assisted partial nephrectomy. In this article, we aimed to present the application of pure transperitoneal laparoscopic partial nephrectomy for the management of a renal mass on the allograft kidney.
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Affiliation(s)
- Ender Ozden
- Department of Urology, Ondokuz Mayıs University, Atakum, Samsun, Turkey.
| | - Murat Gulsen
- Department of Urology, Ondokuz Mayıs University, Atakum, Samsun, Turkey
| | | | - Yakup Bostanci
- Department of Urology, Ondokuz Mayıs University, Atakum, Samsun, Turkey
| | - Saban Sarikaya
- Department of Urology, Ondokuz Mayıs University, Atakum, Samsun, Turkey
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40
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Kinoshita Y, Yagisawa T, Sugihara T, Hara K, Takeshima S, Kubo T, Shinzato T, Shimizu T, Suzuki M, Maeshima A, Kamei J, Fujisaki A, Ando S, Suzuki M, Kume H, Fujimura T. Clinical outcomes in donors and recipients of kidney transplantations involving medically complex living donors - a retrospective study. Transpl Int 2020; 33:1417-1423. [PMID: 32654198 DOI: 10.1111/tri.13699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/14/2020] [Accepted: 07/06/2020] [Indexed: 02/06/2023]
Abstract
We retrospectively compared the post-transplantation graft survival and the donor's estimated glomerular filtration rates (eGFRs) following living donor kidney transplantations (LDKTs) involving medically complex living donors (MCLDs) (the elderly and patients with obesity, hypertension, diabetes mellitus, or reduced renal function) and standard living donors (SLDs). The clinical data on patients who underwent LDKTs at our institution from 2006-2019, including 192 SLDs and 99 MCLDs, were evaluated. Regarding recipients, the log-rank test and multivariable Cox proportional hazards analyses showed a higher incidence of overall and death-censored graft loss in the recipients who received kidneys from MCLDs (Hazard ratio = 2.16 and 3.25, P = 0.015 and 0.004, respectively), after adjusting for recipient-related variables including age, sex, duration of dialysis, ABO compatibility, and donor-specific antibody positivity. Regarding donors, a linear mixed model showed significantly lower postdonation eGFRs (-2.25 ml/min/1.73 m2 , P = 0.048) at baseline in MCLDs than SLDs, but comparable change (difference = 0.01 ml/min/1.73 m2 /year, P = 0.97). In conclusion, although kidneys from MCLDs are associated with impaired graft survival, the donation did not adversely affect the MCLDs' renal health in at least the short-term. LDKTs involving carefully selected MCLDs would be an acceptable alternative for recipients with no SLDs.
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Affiliation(s)
- Yoshitaka Kinoshita
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan.,Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Takashi Yagisawa
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Toru Sugihara
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Konan Hara
- Department of Public Health, The University of Tokyo, Tokyo, Japan
| | - Saki Takeshima
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Taro Kubo
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Takahiro Shinzato
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Toshihiro Shimizu
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Michiko Suzuki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Akito Maeshima
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Jun Kamei
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Akira Fujisaki
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Satoshi Ando
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
| | - Motofumi Suzuki
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tetsuya Fujimura
- Division of Urology, Department of Urology, Jichi Medical University, Tochigi, Japan
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41
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Bisigniano L, Laham G, Giordani MC, Tagliafichi V, Hansen Krogh D, Maceira A, Rosa-Diez GJ. Reduced survival in patients who return to dialysis after kidney allograft failure. Clin Transplant 2020; 34:e14014. [PMID: 32567723 DOI: 10.1111/ctr.14014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The outcome of patients who return to dialysis after Kidney allograft failure (KAF) remains unclear. Our aim was to compare the outcome of KAF patients vs two different types of transplant naive incident dialysis (TNID) patients, those on the waiting list (WL) and those with a kidney transplant contraindication (KTC). METHODS We performed an observational study using data from the Argentinian Dialysis Registry between 2005 and 2016. We compare mortality between KAF, WL, and KTC. RESULTS We included 75 722 patients of which 2734 were KAF. Survival between the three cohorts (KAF vs WL (n = 14 630) vs KTC (n = 58 358) revealed a significant difference (log-rank test: P < .0001) indicating worse survival for KTC patients and best survival for WL. We found that KAF patients had as poor outcome as KTC patients after multivariate adjustment. Cox regression showed that age >65 years: HR: 1.845 (1.79-1.89) P < .0001, transient catheter: HR: 1.303 (1.26-1.34) P < .0001, diabetic: HR: 1.273 (1.22-1.31) P < .0001, hepatitis C: HR: 1.156 (1.09-1.22) P < .0001, and albumin: HR: 1.247 (1.21-1.28) P < .0001 were associated with mortality. CONCLUSION Patients who return to dialysis after KAF have higher mortality than WL patients and similar to KTC patients.
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Affiliation(s)
- Liliana Bisigniano
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Gustavo Laham
- Department of Internal Medicine, Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Maria Cora Giordani
- Nephrology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Viviana Tagliafichi
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Daniela Hansen Krogh
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Alberto Maceira
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
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Fiorentino M, Gallo P, Giliberti M, Colucci V, Schena A, Stallone G, Gesualdo L, Castellano G. Management of patients with a failed kidney transplant: what should we do? Clin Kidney J 2020; 14:98-106. [PMID: 33564409 PMCID: PMC7857798 DOI: 10.1093/ckj/sfaa094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/10/2020] [Indexed: 12/18/2022] Open
Abstract
The number of kidney transplant recipients returning to dialysis after graft failure is steadily increasing over time. Patients with a failed kidney transplant have been shown to have a significant increase in mortality compared with patients with a functioning graft or patients initiating dialysis for the first time. Moreover, the risk for infectious complications, cardiovascular disease and malignancy is greater than in the dialysis population due to the frequent maintenance of low-dose immunosuppression, which is required to reduce the risk of allosensitization, particularly in patients with the prospect of retransplantation from a living donor. The management of these patients present several controversial opinions and clinical guidelines are lacking. This article aims to review the leading evidence on the main issues in the management of patients with failed transplant, including the ideal timing and modality of dialysis reinitiation, the indications for an allograft nephrectomy or the correct management of immunosuppression during graft failure. In summary, retransplantation is a feasible option that should be considered in patients with graft failure and may help to minimize the morbidity and mortality risk associated with dialysis reinitiation.
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Affiliation(s)
- Marco Fiorentino
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Pasquale Gallo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Marica Giliberti
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Vincenza Colucci
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Antonio Schena
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
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Motta G, Ferraresso M, Lamperti L, Di Paolo D, Raison N, Perego M, Favi E. Treatment options for localised renal cell carcinoma of the transplanted kidney. World J Transplant 2020; 10:147-161. [PMID: 32742948 PMCID: PMC7360528 DOI: 10.5500/wjt.v10.i6.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/07/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023] Open
Abstract
Currently, there is no consensus among the transplant community about the treatment of renal cell carcinoma (RCC) of the transplanted kidney. Until recently, graftectomy was universally considered the golden standard, regardless of the characteristics of the neoplasm. Due to the encouraging results observed in native kidneys, conservative options such as nephron-sparing surgery (NSS) (enucleation and partial nephrectomy) and ablative therapy (radiofrequency ablation, cryoablation, microwave ablation, high-intensity focused ultrasound, and irreversible electroporation) have been progressively used in carefully selected recipients with early-stage allograft RCC. Available reports show excellent patient survival, optimal oncological outcome, and preserved renal function with acceptable complication rates. Nevertheless, the rarity and the heterogeneity of the disease, the number of options available, and the lack of long-term follow-up data do not allow to adequately define treatment-specific advantages and limitations. The role of active surveillance and immunosuppression management remain also debated. In order to offer a better insight into this difficult topic and to help clinicians choose the best therapy for their patients, we performed and extensive review of the literature. We focused on epidemiology, clinical presentation, diagnostic work up, staging strategies, tumour characteristics, treatment modalities, and follow-up protocols. Our research confirms that both NSS and focal ablation represent a valuable alternative to graftectomy for kidney transplant recipients with American Joint Committee on Cancer stage T1aN0M0 RCC. Data on T1bN0M0 lesions are scarce but suggest extra caution. Properly designed multi-centre prospective clinical trials are warranted.
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Affiliation(s)
- Gloria Motta
- Urology, IRCCS Policlinico San Donato, San Donato Milanese 27288, Italy
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Luca Lamperti
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Dhanai Di Paolo
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Nicholas Raison
- MRC Centre for Transplantation, King’s College London, London WC2R 2LS, United Kingdom
| | - Marta Perego
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
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44
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Thongprayoon C, Vaitla P, Craici IM, Leeaphorn N, Hansrivijit P, Salim SA, Bathini T, Cabeza Rivera FH, Cheungpasitporn W. The Use of Donor-Derived Cell-Free DNA for Assessment of Allograft Rejection and Injury Status. J Clin Med 2020; 9:E1480. [PMID: 32423115 PMCID: PMC7290747 DOI: 10.3390/jcm9051480] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
Patient monitoring after kidney transplantation (KT) for early detection of allograft rejection remains key in preventing allograft loss. Serum creatinine has poor predictive value to detect ongoing active rejection as its increase is not sensitive, nor specific for acute renal allograft rejection. Diagnosis of acute rejection requires allograft biopsy and histological assessment, which can be logistically challenging in some cases and carries inherent risk for complications related to procedure. Donor-derived cell-free DNA (dd-cfDNA), DNA of donor origin in the blood of KT recipient arising from cells undergoing injury and death, has been examined as a potential surrogate marker for allograft rejection. A rise in dd-cfDNA levels precedes changes in serum creatinine allows early detections and use as a screening tool for allograft rejection. In addition, when used in conjunction with donor-specific antibodies (DSA), it increases the pre-biopsy probability of antibody-mediated rejection (ABMR) aiding the decision-making process. Advancements in noninvasive biomarker assays such as dd-cfDNA may offer the opportunity to improve and expand the spectrum of available diagnostic tools to monitor and detect risk for rejection and positively impact outcomes for KT recipients. In this this article, we discussed the evolution of dd-cfDNA assays and recent evidence of assessment of allograft rejection and injury status of KT by the use of dd-cfDNA.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (C.T.); (I.M.C.)
| | - Pradeep Vaitla
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
| | - Iasmina M. Craici
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (C.T.); (I.M.C.)
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke’s Health System, Kansas City, MO 64111, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Sohail Abdul Salim
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | - Franco H. Cabeza Rivera
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (P.V.); (S.A.S.); (F.H.C.R.)
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45
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Sussell J, Silverstein AR, Goutam P, Incerti D, Kee R, Chen CX, Batty DS, Jansen JP, Kasiske BL. The economic burden of kidney graft failure in the United States. Am J Transplant 2020; 20:1323-1333. [PMID: 32020739 DOI: 10.1111/ajt.15750] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 11/13/2019] [Accepted: 12/04/2019] [Indexed: 01/25/2023]
Abstract
Despite improvements in outcomes for kidney transplant recipients in the past decade, graft failure continues to impose substantial burden on patients. However, the population-wide economic burden of graft failure has not been quantified. This study aims to fill that gap by comparing outcomes from a simulation model of kidney transplant patients in which patients are at risk for graft failure with an alternative simulation in which the risk of graft failure is assumed to be zero. Transitions through the model were estimated using Scientific Registry of Transplant Recipients data from 1987 to 2017. We estimated lifetime costs, overall survival, and quality-adjusted life-years (QALYs) for both scenarios and calculated the difference between them to obtain the burden of graft failure. We find that for the average patient, graft failure will impose additional medical costs of $78 079 (95% confidence interval [CI] $41 074, $112 409) and a loss of 1.66 QALYs (95% CI 1.15, 2.18). Given 17 644 kidney transplants in 2017, the total incremental lifetime medical costs associated with graft failure is $1.38B (95% CI $725M, $1.98B) and the total QALY loss is 29 289 (95% CI 20 291, 38 464). Efforts to reduce the incidence of graft failure or to mitigate its impact are urgently needed.
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Affiliation(s)
| | | | | | | | - Rebecca Kee
- Precision Health Economics, Los Angeles, California
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46
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Lam NN, Boyne DJ, Quinn RR, Austin PC, Hemmelgarn BR, Campbell P, Knoll GA, Tibbles LA, Yilmaz S, Quan H, Ravani P. Mortality and Morbidity in Kidney Transplant Recipients With a Failing Graft: A Matched Cohort Study. Can J Kidney Health Dis 2020; 7:2054358120908677. [PMID: 32313663 PMCID: PMC7158256 DOI: 10.1177/2054358120908677] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/21/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Due to their history of renal disease and exposure to immunosuppression, kidney transplant recipients with a failing graft may be at higher risk of adverse outcomes compared to nontransplant controls. Understanding the burden of disease in transplant recipients may inform treatment decisions of people whose native kidneys are failing and may be eligible for a transplant. Objective: To compare mortality and morbidity in kidney transplant recipients with a failing graft to matched nontransplant controls. Design: Retrospective cohort study. Setting: Alberta, Canada. Patients: Kidney transplant recipients with a failing graft were identified as having at least 2 estimated glomerular filtration rate (eGFR) measurements between 15-30 mL/min/1.73 m2 (90-365 days apart). We also identified nontransplant controls with a similar degree of kidney dysfunction. Measurements: Mortality and hospitalization. Methods: We propensity-score matched 520 kidney transplant recipients with a failing graft to 520 nontransplant controls. Results: The median age of the matched cohort was 57 years and 40% were women. Compared to matched nontransplant controls, recipients with a failing graft had a higher hazard of death (hazard ratio, 1.54; 95% confidence interval [CI], 1.28-1.85; p < .001) and a higher rate of all-cause hospitalization (rate ratio, 1.67; 95% CI, 1.42-1.97; p < .001). Kidney transplant recipients also had a higher rate of several cause-specific hospitalizations including genitourinary, cardiovascular, and infectious causes. Limitations: Observational design with the risk of residual confounding. Conclusions: A failing kidney transplant is associated with an increased burden of mortality and morbidity beyond chronic kidney disease. This information may assist the discussion of prognosis in kidney transplant recipients with a failing graft and the design of strategies to minimize risks.
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Affiliation(s)
- Ngan N Lam
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Devon J Boyne
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Robert R Quinn
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | | | - Brenda R Hemmelgarn
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Patricia Campbell
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Gregory A Knoll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | - Lee Anne Tibbles
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada
| | - Serdar Yilmaz
- Department of Surgery, Division of Transplantation, University of Calgary, AB, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
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47
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Weaning Immunosuppressant in Patients with Failing Kidney Grafts and The Outcomes: A Single-Center Retrospective Cohort Study. Sci Rep 2020; 10:6425. [PMID: 32286398 PMCID: PMC7156393 DOI: 10.1038/s41598-020-63266-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/19/2020] [Indexed: 11/14/2022] Open
Abstract
An immunosuppressant weaning protocol in failing allografts has not yet been established. Maintaining immunosuppressants would preserve residual renal function (RRF) and prevent graft intolerance syndrome and sensitization but would increase the risks of infection and malignancy. In this study, graft failure cases after kidney transplantation in a single center were reviewed retrospectively. The outcome differences in all-cause mortality, infection-related hospitalization, cancer, graft intolerance syndrome, re-transplantation, and RRF duration between the immunosuppressant maintaining and weaning groups 6 months after graft failure were compared. Among the weaning group, the outcome differences according to low-dose steroid use were also compared at 6 and 12 months. In a total of 131 graft failure cases, 18 mortalities, 42 infection-related hospitalizations, 22 cancer cases, 11 graft intolerance syndrome cases, and 28 re-transplantations occurred during the 94-month follow-up. Immunosuppressant maintenance significantly decreased the patient survival rate 6 months after graft failure compared with weaning (log-rank P = 0.008) and was an independent risk factor for mortality, even after adjustments (hazard ratio, 3.01; P = 0.025). Infection-related hospitalization, graft intolerance syndrome development, and re-transplantation were not affected by the immunosuppressant weaning protocol. Among the immunosuppressant weaning group, low-dose steroid maintenance at 6 and 12 months helped preserved RRF (P = 0.008 and P = 0.003, respectively).
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48
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Bindi M, Ferraresso M, De Simeis ML, Raison N, Clementoni L, Delbue S, Perego M, Favi E. Allograft artery mycotic aneurysm after kidney transplantation: A case report and review of literature. World J Clin Cases 2020; 8:912-921. [PMID: 32190627 PMCID: PMC7062617 DOI: 10.12998/wjcc.v8.i5.912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/08/2020] [Accepted: 02/14/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Allograft artery mycotic aneurysm (MA) represents a rare but life-threatening complication of kidney transplantation. Graftectomy is widely considered the safest option. Due to the rarity of the disease and the substantial risk of fatal consequences, experience with conservative strategies is limited. To date, only a few reports on surgical repair have been published. We describe a case of true MA successfully managed by aneurysm resection and arterial re-anastomosis.
CASE SUMMARY An 18-year-old gentleman, on post-operative day 70 after deceased donor kidney transplantation, presented with malaise, low urinary output, and worsening renal function. Screening organ preservation fluid cultures, collected at the time of surgery, were positive for Candida albicans. Doppler ultrasound and contrast-enhanced computer tomography showed a 4-cm-sized, saccular aneurysm of the iuxta-anastomotic segment of the allograft artery, suspicious for MA. The lesion was wide-necked and extended to the distal bifurcation of the main arterial branch, thus preventing endovascular stenting and embolization. After multidisciplinary discussion, the patient underwent surgical exploration, aneurysm excision, and re-anastomosis between the stump of the allograft artery and the internal iliac artery. The procedure was uneventful. Histology and microbiology evaluation of the surgical specimen confirmed the diagnosis of MA caused by Candida infection. Three years after the operation, the patient is doing very well with excellent allograft function and no signs of recurrent disease.
CONCLUSION Surgical repair represents a feasible option in carefully selected patients with allograft artery MA. Anti-fungal prophylaxis is advised when preservation fluid cultures are positive.
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Affiliation(s)
- Marco Bindi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Maria Letizia De Simeis
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Nicholas Raison
- MRC Centre for Transplantation, King’s College London, London WC2R 2LS, United Kingdom
| | - Laura Clementoni
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Serena Delbue
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan 20100, Italy
| | - Marta Perego
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
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Varas J, Pérez-Sáez MJ, Ramos R, Merello JI, de Francisco ALM, Luño J, Praga M, Aljama P, Pascual J. Returning to haemodialysis after kidney allograft failure: a survival study with propensity score matching. Nephrol Dial Transplant 2020; 34:667-672. [PMID: 30053152 DOI: 10.1093/ndt/gfy215] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Patients who return to dialysis after kidney allograft failure (KAF) are classically considered to have lower survival rates than their transplant-naïve incident dialysis counterparts. However, this observation in previous comparisons could be due to poor matching between the two populations. METHODS To compare survival rates between patients who returned to haemodialysis (HD) after KAF versus transplant-naïve incident HD patients, we performed a retrospective study using the EuCliD® database (European Clinical Database) that collects data from Fresenius Medical Care (FMC) outpatient HD facilities in Spain. Propensity score matching (PSM) was performed to homogenize both populations. RESULTS This study included 5216 patients from 65 different FMC clinics between 2009 and 2014. Naïve incident HD patients were mostly male, older, comorbid and more commonly had catheters as vascular access. During the study follow-up, 3915 patients exited, of whom 1534 died. The mean survival time for the entire cohort was 4.86 years [95% confidence interval (CI) 4.78-4.94]. Univariate Cox analysis indicated higher mortality risk among transplant-naïve incident HD patients [hazard ratio (HR) 1.728; 95% CI 1.35-2.21; P < 0.001). However, this difference was no longer significant after multivariate adjustment. After applying PSM to minimize the bias due to indication issue, we obtained an adjusted population composed of 480 naïve and 240 KAF patients. The results analysing the PSM-adjusted cohort confirmed similar survival in both cohorts (log-rank, 3.34; P = 0.068; HR 1.382; 95% CI 0.97-1.95; P = 0.069). CONCLUSIONS When comparing properly matched patient groups, patients who return to HD after KAF present similar survival than survival than transplant-naïve incident patients.
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Affiliation(s)
- Javier Varas
- Medical Direction, Fresenius Medical Care, Madrid, Spain
| | | | - Rosa Ramos
- Medical Direction, Fresenius Medical Care, Madrid, Spain
| | | | | | - José Luño
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,RedInRen, Instituto de Salud Carlos III, Córdoba, Spain
| | - Manuel Praga
- RedInRen, Instituto de Salud Carlos III, Córdoba, Spain.,Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pedro Aljama
- RedInRen, Instituto de Salud Carlos III, Córdoba, Spain.,Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain.,Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,RedInRen, Instituto de Salud Carlos III, Córdoba, Spain
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Evolution of secondary hyperparathyroidism in patients following return to hemodialysis after kidney transplant failure. Nephrol Ther 2019; 16:118-123. [PMID: 31791898 DOI: 10.1016/j.nephro.2019.07.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Severe uncontrolled secondary hyperparathyroidism and kidney transplantation history are both risk factors for fractures in hemodialyzed patients. Moreover, patients who return to dialysis after transplant failure have more severe infections/anemia and higher mortality risk than transplant-naive patients starting dialysis with native kidneys. In this context, our aim was to test the hypothesis that transplant failure patients have more secondary hyperparathyroidism than transplant-naive patients. METHODS We retrospectively compared 29 transplant failure patients to 58 transplant-naive patients matched for age, sex, chronic kidney disease duration and diabetes condition (1 transplant failure/2 transplant-naive ratio), who started dialysis between 2010 and 2014. Clinical and biological data were collected at baseline, 6 and 12 months. FINDINGS At baseline, neither serum parathyroid hormone (transplant-naive: 386±286pg/mL; transplant failure: 547±652pg/mL) nor serum 25-hydroxyvitamin D (transplant-naive: 27.8±17.0μg/L, transplant failure: 31.1±14.9μg/L) differed between groups. However, serum parathyroid hormone at 12 months and the proportion of patients with uncontrolled secondary hyperparathyroidism (parathyroid hormone>540pg/mL, KDIGO criteria) were significantly higher in transplant failure than in transplant-naive (parathyroid hormone: 286±205 vs. 462±449, P<0.01; uncontrolled secondary hyperparathyroidism: 30% vs. 13%, P<0.01, respectively). Within the transplant failure group, patients with uncontrolled secondary hyperparathyroidism at 12 months were younger than patients with normal or low parathyroid hormone. DISCUSSION This retrospective and monocentric study suggests that transplant failure patients are more likely to develop secondary hyperparathyroidism. Thus, finding high serum parathyroid hormone in young transplant failure patients, who are expected to undergo further transplantations, should incite physicians to treat early and more aggressively this complication.
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