A single centre in-depth analysis of death with a functioning kidney graft and reasons for overall graft failure

Perspective: metabolomics has the potential to change the landscape of kidney transplantation diagnostics

Kidney transplantation is the most efficient renal replacement therapy. Current diagnostics for monitoring graft health are either invasive or lack precision. Metabolomics is an emerging discipline focused on the analysis of the small molecules involved in metabolism. Given the kidneys' central role in metabolic homeostasis and previous observations of altered metabolites correlating with restricted kidney graft function, metabolomics is highly promising for the discovery of novel biomarkers and the development of novel diagnostics. In this perspective, we summarize the known metabolic roles for the kidney, discuss biomarkers of graft health and immune status emerging from metabolomics research, and provide our perspective on how these and future findings can be integrated in clinical practice to enable precision diagnostics.

Validation of risk scores for prediction of severe pneumonia in kidney transplant recipients hospitalized with community-acquired pneumonia

PURPOSE

Risk scores for community-acquired pneumonia (CAP) are widely used for standardized assessment in immunocompetent patients and to identify patients at risk for severe pneumonia and death. In immunocompromised patients, the prognostic value of pneumonia-specific risk scores seems to be reduced, but evidence is limited. The value of different pneumonia risk scores in kidney transplant recipients (KTR) is not known.

METHODS

Therefore, we retrospectively analyzed 310 first CAP episodes after kidney transplantation in 310 KTR. We assessed clinical outcomes and validated eight different risk scores (CRB-65, CURB-65, DS-CRB-65, qSOFA, SOFA, PSI, IDSA/ATS minor criteria, NEWS-2) for the prognosis of severe pneumonia and in-hospital mortality. Risk scores were assessed up to 48 h after admission, but always before an endpoint occurred. Multiple imputation was performed to handle missing values.

RESULTS

In total, 16 out of 310 patients (5.2%) died, and 48 (15.5%) developed severe pneumonia. Based on ROC analysis, sequential organ failure assessment (SOFA) and national early warning score 2 (NEWS-2) performed best, predicting severe pneumonia with AUC of 0.823 (0.747-0.880) and 0.784 (0.691-0.855), respectively.

CONCLUSION

SOFA and NEWS-2 are best suited to identify KTR at risk for the development of severe CAP. In contrast to immunocompetent patients, CRB-65 should not be used to guide outpatient treatment in KTR, since there is a 7% risk for the development of severe pneumonia even in patients with a score of zero.

Diagnosis, Prevention, and Treatment of Infections in Kidney Transplantation

Kidney transplant often is complicated by infections in the recipient from therapy-related and patient-related risk factors. Infections in kidney transplant recipients are associated with increased morbidity, mortality, and allograft dysfunction. There is a predictable timeline after kidney transplant regarding the types of pathogens causing infections, reflecting the net state of immunosuppression. In the early post-transplant period, bacterial infections comprise two thirds of all infections, followed by viral and fungal infections. Infections occurring early after kidney transplantation are generally the result of postoperative complications. In most cases, opportunistic infections occur within 6 months after kidney transplantation. They may be caused by a new infection, a donor-derived infection, or reactivation of a latent infection. Community-acquired pneumonia, upper respiratory tract infections, urinary tract infections, and gastrointestinal infections are the most common infections in the late period after transplantation when the net immunosuppression is minimal. It is crucial to seek information on the time after transplant, reflecting the net state of immunosuppression, previous history of exposure/infections, geography, and seasonal outbreaks. It is imperative that we develop regionally specific guidelines on screening, prevention, and management of infections after kidney transplantation.

Changes in socioeconomic status and patient outcomes in kidney transplantation recipients in South Korea

Background

Socioeconomic status is an important factor affecting the accessibility and prognosis of kidney transplantation. We aimed to investigate changes in kidney transplant recipients' socioeconomic status in South Korea and whether such changes were associated with patient prognosis.

Methods

This retrospective nationwide observational cohort study in South Korea included kidney transplant recipients between 2007 and 2016. South Korea provides a single-insurer health insurance service, and information on the socioeconomic status of the recipients is identifiable through the claims database. First, a generalized linear mixed model was used to investigate changes in recipients' socioeconomic status as an outcome. Second, the risk of graft failure was analyzed using Cox regression as another outcome to investigate whether changes in socioeconomic status were associated with patient prognosis.

Results

Among the 15,215 kidney transplant recipients included in the study, economic levels (defined based on insurance fee percentiles) and employment rates declined within the first 2 years after transplantation. Beyond 2 years, the employment rate increased significantly, while no significant changes were observed in economic status. Patients whose economic status did not improve 3 years after kidney transplantation showed a higher risk of death than those whose status improved. When compared to those who remained employed after kidney transplantation, unemployment was associated with a significantly higher risk of death-censored graft failure.

Conclusions

The socioeconomic status of kidney transplant recipients changed dynamically after kidney transplantation, and these changes were associated with patient prognosis.