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Choudhry S, Denfield SW, Dharnidharka VR, Wang Y, Tunuguntla HP, Cabrera AG, Price JF, Dreyer WJ. Simultaneous pediatric heart-kidney transplant outcomes in the US: A-25 year National Cohort Study. Pediatr Transplant 2022; 26:e14149. [PMID: 34585490 DOI: 10.1111/petr.14149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric sHKTx remains uncommon in the US. We examined outcomes of pediatric sHKTx compared to PHTx alone. Our objective was to identify a threshold eGFR that justified pediatric sHKTx. METHODS Data from the SRTR heart and kidney databases were used to identify 9245 PHTx, and 63 pediatric sHKTx performed between 1992 and 2017 (age ≤21 years). RESULTS The median age for sHKTx was 16 years, and included 31 males (31/63 = 49%). Over half of sHKTx (36/63 = 57%) were performed in cases where pretransplant dialysis was initiated. Among patients who required pretransplant dialysis, the risk of death in sHKTx recipients was significantly lower than PHTx alone (sHKTx vs. PHTx: HR 0.4, 95% CI [0.2, 0.9], p = .01). In those without pretransplant dialysis, there was no improvement in survival between sHKTx and PHTx (p = .2). When stratified by eGFR, PHTx alone recipients had worse survival than sHKTx in the group with eGFR ≤35 ml/min/1.73 m2 (p = .04). The 1- and 5-year actuarial survival rates in pediatric sHKTx recipients were 87% and 81.5% respectively and was similar to isolated PHTx (p = .5). One-year rates of treated heart (11%) and kidney (7.9%) rejection were similar in sHKTx compared to PHTx alone (p = .7) and pediatric kidney transplant alone (p = .5) respectively. CONCLUSION Pediatric sHKTx should be considered in HTx candidates with kidney failure requiring dialysis or eGFR ≤35 ml/min/1.73 m2 . The utility of sHKTx in cases of kidney failure not requiring dialysis warrants further study.
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Affiliation(s)
- Swati Choudhry
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Susan W Denfield
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Pheresis, Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Yunfei Wang
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Hari P Tunuguntla
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Antonio G Cabrera
- Section of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Jack F Price
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - William J Dreyer
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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Mejia C, Yadav A. Kidney Disease After Nonkidney Solid Organ Transplant. Adv Chronic Kidney Dis 2021; 28:577-586. [PMID: 35367026 DOI: 10.1053/j.ackd.2021.10.010] [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: 08/25/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022]
Abstract
Nonkidney solid organ transplants (NKSOTs) are increasing in the United States with improving long-term allograft and patient survival. CKD is prevalent in patients with NKSOT and is associated with increased morbidity and mortality especially in those who progress to end-stage kidney disease. Calcineurin inhibitor nephrotoxicity is a main contributor to CKD after NKSOT, but other factors in the pretransplant, peritransplant, and post-transplant period can predispose to progressive kidney dysfunction. The management of CKD after NKSOT generally follows society guidelines for native kidney disease. Kidney-protective and calcineurin inhibitor-sparing immunosuppression has been explored in this population and warrants a discussion with transplant teams. Kidney transplantation in NKSOT recipients remains the kidney replacement therapy of choice for suitable candidates, as it provides a survival benefit over remaining on dialysis.
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Bayne J, Francke M, Ma E, Rubin GA, Avula UMR, Baksh H, Givens R, Wan EY. Increased Incidence of Chronic Kidney Injury in African Americans Following Cardiac Transplantation. J Racial Ethn Health Disparities 2020; 8:1435-1446. [PMID: 33113077 DOI: 10.1007/s40615-020-00906-4] [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: 07/19/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study examined whether African American race was associated with an elevated risk of chronic kidney disease (CKD) post-cardiac transplantation. BACKGROUND CKD often occurs after cardiac transplantation and may require renal replacement therapy (RRT) or renal transplant. African American patients have a higher risk for kidney disease as well as worse post-cardiac transplant morbidity and mortality. It is unclear, however, if there is a propensity for African Americans to develop CKD after cardiac transplant. METHODS The Institutional Review Board of Columbia University Medical Center approved the retrospective study of 151 adults (57 African American and 94 non-African American) who underwent single-organ heart transplant from 2013 to 2016. The primary outcome was a decrease in estimated glomerular filtration rate (eGFR), development of CKD, and end-stage renal disease (ESRD) requiring RRT after 2 years. RESULTS African American patients had a significant decline in eGFR post-cardiac transplant compared to non-African American patients (- 34 ± 6 vs. - 20 ± 4 mL/min/1.73 m2, p < 0.0006). African American patients were more likely to develop CKD stage 2 or worse (eGFR < 90 mL/min/1.73 m2) than non-African American patients (81% vs. 59%, p < 0.0005). CONCLUSIONS This is the first study to report that African American patients are at a significantly higher risk for eGFR decline and CKD at 2 years post-cardiac transplant. Future investigation into risk reduction is necessary for this patient population.
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Affiliation(s)
- Joseph Bayne
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Michael Francke
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Elaine Ma
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Geoffrey A Rubin
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Uma Mahesh R Avula
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Haajra Baksh
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Raymond Givens
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Elaine Y Wan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA.
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A Recipient Risk Prediction Tool for Short-term Mortality After Pediatric Heart Transplantation. Transplantation 2019; 103:2434-2439. [DOI: 10.1097/tp.0000000000002679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Choudhry S, Dharnidharka VR, Castleberry CD, Goss CW, Simpson KE, Schechtman KB, Canter CE. End-stage renal disease after pediatric heart transplantation: A 25-year national cohort study. J Heart Lung Transplant 2017; 37:S1053-2498(17)32042-9. [PMID: 29055603 PMCID: PMC5880747 DOI: 10.1016/j.healun.2017.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/23/2017] [Accepted: 09/26/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND End-stage renal disease (ESRD), defined as the need for chronic dialysis and/or kidney transplantation (KTx), is a known complication after heart transplant (HTx). However, factors associated with ESRD are not well elucidated. The objectives of this study were to determine the prevalence, risk factors, and outcomes associated with ESRD after pediatric HTx. METHODS Scientific Registry of Transplant Recipients data were linked, using direct identifiers, to the United States Renal Data System to identify patients (aged ≤ 18 years) who underwent primary HTx between 1989 and 2013. Risk factors for ESRD and death were analyzed using Cox regression analysis. RESULTS Combining the above 2 databases identified ~25% additional HTx patients who developed ESRD that were not captured by either database alone. During a median follow-up of 11.8 years, ESRD developed in 276 of 6,901 patients (4%). The actuarial risk of developing ESRD after HTx was 3% at 10 years and 16% at 20 years. Age at HTx > 1 year, African-American race, year of HTx before 2000, hypertension, diabetes mellitus, re-HTx, acute dialysis, graft failure, and hospitalized infection were significant risk factors for ESRD development. Those who remained on chronic dialysis had higher risk of death than those who received KTx (hazard ratio, 31.4; 95% confidence interval, 20.8-48.4; p < 0.0001). CONCLUSIONS ESRD after pediatric HTx is more prevalent in HTx survivors than documented by a transplant database alone. A number of factors develop at or after HTx that increase the risk for developing ESRD. Use of KTx in post-HTx ESRD is associated with improved survival.
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Affiliation(s)
- Swati Choudhry
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Vikas R Dharnidharka
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Chesney D Castleberry
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Charles W Goss
- Department of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Kathleen E Simpson
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Kenneth B Schechtman
- Department of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Charles E Canter
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
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Nehus EJ, Laskin BL, Kathman TI, Bissler JJ. Performance of cystatin C-based equations in a pediatric cohort at high risk of kidney injury. Pediatr Nephrol 2013; 28:453-61. [PMID: 23142864 DOI: 10.1007/s00467-012-2341-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 09/11/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Limited data exist on the performance of cystatin C-based glomerular filtration rate (GFR) equations in pediatric transplant recipients and other high-risk patients. The aim of our study was therefore to evaluate the performance of current cystatin C-based equations in this population. METHODS This was a retrospective, cross-sectional study of 141 consecutive patients (58 % post-transplant) who received a nuclear medicine GFR (NucGFR) examination using (99m)Tc- diethylenetriaminepentaacetic acid at our institution. Subjects included children receiving liver, kidney or hematopoietic stem cell transplants and patients with oncologic or urologic disease. GFR estimates using published GFR estimating equations, including those based on cystatin C (Filler, Zappitelli, Larsson, Hoek, Rule and Le Bricon equations, respectively) and on both cystatin C and creatinine (Zappitelli, Bouvet and Schwartz equations, respectively), were evaluated and compared to the NucGFR measurement using Bland-Altman analysis. RESULTS The mean NucGFR was 95 (interquartile range 76-111) ml/min/1.73 m(2). Of the cystatin C-based equations, the Rule, Hoek, Zappitelli and Schwartz (2009 CKiD equation) formulas provided the closest agreement to the NucGFR estimate. All other formulas overestimated the GFR in our cohort. CONCLUSION Cystatin C-based GFR formulas can provide an accurate estimation of NucGFR in a pediatric population with a high proportion of transplant recipients and oncology patients.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH 45229-3039, USA
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Ruebner RL, Reese PP, Denburg MR, Rand EB, Abt PL, Furth SL. Risk factors for end-stage kidney disease after pediatric liver transplantation. Am J Transplant 2012; 12:3398-405. [PMID: 22994862 PMCID: PMC4332846 DOI: 10.1111/j.1600-6143.2012.04270.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Adult liver transplant (LT) recipients commonly develop advanced kidney disease. However, burden of end-stage kidney disease (ESKD) after pediatric LT has not been well-described. We performed a retrospective cohort study of pediatric LTs in the United States from 1990 to 2010. Multivariable Cox regression models were fit to determine risk factors for ESKD and death. Eight thousand nine hundred seventy six children received LTs. During median follow-up of 7.8 years, 2005 (22%) subjects died (mortality rate 26.1 cases/1000 person-years); 167 (2%) developed ESKD (incidence rate 2.2 cases/1000 person-years). Risk factors for ESKD included older age at LT (highest risk age >15 vs. < 5 years, HR = 4.94, p < 0.001), hepatitis C (HR 2.79, p = 0.004), liver re-transplant (HR 2.67, p < 0.001), eGFR pre-LT < 60 versus ≥ 60 (HR 2.37, p < 0.001), hepatitis B (HR 2.25, p = 0.027), black race (HR 1.46, p = 0.046), and male sex (HR 1.44, p = 0.022). LT recipients with ESKD had increased risk of mortality (HR 2.37, p < 0.001). Among pediatric LT recipients, rate of ESKD was lower than among adults and far exceeded by rate of death, however follow-up time in this study may underestimate lifetime burden of ESKD. Although uncommon, ESKD was highly associated with mortality. Pediatric LT recipients should be routinely monitored for kidney disease, particularly those at highest risk of ESKD.
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Affiliation(s)
- RL Ruebner
- Children’s Hospital of Philadelphia, Division of Nephrology, Department of Pediatrics, Philadelphia, Pennsylvania, United States
| | - PP Reese
- University of Pennsylvania, Center for Clinical Epidemiology and Biostatistics, Philadelphia, Pennsylvania, United States,University of Pennsylvania, Renal Division, Department of Medicine, Philadelphia, Pennsylvania, United States
| | - MR Denburg
- Children’s Hospital of Philadelphia, Division of Nephrology, Department of Pediatrics, Philadelphia, Pennsylvania, United States,University of Pennsylvania, Center for Clinical Epidemiology and Biostatistics, Philadelphia, Pennsylvania, United States
| | - EB Rand
- Children’s Hospital of Philadelphia, Division of Gastroenterology, Department of Pediatrics, Philadelphia, Pennsylvania, United States
| | - PL Abt
- University of Pennsylvania, Transplant Institute, Department of Surgery, Philadelphia, Pennsylvania, United States
| | - SL Furth
- Children’s Hospital of Philadelphia, Division of Nephrology, Department of Pediatrics, Philadelphia, Pennsylvania, United States,University of Pennsylvania, Center for Clinical Epidemiology and Biostatistics, Philadelphia, Pennsylvania, United States
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Chronic Kidney Disease—A Common and Serious Complication After Intestinal Transplantation. Transplantation 2008; 86:108-13. [DOI: 10.1097/tp.0b013e31817613f8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Bloom RD, Reese PP. Chronic kidney disease after nonrenal solid-organ transplantation. J Am Soc Nephrol 2008; 18:3031-41. [PMID: 18039925 DOI: 10.1681/asn.2007040394] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Chronic kidney disease (CKD) is a common complication after nonrenal solid-organ transplantation. The risk for CKD is influenced by many factors, some of which have a direct impact on how such patients are treated in the pre-, peri-, and posttransplantation settings. This review describes hazards for acute and chronic kidney injury, with particular emphasis on calcineurin inhibitor-mediated nephrotoxicity. Rather than a detailed description of management issues that are common to the general CKD population, highlighted are aspects that are more specific to nonrenal solid-organ transplant recipients with a focus on liver, heart, and lung recipients. Strategies to minimize nephrotoxic insults and retard progressive renal injury are discussed, as are issues that are pertinent to dialysis and transplantation. Finally, future approaches to prevent and treat CKD without compromising function of the transplanted organ are addressed.
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Affiliation(s)
- Roy D Bloom
- Department of Medicine, Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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