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Ali H, Mohamed M, Molnar MZ, Fülöp T, Burke B, Shroff A, Shroff S, Briggs D, Krishnan N. Deceased-Donor Kidney Transplant Outcome Prediction Using Artificial Intelligence to Aid Decision-Making in Kidney Allocation. ASAIO J 2024; 70:808-818. [PMID: 38552178 DOI: 10.1097/mat.0000000000002190] [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: 04/06/2024] Open
Abstract
In kidney transplantation, pairing recipients with the highest longevity with low-risk allografts to optimize graft-donor survival is a complex challenge. Current risk prediction models exhibit limited discriminative and calibration capabilities and have not been compared to modern decision-assisting tools. We aimed to develop a highly accurate risk-stratification index using artificial intelligence (AI) techniques. Using data from the UNOS database (156,749 deceased kidney transplants, 2007-2021), we randomly divided transplants into training (80%) and validation (20%) sets. The primary measure was death-censored graft survival. Four machine learning models were assessed for calibration (integrated Brier score [IBS]) and discrimination (time-dependent concordance [CTD] index), compared with existing models. We conducted decision curve analysis and external validation using UK Transplant data. The Deep Cox mixture model showed the best discriminative performance (area under the curve [AUC] = 0.66, 0.67, and 0.68 at 6, 9, and 12 years post-transplant), with CTD at 0.66. Calibration was adequate (IBS = 0.12), while the kidney donor profile index (KDPI) model had lower CTD (0.59) and AUC (0.60). AI-based D-TOP outperformed the KDPI in evaluating transplant pairs based on graft survival, potentially enhancing deceased donor selection. Advanced computing is poised to influence kidney allocation schemes.
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Affiliation(s)
- Hatem Ali
- From the University Hospitals of Coventry and Warwickshire, United Kingdom
| | | | - Miklos Z Molnar
- Division of Nephrology & Hypertension, Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tibor Fülöp
- Division of Nephrology, Department of Medicine, Medical University Hospitals of South Carolina
- Medicine Service, Ralph H Johnson VA Medical Center, Charleston, South Carolina
| | - Bernard Burke
- Research Centre for Health and Life Sciences, Coventry University, Coventry, United Kingdom
| | | | | | - David Briggs
- Histocompatibility and Immunogenetics NHS Blood and Transplant, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Nithya Krishnan
- From the University Hospitals of Coventry and Warwickshire, United Kingdom
- Research Centre for Health and Life Sciences, Coventry University, Coventry, United Kingdom
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2
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Caldwell JS, Parvathinathan G, Stedman MR, Ahearn P, Tan JC, Cheng XS. Immunologic Benefits of 0-antigen Mismatched Transplants: No Added Boost for Racial and Ethnic Minorities. Transplant Direct 2024; 10:e1653. [PMID: 38881747 PMCID: PMC11177818 DOI: 10.1097/txd.0000000000001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/21/2024] [Indexed: 06/18/2024] Open
Abstract
Background Systemic barriers to posttransplant care, including access to immunosuppressant medications, contribute to higher rates of kidney transplant failure in racial minorities. Matching donor and recipient HLA alleles reduce allorecognition, easing reliance on immunosuppression. We hypothesize that 0-antigen mismatch transplants may provide stronger protection against graft loss in racial minorities. Methods We compared adult, single-organ, deceased-donor kidney transplants in the United States from 2007 to 2016 by degree of HLA mismatch (0- versus ≥1-antigen mismatch). We examined time-to-allograft failure, with death as a competing event, using multivariable Weibull models, stratified by recipient race (White versus non-White), and evaluated the interaction between mismatch and recipient race. We used Kaplan-Meier imputation to account for competing risk of death. Results We analyzed 102 114 transplants (median follow-up, 5.6 y; 16 862 graft losses, 18 994 deaths). Zero-antigen mismatch was associated with improved allograft survival (adjusted subdistribution hazard ratio [sHR] 0.80; 95% confidence interval [CI], 0.75-0.85). When stratified by recipient race, the effect of 0-antigen mismatch was more pronounced in White (unadjusted sHR 0.78; 95% CI, 0.72-0.83) versus non-White recipients (sHR 0.88; 95% CI, 0.79-0.99; interaction P = 0.04). The differential effect was attenuated after adjusting for covariates (sHR 0.78; 95% CI, 0.73-0.84 versus sHR 0.87; 95% CI, 0.77-0.98; interaction P = 0.10). Conclusions Zero-antigen mismatch transplants conferred a 20% risk reduction in allograft loss, which was similar between non-White and White recipients. This may reflect an increased degree of mismatch at other HLA alleles and non-HLA alleles in non-White recipients or because of the extent of systemic barriers to healthcare borne by minority recipients.
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Affiliation(s)
| | | | | | - Patrick Ahearn
- Division of Nephrology, Stanford University, Palo Alto, CA
| | - Jane C. Tan
- Division of Nephrology, Stanford University, Palo Alto, CA
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Zanoni F, Neugut YD, Obayemi JE, Liu L, Zhang JY, Ratner LE, Cohen DJ, Mohan S, Gharavi AG, Keating B, Kiryluk K. Genetic versus self-reported African ancestry of the recipient and neighborhood predictors of kidney transplantation outcomes in 2 multiethnic urban cohorts. Am J Transplant 2024; 24:1003-1015. [PMID: 38331047 PMCID: PMC11144562 DOI: 10.1016/j.ajt.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024]
Abstract
African American (AA) kidney recipients have a higher risk of allograft rejection and failure compared to non-AAs, but to what extent these outcomes are due to genetic versus environmental effects is currently unknown. Herein, we tested the effects of recipient self-reported race versus genetic proportion of African ancestry (pAFR), and neighborhood socioeconomic status (SES) on kidney allograft outcomes in multiethnic kidney transplant recipients from Columbia University (N = 1083) and the University of Pennsylvania (N = 738). All participants were genotyped with SNP arrays to estimate genetic admixture proportions. US census tract variables were used to analyze the effect of neighborhood factors. In both cohorts, self-reported recipient AA race and pAFR were individually associated with increased risk of rejection and failure after adjustment for known clinical risk factors and neighborhood SES factors. Joint analysis confirmed that self-reported recipient AA race and pAFR were both associated with a higher risk of allograft rejection (AA: HR 1.61 (1.31-1.96), P = 4.05E-06; pAFR: HR 1.90 (1.46-2.48), P = 2.40E-06) and allograft failure (AA: HR 1.52 (1.18-1.97), P = .001; pAFR: HR 1.70 (1.22-2.35), P = .002). Further research is needed to disentangle the role of genetics versus environmental, social, and structural factors contributing to poor transplantation outcomes in kidney recipients of African ancestry.
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Affiliation(s)
- Francesca Zanoni
- Department of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Y Dana Neugut
- Division of Pediatric Gastroenterology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joy E Obayemi
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lili Liu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Jun Y Zhang
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Ali G Gharavi
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Brendan Keating
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA.
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Tsai YL, Chung MH, Lin NC, Chen CY, Lin YP, Tsai MT, Tsai HL, Chen YA, Ou SM, Chu CJ, Wu TH, Tsai CY. The Risk Factors and Clinical Outcomes in Hepatitis B Seropositive and Seronegative Renal Transplant Patients. Am J Nephrol 2024; 55:477-486. [PMID: 38498992 DOI: 10.1159/000538231] [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: 11/19/2023] [Accepted: 02/29/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Hepatitis B virus (HBV) infection is prevalent in Asia including Taiwan. We retrospectively evaluated the risk of HBV reactivation and clinical outcomes in HBV+ and HBV- kidney transplant recipients. METHODS Patients who underwent kidney transplantation between January 2004 and December 2021 were reviewed. The outcomes of interest included risks of HBV reactivation and patient/graft survival. RESULTS We identified 337 patients (47.5 ± 12 years) in our final cohort. Fifty-two (15.4%) had hepatitis B surface antigen (HBsAg) positive at the time of transplantation. Seventeen developed viral reactivations, with 41.2% of them accompanied by active hepatitis. The graft survival, acute rejection rate, and cancer development after kidney transplantation did not differ in terms of HBsAg status. The Cox multivariate analysis indicated the HBV reactivation risk was increased by a lack of pretransplant anti-HBV medication (hazard ratio [HR], 5.95; 95% confidence interval [CI], 1.31-27.02; p = 0.021) or an absence of lifelong antiviral therapy (HR: 3.14; 95% CI: 1.01-9.74; p = 0.047). CONCLUSION Individuals, independent of HBsAg status, had similar prognosis in terms of patient and graft survival, acute rejection rate, and cancer development. The absence of either pretransplant anti-HBV medication or lifelong antiviral therapy was significantly associated with an increased risk of HBV reactivation.
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Affiliation(s)
- Yu-Lien Tsai
- Department of Internal Medicine, Division of Nephrology, En Chu Kong Hospital, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Meng-Hsuan Chung
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Trauma, Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Niang-Cheng Lin
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Cheng-Yen Chen
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yao-Ping Lin
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Ming-Tsun Tsai
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Hsin-Lin Tsai
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yee-An Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Shuo-Ming Ou
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Chi-Jen Chu
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Gastroenterology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsai-Hung Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Chang-Youh Tsai
- School of Medicine, College of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Division of Immunology and Rheumatology, Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
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Warzyszyńska K, Zawistowski M, Karpeta E, Jałbrzykowska A, Kosieradzki M. CYP3A5 Expressor Genotype of the Transplanted Kidney Increases the Risk of Preterm Graft Loss and Acute Rejection. Nephron Clin Pract 2023; 147:441-450. [PMID: 36630936 DOI: 10.1159/000528109] [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: 04/06/2022] [Accepted: 10/25/2022] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Tacrolimus is metabolized mainly in the liver by the CYP3A enzyme family, with a particularly well-documented role of CYP3A5. CYP3A5 is also expressed in the renal tissue and is present in the transplanted kidney. To date, the association between donor CYP3A5 polymorphisms and transplant outcome remains poorly understood. The aim of this study was to assess the effect of donor CYP3A5 expression on early and long-term transplant outcomes. METHODS A retrospective cohort study including 207 patients who received kidney grafts from 110 deceased donors was conducted at a single Central European Center. Tissue samples from all donors were studied for CYP3A5 single-nucleotide polymorphism (rs776746). Death-censored graft loss within 5-year follow-up, acute rejection occurrence, and kidney function, measured using serum creatinine and MDRD eGFR, were compared between groups of patients with allografts from rs776746 carriers (CYP3A5 expressors) and noncarriers (CYP3A5 nonexpressors). RESULTS Recipients who received kidneys from CYP3A5 expressors (n = 24) were at significantly higher risk of death-censored graft loss within 5-year follow-up (adjusted HR, 95% CI: 6.82, 2.01-23.12; p = 0.002) and acute rejection within the 1st posttransplant year (adjusted OR, 95% CI: 4.62, 1.67-12.77; p = 0.003) than those who did not (n = 183). The median time to loss of function was 1.93 [IQR; 0.77-3.19] years. CONCLUSIONS Donor CYP3A5 expressor status is associated with worse renal graft survival and a higher risk of acute rejection. Determination of donor CYP3A5 genotype is a potentially useful tool that may improve kidney transplant outcomes.
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Affiliation(s)
- Karola Warzyszyńska
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Zawistowski
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
- Military Institute of Medicine, Warsaw, Poland
| | - Edyta Karpeta
- Department of Surgical and Transplantation Nursing and Extracorporeal Therapies, Medical University of Warsaw, Warsaw, Poland
| | | | - Maciej Kosieradzki
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Kurnikowski A, Nordheim E, Schwaiger E, Krenn S, Harreiter J, Kautzky‐Willer A, Leutner M, Werzowa J, Tura A, Budde K, Eller K, Pascual J, Krebs M, Jenssen TG, Hecking M. Criteria for prediabetes and posttransplant diabetes mellitus after kidney transplantation: A 2-year diagnostic accuracy study of participants from a randomized controlled trial. Am J Transplant 2022; 22:2880-2891. [PMID: 36047565 PMCID: PMC10087499 DOI: 10.1111/ajt.17187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 08/09/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
Posttransplant diabetes mellitus (PTDM) and prediabetes (impaired glucose tolerance [IGT] and impaired fasting glucose [IFG]) are associated with cardiovascular events. We assessed the diagnostic performance of fasting plasma glucose (FPG) and HbA1c as alternatives to oral glucose tolerance test (OGTT)-derived 2-hour plasma glucose (2hPG) using sensitivity and specificity in 263 kidney transplant recipients (KTRs) from a clinical trial. Between visits at 6, 12, and 24 months after transplantation, 28%-31% of patients switched glycemic category (normal glucose tolerance [NGT], IGT/IFG, PTDM). Correlations of FPG and HbA1c against 2hPG were lower at 6 months (r = 0.59 [FPG against 2hPG]; r = 0.45 [HbA1c against 2hPG]) vs. 24 months (r = 0.73 [FPG against 2hPG]; r = 0.74 [HbA1c against 2hPG]). Up to 69% of 2hPG-defined PTDM cases were missed by conventional HbA1c and FPG thresholds. For prediabetes, concordance of FPG and HbA1c with 2hPG ranged from 6%-9%. In conclusion, in our well-defined randomized trial cohort, one-third of KTRs switched glycemic category over 2 years and although the correlations of FPG and HbA1c with 2hPG improved with time, their diagnostic concordance was poor for PTDM and, especially, prediabetes. Considering posttransplant metabolic instability, FPG's and HbA1c 's diagnostic performance, the OGTT remains indispensable to diagnose PTDM and prediabetes after kidney transplantation.
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Affiliation(s)
- Amelie Kurnikowski
- Internal Medicine III, Nephrology and DialysisMedical University of ViennaViennaAustria
| | - Espen Nordheim
- Department of Transplantation Medicine, NephrologyOslo University Hospital, RikshospitaletOsloNorway
- Faculty of Clinical MedicineUniversity of OsloOsloNorway
| | - Elisabeth Schwaiger
- Internal Medicine III, Nephrology and DialysisMedical University of ViennaViennaAustria
- Department of Internal Medicine I, Cardiology and Nephrology, Krankenhaus der Barmherzigen Brüder EisenstadtEisenstadtAustria
| | - Simon Krenn
- Internal Medicine III, Nephrology and DialysisMedical University of ViennaViennaAustria
| | - Jürgen Harreiter
- Internal Medicine III, Endocrinology and MetabolismMedical University of ViennaViennaAustria
| | | | - Michael Leutner
- Internal Medicine III, Endocrinology and MetabolismMedical University of ViennaViennaAustria
| | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre MeidlingViennaAustria
- 1st Medical Department, Hanusch HospitalViennaAustria
| | | | - Klemens Budde
- Medizinische Klinik m. S. NephrologieCharité Universitätsmedizin BerlinBerlinGermany
| | - Kathrin Eller
- Clinical Division of Nephrology, Department of Internal MedicineMedical University of GrazGrazAustria
| | - Julio Pascual
- Department of NephrologyHospital del Mar‐Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)BarcelonaSpain
| | - Michael Krebs
- Internal Medicine III, Endocrinology and MetabolismMedical University of ViennaViennaAustria
| | - Trond Geir Jenssen
- Department of Transplantation Medicine, NephrologyOslo University Hospital, RikshospitaletOsloNorway
- Faculty of Clinical MedicineUniversity of OsloOsloNorway
- Metabolic and Renal Research Group, Faculty of Health SciencesUiT‐ The Arctic University of NorwayTromsøNorway
| | - Manfred Hecking
- Internal Medicine III, Nephrology and DialysisMedical University of ViennaViennaAustria
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Magga L, Maturana S, Olivares M, Valdevenito M, Cabezas J, Chapochnick J, González F, Kompatzki A, Müller H, Pefaur J, Ulloa C, Valjalo R. Identifying Factors Predicting Kidney Graft Survival in Chile Using Elastic-Net-Regularized Cox’s Regression. Medicina (B Aires) 2022; 58:medicina58101348. [PMID: 36295509 PMCID: PMC9608564 DOI: 10.3390/medicina58101348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/15/2022] [Accepted: 09/19/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Objectives: We developed a predictive statistical model to identify donor–recipient characteristics related to kidney graft survival in the Chilean population. Given the large number of potential predictors relative to the sample size, we implemented an automated variable selection mechanism that could be revised in future studies as more national data is collected. Materials and Methods: A retrospective multicenter study was conducted to analyze data from 822 adult kidney transplant recipients from adult donors between 1998 and 2018. To the best of our knowledge, this is the largest kidney transplant database to date in Chile. A procedure based on a cross-validated regularized Cox regression using the Elastic Net penalty was applied to objectively identify predictors of death-censored graft failure. Hazard ratios were estimated by adjusting a multivariate Cox regression with the selected predictors. Results: Seven variables were associated with the risk of death-censored graft failure; four from the donor: age (HR = 1.02, 95% CI: 1.00–1.03), male sex (HR = 0.64, 95% CI: 0.46–0.90), history of hypertension (HR = 1.49, 95% CI: 0.98–2.28), and history of diabetes (HR = 2.04, 95% CI: 0.97–4.29); two from the recipient: years on dialysis log-transformation (HR = 1.29, 95% CI: 0.99–1.67) and history of previous solid organ transplantation (HR = 2.02, 95% CI: 1.18–3.47); and one from the transplant: number of HLA mismatches (HR = 1.13, 95% CI: 0.99–1.28). Only the latter is considered for patient prioritization in deceased kidney allocation in Chile. Conclusions: A risk model for kidney graft failure was developed and trained for the Chilean population, providing objective criteria which can be used to improve efficiency in deceased kidney allocation.
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Affiliation(s)
- Leandro Magga
- Department of Industrial Engineering, University of Chile, Santiago 8370456, Chile
| | - Simón Maturana
- Department of Industrial Engineering, University of Chile, Santiago 8370456, Chile
- Instituto Sistemas Complejos de Ingeniería, Santiago 8370398, Chile
| | - Marcelo Olivares
- Department of Industrial Engineering, University of Chile, Santiago 8370456, Chile
- Instituto Sistemas Complejos de Ingeniería, Santiago 8370398, Chile
- Correspondence: ; Tel.: +56-(2)26894429 or +56-(2)26894403
| | - Martín Valdevenito
- Department of Industrial Engineering, University of Chile, Santiago 8370456, Chile
| | - Josefa Cabezas
- Department of Industrial Engineering, University of Chile, Santiago 8370456, Chile
| | | | | | | | - Hans Müller
- Hospital Las Higueras, Talcahuano 4270918, Chile
| | | | - Camilo Ulloa
- Clínica Alemana de Santiago, Santiago 8320000, Chile
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Karakizlis H, van Rosmalen M, Boide P, Askevold I, Vogelaar S, Lorf T, Berlakovich G, Nitschke M, Padberg W, Weimer R. Retransplanting a previously transplanted kidney: A safe strategy in times of organ shortage? Clin Transplant 2021; 36:e14554. [PMID: 34862985 DOI: 10.1111/ctr.14554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The shortage of organs for transplantation remains a global problem. The retransplantation of a previously transplanted kidney might be a possibility to expand the pool of donors. We provide our experience with the successful reuse of transplanted kidneys in the Eurotransplant region. METHODS A query in the Eurotransplant database was performed between January 1, 1995 and December 31, 2015, to find kidney donors who themselves had previously received a kidney graft. RESULTS Nine out of a total of 68,554 allocated kidneys had previously been transplanted. Four of these kidneys were transplanted once again. The mean interval between the first transplant and retransplantation was 1689±1682 days (SD; range 55-5,333 days). At the time of the first transplantation the mean serum creatinine of the donors was 1.0 mg/dl (.6-1.3 mg/dl) and at the second transplantation 1.4 mg/dl (.8-1.5 mg/dl). The mean graft survival in the first recipient was 50 months (2-110 months) and in the second recipient 111 months (40-215 months). CONCLUSION Transplantation of a previously transplanted kidney may successfully be performed with well-preserved graft function and long-term graft survival, even if the first transplantation was performed a long time ago. Such organs should be considered even for younger recipients in carefully selected cases.
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Affiliation(s)
- Hristos Karakizlis
- Department of Internal Medicine II, Division of Nephrology and Renal Transplantation, Justus-Liebig-University of Giessen, Giessen, Germany
| | | | - Philipp Boide
- Department of Internal Medicine II, Division of Nephrology and Renal Transplantation, Justus-Liebig-University of Giessen, Giessen, Germany
| | - Ingolf Askevold
- Department of General, Visceral and Thoracic Surgery, Justus-Liebig-University of Giessen, Gießen, Germany
| | - Serge Vogelaar
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Thomas Lorf
- Department of General, Visceral and Pediatric Surgery, Georg-August-University of Göttingen, Göttingen, Germany
| | - Gabrielle Berlakovich
- Department of General Surgery and Transplantation, University of Vienna, Vienna, Austria
| | - Martin Nitschke
- Division of Nephrology and Transplantation, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Winfried Padberg
- Department of General, Visceral and Thoracic Surgery, Justus-Liebig-University of Giessen, Gießen, Germany
| | - Rolf Weimer
- Department of Internal Medicine II, Division of Nephrology and Renal Transplantation, Justus-Liebig-University of Giessen, Giessen, Germany
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9
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Schumacher L, Fang F, Kidwell KM, Shakeel F, Hertz DL, Park JM, Pasternak AL. SLCO1B3 polymorphisms and clinical outcomes in kidney transplant recipients receiving mycophenolate. Pharmacogenomics 2021; 22:1111-1120. [PMID: 34612072 DOI: 10.2217/pgs-2021-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Determine the influence of SLCO1B3 polymorphisms on outcomes in kidney transplant recipients. Materials & methods: We retrospectively evaluated 181 adult kidney transplant recipients receiving mycophenolate. Outcomes included treated biopsy-proven acute rejection (tBPAR), de novo donor-specific antibody (dnDSA) formation, graft survival, patient survival and mycophenolate-related adverse effects among SLCO1B3 genotypes. Results: The presence of SLCO1B3 variants was not associated with increased risk of tBPAR (HR: 1.45, 95% CI: 0.76-2.74), dnDSA (HR: 0.46, 95% CI: 0.16-1.36) or composite of tBPAR or dnDSA (HR: 1.14, 95% CI: 0.64-2.03). Graft and patient survival were reduced among variant carriers; however, inconsistent findings with the primary analysis suggest these associations were not due to genotype. Adverse effects were similar between groups. Conclusion: Presence of SLCO1B3 polymorphisms were not predictive of rejection or dnDSA in kidney transplant recipients.
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Affiliation(s)
| | - Fang Fang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - Faisal Shakeel
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | - Jeong M Park
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI 48109, USA.,Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
| | - Amy L Pasternak
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI 48109, USA.,Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA
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10
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Schold JD, Augustine JJ, Huml AM, Fatica R, Nurko S, Wee A, Poggio ED. Effects of body mass index on kidney transplant outcomes are significantly modified by patient characteristics. Am J Transplant 2021; 21:751-765. [PMID: 32654372 PMCID: PMC8905683 DOI: 10.1111/ajt.16196] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/23/2020] [Accepted: 06/28/2020] [Indexed: 02/06/2023]
Abstract
Body mass index (BMI) is a known risk factor associated with kidney transplant outcomes and is incorporated for determining transplant candidate eligibility. However, BMI is a coarse health measure and risks associated with BMI may vary by patient characteristics. We evaluated 296 807 adult (age > 17) solitary kidney transplant recipients from the Scientific Registry of Transplant Recipients (2000-2019). We examined effects of BMI using survival models and tested interactions with recipient characteristics. Overall, BMI demonstrated a "J-Shaped" risk profile with elevated risks for overall graft loss with low BMI and obesity. However, multivariable models indicated interactions between BMI with recipient age, diagnosis, gender, and race/ethnicity. Low BMI was relatively higher risk for older recipients (>60 years), people with type I diabetes, and males and demonstrated no additional risk among younger (18-39) and Hispanic recipients. High BMI was associated with elevated risk for Caucasians and attenuated risk among African Americans and people with type II diabetes. Effects of BMI had variable risks for mortality vs graft loss by recipient characteristics in competing risks models. The association of BMI with posttransplant outcomes is highly variable among kidney transplant recipients. Results are important considerations for personalized care and risk stratification. Findings suggest that transplant contraindications should not be based on absolute BMI thresholds but modified based on patient characteristics.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Anne M. Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard Fatica
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Saul Nurko
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alvin Wee
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D. Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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11
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Meister FA, Czigany Z, Rietzler K, Miller H, Reichelt S, Liu WJ, Boecker J, Moeller MJ, Tolba RH, Hamesch K, Strnad P, Boor P, Stoppe C, Neumann UP, Lurje G. Decrease of renal resistance during hypothermic oxygenated machine perfusion is associated with early allograft function in extended criteria donation kidney transplantation. Sci Rep 2020; 10:17726. [PMID: 33082420 PMCID: PMC7575556 DOI: 10.1038/s41598-020-74839-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/30/2020] [Indexed: 12/19/2022] Open
Abstract
Hypothermic oxygenated machine perfusion (HOPE) was recently tested in preclinical trials in kidney transplantation (KT). Here we investigate the effects of HOPE on extended-criteria-donation (ECD) kidney allografts (KA). Fifteen ECD-KA were submitted to 152 ± 92 min of end-ischemic HOPE and were compared to a matched group undergoing conventional-cold-storage (CCS) KT (n = 30). Primary (delayed graft function-DGF) and secondary (e.g. postoperative complications, perfusion parameters) endpoints were analyzed within 6-months follow-up. There was no difference in the development of DGF between the HOPE and CCS groups (53% vs. 33%, respectively; p = 0.197). Serum urea was lower following HOPE compared to CCS (p = 0.003), whereas the CCS group displayed lower serum creatinine and higher eGFR rates on postoperative days (POD) 7 and 14. The relative decrease of renal vascular resistance (RR) following HOPE showed a significant inverse association with serum creatinine on POD1 (r = − 0.682; p = 0.006) as well as with serum urea and eGFR. Besides, the relative RR decrease was more prominent in KA with primary function when compared to KA with DGF (p = 0.013). Here we provide clinical evidence on HOPE in ECD-KT after brain death donation. Relative RR may be a useful predictive marker for KA function. Further validation in randomized controlled trials is warranted. Trial registration: clinicaltrials.gov (NCT03378817, Date of first registration: 20/12/2017).
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Affiliation(s)
- Franziska A Meister
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Katharina Rietzler
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Hannah Miller
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Sophie Reichelt
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Wen-Jia Liu
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Joerg Boecker
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcus J Moeller
- Division of Nephrology, Department of Medicine II, University Hospital RWTH Aachen, Aachen, Germany
| | - Rene H Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Karim Hamesch
- Division of Gastroenterology and Hepatology, Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Pavel Strnad
- Division of Gastroenterology and Hepatology, Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Boor
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany. .,Department of Surgery, Chirugische Klinik, Campus Charité Mitte
- Campus Virchow Klinikum-Charité Universitätsmedizin Berlin, Berlin, Germany.
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12
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Ahmadpoor P, Seifi B, Zoghy Z, Bakhshi E, Dalili N, Poorrezagholi F, Nafar M. Time-Varying Covariates and Risk Factors for Graft Loss in Kidney Transplantation. Transplant Proc 2020; 52:3069-3073. [PMID: 32694057 DOI: 10.1016/j.transproceed.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/27/2020] [Accepted: 06/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The present study was designed to evaluate the factors involved in long-term graft survival in recipients of kidney transplantation. MATERIALS AND METHODS We reviewed 755 Iranian adult recipients who underwent kidney transplantation at Shahid Labbafinejad Medical Center in Tehran, Iran. Patients were followed for 5 years after transplantation. The primary outcome was the time between transplantation and graft loss. Using Cox regression, we studied the effect of time-independent variables (recipients' age and sex, donors' age, and type of donor), time-dependent covariates (body mass index [BMI], systolic blood pressure, diastolic blood pressure, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol levels, proteinuria and serum creatinine level), and immunosuppressive drugs on graft loss 60 months after transplantation. The results are presented as the hazard ratio (HR) with 95% confidence intervals. RESULTS Result from Cox proportional hazards model showed that the HR of graft loss was 1.62 (95% CI: 1.03-2.54) in cadaveric donor compared with living donor kidney recipients. The HR of graft loss for recipient age was 1.02 (95% CI: 1.002-1.030). Moreover, according to obtained results, the risk of losing functional transplant increased for each mg/dL rise in serum creatinine at least 9% and at most 40%. Our results also showed that 1 unit increase of BMI has at least a 2% and at most a 15% decremented effect on the hazard ratio of graft loss. CONCLUSIONS Having lower levels of creatinine and receiving a kidney from a younger living donor were associated with a decreased risk of graft loss. Graft loss is more likely to occur in patients with lower BMI.
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Affiliation(s)
- Pedram Ahmadpoor
- Department of Nephrology and Renal Transplantation, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behjat Seifi
- Department of Physiology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Zoghy
- Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Enayatollah Bakhshi
- Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
| | - Nooshin Dalili
- Department of Nephrology and Renal Transplantation, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Poorrezagholi
- Department of Nephrology and Renal Transplantation, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Nafar
- Department of Nephrology and Renal Transplantation, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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13
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Giffen ZC, Siddique AB, Koizumi N, Ortiz J. Small donor size does not negatively impact outcomes after deceased-donor renal transplantation. Clin Transplant 2020; 34:e13886. [PMID: 32335953 DOI: 10.1111/ctr.13886] [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: 12/30/2019] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 11/28/2022]
Abstract
Higher body mass index (BMI) of deceased-donors is associated with poorer outcomes in transplant recipients. The effect of low donor BMI on recipient graft function is not clear. Scientific Registry of Transplant Recipients data on recipients of deceased-donor kidneys from 2000 to 2019 were categorized by donor BMI (donor BMI < 18, 18-27, and >27). Primary outcome was death-censored graft survival. The impact of multiple recipient and donor variables, including low donor BMI and the difference between donor and recipient BMI, was evaluated using a multivariate Cox proportional-hazards model. Low BMI donors (LBD) were more likely to be younger, female, and white (all P < .05). LBD were less likely to be Hispanic, diabetic, or have hypertension (all P < .001). LBD recipients were more likely to be younger and female (both P < .001). Low donor BMI was not significantly associated with recipient graft survival. Donor-recipient BMI difference did not correlate with an increased risk of graft failure. Similar results were obtained when donors were classified using body surface area (BSA). Small donor size in terms of BMI or BSA or a large discrepancy between donor and recipient size should not necessarily preclude transplantation of an otherwise acceptable kidney.
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Affiliation(s)
- Zane C Giffen
- Department of Urology, University of Toledo, Toledo, OH, USA
| | - Abu Bakkar Siddique
- Schar School of Policy and Government, George Mason University, Arlington, VA, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University, Arlington, VA, USA
| | - Jorge Ortiz
- Department of Surgery, University of Toledo, Toledo, OH, USA
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14
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Hu XJ, Zheng J, Li Y, Tian XH, Tian PX, Xiang HL, Pan XM, Ding CG, Ding XM, Xue WJ. Prediction of kidney transplant outcome based on different DGF definitions in Chinese deceased donation. BMC Nephrol 2019; 20:409. [PMID: 31722677 PMCID: PMC6854725 DOI: 10.1186/s12882-019-1557-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/09/2019] [Indexed: 12/03/2022] Open
Abstract
Background Delayed graft function (DGF) is an important complication of kidney transplantation and can be diagnosed according to different definitions. DGF has been suggested to be associated with the long-term outcome of kidney transplantation surgery. However, the best DGF definition for predicting renal transplant outcomes in Chinese donations after cardiac death (DCDs) remains to be determined. Method A total of 372 DCD kidney transplant recipients from June 2013 to July 2017 in the First Affiliated Hospital of Xi’an Jiaotong University were included in this retrospective study to compare 6 different DGF definitions. The relationships of the DGF definitions with transplant outcome were analyzed, including graft loss (GL) and death-censored graft loss (death-censored GL). Renal function indicators, including one-year estimated glomerular filtration rate (eGFR) and three-year eGFR, and were compared between different DGF groups. Results The incidence of DGF varied from 4.19 to 35.22% according to the different DGF diagnoses. All DGF definitions were significantly associated with three-year GL as well as death-censored GL. DGF based on requirement of hemodialysis within the first week had the best predictive value for GL (AUC 0.77), and DGF based on sCr variation during the first 3 days post-transplant had the best predictive value for three-year death-censored GL (AUC 0.79). Combination of the 48-h sCr reduction ratio and classical DGF can improve the AUC for GL (AUC 0.85) as well as the predictive accuracy for death-censored GL (83.3%). Conclusion DGF was an independent risk factor for poor transplant outcome. The combination of need for hemodialysis within the first week and the 48-h serum creatinine reduction rate has a better predictive value for patient and poor graft outcome.
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Affiliation(s)
- Xiao-Jun Hu
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Jin Zheng
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yang Li
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xiao-Hui Tian
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Pu-Xun Tian
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - He-Li Xiang
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xiao-Ming Pan
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Chen-Guang Ding
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xiao-Ming Ding
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Wu-Jun Xue
- Department of Renal Transplantation, Nephropathy Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China. .,Institute of Organ Transplantation, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.
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15
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Hoz RML, Sandıkçı B, Ariyamuthu VK, Tanriover B. Short-term outcomes of deceased donor renal transplants of HCV uninfected recipients from HCV seropositive nonviremic donors and viremic donors in the era of direct-acting antivirals. Am J Transplant 2019; 19:3058-3070. [PMID: 31207073 PMCID: PMC6864234 DOI: 10.1111/ajt.15496] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/21/2019] [Accepted: 06/07/2019] [Indexed: 01/25/2023]
Abstract
The United States opioid use epidemic over the past decade has coincided with an increase in hepatitis C virus (HCV) positive donors. Using propensity score matching, and the Organ Procurement Transplant Network data files from January 2015 to June 2019, we analyzed the short-term outcomes of adult deceased donor kidney transplants of HCV uninfected recipients with two distinct groups of HCV positive donors (HCV seropositive, nonviremic n = 352 and viremic n = 196) compared to those performed using HCV uninfected donors (n = 36 934). Compared to the reference group, the transplants performed using HCV seropositive, nonviremic and viremic donors experienced a lower proportion of delayed graft function (35.2 vs 18.9%; P < .001 [HCV seropositive, nonviremic donors] and 36.2 vs 16.8% ; P < .001[HCV viremic donors]). The recipients of HCV viremic donors had better allograft function at 6 months posttransplant (eGFR [54.1 vs 68.3 mL/min/1.73 m2; P = .004]. Furthermore, there was no statistical difference in the overall graft failure risk at 12 months posttransplant by propensity score matched multivariable Cox proportional analysis (HR = 0.60, 95% CI 0.23 to 1.29 [HCV seropositive, nonviremic donors] and HR = 0.85, 95% CI 0.25 to 2.96 [HCV viremic donors]). Further studies are required to determine the long-term outcomes of these transplants and address unanswered questions regarding the use of HCV viremic donors.
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Affiliation(s)
- Ricardo M. La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Bekir Tanriover
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
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16
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Syu SH, Lin YW, Lin KH, Lee LM, Hsiao CH, Wen YC. Risk factors for complications and graft failure in kidney transplant patients with sepsis. Bosn J Basic Med Sci 2019; 19:304-311. [PMID: 30242808 DOI: 10.17305/bjbms.2018.3874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/16/2018] [Indexed: 11/16/2022] Open
Abstract
Immunosuppressive therapies decrease the incidence of acute kidney rejection after kidney transplantation, but also increase the risk of infections and sepsis. This study aimed to identify the risk factors associated with complications and/or graft failure in kidney transplant patients with sepsis. A total of 14,658 kidney transplant patients with sepsis, identified in the National Inpatient Sample (NIS) database (data from 2005-2014), were included in the study and classified into three groups: patients without complications or graft failure/dialysis (Group 1), patients with complications only (Group 2), and patients with complications and graft failure/dialysis (Group 3). Multinomial logistic regression analyses were conducted to evaluate factors associated with kidney transplant recipients. Multivariate analysis showed that, compared to Group 1, patients from Group 2 or Group 3 were more likely to be Black and to have cytomegalovirus infection, coagulopathy, and glomerulonephritis (p ≤ 0.041). Also, Group 2 was more likely to have herpes simplex virus infection, and Group 3 was more likely to have hepatitis C infection and peripheral vascular disorders, compared to Group 1 (p ≤ 0.002). In addition, patients in Group 3 were more likely to be Black and to have hepatitis C infection, peripheral vascular disorders, coagulopathy, and hypertension compared to Group 2 (p ≤ 0.039). Age and female gender were associated with lower odds of complications after kidney transplantation regardless of graft rejection/dialysis (p ≤ 0.049). Hyperlipidemia and diabetes decreased the chance of complications and graft failure/dialysis after kidney transplant (p < 0.001). In conclusion, the study highlights that black race, male gender, and specific comorbidities can increase the risk of complications and graft failure in kidney transplant patients with sepsis.
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Affiliation(s)
- Syuan-Hao Syu
- Department of Urology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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17
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Schwartz JJ, Wilson S, Shi F, Elsouda D, Undre N, Kumar MSA. Prolonged-Release vs Immediate-Release Tacrolimus Capsules in Black vs White Kidney Transplant Patients: A Post Hoc Analysis of Phase III Data. Transplant Proc 2018; 50:3283-3295. [PMID: 30577198 DOI: 10.1016/j.transproceed.2018.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/27/2018] [Accepted: 08/16/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Black kidney transplant patients experience inferior outcomes compared with other ethnicities. Because scrutiny is required when immunosuppressant drugs are used in such at-risk populations, we report the first large-scale clinical efficacy data assessing prolonged-release tacrolimus (PR-T) in black de novo kidney transplant patients. METHODS AND MATERIALS We used logistic regression and proportionate hazards to compare a composite outcome measure (biopsy-proven acute rejection, graft loss, mortality, and loss to follow-up) in black and white patients in treatment groups longer than 24 weeks, from 3 large Phase III randomized controlled trials. Secondary endpoints included tacrolimus trough concentration, dose, and estimated glomerular filtration rate. RESULTS The study included 2162 patients whose treatments belonged to two categories (immediate-release tacrolimus: 77 black patients, 721 white patients; and PR-T: 87 black patients, 1277 white patients). Despite demographic factors generally predictive of worse outcomes, efficacy failure among black patients who received PR-T was non-inferior to that among white patients who received either therapy. Compared with immediate-release tacrolimus, black patients who received PR-T achieved stable tacrolimus concentrations 2.5 times faster (21 vs 56 days, P = .04), and more achieved stable target concentrations (76.7% vs 69.3%). Treatment-emergent adverse events were consistent with those reported separately in pivotal trials. CONCLUSIONS Overall, black patients who received PR-T achieved non-inferior outcomes compared to white patients, despite higher pretransplant risk among black patients. Moreover, PR-T improved the time to achieve, and the likelihood of reaching, stable therapeutic concentrations among black patients, suggesting that PR-T could improve the consistency of tacrolimus exposure in this patient population.
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Affiliation(s)
- J J Schwartz
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois.
| | - S Wilson
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - F Shi
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - D Elsouda
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - N Undre
- Medical Affairs, Astellas Pharma Global Development, Inc, Chertsey, United Kingdom
| | - M S A Kumar
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
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18
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Wilkins LJ, Nyame YA, Gan V, Lin S, Greene DJ, Flechner SM, Modlin CS. A Contemporary Analysis of Outcomes and Modifiable Risk Factors of Ethnic Disparities in Kidney Transplantation. J Natl Med Assoc 2018; 111:202-209. [PMID: 30409716 DOI: 10.1016/j.jnma.2018.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/29/2018] [Accepted: 10/05/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to provide a contemporary analysis of longitudinal kidney transplant outcomes and to evaluate potential causes of ethnic disparities among African American (AA) and Caucasian American (CA) patients undergoing kidney transplantation at our institution. PATIENTS AND METHODS 1400 patients were identified who underwent kidney transplantation from 2003 to 2013 from a large, academic institution in Cleveland, OH. Relevant recipient and donor demographic and clinical covariates were obtained from an institutional transplant database. Simple descriptive statistics and comparative survival analyses were performed to assess overall survival and graft survival. RESULTS The final cohort was comprised of 341 AA and 1059 CA patients. AAs were less likely to receive a living donor transplant (27.6% vs. 57.2%, p < 0.001) compared to CAs. Overall patient survival did not significantly differ between the two groups even when stratified by ethnicity. However, AAs had a significantly lower rate of graft survival (p < 0.001). On stratified analysis, there was no difference in the rate of graft survival among AAs and CAs who received living donor grafts. On univariate analysis, AAs demonstrated higher rates of immunosuppression non-compliance and chronic rejection (both p < 0.05). On multivariate analysis, AA recipient ethnicity (HR 1.56, p = 0.047), recipient history of diabetes (HR 1.67, p < 0.001), and AA donor ethnicity (HR 1.56, p = 0.047) were significantly associated with graft failure. CONCLUSION AAs undergoing deceased donor renal transplantation demonstrated lower graft survival compared to CAs. Conversely, this disparity did not exist among AAs undergoing living donor transplantation. AAs had higher rates of deceased donor transplantation, immunosuppression non-compliance, chronic rejection, and diabetes. Opportunities exist to use patient education, alternative immunosuppression regimens, and living transplantation to close the ethnic disparity in renal allograft survival.
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Affiliation(s)
- Lamont J Wilkins
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Lerner College of Medicine, Cleveland Clinic, Cleveland OH, USA
| | - Yaw A Nyame
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Valerie Gan
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Songhua Lin
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel J Greene
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stuart M Flechner
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles S Modlin
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
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19
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Avery LM, Fominaya CE, Crawford RC, Pleasants KP, Taber DJ. Characterization of Potentially Unsafe Ambulatory Antibiotic Use and Associated Outcomes in an Adult Kidney Transplant Population. Ann Pharmacother 2018; 52:974-982. [PMID: 29770702 DOI: 10.1177/1060028018776606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed to kidney transplant (KTX) recipients in the outpatient setting, but there are limited data assessing the safety and outcomes associated with this practice. OBJECTIVE The primary objective of this study was to describe ambulatory antibiotic prescribing in a large cohort of adult KTX recipients. The secondary objective was to assess the outcomes associated with potentially unsafe antibiotic use in this population. METHODS National Veterans Health Administration data compiled between 2001 and 2010 were used to conduct a pharmacovigilance assessment of antibiotic prescribing, excluding intravenous agents, antifungals, antivirals, and prophylactic regimens. Multivariable Cox proportional hazard regression was used to determine the impact of safe and potentially unsafe antibiotic use on time to event for graft loss. RESULTS Among 5130 KTX recipients and 30 127 patient-years of follow-up, 14 259 antibiotic courses were prescribed at a rate of 0.47 courses per patient-year. Transplant or nephrology providers prescribed 24.8% of courses. Overall, 608 courses (4.3%) in 311 patients (6.1%) were considered potentially unsafe for dosages in disagreement with recommended adjustments for renal function, interaction with immunosuppressive regimens, and other pertinent safety concerns. After adjusting for baseline characteristics, unsafe antibiotic use was associated with a 40% higher risk of graft loss (adjusted hazard ratio = 1.40; 95% CI = 1.03-1.89; P = 0.030) compared with safe use. CONCLUSIONS AND RELEVANCE Although unsafe antibiotic prescribing was uncommon, it was associated with increased risk of graft loss. Prospective research is needed to elucidate whether the driver of poor outcomes is the safety of the antibiotic prescription or fragmented care.
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Affiliation(s)
| | | | - Rena C Crawford
- 1 Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
| | | | - David J Taber
- 1 Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
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Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, Waldrip K. Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map. Am J Public Health 2018; 108:e1-e11. [PMID: 29412713 PMCID: PMC5803811 DOI: 10.2105/ajph.2017.304246] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types. OBJECTIVES To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA. SEARCH METHODS Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities. SELECTION CRITERIA We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review). DATA COLLECTION AND ANALYSIS Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group. MAIN RESULTS From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength). AUTHOR'S CONCLUSIONS Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.
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Affiliation(s)
- Kim Peterson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Johanna Anderson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Erin Boundy
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Lauren Ferguson
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Ellen McCleery
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
| | - Kallie Waldrip
- Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, Kallie Waldrip, are with the Department of Veterans Affairs, VA Portland Health Care System, Evidence-Based Synthesis Program Coordinating Center, Portland, OR
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Tacrolimus Trough Concentration Variability and Disparities in African American Kidney Transplantation. Transplantation 2017; 101:2931-2938. [PMID: 28658199 DOI: 10.1097/tp.0000000000001840] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Low tacrolimus concentrations have been associated with higher risk of acute rejection, particularly within African American (AA) kidney transplant recipients; little is known about intrapatient tacrolimus variabilities impact on racial disparities. METHODS Ten year, single-center, longitudinal cohort study of kidney recipients. Intrapatient tacrolimus variability was assessed using the coefficient of variation (CV) measured between 1 month posttransplant and the clinical event, with a comparable period assessed in those without events. Pediatrics, nontacrolimus/mycophenolate regimens, and nonrenal transplants were excluded. Multivariable Cox regression models were used to analyze data. RESULTS One thousand four hundred eleven recipients were included (54.4% AA) with 39 521 concentrations used to assess intrapatient tacrolimus CV. Overall, intrapatient tacrolimus CV was higher in AAs versus non-AAs (39.9 ± 19.8 % vs 34.8 ± 15.8% P < 0.001). Tacrolimus variability was a significant risk factor for deleterious clinical outcomes. A 10% increase in tacrolimus CV augmented the risk of acute rejection by 20% (adjusted hazard ratio, 1.20, 1.13-1.28; P < 0.001) and the risk of graft loss by 30% (adjusted hazard ratio, 1.30, 1.23-1.37; P < 0.001), with significant effect modification by race for acute rejection, but not graft loss. High tacrolimus variability (CV >40%) was a significant explanatory variable for disparities in AAs; the crude relative risk of acute rejection in AAs was reduced by 46% when including tacrolimus variability in modeling and reduced by 40% for graft loss. CONCLUSIONS These data demonstrate that intrapatient tacrolimus variability is strongly associated with acute rejection in AAs and graft loss in all patients. Tacrolimus variability is a significant explanatory variable for disparities in AA recipients.
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Taber DJ, Fleming JN, Fominaya CE, Gebregziabher M, Hunt KJ, Srinivas TR, Baliga PK, McGillicuddy JW, Egede LE. The Impact of Health Care Appointment Non-Adherence on Graft Outcomes in Kidney Transplantation. Am J Nephrol 2016; 45:91-98. [PMID: 27907919 DOI: 10.1159/000453554] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Non-adherence to medication is a well-studied and known cause of late allograft loss, but it is difficult to measure and prospectively monitor. The aim of this study was to assess if appointment non-adherence was correlated with medication non-adherence and a predictor of graft outcomes. METHODS This was a longitudinal cohort study that used the National United States Renal Data System and veterans affairs health records data with time-to-event analyses conducted to assess the impact on graft and patient survival. RESULTS The number of transplants that were included in the analysis was 4,646 (3,656 with complete records); 14.6% of patients had an appointment no show rate of ≥12% (non-adherence). Appointment and medication non-adherence were highly correlated and both were significant independent predictors of outcomes. Those with appointment non-adherence had 1.5 times the risk of acute rejection (22.0 vs. 14.7%, p < 0.0001) and a 65% higher risk of graft loss (adjusted hazards ratio (aHR) 1.65, 95% CI 1.38-1.97, p < 0.0001). There was a significant interaction between appointment and medication non-adherence; those with appointment and medication non-adherence were at very high risk of graft loss (aHR 4.18, 95% CI 3.39-5.15, p < 0.0001), compared to those with only appointment non-adherence (aHR 1.39, 95% CI 0.97-2.01, p = 0.0766) or only medication non-adherence (aHR 2.44, 95% CI 2.11-2.81, p < 0.0001). CONCLUSION These results demonstrate that non-adherence to health care appointments is a significant and independent risk factor for graft loss.
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Affiliation(s)
- David J Taber
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, S.C., USA
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Taber DJ, Hunt KJ, Fominaya CE, Payne EH, Gebregziabher M, Srinivas TR, Baliga PK, Egede LE. Impact of Cardiovascular Risk Factors on Graft Outcome Disparities in Black Kidney Transplant Recipients. Hypertension 2016; 68:715-25. [PMID: 27402921 DOI: 10.1161/hypertensionaha.116.07775] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 06/05/2016] [Indexed: 12/25/2022]
Abstract
Although outcome inequalities for non-Hispanic black (NHB) kidney transplant recipients are well documented, there is paucity in data assessing the impact of cardiovascular disease (CVD) risk factors on this disparity in kidney transplantation. This was a longitudinal study of a national cohort of veteran kidney recipients transplanted between January 2001 and December 2007. Data included baseline characteristics acquired through the United States Renal Data System linked to detailed clinical follow-up information acquired through the Veterans Affairs electronic health records. Analyses were conducted using sequential multivariable modeling (Cox regression), incorporating blocks of variables into iterative nested models; 3139 patients were included (2095 non-Hispanic whites [66.7%] and 1044 NHBs [33.3%]). NHBs had a higher prevalence of hypertension (100% versus 99%; P<0.01) and post-transplant diabetes mellitus (59% versus 53%; P<0.01) with reduced control of hypertension (blood pressure <140/90 60% versus 69%; P<0.01), diabetes mellitus (A1c <7%, 35% versus 47%; P<0.01), and low-density lipoprotein (<100 mg/dL, 55% versus 61%; P<0.01). Adherence to medications used to manage CVD risk was significantly lower in NHBs. In the fully adjusted models, the independent risk of graft loss in NHBs was substantially reduced (unadjusted hazard ratio, 2.00 versus adjusted hazard ratio, 1.49). CVD risk factors and control reduced the influence of NHB race by 9% to 18%. Similar trends were noted for mortality, and estimates were robust across in sensitivity analyses. These results demonstrate that NHB kidney transplant recipients have significantly higher rates of CVD risk factors and reduced CVD risk control. These issues are likely partly related to medication nonadherence and meaningfully contribute to racial disparities for graft outcomes.
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Affiliation(s)
- David J Taber
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC.
| | - Kelly J Hunt
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Cory E Fominaya
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Elizabeth H Payne
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Mulugeta Gebregziabher
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Titte R Srinivas
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Prabhakar K Baliga
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
| | - Leonard E Egede
- From the Division of Transplant Surgery (D.J.T., P.K.B.), Department of Public Health Sciences (K.J.H., E.H.P., M.G.), and Division of Transplant Nephrology (T.R.S.), College of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Pharmacy Services (D.J.T., C.E.F.) and Veteran Affairs HSR&D Health Equity and Rural Outreach Innovation Center (L.E.E.), Ralph H Johnson VAMC, Charleston, SC
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