Association Between Age and Graft Failure Rates in Young Kidney Transplant Recipients

Barriers and facilitators to transition from pediatric to adult healthcare for immigrant youth with chronic health conditions

PURPOSE

The objective of this study was to investigate the experience of first- and second- generation immigrant youth living with chronic health conditions in Canada, their parents or caregivers, and healthcare and service providers who care for immigrant youth, regarding the transition from pediatric to adult healthcare.

DESIGN AND METHODS

We conducted semi-structured individual interviews and focus groups. Youth were 1st or 2nd generation immigrants, aged 16-25, with pediatric-onset chronic health conditions. Parents or caregivers had raised youth children as described. Providers delivered healthcare or other services to immigrant populations. Thematic analysis was conducted of all transcripts.

RESULTS

Twenty youth, 14 parents/caregivers and five service providers participated. Most participants described healthcare transition as very difficult to navigate. Two major themes emerged across participant narratives: 1. Barriers to transition: lack of family experience in Canada, language, discrimination, financial strain, stigma, and long wait times. Some of these barriers are specific to newcomer families, but others are generalizable to the Canadian population. 2. Facilitators of transition: youth independence, youth acting as cultural bridges within their families, and cross-sector support between healthcare, education, social work and settlement services.

CONCLUSIONS

Immigrant youth and their families face a broad range of barriers to healthcare transition. The collaborative nature of cross-sector support effectively addressed some of the barriers faced by newcomer families.

PRACTICE IMPLICATIONS

Clinicians should provide immigrant youth and their families with accessible information about the health condition and how to navigate the adult healthcare system prior to transition, particularly when language barriers exist.

Adult and late adolescent complications of pediatric solid organ transplantation

BACKGROUND

There have been over 51 000 pediatric solid organ transplants since 1988 in the United States alone, leading to a growing population of long-term survivors who face complications of childhood organ failure and long-term immunosuppression.

AIMS

This is an educational review of existing literature.

RESULTS

Pediatric solid organ transplant recipients are at increased risk for risk for cardiovascular and kidney disease, skin cancers, and growth problems, though the severity of impact may vary by organ type. Pediatric recipients often are able to complete schooling, maintain a job, and form family and social networks in adulthood, though at somewhat lower rates than the general population, but face additional challenges related to neurocognitive deficits, mental health disorders, and discrimination.

CONCLUSIONS

Transplant centers and research programs should expand their focus to include long-term well-being. Increased collaboration between pediatric and adult transplant specialists will be necessary to better understand and manage long-term complications.

Strategies for choosing the best living donor: A review of the literature and a proposal of a decision-making paradigm

Transplantation remains the gold-standard treatment for pediatric end-stage kidney disease. While living donor transplant is the preferred option for most pediatric patients, it is not the right choice for all. For those who have the option to choose between deceased donor and living donor transplantation, or from among multiple potential living donors, the transplant clinician must weigh multiple dynamic factors to identify the most optimal donor. This review will cover the key considerations when choosing between potential living donors and will propose a decision-making algorithm.

Optimizing the approach to monitoring allograft inflammation using serial urinary CXCL10/creatinine testing in pediatric kidney transplant recipients

BACKGROUND

Urinary CXCL10/creatinine (uCXCL10/Cr) is proposed as an effective biomarker of subclinical rejection in pediatric kidney transplant recipients. This study objective was to model implementation in the clinical setting.

METHODS

Banked urine samples at a single center were tested for uCXCL10/Cr to validate published thresholds for rejection diagnosis (>80% specificity). The positive predictive value (PPV) for rejection diagnosis for uCXCL10/Cr-indicated biopsy was modeled with first-positive versus two-test-positive approaches, with accounting for changes associated with urinary tract infection (UTI), BK and CMV viremia, and subsequent recovery.

RESULTS

Seventy patients aged 10.5 ± 5.6 years at transplant (60% male) had n = 726 urine samples with n = 236 associated biopsies (no rejection = 167, borderline = 51, and Banff 1A = 18). A threshold of 12 ng/mmol was validated for Banff 1A versus no-rejection diagnosis (AUC = 0.74, 95% CI = 0.57-0.92). The first-positive test approach (n = 69) did not resolve a clinical diagnosis in 38 cases (55%), whereas the two-test approach resolved a clinical diagnosis in the majority as BK (n = 17/60, 28%), CMV (n = 4/60, 7%), UTI (n = 8/60, 13%), clinical rejection (n = 5/60, 8%), and transient elevation (n = 18, 30%). In those without a resolved clinical diagnosis, PPV from biopsy for subclinical rejection is 24% and 71% (p = .017), for first-test versus two-test models, respectively. After rejection treatment, uCXCL10/Cr level changes were all concordant with change in it-score. Sustained uCXCL10/Cr after CMV and BK viremia resolution was associated with later acute rejection.

CONCLUSIONS

Urinary CXCL10/Cr reliably identifies kidney allograft inflammation. These data support a two-test approach to reliably exclude other clinically identifiable sources of inflammation, for kidney biopsy indication to rule out subclinical rejection.

Gender and kidney transplantation

Kidney transplantation provides the best form of kidney replacement therapy with improvement in quality of life and longevity. However, disparity exists in its availability, utilisation and outcomes, not only due to donor availability or financial constraints but also arising from the influence of biological sex and its sociocultural attribute i.e., Gender. Women make up the majority of kidney donors but are less likely to be counselled regarding transpantation, be waitlisted or receive living/deceased donor kidney. Biological differences also contribute to differences in kidney transplantation among the sexes. Women are more likely to be sensitised owing to pregnancy, especially in multiparous individuals, complicating donor compatibility. A heightened immune system in women, evidenced by more autoimmune illnesses, increases the risk of allograft rejection and loss. Differences in the pharmacokinetics of transplant drugs owing to biological variances could also contribute to variability in outcomes. Transgender medicine is also increasingly becoming a relevant topic of study, providing greater challenges in the form of hormonal manipulations and anatomic changes. It is thus important to determine and study transplantation and its nuances in this backdrop to be able to provide relevant sex and gender-specific interventions and design better practices for optimum kidney transplant utilisation and outcomes.

Pulmonary Hypertension in Adult Congenital Heart Disease-Related Heart Failure

Already a challenging condition to define, adult congenital heart disease (ACHD) -associated heart failure (HF) often incorporates specific anatomies, including intracardiac and extracardiac shunts, which require rigorous diagnostic characterization and heighten the importance of clinicians proactively considering overall hemodynamic impacts of using specific therapies. The presence of elevated pulmonary vascular resistance dramatically increases the complexity of managing patients with ACHD-HF. Total circulatory management in patients with ACHD-HF requires input from multidisciplinary care teams and thoughtful and careful utilization of medical, interventional, and surgical approaches.

Time-Varying Determinants of Graft Failure in Pediatric Kidney Transplantation in Europe

BACKGROUND

Little is known about the time-varying determinants of kidney graft failure in children.

METHODS

We performed a retrospective study of primary pediatric kidney transplant recipients (younger than 18 years) from the Eurotransplant registry (1990-2020). Piece-wise exponential additive mixed models were applied to analyze time-varying recipient, donor, and transplant risk factors. Primary outcome was death-censored graft failure.

RESULTS

We report on 4528 kidney transplantations, of which 68% with deceased and 32% with living donor. One thousand six hundred and thirty-eight recipients experienced graft failure, and 168 died with a functioning graft. Between 2011 and 2020, the 5-year graft failure risk was 10% for deceased donor and 4% for living donor kidney transplant recipients. Risk of graft failure decreased five-fold from 1990 to 2020. The association between living donor transplantation and the lower risk of graft failure was strongest in the first month post-transplant (adjusted hazard ratio, 0.58; 95% confidence interval, 0.46 to 0.73) and remained statistically significant until 12 years post-transplant. Risk factors for graft failure in the first 2 years were deceased donor younger than 12 years or older than 46 years, potentially recurrent kidney disease, and panel-reactive antibody >0%. Other determinants of graft failure included dialysis before transplantation (until 5 years post-transplant), human leukocyte antigen mismatch 2-4 (0-15 years post-transplant), human leukocyte antigen mismatch 5-6 (2-12 years post-transplant), and hemodialysis (8-14 years post-transplant). Recipients older than 11 years at transplantation had a higher risk of graft failure 1-8 years post-transplant compared with other age groups, whereas young recipients had a lower risk throughout follow-up. Analysis of the combined effect of post-transplant time and recipient age showed a higher rate of graft failure during the first 5 years post-transplant in adolescents compared with young transplant recipients. In contrast to deceased donor younger than 12 years, deceased donor older than 46 years was consistently associated with a higher graft failure risk.

CONCLUSIONS

We report a long-term inverse association between living donor kidney transplantation and the risk of graft failure. The determinants of graft failure varied with time. There was a significant cumulative effect of adolescence and time post-transplant. The ideal donor age window was dependent on time post-transplant.

Cardiac allograft vasculopathy and survival in pediatric heart transplant recipients transitioned to adult care

BACKGROUND

Cardiac allograft vasculopathy (CAV) is an important cause of mortality after pediatric heart transplantation (HT) but there is a paucity of data regarding its incidence and impact on survival in pediatric recipients transitioned to adult care.

METHODS

We conducted a retrospective review of consecutive pediatric HT patients from 1989 to 2017 at the Hospital for Sick Children who transitioned to adult care at ≥18 years at Toronto General Hospital. We evaluated the incidence of International Society of Heart and Lung Transplantation CAV grade ≥1 using competing risk models. We assessed the association between all-cause mortality and CAV using Cox proportional hazards and used Kaplan Meier methods to evaluate all-cause mortality stratified by CAV and transplant era (1989-2001, 2002-2017).

RESULTS

Ninety-six patients were transitioned to adult care by January 2022, of which 53 underwent repeat coronary angiography as adults. CAV was newly diagnosed in 49% patients after transition to adult care. The overall incidence of CAV was 3.9 cases per 100 person-years. There was no difference in the adjusted incidence of CAV according to transplant era (subdistribution hazard ratios = 1.17, 95% confidence interval (CI) 0.54-2.66). CAV was associated with a higher risk of death in the early era (hazard ratio (HR) 10.29, 95% CI 2.16-49.96), but not in the recent era (HR 1.61, 95% 0.35-7.47).

CONCLUSIONS

There is a role for continued CAV surveillance after the transition to adult care. The implications of diagnosing CAV after the transition to adult care require further study, particularly because the risk of death in pediatric HT recipients diagnosed with CAV in the more recent era may be attenuated compared to the earlier HT era.

Medication adherence in pediatric kidney transplantation: How to build a bridge over troubled water

Adhering to the immunosuppressive regimen remains one of the biggest challenges for children and adolescents after kidney transplantation. The first paper on nonadherence, co-authored by Dr. Fine, appeared in Pubmed over 45 years ago. Since then, many clinicians and researchers tried to better understand nonadherence and are looking for effective ways to support young people in implementing the complex medication regimen in their daily lives. As a tribute to Dr. Fine, we conducted a comprehensive review providing an overview of adherence-enhancing interventions in the field of pediatric kidney transplantation, thereby focusing on strategies that not only are effective but can also be embedded in daily clinical practice successfully and sustainably. This overview is preceded by a discussion about how to find out who is in need of supportive interventions. We will also argue that interventions should already start before pediatric kidney transplantation and discuss how to decide whether or not a young patient with nonadherence-induced graft loss should undergo retransplantation. We hope this comprehensive overview will rekindle the hope that we can finally turn the tide and beat one of pediatric kidney transplantation's main enemies.

Trajectories of eGFR after kidney transplantation according to trajectories of eGFR prior to kidney replacement therapies in children with chronic kidney disease

BACKGROUND

In children with chronic kidney disease (CKD), certain risk factors are associated with faster eGFR decline and earlier kidney failure. Whether these factors have lingering effects on post-transplant eGFR trajectory remains unclear. We characterized pre- and post-transplant eGFR trajectories in pediatric kidney transplant recipients by their pre-kidney replacement therapy (KRT) risk factors.

METHODS

We studied eGFR trajectories before KRT initiation and after transplantation among Chronic Kidney Disease in Children (CKiD) Study participants. We used mixed-effects models to compare pre-KRT versus post-transplant eGFR trajectories within individual participants by 7 pre-KRT risk factors: glomerular/non-glomerular etiology, race, preemptive transplant, proteinuria, albuminuria, and systolic/diastolic blood pressure (SBP/DBP).

RESULTS

We analyzed 1602 pre-KRT and 592 post-transplant eGFR measurements from 246 transplant recipients. Mean annual eGFR decline was decreased from 18.0% pre-KRT (95%CI, 16.1-19.8) to 5.0% post-transplant (95%CI, 3.3-6.7). All 7 pre-KRT risk factors showed strong associations with faster pre-KRT eGFR decline, but not with post-transplant eGFR decline; only albuminuria, high SBP, and high DBP reached statistical significance with notably attenuated associations. In our multivariable model of the pre-KRT risk factors, post-transplant eGFR decline was more rapid only when albuminuria and high SBP were both present.

CONCLUSIONS

eGFR decline substantially slows down after transplant even among children with rapidly progressing forms of CKD. Nonetheless, those who had albuminuria and high SBP before KRT might continue to show faster eGFR decline after transplant, specifically when both risk factors were present. This subgroup might benefit from intensive pre-transplant management for at least one of the two risk factors. A higher resolution version of the Graphical abstract is available as Supplementary information.

Understanding the impact of pediatric kidney transplantation on cognition: A review of the literature

BACKGROUND

Chronic kidney disease (CKD) is a relatively rare childhood disease that is associated with a wide array of medical comorbidities. Roughly half of all pediatric patients acquire CKD due to congenital anomalies of the kidneys and urinary tract, and of those with congenital disease, 50% will progress to end-stage kidney disease (ESKD) necessitating a kidney transplantation. The medical sequelae of advanced CKD/ESKD improve dramatically following successful kidney transplantation; however, the impact of kidney transplantation on neurocognition in children is less clear. It is generally thought that cognition improves following kidney transplantation; however, our knowledge on this topic is limited by the sparsity of high-quality data in the context of the relative rarity of pediatric CKD/ESKD.

METHOD

We conducted a narrative review to gauge the scope of the literature, using the PubMed database and the following keywords: cognition, kidney, brain, pediatric, neurocognition, intelligence, executive function, transplant, immunosuppression, and neuroimaging.

RESULTS

There are few published longitudinal studies, and existing work often includes wide heterogeneity in age at transplant, variable dialysis exposure/duration prior to transplant, and unaccounted cofounders which persist following transplantation, including socio-economic status. Furthermore, the impact of long-term maintenance immunosuppression on the brain and cognitive function of pediatric kidney transplant (KT) recipients remains unknown.

CONCLUSION

In this educational review, we highlight what is known on the topic of neurocognition and neuroimaging in the pediatric KT population.

Validation of a prediction system for risk of kidney allograft failure in pediatric kidney transplant recipients: An international observational study

Predicting long-term kidney allograft failure is an unmet need for clinical care and clinical trial optimization in children. We aimed to validate a kidney allograft failure risk prediction system in a large international cohort of pediatric kidney transplant recipients. Patients from 20 centers in Europe and the United States, transplanted between 2004 and 2017, were included. Allograft assessment included estimated glomerular filtration rate, urine protein-to-creatinine ratio, circulating antihuman leukocyte antigen donor-specific antibody, and kidney allograft histology. Individual predictions of allograft failure were calculated using the integrative box (iBox) system. Prediction performances were assessed using discrimination and calibration. The allograft evaluations were performed in 706 kidney transplant recipients at a median time of 9.1 (interquartile range, 3.3-19.2) months posttransplant; mean estimated glomerular filtration rate was 68.7 ± 28.1 mL/min/1.73 m2, and median urine protein-to-creatinine ratio was 0.1 (0.0-0.4) g/g, and 134 (19.0%) patients had antihuman leukocyte antigen donor-specific antibodies. The iBox exhibited accurate calibration and discrimination for predicting the outcomes up to 10 years after evaluation, with a C-index of 0.81 (95% confidence interval, 0.75-0.87). This study confirms the generalizability of the iBox to predict long-term kidney allograft failure in children, with performances similar to those reported in adults. These results support the use of the iBox to improve patient monitoring and facilitate clinical trials in children.

Mycophenolate Mofetil Dose Adjustment in Pediatric Kidney Transplant Recipients

BACKGROUND

The Immunosuppressant Bayesian Dose Adjustment web site aids clinicians and pharmacologists involved in the care of transplant recipients; it proposes dose adjustments based on the estimated area under the concentration-time curve (AUCs). Three concentrations (T 20 min , T 1 h , and T 3 h ) are sufficient to estimate mycophenolic acid (MPA) AUC 0-12 h in pediatric kidney transplant recipients. This study investigates mycophenolate mofetil (MMF) doses and MPA AUC values in pediatric kidney transplant recipients, and target exposure attainment when the proposed doses were followed, through a large-scale analysis of the data set collated since the inception of the Immunosuppressant Bayesian Dose Adjustment web site.

METHODS

In this study, 4051 MMF dose adjustment requests, corresponding to 1051 patients aged 0-18 years, were retrospectively analyzed. AUC calculations were performed in the back office of the Immunosuppressant Bayesian Dose Adjustment using published Bayesian and population pharmacokinetic models.

RESULTS

The first AUC request was posted >12 months posttransplantation for 41% of patients. Overall, only 50% had the first MPA AUC 0-12 h within the recommended 30-60 mg.h/L range. When the proposed dose was not followed, the proportion of patients with an AUC in the therapeutic range for MMF with cyclosporine or tacrolimus at the subsequent request was lower (40% and 45%, respectively) than when it was followed (58% and 60%, respectively): P = 0.08 and 0.006, respectively. Furthermore, 3 months posttransplantation, the dispersion of AUC values was often lower at the second visit when the proposed doses were followed, namely, P = 0.03, 0.003, and 0.07 in the 4 months-1 year, and beyond 1 year with <6-month or >6-month periods between both visits, respectively.

CONCLUSIONS

Owing to extreme interindividual variability in MPA exposure, MMF dose adjustment is necessary; it is efficient at reducing such variability when based on MPA AUC.

Transition of Kidney Care at 18: Challenges and Practical Solutions for India

Health-care transition (HCT) from pediatric-centered to adult-oriented health-care setting is more than a simple transfer of care. It is a carefully planned movement specially tailored for the needs of adolescents and young adults (AYAs). Similar to other chronic diseases, the need for HCT for AYAs with kidney disease has been well established by the International Society of Nephrology (ISN) and the International Pediatric Nephrology Association (IPNA) consensus statements since 2011. However, successful HCT in India and other low- and middle-income countries (LMICs) has been limited. Undertaking the HCT program in India requires involvement of many stakeholders, that is, AYAs, parents/caregivers, health-care providers, and the health-care system. In this article, we discuss the need for HCT, the challenges faced during the transition, and the recommended models for HCT in kidney care. We focus on the unique challenges faced in India and conclude with practical suggestions to implement HCT in our setting.

Just TRAC it! Transitioning Responsibly to Adult Care Using Smart Phone Technology

PURPOSE

There is little evidence on whether smartphone technology influences transition readiness among adolescents with heart disease. Just TRAC it! is a method of using existing smartphone features (Notes, Calendar, Contacts, Camera) to manage personal health. We evaluated the impact of Just TRAC it! on self-management skills.

METHODS

Randomized clinical trial of 16-18 year-olds with heart disease. Participants were randomly allocated 1:1 to either usual care (education session) or intervention (education session including Just TRAC it!). The primary outcome was change in TRANSITION-Q score between baseline, 3 and 6 months. Secondary outcomes were frequency of use and perceived usefulness of Just TRAC it! Analysis was intention-to-treat.

RESULTS

We enrolled 68 patients (41% female, mean age 17.3 years), 68% having previous cardiac surgery and 26% had cardiac catheterization. TRANSITION-Q scores were similar at baseline and increased over time in both groups but were not significantly different between groups. Each additional point at the baseline score brought, on average, a 0.7-point increase in TRANSITION-Q score (95% CI 0.5-0.9) at each of 3 and 6 months. The Camera, Calendar and Notes apps were reported as most useful. All intervention participants would recommend Just TRAC it! to others.

DISCUSSION

A nurse-led transition teaching with versus without Just TRAC it! improved transition readiness, with no significant difference between groups. Higher baseline TRANSITION-Q scores were associated with greater increase in scores over time. Participants had a positive reception to Just TRAC it! and would recommend it to others. Smartphone technology may be useful in transition education.

Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics

Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.

Pathophysiology of Rejection in Kidney Transplantation

Kidney transplantation has been the optimal treatment for end-stage kidney disease for almost 70 years, with increasing frequency over this period. Despite the prevalence of the procedure, allograft rejection continues to impact transplant recipients, with consequences ranging from hospitalization to allograft failure. Rates of rejection have declined over time, which has been largely attributed to developments in immunosuppressive therapy, understanding of the immune system, and monitoring. Developments in these therapies, as well as an improved understanding of rejection risk and the epidemiology of rejection, are dependent on a foundational understanding of the pathophysiology of rejection. This review explains the interconnected mechanisms behind antibody-mediated and T-cell-mediated rejection and highlights how these processes contribute to outcomes and can inform future progress.

Patient preferences of patient selection criteria for upper extremity vascularized composite allotransplantation: A qualitative study

Background

Upper extremity vascularized composite allotransplantation is a life-enhancing reconstructive treatment option that aims to improve recipients' quality of life and maximize function. This study assessed upper extremity vascularized composite allotransplantation patient selection criteria perceptions among individuals with upper extremity limb loss. The perceptions of individuals with upper extremity limb loss on patient selection criteria may enable vascularized composite allotransplantation centers to improve criteria to avoid mismatched expectations about the posttransplant vascularized composite allotransplantation experience and outcomes. Realistic patient expectations may increase patient adherence, improve outcomes, and reduce vascularized composite allotransplantation graft loss.

Methods

We conducted in-depth interviews with civilian and military service members with upper extremity limb loss and upper extremity vascularized composite allotransplantation candidates, participants, and recipients from three US institutions. Interviews assessed perceptions of patient selection criteria for suitability as a candidate for upper extremity vascularized composite allotransplantation. Thematic analysis was used to analyze qualitative data.

Results

A total of 50 individuals participated (66% participation rate). Most participants were male (78%), White (72%), with a unilateral limb loss (84%), and a mean age of 45 years. Six themes emerged regarding upper extremity vascularized composite allotransplantation patient selection criteria, including support for candidates who: (1) are of younger age, (2) are in good physical health, (3) have mental stability, (4) are willing to "put in the work," (5) have specific amputation characteristics, and (6) have sufficient social support. Patients had preferences about selecting candidates with unilateral versus bilateral limb loss.

Conclusions

Our findings suggest that numerous factors, including medical, social, and psychological characteristics, inform patients' perceptions of patient selection criteria for upper extremity vascularized composite allotransplantation. Patient perceptions of patient selection criteria should inform the development of validated screening measures that optimize patient outcomes.

Can eHealth applications improve renal transplant outcomes for adolescents and young adults? A systematic review

BACKGROUND AND OBJECTIVES

Adherence to medical treatment following a kidney transplant is particularly challenging during adolescence and young adulthood. There is increasing evidence of the benefits of the use of computer and mobile technology (labelled as eHealth hereafter) including serious gaming and gamification in many clinical areas. We aimed to conduct a systematic review of such interventions designed to improve self-management skills, treatment adherence and clinical outcomes in young kidney transplant recipients aged 16 to 30 years.

METHOD

The Cochrane Library, MEDLINE, EMBASE, PsychINFO, SCOPUS and CINAHL databases were searched for studies published between 01 January 1990 and 20 October 2020. Articles were short-listed by two independent reviewers based on pre-defined inclusion/exclusion criteria. Reference lists were screened and authors of published conference abstracts contacted. Two reviewers independently appraised selected articles, systematically extracted data and assessed the quality of individual studies (CASP and SORT). Thematic analysis was used for evidence synthesis; quantitative meta-analysis was not possible.

RESULTS

A total of 1098 unique records were identified. Short-listing identified four eligible studies, all randomized controlled trials (n = 266 participants). Trials mainly focused on mHealth applications or electronic pill dispensers (mostly for patients >18 years old). Most studies reported on clinical outcome measures. All showed improved adherence but there were no differences in the number of rejections. Study quality was low for all four studies.

CONCLUSIONS

The findings of this review suggest that eHealth interventions can improve treatment adherence and clinical outcomes for young kidney transplant patients. More robust and high-quality studies are now needed to validate these findings. Future studies should also extend beyond short-term outcomes, and consider cost of implementation. The review was registered with PROSPERO (CRD42017062469).

Differences in medication adherence by sex and organ type among adolescent and young adult solid organ transplant recipients

BACKGROUND

Identification of differences in medication adherence by sex or organ type may help in planning interventions to optimize outcomes. We compared immunosuppressive medication adherence between males and females, and between kidney, liver and heart transplant recipients.

METHODS

This multicenter study of prevalent kidney, liver and heart transplant recipients 14-25 years assessed adherence 3 times (0, 3, 6 months post-enrollment) with the BAASIS self-report tool. At each visit, participants were classified as adherent if they missed no doses in the prior 4 weeks and non-adherent otherwise. Adherence was also assessed using the coefficient of variation (CV) of tacrolimus trough levels; CV < 30% was classified as adherent. We used multivariable mixed effects logistic regression models adjusted for potential confounders to compare adherence by sex and by organ.

RESULTS

Across all visits, males (n = 150, median age 20.4 years, IQR 17.2-23.3) had lower odds of self-reported adherence than females (n = 120, median age 19.8 years, IQR 17.1-22.7) (OR 0.41, 95% CI 0.21-0.80) but higher odds of adherence by tacrolimus CV (OR 2.50, 95% CI 1.30-4.82). No significant differences in adherence (by self-report or tacrolimus CV) were noted between the 184 kidney, 58 liver, and 28 heart recipients.

CONCLUSION

Females show better self-reported adherence than males but greater variability in tacrolimus levels. Social desirability bias, more common in females than males, may contribute to better self-reported adherence among females. Higher tacrolimus variability among females may reflect biologic differences in tacrolimus metabolism between males and females rather than sex differences in adherence. There were no significant differences in adherence by organ type.

The Educational Needs of Adolescent and Young Adult Renal Transplant Recipients-A Scoping Review

Renal transplantation is the gold-standard treatment for adolescents and young adults with end-stage renal disease. Despite enjoying excellent short-term outcomes, they suffer the worst rates of premature transplant function loss. Health behaviors: such as lack of adherence to immunosuppressive medications, are felt to be the major contributory factor. Understanding the educational needs of young renal transplant recipients allows healthcare practitioners to better support patients in managing their chronic disease. The aim of this scoping review was to understand what is known about their educational needs. A scoping review methodology was followed. Following an online search, study titles, and abstracts were screened for eligibility, followed by full-text assessment and data extraction. Data were qualitatively analyzed using thematic analysis. A total of 29 studies were included in the scoping review. In young people who struggled with self-management, three themes were identified (1) the Needs of the disrupted youth, (2) the Needs of the disorganized youth (3) the Needs of the distressed youth. There was a paucity of research to identify the protective factors that enable young recipients to successfully manage their health. This review outlines current knowledge of the patient education needs of young transplant recipients. It also highlights remaining research gaps that will need to be addressed with future research.

Envarsus XR® pharmacokinetics in adolescents post-kidney transplantation - A pilot study

INTRODUCTION

Envarsus XR® (LCPT), a once daily dosage formulation of tacrolimus, is an FDA-approved medication in adult renal transplant recipients (RTRs). There are limited data on its pharmacokinetics (PK) in adolescent RTRs. We report here the PK profile of LCPT in adolescent RTRs.

METHODS

The dose of LCPT was determined using a dose conversion ratio targeting 0.7 relative to the total daily immediate-release tacrolimus (IR-Tac) dose. On day 7 after converting to LCPT, patients had an abbreviated PK assessment with sampling at: 0 h (pre-dose), 8-, and 12-h post-dose. The PK data analysis was performed using Bayesian estimators. Our results were compared to those of published adult PK data for LCPT and pediatric PK data for IR-Tac and extended release tacrolimus (ER-Tac) formulation (Advagraf).

RESULTS

PK data from three adolescent patients on LCPT were evaluated. The mean (±SD) area under the time-concentration curve (AUC) was 240 (±20.22) h*ng/mL. The mean T_max was 9.01 ± 2.12 h, and the % fluctuation was 77.71 ± 3.96%. The AUC, T_max , and % fluctuation were similar to reported results in adult patients taking LCPT. The AUC was higher and the T_max was longer than what has been reported in pediatric patients taking IR-Tac and ER-Tac. In addition, the LCPT group showed a lower % fluctuation than patients receiving ER-Tac.

CONCLUSION

The PK evaluation of LCPT in adolescent RTRs showed similar results to adults. Adolescents taking LCPT had a higher AUC, a more attenuated T_max , and a lower fluctuation than that seen with ER-Tac in pediatrics.

Transition of young adult kidney transplant recipients

Survival of pediatric kidney transplant recipients has improved over the past six decades. However, adolescents and young adults still have the highest graft failure rates of any age group. There is a growing need for well-designed transition programs to ensure the successful integration of young adults into adult society with eventual transfer of care and management in adult transplant centers. In this review, we discuss the risk factors contributing to the high risk of kidney graft failure observed between 17 and 24 years of age, including the role of transfer from pediatric to adult care. We also address the unique challenges of adolescents with kidney transplant: the impact of chronic kidney disease on neurocognition, age-related changes in immune activity, and suboptimal adherence during the transition process. We then describe strategies to mitigate these risks by designing developmentally appropriate transition programs, and review the evidence supporting the benefits of well-designed multidisciplinary transition programs.

Kidney-transplanted Adolescents—Nonadherence and Graft Outcomes During the Transition Phase: A Nationwide Analysis, 2000–2020

BACKGROUND

The transition from pediatric to young adult care is a vulnerable period for the renal transplant patient. We aimed to identify medication nonadherence (noninitiation, nonimplementation, and nonpersistence) and graft loss rates among adolescents and young adults and elucidate the influence of the transition phase on transplant outcomes.

METHODS

A retrospective nationwide cohort analysis of all renal transplantations in Norway from 2000 to 2020 was performed. Data were retrieved from the Norwegian Renal Registry, and adherence data from hospital charts. Patients transplanted aged <50 y, with functioning graft at 6 mo, were included. Recipients transplanted aged <26 y were compared with recipients transplanted aged 26-50 y. Graft loss, acute rejection, and development of de novo donor-specific antibodies were assessed in relation to the transition phase, defined as 14-26 y.

RESULTS

Data from 1830 kidney recipients were included: 371 (20%) transplanted <26 y (64% male, 68% living donor) versus 1459 transplanted 26-50 y (63% male, 44% living donor). There were 298 graft losses, 78 (21%) in the <26-y group versus 220 (15%) in the 26- to 50-y group. During the transition phase, 36 grafts were lost, 29 (81%) after transfer to the adult service. Medication nonadherence was the reason for 58% (21 of 36) of the losses during the transition phase, versus 12% (27 of 220) in the 26- to 50-y group ( P < 0.001). The 5-y graft survival rate was 89% (95% confidence interval, 85%-92%) and 94% (92%-95%), respectively ( P = 0.01).

CONCLUSIONS

Nonadherence was verified as the main cause of kidney graft loss in the transition phase.

Patient and care provider inclusion in the development of an educational graphic novel for heart transplanted teenagers

PURPOSE

Teenagers experience high rates of rejection and organ failure after heart transplantation due to non-adherence to medications, poor transition into adult care, and difficulties communicating with adults including healthcare providers. This project aimed to creatively bridge this gap-including teenage patients, their parents, and healthcare providers in the development of a new resource meant to motivate teenage heart-transplant-patients to take interest and ownership of their long-term health.

METHODS

Four teenage heart-transplanted patients, four parents, and three healthcare providers provided insight into relevant content for an educational resource through semi-standardized questionnaires and interviews. Their input guided the style and substance of the resource developed under the supervision of Fine Arts professors and the pediatric heart transplant team.

RESULTS

Parents and healthcare providers were concerned about teenagers' health choices and lack of perspective while patients were more bothered by parental nagging and being careful about infections than worrying about post-transplant risks. The resource that was developed therefore used subtlety within a narrative medium: a graphic novel that involved mutant worms, secret plots, and daring escapes, to address identified medical concerns and encouragements without triggering teenage resistance to instruction.

CONCLUSION

The discrepancies between the priorities of healthcare providers, parents, and teenage heart-transplant-patients illustrate the significance of basing resource-development on input from the target population. We developed the first graphic novel written for teenage heart-transplant-patients with patient input and interdisciplinary cooperation, using the subtlety of a narrative medium as a model for integrating medical content within an appealing, motivational, patient-centered, and age-appropriate resource.

Psychosocial impact of structured transfer of adolescents with kidney transplants to adult services: An interventional national cohort study

BACKGROUND

Pediatric kidney transplantation entails a well-timed transition from pediatric to adult medical care. We aimed to construct a structured transition protocol and evaluate its impact on transfer-related psychosocial problems in Slovenian patients with kidney transplants.

METHODS

Individual transition-related perceptions of our patients and their parents were first assessed, and the gathered information was used to establish a country-specific transition protocol. Eleven kidney transplant patients qualified for actual transfer and were considered for further analysis. Comprehension and attitude towards transfer, coping strategies, personality resilience, behavioral, and emotional problems were assessed using questionnaires and established psychological tools before and after the completed transfer. The results were compared and analyzed.

RESULTS

Ten of the eleven eligible patients were transferred to adult services between April 2020 and January 2021. The median age at enrollment was 19.7 years (range: 18.2-22.8 years). The most frequent concerns regarding upcoming health care were worse accessibility (50%), less supportive and less committed healthcare providers (40%), and deterioration of medical condition (10.0%). After the completed protocol-guided transfer, the patients declared to have no further concerns or worries. Before transfer, 28.9% of the patients' responses rated the amount and relevance of received information and counseling as "Adequate" or "Very adequate," whereas, after the transfer, the proportion of positive responses increased to 48.9%. Anxiety and withdrawn depressive symptoms were the predominant emotional problems before transfer. Their prevalence decreased after the completed transfer.

CONCLUSIONS

Our results suggest that transfer-related anxieties and concerns can be significantly reduced by applying a structured transition protocol in transplant patients.

Post-transplant education for kidney recipients and their caregivers

Successful outcomes in pediatric kidney transplantation require the involvement of the transplant team as well as recipients and their caregivers. Enhancing patient and family understanding of the disease and of post-transplant care can result in improved adherence and outcomes. Educational strategies should aim to be broad, understandable, innovative, and inclusive while maintaining a tailored approach to individualized care. Teaching should not be viewed as a one-time event but rather as an ongoing conversation throughout the duration of care, emphasizing different aspects throughout the patient's various developmental stages. The following review article discusses the content and methods of post-transplant education.

A Cost-effectiveness Analysis of Adherence Promotion Strategies to Improve Rejection Rates in Adolescent Kidney Transplant Recipients

RATIONALE & OBJECTIVE

Nonadherence to medical regimens increases the risk of graft loss among adolescent and young adult recipients of kidney transplants. Interventions that improve adherence may decrease rejection rates, but their perceived costs are a barrier to clinical implementation. We developed a model to assess the cost-effectiveness of an adherence promotion strategy, the Medication Adherence Promotion System (MAPS).

STUDY DESIGN

Simulation-based. Data sources included published articles indexed in Medline or referenced in bibliographies of relevant English-language articles. Data on costs and outcomes were taken from a single clinical center.

SETTING & POPULATION

US adolescent patients after their first kidney transplant.

INTERVENTION

Usual posttransplant care versus usual care plus MAPS.

OUTCOME

Effectiveness measured in quality-adjusted life years (QALYs) and costs measured in 2020 US dollars.

MODEL, PERSPECTIVE, & TIMEFRAME

Markov state transition decision model. We used a health care system perspective with a lifelong time horizon.

RESULTS

In the base-case analysis, MAPS was more effective and less costly than usual care. MAPS cost $9,106 per patient less than usual care and resulted in a gain of 0.32 QALYs. In probabilistic sensitivity analyses, MAPS was cost saving 100% of the time. Extending results to a program level with 100 patients, any adherence promotion intervention similar in effectiveness to MAPS would cost less than $50,000/QALY if the start-up costs were <$2.5 million and annual costs <$188,000. Strategies with costs similar to MAPS that reduce the risk of rejection by as little as 3% would also have similar cost-effectiveness.

LIMITATIONS

Estimates of components and costs for MAPS were based on a single center.

CONCLUSIONS

Adherence promotion strategies with costs similar to MAPS can be cost-effective as long as they reduce rejection rates by at least 3%. This model can be applied to study the cost-effectiveness of adherence promotion strategies with varying costs and outcomes.

Sex differences in the likelihood of pre-emptive living donor kidney transplantation, and outcomes after kidney transplantation in children and adolescents

BACKGROUND

Data on sex-based disparities in children with kidney failure and outcomes after kidney transplantation are relatively sparse. This study examined the association between sex differences and the odds of receiving a pre-emptive living donor kidney transplantation, and post-transplant outcomes in children and adolescents.

METHODS

We studied all patients (aged <20 years) who commenced kidney replacement therapy (KRT) between 2002 and 2017 using data from the ANZDATA Registry. Factors associated with graft loss and acute rejection after transplantation were assessed using multivariable Cox regression model. Differences in the odds of receiving a pre-emptive live donor transplant between sexes were assessed using adjusted logistic regression.

RESULTS

Of the 757 children transplanted during the study period, 497 (65.7%) received a live donor kidney (163, 21.5% pre-emptive). In total, 168 (22.2%) patients experienced graft loss and 213 (28.1%) patients experienced a first episode of acute rejection during the median follow-up period of 6.9 years (IQR 3.5-11.5 years). There were no differences in the rates of graft loss or acute rejection by sex. Compared with boys, the adjusted hazard ratios (aHR) (95% confidence interval) for graft loss and acute rejection in girls were 0.97 (0.71-1.33) and 1.09 (0.82-1.44), respectively. Among children who received living donor kidney transplants, there were no sex differences in the odds of receiving a pre-emptive transplant (adjusted odds ratio (aOR) 0.90 (95% CI 0.56-1.45)).

CONCLUSIONS

No sex differences were observed in the odds of receiving a pre-emptive living donor kidney transplant or outcomes after kidney transplantation.

Initial attendance and retention in adult healthcare as criteria for transition success among organ transplant recipients

BACKGROUND

Adolescent and young adult (AYA) solid organ transplant recipients experience worsening medical outcomes during transition to adult healthcare. Current understanding and definitions of transition success emphasize first initiation of appointment attendance in adult healthcare; however, declines in attendance over time after transfer remain possible, particularly as AYAs are further removed from their pediatric provider and assume greater independence in their care.

METHODS

The current study assessed health-care utilization, medical outcomes, and transition success among 49 AYA heart, kidney, or liver recipients recently transferred to adult healthcare. Differences in outcomes were examined along two transition success criteria: (1) initial engagement in adult healthcare within 6 or 12 months of last pediatric appointment and (2) retention in adult healthcare over 3 years following last pediatric appointment. Growth curve modeling examined change in attendance over time.

RESULTS

Successful retention in adult healthcare was significantly related to more improved clinical outcomes, including decreased number and duration of hospitalizations and greater medication adherence, as compared to initial engagement. Significant declines in appointment attendance over 3 years were noted, and individual differences in declines were not accounted for by age at transfer or time since transplant.

CONCLUSIONS

Findings underscore support for AYAs after transfer, as significant declines in attendance were noted after initiating adult care. Clinical care teams should examine transition success longitudinally to address changes in health-care utilization and medical outcomes. Attention to interventions and administrative support aimed at maintaining or increasing attendance and identifying risk factors and intervention for unsuccessful transition is warranted.

The psychosocial needs of adolescent and young adult kidney transplant recipients, and associated interventions: a scoping review

Background

Renal transplantation is considered the gold standard treatment for end-stage kidney disease. Adolescent and young adult kidney transplant recipients have the highest rate of graft loss amongst transplanted patients. It is largely accepted this is due to psychosocial and behavioural difficulties, which impact adherence to prescribed therapies. This phenomenon is not isolated to a particular healthcare system having been observed in multiple countries across different continents. It is a global issue of concern. We sought to review the psychosocial needs of these patients, and the interventions designed to meet these needs.

Methods

A scoping review was conducted based on Arksey and O’Malley’s six-stage framework. Eligibility criteria included primary studies of any type that investigated the psychosocial needs of adolescent and/or young adult renal transplant recipients or studies which examined interventions designed to address these needs. Search strategies were developed and conducted on PsycINFO, PubMed, Embase, and CINAHL. Articles meeting the inclusion criteria were critically reviewed using a descriptive-analytical narrative method.

Results

Thirty-nine studies met our inclusion criteria, 30 of which related to psychosocial needs, and the remainder examined psychosocial interventions. Four main themes were derived from our analysis of psychosocial needs literature, as follows: the need for (1) emotional support, (2) acceptance, (3) direction, (4) equality in healthcare. 2 main themes emerged from analysis of psychosocial intervention literature, namely: psychosocial (1) capability, (2) assessment. Despite the evidence that graft health is strongly associated with psychosocial wellbeing, findings revealed a significant lack of literature investigating how best to meet psychosocial needs. Trends were observed amongst intervention studies, namely interventions of novel and non-evidenced based design, with the aim of improving medication adherence through organisational strategies and education. However, literature regarding psychosocial needs showed non-adherence to therapies was not simply a result of disorganisation or lack of understanding, but rather, was founded on a recipient’s idiosyncratic relationship with their prescribed therapies e.g., psychological, social or financial reasons for non-adherence.

Conclusions

Future research should be directed at investigating the efficacy of evidence-based interventions that empower the individual patient to overcome their specific barrier to an optimal relationship with their therapies.

Age-dependent Sex Differences in Graft Loss After Kidney Transplantation

BACKGROUND

Sex differences in kidney graft loss rates were reported in the United States. Whether these differences are present in other countries is unknown.

METHODS

We estimated the association between recipient sex and death-censored graft loss in patients of all ages recorded in the Scientific Registry of Transplant Recipients, Australia and New Zealand Dialysis and Transplant Registry, and Collaborative Transplant Study registries who received a first deceased donor kidney transplant (1988-2019). We used multivariable Cox regression models, accounting for the modifying effects of donor sex and recipient age, in each registry separately; results were combined using individual patient data meta-analysis.

RESULTS

We analyzed 438 585 patients. Young female patients 13-24 y old had the highest crude graft loss rates (female donor: 5.66; male donor: 5.50 per 100 person-years). Among young recipients of male donors, females showed higher graft loss risks than males (0-12 y: adjusted hazard ratio [aHR] 1.42, (95% confidence interval [CI], 1.17-1.73); 13-24 y: 1.24 (1.17-1.32); 25-44 y: 1.09 (1.06-1.13)). When the donor was female, there were no significant differences by recipient sex among those of age <45 y; however, the aHR for females was 0.93 (0.89-0.98) in 45-59 y-old and 0.89 (0.86-0.93) in ≥ 60 y-old recipients. Findings were similar for all 3 registries in most age intervals; statistically significant heterogeneity was seen only among 13-24-y-old recipients of a female donor (I2 = 71.5%, P = 0.03).

CONCLUSIONS

There is an association between recipient sex and kidney transplantation survival that is modified by recipient age and donor sex.

The causes and consequences of paediatric kidney disease on adult nephrology care

Adult nephrologists often look after patients who have been diagnosed with kidney disease in childhood. This does present unique challenges to the adult nephrologist, who may be unfamiliar with the underlying cause of kidney disease as well as the complications of chronic kidney disease (CKD) that may have accumulated during childhood. This review discusses common causes of childhood CKD, in particular congenital anomalies of the kidney and urinary tract (CAKUT), autosomal dominant tubulointerstitial kidney disease (ADTKD), polycystic kidney disease, hereditary stone disease, nephrotic syndrome and atypical haemolytic uraemic syndrome. The long-term consequences of childhood CKD, such as the cardiovascular consequences, cognition and education as well as bone health, nutrition and growth are also discussed.

How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond

Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.

Sex and Gender Differences in Kidney Transplantation

Sex and gender often are used interchangeably, but are two distinct entities, with sex being the biological attribute and gender including the social, psychological, and cultural aspects of one's identity. Kidney transplantation has been proven to be the best treatment for end-stage kidney disease, improving both quality of life and life-expectancy for most patients. However, gender disparities in access to and outcomes of kidney transplantation remain despite the plethora of evidence showing the advantages of kidney transplantation to our patients. Data have shown that women are less likely to be waitlisted for a kidney transplant and to receive a deceased donor or a living donor kidney. On the other hand, women are more likely than men to become living kidney donors. Although some state the latter is the result of the female gender to nurture and care for loved ones, others believe this observation is because women often are incompatible with their spouse or child because pregnancy is a strong sensitizing event, which stems from the biological rather than the social differences between the sexes. Influence of sex and gender is not limited to access to kidney transplantation, but rather exist in other areas of transplant medicine, such as the difference observed in transplant outcomes between the sexes, variability in immunosuppression metabolism, and even in more contemporary areas such as recent data showing sex-based differences in outcomes of kidney transplant recipients with coronavirus disease-2019, with males having an increased incidence of acute kidney injury and death.

Kidney Transplantation in Small Children: Association Between Body Weight and Outcome-A Report From the ESPN/ERA-EDTA Registry

BACKGROUND

Many centers accept a minimum body weight of 10 kg as threshold for kidney transplantation (Tx) in children. As solid evidence for clinical outcomes in multinational studies is lacking, we evaluated practices and outcomes in European children weighing below 10 kg at Tx.

METHODS

Data were obtained from the European Society of Paediatric Nephrology/European Renal Association and European Dialysis and Transplant Association Registry on all children who started kidney replacement therapy at <2.5 y of age and received a Tx between 2000 and 2016. Weight at Tx was categorized (<10 versus ≥10 kg) and Cox regression analysis was used to evaluate its association with graft survival.

RESULTS

One hundred of the 601 children received a Tx below a weight of 10 kg during the study period. Primary renal disease groups were equal, but Tx <10 kg patients had lower pre-Tx weight gain per year (0.2 versus 2.1 kg; P < 0.001) and had a higher preemptive Tx rate (23% versus 7%; P < 0.001). No differences were found for posttransplant estimated glomerular filtration rates trajectories (P = 0.23). The graft failure risk was higher in Tx <10 kg patients at 1 y (graft survival: 90% versus 95%; hazard ratio, 3.84; 95% confidence interval, 1.24-11.84), but not at 5 y (hazard ratio, 1.71; 95% confidence interval, 0.68-4.30).

CONCLUSIONS

Despite a lower 1-y graft survival rate, graft function, and survival at 5 y were identical in Tx <10 kg patients when compared with Tx ≥10 kg patients. Our results suggest that early transplantation should be offered to a carefully selected group of patients weighing <10 kg.

Age- and sex-mediated differences in T lymphocyte populations of kidney transplant recipients

BACKGROUND

Graft failure rates increase through childhood and adolescence, decline in adulthood, and are higher in female than male kidney transplant recipients (KTR) until middle age. We aimed to describe age- and sex-related differences in T-cell subsets among KTR to determine which differences may help to explain the differences in kidney graft failure rates.

METHODS

Effector T (Teff)-cell and regulatory T (Treg)-cell phenotypes in PBMCs from healthy controls and KTR, who were at least 1 year post-transplant with stable graft function under immunosuppression, were analyzed by flow cytometry. The effects of age, sex, and status (KTR or control) were analyzed using linear regressions.

RESULTS

We enrolled 20 male and 21 female KTR and 20 male and 20 female controls between 3 and 29 years of age. CD3+ T-cell frequencies were not associated with age or sex but were higher in KTR than controls. There were no differences in CD4+ and CD8+ frequencies. Th1 (IFNγ+ IL-4- IL-17A-) and Th17 (IL-17A+) frequencies within the CD4+ T-cell population were higher at older ages. The frequencies of FOXP3 + Helios + Treg cells in CD4+ CD25+ CD127- T cells were lower in females than males and in KTR than controls.

CONCLUSIONS

Increasing frequencies of Th1 and Th17 cells with increasing age mirrors the increasing graft failure rates from childhood to young adulthood. Importantly, sex differences in frequencies of circulating Treg cells may suggest a role in the sex differences in graft failure rates.

Long-Term Care of the Pediatric Kidney Transplant Recipient

Pediatric kidney transplant recipients are distinguished from adult recipients by the need for many decades of graft function, the potential effect of CKD on neurodevelopment, and the changing immune environment of a developing human. The entire life of an individual who receives a transplant as a child is colored by their status as a transplant recipient. Not only must these young recipients negotiate all of the usual challenges of emerging adulthood (transition from school to work, romantic relationships, achieving independence from parents), but they must learn to manage a life-threatening medical condition independently. Regardless of the age at transplantation, graft failure rates are higher during adolescence and young adulthood than at any other age. All pediatric transplant recipients must pass through this high-risk period. Factors contributing to the high graft failure rates in this period include poor adherence to treatment, potentially exacerbated by the transfer of care from pediatric- to adult-oriented care providers, and perhaps an increased potency of the immune response. We describe the characteristics of pediatric kidney transplant recipients, particularly those factors that may influence their care throughout their lives. We also discuss the risks associated with the transition from pediatric- to adult-oriented care and provide some suggestions to optimize the transition to adult-oriented transplant care and long-term outcomes.

Detecting, preventing, and treating non-adherence to immunosuppression after kidney transplantation

Medication non-adherence (MNA) is a major issue in kidney transplantation and it is associated with increased risk of rejection, allograft loss, patients’ death and higher healthcare costs. Despite its crucial importance, it is still unclear what are the best strategies to diagnose, prevent and treat MNA. MNA can be intentional (deliberate refusal to take the medication as prescribed) or unintentional (non-deliberate missing the prescribed medication). Its diagnosis may rely on direct methods, aiming at measuring drug ingestions, or indirect methods that analyse the habits of patients to adhere to correct drug dose (taking adherence) and interval (time adherence). Identifying individual risk factors for MNA may provide the basis for a personalized approach to the treatment of MNA. Randomized control trials performed so far have tested a combination of strategies, such as enhancing medication adherence through the commitment of healthcare personnel involved in drug distribution, the use of electronic reminders, therapy simplification or various multidisciplinary approaches to maximize the correction of individual risk factors. Although most of these approaches reduced MNA in the short-term, the long-term effects on MNA and, more importantly, on clinical outcomes remain unclear. In this review, we provide a critical appraisal of traditional and newer methods for detecting, preventing and treating non-adherence to immunosuppression after kidney transplantation from the perspective of the practising physician.

Optimal Sequencing of Deceased Donor and Live Donor Kidney Transplant Among Pediatric Patients With Kidney Failure

IMPORTANCE

In the US, live donor (LD) kidney transplant rates have decreased in pediatric recipients. Pediatric patients with kidney failure will likely need more than 1 kidney transplant during their lifetime, but the optimal sequence of transplant (ie, deceased donor [DD] followed by LD or vice versa) is not known.

OBJECTIVE

To determine whether pediatric recipients should first receive a DD allograft followed by an LD allograft (DD-LD sequence) or an LD allograft followed by a DD allograft (LD-DD sequence).

DESIGN, SETTING, AND PARTICIPANTS

This decision analytical model examined US pediatric patients with kidney failure included in the US Renal Data System 2019 Report who were waiting for a kidney transplant, received a transplant, or experienced graft failure.

INTERVENTIONS

Kidney transplant sequences of LD-DD vs DD-LD.

MAIN OUTCOMES AND MEASURES

Difference in projected life-years between the 2 sequence options.

RESULTS

Among patients included in the analysis, the LD-DD sequence provided more net life-years in those 5 years of age (1.82 [95% CI, 0.87-2.77]) and 20 years of age (2.23 [95% CI, 1.31-3.15]) compared with the DD-LD sequence. The net outcomes in patients 10 years of age (0.36 [95% CI, -0.51 to 1.23] additional life-years) and 15 years of age (0.64 [95% CI, -0.15 to 1.39] additional life-years) were not significantly different. However, for those aged 10 years, an LD-DD sequence was favored if eligibility for a second transplant was low (2.09 [95% CI, 1.20-2.98] additional life-years) or if the LD was no longer available (2.32 [95% CI, 1.52-3.12] additional life-years). For those aged 15 years, the LD-DD sequence was favored if the eligibility for a second transplant was low (1.84 [95% CI, 0.96-2.72] additional life-years) or if the LD was no longer available (2.49 [95% CI, 1.77-3.27] additional life-years). Access to multiple DD transplants did not compensate for missing the LD opportunity.

CONCLUSIONS AND RELEVANCE

These findings suggest that the decreased use of LD kidney transplants in pediatric recipients during the past 2 decades should be scrutinized. Given the uncertainty of future recipient eligibility for retransplant and future availability of an LD transplant, the LD-DD sequence is likely the better option. This strategy of an LD transplant first would not only benefit pediatric recipients but allow DD kidneys to be used by others who do not have an LD option.

Biomarkers of alloimmune events in pediatric kidney transplantation

Alloimmune events such as the development of de novo donor-specific antibody (dnDSA), T cell-mediated rejection (TCMR), and antibody-mediated rejection (ABMR) are the primary contributors to kidney transplant failure in children. For decades, a creatinine-based estimated glomerular filtration rate (eGFR) has been the non-invasive gold standard biomarker for detecting clinically significant alloimmune events, but it suffers from low sensitivity and specificity, especially in smaller children and older allografts. Many clinically "stable" children (based on creatinine) will have alloimmune events known as "subclinical acute rejection" (based on biopsy) that merely reflect the inadequacy of creatinine-based estimates for alloimmune injury rather than a distinct phenotype from clinical rejection with allograft dysfunction. The poor biomarker performance of creatinine leads to many unnecessary surveillance and for-cause biopsies that could be avoided by integrating non-invasive biomarkers with superior sensitivity and specificity into current clinical paradigms. In this review article, we will present and appraise the current state-of-the-art in monitoring for alloimmune events in pediatric kidney transplantation. We will first discuss the current clinical standards for assessing the presence of alloimmune injury and predicting long-term outcomes. We will review principles of biomarker medicine and the application of comprehensive metrics to assess the performance of a given biomarker against the current gold standard. We will then highlight novel blood- and urine-based biomarkers (with special emphasis on pediatric biomarker studies) that have shown superior diagnostic and prognostic performance to the current clinical standards including creatinine-based eGFR. Finally, we will review some of the barriers to translating this research and implementing emerging biomarkers into common clinical practice, and present a transformative approach to using multiple biomarker platforms at different times to optimize the detection and management of critical alloimmune events in pediatric kidney transplant recipients.

Care processes and structures associated with higher medication adherence in adolescent and young adult transplant recipients

BACKGROUND

We aimed to identify care processes and structures that were independently associated with higher medication adherence among young transplant recipients.

METHODS

We conducted a prospective, observational cohort study of 270 prevalent kidney, liver, and heart transplant recipients 14-25 years old. Patients were ≥3 months post-transplant, ≥2 months post-discharge, and followed in one of 14 pediatric or 14 adult transplant programs in Canada. Patients were enrolled between June 2015 and March 2018 and followed for 6 months. Adherence was assessed at baseline, 3, and 6 months using the BAASIS^© self-report tool. Patients were classified as adherent if no doses were missed in the prior 4 weeks. Transplant program directors and nurses completed questionnaires regarding care organization and processes.

RESULTS

Of the 270 participants, 99 were followed in pediatric programs and 171 in adult programs. Median age was 20.3 years, and median time since transplant was 5 years. At baseline, 71.5% were adherent. Multivariable mixed effects logistic regression models with program as a random effect identified two program-level factors as independently associated with better adherence: minimum number of prescribed blood draws per year for those >3 years post-transplant (per 1 additional) (OR 1.12 [95% CI 1.00, 1.26]; p = .047), and average time nurses spend with patients in clinic (per 5 additional minutes) (OR 1.15 [1.03, 1.29]; p = .017).

CONCLUSION

Program-level factors including protocols with a greater frequency of routine blood testing and more nurse time with patients were associated with better medication adherence. This suggests that interventions at the program level may support better adherence.

Not all eplet mismatches are created equal - A cohort study illustrating implications to long-term graft outcomes

We assessed implications of various eplet-compatibility strategies to death-censored graft failure (DCGF), defined as return to dialysis or re-transplantation, in a base-case scenario from the Scientific Registry of Transplant Recipients. To inform personalized care, we evaluated how recipient, donor, and transplant characteristics affect DCGF by ascending categories of eplet mismatches (EMM), and derived adjusted hazard ratios (HR). The base-case analysis demonstrated 15-year estimated survival probabilities of 77.1%, 75.4%, 73.6%, 72.2%, 74.9%, and 73.5% for the lowest EMM categories (complete epitype: 0-19, antibody-verified (AbVer) epitype and class II eplets: 0-9, class II AbVer eplets: 0-4, 55 high-risk eplets associated with DCGF: 0-3, and subset of 15 high-risk eplets validated in an independent subcohort: 0 EMM, respectively). Beyond the lowest EMM categories, the Epi15 strategy allowed better differentiation of change in DCGF risk per EMM, with additional 5.2%, 3.9% and 4.1% decrease in estimated graft survival for each additional EMM (1, 2, and ≥ 3, respectively). Recipients < 25 years, donors > 55 years, and immunosuppression regimens excluding calcineurin inhibitors and steroids, demonstrated higher HR for DCGF. High-risk EMM allowed better differentiation between DCGF probabilities per EMM, suggesting that recipients at higher risk for graft failure could benefit most from allocation schemes ensuring compatibility on these eplets.

Re-transplantation in pediatric patients with failure of primary transplant due to recurrent focal segmental glomerulosclerosis: A pediatric nephrology research consortium study

INTRODUCTION

Recurrent focal and segmental glomerulosclerosis (FSGS) in kidney transplant recipients is associated with lower graft survival and increased morbidity. There are limited data to guide the decision to re-transplant patients with transplant failure due to FSGS recurrence. We aimed to evaluate outcomes in patients re-transplanted after having initial graft failure due to recurrent FSGS and to study physician attitudes and practice patterns.

METHODS

Retrospective data from 10 centers were collected on 20 patients transplanted between January 1997 and September 2018. A survey was sent to nephrologist members of the Pediatric Nephrology Research Consortium.

RESULTS

Mean patient age (years) was 9.8 ± 4.8 at first transplant and 15.9 ± 4.9 at re-transplantation. Pre-transplant plasmapheresis was used in 1 (5.3%) primary transplant vs. 7 (38.9%) re-transplants (p = .03). Nephrotic syndrome recurred in 14 patients (70%) after re-transplantation and was severe in 21.1% vs. 64.7% after first transplant (p = .04). Graft survival was significantly higher in the second transplant (p .009) with 70% having functioning grafts at a median of 25.2 months. Thirty-one physicians from 21 centers completed the survey, 94% indicated they would re-transplant such patients, 44.4% preferred a minimum waiting period before re-transplantation, 36.4% preferred living donors, and 22.2% indicated having protocols for re-transplantation at their centers.

CONCLUSIONS

Consideration for re-transplantation is high among pediatric nephrologists. Pre-transplant plasmapheresis was more frequent in re-transplanted patients. Nephrotic syndrome recurrence was less severe, with better graft survival. More data and a larger population are necessary to further evaluate outcome determinants and best practices in this special population.

Mitigating Risk Associated With the Transition From Pediatric to Adult Kidney Transplant Care: Strategies to Promote Success

Young adult kidney transplant recipients experience poorer outcomes. Specifically worse allograft survival has been reported in the United States and worldwide. Pediatric to adult transition-related research has focused predominantly on medication nonadherence. However, the cause of worse graft outcomes in young adults is likely due to a multitude of complex factors. Consensus guidelines were issued to guide pediatric and adult transplant teams during the transition process. To what extent these transition guidelines are utilized and their impact on improving outcomes for young adult patients is unclear. The consensus guidelines serve as a useful resource, but investigation of the potential barriers to putting these transition guidelines into practice is lacking. One must consider the unique needs of medically complex patients, financial disincentives to transition programs, paucity of evidence-based data to support individual aspects of a transition program and their impact on transition success, and absence of strategies to address health care disparities, all of which can have a multiplicative risk for this population. Key transition research is needed to yield evidence-based data to support transition practices that are successful and truly improve outcomes in this high-risk transplant population. It will also allow better stewardship of transplant organs by optimizing outcomes and allograft longevity.

Differences in Heart Graft Survival by Recipient Sex

Supplemental Digital Content is available in the text.

We aimed to characterize patterns of differences in heart graft failure rates by recipient sex, accounting for modifying effects of donor sex and recipient age.