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Tirtayasa PMW, Situmorang GR, Duarsa GWK, Mahadita GW, Ghinorawa T, Myh E, Nugroho EA, Kandarini Y, Rodjani A, Rasyid N. Risk factors of delayed graft function following living donor kidney transplantation: A meta-analysis. Transpl Immunol 2024; 86:102094. [PMID: 39053613 DOI: 10.1016/j.trim.2024.102094] [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: 11/16/2023] [Revised: 07/13/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Delayed graft function (DGF) is a common condition that necessitates dialysis during the first week after transplantation. Although DGF rarely occurs following living-donor kidney transplantation (LDKT), it may eventually lead to acute or chronic graft rejection. This study aimed to assess the risk factors for DGF in patients who underwent LDKT. METHODS A systematic review and meta-analysis of studies published before August 2022 was conducted using the PubMed, Science Direct, Cochrane, and Directory of Open Access Journal (DOAJ) databases. The review included studies that assessed the incidence of DGF following LDKT, and examined its risk factors, while excluding studies involving deceased donors. Potential risk factors were analyzed using pooled mean differences or odds ratios with 95% confidence intervals (CIs). Review Manager 5.3 was used for the meta-analysis. RESULTS Among the 13 included studies, 3685 cases of DGF were identified in a total of 113,261 patients (3.25%). Potential risk factors for DGF following LDKT were examined across several aspects, including donor, recipient, donor/recipient relationship, and immunological and intraoperative factors. The identified risk factors included older donors (P = 0.07), male recipients (P < 0.0001), higher recipient body mass index (BMI) (P < 0.0001), non-white recipients (P < 0.0001), pre-existing diabetes (P < 0.0001), pre-existing hypertension (P = 0.01), history of dialysis (P < 0.0001), re-transplantation (P = 0.004), unrelated donor/recipient (P = 0.02), ABO incompatibility (P < 0.0001), higher panel reactive antibody (PRA) levels (P < 0.0001), utilization of right kidney (P < 0.0001), and longer cold ischemia time (CIT) (P = 0.004). CONCLUSION Several factors related to the donor, recipient, donor/recipient relationship, and immunological and intraoperative aspects were identified as potential risk factors for the development of DGF following LDKT. Addressing and optimizing these factors may improve the long-term outcomes of LDKT.
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Affiliation(s)
- Pande Made Wisnu Tirtayasa
- Department of Urology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Teaching Hospital, Bali, Indonesia.
| | - Gerhard Reinaldi Situmorang
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
| | - Gede Wirya Kusuma Duarsa
- Department of Urology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G. Ngoerah General Hospital, Bali, Indonesia
| | - Gede Wira Mahadita
- Department of Nephrology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G. Ngoerah General Hospital, Bali, Indonesia
| | - Tanaya Ghinorawa
- Department of Urology, Faculty of Medicine, Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Etriyel Myh
- Department of Urology, Faculty of Medicine, Universitas Andalas, Dr. M.Djamil General Hospital, Padang, Indonesia
| | - Eriawan Agung Nugroho
- Department of Urology, Faculty of Medicine, Universitas Diponegoro, Dr. Kariadi General Hospital, Semarang, Indonesia
| | - Yenny Kandarini
- Department of Nephrology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G. Ngoerah General Hospital, Bali, Indonesia
| | - Arry Rodjani
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
| | - Nur Rasyid
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia
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Ostermann M, Auzinger G, Grocott M, Morton-Bailey V, Raphael J, Shaw AD, Zarbock A. Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary PeriOperative Quality Initiative. Br J Anaesth 2024:S0007-0912(24)00506-3. [PMID: 39341776 DOI: 10.1016/j.bja.2024.07.038] [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: 11/25/2023] [Revised: 07/11/2024] [Accepted: 07/31/2024] [Indexed: 10/01/2024] Open
Abstract
Fluid therapy is an integral component of perioperative management. In light of emerging evidence in this area, the Perioperative Quality Initiative (POQI) convened an international multiprofessional expert meeting to generate evidence-based consensus recommendations for fluid management in patients undergoing surgery. This article provides a summary of the recommendations for perioperative fluid management of surgical patients from the preoperative period until hospital discharge and for all types of elective and emergency surgery, apart from burn injuries and head and neck surgery. Where evidence was lacking, recommendations for future research were generated. Specific recommendations are made for fluid management in elective major noncardiac surgery, cardiopulmonary bypass, thoracic surgery, neurosurgery, minor noncardiac surgery under general anaesthesia, and critical illness. There are ongoing gaps in knowledge resulting in variation in practice and some disagreement with our consensus recommendations. Perioperative fluid management should be individualised, taking into account the type of surgery and important patient factors, including intravascular volume status and acute and chronic comorbidities. Recommendations are made for further research in perioperative fluid management to address important gaps.
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Affiliation(s)
- Marlies Ostermann
- Department of Intensive Care, Guy's & St Thomas' Hospital, London, UK; King's College London, Faculty of Life Sciences & Medicine, London, UK.
| | - Georg Auzinger
- Department of Critical Care, Cleveland Clinic London, London, UK; King's College London, Faculty of Life Sciences & Medicine, London, UK
| | - Michael Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, UK
| | | | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany
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Ahlmark A, Sallinen V, Eerola V, Lempinen M, Helanterä I. Characteristics of Delayed Graft Function and Long-Term Outcomes After Kidney Transplantation From Brain-Dead Donors: A Single-Center and Multicenter Registry-Based Retrospective Study. Transpl Int 2024; 37:12309. [PMID: 38495816 PMCID: PMC10942003 DOI: 10.3389/ti.2024.12309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/19/2024] [Indexed: 03/19/2024]
Abstract
Delayed graft function (DGF) after kidney transplantation is common and associated with worse graft outcomes. However, little is known about factors affecting graft survival post-DGF. We studied the association of cold ischemia time (CIT) and Kidney Donor Profile Index (KDPI) with the long-term outcomes of deceased brain-dead donor kidneys with and without DGF. Data from Finland (n = 2,637) and from the US Scientific Registry of Transplant Recipients (SRTR) registry (n = 61,405) was used. The association of KDPI and CIT with the graft survival of kidneys with or without DGF was studied using multivariable models. 849 (32%) kidneys had DGF in the Finnish cohort. DGF and KDPI were independent risk factors for graft loss, [HR 1.32 (95% CI 1.14-1.53), p < 0.001, and HR 1.01 per one point (95% CI 1.01-1.01), p < 0.001, respectively], but CIT was not, [HR 1.00 per CIT hour (95% CI 0.99-1.02), p = 0.84]. The association of DGF remained similar regardless of CIT and KDPI. The US cohort had similar results, but the association of DGF was stronger with higher KDPI. In conclusion, DGF and KDPI, but not CIT, are independently associated with graft survival. The association of DGF with worse graft survival is consistent across different CITs but stronger among marginal donors.
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Affiliation(s)
- Amanda Ahlmark
- Department of Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Christianson A, Kaul H, Parsikia A, Chandolias N, Khanmoradi K, Zaki R. Delayed Graft Function in Kidney Retransplantation: United Network for Organ Sharing Data With Linked Primary and Retransplant. J Surg Res 2023; 292:289-296. [PMID: 37678109 DOI: 10.1016/j.jss.2023.07.033] [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: 12/01/2022] [Revised: 06/21/2023] [Accepted: 07/14/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION There are several articles exploring the risk factors for primary delayed graft function (DGF). However, current literature does not include many resources on the risk factors for DGF when it is a recipient's second kidney transplant or look at short-term graft and patient survival of DGF retransplants. METHODS United Network for Organ Sharing data from January 2008 to June 2021 were analyzed. Pancreas transplants, multi-organ transplants, and lost to follow-up transplants were excluded. Second transplant patients with DGF were identified. Multivariate logistic regression models based on the primary and second transplant characteristics were created. Survival analysis was performed with Kaplan-Meier methodology and assessed with log-rank test. RESULTS A total of 2964 second kidney transplants were identified. Rate of DGF in the second transplant was 28.4% (843/2964) and 49.2% of them had a prior DGF in their first transplant (P < 0.001). Multivariate analysis confirmed that occurrence of DGF (odds ratio [OR] 1.5, P < 0.001) and graft loss due to acute rejection (OR 1.2, P < 0.005) in the primary transplant were predictors of reappearing DGF in the second transplant. Dialysis at transplant was the greatest risk factor from the second transplant (OR 3.539, P < 0.001). There was a decreased graft survival after 12 mo (77% versus 49% with log t-test <0.001) in the second transplant. However, DGF was not significantly associated with patient survival. CONCLUSIONS This study shows the interaction between primary and second transplant in developing DGF. Survival analysis shows lower graft survival for retransplants in the case of DGF. This study opens the possibility of identifying additional risk factors for patients undergoing retransplant surgeries.
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Affiliation(s)
- Alex Christianson
- Philadelphia College of Osteopathic Medicine - Georgia Campus, Suwanee, Georgia
| | - Hitesh Kaul
- Department of Surgery, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Afshin Parsikia
- Department of Surgery, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Nikolaos Chandolias
- Department of Surgery, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Kamran Khanmoradi
- Department of Surgery, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Radi Zaki
- Department of Surgery, Jefferson Einstein Hospital, Philadelphia, Pennsylvania.
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Collins MG, Fahim MA, Pascoe EM, Hawley CM, Johnson DW, Varghese J, Hickey LE, Clayton PA, Dansie KB, McConnochie RC, Vergara LA, Kiriwandeniya C, Reidlinger D, Mount PF, Weinberg L, McArthur CJ, Coates PT, Endre ZH, Goodman D, Howard K, Howell M, Jamboti JS, Kanellis J, Laurence JM, Lim WH, McTaggart SJ, O'Connell PJ, Pilmore HL, Wong G, Chadban SJ. Balanced crystalloid solution versus saline in deceased donor kidney transplantation (BEST-Fluids): a pragmatic, double-blind, randomised, controlled trial. Lancet 2023; 402:105-117. [PMID: 37343576 DOI: 10.1016/s0140-6736(23)00642-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/10/2023] [Accepted: 03/23/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Delayed graft function (DGF) is a major adverse complication of deceased donor kidney transplantation. Intravenous fluids are routinely given to patients receiving a transplant to maintain intravascular volume and optimise graft function. Saline (0·9% sodium chloride) is widely used but might increase the risk of DGF due to its high chloride content. We aimed to test our hypothesis that using a balanced low-chloride crystalloid solution (Plasma-Lyte 148) instead of saline would reduce the incidence of DGF. METHODS BEST-Fluids was a pragmatic, registry-embedded, multicentre, double-blind, randomised, controlled trial at 16 hospitals in Australia and New Zealand. Adults and children of any age receiving a deceased donor kidney transplant were eligible; those receiving a multi-organ transplant or weighing less than 20 kg were excluded. Participants were randomly assigned (1:1) using an adaptive minimisation algorithm to intravenous balanced crystalloid solution (Plasma-Lyte 148) or saline during surgery and up until 48 h after transplantation. Trial fluids were supplied in identical bags and clinicians determined the fluid volume, rate, and time of discontinuation. The primary outcome was DGF, defined as receiving dialysis within 7 days after transplantation. All participants who consented and received a transplant were included in the intention-to-treat analysis of the primary outcome. Safety was analysed in all randomly assigned eligible participants who commenced surgery and received trial fluids, whether or not they received a transplant. This study is registered with Australian New Zealand Clinical Trials Registry, (ACTRN12617000358347), and ClinicalTrials.gov (NCT03829488). FINDINGS Between Jan 26, 2018, and Aug 10, 2020, 808 participants were randomly assigned to balanced crystalloid (n=404) or saline (n=404) and received a transplant (512 [63%] were male and 296 [37%] were female). One participant in the saline group withdrew before 7 days and was excluded, leaving 404 participants in the balanced crystalloid group and 403 in the saline group that were included in the primary analysis. DGF occurred in 121 (30%) of 404 participants in the balanced crystalloid group versus 160 (40%) of 403 in the saline group (adjusted relative risk 0·74 [95% CI 0·66 to 0·84; p<0·0001]; adjusted risk difference 10·1% [95% CI 3·5 to 16·6]). In the safety analysis, numbers of investigator-reported serious adverse events were similar in both groups, being reported in three (<1%) of 406 participants in the balanced crystalloid group versus five (1%) of 409 participants in the saline group (adjusted risk difference -0·5%, 95% CI -1·8 to 0·9; p=0·48). INTERPRETATION Among patients receiving a deceased donor kidney transplant, intravenous fluid therapy with balanced crystalloid solution reduced the incidence of DGF compared with saline. Balanced crystalloid solution should be the standard-of-care intravenous fluid used in deceased donor kidney transplantation. FUNDING Medical Research Future Fund and National Health and Medical Research Council (Australia), Health Research Council (New Zealand), Royal Australasian College of Physicians, and Baxter.
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Affiliation(s)
- Michael G Collins
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia; Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia.
| | - Magid A Fahim
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia; Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia; Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia; Translational Research Institute, Brisbane, QLD, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia; Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia; Translational Research Institute, Brisbane, QLD, Australia
| | - Julie Varghese
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - Laura E Hickey
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - Philip A Clayton
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Kathryn B Dansie
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | | | - Liza A Vergara
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - Charani Kiriwandeniya
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, QLD, Australia
| | - Peter F Mount
- Department of Nephrology, Austin Health, Melbourne, VIC, Australia; Department of Medicine (Austin), University of Melbourne, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - P Toby Coates
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Hospital, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - David Goodman
- Department of Nephrology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, NSW, Australia
| | - Martin Howell
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, NSW, Australia
| | - Jagadish S Jamboti
- Department of Nephrology and Renal Transplantation, Fiona Stanley Hospital, Murdoch, WA, Australia; School of Medicine, University of Western Australia, Perth, WA, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health, Melbourne, VIC, Australia; Centre for Inflammatory Diseases, Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Jerome M Laurence
- Institute of Academic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Wai H Lim
- School of Medicine, University of Western Australia, Perth, WA, Australia; Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steven J McTaggart
- Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Philip J O'Connell
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Renal and Transplantation Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Helen L Pilmore
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Germaine Wong
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia; Department of Renal and Transplantation Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Steven J Chadban
- Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia; Department of Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Sandal S, Cantarovich M, Cardinal H, Ramankumar AV, Senecal L, Collette S, Saw CL, Paraskevas S, Tchervenkov J. Predicting Long-term Outcomes in Deceased Donor Kidney Transplant Recipients Using Three Short-term Graft Characteristics. KIDNEY360 2023; 4:e809-e816. [PMID: 37211638 PMCID: PMC10371380 DOI: 10.34067/kid.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/28/2023] [Indexed: 05/23/2023]
Abstract
Key Points Delayed graft function is not an ideal measure of graft function, yet is used to assess risk in kidney transplantation. We propose a model that combines it with two other measures of 90-day graft function to identify recipients at incremental risk of inferior long-term outcomes. Background Delayed graft function (DGF) in kidney transplant recipients is used to determine graft prognosis, make organ utilization decisions, and as an important end point in clinical trials. However, DGF is not an ideal measure of graft function. We aimed to develop and validate a model that provides incremental risk assessment for inferior patient and graft outcomes. Methods We included adult kidney-only deceased donor transplant recipients from 1996 to 2016. In addition to DGF, two short-term measures were used to assess risk: renal function recovery <100% (attaining half the donor's eGFR) and recipient's 90-day eGFR <30. Recipients were at no, low, moderate, or high risk if they met zero, one, two, or all criteria, respectively. Cox proportional hazard models were used to assess the independent relationship between exposure and death-censored graft failure (DCGF) and mortality. Results Of the 792 eligible recipients, 24.5% experienced DGF, 40.5% had renal function recovery <100%, and 6.9% had eGFR <30. Over a median follow-up of 7.3 years, the rate of DCGF was 18.7% and mortality was 25.1%. When compared with recipients at no risk, those at low, moderate, and high risk were noted to have an increase in risk of DCGF (adjusted hazard ratio [aHR], 1.53; 95% confidence interval [CI], 1.03 to 2.27; aHR, 2.84; 95% CI, 1.68 to 4.79; aHR, 15.46; 95% CI, 8.04 to 29.71) and mortality (aHR, 1.16; 95% CI, 0.84 to 1.58; aHR, 1.85; 95% CI, 1.13 to 3.07; aHR, 2.66; 95% CI, 1.19 to 5.97). When using a hierarchical approach, each additional exposure predicted the risk of DCGF better than DGF alone and 100 random bootstrap replications supported the internal validity of the risk model. In an external validation cohort deemed to be at lower risk of DCGF, similar nonsignificant trends were noted. Conclusion We propose a risk model that provides an incremental assessment of recipients at higher risk of adverse long-term outcomes than DGF alone. This can help advance the field of risk assessment in transplantation and inform therapeutic decision making in patients at the highest spectrum of inferior outcomes.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Heloise Cardinal
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | | | - Lynne Senecal
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Suzon Collette
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Chee Long Saw
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Hematology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Steven Paraskevas
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean Tchervenkov
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Multiorgan Transplant Program, Departments of Medicine and Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Quinino RM, Agena F, Modelli de Andrade LG, Furtado M, Chiavegatto Filho ADP, David-Neto E. A Machine Learning Prediction Model for Immediate Graft Function After Deceased Donor Kidney Transplantation. Transplantation 2023; 107:1380-1389. [PMID: 36872507 DOI: 10.1097/tp.0000000000004510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND After kidney transplantation (KTx), the graft can evolve from excellent immediate graft function (IGF) to total absence of function requiring dialysis. Recipients with IGF do not seem to benefit from using machine perfusion, an expensive procedure, in the long term when compared with cold storage. This study proposes to develop a prediction model for IGF in KTx deceased donor patients using machine learning algorithms. METHODS Unsensitized recipients who received their first KTx deceased donor between January 1, 2010, and December 31, 2019, were classified according to the conduct of renal function after transplantation. Variables related to the donor, recipient, kidney preservation, and immunology were used. The patients were randomly divided into 2 groups: 70% were assigned to the training and 30% to the test group. Popular machine learning algorithms were used: eXtreme Gradient Boosting (XGBoost), Light Gradient Boosting Machine, Gradient Boosting classifier, Logistic Regression, CatBoost classifier, AdaBoost classifier, and Random Forest classifier. Comparative performance analysis on the test dataset was performed using the results of the AUC values, sensitivity, specificity, positive predictive value, negative predictive value, and F1 score. RESULTS Of the 859 patients, 21.7% (n = 186) had IGF. The best predictive performance resulted from the eXtreme Gradient Boosting model (AUC, 0.78; 95% CI, 0.71-0.84; sensitivity, 0.64; specificity, 0.78). Five variables with the highest predictive value were identified. CONCLUSIONS Our results indicated the possibility of creating a model for the prediction of IGF, enhancing the selection of patients who would benefit from an expensive treatment, as in the case of machine perfusion preservation.
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Affiliation(s)
- Raquel M Quinino
- Renal Transplant Service, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Fabiana Agena
- Renal Transplant Service, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Mariane Furtado
- Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
| | | | - Elias David-Neto
- Renal Transplant Service, Hospital das Clinicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Song J, Yao Y, He Y, Lin S, Pan S, Zhong M. Contrast-Enhanced Ultrasonography Value for Early Prediction of Delayed Graft Function in Renal Transplantation Patients. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:201-210. [PMID: 35603734 DOI: 10.1002/jum.16010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/11/2022] [Accepted: 05/03/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Delayed graft function (DGF) is a common early complication after kidney transplantation. The aim of the present study was to evaluate the value of contrast-enhanced ultrasonography (CEUS) in the early prediction of DGF after kidney transplantation. METHODS A total of 89 renal transplant recipients were retrospectively enrolled and divided into DGF group or normal graft function (NGF) group according to the allograft function. Conventional Doppler ultrasound and CEUS examination data on the first postoperative day were collected and analyzed. RESULTS The resistive indices of segmental and interlobar artery in the DGF group were significantly higher than those in the NGF group (0.71 ± 0.17 versus 0.63 ± 0.08, P = .006; 0.70 ± 0.16 versus 0.62 ± 0.08, P = .004, respectively). The patients experiencing DGF had significantly lower PI-c (14.7 dB ± 6.1 dB versus 18.5 dB ± 3.3 dB, P = .001) and smaller AUC-c (779.8 ± 375.8 dB·seconds versus 991.0 ± 211.7 dB·seconds, P = .003), as well as significantly lower PI-m (12.6 dB ± 5.9 dB versus 15.9 dB ± 3.9 dB, P = .006), shorter MTT-m (30.7 ± 9.4 seconds versus 36.3 ± 7.1 seconds, P = .01), and smaller AUC-m (P = .007). Multivariate analysis demonstrated that PI-c, AUC-c, and MTT-m were independent risk factors for DGF. The area under the receiver operating characteristic curve values of the combined predicted value (PI-c + MTT-m, PI-c + AUC-c + MTT-m) of DGF incidence were bigger than that of PI-c, AUC-c, or MTT-m. CONCLUSIONS CEUS parameters of the cortex and medulla have a good value for an early prediction of DGF after renal transplantation.
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Affiliation(s)
- Jieqiong Song
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yao Yao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yizhou He
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shilong Lin
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Simeng Pan
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
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9
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Zhang Y, Liu R, Zhao X, Ou Z, Wang S, Wang D, Huang K, Pan S, Wu Y. Dynamic changes of neutrophil-to-lymphocyte ratio in brain-dead donors and delayed graft function in kidney transplant recipients. Ren Fail 2022; 44:1897-1903. [PMID: 36346017 PMCID: PMC9648373 DOI: 10.1080/0886022x.2022.2141646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives Neutrophil-to-lymphocyte ratio (NLR) is a simple parameter implying the inflammatory status. We aimed to explore the association of brain-dead donor NLR change with delayed graft function (DGF) in kidney transplant recipients. Methods We retrospectively analyzed the data on 102 adult brain-dead donors and their corresponding 199 kidney transplant recipients (2018 − 2021). We calculated ΔNLR by subtracting the NLR before evaluating brain death from the preoperative NLR. Increasing donor NLR was defined as ΔNLR > 0. Results Forty-four (22%) recipients developed DGF after transplantation. Increasing donor NLR was significantly associated with the development of DGF in recipients (OR 2.8, 95% CI 1.2 − 6.6; p = .018), and remained significant (OR 2.6, 95% CI 1.0 − 6.4; p = .040) after adjustment of confounders including BMI, hypertension, diabetes, and the occurrence of cardiac arrest. When acute kidney injury (AKI) was included in the multivariable analysis, increasing donor NLR lost its independent correlation with DGF, while AKI remained an independent risk factor of recipient DGF (OR 4.5, 95% CI 2.7 − 7.6; p < .001). The area under the curve of combined increasing NLR and AKI in donors (0.873) for predicting DGF was superior to increasing donor NLR (0.625, p = .015) and AKI alone (0.859, p < .001). Conclusions Dynamic changes of donor NLR are promising in predicting post-transplant DGF. It will assist clinicians in the early recognition and management of renal graft dysfunction. Validation of this new biomarker in a large study is needed.
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Affiliation(s)
- Yongfang Zhang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Rumin Liu
- Department of Kidney Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaolin Zhao
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiyu Ou
- Department of Kidney Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengnan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Dongmei Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kaibin Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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10
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Jadlowiec CC, Frasco P, Macdonough E, Wagler J, Das D, Budhiraja P, Mathur AK, Katariya N, Reddy K, Khamash H, Heilman R. Association of DGF and Early Readmissions on Outcomes Following Kidney Transplantation. Transpl Int 2022; 35:10849. [PMID: 36620699 PMCID: PMC9817097 DOI: 10.3389/ti.2022.10849] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Concerns regarding outcomes and early resource utilization are potential deterrents to broader use of kidneys at risk for delayed graft function (DGF). We assessed outcomes specific to kidneys with DGF that required early readmission following transplant. Three groups were identified: 1) recipients with DGF not requiring readmission, 2) recipients with DGF having an isolated readmission, and 3) recipients with DGF requiring ≥2 readmissions. Most recipients either required a single readmission (26.8%, n = 247) or no readmission (56.1%, n = 517); 17.1% (n = 158), had ≥2 readmissions. Recipients requiring ≥2 readmissions were likely to be diabetic (53.8%, p = 0.04) and have longer dialysis vintage (p = 0.01). Duration of DGF was longer with increasing number of readmissions (p < 0.001). There were no differences in patient survival for those with DGF and 0, 1 and ≥2 readmissions (p = 0.13). Graft survival, however, was lower for those with ≥2 readmissions (p < 0.0001). This remained true when accounting for death-censored graft loss (p = 0.0012). Additional subgroup analysis was performed on mate kidneys with and without DGF and mate kidneys, both with DGF, with and without readmissions. For these subgroups, there were no differences in patient or graft survival. As a whole, patients with DGF have excellent outcomes, however, patients with DGF requiring ≥2 readmissions have lower graft survival. A better understanding of recipient variables contributing to multiple readmissions may allow for improvements in the utilization of DGF at-risk kidneys.
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Affiliation(s)
- Caroline C. Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, United States,*Correspondence: Caroline C. Jadlowiec,
| | - Peter Frasco
- Division of Anesthesiology, Mayo Clinic, Phoenix, AZ, United States
| | - Elizabeth Macdonough
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, United States
| | - Josiah Wagler
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, United States
| | - Devika Das
- Division of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Pooja Budhiraja
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
| | - Amit K. Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, United States
| | - Nitin Katariya
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, United States
| | - Kunam Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, United States
| | - Hasan Khamash
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
| | - Raymond Heilman
- Division of Nephrology, Mayo Clinic, Phoenix, AZ, United States
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11
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Jadlowiec CC, Thongprayoon C, Leeaphorn N, Kaewput W, Pattharanitima P, Cooper M, Cheungpasitporn W. Use of Machine Learning Consensus Clustering to Identify Distinct Subtypes of Kidney Transplant Recipients With DGF and Associated Outcomes. Transpl Int 2022; 35:10810. [PMID: 36568137 PMCID: PMC9773391 DOI: 10.3389/ti.2022.10810] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
Data and transplant community opinion on delayed graft function (DGF), and its impact on outcomes, remains varied. An unsupervised machine learning consensus clustering approach was applied to categorize the clinical phenotypes of kidney transplant (KT) recipients with DGF using OPTN/UNOS data. DGF was observed in 20.9% (n = 17,073) of KT and most kidneys had a KDPI score <85%. Four distinct clusters were identified. Cluster 1 recipients were young, high PRA re-transplants. Cluster 2 recipients were older diabetics and more likely to receive higher KDPI kidneys. Cluster 3 recipients were young, black, and non-diabetic; they received lower KDPI kidneys. Cluster 4 recipients were middle-aged, had diabetes or hypertension and received well-matched standard KDPI kidneys. By cluster, one-year patient survival was 95.7%, 92.5%, 97.2% and 94.3% (p < 0.001); one-year graft survival was 89.7%, 87.1%, 91.6%, and 88.7% (p < 0.001). There were no differences between clusters after accounting for death-censored graft loss (p = 0.08). Clinically meaningful differences in recipient characteristics were noted between clusters, however, after accounting for death and return to dialysis, there were no differences in death-censored graft loss. Greater emphasis on recipient comorbidities as contributors to DGF and outcomes may help improve utilization of DGF at-risk kidneys.
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Affiliation(s)
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine, Saint Luke’s Health System, Kansas City, MO, United States
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Georgetown University, Washington, DC, United States
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States
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12
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Baseline Characteristics and Representativeness of Participants in the BEST-Fluids Trial: A Randomized Trial of Balanced Crystalloid Solution Versus Saline in Deceased Donor Kidney Transplantation. Transplant Direct 2022; 8:e1399. [PMID: 36479278 PMCID: PMC9722559 DOI: 10.1097/txd.0000000000001399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/07/2022] [Indexed: 01/24/2023] Open
Abstract
UNLABELLED Delayed graft function (DGF) is a major complication of deceased donor kidney transplantation. Saline (0.9% sodium chloride) is a commonly used intravenous fluid in transplantation but may increase the risk of DGF because of its high chloride content. Better Evidence for Selecting Transplant Fluids (BEST-Fluids), a pragmatic, registry-based, double-blind, randomized trial, sought to determine whether using a balanced low-chloride crystalloid solution (Plasma-Lyte 148) instead of saline would reduce DGF. We sought to evaluate the generalizability of the trial cohort by reporting the baseline characteristics and representativeness of the trial participants in detail. METHODS We compared the characteristics of BEST-Fluids participants with those of a contemporary cohort of deceased donor kidney transplant recipients in Australia and New Zealand using data from the Australia and New Zealand Dialysis and Transplant Registry. To explore potential international differences, we compared trial participants with a cohort of transplant recipients in the United States using data from the Scientific Registry of Transplant Recipients. RESULTS During the trial recruitment period, 2373 deceased donor kidney transplants were performed in Australia and New Zealand; 2178 were eligible' and 808 were enrolled in BEST-Fluids. Overall, trial participants and nonparticipants were similar at baseline. Trial participants had more coronary artery disease (standardized difference [d] = 0.09; P = 0.03), longer dialysis duration (d = 0.18, P < 0.001), and fewer hypertensive (d = -0.11, P = 0.03) and circulatory death (d = -0.14, P < 0.01) donors than nonparticipants. Most key characteristics were similar between trial participants and US recipients, with moderate differences (|d| ≥ 0.2; all P < 0.001) in kidney failure cause, diabetes, dialysis duration, ischemic time, and several donor risk predictors, likely reflecting underlying population differences. CONCLUSIONS BEST-Fluids participants had more comorbidities and received slightly fewer high-risk deceased donor kidneys but were otherwise representative of Australian and New Zealand transplant recipients and were generally similar to US recipients. The trial results should be broadly applicable to deceased donor kidney transplantation practice worldwide.
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13
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Xiao Q, Zhang X, Zhao S, Yan Y, Wan H, Xiao J. A Multiparametric Nomogram for Predicting Delayed Graft Function in Adult Recipients of Pediatric Donor Kidneys. Transplant Proc 2022; 54:2147-2153. [DOI: 10.1016/j.transproceed.2022.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/09/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022]
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14
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Goujon A, Khene ZE, Thenault R, Vigneau C, Peyronnet B, Belabbas D, Guérin S, Chemouny J, Gasmi A, Verhoest G, Shariat S, Bensalah K, Mathieu R. Contrast-enhanced CT texture analysis for the prediction of delayed graft function following kidney transplantation from cadaveric donors. Prog Urol 2022; 32:868-874. [DOI: 10.1016/j.purol.2022.07.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/09/2022] [Accepted: 07/11/2022] [Indexed: 10/15/2022]
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15
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Nimmo A, Latimer N, Oniscu GC, Ravanan R, Taylor DM, Fotheringham J. Propensity Score and Instrumental Variable Techniques in Observational Transplantation Studies: An Overview and Worked Example Relating to Pre-Transplant Cardiac Screening. Transpl Int 2022; 35:10105. [PMID: 35832035 PMCID: PMC9271574 DOI: 10.3389/ti.2022.10105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
Inferring causality from observational studies is difficult due to inherent differences in patient characteristics between treated and untreated groups. The randomised controlled trial is the gold standard study design as the random allocation of individuals to treatment and control arms should result in an equal distribution of known and unknown prognostic factors at baseline. However, it is not always ethically or practically possible to perform such a study in the field of transplantation. Propensity score and instrumental variable techniques have theoretical advantages over conventional multivariable regression methods and are increasingly being used within observational studies to reduce the risk of confounding bias. An understanding of these techniques is required to critically appraise the literature. We provide an overview of propensity score and instrumental variable techniques for transplant clinicians, describing their principles, assumptions, strengths, and weaknesses. We discuss the different patient populations included in analyses and how to interpret results. We illustrate these points using data from the Access to Transplant and Transplant Outcome Measures study examining the association between pre-transplant cardiac screening in kidney transplant recipients and post-transplant cardiac events.
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Affiliation(s)
- Ailish Nimmo
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
- *Correspondence: Ailish Nimmo,
| | - Nicholas Latimer
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Gabriel C. Oniscu
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Rommel Ravanan
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Dominic M. Taylor
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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16
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Naesens M, Loupy A, Hilbrands L, Oberbauer R, Bellini MI, Glotz D, Grinyó J, Heemann U, Jochmans I, Pengel L, Reinders M, Schneeberger S, Budde K. Rationale for Surrogate Endpoints and Conditional Marketing Authorization of New Therapies for Kidney Transplantation. Transpl Int 2022; 35:10137. [PMID: 35669977 PMCID: PMC9163307 DOI: 10.3389/ti.2022.10137] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/10/2022] [Indexed: 12/13/2022]
Abstract
Conditional marketing authorization (CMA) facilitates timely access to new drugs for illnesses with unmet clinical needs, such as late graft failure after kidney transplantation. Late graft failure remains a serious, burdensome, and life-threatening condition for recipients. This article has been developed from content prepared by members of a working group within the European Society for Organ Transplantation (ESOT) for a Broad Scientific Advice request, submitted by ESOT to the European Medicines Agency (EMA), and reviewed by the EMA in 2020. The article presents the rationale for using surrogate endpoints in clinical trials aiming at improving late graft failure rates, to enable novel kidney transplantation therapies to be considered for CMA and improve access to medicines. The paper also provides background data to illustrate the relationship between primary and surrogate endpoints. Developing surrogate endpoints and a CMA strategy could be particularly beneficial for studies where the use of primary endpoints would yield insufficient statistical power or insufficient indication of long-term benefit following transplantation.
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Affiliation(s)
- Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, Hôpital Saint Louis, Paris, France
| | | | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Marlies Reinders
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
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17
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Pascoe EM, Chadban SJ, Fahim MA, Hawley CM, Johnson DW, Collins MG. Statistical analysis plan for Better Evidence for Selecting Transplant Fluids (BEST-Fluids): a randomised controlled trial of the effect of intravenous fluid therapy with balanced crystalloid versus saline on the incidence of delayed graft function in deceased donor kidney transplantation. Trials 2022; 23:52. [PMID: 35042554 PMCID: PMC8764824 DOI: 10.1186/s13063-021-05989-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
Background Delayed graft function, or the requirement for dialysis due to poor kidney function, is a frequent complication of deceased donor kidney transplantation that is associated with inferior outcomes. Intravenous fluids with a high chloride content, such as isotonic sodium chloride (0.9% saline), are widely used in transplantation but may increase the risk of poor kidney function. The primary objective of the BEST-Fluids trial is to compare the effect of a balanced low-chloride crystalloid, Plasma-Lyte 148 (Plasmalyte), versus 0.9% saline on the incidence of DGF in deceased donor kidney transplant recipients. This article describes the statistical analysis plan for the trial. Methods and design BEST-Fluids is an investigator-initiated, pragmatic, registry-based, multi-centre, double-blind, randomised controlled trial. Eight hundred patients (adults and children) in Australia and New Zealand with end-stage kidney disease admitted for a deceased donor kidney transplant were randomised to intravenous fluid therapy with Plasmalyte or 0.9% saline in a 1:1 ratio using minimization. The primary outcome is delayed graft function (dialysis within seven days post-transplant), which will be modelled using a log-binomial generalised linear mixed model with fixed effects for treatment group, minimization variables, and ischaemic time and a random intercept for study centre. Secondary outcomes including early kidney transplant function (a ranked composite of dialysis duration and the rate of graft function recovery), treatment for hyperkalaemia, and graft survival and will be analysed using a similar modelling approach appropriate for the type of outcome. Discussion BEST-Fluids will determine whether Plasmalyte reduces the incidence of DGF and has a beneficial effect on early kidney transplant outcomes relative to 0.9% saline and will inform clinical guidelines on intravenous fluids for deceased donor kidney transplantation. The statistical analysis plan describes the analyses to be undertaken and specified before completion of follow-up and locking the trial databases. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12617000358347. Prospectively registered on 8 March 2017 ClinicalTrials.gov identifier NCT03829488. Registered on 4 February 2019 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05989-w.
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Affiliation(s)
- Elaine M Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Magid A Fahim
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,The Translational Research Institute, Brisbane, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,The Translational Research Institute, Brisbane, Australia
| | - Michael G Collins
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia. .,Department of Renal Medicine, Auckland District Health Board, Auckland City Hospital, Level 15, Park Road, Grafton, Auckland, New Zealand. .,Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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18
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Goulamhoussen N, Slapcoff L, Baran D, Boucher A, Houde I, Masse M, Albert M, Marsolais P, Cardinal H, Bouchard J. Factors Associated With the Use of Hypothermic Machine Perfusion in Kidney Transplant Recipients: A Multicenter Retrospective Cohort Study. Can J Kidney Health Dis 2022; 9:20543581211048338. [PMID: 36062213 PMCID: PMC9434662 DOI: 10.1177/20543581211048338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Delayed graft function (DGF) is associated with an increased risk of graft
loss. The use of cold hypothermic machine perfusion (HMP) has been shown to
reduce the incidence of DGF in kidney transplant recipients (KTRs),
especially when extended-criteria donors (ECDs) are used. HMP can also
improve graft survival. However, there is a paucity of data on the
determinants of HMP use in clinical practice. Objective: We aimed to determine the factors associated with the use of HMP in a cohort
of donors and KTRs. Design: Multicenter retrospective cohort study. Setting: 5 transplant centers in Quebec. Patients: 159 neurologically deceased donors (NDD) and 281 KTR. Measurements: Use of HMP. Methods: We collected data on consecutive NDD admitted to a dedicated donor unit in a
single university-affiliated center and their KTRs between June 2013 and
December 2018 in 5 adult transplant centers across the province of Quebec,
Canada. All organs were recovered in a single hospital center where a HMP
device was available for every organ recovered and the decision to use HMP
was left at the discretion of the procurement surgeon. Generalized
estimating equations were used to predict the use of HMP. Results: The cohort included 159 NDDs and their 281 KTRs. Thirty-three percent of
donors were ECDs, and 59% of KTRs received organs placed on HMP. The median
cold ischemia time (CIT) was 12.5 (IQR 7.9-16.3) hours. In univariate
analysis, none of the donors’ characteristics were associated with the use
of HMP. ECD represented 33% of KTR on HMP vs 35% of those not placed on HMP
(P = .77). In univariate analysis, the use of HMP was
associated with KTR race (non-Caucasian), longer CIT, use of
basiliximab/alemtuzumab, year of transplant, and transplant center. The use
of HMP varied largely across transplant centers, ranging from 15% to 82%. In
multivariate analysis, use of HMP was associated with longer CIT (odds ratio
[OR] 1.15, 95% confidence interval [CI] = 1.07-1.25), transplant center as
well as transplantations performed after 2013. Limitations: One dedicated donor unit including NDD only, absence of specific data on
surgeons’ experience and personal or logistic reasons for using or not
HMP. Conclusions: We found that use of HMP remains low and varies largely across transplant
centers. The use of HMP was strongly associated with the transplant center
where the surgeons practiced, suggesting that surgeon preference/training
plays an important role in determining the use of HMP. Availability of HMP
at the time of organ procurement might also be limited by logistic issues
such as difficulty in returning the device. Further studies aimed at
determining the reasons underlying the barriers precluding the use of HMP
could help increasing its use and improve transplant outcomes.
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Affiliation(s)
- Nadir Goulamhoussen
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, QC, Canada
| | - Lawrence Slapcoff
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Dana Baran
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Anne Boucher
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, QC, Canada
| | - Isabelle Houde
- Department of Medicine, Centre Hospitalier Universitaire de Québec, QC, Canada
| | - Mélanie Masse
- Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke, QC, Canada
| | - Martin Albert
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, QC, Canada
| | - Pierre Marsolais
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, QC, Canada
| | - Heloïse Cardinal
- Research center, Centre Hospitalier de l’Université de Montréal, Université de Montréal, QC, Canada
| | - Josée Bouchard
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, QC, Canada
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19
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Kothari R, Tolles J, Adelmann D, Lewis RJ, Malinoski DJ, Niemann CU. Organ donor management goals and delayed graft function in adult kidney transplant recipients. Clin Transplant 2021; 36:e14528. [PMID: 34739731 DOI: 10.1111/ctr.14528] [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: 05/03/2021] [Revised: 10/07/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed graft function (DGF) after kidney transplantation is a common occurrence and correlates with poor graft and patient outcomes. Donor characteristics and care are known to impact DGF. We attempted to show the relationship between achievement of specific donor management goals (DMG) and DGF. METHODS This is a retrospective case-control study using data from 14 046 adult kidney donations after brain death from hospitals in 18 organ procurement organizations (OPOs) which were transplanted to adult recipients between 2012 and 2018. Data on DMG compliance and donor, recipient, and ischemia-related factors were used to create multivariable logistic regression models. RESULTS The overall rate of DGF was 29.4%. Meeting DMGs for urine output and vasopressor use were associated with decreased risk of DGF. Sensitivity analyses performed with different imputation methods, omitting recipient factors, and analyzing multiple time points yielded largely consistent results. CONCLUSIONS The development of DMGs continues to show promise in improving outcomes in the kidney transplant recipient population. Studies have already shown increased kidney utilization in smaller cohorts, as well as other organs, and shown decreased rates of DGF. Additional research and analysis are required to assess interactions between meeting DMGs and correlation versus causality in DMGs and DGF.
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Affiliation(s)
- Rishi Kothari
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Juliana Tolles
- Department of Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Dieter Adelmann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-University of California Los Angeles Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Darren J Malinoski
- Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA.,Department of Surgery, University of California San Francisco, San Francisco, California, USA
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20
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Bakirdogen S, Kurt HA, Kamış F, Bek S, Erbayraktar A. The Association Between Delayed Graft Function and Renal Resistive Index in Kidney Transplant Recipients. Cureus 2021; 13:e17315. [PMID: 34557363 PMCID: PMC8449821 DOI: 10.7759/cureus.17315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 11/28/2022] Open
Abstract
Background and objectives Delayed graft function (DGF) may increase the risk for kidney graft dysfunction. Renal resistive index (RRI) in Doppler ultrasonography is useful in measuring blood flow changes in kidneys which is indicative of tubulointerstitial damage. Most of the diseases in DGF etiology are related to tubulointerstitium and arteries of the kidneys. In this study, we investigated whether there is a relationship between delayed graft function and renal resistive index in kidney transplant recipients (KTR). Materials and methods Patients who underwent kidney transplantation were included in this retrospective study. KTR were divided into two groups as DGF (+) and DGF (−). Comparison of RRI values of DGF (+) and DGF (−) groups according to the measurements at different times. Results The findings showed that both RRI measurements (post-transplant in the first week and the end of the first year) of the DGF (+) group were higher than DGF (−) group (p=0.001 and p=0.003, respectively). The interaction of measurements and DGF did not have an effect on RRI (p>0.05). Conclusion The value of RRI in the DGF (−) group was lower than DGF (+) group in the first week after kidney transplantation.
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Affiliation(s)
| | - Hasan Anil Kurt
- Urology, Canakkale Onsekiz Mart University, School of Medicine, Canakkale, TUR
| | - Fatih Kamış
- Internal Medicine, Canakkale Onsekiz Mart University, School of Medicine, Canakkale, TUR
| | - Sibel Bek
- Nephrology, Kocaeli University Hospital, Kocaeli, TUR
| | - Aysegul Erbayraktar
- Internal Medicine, Canakkale Onsekiz Mart University, School of Medicine, Canakkale, TUR
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21
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Tubular Cell Dropout in Preimplantation Deceased Donor Biopsies as a Predictor of Delayed Graft Function. Transplant Direct 2021; 7:e716. [PMID: 34476295 PMCID: PMC8384397 DOI: 10.1097/txd.0000000000001168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/16/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Delayed graft function (DGF) affects over 25% of deceased donor kidney transplants (DDKTs) and is associated with increased cost, worsened graft outcomes, and mortality. While approaches to preventing DGF have focused on minimizing cold ischemia, donor factors such as acute tubular injury can influence risk. There are currently no pharmacologic therapies to modify DGF risk or promote repair, in part due to our incomplete understanding of the biology of preimplantation tubular injury. Methods. We collected intraoperative, preimplantation kidney biopsies from 11 high-risk deceased donors and 10 living donors and followed transplant recipients for graft function. We performed quantitative high-dimensional histopathologic analysis using imaging mass cytometry to determine the cellular signatures that distinguished deceased and living donor biopsies as well as deceased donor biopsies which either did or did not progress to DGF. Results. We noted decreased tubular cells (P < 0.0001) and increased macrophage infiltration (P = 0.0037) in high-risk DDKT compared with living donor biopsies. For those high-risk DDKTs that developed postimplant DGF (n = 6), quantitative imaging mass cytometry analysis showed a trend toward reduced tubular cells (P = 0.02) and increased stromal cells (P = 0.04) versus those that did not (n = 5). Notably, these differences were not identified by conventional histopathologic evaluation. Conclusions. The current study identifies donor tubular cell loss as a precursor of DGF pathogenesis and highlights an area for further investigation and potential therapeutic intervention.
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22
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Lee H, Park Y, Ban TH, Song SH, Song SH, Yang J, Ahn C, Yang CW, Chung BH. Synergistic impact of pre-sensitization and delayed graft function on allograft rejection in deceased donor kidney transplantation. Sci Rep 2021; 11:16095. [PMID: 34373479 PMCID: PMC8352860 DOI: 10.1038/s41598-021-95327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/22/2021] [Indexed: 11/26/2022] Open
Abstract
The aim of this study is to investigate whether or not delayed graft function (DGF) and pre-transplant sensitization have synergistic adverse effects on allograft outcome after deceased donor kidney transplantation (DDKT) using the Korean Organ Transplantation Registry (KOTRY) database, the nationwide prospective cohort. The study included 1359 cases between May 2014 and June 2019. The cases were divided into 4 subgroups according to pre-sensitization and the development of DGF post-transplant [non-pre-sensitized-DGF(−) (n = 1097), non-pre-sensitized-DGF(+) (n = 127), pre-sensitized-DGF(−) (n = 116), and pre-sensitized-DGF(+) (n = 19)]. We compared the incidence of biopsy-proven allograft rejection (BPAR), time-related change in allograft function, allograft or patient survival, and post-transplant complications across 4 subgroups. The incidence of acute antibody-mediated rejection (ABMR) was significantly higher in the pre-sensitized-DGF(+) subgroup than in other 3 subgroups. In addition, multivariable cox regression analysis demonstrated that pre-sensitization combined with DGF is an independent risk factor for the development of acute ABMR (hazard ratio 4.855, 95% confidence interval 1.499–15.727). Moreover, DGF and pre-sensitization showed significant interaction (p-value for interaction = 0.008). Pre-sensitization combined with DGF did not show significant impact on allograft function, and allograft or patient survival. In conclusion, the combination of pre-sensitization and DGF showed significant synergistic interaction on the development of allograft rejection after DDKT.
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Affiliation(s)
- Hanbi Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, Seoul, South Korea
| | - Yohan Park
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, Konyang University Hospital, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, Seoul, South Korea
| | - Sang Heon Song
- Organ Transplantation Center and Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea
| | - Seung Hwan Song
- Department of Surgery, Ewha Womans University Medical Center, Seoul, South Korea
| | - Jaeseok Yang
- Department of Nephrology, Seoul National University Hospital, Seoul, South Korea
| | - Curie Ahn
- Department of Nephrology, Seoul National University Hospital, Seoul, South Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, Seoul, South Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, Seoul, South Korea.
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23
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Codina S, Manonelles A, Tormo M, Sola A, Cruzado JM. Chronic Kidney Allograft Disease: New Concepts and Opportunities. Front Med (Lausanne) 2021; 8:660334. [PMID: 34336878 PMCID: PMC8316649 DOI: 10.3389/fmed.2021.660334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is increasing in most countries and kidney transplantation is the best option for those patients requiring renal replacement therapy. Therefore, there is a significant number of patients living with a functioning kidney allograft. However, progressive kidney allograft functional deterioration remains unchanged despite of major advances in the field. After the first post-transplant year, it has been estimated that this chronic allograft damage may cause a 5% graft loss per year. Most studies focused on mechanisms of kidney graft damage, especially on ischemia-reperfusion injury, alloimmunity, nephrotoxicity, infection and disease recurrence. Thus, therapeutic interventions focus on those modifiable factors associated with chronic kidney allograft disease (CKaD). There are strategies to reduce ischemia-reperfusion injury, to improve the immunologic risk stratification and monitoring, to reduce calcineurin-inhibitor exposure and to identify recurrence of primary renal disease early. On the other hand, control of risk factors for chronic disease progression are particularly relevant as kidney transplantation is inherently associated with renal mass reduction. However, despite progress in pathophysiology and interventions, clinical advances in terms of long-term kidney allograft survival have been subtle. New approaches are needed and probably a holistic view can help. Chronic kidney allograft deterioration is probably the consequence of damage from various etiologies but can be attenuated by kidney repair mechanisms. Thus, besides immunological and other mechanisms of damage, the intrinsic repair kidney graft capacity should be considered to generate new hypothesis and potential therapeutic targets. In this review, the critical risk factors that define CKaD will be discussed but also how the renal mechanisms of regeneration could contribute to a change chronic kidney allograft disease paradigm.
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Affiliation(s)
- Sergi Codina
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Maria Tormo
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Sola
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M. Cruzado
- Department of Nephrology, Hospital Universitari Bellvitge, Barcelona, Spain
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
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24
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Butala NM, Makkar R, Secemsky EA, Gallup D, Marquis-Gravel G, Kosinski AS, Vemulapalli S, Valle JA, Bradley SM, Chakravarty T, Yeh RW, Cohen DJ. Cerebral Embolic Protection and Outcomes of Transcatheter Aortic Valve Replacement: Results From the Transcatheter Valve Therapy Registry. Circulation 2021; 143:2229-2240. [PMID: 33619968 PMCID: PMC8184596 DOI: 10.1161/circulationaha.120.052874] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), which has persisted despite refinements in technique and increased operator experience. While cerebral embolic protection devices (EPDs) have been developed to mitigate this risk, data regarding their impact on stroke and other outcomes after TAVR are limited. METHODS We performed an observational study using data from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Patients were included if they underwent elective or urgent transfemoral TAVR between January 2018 and December 2019. The primary outcome was in-hospital stroke. To adjust for confounding, the association between EPD use and clinical outcomes was evaluated using instrumental variable analysis, a technique designed to support causal inference from observational data, with site-level preference for EPD use within the same quarter of the procedure as the instrument. We also performed a propensity score-based secondary analysis using overlap weights. RESULTS Our analytic sample included 123 186 patients from 599 sites. The use of EPD during TAVR increased over time, reaching 28% of sites and 13% of TAVR procedures by December 2019. There was wide variation in EPD use across hospitals, with 8% of sites performing >50% of TAVR procedures with an EPD and 72% performing no procedures with an EPD in the last quarter of 2019. In our primary analysis using the instrumental variable model, there was no association between EPD use and in-hospital stroke (adjusted relative risk, 0.90 [95% CI, 0.68-1.13]; absolute risk difference, -0.15% [95% CI, -0.49 to 0.20]). However, in our secondary analysis using the propensity score-based model, EPD use was associated with 18% lower odds of in-hospital stroke (adjusted odds ratio, 0.82 [95% CI, 0.69-0.97]; absolute risk difference, -0.28% [95% CI, -0.52 to -0.03]). Results were generally consistent across the secondary end points, as well as subgroup analyses. CONCLUSIONS In this nationally representative observational study, we did not find an association between EPD use for TAVR and in-hospital stroke in our primary instrumental variable analysis, and found only a modestly lower risk of in-hospital stroke in our secondary propensity-weighted analysis. These findings provide a strong basis for large-scale randomized, controlled trials to test whether EPDs provide meaningful clinical benefit for patients undergoing TAVR.
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Affiliation(s)
- Neel M. Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Raj Makkar
- Cedars–Sinai Medical Center, Los Angeles, CA
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | | | | | | | | | - Javier A. Valle
- University of Colorado School of Medicine, Aurora, CO and Michigan Heart and Vascular Institute, Ann Arbor, MI
| | | | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY
- St. Francis Hospital, Roslyn, NY
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25
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Maia LF, Lasmar MF, Fabreti-Oliveira RA, Nascimento E. Effect of Delayed Graft Function on the Outcome and Allograft Survival of Kidney Transplanted Patients from a Deceased Donor. Transplant Proc 2021; 53:1470-1476. [PMID: 34006380 DOI: 10.1016/j.transproceed.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/21/2021] [Accepted: 04/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In kidney transplantation (KT), delayed graft function (DGF) is a significant early complication observed in the first week. The study aimed to investigate the impact of DGF on the outcome, allograft, and patient survival after KT with organs from deceased donors. METHODS This retrospective study was conducted using 304 KT patients who received an organ from deceased donors from 2008 to 2018. The patients were divided into 2 groups, DGF positive (DGF+) and DGF negative (DGF-). The database containing the clinical, laboratory, and immunologic information of donors and recipients was statistically analyzed using the SSPS program. RESULTS In this study, 189 (62.17%) were DGF+ and 115 (37.83%) were DGF-. Until 6 months after KT, the estimate glomerular filtration rate was better in group DGF-, but it was similar between the groups during 10-year follow-up. Graft losses were higher in DGF+ group than in the DGF- (P = .046). The serum creatinine level was persistently higher in DGF+ group until the sixth month (P ≤ .05). Allograft survival rates were better in patients who were DGF- (P = .033). Those who had DGF for more than 15 days had a worse graft survival (P = .003), but in 10 year follow-up, patient survival rates were similar (P = .705). CONCLUSION DGF+ patients were associated with dialysis time before KT, ischemia time, and the donors' clinical status, such as age, organ quality, and serum creatinine. All these factors had a great impact on graft survival but not on patient survival.
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Affiliation(s)
- Lorena Fernandes Maia
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; University Jose do Rosário Vellano - UNIFENAS, Belo Horizonte, Minas Gerais, Brazil
| | - Marcus Faria Lasmar
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; University Hospital of the Faculty of Medical Science, Belo Horizonte, Minas Gerais, Brazil
| | - Raquel Aparecida Fabreti-Oliveira
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil.
| | - Evaldo Nascimento
- Faculty of Medical Sciences, Belo Horizonte, Minas Gerais, Brazil; IMUNOLAB - Laboratory of Histocompatibility, Belo Horizonte, Minas Gerais, Brazil
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26
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Zhang H, Fu Q, Liu J, Li J, Deng R, Wu C, Nie W, Chen X, Liu L, Wang C. Risk factors and outcomes of prolonged recovery from delayed graft function after deceased kidney transplantation. Ren Fail 2021; 42:792-798. [PMID: 32772773 PMCID: PMC7472517 DOI: 10.1080/0886022x.2020.1803084] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objective We aimed to evaluate the effect of prolonged recovery from DGF on outcomes, using a new definition of DGF recovery time, among deceased donor kidney transplant recipients with DGF, and to examine the risk factors for prolonged recovery. Methods From 2007 to 2016, 91 deceased donor kidney transplant recipients with DGF were retrospectively analyzed. DGF recovery time was defined as the time from transplantation to achieve a stable estimated glomerular filtration rate (eGFR). Recipients with a DGF recovery time greater than or equal to the median were assigned to the prolonged recovery group, while the others were assigned to the rapid recovery group. Result The median DGF recovery time was 27 days. Donor terminal eGFR was significantly lower in the prolonged recovery group (n = 46) compared with the rapid recovery group (n = 45) (median 24.9 vs. 65.4 ml/min/1.73m2, p = 0.004). The eGFR at 1 year post-transplant in the prolonged recovery group was significantly lower than that in the rapid recovery group (50.6 ± 20.0 vs. 63.5 ± 21.4 ml/min/1.73m2, p = 0.005). The risk of adverse outcomes (acute rejection, pneumonia, graft failure, and death) was significantly greater in the prolonged recovery group (hazard ratio 2.604, 95% confidence interval 1.102–6.150, p = 0.029) compared with the rapid recovery group. Conclusion Decreased donor terminal eGFR is a risk factor for prolonged recovery from DGF after deceased kidney transplantation. Prolonged DGF recovery time is associated with reduced graft function at 1-year post-transplant, and poor transplant outcome.
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Affiliation(s)
- Huanxi Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jinqi Liu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ronghai Deng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chenglin Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weijian Nie
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xutao Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Longshan Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
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27
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Watari S, Araki M, Wada K, Yoshinaga K, Maruyama Y, Mitsui Y, Sadahira T, Kubota R, Nishimura S, Kobayashi Y, Takeuchi H, Tanabe K, Kitagawa M, Morinaga H, Kitamura S, Sugiyama H, Wada J, Watanabe M, Watanabe T, Nasu Y. ABO Blood Incompatibility Positively Affects Early Graft Function: Single-Center Retrospective Cohort Study. Transplant Proc 2021; 53:1494-1500. [PMID: 33931247 DOI: 10.1016/j.transproceed.2021.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND We investigated the association between ABO-incompatible (ABO-I) kidney transplantation and early graft function. METHODS We retrospectively analyzed 95 patients who underwent living donor kidney transplantation between May 2009 and July 2019. It included 61 ABO-compatible (ABO-C) and 34 ABO-I transplantations. We extracted data on immunologic profile, sex, age, cold ischemic time, type of immunosuppression, and graft function. Two definitions were used for slow graft function (SGF) as follows: postoperative day (POD) 3 serum creatinine level >3 mg/dL and estimated glomerular filtration rate (eGFR) <20 mL/min/1.73 m2. Logistic regression analysis was performed to analyze the effect of ABO-I on the incidence of SGF. RESULTS The characteristics between the ABO-C and ABO-I were not different. ABO-I received rituximab and plasma exchange. Patients also received tacrolimus and mycophenolate mofetil for 2 weeks and prednisolone for 1 week before transplantation as preconditioning. Of the 95 study patients, 19 (20%) and 21 (22%) were identified with SGF according to POD 3 serum creatinine level or eGFR, respectively. Multivariable analysis revealed that ABO-I significantly reduced the incidence of SGF (odds ratio, 0.15; 95% confidence interval, 0.03-0.7; P = .02), and cold ischemic time >150 min increased the incidence of SGF (odds ratio, 6.5; 95% confidence interval, 1.7-25; P = .006). Similar results were identified in POD 3 eGFR. Inferior graft function in patients with SGF was identified up to 6 months after transplantation. CONCLUSION ABO-I reduces the incidence of SGF, which is associated with an inferior graft function up to 6 months.
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Affiliation(s)
- Shogo Watari
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan.
| | - Koichiro Wada
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Kasumi Yoshinaga
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Yuki Maruyama
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Yosuke Mitsui
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Takuya Sadahira
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Risa Kubota
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Shingo Nishimura
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Yasuyuki Kobayashi
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Hidemi Takeuchi
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Katsuyuki Tanabe
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Masashi Kitagawa
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Hiroshi Morinaga
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Shinji Kitamura
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Hitoshi Sugiyama
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology, and Metabolism, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Masami Watanabe
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Toyohiko Watanabe
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
| | - Yasutomo Nasu
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Kita-ku, Okayama, Japan
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Kim KD, Lee KW, Kim SJ, Lee O, Lim M, Jeong ES, Kwon J, Yang J, Oh J, Park JB. Safety and effectiveness of kidney transplantation using a donation after brain death donor with acute kidney injury: a retrospective cohort study. Sci Rep 2021; 11:5572. [PMID: 33692385 PMCID: PMC7946918 DOI: 10.1038/s41598-021-84977-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/22/2021] [Indexed: 12/29/2022] Open
Abstract
The use of kidneys from donation after brain death (DBD) donors with acute kidney injury (AKI) is a strategy to expand the donor pool. The aim of this study was to evaluate how kidney transplantation (KT) from a donor with AKI affects long-term graft survival in various situations. All patients who underwent KT from DBD donors between June 2003 and April 2016 were retrospectively reviewed. The KDIGO (Kidney Disease: Improving Global Outcomes) criteria were used to classify donor AKI. The cohort included 376 donors (no AKI group, n = 117 [31.1%]; AKI group n = 259 [68.9%]). Death-censored graft survival was similar according to the presence of AKI, AKI severity, and the AKI trend (p = 0.929, p = 0.077, and p = 0.658, respectively). Patients whose donors had AKI who received using low dose (1.5 mg/kg for three days) rabbit anti-thymocyte globulin (r-ATG) as the induction agent had significantly superior death-censored graft survival compared with patients in that group who received basiliximab (p = 0.039). AKI in DBD donors did not affect long-term death-censored graft survival. Low-dose r-ATG may be considered as an induction immunosuppression in recipients receiving kidneys with AKI because it showed better graft survival than basiliximab.
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Affiliation(s)
- Kyeong Deok Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea.
| | - Sang Jin Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
| | - Okjoo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
| | - Manuel Lim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
| | - Eun Sung Jeong
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
| | - Jieun Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
| | - Jaehun Yang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
| | - Jongwook Oh
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06355, Republic of Korea
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Jahn L, Rüster C, Schlosser M, Winkler Y, Foller S, Grimm MO, Wolf G, Busch M. Rate, Factors, and Outcome of Delayed Graft Function After Kidney Transplantation of Deceased Donors. Transplant Proc 2021; 53:1454-1461. [PMID: 33612277 DOI: 10.1016/j.transproceed.2021.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/08/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Delayed graft function (DGF) is a frequent complication after kidney transplantation affecting long-term outcome. PATIENTS AND METHODS A total of 525 consecutive recipients (age 54.2 ± 13.4 years, 33% female) of kidneys from deceased donors transplanted between 2005 and 2012 were retrospectively examined. DGF was defined as the need of dialysis within the first week after transplantation. RESULTS DGF developed in 21.1% (n = 111). Factors associated with DGF (P ≤ .035, respectively) were recipient body mass index, C-reactive protein of the recipient, residual diuresis, cold ischemia time, donor age, and diuresis in the first hour after transplantation. Median duration of DGF was 16 (2-66) days. Patients after DGF had a significantly lower GFR compared with recipients without DGF either after 3 (32.9 ± 16.5 vs 46.3 ± 18.4 mL/min/1.73 m2) or after 12 months (38.9 ± 19.3 vs 48.6 ± 20.4 mL/min/1.73 m2, P < .001, resp.). During DGF, 12.4% developed BANFF II and 18.0% BANFF I rejection, 20.2% had signs of transplant glomerulitis (first biopsy), and 16.2% (n = 18) remained on dialysis. CONCLUSION DGF affects 1 out of 5 kidney transplants from deceased donors. Minimizing modifiable risk factors, in particular immunologic risk, may ameliorate the incidence and outcome of DGF. The outcome of DGF depends mainly on the diagnosis of any rejection and worsens upon detection of transplant glomerulitis and pronounced interstitial fibrosis and tubular atrophy (IFTA).
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Affiliation(s)
- Laura Jahn
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Christiane Rüster
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Mandy Schlosser
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Yvonne Winkler
- Department of Urology/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Susan Foller
- Department of Urology/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Marc-Oliver Grimm
- Department of Urology/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Gunter Wolf
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany
| | - Martin Busch
- Department of Internal Medicine III/Collaborative Kidney Transplant Center, University Hospital Jena - Friedrich Schiller University, Jena, Germany.
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Influence of cold ischemia time on the outcome of kidney transplants from donors aged 70 years and above - A Collaborative Transplant Study Report. Transplantation 2021; 105:2461-2469. [PMID: 33988347 DOI: 10.1097/tp.0000000000003629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The use of kidney allografts from ≥70-year-old donors has increased persistently over the last twenty years. Prolonged cold ischemia time (CIT) is well known to increase graft failure risk. However, despite their growing importance, no data is available on the impact of CIT specifically on survival of allografts from ≥70-year-old donors. METHODS 47,585 kidney transplantations from expanded criteria donors (ECDs) performed during 2000-2017 and reported to the Collaborative Transplant Study were analysed. The impact of CIT on five-year death-censored graft and patient survival was studied for transplantations from <70- (n=33,305) and ≥70-year-old ECDs (n=14,280). RESULTS Compared to the reference of ≤12-hours CIT, a CIT of 13-18 hours did not increase the risk of graft failure significantly, neither for recipients of kidneys from <70- nor from ≥70-year-old ECDs. In contrast, graft failure risk increased significantly when CIT exceeded 18 hours, both in recipients of kidneys from <70- and, more pronounced, from ≥70-year-old ECDs (CIT 19-24 hours: hazard ratio (HR) =1.19 and =1.24; P<0.001; CIT ≥24 hours: HR=1.28 and =1.32, P<0.001 and =0.003, respectively). Within the 18-hour CIT interval, additional human leukocyte antigen (HLA) matching further improved survival of ECD transplants significantly, whereas the negative impact of a prolonged CIT >18 hours was stronger in >65-year-old recipients and for transplants with multiple HLA mismatches. The influence of CIT on patient survival was less pronounced. CONCLUSIONS CIT, as long it is kept ≤18 hours, has no significant impact on survival of kidney transplants even from ≥70-year-old ECDs.
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Yoo KD, An JN, Kim YC, Lee J, Joo KW, Oh YK, Kim YS, Lim CS, Oh S, Lee JP. Low serum total CO 2 and its association with mortality in patients being followed up in the nephrology outpatients clinic. Sci Rep 2021; 11:1711. [PMID: 33462380 PMCID: PMC7814051 DOI: 10.1038/s41598-021-81332-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
Large-scale studies have not been conducted to assess whether serum hypobicarbonatemia increases the risk for kidney function deterioration and mortality among East-Asians. We aimed to determine the association between serum total CO2 (TCO2) concentrations measured at the first outpatient visit and clinical outcomes. In this multicenter cohort study, a total of 42,231 adult nephrology outpatients from 2001 to 2016 were included. End-stage renal disease (ESRD) patients on dialysis within 3 months of the first visit were excluded. Instrumental variable (IV) was used to define regions based on the proportion of patients with serum TCO2 < 22 mEq/L. The crude mortality rate was 12.2% during a median 77.0-month follow-up period. The Cox-proportional hazard regression model adjusted for initial kidney function, alkali supplementation, and the use of diuretics demonstrated that low TCO2 concentration was not associated with progression to ESRD, but significantly increased the risk of death. The IV analysis also confirmed a significant association between initial TCO2 concentration and mortality (HR 0.56; 95% CI 0.49–0.64). This result was consistently significant regardless of the underlying renal function. In conclusion, low TCO2 levels are significantly associated with mortality but not with progression to ESRD in patients with ambulatory care.
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Affiliation(s)
- Kyung Don Yoo
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jung Nam An
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Kwon-Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea.
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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Risk factors for delayed graft function and their impact on graft outcomes in live donor kidney transplantation. Int Urol Nephrol 2021; 53:439-446. [PMID: 33394282 DOI: 10.1007/s11255-020-02687-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/14/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Delayed graft function (DGF) is a manifestation of acute kidney injury uniquely framed within the transplant process and a predictor of poor long-term graft function1. It is less common in the setting of living donor (LD) kidney transplantation. However, the detrimental impact of DGF on graft survival is more pronounced in LD2. PURPOSE To study the effects of DGF in the setting of LD kidney transplantation. METHODS We performed a retrospective analysis of LD kidney transplantations performed between 2010 and 2018 in the UNOS/OPTN database for DGF and its effect on graft survival. RESULTS A total of 42,736 LD recipients were identified, of whom 1115 (2.6%) developed DGF. Recipient dialysis status, male gender, diabetes, end-stage renal disease, donor age, right donor nephrectomy, panel reactive antibodies, HLA mismatch, and cold ischemia time were independent predictors of DGF. Three-year graft survival in patients with and without DGF was 89% and 95%, respectively. DGF was the greatest predictor of graft failure at three years (hazard ratio = 1.766, 95% CI: 1.514-2.059, P = 0.001) and was associated with higher rates of rejection (9% vs. 6.28%, P = 0.0003). Among patients with DGF, the graft survival rates with and without rejection were not different. CONCLUSION DGF is a major determinant of poor graft functional outcomes, independent of rejection.
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New-Onset Gout as an Independent Risk Factor for Returning to Dialysis After Kidney Transplantation. Transplant Direct 2020; 6:e634. [PMID: 33225059 PMCID: PMC7673774 DOI: 10.1097/txd.0000000000001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/13/2020] [Indexed: 11/25/2022] Open
Abstract
Background. The causal relationship between gout and renal transplant outcomes is difficult to assess due to multiple interacting covariates. This study sought to estimate the independent effect of new-onset gout on renal transplant outcomes using a methodology that accounted for these interactions. Methods. This study analyzed data on patients in the US Renal Data System (USRDS) who received a primary kidney transplant between 2008 and 2015. The exposure was new-onset gout, and the primary endpoint was returning to dialysis >12 months postindex date (transplant date). A marginal structural model (MSM) was fitted to determine the relative risk of new-onset gout on return to dialysis. Results. 18 525 kidney transplant recipients in the USRDS met study eligibility. One thousand three hundred ninety-nine (7.6%) patients developed new-onset gout, and 1420 (7.7%) returned to dialysis >12 months postindex. Adjusting for baseline and time-varying confounders via the MSM showed new-onset gout was associated with a 51% increased risk of return to (RR, 1.51; 95% CI, 1.03-2.20). Conclusions. This finding suggests that new onset gout after kidney transplantation could be a harbinger for poor renal outcomes, and to our knowledge is the first study of kidney transplant outcomes using a technique that accounted for the dynamic relationship between renal dysfunction and gout.
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Morath C, Döhler B, Kälble F, Pego da Silva L, Echterdiek F, Schwenger V, Živčić-Ćosić S, Katalinić N, Kuypers D, Benöhr P, Haubitz M, Ziemann M, Nitschke M, Emmerich F, Pisarski P, Karakizlis H, Weimer R, Ruhenstroth A, Scherer S, Tran TH, Mehrabi A, Zeier M, Süsal C. Pre-transplant HLA Antibodies and Delayed Graft Function in the Current Era of Kidney Transplantation. Front Immunol 2020; 11:1886. [PMID: 32983110 PMCID: PMC7489336 DOI: 10.3389/fimmu.2020.01886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/13/2020] [Indexed: 12/04/2022] Open
Abstract
Delayed graft function (DGF) occurs in a significant proportion of deceased donor kidney transplant recipients and was associated with graft injury and inferior clinical outcome. The aim of the present multi-center study was to identify the immunological and non-immunological predictors of DGF and to determine its influence on outcome in the presence and absence of human leukocyte antigen (HLA) antibodies. 1,724 patients who received a deceased donor kidney transplant during 2008–2017 and on whom a pre-transplant serum sample was available were studied. Graft survival during the first 3 post-transplant years was analyzed by multivariable Cox regression. Pre-transplant predictors of DGF and influence of DGF and pre-transplant HLA antibodies on biopsy-proven rejections in the first 3 post-transplant months were determined by multivariable logistic regression. Donor age ≥50 years, simultaneous pre-transplant presence of HLA class I and II antibodies, diabetes mellitus as cause of end-stage renal disease, cold ischemia time ≥18 h, and time on dialysis >5 years were associated with increased risk of DGF, while the risk was reduced if gender of donor or recipient was female or the reason for death of donor was trauma. DGF alone doubled the risk for graft loss, more due to impaired death-censored graft than patient survival. In DGF patients, the risk of death-censored graft loss increased further if HLA antibodies (hazard ratio HR=4.75, P < 0.001) or donor-specific HLA antibodies (DSA, HR=7.39, P < 0.001) were present pre-transplant. In the presence of HLA antibodies or DSA, the incidence of biopsy-proven rejections, including antibody-mediated rejections, increased significantly in patients with as well as without DGF. Recipients without DGF and without biopsy-proven rejections during the first 3 months had the highest fraction of patients with good kidney function at year 1, whereas patients with both DGF and rejection showed the lowest rate of good kidney function, especially when organs from ≥65-year-old donors were used. In this new era of transplantation, besides non-immunological factors, also the pre-transplant presence of HLA class I and II antibodies increase the risk of DGF. Measures to prevent the strong negative impact of DGF on outcome are necessary, especially during organ allocation for presensitized patients.
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Affiliation(s)
- Christian Morath
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Kälble
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Fabian Echterdiek
- Department of Nephrology and Autoimmune Diseases, Transplantation Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology and Autoimmune Diseases, Transplantation Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Stela Živčić-Ćosić
- Department of Nephrology, Dialysis and Kidney Transplantation, Department of Internal Medicine, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Nataša Katalinić
- Tissue Typing Laboratory, Clinical Institute of Transfusion Medicine, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Peter Benöhr
- Department of Nephrology and Hypertension, Center for Internal Medicine and Medical Clinic III, Klinikum Fulda, Fulda, Germany
| | - Marion Haubitz
- Department of Nephrology and Hypertension, Center for Internal Medicine and Medical Clinic III, Klinikum Fulda, Fulda, Germany
| | - Malte Ziemann
- Institute of Transfusion Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Martin Nitschke
- Medical Clinic 1, Transplantation Center, University of Lübeck, Lübeck, Germany
| | - Florian Emmerich
- Institute for Transfusion Medicine and Gene Therapy, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Przemyslaw Pisarski
- Department of General and Digestive Surgery, University Medical Centre Freiburg, Freiburg, Germany
| | - Hristos Karakizlis
- Department of Internal Medicine, University of Giessen, Giessen, Germany
| | - Rolf Weimer
- Department of Internal Medicine, University of Giessen, Giessen, Germany
| | - Andrea Ruhenstroth
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sabine Scherer
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thuong Hien Tran
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Division of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
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Williams N, Korneffel K, Koizumi N, Ortiz J. African American polycystic kidney patients receive higher risk kidneys, but do not face increased risk for graft failure or post-transplant mortality. Am J Surg 2020; 221:1093-1103. [PMID: 33028497 DOI: 10.1016/j.amjsurg.2020.09.028] [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: 06/02/2020] [Revised: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
African Americans (AA) are disproportionately affected by end-stage renal disease (ESRD) and have worse outcomes following renal transplantation. Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic condition leading to ESRD necessitating transplant. We explored this population with respect to race by conducting a retrospective analysis of the UNOS database between 2005 and 2019. Our study included 10,842 (AA n = 1661; non-AA n = 9181) transplant recipients whose primary diagnosis was ADPKD. We further stratified the AA ADPKD population with respect to blood groups (AA blood type B n = 295 vs AA non-B blood type n = 1366), and also compared this cohort to AAs with a diagnosis of DM (n = 16,706) to identify unique trends in the ADPKD population. We analyzed recipient and donor characteristics, generated survival curves, and conducted multivariate analyses. African American ADPKD patients waited longer for transplants (924 days vs 747 days P < .001), and were more likely to be on dialysis (76% vs 62%; p < .001). This same group was also more likely to have AA donors (21% vs 9%; p < .001) and marginally higher KDPI kidneys (0.48 vs 0.45; p < .001). AA race was a risk factor for delayed graft function (DGF), increasing the chance of DGF by 45% (OR 1.45 95% CI 1.26-1.67; p < .001). AA race was not associated with graft failure (HR 1.10 95% CI 0.95-1.28; p = .21) or patient mortality (HR 0.84 95% CI 0.69-1.03; p = .09). Racial disparities exist in the ADPKD population. They should be continually studied and addressed to improve transplant equity.
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Affiliation(s)
- Nathan Williams
- College of Medicine and Life Science, University of Toledo, Toledo, OH, USA.
| | - Katie Korneffel
- College of Medicine and Life Science, University of Toledo, Toledo, OH, USA
| | | | - Jorge Ortiz
- Department of Surgery, Albany Medical College, Albany, NY, USA
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Delayed Graft Function and Acute Rejection in Kidney Transplant Patients with Positive Panel-Reactive Antibody and Negative Donor-Specific Antibodies. Nephrourol Mon 2020. [DOI: 10.5812/numonthly.107969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Delayed graft function (DGF) and acute rejection (AR) are common complications in kidney transplant patients. Objectives: The study evaluated DGF and AR in highly sensitized patients and their effects on kidney function for six months post-transplantation. Methods: We enrolled 95 patients with kidney transplants from living donors who were divided into two groups. Group 1 included 47 highly sensitized patients with panel reactive antibody (PRA) < 20.0% and negative donor-specific antigen, and group 2 included 48 patients with negative PRA. All patients were followed for the state of DGF, AR, and kidney function for six months. Results: Group 1 showed a significantly higher proportion of DGF and AR than group 2 (27.7% versus 2.1%, P < 0.001 and 14.9% versus 2.1%, P = 0.031, respectively). The rates of positive PRA in DGF and AR patients were significantly higher than those in non-DGF and non-AR patients (92.9% versus 42.0%, P < 0.001 and 87.5% versus 46.0%, P = 0.031, respectively). Transplanted kidney function was significantly worse in patients with PRA and DGF and/or AR than in patients with negative PRA and non-DGF and non-AR only in the seventh-day post-transplantation. Conclusions: Kidney transplant in highly sensitized patients with positive PRA was related to the increased ratio of DGF and AR.
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37
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Expanding the Utilization of Kidneys from Donors with Acute Kidney Injury. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00289-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Differential Impact of Delayed Graft Function in Deceased Donor Renal Transplant Recipients With and Without Donor-specific HLA-antibodies. Transplantation 2020; 103:e273-e280. [PMID: 31205266 DOI: 10.1097/tp.0000000000002802] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed graft function (DGF) and pretransplant donor-specific HLA-antibodies (DSA) are both regarded as risk factors for rejection and lower graft survival. However, the combined impact of DGF and DSA has not been studied in detail. METHODS We investigated 375 deceased donor kidney transplantations, which had DSA assignment by single-antigen bead technology and which had surveillance biopsies at 3 of 6 months. Median follow-up time was 6.1 years. RESULTS DGF occurred in 137 of 375 patients (37%), and DSA were present in 85 of 375 patients (23%). The incidence of DGF was similar in DSA-positive (DSApos)-patients and DSA-negative (DSAneg)-patients (40% versus 36%; P = 0.45). In DSAneg-patients, 5-year graft survival was not different with/without DGF (81% versus 83%; P = 0.48). By contrast, in DSApos-patients, 5-year graft survival was significantly lower with DGF (64% versus 79%; P = 0.01). Moreover, DSApos-patients with DGF had a higher 1-year incidence of subclinical rejection, which were mostly antibody-mediated or mixed rejection phenotypes. Graft loss due to rejection was significantly more frequent in DSApos-patients with DGF (5/34; 15%) compared to DSApos-patients without DGF (2/51; 4%), and DSAneg-patients with/without DGF (3/103; 3% and 4/187; 2%, respectively) (P = 0.005). In a multivariate Cox model, DSA with DGF was an independent predictor for graft (hazard ratio = 2.84 [95% confidence interval, 1.54-5.06]; P = 0.001) and death-censored graft loss (hazard ratio = 4.65 [95% confidence interval, 1.83-11.51]; P = 0.002). CONCLUSIONS DGF has a much more detrimental impact in DSApos-patients than in DSAneg-patients, which is likely related to a higher incidence of antibody-mediated rejection. If possible, the combined risks of DGF and DSA should be avoided.
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Collins MG, Fahim MA, Pascoe EM, Dansie KB, Hawley CM, Clayton PA, Howard K, Johnson DW, McArthur CJ, McConnochie RC, Mount PF, Reidlinger D, Robison L, Varghese J, Vergara LA, Weinberg L, Chadban SJ. Study Protocol for Better Evidence for Selecting Transplant Fluids (BEST-Fluids): a pragmatic, registry-based, multi-center, double-blind, randomized controlled trial evaluating the effect of intravenous fluid therapy with Plasma-Lyte 148 versus 0.9% saline on delayed graft function in deceased donor kidney transplantation. Trials 2020; 21:428. [PMID: 32450917 PMCID: PMC7249430 DOI: 10.1186/s13063-020-04359-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/28/2020] [Indexed: 02/08/2023] Open
Abstract
Background Delayed graft function, the requirement for dialysis due to poor kidney function post-transplant, is a frequent complication of deceased donor kidney transplantation and is associated with inferior outcomes and higher costs. Intravenous fluids given during and after transplantation may affect the risk of poor kidney function after transplant. The most commonly used fluid, isotonic sodium chloride (0.9% saline), contains a high chloride concentration, which may be associated with acute kidney injury, and could increase the risk of delayed graft function. Whether using a balanced, low-chloride fluid instead of 0.9% saline is safe and improves kidney function after deceased donor kidney transplantation is unknown. Methods BEST-Fluids is an investigator-initiated, pragmatic, registry-based, multi-center, double-blind, randomized controlled trial. The primary objective is to compare the effect of intravenous Plasma-Lyte 148 (Plasmalyte), a balanced, low-chloride solution, with the effect of 0.9% saline on the incidence of delayed graft function in deceased donor kidney transplant recipients. From January 2018 onwards, 800 participants admitted for deceased donor kidney transplantation will be recruited over 3 years in Australia and New Zealand. Participants are randomized 1:1 to either intravenous Plasmalyte or 0.9% saline peri-operatively and until 48 h post-transplant, or until fluid is no longer required; whichever comes first. Follow up is for 1 year. The primary outcome is the incidence of delayed graft function, defined as dialysis in the first 7 days post-transplant. Secondary outcomes include early kidney transplant function (composite of dialysis duration and rate of improvement in graft function when dialysis is not required), hyperkalemia, mortality, graft survival, graft function, quality of life, healthcare resource use, and cost-effectiveness. Participants are enrolled, randomized, and followed up using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Discussion If using Plasmalyte instead of 0.9% saline is effective at reducing delayed graft function and improves other clinical outcomes in deceased donor kidney transplantation, this simple, inexpensive change to using a balanced low-chloride intravenous fluid at the time of transplantation could be easily implemented in the vast majority of transplant settings worldwide. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12617000358347. Registered on 8 March 2017. ClinicalTrials.gov: NCT03829488. Registered on 4 February 2019.
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Affiliation(s)
- Michael G Collins
- Department of Renal Medicine, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand. .,Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. .,Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.
| | - Magid A Fahim
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Kathryn B Dansie
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia.,Department of Medicine, The University of Adelaide, Adelaide, Australia.,Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - Peter F Mount
- Department of Nephrology, Austin Health, Melbourne, Australia.,Department of Medicine (Austin), The University of Melbourne, Parkville, Melbourne, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Laura Robison
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Julie Varghese
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Liza A Vergara
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Melbourne, Australia.,Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia
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Jadlowiec CC, Heilman RL, Smith ML, Khamash HA, Huskey JL, Harbell J, Reddy KS, Moss AA. Transplanting kidneys from donation after cardiac death donors with acute kidney injury. Am J Transplant 2020; 20:864-869. [PMID: 31612611 DOI: 10.1111/ajt.15653] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/10/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023]
Abstract
Donation after cardiac death (DCD) and acute kidney injury (AKI) donors have historically been considered independent risk factors for delayed graft function (DGF), allograft failure, and inferior outcomes. With growing experience, updated analyses have shown good outcomes. There continues to be limited data, however, on outcomes specific to DCD donors who have AKI. Primary outcomes for this study were post-kidney transplant patient and allograft survival comparing two donor groups: DCD AKIN stage 2-3 and DBD AKIN stage 2-3. In comparing these groups, there were no short- or long-term differences in patient (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.54-1.93, P = .83) or allograft survival (HR 1.47, 95% CI 0.64-2.97, P = .32). In multivariate models, the DCD/DBD status had no significant impact on the estimated GFR (eGFR) at 1 (P = .38), 2 (P = .60), and 3 years (P = .52). DGF (57.9% vs 67.9%, P = .09), rejection (12.1% vs 13.9%, P = .12), and progression of interstitial fibrosis/tubular atrophy (IFTA) on protocol biopsy (P = .16) were similar between the two groups. With careful selection, good outcomes can be achieved utilizing severe AKI DCD kidneys. Historic concerns regarding primary nonfunction, DGF resulting in interstitial fibrosis and rejection, and inferior outcomes were not observed. Given the ongoing organ shortage, increased effort should be undertaken to further utilize these donors.
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Affiliation(s)
| | | | - Maxwell L Smith
- Division of Anatomic Pathology, Mayo Clinic, Phoenix, Arizona
| | - Hasan A Khamash
- Division of Transplant Nephrology, Mayo Clinic, Phoenix, Arizona
| | - Janna L Huskey
- Division of Transplant Nephrology, Mayo Clinic, Phoenix, Arizona
| | - Jack Harbell
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | - Adyr A Moss
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
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Costa SD, de Andrade LGM, Barroso FVC, de Oliveira CMC, Daher EDF, Fernandes PFCBC, Esmeraldo RDM, de Sandes-Freitas TV. The impact of deceased donor maintenance on delayed kidney allograft function: A machine learning analysis. PLoS One 2020; 15:e0228597. [PMID: 32027717 PMCID: PMC7004552 DOI: 10.1371/journal.pone.0228597] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/18/2020] [Indexed: 12/23/2022] Open
Abstract
Background This study evaluated the risk factors for delayed graft function (DGF) in a country where its incidence is high, detailing donor maintenance-related (DMR) variables and using machine learning (ML) methods beyond the traditional regression-based models. Methods A total of 443 brain dead deceased donor kidney transplants (KT) from two Brazilian centers were retrospectively analyzed and the following DMR were evaluated using predictive modeling: arterial blood gas pH, serum sodium, blood glucose, urine output, mean arterial pressure, vasopressors use, and reversed cardiac arrest. Results Most patients (95.7%) received kidneys from standard criteria donors. The incidence of DGF was 53%. In multivariable logistic regression analysis, DMR variables did not impact on DGF occurrence. In post-hoc analysis including only KT with cold ischemia time<21h (n = 220), urine output in 24h prior to recovery surgery (OR = 0.639, 95%CI 0.444–0.919) and serum sodium (OR = 1.030, 95%CI 1.052–1.379) were risk factors for DGF. Using elastic net regularized regression model and ML analysis (decision tree, neural network and support vector machine), urine output and other DMR variables emerged as DGF predictors: mean arterial pressure, ≥ 1 or high dose vasopressors and blood glucose. Conclusions Some DMR variables were associated with DGF, suggesting a potential impact of variables reflecting poor clinical and hemodynamic status on the incidence of DGF.
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Affiliation(s)
- Silvana Daher Costa
- Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
- Walter Cantídio University Hospital, Fortaleza, Ceará, Brazil
- Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil
| | | | | | | | | | | | | | - Tainá Veras de Sandes-Freitas
- Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
- Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil
- * E-mail:
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Huang E, Vo A, Choi J, Ammerman N, Lim K, Sethi S, Kim I, Kumar S, Najjar R, Peng A, Jordan SC. Three-Year Outcomes of a Randomized, Double-Blind, Placebo-Controlled Study Assessing Safety and Efficacy of C1 Esterase Inhibitor for Prevention of Delayed Graft Function in Deceased Donor Kidney Transplant Recipients. Clin J Am Soc Nephrol 2019; 15:109-116. [PMID: 31843975 PMCID: PMC6946080 DOI: 10.2215/cjn.04840419] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 10/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Delayed graft function is related to ischemia-reperfusion injury and may be complement dependent. We previously reported from a randomized, placebo-controlled trial that treatment with C1 esterase inhibitor was associated with a shorter duration of delayed graft function and higher eGFR at 1 year. Here, we report longer-term outcomes from this trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a post hoc analysis of a phase 1/2, randomized, controlled trial enrolling 70 recipients of deceased donor kidney transplants at risk for delayed graft function (NCT02134314). Subjects were randomized to receive C1 esterase inhibitor 50 U/kg (n=35) or placebo (n=35) intraoperatively and at 24 hours. The cumulative incidence functions method was used to compare graft failure and death over 3.5 years. eGFR slopes were compared using a linear mixed effects model. RESULTS Three deaths occurred among C1 esterase inhibitor-treated patients compared with none receiving placebo. Seven graft failures developed in the placebo group compared with one among C1 esterase inhibitor-treated recipients; the cumulative incidence of graft failure was lower over 3.5 years among C1 esterase inhibitor-treated recipients compared with placebo (P=0.03). Although no difference in eGFR slopes was observed between groups (P for group-time interaction =0.12), eGFR declined in placebo-treated recipients (-4 ml/min per 1.73 m2 per year; 95% confidence interval, -8 to -0.1) but was stable in C1 esterase inhibitor-treated patients (eGFR slope: 0.5 ml/min per 1.73 m2 per year; 95% confidence interval, -4 to 5). At 3.5 years, eGFR was 56 ml/min per 1.73 m2 (95% confidence interval, 42 to 70) in the C1 esterase inhibitor group versus 35 ml/min per 1.73 m2 (95% confidence interval, 21 to 48) in the placebo group, with an estimated mean eGFR difference of 21 ml/min per 1.73 m2 (95% confidence interval, 2 to 41 ml/min per 1.73 m2). CONCLUSIONS Treatment of patients at risk for ischemia-reperfusion injury and delayed graft function with C1 esterase inhibitor was associated with a lower incidence of graft failure.
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Affiliation(s)
- Edmund Huang
- Division of Nephrology, Department of Medicine and
| | - Ashley Vo
- Division of Nephrology, Department of Medicine and
| | - Jua Choi
- Division of Nephrology, Department of Medicine and
| | | | - Kathlyn Lim
- Division of Nephrology, Department of Medicine and
| | | | - Irene Kim
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Reiad Najjar
- Division of Nephrology, Department of Medicine and
| | - Alice Peng
- Division of Nephrology, Department of Medicine and
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Kulkarni S, Wei G, Jiang W, Lopez LA, Parikh CR, Hall IE. Outcomes From Right Versus Left Deceased-Donor Kidney Transplants: A US National Cohort Study. Am J Kidney Dis 2019; 75:725-735. [PMID: 31812448 DOI: 10.1053/j.ajkd.2019.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 08/10/2019] [Indexed: 12/11/2022]
Abstract
RATIONALE & OBJECTIVE There may be important transplant-related differences between right and left kidneys, including logistical/surgical considerations about vessel length for the right compared to the left kidney from the same donor. Because US centers choose between the right and left kidney when their recipient is ranked higher on a "match-run," we sought to determine whether deceased-donor right kidneys have had worse posttransplantation outcomes than left kidneys. STUDY DESIGN Paired Organ Procurement and Transplantation Network analysis. SETTING & PARTICIPANTS Deceased-donor kidney pairs transplanted during 1990 to 2016. EXPOSURE Right versus left kidney controlling for other significant factors. OUTCOMES Delayed graft function (DGF), all-cause and death-censored graft failure, and mortality. ANALYTICAL APPROACH Multivariable conditional logistic regression for DGF; proportional hazards models (conditional on same donor) for failure/mortality with right kidneys (operationalized as 6-month time-varying coefficients) adjusting for DGF and other confounders. RESULTS 87,112 recipient pairs shared the following donor characteristics: mean age of 41 ± 14 years, 60% males, and 11% with cardiac death. Recipient characteristics were numerically similar by donor kidney side but with some statistical differences given the sample size. Right kidneys had slightly longer cold ischemia time. DGF occurred more often for right kidneys (28% vs 25.8%; P < 0.001; adjusted OR, 1.15 [95% CI, 1.12-1.17]). The adjusted hazard ratio (aHR) for all-cause graft failure with right kidneys within 6 months was 1.07 (95% CI, 1.03-1.11), and was 0.99 (95% CI, 0.97-1.01) thereafter. The aHRs for death-censored graft failure with right kidneys before and after 6 months were 1.11 (95% CI, 1.06-1.16) and 0.96 (95% CI, 0.93-0.99), respectively; the corresonding aHRs for mortality were 0.99 (95% CI, 0.93-1.04) and 1.00 (95% CI, 0.98-1.03), respectively. LIMITATIONS Registry data, different transplant eras, reasons for kidney side unavailable. CONCLUSIONS There is modest association for transplantation of right kidneys with DGF and graft loss within the first 6 months, which is lost beyond this time point. These findings do not support the use of laterality of deceased-donor kidneys as an important factor in organ acceptance decisions.
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Affiliation(s)
- Sanjay Kulkarni
- Section of Organ Transplantation and Immunology, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Guo Wei
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Wei Jiang
- Yale University Graduate School of Arts and Sciences, New Haven, CT
| | - Licia A Lopez
- Department of Pediatrics, Native American Research Internship, University of Utah School of Medicine, Salt Lake City, UT
| | - Chirag R Parikh
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Isaac E Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT.
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Long-term Outcomes Following Kidney Transplantation From Donors With Acute Kidney Injury. Transplantation 2019; 103:e263-e272. [DOI: 10.1097/tp.0000000000002792] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Association Between Duration of Delayed Graft Function, Acute Rejection, and Allograft Outcome After Deceased Donor Kidney Transplantation. Transplantation 2019; 103:412-419. [PMID: 29762458 DOI: 10.1097/tp.0000000000002275] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prolonged duration of delayed graft function (DGF) may be associated with adverse allograft outcomes, but the association between threshold duration of DGF, acute rejection and long-term allograft loss remains undefined. We aimed to determine the impact of DGF duration on allograft outcomes and to assess whether this association was mediated by acute rejection. METHODS Using data from the Australian and New Zealand Dialysis and Transplant Registry, Cox proportional modeling was used to determine the association between quartiles of DGF duration, acute rejection at 6 months and death-censored graft loss (DCGL). Mediation analysis was conducted to determine whether acute rejection was a causal intermediate between DGF and DCGL. RESULTS Of 7668 deceased donor kidney transplants between 1997 and 2014, 1497 (19.5%) recipients experienced DGF requiring dialysis. The median (interquartile range) duration of DGF was 7 (9) days, with 25% requiring dialysis for 14 days or longer. Among recipients who had experienced a DGF duration of 1 to 4 days, the adjusted hazard ratio for duration of 5 to 7, 8 to 13, and 14 days or longer were 1.13 (95% confidence interval [CI], 0.83-1.55; P = 0.43), 1.44 (95% CI, 1.08-1.91; P = 0.013), and 1.99 (95% CI, 1.50-2.65; P < 0.001), respectively, for acute rejection; and were 1.10 (95% CI< 0.73-1.67; P = 0.64), 1.45 (95% CI, 1.00-2.11; P = 0.05) and 1.60 (95% CI, 1.10-2.31; P = 0.01), respectively, for DCGL. On average, 8% of the effects between DGF duration and DCGL were explained by acute rejection. CONCLUSIONS There was a direct dose-dependent effect between DGF duration and DCGL, with acute rejection explaining less than 10% of the effects between DGF duration and DCGL. Future research identifying other potential modifiable mediators that lies in the causal pathway between DGF duration and allograft loss is essential.
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Mogulla MR, Bhattacharjya S, Clayton PA. Risk factors for and outcomes of delayed graft function in live donor kidney transplantation – a retrospective study. Transpl Int 2019; 32:1151-1160. [DOI: 10.1111/tri.13472] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/07/2019] [Accepted: 06/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Manohar Reddy Mogulla
- Central and Northern Adelaide Renal and Transplantation Services Adelaide SA Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry Adelaide SA Australia
| | | | - Philip A. Clayton
- Central and Northern Adelaide Renal and Transplantation Services Adelaide SA Australia
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry Adelaide SA Australia
- Discipline of Medicine University of Adelaide Adelaide SA Australia
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Xie LB, Chen X, Chen B, Wang XD, Jiang R, Lu YP. Protective effect of bone marrow mesenchymal stem cells modified with klotho on renal ischemia-reperfusion injury. Ren Fail 2019; 41:175-182. [PMID: 30942135 PMCID: PMC6450585 DOI: 10.1080/0886022x.2019.1588131] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: To detect the combination protective effect of bone marrow mesenchymal stem cells (BMSCs) and Klotho gene on the renal ischemia-reperfusion injury (RIRI). Methods: BMSCs isolated from rats were transfected with Klotho gene to form BMSCKl. We injected BMSCKl to allogenic rat RIRI model. After 24 h and 72 h, we detected the serum creatinine (SCr), malondialdehyde (MDA), and superoxide dismutase (SOD) in renal tissue, Hematoxylin-eosin (HE) staining, and TUNEL of renal pathology. The expression of FoxO1 and p-FoxO1 in post-hypoxia tubular epithelial cells of normal rat kidney (NRK-52E) were detected by Western blot after cocultured with BMSCKl. Results: Comparing with BMSCCon group, Rats in BMSCKl group had lower SCr and MDA but higher SOD. Both HE and TUNEL score of renal tissue in BMSCKl group were lower than that of BMSCCon group. Western blot indicated that FoxO1 was upregulated, while p-FoxO1 was downregulated in post-hypoxia NRK-52E cells. Conclusions: BMSCs transfected with Klotho gene can further ameliorate RIRI. The possible mechanism may be attributed to the upregulation of SOD in NRK-52E caused by Klotho-FoxO1 axis.
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Affiliation(s)
- Li-Bo Xie
- a Department of Urology , The Affiliated Hospital of Southwest Medical University , Luzhou , China
| | - Xi Chen
- b School of Biology Science , East China Normal University , Shanghai , China
| | - Bo Chen
- c Department of Human Anatomy , Southwest Medical University , Luzhou , China
| | - Xian-Ding Wang
- d Department of Urology , The Institution of Urology, West China Hospital, Sichuan University , Chengdu , China
| | - Rui Jiang
- a Department of Urology , The Affiliated Hospital of Southwest Medical University , Luzhou , China
| | - Yi-Ping Lu
- d Department of Urology , The Institution of Urology, West China Hospital, Sichuan University , Chengdu , China
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Baar W, Goebel U, Buerkle H, Jaenigen B, Kaufmann K, Heinrich S. Lower rate of delayed graft function is observed when epidural analgesia for living donor nephrectomy is administered. BMC Anesthesiol 2019; 19:38. [PMID: 30885139 PMCID: PMC6421667 DOI: 10.1186/s12871-019-0713-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background The beneficial effects of epidural analgesia (EDA) in terms of pain control and postoperative convalescence are widely known and led to a frequent use for patients who underwent living donor kidney nephrectomy. The objective of this study was to determine whether general anesthesia (GA) plus EDA compared to GA only, administered for living donor nephrectomy has effects on postoperative graft function in recipients. Methods In this monocentric, retrospective cohort analysis we analyzed the closed files of all consecutive donor- recipient pairs who underwent living donor kidney transplantations from 2008 to 2017. The outcome variable was delayed graft function (DGF), defined as at least one hemodialysis within seven days postoperatively, once hyperacute rejection, vascular or urinary tract complications were ruled out. Statistical analyses of continuous variables were calculated using the two-tail Student’s t test and Fisher exact test for categorical variables with a significance level of p < 0.05, respectively. Results The study enclosed 291 consecutive living donor kidney transplantations. 99 kidney donors received epidural analgesia whereas 192 had no epidural analgesia. The groups showed balanced pretransplantational characteristics and comparable donors´ and recipients’ risk factors. 9 out of all 291 recipients needed renal replacement therapy (RRT) during the first 7 days due to delayed graft function; none of these donors received EDA. The observed rate of DGF in recipients whose kidney donors received epidural analgesia was significantly lower (0% vs. 4.6%; p = 0.031). Conclusions In our cohort we observed a significantly lower rate of DGF when epidural analgesia for donor nephrectomy was administered. Due to restrictions of the study design this observation needs further confirmation by prospective studies.
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Affiliation(s)
- Wolfgang Baar
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Hartmut Buerkle
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Bernd Jaenigen
- Department of General and Visceral Surgery, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Kai Kaufmann
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Sebastian Heinrich
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
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Wright C, Patel MS, Gao X, Witt M, Sally M, Groat T, Crutchfield M, Neidlinger N, Pilot M, Malinoski DJ. The Impact of Therapeutic Hypothermia Used to Treat Anoxic Brain Injury After Cardiopulmonary Resuscitation on Organ Donation Outcomes. Ther Hypothermia Temp Manag 2019; 9:258-264. [PMID: 30848704 DOI: 10.1089/ther.2018.0043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Therapeutic hypothermia (TH) is clinically used to improve neurologic outcomes in patients with anoxic brain injury after cardiopulmonary resuscitation (CPR). For patients that regress and become organ donors after neurologic determination of death (DNDDs), the impact of TH received before determination of death on organ donation outcomes remains unknown. A prospective observational study of all adult DNDDs that received CPR and had anoxia as a cause of death from March 2013 to December 2014 was conducted across 20 organ procurement organizations (OPOs) in the United States. Main outcome measures included organs transplanted per donor (OTPD), specific organ transplantation rates, and recipient graft outcomes. One thousand ninety eight DNDDs met inclusion criteria, with 46% having received TH before determination of death. DNDDs with hypothermia before death had a similar number of OTPD (2.74 vs. 2.69, p = 0.61) and similar transplantation rates of individual organs. With regards to recipients, there was significantly less delayed graft function (DGF) in kidney grafts from donors who received TH before death (24% vs. 30%, p = 0.02). After adjusting for donor, recipient, and graft related factors, the protective effect of TH on DGF persisted (OR 0.75, 95%CI [0.56-0.995], p = 0.046). TH before death in the donor is independently associated with a 25% decrease in DGF among kidney recipients. This should be considered a protective donor selection factor in guiding the decision to accept or reject an organ for transplantation.
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Affiliation(s)
| | - Madhukar S Patel
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiang Gao
- Department of Surgery, University of Iowa, Iowa City, Iowa
| | - Maxwell Witt
- School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mitchell Sally
- Surgical Critical Care Section, Portland Veterans Affairs Medical Center, Portland, Oregon.,Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Tahnee Groat
- Surgical Critical Care Section, Portland Veterans Affairs Medical Center, Portland, Oregon
| | - Megan Crutchfield
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Nikole Neidlinger
- Donor Network West, San Ramon, California.,California Pacific Medical Center, San Francisco, California
| | | | - Darren J Malinoski
- Surgical Critical Care Section, Portland Veterans Affairs Medical Center, Portland, Oregon.,Department of Surgery, Oregon Health & Science University, Portland, Oregon
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Cardinal H, Lamarche F, Grondin S, Marsolais P, Lagacé AM, Duca A, Albert M, Houde I, Boucher A, Masse M, Baran D, Bouchard J. Organ donor management and delayed graft function in kidney transplant recipients: A multicenter retrospective cohort study. Am J Transplant 2019; 19:277-284. [PMID: 30253052 DOI: 10.1111/ajt.15127] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 01/25/2023]
Abstract
Meeting donor management goals (DMGs) has been reported to decrease the incidence of delayed graft function (DGF) after kidney transplant, but whether this relationship is independent of cold machine perfusion is unclear. We aimed to determine whether meeting DMGs is associated with a reduced incidence of DGF, independent of the use of machine perfusion. We collected data on consecutive brain-dead donors and their KT recipients (KTRs) between June 2013 and December 2016 in 5 adult transplant centers. We evaluated whether DMGs were met at donor neurologic death (DND) and later time points. We defined a priori meeting optimal DMG as achieving ≥7 DMGs. Generalized estimating equations were used to predict DGF. Among 122 donors, 34% were extended-criteria donors (ECDs). The number of DMGs met increased over time (5.6 ± 1.4 at DND and 6.1 ± 1.3 at organ procurement [P < .001]). DGF occurred in 23% of 214 KTRs, and 55% received organs placed on machine perfusion. In multivariate analysis, ECD (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.13-4.45), use of machine perfusion (OR 0.45, 95% CI 0.22-0.94), and optimal DMG at DND (OR 0.39, 95% CI 0.16-0.99) were associated with DGF. Early achievement of DMGs was associated with a reduced risk of the development of DGF, independent of the use of machine perfusion.
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Affiliation(s)
- Heloise Cardinal
- Department of Medicine, Centre Hospitalier Universitaire de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Florence Lamarche
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Stéphanie Grondin
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Marsolais
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Anne-Marie Lagacé
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Anatolie Duca
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Martin Albert
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Isabelle Houde
- Department of Medicine, Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, Canada
| | - Anne Boucher
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Mélanie Masse
- Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke, Sherbroooke, Quebec, Canada
| | - Dana Baran
- Department of Medicine, McGill University Health Centre, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Josée Bouchard
- Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
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