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Caldwell JS, Parvathinathan G, Stedman MR, Ahearn P, Tan JC, Cheng XS. Immunologic Benefits of 0-antigen Mismatched Transplants: No Added Boost for Racial and Ethnic Minorities. Transplant Direct 2024; 10:e1653. [PMID: 38881747 PMCID: PMC11177818 DOI: 10.1097/txd.0000000000001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/21/2024] [Indexed: 06/18/2024] Open
Abstract
Background Systemic barriers to posttransplant care, including access to immunosuppressant medications, contribute to higher rates of kidney transplant failure in racial minorities. Matching donor and recipient HLA alleles reduce allorecognition, easing reliance on immunosuppression. We hypothesize that 0-antigen mismatch transplants may provide stronger protection against graft loss in racial minorities. Methods We compared adult, single-organ, deceased-donor kidney transplants in the United States from 2007 to 2016 by degree of HLA mismatch (0- versus ≥1-antigen mismatch). We examined time-to-allograft failure, with death as a competing event, using multivariable Weibull models, stratified by recipient race (White versus non-White), and evaluated the interaction between mismatch and recipient race. We used Kaplan-Meier imputation to account for competing risk of death. Results We analyzed 102 114 transplants (median follow-up, 5.6 y; 16 862 graft losses, 18 994 deaths). Zero-antigen mismatch was associated with improved allograft survival (adjusted subdistribution hazard ratio [sHR] 0.80; 95% confidence interval [CI], 0.75-0.85). When stratified by recipient race, the effect of 0-antigen mismatch was more pronounced in White (unadjusted sHR 0.78; 95% CI, 0.72-0.83) versus non-White recipients (sHR 0.88; 95% CI, 0.79-0.99; interaction P = 0.04). The differential effect was attenuated after adjusting for covariates (sHR 0.78; 95% CI, 0.73-0.84 versus sHR 0.87; 95% CI, 0.77-0.98; interaction P = 0.10). Conclusions Zero-antigen mismatch transplants conferred a 20% risk reduction in allograft loss, which was similar between non-White and White recipients. This may reflect an increased degree of mismatch at other HLA alleles and non-HLA alleles in non-White recipients or because of the extent of systemic barriers to healthcare borne by minority recipients.
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Affiliation(s)
| | | | | | - Patrick Ahearn
- Division of Nephrology, Stanford University, Palo Alto, CA
| | - Jane C Tan
- Division of Nephrology, Stanford University, Palo Alto, CA
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2
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Gately R, Milanzi E, Lim W, Teixeira-Pinto A, Clayton P, Isbel N, Johnson DW, Hawley C, Campbell S, Wong G. Incidence, Risk Factors, and Outcomes of Kidney Transplant Recipients With BK Polyomavirus-Associated Nephropathy. Kidney Int Rep 2023; 8:531-543. [PMID: 36938086 PMCID: PMC10014440 DOI: 10.1016/j.ekir.2022.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction BK polyomavirus-associated nephropathy (BKPyVAN) is associated with graft dysfunction and loss; however, knowledge of immunosuppression reduction strategies and long-term graft, and patient outcomes across the disease spectrum is lacking. Methods This cohort study included 14,697 kidney transplant recipients in Australia and New Zealand (2005-2019), followed for 91,306 person years. Results BKPyVAN occurred in 460 recipients (3%) at a median posttransplant time of 4.8 months (interquartile range, 3.1-10.8). Graft loss (35% vs. 21%, P < 0.001), rejection (42% vs. 25%, P < 0.001), and death (18% vs. 13%, P = 0.002) were more common in the BKPyVAN group. The most frequent changes in immunosuppression after BKPyVAN were reduction (≤50%) in tacrolimus (172, 51%) and mycophenolate doses (134, 40%), followed by the conversion of mycophenolate to leflunomide (62, 19%) and tacrolimus to ciclosporin (20, 6%). Factors associated with the development of BKPyVAN included (adjusted hazard ratio [HR]; 95% confidence interval) male sex (1.66; 1.34-2.05), recipient age (≥70 vs. <20 [2.46; 1.30-4.65]), recipient blood group (A vs. B [2.00; 1.19-3.34]), donor age (≥70 vs. <20 [2.99; 1.71-5.22]), earlier era (1.74; 1.35-2.25), donor/recipient ethnic mismatch (1.52; 1.23-1.87), tacrolimus use (1.46; 1.11-1.91), and transplantation at a lower-volume transplant center (1.61; 1.24-2.09). The development of BKPyVAN was associated with an increased risk of all-cause (1.75; 1.46-2.09) and death-censored graft loss (2.49; 1.99-3.11), but not mortality (1.15; 0.91-1.45). Conclusions BKPyVAN is associated with an increased risk of all-cause and death-censored graft loss, but not death. Interventional trials are urgently needed to evaluate the efficacy of immunosuppression reduction and novel strategies to minimize the adverse outcomes associated with BKPyVAN.
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Affiliation(s)
- Ryan Gately
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- Correspondence: Ryan Gately, Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba Queensland 4102, Australia.
| | - Elasma Milanzi
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Wai Lim
- Faculty of Health and Medical Science, University of Western Australia, Perth, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Phil Clayton
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nicole Isbel
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Scott Campbell
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, NSW, Australia
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Ammary FA, Bowring MG, Massie AB, Yu S, Waldram MM, Garonzik-Wang J, Thomas AG, Holscher CM, Qadi MA, Henderson ML, Wiseman A, Gralla J, Brennan DC, Segev DL, Muzaale AD. The changing landscape of live kidney donation in the United States from 2005 to 2017. Am J Transplant 2019; 19:2614-2621. [PMID: 30903733 PMCID: PMC6711793 DOI: 10.1111/ajt.15368] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 01/25/2023]
Abstract
The number of live kidney donors has declined since 2005. This decline parallels the evolving knowledge of risk for biologically related, black, and younger donors. To responsibly promote donation, we sought to identify declining low-risk donor subgroups that might serve as targets for future interventions. We analyzed a national registry of 77 427 donors and quantified the change in number of donors per 5-year increment from 2005 to 2017 using Poisson regression stratified by donor-recipient relationship and race/ethnicity. Among related donors aged <35, 35 to 49, and ≥50 years, white donors declined by 21%, 29%, and 3%; black donors declined by 30%, 31%, and 12%; Hispanic donors aged <35 and 35 to 49 years declined by 18% and 15%, and those aged ≥50 increased by 10%. Conversely, among unrelated donors aged <35, 35 to 49, and ≥50 years, white donors increased by 12%, 4%, and 24%; black donors aged <35 and 35 to 49 years did not change but those aged ≥50 years increased by 34%; Hispanic donors increased by 16%, 21%, and 46%. Unlike unrelated donors, related donors were less likely to donate in recent years across race/ethnicity. Although this decline might be understandable for related younger donors, it is less understandable for lower-risk related older donors (≥50 years). Biologically related older individuals are potential targets for interventions to promote donation.
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Affiliation(s)
- Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Madeleine M. Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Alvin G. Thomas
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Courtenay M. Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohamud A. Qadi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Macey L. Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander Wiseman
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jane Gralla
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel C. Brennan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Al Ammary F, Thomas AG, Massie AB, Muzaale AD, Shaffer AA, Koons B, Qadi MA, Crews DC, Garonzik-Wang J, Fang H, Brennan DC, Lentine KL, Segev DL, Henderson ML. The landscape of international living kidney donation in the United States. Am J Transplant 2019; 19:2009-2019. [PMID: 30615253 PMCID: PMC6591087 DOI: 10.1111/ajt.15256] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/31/2018] [Accepted: 01/01/2019] [Indexed: 01/25/2023]
Abstract
In the United States, kidney donation from international (noncitizen/nonresident) living kidney donors (LKDs) is permitted; however, given the heterogeneity of healthcare systems, concerns remain regarding the international LKD practice and recipient outcomes. We studied a US cohort of 102 315 LKD transplants from 2000-2016, including 2088 international LKDs, as reported to the Organ Procurement and Transplantation Network. International LKDs were more tightly clustered among a small number of centers than domestic LKDs (Gini coefficient 0.76 vs 0.58, P < .001). Compared with domestic LKDs, international LKDs were more often young, male, Hispanic or Asian, and biologically related to their recipient (P < .001). Policy-compliant donor follow-up was substantially lower for international LKDs at 6, 12, and 24 months postnephrectomy (2015 cohort: 45%, 33%, 36% vs 76%, 71%, 70% for domestic LKDs, P < .001). Among international LKDs, Hispanic (aOR = 0.23 0.360.56 , P < .001) and biologically related (aOR = 0.39 0.590.89 , P < .01) donors were more compliant in donor follow-up than white and unrelated donors. Recipients of international living donor kidney transplant (LDKT) had similar graft failure (aHR = 0.78 0.891.02 , P = .1) but lower mortality (aHR = 0.53 0.620.72 , P < .001) compared with the recipients of domestic LDKT after adjusting for recipient, transplant, and donor factors. International LKDs may provide an alternative opportunity for living donation. However, efforts to improve international LKD follow-up and engagement are warranted.
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Affiliation(s)
- Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Abimereki D Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ashton A Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Brittany Koons
- Department of Nursing, Villanova University, Villanova, Pennsylvania
| | - Mohamud A Qadi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deidra C Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Hai Fang
- Department of Health Systems, Management and Policy, University of Colorado School of Public Health, Aurora, Colorado
| | - Daniel C Brennan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista L Lentine
- Department of Medicine, Saint Louis University, St. Louis, Missouri
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
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Cao B, Adler JT, Bababekov YJ, Markmann JF, Chang DC, Yeh H. Pediatric kidney transplantation and mortality: Distance to transplant center matters. Pediatr Transplant 2018; 22. [PMID: 29316061 DOI: 10.1111/petr.13120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2017] [Indexed: 11/28/2022]
Abstract
Distance from pediatric kidney transplant centers may be a significant barrier in accessing care for patients and families, particularly due to the lower number of pediatric kidney transplant centers compared with the number of adult centers. We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients to determine the effect of distance on pediatric kidney transplant waitlist outcomes. We found that distance did not play a role in the likelihood of transplantations for patients who were placed on the waitlist. However, living a greater distance from the transplant center was associated with a greater risk of death while on the waitlist. Larger volume centers attracted patients from greater distances, many of whom had other centers closer to their home. Further investigation on the role of distance to transplant center and the likelihood of being evaluated and listed for a kidney transplant would elucidate whether there are additional barriers these patients face.
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Affiliation(s)
- Bonnie Cao
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Joel T Adler
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yanik J Bababekov
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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6
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Socioeconomic factors as predictors of organ donation. J Surg Res 2018; 221:88-94. [DOI: 10.1016/j.jss.2017.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/28/2017] [Accepted: 08/10/2017] [Indexed: 11/18/2022]
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7
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Adler JT, Bababekov YJ, Markmann JF, Chang DC, Yeh H. Distance is associated with mortality on the waitlist in pediatric liver transplantation. Pediatr Transplant 2017; 21. [PMID: 27804189 DOI: 10.1111/petr.12842] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2016] [Indexed: 11/29/2022]
Abstract
The distance to liver transplant centers affects outcomes in adult liver transplantation. Because pediatric patients are particularly vulnerable, we hypothesized that distance adversely affects the time to transplantation and waitlist mortality. The SRTR was queried for isolated pediatric liver transplant registrants (under age 18) with valid ZIP code information from 2003 to 2012. Distance was measured from home ZIP code to listing transplant center. Competing events analysis, adjusted for demographic factors, indication, and PELD, was undertaken for transplantation and death while on the waitlist. The median distance to listing transplant center for 6924 children was 65 (IQR 17.5-189) miles. Median distance traveled increased by listing volume (73.9 vs 33.8 miles, highest vs lowest volume quartile, P<.001 for trend) and varied across the country. Longer distance was not associated with time to transplantation (HR 0.99, longest vs shortest distance quartile, P=.80), but was associated with increased mortality (HR 1.75, P<.001). Larger centers attract patients from a distance, while smaller centers serve local populations. Increasing distance is associated with a higher risk of waitlist death, which may reflect decreased access to specialist and tertiary care associated with a transplant center.
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Affiliation(s)
- Joel T Adler
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yanik J Bababekov
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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Adler JT, Hyder JA, Markmann JF, Axelrod DA, Yeh H. Socioeconomic gradients between locally transplanted and exported liver donors and recipients. Liver Transpl 2016; 22:557-8. [PMID: 26845498 DOI: 10.1002/lt.24410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 01/20/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Joel T Adler
- Division of Transplant Surgery, Massachusetts General Hospital, Boston, MA
| | - Joseph A Hyder
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Boston, MA
| | - David A Axelrod
- Division of Transplant Surgery, Massachusetts General Hospital, Boston, MA.,Section of Transplant Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Heidi Yeh
- Division of Transplant Surgery, Massachusetts General Hospital, Boston, MA
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