1
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Engen RM. Predicting pediatric kidney transplant wait times: The unexplored landscape and pre-allocation transplant policies. Pediatr Nephrol 2024; 39:2275-2278. [PMID: 38302675 DOI: 10.1007/s00467-024-06308-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
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Cantu E, Diamond J, Ganjoo N, Nottigham A, Ramon CV, McCurry M, Friskey J, Jin D, Anderson MR, Lisowski J, Le Mahajan A, Localio AR, Gallop R, Hsu J, Christie J, Schaubel DE. Scoring donor lungs for graft failure risk: The Lung Donor Risk Index (LDRI). Am J Transplant 2024; 24:839-849. [PMID: 38266712 DOI: 10.1016/j.ajt.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
Lung transplantation lags behind other solid organ transplants in donor lung utilization due, in part, to uncertainty regarding donor quality. We sought to develop an easy-to-use donor risk metric that, unlike existing metrics, accounts for a rich set of donor factors. Our study population consisted of n = 26 549 adult lung transplant recipients abstracted from the United Network for Organ Sharing Standard Transplant Analysis and Research file. We used Cox regression to model graft failure (GF; earliest of death or retransplant) risk based on donor and transplant factors, adjusting for recipient factors. We then derived and validated a Lung Donor Risk Index (LDRI) and developed a pertinent online application (https://shiny.pmacs.upenn.edu/LDRI_Calculator/). We found 12 donor/transplant factors that were independently predictive of GF: age, race, insulin-dependent diabetes, the difference between donor and recipient height, smoking, cocaine use, cytomegalovirus seropositivity, creatinine, human leukocyte antigen (HLA) mismatch, ischemia time, and donation after circulatory death. Validation showed the LDRI to have GF risk discrimination that was reasonable (C = 0.61) and higher than any of its predecessors. The LDRI is intended for use by transplant centers, organ procurement organizations, and regulatory agencies and to benefit patients in decision-making. Unlike its predecessors, the proposed LDRI could gain wide acceptance because of its granularity and similarity to the Kidney Donor Risk Index.
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Affiliation(s)
- Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joshua Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nikhil Ganjoo
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ana Nottigham
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christian Vivar Ramon
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Madeline McCurry
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jacqueline Friskey
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dun Jin
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jessica Lisowski
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Audrey Le Mahajan
- Division of Infectious Disease, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, Pennsylvania, USA
| | - Jesse Hsu
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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3
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Maclay LM, Husain SA. Embracing Complexity to Better Serve Pediatric Kidney Transplant Recipients. Clin J Am Soc Nephrol 2024; 19:286-288. [PMID: 38319991 PMCID: PMC10937015 DOI: 10.2215/cjn.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Lindsey M Maclay
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
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Zhang Q, Su X, Liu L, Huang M, Wu W, Zhang H, Wu C, Fu Q, Gao P, Ling L, Chen W, Xu B, Liao Y, Li J, Wang C. The Outcome of Transplanting Kidneys From Very Small Pediatric Deceased Donors. Transplantation 2023; 107:1564-1572. [PMID: 36788440 DOI: 10.1097/tp.0000000000004534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Kidneys from very small pediatric donors (VSPDs, aged <2 y) are underutilized. Concerns regarding potentially inferior outcomes hinder the use in pediatric recipients. METHODS All pediatric kidney-only transplants from <18-year-old donors between January 2012 and May 2021 in our center were included in this study. Outcomes were compared between VSPD and normal pediatric donor (NPD, aged 2-18 y) groups, and 3-y death-censored graft survival was assessed by the multivariable Cox proportional hazard model. RESULTS Of all 252 enrolled patients, 149 (59.1%) received kidneys from NPDs and 103 (40.9%) from VSPDs. The 3-y graft survival rates of the NPD and VSPD groups were 91.2% and 88.6%, respectively ( P = 0.385). The adjusted hazard ratio of 3-y graft loss was 1.2 (95% confidence interval, 0.6-2.5; P = 0.659) for the VSPD group compared with the NPD group. There was no significant difference in estimated glomerular filtration rate at 3 y posttransplant observed between NPD and VSPD groups (86.9 ± 26.8 versus 87 ± 27.9 mL/min/1.73 m 2 ; P = 0.991). Patients (n = 12, 4.8%) who received kidneys from donors <5 kg contributed 5 (5/39, 12.8%) with delayed graft function and the sole primary nonfunction in our cohort. CONCLUSIONS Although attention to preventing complications is necessary, especially for kidneys from donors <5 kg, kidneys from VSPDs did not appear to impart added risk for 3-y graft loss and renal function.
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Affiliation(s)
- Qiang Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaojun Su
- 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
| | - Mingchuan Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenrui Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huanxi Zhang
- 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
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pengfei Gao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liuting Ling
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenting Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bowen Xu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuan Liao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial Key Laboratory Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
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5
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Montgomery A, Goff C, Adeyeri B, Ferreira LD, Kamepalli S, Lynn J, Galvan NTN, Srivaths PR, Brewer ED, Rana A. A modified Kidney Donor Risk Index for pediatric kidney transplant recipients. Pediatr Nephrol 2023; 38:1309-1317. [PMID: 36066770 DOI: 10.1007/s00467-022-05722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Kidney Donor Risk Index (KDRI) by Rao et al. was developed to measure the quality of kidney allografts. While Rao's KDRI has been found to be a robust measure of kidney allograft survival for adult kidney transplant recipients, many studies have indicated the need to create a distinct pediatric KDRI. METHODS Our retrospective study utilized data from the United Network for Organ Sharing database. We examined 9295 deceased donor recipients' data for age < 18 years from 1990 to 2020. We performed a multivariate Cox regression to determine the significant recipient and transplant factors impacting pediatric kidney allograft survival. RESULTS Multivariate analysis found 5 donor factors to be independently associated with graft failure or recipient death: age, female sex, anoxia as the cause of death, history of cigarette use, and cold ischemia time. Using receiver operator characteristic (ROC) curve analysis and analyzing the predictive value of each KDRI at 1, 5, and 10 years, the proposed pediatric KDRI had a statistically significant and higher predictive value for pediatric recipients at 5 (0.60 versus 0.57) and 10 years (0.61 versus 0.57) than the Rao KDRI. CONCLUSIONS The proposed pediatric KDRI may provide a more accurate and simpler index to assess the quality of kidney allografts for pediatric recipients. However, due to the mild increase in predictive capabilities over the Rao index, the study serves as a proof of concept to develop a pediatric KDRI. Further studies should focus on increasing the index's predictive capabilities. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Ashley Montgomery
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA.
| | - Cameron Goff
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Bolatito Adeyeri
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Liam D Ferreira
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Spoorthi Kamepalli
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Jake Lynn
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Eileen D Brewer
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Ettenger R, Venick RS, Gritsch HA, Alejos JC, Weng PL, Srivastava R, Pearl M. Deceased donor organ allocation in pediatric transplantation: A historical narrative. Pediatr Transplant 2023; 27 Suppl 1:e14248. [PMID: 36468338 DOI: 10.1111/petr.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since the earliest clinical successes in solid organ transplantation, the proper method of organ allocation for children has been a contentious subject. Over the past 30-35 years, the medical and social establishments of various countries have favored some degree of preference for children on the respective waiting lists. However, the specific policies to accomplish this have varied widely and changed frequently between organ type and country. METHODS Organ allocation policies over time were examined. This review traces the reasons behind and the measures/principles put in place to promote early deceased donor transplantation in children. RESULTS Preferred allocation in children has been approached in a variety of ways and with varying degrees of commitment in different solid organ transplant disciplines and national medical systems. CONCLUSION The success of policies to advantage children has varied significantly by both organ and medical system. Further work is needed to optimize allocation strategies for pediatric candidates.
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Affiliation(s)
- Robert Ettenger
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Robert S Venick
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hans A Gritsch
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Juan C Alejos
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Patricia L Weng
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rachana Srivastava
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Meghan Pearl
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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7
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Charnaya O, Levy Erez D, Amaral S, Monos DS. Pediatric Kidney Transplantation-Can We Do Better? The Promise and Limitations of Epitope/Eplet Matching. Front Pediatr 2022; 10:893002. [PMID: 35722502 PMCID: PMC9204054 DOI: 10.3389/fped.2022.893002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/16/2022] [Indexed: 12/02/2022] Open
Abstract
Kidney transplant is the optimal treatment for end-stage kidney disease as it offers significant survival and quality of life advantages over dialysis. While recent advances have significantly improved early graft outcomes, long-term overall graft survival has remained largely unchanged for the last 20 years. Due to the young age at which children receive their first transplant, most children will require multiple transplants during their lifetime. Each subsequent transplant becomes more difficult because of the development of de novo donor specific HLA antibodies (dnDSA), thereby limiting the donor pool and increasing mortality and morbidity due to longer time on dialysis awaiting re-transplantation. Secondary prevention of dnDSA through increased post-transplant immunosuppression in children is constrained by a significant risk for viral and oncologic complications. There are currently no FDA-approved therapies that can meaningfully reduce dnDSA burden or improve long-term allograft outcomes. Therefore, primary prevention strategies aimed at reducing the risk of dnDSA formation would allow for the best possible long-term allograft outcomes without the adverse complications associated with over-immunosuppression. Epitope matching, which provides a more nuanced assessment of immunological compatibility between donor and recipient, offers the potential for improved donor selection. Although epitope matching is promising, it has not yet been readily applied in the clinical setting. Our review will describe current strengths and limitations of epitope matching software, the evidence for and against improved outcomes with epitope matching, discussion of eplet load vs. variable immunogenicity, and conclude with a discussion of the delicate balance of improving matching without disadvantaging certain populations.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniella Levy Erez
- Schneider Children's Medical Center, Institute of Pediatric Nephrology, Petah Tikvah, Israel
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sandra Amaral
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Dimitrios S. Monos
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Ott L, Vakili K, Cuenca AG. Organ allocation in pediatric abdominal transplant. Semin Pediatr Surg 2022; 31:151180. [PMID: 35725055 PMCID: PMC9333194 DOI: 10.1016/j.sempedsurg.2022.151180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pediatric patients constitute an important group within the general transplant population, given the opportunity to significantly extend their lives with successful transplantation. Children have historically received special consideration under the various abdominal solid organ allocation algorithms, but matching patients with size and weight restrictions with appropriate donors remains an ongoing issue. Here, we describe the historical trends in pediatric organ allocation policies for liver, kidney, intestine, and pancreas transplantation. We also review recent changes to these allocation policies, with particular attention to recent amendments to geographical prioritization, with the dissolution of donor service areas and United Network for Organ Sharing (UNOS) regions and the subsequent creation of acuity circles.
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Affiliation(s)
- Leah Ott
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Khashayar Vakili
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Alex G Cuenca
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States.
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Krissberg JR, Kaufmann MB, Gupta A, Bendavid E, Stedman M, Cheng XS, Tan JC, Grimm PC, Chaudhuri A. Racial Disparities in Pediatric Kidney Transplantation under the New Kidney Allocation System in the United States. Clin J Am Soc Nephrol 2021; 16:1862-1871. [PMID: 34670797 PMCID: PMC8729489 DOI: 10.2215/cjn.06740521] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES In December 2014, the Kidney Allocation System (KAS) was implemented to improve equity in access to transplantation, but preliminary studies in children show mixed results. Thus, we aimed to assess how the 2014 KAS policy change affected racial and ethnic disparities in pediatric kidney transplantation access and related outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study of children <18 years of age active on the kidney transplant list from 2008 to 2019 using the Scientific Registry of Transplant Recipients. Log-logistic accelerated failure time models were used to determine the time from first activation on the transplant list and the time on dialysis to deceased donor transplant, each with KAS era or race and ethnicity as the exposure of interest. We used logistic regression to assess odds of delayed graft function. Log-rank tests assessed time to graft loss within racial and ethnic groups across KAS eras. RESULTS All children experienced longer wait times from activation to transplantation post-KAS. In univariable analysis, Black and Hispanic children and other children of color experienced longer times from activation to transplant compared with White children in both eras; this finding was largely attenuated after multivariable analysis (time ratio, 1.16; 95% confidence interval, 1.01 to 1.32; time ratio, 1.13; 95% confidence interval, 1.00 to 1.28; and time ratio, 1.17; 95% confidence interval, 0.96 to 1.41 post-KAS, respectively). Multivariable analysis also showed that racial and ethnic disparities in time from dialysis initiation to transplantation in the pre-KAS era were mitigated in the post-KAS era. There were no disparities in odds of delayed graft function. Black and Hispanic children experienced longer times with a functioning graft in the post-KAS era. CONCLUSIONS No racial and ethnic disparities from activation to deceased donor transplantation were seen before or after implementation of the KAS in multivariable analysis, whereas time on dialysis to transplantation and odds of short-term graft loss improved in equity after the implementation of the KAS, without compromising disparities in delayed graft function. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_07_CJN06740521.mp3.
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Affiliation(s)
- Jill R. Krissberg
- Department of Pediatrics, Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Department of Nephrology, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Matthew B. Kaufmann
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Anshal Gupta
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Eran Bendavid
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Margaret Stedman
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Xingxing S. Cheng
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jane C. Tan
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Paul C. Grimm
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Abanti Chaudhuri
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, California
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11
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Chandar J, Chen L, Defreitas M, Ciancio G, Burke G. Donor considerations in pediatric kidney transplantation. Pediatr Nephrol 2021; 36:245-257. [PMID: 31932959 DOI: 10.1007/s00467-019-04362-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/18/2019] [Accepted: 09/06/2019] [Indexed: 01/10/2023]
Abstract
This article reviews kidney transplant donor options for children with end-stage kidney disease (ESKD). Global access to kidney transplantation is variable. Well-established national policies, organizations for organ procurement and allocation, and donor management policies may account for higher deceased donor (DD transplants) in some countries. Living donor kidney transplantation (LD) predominates in countries where organ donation has limited national priority. In addition, social, cultural, religious and medical factors play a major role in both LD and DD kidney transplant donation. Most children with ESKD receive adult-sized kidneys. The transplanted kidney has a finite survival and the expectation is that children who require renal replacement therapy from early childhood will probably have 2 or 3 kidney transplants in their lifetime. LD transplant provides better long-term graft survival and is a better option for children. When a living related donor is incompatible with the intended recipient, paired kidney exchange with a compatible unrelated donor may be considered. When the choice is a DD kidney, the decision-making process in accepting a donor offer requires careful consideration of donor history, kidney donor profile index, HLA matching, cold ischemia time, and recipient's time on the waiting list. Accepting or declining a DD offer in a timely manner can be challenging when there are undesirable facts in the donor's history which need to be balanced against prolonging dialysis in a child. An ongoing global challenge is the significant gap between organ supply and demand, which has increased the need to improve organ preservation techniques and awareness for organ donation.
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Affiliation(s)
- Jayanthi Chandar
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami Transplant Institute, PO Box 016960 (M714), Miami, FL, 33101, USA.
| | - Linda Chen
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
| | - Marissa Defreitas
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami Transplant Institute, PO Box 016960 (M714), Miami, FL, 33101, USA
| | - Gaetano Ciancio
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
| | - George Burke
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
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Jackson KR, Bowring MG, Kernodle A, Boyarsky B, Desai N, Charnaya O, Garonzik-Wang J, Massie AB, Segev DL. Changes in offer and acceptance patterns for pediatric kidney transplant candidates under the new Kidney Allocation System. Am J Transplant 2020; 20:2234-2242. [PMID: 32012451 PMCID: PMC8555691 DOI: 10.1111/ajt.15799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 01/25/2023]
Abstract
Stakeholders have expressed concerns regarding decreased deceased donor kidney transplant (DDKT) rates for pediatric candidates under the Kidney Allocation System (KAS). To better understand what might be driving this, we studied Scientific Registry of Transplant Recipients kidney offer data for 3642 pediatric (age <18 years) kidney-only transplant candidates between December 31, 2012 to December 3, 2014 (pre-KAS) and December 4, 2014 to January 6, 2017 (post-KAS). We used negative binomial regression and multilevel logistic regression to compare offer and acceptance rates pre- and post-KAS. We stratified by donor age (<18, 18-34, and 35+ years) and KDPI (<35% and ≥35%) to reflect differing allocation prioritization pre-KAS and post-KAS. As might be expected from prioritization changes, post-KAS candidates were less likely to receive offers for donors 18-34 years old with KDPI ≥ 35% (adjusted incidence rate ratio [aIRR]: 0.18 0.210.25 , P < .001), and more likely to receive offers for donors 18-34 years old and KDPI < 35% (aIRR: 1.12 1.201.29 , P < .001). However, offer acceptance practices also changed post-KAS: kidneys from donors 18-34 years old and KDPI < 35% were 23% less likely to be accepted post-KAS (adjusted odds ratio: 0.61 0.770.98 , P = .03). Using kidneys from donors 18-34 years old with KDPI < 35% post-KAS to the same extent they were used pre-KAS might be an effective strategy to mitigate any decrease in DDKT rates for pediatric candidates.
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Affiliation(s)
- Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amber Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Allan B. Massie
- Department of Surgery, 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
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14
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Su X, Shang W, Liu L, Li J, Fu Q, Feng Y, Zhang H, Deng R, Wu C, Wang Z, Pang X, Nashan B, Feng G, Wang C. Transplantation of a single kidney from pediatric donors less than 10 kg to children with poor access to transplantation: a two-year outcome analysis. BMC Nephrol 2020; 21:250. [PMID: 32616005 PMCID: PMC7330989 DOI: 10.1186/s12882-020-01895-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022] Open
Abstract
Background Access to kidney transplantation by uremic children is very limited due to the lack of donors in many countries. We sought to explore small pediatric kidney donors as a strategy to provide transplant opportunities for uremic children. Methods A total of 56 cases of single pediatric kidney transplantation and 26 cases of en bloc kidney transplantation from pediatric donors with body weight (BW) less than 10 kg were performed in two transplant centers in China and the transplant outcomes were retrospectively analyzed. Results The 1-year and 2-year death-censored graft survival in the en bloc kidney transplantation (KTx) group was inferior to that in the single KTx group. Subgroup analysis of the single KTx group found that the 1-year and 2-year death-censored graft survival in the group where the donor BW was between 5 and 10 kg was 97.7 and 90.0%, respectively. However, graft survival was significantly decreased when donor BW was ≤5 kg (p < 0.01), mainly because of the higher rate of thrombosis (p = 0.035). In the single KTx group, the graft length was increased from 6.7 cm at day 7 to 10.5 cm at 36 months posttransplant. The estimated glomerular filtration rate increased up to 24 months posttransplant. Delayed graft function and urethral complications were more common in the group with BW was ≤5 kg. Conclusions Our study suggests that single kidney transplantation from donors weighing over 5 kg to pediatric recipients is a feasible option for children with poor access to transplantation.
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Affiliation(s)
- Xiaojun Su
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Wenjun Shang
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Longshan Liu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Yonghua Feng
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Huanxi Zhang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Ronghai Deng
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Chenglin Wu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Zhigang Wang
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Xinlu Pang
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Björn Nashan
- Organ Transplant Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230027, People's Republic of China
| | - Guiwen Feng
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China.
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China. .,Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.
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15
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Small Split Pediatric Kidneys to Expand the Donor Pool: An Analysis of Scientific Registry of Transplant Recipients (SRTR) Data. Transplantation 2020; 103:2549-2557. [PMID: 30893290 DOI: 10.1097/tp.0000000000002706] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increased use of pediatric deceased donor kidneys could enlarge the deceased donor kidney pool. Kidney transplant outcomes from small pediatric donors were compared with those from ideal kidney (IK) and expanded criteria kidney (ECK) donors to understand the optimal use of pediatric donor kidneys. METHODS Kaplan-Meier analyses compared long-term patient and death-censored graft survival of en bloc kidney (EBK) and split kidney (SpK) transplants from small pediatric donors (aged ≤8 y and weight <30 kg) with those from IK and ECK. Posttransplant serum creatinine) was compared among these cohorts. Deceased donor kidney disposition was determined from small pediatric donors with ≥1 organ transplanted. RESULTS Patient and death-censored graft survival were similar among recipients of IK, EBK, and SpK transplants, and were superior to those of recipients of ECK. EBK and SpK transplants from donors 5-30 kg had first-year graft loss similar to ECK. Long-term graft survival and serum creatinine with kidneys from SpK donors >10 kg were better than that with ECK donors. About 3901 transplants were performed from 3660 pediatric donors (53% yield). CONCLUSIONS Pediatric kidneys can augment the kidney donor pool and should not be considered ECK. If 90% of kidneys from donors (aged ≤8 y and weight <30 kg) with ≥1 organ transplanted been used (as SpK when >10 kg) an additional 159 kidney transplants per year could have been performed. Expanding the use of pediatric kidneys should be further explored by the transplant community.
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16
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Philogene MC, Amin A, Zhou S, Charnaya O, Vega R, Desai N, Neu AM, Pruette CS. Eplet mismatch analysis and allograft outcome across racially diverse groups in a pediatric transplant cohort: a single-center analysis. Pediatr Nephrol 2020; 35:83-94. [PMID: 31599339 PMCID: PMC6901410 DOI: 10.1007/s00467-019-04344-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/05/2019] [Accepted: 08/26/2019] [Indexed: 11/25/2022]
Abstract
HLA eplet mismatch load has been suggested as an improvement to HLA antigen mismatch determination for organ selection. Given that eplet mismatches are determined based on amino acid sequence difference among HLA alleles, and that the frequency of HLA alleles varies between racial groups, we investigated the correlation between eplet mismatch load and allograft outcomes in 110 pediatric kidney transplant recipients who received their first organ from a donor of the same race (SRT) versus a donor of a different race (DRT). Adjusted modified Poisson regression was used to assess the interaction between eplet mismatch load and race mismatch and its effect on outcome. Caucasians and living donor recipients had lower eplet mismatched loads against their donors compared with non-Caucasian and deceased donor recipients. Overall, for the entire population, the risk of de novo HLA-DSA development was significantly increased with higher eplet loads (p < 0.001). Compared with the SRT group, the DRT group had higher eplet loads when compared with their donor, for HLA class I but not HLA class II molecules; however, there was no significant difference in the incidence of de novo HLA-DSA between the 2 groups. The risk of rejection increased significantly for DRT compared with SRT, only when class I eplet load was ≥ 70 (p = 0.04). Together this data show that eplet mismatch load analysis is an effective tool for alloimmune risk assessment. If considered for donor selection, acceptable eplet mismatch loads determined from studies in homogenous populations may restrict transplantation across racially diverse donor and patient groups with no evidence of poor outcome. Therefore, an acceptable eplet mismatch load threshold must consider the heterogeneity of the transplant population.
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Affiliation(s)
- Mary Carmelle Philogene
- Department of Medicine, Johns Hopkins School of Medicine, 2041 E. Monument Street, Baltimore, MD, 21205, USA.
- Immunogenetics Laboratory, 2041 E. Monument Street, Baltimore, MD, 21205, USA.
| | - Anita Amin
- Department of Neurology, University of North Carolina School of Medicine, 115 Mason Farm Road, Chapel Hill, NC, 27599, USA
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Ave Turner 34, Baltimore, MD, 21205, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Olga Charnaya
- Department of Pediatric Nephrology, Rubenstein Child Health Building, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Renato Vega
- Department of Medicine, Johns Hopkins School of Medicine, 2041 E. Monument Street, Baltimore, MD, 21205, USA
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Ave Turner 34, Baltimore, MD, 21205, USA
| | - Alicia M Neu
- Department of Pediatric Nephrology, Rubenstein Child Health Building, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Cozumel S Pruette
- Department of Pediatric Nephrology, Rubenstein Child Health Building, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Baltimore, MD, 21287, USA
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17
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Jackson KR, Zhou S, Ruck J, Massie AB, Holscher C, Kernodle A, Glorioso J, Motter J, Neu A, Desai N, Segev DL, Garonzik-Wang J. Pediatric deceased donor kidney transplant outcomes under the Kidney Allocation System. Am J Transplant 2019; 19:3079-3086. [PMID: 31062464 PMCID: PMC6834871 DOI: 10.1111/ajt.15419] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 04/08/2019] [Accepted: 04/26/2019] [Indexed: 01/25/2023]
Abstract
The Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This had prompted concerns that post-pDDKT outcomes may worsen. To study this, we used SRTR data to compare the outcomes of 953 pre-KAS pDDKT (age <18 years) recipients (December 4, 2012-December 3, 2014) with the outcomes of 934 post-KAS pDDKT recipients (December 4, 2014-December 3, 2016). We analyzed mortality and graft loss by using Cox regression, delayed graft function (DGF) by using logistic regression, and length of stay (LOS) by using negative binomial regression. Post-KAS recipients had longer pretransplant dialysis times (median 1.26 vs 1.07 years, P = .02) and were more often cPRA 100% (2.0% vs 0.1%, P = .001). Post-KAS recipients had less graft loss than pre-KAS recipients (hazard ratio [HR]: 0.35 0.540.83 , P = .005) but no statistically significant differences in mortality (HR: 0.29 0.721.83 , P = .5), DGF (odds ratio: 0.93 1.321.93 , P = .2), and LOS (LOS ratio: 0.96 1.061.19 , P = .4). After adjusting for donor-recipient characteristics, there were no statistically significant post-KAS differences in mortality (adjusted HR: 0.37 1.042.92 , P = .9), DGF (adjusted odds ratio: 0.94 1.412.13 , P = .1), or LOS (adjusted LOS ratio: 0.93 1.041.16 , P = .5). However, post-KAS pDDKT recipients still had less graft loss (adjusted HR: 0.38 0.590.91 , P = .02). KAS has had a mixed effect on short-term posttransplant outcomes for pDDKT recipients, although our results are limited by only 2 years of posttransplant follow-up.
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Affiliation(s)
- Kyle R. Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica Ruck
- 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
| | - Courtenay Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amber Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jaime Glorioso
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niraj Desai
- Department of Surgery, 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
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18
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Meyers MR, Shults J, Laskin B, Porrett P, Levine M, Abt P, Amaral S, Goldberg DS. Use of public health service increased risk kidneys in pediatric renal transplant recipients. Pediatr Transplant 2019; 23:e13405. [PMID: 31271263 PMCID: PMC7197411 DOI: 10.1111/petr.13405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/13/2019] [Indexed: 11/30/2022]
Abstract
With the opioid epidemic and expansion of "IR" classification, 25% of deceased donors are categorized PHS-IR. Studies have assessed utilization of PHS-IR organs among adults, but little is known about pediatric recipients. This retrospective cohort study from 2004-2016 (IR period) aimed to: (a) assess IR kidney utilization patterns between adults and children; (b) identify recipient factors associated with transplant from IR donors among pediatric kidney recipients; and (c) determine geography's role in IR kidney utilization for children. The proportion of pediatric recipients receiving IR kidneys was significantly lower than adults (P < 0.001), even when stratified by donor mechanism of death (non-overdose/overdose) and era. In mixed effects models accounting for clustering within centers and regions, older recipient age, later era (post-PHS-IR expansion), and blood type were associated with significantly higher odds of receiving an IR kidney (17 years era 5: OR 5.16 [CI 2.05-13.1] P < 0.001; 18-21 years era 5: OR 2.72 [CI 1.05-7.06] P = 0.04; blood type O: OR 1.32 [CI 1.06-1.64] P = 0.013). The median odds ratio for center within region was 1.77 indicating that when comparing two patients in a region, the odds of receiving an IR kidney were 77% higher for a patient from a center with higher likelihood of receiving an IR kidney. Utilization of PHS-IR kidneys is significantly lower among pediatric recipients versus adult counterparts. More work is needed to understand the reasons for these differences in children in order to continue their access to this life-prolonging therapy.
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Affiliation(s)
- Melissa R. Meyers
- The Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology, and Informatics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justine Shults
- The Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology, and Informatics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Benjamin Laskin
- The Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paige Porrett
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew Levine
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peter Abt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sandra Amaral
- The Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology, and Informatics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David S. Goldberg
- Department of Biostatistics, Epidemiology, and Informatics; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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19
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Pereira LDNG, Nogueira PCK. Non-standard criteria donors in pediatric kidney transplantation. Pediatr Transplant 2019; 23:e13452. [PMID: 31066489 DOI: 10.1111/petr.13452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 12/21/2022]
Abstract
KT remains the treatment of choice for ESRD in children. However, the demand for kidney transplants continues to outstrip supply, even in the pediatric scenario. We reviewed the applicability of nonSCDs for pediatric KT. There is a lack of studies analyzing this modality among pediatric donors and recipients, where most conclusions are based on predictions from adult data. Nevertheless, marginal donors might be a reasonable option in selected cases. For example, the use of older LDs is an acceptable option, with outcomes comparable to SCDs. Organs donated after cardiac death represent another possibility, albeit with logistic, ethical, and legal limitations in some countries. AKI donors also constitute an option in special situations, although there are no pediatric data on these transplants. Likewise, there are no data on the use of expanded criteria donors in pediatric patients, but this appears not to be a good option, considering the compromised long-term survival.
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Affiliation(s)
| | - Paulo Cesar Koch Nogueira
- Pediatric Nephrology Division, Pediatric Department, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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20
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Rogers J, Farney AC, Orlando G, Harriman D, Reeves-Daniel A, Jay CL, Doares W, Kaczmorski S, Gautreaux MD, Stratta RJ. Dual Kidney Transplantation from Donors at the Extremes of Age. J Am Coll Surg 2019; 228:690-705. [PMID: 30630083 DOI: 10.1016/j.jamcollsurg.2018.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The study purpose was to analyze outcomes in recipients of pediatric dual en bloc (PEB) kidneys from small pediatric donors (SPDs, age ≤ 3 years) and dual kidney transplants (KTs) from adult marginal deceased donors (DDs) in the context of the Kidney Donor Profile Index (KDPI). STUDY DESIGN This was a single center retrospective review. Recipient selection included primary transplant, low BMI, low immunologic risk, and informed consent. All patients received antibody induction with FK/MPA/± prednisone. RESULTS From 2002 to 2015, we performed 34 PEB and 73 adult dual KTs. Mean donor ages were 17 months for the PEB and 59 years for the dual KTs; mean KDPIs were 73% for PEB and 83% for dual KT, and mean cold ischemia times were 21.0 hours for PEB and 26.5 hours for dual KT. Adult dual KT recipients were older (mean age 38 years for PEB and 60 years for dual KT) and had shorter waiting times (mean 25 months for PEB and 12 months for dual KT). With a mean follow-up of 7.6 years, actual patient survival (88% for PEB and 62% for dual KT) and graft survival (71% for PEB and 44% for dual KT) rates were higher in PEB compared with dual KT. Death-censored kidney graft survival rates were 77% for PEB and 58% for dual KT. Delayed graft function (DGF) rates were 15% for PEB and 23% for dual KT; incidences of DGF in single kidney transplantations from SPDs and adult nonmarginal DDs were 20% and 32%, respectively. Based on actual 5-year graft survival rates, the adjusted KDPIs for dual PEB and dual KTs were 3% and 60%, respectively. CONCLUSIONS Acceptable mid-term outcomes are associated with PEB and adult dual KTs, which may expand the donor pool and prevent kidney discard. The KDPI is inaccurate for predicting outcomes from either PEB from SPDs or dual KT from adult marginal DDs, which may prevent acceptance of these organs.
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Affiliation(s)
- Jeffrey Rogers
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan C Farney
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Giuseppe Orlando
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - David Harriman
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Colleen L Jay
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - William Doares
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, NC
| | - Scott Kaczmorski
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Robert J Stratta
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
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21
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Sexton DJ, O'Kelly P, Kennedy C, Denton M, de Freitas DG, Magee C, O'Seaghdha CM, Conlon PJ. Assessing the discrimination of the Kidney Donor Risk Index/Kidney Donor Profile Index scores for allograft failure and estimated glomerular filtration rate in Ireland's National Kidney Transplant Programme. Clin Kidney J 2019; 12:569-573. [PMID: 31411596 PMCID: PMC6671481 DOI: 10.1093/ckj/sfy130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Indexed: 01/05/2023] Open
Abstract
Background The Kidney Donor Risk Index (KDRI)/Kidney Donor Profile Index (KDPI) is relied upon for donor organ allocation in the USA, based on its association with graft failure in time-to-event models. However, the KDRI/KDPI has not been extensively evaluated in terms of predictive metrics for graft failure and allograft estimated glomerular filtration rate (eGFR) outside of the USA. Methods We performed a retrospective analysis of outcomes in the Irish National Kidney Transplant Service Registry for the years 2006–13. Associations of the KDRI/KDPI score with eGFR at various time points over the follow-up and ultimate graft failure were modelled. Results A total of 772 patients had complete data regarding KDRI/KDPI calculation and 148 of these allografts failed over the follow-up. The median and 25–75th centile for KDRI/KDPI was 51 (26–75). On repeated-measures analysis with linear mixed effects models, the KDRI/KDPI (fixed effect covariate) associated with eGFR over 5 years: eGFR = −0.25 (standard error 0.02; P < 0.001). The variability in eGFR mathematically accounted for by the KDRI/KDPI score was only 21%. The KDRI/KDPI score did not add significantly to graft failure prediction above donor age alone (categorized as > and <50 years of age) when assessed by the categorical net reclassification index. Conclusions In this cohort, while the KDRI/KDPI was predictive of eGFR over the follow-up, it did not provide additive discrimination above donor age alone in terms of graft failure prediction. Therefore it is unlikely to help inform decisions regarding kidney organ allocation in Ireland.
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Affiliation(s)
- Donal J Sexton
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland
| | - Claire Kennedy
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland
| | - Mark Denton
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland
| | - Declan G de Freitas
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Colm Magee
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland
| | - Conall M O'Seaghdha
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology and Kidney Transplantation, National Kidney Transplant Service, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
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22
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Bikbov B. R Open Source Programming Code for Calculation of the Kidney Donor Profile Index and Kidney Donor Risk Index. KIDNEY DISEASES (BASEL, SWITZERLAND) 2018; 4:269-272. [PMID: 30574504 PMCID: PMC6276747 DOI: 10.1159/000492427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/25/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Kidney Donor Profile Index (KDPI) and Kidney Donor Risk Index (KDRI) were developed by the United States Organ Procurement and Transplantation Network (OPTN). They may influence the clinical decision whether to accept or discard a donor kidney, but still there are debates about KDPI/KDRI applicability and its consequences. To further evaluate these indexes in different populations, more data should be analyzed, and a universally applicable program code would facilitate it. Currently, KDPI/KDRI calculation could be readily done only on the OPTN website that is convenient for a single donor, but not suitable for processing data sets with many records. SUMMARY A universally applicable program algorithm in widely used R language for calculating KDPI and KDRI was developed according to donor factors and coefficients described in the OPTN guide. KEY MESSAGES The open R code permits to calculate KDPI/KDRI either for a single donor or for an unlimited number of records in large data sets. The presented software code would save substantial time to research groups all over the world and help to clarify the KDPI/KDRI role in global settings.
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Affiliation(s)
- Boris Bikbov
- Academician V.I.Shumakov Federal Research Center of Transplantology and Artificial Organs, Moscow, Russian Federation
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23
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Kling CE, Perkins JD, Johnson CK, Blosser CD, Leca N, Sibulesky L. Utilization of Standard Criteria Donor and Expanded Criteria Donor Kidneys After Kidney Allocation System Implementation. Ann Transplant 2018; 23:691-703. [PMID: 30287804 PMCID: PMC6255331 DOI: 10.12659/aot.910504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Implementation of the Kidney Allocation System (KAS) changed how kidneys are allocated and the information on which organ utilization decisions are based. We aimed to evaluate how KAS implementation changed kidney utilization and recipient outcomes. MATERIAL AND METHODS Using the United Network for Organ Sharing database, we identified recipients of kidney transplants from donors with kidney donor profile index (KDPI) of 61-90% in the 5-years pre- and 18-months post-KAS implementation and examined patient and graft survival and donor kidney discard rates based on standard criteria donor (SCD) or expanded criteria donor (ECD) status. RESULTS The proportion of ECD kidneys was unchanged pre- versus post-KAS. Post-KAS, SCD kidneys were less likely to be transplanted into young recipients while ECD kidneys were more likely to be transplanted. SCD kidneys in the post-KAS period conferred a 1.42 (95% CI: 1.18-1.73) times higher adjusted mortality and 2% lower 1-year survival (94.2% vs. 96.2%, P<0.001) but had unchanged graft failure compared to pre-KAS. For ECD kidneys, there was no difference in mortality or graft survival. The discard rate increased after KAS for both SCD and ECD kidneys (P<0.05) but was not different between SCD and ECD kidneys for any KDPI group. CONCLUSIONS After KAS implementation, patient survival for recipients of SCD kidneys was significantly worse.
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Affiliation(s)
- Catherine E Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - James D Perkins
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - Christopher K Johnson
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher D Blosser
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lena Sibulesky
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
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Shelton BA, Locke JE. Response to "It is time to revise the kidney allocation system to restore the pediatric advantage". Am J Transplant 2018; 18:2367. [PMID: 29762906 DOI: 10.1111/ajt.14934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Brittany A Shelton
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Jayme E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
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Gallo AE, Parker WF, Thistlethwaite JR, Ross LF. It is time to revise the kidney allocation system to restore the pediatric advantage. Am J Transplant 2018; 18:2365-2366. [PMID: 29706006 PMCID: PMC6117209 DOI: 10.1111/ajt.14898] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Amy E. Gallo
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - William F. Parker
- Department of Medicine, University of Chicago, Chicago, IL, USA,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - James R. Thistlethwaite
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA,Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Lainie F. Ross
- Department of Medicine, University of Chicago, Chicago, IL, USA,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA,Department of Pediatrics, University of Chicago, Chicago, IL, USA,Department of Surgery, University of Chicago, Chicago, IL, USA
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26
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Tafesse E. The kidney allocation system and its implications for pediatric recipients. Am J Transplant 2018; 18:1824. [PMID: 29673095 DOI: 10.1111/ajt.14881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Nazarian SM, Levine MH, Amaral S. Invited Letter Re: The kidney allocation system and its implications for pediatric recipients. Am J Transplant 2018; 18:1825. [PMID: 29673056 DOI: 10.1111/ajt.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Susanna M Nazarian
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew H Levine
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Surgical Co-Director of Transplantation, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sandra Amaral
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Center for Clinical Epidemiology and Biostatistics, Pennsylvania, Philadelphia, PA, USA
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Parker WF, Ross LF, Richard Thistlethwaite J, Gallo AE. Impact of the kidney allocation system on young pediatric recipients. Clin Transplant 2018; 32:e13223. [PMID: 29457274 DOI: 10.1111/ctr.13223] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2018] [Indexed: 01/27/2023]
Abstract
The kidney allocation system (KAS) altered pediatric candidate prioritization. We determined KAS's impact on pediatric kidney recipients by examining delayed graft function (DGF) rates from 2010 to 2016. A propensity score-matched pediatric recipients pre- and post-KAS. A semiparametric decomposition analysis estimated the contributions of KAS-related changes in donor characteristics and dialysis time on DGF rate. The unadjusted odds of DGF were 69% higher post-KAS for young (<10 years at listing) recipients (N = 1153, P = .02) but were not significantly increased for older pediatric (10-17 years at listing) recipients (N = 2624, P = .48). Post-KAS, young recipients received significantly fewer pediatric (<18 years) donor kidneys (21% vs 32%, P < .01) and had longer median pretransplant dialysis time (603 vs 435 days, P < .01). After propensity score matching, post-KAS status increased the odds of DGF in young recipients 71% (OR 1.71, 95% CI 1.01-2.46). In decomposition analysis, 24% of the higher DGF rate post-KAS was attributable to donor characteristics and 19% to increased recipient dialysis time. In a confirmatory survival analysis, DGF was associated with a 2.2 times higher risk of graft failure (aHR2.28, 95% CI 1.46-3.54). In conclusion, KAS may lead to worse graft survival outcomes in children. Allocation changes should be considered.
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Affiliation(s)
- William Fiske Parker
- Department of Medicine, University of Chicago, Chicago, IL, USA.,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - Lainie Friedman Ross
- Department of Medicine, University of Chicago, Chicago, IL, USA.,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA.,Department of Pediatrics, University of Chicago, Chicago, IL, USA.,Department of Surgery, University of Chicago, Chicago, IL, USA
| | - J Richard Thistlethwaite
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA.,Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Amy E Gallo
- Department of Surgery, Stanford University, Palo Alto, CA, USA
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