1
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Davidson B, Du Toit T, Jones ESW, Barday Z, Manning K, Mc Curdie F, Thomson D, Rayner BL, Muller E, Wearne N. Outcomes and challenges of a kidney transplant programme at Groote Schuur Hospital, Cape Town: A South African perspective. PLoS One 2019; 14:e0211189. [PMID: 30682138 PMCID: PMC6347365 DOI: 10.1371/journal.pone.0211189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/08/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction Access to dialysis and transplantation in the developing world remains limited. Therefore, optimising renal allograft survival is essential. This study aimed to evaluate clinical outcomes and identify poor prognostic factors in the renal transplant programme at Groote Schuur Hospital [GSH], Cape Town. Method Data were collected on all patients who underwent a kidney transplant at GSH from 1st July 2010 to the 30 June 2015. Analyses were performed to assess baseline characteristics, graft and patient survival, as well as predictors of poor outcome. Results 198 patients were transplanted. The mean age was 38 +/- 10.5 years, 127 (64.1%) were male, and 86 (43.4%) were of African ethnicity. Deceased donor organs were used for 130 (66.7%) patients and living donors for 65 (33.3%). There were > 5 HLA mismatches in 58.9% of transplants. Sepsis was the commonest cause of death and delayed graft function [DGF] occurred in 41 (21.4%) recipients. Patient survival was 90.4% at 1 year and 83.1% at 5 years. Graft survival was 89.4% at 1 year and 80.0% at 5 years. DGF (HR 2.83 (1.12–7.19), p value = 0.028) and recipient age > 40 years (HR 3.12 (1.26–7.77), p value = 0.014) were predictors of death. Conclusion Despite the high infectious burden, stratified immunosuppression and limited tissue typing this study reports encouraging results from a resource constrained transplant programme in South Africa. Renal transplantation is critical to improve access to treatment of end stage kidney disease where access to dialysis is limited.
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Affiliation(s)
- Bianca Davidson
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Western Cape, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Western Cape, South Africa
- * E-mail:
| | - Tinus Du Toit
- Department of Surgery, University of Cape Town, Western Cape, South Africa
| | - Erika S. W. Jones
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Western Cape, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Western Cape, South Africa
| | - Zunaid Barday
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Western Cape, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Western Cape, South Africa
| | - Kathryn Manning
- Department of Surgery, University of Cape Town, Western Cape, South Africa
| | - Fiona Mc Curdie
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Western Cape, South Africa
| | - Dave Thomson
- Department of Surgery, University of Cape Town, Western Cape, South Africa
| | - Brian L. Rayner
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Western Cape, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Western Cape, South Africa
| | - Elmi Muller
- Department of Surgery, University of Cape Town, Western Cape, South Africa
| | - Nicola Wearne
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Western Cape, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Western Cape, South Africa
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2
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Schwartz JJ, Wilson S, Shi F, Elsouda D, Undre N, Kumar MSA. Prolonged-Release vs Immediate-Release Tacrolimus Capsules in Black vs White Kidney Transplant Patients: A Post Hoc Analysis of Phase III Data. Transplant Proc 2018; 50:3283-3295. [PMID: 30577198 DOI: 10.1016/j.transproceed.2018.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/27/2018] [Accepted: 08/16/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Black kidney transplant patients experience inferior outcomes compared with other ethnicities. Because scrutiny is required when immunosuppressant drugs are used in such at-risk populations, we report the first large-scale clinical efficacy data assessing prolonged-release tacrolimus (PR-T) in black de novo kidney transplant patients. METHODS AND MATERIALS We used logistic regression and proportionate hazards to compare a composite outcome measure (biopsy-proven acute rejection, graft loss, mortality, and loss to follow-up) in black and white patients in treatment groups longer than 24 weeks, from 3 large Phase III randomized controlled trials. Secondary endpoints included tacrolimus trough concentration, dose, and estimated glomerular filtration rate. RESULTS The study included 2162 patients whose treatments belonged to two categories (immediate-release tacrolimus: 77 black patients, 721 white patients; and PR-T: 87 black patients, 1277 white patients). Despite demographic factors generally predictive of worse outcomes, efficacy failure among black patients who received PR-T was non-inferior to that among white patients who received either therapy. Compared with immediate-release tacrolimus, black patients who received PR-T achieved stable tacrolimus concentrations 2.5 times faster (21 vs 56 days, P = .04), and more achieved stable target concentrations (76.7% vs 69.3%). Treatment-emergent adverse events were consistent with those reported separately in pivotal trials. CONCLUSIONS Overall, black patients who received PR-T achieved non-inferior outcomes compared to white patients, despite higher pretransplant risk among black patients. Moreover, PR-T improved the time to achieve, and the likelihood of reaching, stable therapeutic concentrations among black patients, suggesting that PR-T could improve the consistency of tacrolimus exposure in this patient population.
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Affiliation(s)
- J J Schwartz
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois.
| | - S Wilson
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - F Shi
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - D Elsouda
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
| | - N Undre
- Medical Affairs, Astellas Pharma Global Development, Inc, Chertsey, United Kingdom
| | - M S A Kumar
- Medical Affairs, Astellas Pharma Global Development, Inc, Northbrook, Illinois
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3
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Soliman KM, Posadas Salas AC, Taber DJ. Change in Mycophenolate and Tacrolimus Exposure by Transplant Vintage and Race. EXP CLIN TRANSPLANT 2018; 17:707-713. [PMID: 30570456 DOI: 10.6002/ect.2018.0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although both tacrolimus and mycophenolate have improved outcomes after kidney transplant, studies regarding effects of exposure on outcomes, specifically related to racial disparities, are sparse. MATERIALS AND METHODS In this 8-year longitudinal cohort study of adult kidney transplant recipients, mycophenolate and tacrolimus levels were compared across transplant vintage stratified by non-African Americans versus African Americans. Data were analyzed with standard univariate tests and multivariable regression models. RESULTS Our study included 1217 patients (transplanted from 2005-2013) who had tacrolimus and myco-phenolate exposure data, with follow-up through 2015 (53.7% were African Americans). Mean mycophenolate dose was 1672 ± 463 mg/day during the first 3 years posttransplant. Although transplant vintage did not appreciably impact mycophenolate dosing in non-African Americans (0.7 mg/day/y; P = .903), doses significantly decreased in African Americans across transplant vintage (-20.5 mg/day/y; P < .001). Rate of mycophenolate being held or discontinued based on transplant vintage significantly increased in African Americans but did not change in non-African Americans. At the beginning of the study, mean tacrolimus levels were lower in African Americans; however, levels then slightly decreased in non-African Americans (-0.03 ng/mL/y; P = .279) and slightly increased in African Americans (+0.03 ng/mL/y; P = .247), with similar levels by 2013. Higher tacrolimus levels were protective against rejection in African Americans only but were protective against death-censored graft loss in both race/ethnicity groups. Mycophenolate dosing had no appreciable impact on outcomes in African Americans, but higher mycophenolate dosing was a significant risk factor for death-censored graft loss in non-African Americans. CONCLUSIONS Tacrolimus and mycophenolate exposure levels have significantly changed over time and differed by race/ethnicity. In non-African Americans, those transplanted more recently tended to have lower tacrolimus but similar mycophenolate exposure. Although mycophenolate exposure in African Americans has recently decreased, tacrolimus has increased. Differences in outcomes likely reflect improved understanding of immunosuppressant tolerability by recipient race/ethnicity.
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Affiliation(s)
- Karim M Soliman
- From the Division of Nephrology and Hypertension, Department of Medicine Medical University of South Carolina, Charleston, South Carolina, USA and the Cairo University, Division of Nephrology, Department of Medicine, Cairo, Egypt
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4
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Liu A, Woodside KJ, Augustine JJ, Sarabu N. Racial disparity in kidney transplant survival relates to late rejection and is independent of steroid withdrawal. Clin Transplant 2018; 32:e13381. [PMID: 30098053 DOI: 10.1111/ctr.13381] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/24/2018] [Accepted: 08/06/2018] [Indexed: 01/06/2023]
Abstract
Black kidney transplant recipients have more acute rejection (AR) and inferior graft survival. We sought to determine whether early steroid withdrawal (ESW) had an impact on AR and death-censored graft loss (DCGL) in blacks. From 2006 to 2012, AR and graft survival were analyzed in 483 kidney recipients (208 black and 275 non-black). Rates of ESW were similar between blacks (65%) and non-blacks (67%). AR was defined as early (≤3 months) or late (>3 months). The impact of black race, early AR, and late AR on death-censored graft failure was analyzed using univariate and multivariate Cox models. Blacks had greater dialysis vintage, more deceased donor transplants, and less HLA matching, yet rates of early AR were comparable between blacks and non-blacks. However, black race was a risk factor for late AR (HR: 3.48 (95% CI: 1.87-6.47)) Blacks had a greater rate of DCGL, partially driven by late AR (HR with late AR: 5.6; 95% CI: 3.3-9.3). ESW had no significant interaction with black race for risk of early AR, late AR, or DCGL. Independent of ESW, black kidney recipients had a higher rate of late AR after kidney transplantation. Late AR was highly predictive of DCGL and contributed to inferior graft survival in blacks.
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Affiliation(s)
- Angela Liu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Nagaraju Sarabu
- Case Western Reserve University School of Medicine, Cleveland, Ohio.,Division of Nephrology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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5
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Patient and Kidney Allograft Survival in Recipients With End-Stage Renal Disease From Amyloidosis. Transplantation 2018; 102:300-309. [DOI: 10.1097/tp.0000000000001930] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Trofe-Clark J, Brennan DC, West-Thielke P, Milone MC, Lim MA, Neubauer R, Nigro V, Bloom RD. Results of ASERTAA, a Randomized Prospective Crossover Pharmacogenetic Study of Immediate-Release Versus Extended-Release Tacrolimus in African American Kidney Transplant Recipients. Am J Kidney Dis 2017; 71:315-326. [PMID: 29162334 DOI: 10.1053/j.ajkd.2017.07.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 07/20/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Differences in tacrolimus dosing across ancestries is partly attributable to polymorphisms in CYP3A5 genes that encode tacrolimus-metabolizing cytochrome P450 3A5 enzymes. The CYP3A5*1 allele, preponderant in African Americans, is associated with rapid metabolism, subtherapeutic concentrations, and higher dose requirements for tacrolimus, all contributing to worse outcomes. Little is known about the relationship between CYP3A5 genotype and the tacrolimus pharmacokinetic area under the curve (AUC) profile in African Americans or whether pharmacogenetic differences exist between conventional twice-daily, rapidly absorbed, immediate-release tacrolimus (IR-Tac) and once-daily extended-release tacrolimus (LifeCycle Pharma Tac [LCPT]) with a delayed absorption profile. STUDY DESIGN Randomized prospective crossover study. SETTING & PARTICIPANTS 50 African American maintenance kidney recipients on stable IR-Tac dosing. INTERVENTION Recipients were randomly assigned to continue IR-Tac on days 1 to 7 and then switch to LCPT on day 8 or receive LCPT on days 1 to 7 and then switch to IR-Tac on day 8. The LCPT dose was 85% of the IR-Tac total daily dose. OUTCOMES Tacrolimus 24-hour AUC (AUC0-24), peak and trough concentrations (Cmax and Cmin), time to peak concentration, and bioavailability of LCPT versus IR-Tac, according to CYP3A5 genotype. MEASUREMENTS CYP3A5 genotype, 24-hour tacrolimus pharmacokinetic profiles. RESULTS ∼80% of participants carried the CYP3A5*1 allele (CYP3A5 expressers). There were no significant differences in AUC0-24 or Cmin between CYP3A5 expressers and nonexpressers during administration of either IR-Tac or LCPT. With IR-Tac, tacrolimus Cmax was 33% higher in CYP3A5 expressers compared with nonexpressers (P=0.04): With LCPT, this difference was 11% (P=0.4). LIMITATIONS This was primarily a pharmacogenetic study rather than an efficacy study; the follow-up period was too short to capture clinical outcomes. CONCLUSIONS Achieving therapeutic tacrolimus trough concentrations with IR-Tac in most African Americans results in significantly higher peak concentrations, potentially magnifying the risk for toxicity and adverse outcomes. This pharmacogenetic effect is attenuated by delayed tacrolimus absorption with LCPT. TRIAL REGISTRATION Registered at ClinicalTrials.gov, with study number NCT01962922.
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Affiliation(s)
- Jennifer Trofe-Clark
- Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA; Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Michael C Milone
- Perelman School of Medicine, University of Pennsylvania, Penn Institute for Immunology, Philadelphia, PA
| | - Mary Ann Lim
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin Neubauer
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Roy D Bloom
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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7
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Belatacept Compared With Tacrolimus for Kidney Transplantation: A Propensity Score Matched Cohort Study. Transplantation 2017; 101:2582-2589. [PMID: 27941427 DOI: 10.1097/tp.0000000000001589] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although tacrolimus is the basis of most maintenance immunosuppression regimens for kidney transplantation, concerns about toxicity have made alternative agents, such as belatacept, attractive to clinicians. However, limited data exist to directly compare outcomes with belatacept-based regimens to tacrolimus. METHODS We performed a propensity score matched cohort study of adult kidney transplant recipients transplanted between May 1, 2001, and December 31, 2015, using national transplant registry data to compare patient and allograft survival in patients discharged from their index hospitalization on belatacept-based versus tacrolimus-based regimens. RESULTS In the primary analysis, we found that belatacept was not associated with a statistically significant difference in risk of patient death (hazard ratio, 0.84; 95% confidence interval [CI], 0.61-1.15, P = 0.28) or allograft loss (hazard ratio, 0.83; 95% CI, 0.62-1.11; P = 0.20) despite an increased risk of acute rejection in the first year posttransplant (odds ratio, 3.12; 95% CI, 2.13-4.57; P < 0.001). These findings were confirmed in additional sensitivity analyses that accounted for use of belatacept in combination with tacrolimus, transplant center effects, and differing approaches to matching. CONCLUSIONS Belatacept appears to have similar longitudinal risk of mortality and allograft failure compared with tacrolimus-based regimens. These data are encouraging but require confirmation in prospective randomized controlled trials.
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8
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Cohen JB, Eddinger KC, Shelton B, Locke JE, Forde KA, Sawinski D. Effect of kidney donor hepatitis C virus serostatus on renal transplant recipient and allograft outcomes. Clin Kidney J 2017; 10:564-572. [PMID: 28852496 PMCID: PMC5569958 DOI: 10.1093/ckj/sfx048] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/24/2017] [Indexed: 02/06/2023] Open
Abstract
Background Hepatitis C virus (HCV) infection is common in dialysis patients and renal transplant recipients and has been associated with diminished patient and allograft survival. HCV-positive (HCV+) kidneys have been used in HCV-positive (HCV+) recipients as a means of facilitating transplantation and expanding the organ donor pool; however, the effect of donor HCV serostatus in the modern era is unknown. Methods Using national transplant registry data, we created a propensity score–matched cohort of HCV+ recipients who received HCV-positive donor kidneys compared to those transplanted with HCV-negative kidneys. Results Transplantation with an HCV+ kidney was associated with an increased risk of death {hazard ratio [HR] 1.43 [95% confidence interval (CI) 1.18–1.76]; P < 0.001} and allograft loss [HR 1.39 (95% CI 1.16–1.67); P < 0.001] compared with their propensity score–matched counterparts. However, HCV+ kidneys were not associated with an increased risk of acute rejection [odds ratio 1.16 (95% CI 0.84–1.61); P = 0.35]. Conclusions While use of HCV+ donor kidneys can shorten the wait for renal transplantation and maximize organ utility for all candidates on the waiting list, potential recipients should be counseled about the increased risks associated with HCV+ kidney.
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Affiliation(s)
- Jordana B Cohen
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin C Eddinger
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany Shelton
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kimberly A Forde
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deirdre Sawinski
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA
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9
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Cohen JB, Eddinger KC, Locke JE, Forde KA, Reese PP, Sawinski DL. Survival Benefit of Transplantation with a Deceased Diabetic Donor Kidney Compared with Remaining on the Waitlist. Clin J Am Soc Nephrol 2017; 12:974-982. [PMID: 28546439 PMCID: PMC5460711 DOI: 10.2215/cjn.10280916] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/02/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Use of diabetic donor kidneys has been a necessary response to the donor organ shortage. Recipients of diabetic donor kidneys have higher mortality risk compared with recipients of nondiabetic donor kidneys. However, the survival benefit of transplantation with diabetic donor kidneys over remaining on the waitlist has not been previously evaluated. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed an observational cohort study of 437,619 kidney transplant candidates from the Organ Procurement and Transplantation Network database, including 8101 recipients of diabetic donor kidneys and 126,560 recipients of nondiabetic donor kidneys. We used time-varying Cox proportional hazards modeling to assess the mortality risk of accepting a diabetic donor kidney compared with remaining on the waitlist or receiving a nondiabetic donor kidney. RESULTS Among transplant recipients, median follow-up was 8.9 years and mortality rate was 35 deaths per 1000 person-years. Recipients of diabetic donor kidneys had 9% lower mortality compared with remaining on the waitlist or transplantation with a nondiabetic donor kidney (adjusted hazard ratio, 0.91; 95% confidence interval, 0.84 to 0.98). Although recipients of nondiabetic donor kidneys with a Kidney Donor Profile Index score >85% had lower mortality risk (adjusted hazard ratio, 0.86; 95% confidence interval, 0.81 to 0.91), recipients of diabetic donor kidneys with an index score >85% did not show any difference (adjusted hazard ratio, 1.09; 95% confidence interval, 0.97 to 1.22). Patients aged <40 years attained no survival benefit from transplantation with diabetic donor kidneys; diabetic patients at centers with long waitlist times attained the greatest survival benefit. CONCLUSIONS Diabetic donor kidneys appear associated with higher mortality risk compared with nondiabetic donor kidneys, but offer greater survival benefit compared with remaining on the waitlist for many candidates. Patients with high risk of mortality on the waitlist at centers with long wait times appear to benefit most from transplantation with diabetic donor kidneys.
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Affiliation(s)
| | | | - Jayme E. Locke
- Department of Surgery, University of Alabama-Birmingham, Birmingham, Alabama; and
| | - Kimberly A. Forde
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter P. Reese
- Renal, Electrolyte, and Hypertension Division
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Chen A, Farney A, Russell GB, Nicolotti L, Stratta R, Rogers J, Lin JJ. Severe intellectual disability is not a contraindication to kidney transplantation in children. Pediatr Transplant 2017; 21. [PMID: 28145624 DOI: 10.1111/petr.12887] [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: 12/22/2016] [Indexed: 11/28/2022]
Abstract
Renal transplantation in children with ID is controversial. Acceptability of these children as candidates varies between programs. Limited outcome data in pediatric renal TXP recipients with cognitive impairment diminish their access to TXP. A retrospective chart review was performed of all children who underwent renal transplantation between January 1, 2002 and June 30, 2012 (N=72). Patients were divided into two groups, those with ID prior to transplantation (n=10) and those without (non-ID; n=62). Graft survival and BPAR episodes were compared between the two groups using Kaplan-Meier estimates. Graft survival rates at 3 years post-TXP were 100% in the ID group and 80% in the non-ID group (P=.13). Rates of BPAR at 3 years post-TXP were 10% in the ID group and 27% in the non-ID group (P=.29). Graft survival and acute rejection-free survival rates are similar between children with ID and those without. Based on midterm outcomes, there is no apparent contraindication to renal transplantation in pediatric patients with ID. Children with ID should be considered as TXP candidates provided that they have an adequate social support network.
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Affiliation(s)
- Ashton Chen
- Department of Pediatrics, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Alan Farney
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Gregory B Russell
- Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Linda Nicolotti
- Department of Pediatrics, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Robert Stratta
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jeffrey Rogers
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jen-Jar Lin
- Department of Pediatrics, Wake Forest Baptist Health, Winston-Salem, NC, USA
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11
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Andrews LM, De Winter BC, Van Gelder T, Hesselink DA. Consideration of the ethnic prevalence of genotypes in the clinical use of tacrolimus. Pharmacogenomics 2016; 17:1737-1740. [PMID: 27790923 DOI: 10.2217/pgs-2016-0136] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Louise M Andrews
- Department of Hospital Pharmacy, Erasmus Medical Center, Room Na-206, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Brenda Cm De Winter
- Department of Hospital Pharmacy, Erasmus Medical Center, Room Na-206, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Teun Van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Center, Room Na-206, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
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12
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Patel SJ, Suki WN, Loucks-DeVos J, Graviss EA, Nguyen DT, Knight RJ, Kuten SA, Moore LW, Teeter LD, Gaber LW, Gaber AO. Disparate rates of acute rejection and donor-specific antibodies among high-immunologic risk renal transplant subgroups receiving antithymocyte globulin induction. Transpl Int 2016; 29:897-908. [PMID: 27196395 DOI: 10.1111/tri.12791] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/29/2016] [Accepted: 04/27/2016] [Indexed: 01/15/2023]
Abstract
Lymphocyte-depleting induction lowers acute rejection (AR) rates among high-immunologic risk (HIR) renal transplant recipients, including African Americans (AAs), retransplants, and the sensitized. It is unclear whether different HIR subgroups experience similarly low rates of AR. We aimed to describe the incidence of AR and de novo donor-specific antibody (dnDSA) among HIR recipients categorized by age, race, or donor type. All received antithymocyte globulin (ATG) induction and triple maintenance immunosuppression. A total of 464 HIR recipients from 2007 to 2014 were reviewed. AR and dnDSA rates at 1 year for the entire population were 14% and 27%, respectively. AR ranged from 6.7% among living donor (LD) recipients to 30% in younger AA deceased donor (DD) recipients. De novo donor-specific antibody at 1 year ranged from 7% in older non-AA LD recipients to 32% in AAs. AA race remained as an independent risk factor for AR among DD recipients and for dnDSA among all HIR recipients. Development of both AR and dnDSA within the first year was associated with a 54% graft survival at 5 years and was an independent risk factor for graft loss. Despite utilization of recommended immunosuppression for HIR recipients, substantial disparities exist among subgroups, warranting further consideration of individualized immunosuppression in certain HIR subgroups.
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Affiliation(s)
- Samir J Patel
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Wadi N Suki
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | | | - Edward A Graviss
- Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Richard J Knight
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Samantha A Kuten
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Linda W Moore
- Department of Pharmacy, Kansas University Medical Center, Kansas City, KS, USA
| | | | - Lillian W Gaber
- Department of Pathology, Houston Methodist Hospital, Houston, TX, USA
| | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
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13
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Ling JD, Mehta V, Fathy C, Rapoport Y, Zhang MM, Daniels A, Kohanim S. Racial Disparities in Corneal Transplantation Rates, Complications, and Outcomes. Semin Ophthalmol 2016; 31:337-44. [PMID: 27092728 DOI: 10.3109/08820538.2016.1154162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Corneal transplantation is a common type of tissue transplantation that aims to improve vision or relieve pain. Given the immune privilege of the cornea, the primary graft often has a high success rate, approaching 90%. Despite the good overall outcome of corneal transplantation in various studies, the individual graft survival rate varies, depending on the preoperative diagnosis and donor and recipient factors. Race and ethnicity have been shown to be important in other types of organ transplantation. The aim of this study was to review the available ophthalmic literature regarding any differences in rates and outcomes of corneal transplantation based on ethnicity and race. A small body of evidence suggests that race might be an important risk factor for graft rejection and graft failure. More robust studies are needed to clarify these associations.
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Affiliation(s)
- Jeanie D Ling
- a Vanderbilt Eye Institute, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Viraj Mehta
- a Vanderbilt Eye Institute, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Cherie Fathy
- a Vanderbilt Eye Institute, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Yuna Rapoport
- a Vanderbilt Eye Institute, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Matthew M Zhang
- a Vanderbilt Eye Institute, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Anthony Daniels
- a Vanderbilt Eye Institute, Vanderbilt University Medical Center , Nashville , TN , USA
| | - Sahar Kohanim
- a Vanderbilt Eye Institute, Vanderbilt University Medical Center , Nashville , TN , USA
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14
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Bunnapradist S, Rostaing L, Alloway RR, West-Thielke P, Denny J, Mulgaonkar S, Budde K. LCPT once-daily extended-release tacrolimus tablets versus twice-daily capsules: a pooled analysis of two phase 3 trials in important de novo and stable kidney transplant recipient subgroups. Transpl Int 2016; 29:603-11. [PMID: 26953629 DOI: 10.1111/tri.12770] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/07/2015] [Accepted: 02/26/2016] [Indexed: 11/29/2022]
Abstract
African-American and elderly kidney transplant recipients (KTR) have increased risk for poor clinical outcomes post-transplant. Management of immunosuppression may be challenging in these patients and contribute to worse outcomes. A novel once-daily formulation of tacrolimus (LCPT) has demonstrated noninferiority, similar safety, improved bioavailability, a consistent concentration time profile, and less peak and peak-trough fluctuations vs. tacrolimus twice-daily (Tac BID). This pooled analysis of two phase 3 randomized, controlled trials, including 861 (LCPT N = 428; Tac BID N = 433; 38% of patients were stable KTR, and 62% were de novo KTR) patients, examined the efficacy of LCPT in KTR subgroups (blacks, females, and age ≥65). Overall, treatment failure [death, graft failure, centrally read biopsy-proven acute rejection (BPAR), or lost to follow-up] at 12 months was as follows: LCPT: 11.9%, BID Tac: 13.4% [-1.48% (-5.95%, 2.99%)]. BPAR rates were as follows: LCPT: 8.2%, Tac BID: 9.5% [-1.29% (-5.14%, 2.55%)]. Numerically, fewer treatment failure events with LCPT were found in the majority of subgroups, with significantly less treatment failure associated with LCPT among black KTR [-13.82% (-27.22%, -0.31%)] and KTR ≥65 [-13.46% (-25.27%, -0.78%)]. This pooled analysis suggests numerically lower efficacy failure rates associated with LCPT among high-risk subgroups, in particular black KTR and KTR ≥65 years old.
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Affiliation(s)
| | | | - Rita R Alloway
- University of Cincinnati Medical Center & The Christ Hospital, Cincinnati, OH, USA
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15
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Nadkarni GN, Horowitz CR. Genomics in CKD: Is This the Path Forward? Adv Chronic Kidney Dis 2016; 23:120-4. [PMID: 26979150 DOI: 10.1053/j.ackd.2016.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 01/26/2016] [Indexed: 01/13/2023]
Abstract
Recent advances in genomics and sequencing technology have led to a better understanding of genetic risk in CKD. Genetics could account in part for racial differences in treatment response for medications including antihypertensives and immunosuppressive medications due to its correlation with ancestry. However, there is still a substantial lag between generation of this knowledge and its adoption in routine clinical care. This review summarizes the recent advances in genomics and CKD, discusses potential reasons for its underutilization, and highlights potential avenues for application of genomic information to improve clinical care and outcomes in this particularly vulnerable population.
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16
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Oetting WS, Schladt DP, Guan W, Miller MB, Remmel RP, Dorr C, Sanghavi K, Mannon RB, Herrera B, Matas AJ, Salomon DR, Kwok PY, Keating BJ, Israni AK, Jacobson PA. Genomewide Association Study of Tacrolimus Concentrations in African American Kidney Transplant Recipients Identifies Multiple CYP3A5 Alleles. Am J Transplant 2016; 16:574-82. [PMID: 26485092 PMCID: PMC4733408 DOI: 10.1111/ajt.13495] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/05/2015] [Accepted: 08/15/2015] [Indexed: 01/25/2023]
Abstract
We previously reported that tacrolimus (TAC) trough blood concentrations for African American (AA) kidney allograft recipients were lower than those observed in white patients. Subtherapeutic TAC troughs may be associated with acute rejection (AR) and AR-associated allograft failure. This variation in TAC troughs is due, in part, to differences in the frequency of the cytochrome P450 CYP3A5*3 allele (rs776746, expresses nonfunctional enzyme) between white and AA recipients; however, even after accounting for this variant, variability in AA-associated troughs is significant. We conducted a genomewide association study of TAC troughs in AA kidney allograft recipients to search for additional genetic variation. We identified two additional CYP3A5 variants in AA recipients independently associated with TAC troughs: CYP3A5*6 (rs10264272) and CYP3A5*7 (rs41303343). All three variants and clinical factors account for 53.9% of the observed variance in troughs, with 19.8% of the variance coming from demographic and clinical factors including recipient age, glomerular filtration rate, anticytomegalovirus drug use, simultaneous pancreas-kidney transplant and antibody induction. There was no evidence of common genetic variants in AA recipients significantly influencing TAC troughs aside from the CYP3A gene. These results reveal that additional and possibly rare functional variants exist that account for the additional variation.
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Affiliation(s)
- W. S. Oetting
- University of Minnesota, Experimental and Clinical Pharmacology, Minneapolis, MN,Corresponding author: William S. Oetting,
| | - D. P. Schladt
- Minneapolis Medical Research Foundation, Minneapolis, MN
| | - W. Guan
- University of Minnesota, Department of Biostatistics, Minneapolis, MN
| | - M. B. Miller
- University of Minnesota, Experimental and Clinical Pharmacology, Minneapolis, MN
| | - R. P. Remmel
- University of Minnesota, Experimental and Clinical Pharmacology, Minneapolis, MN
| | - C. Dorr
- Minneapolis Medical Research Foundation, Minneapolis, MN
| | - K. Sanghavi
- University of Minnesota, Experimental and Clinical Pharmacology, Minneapolis, MN
| | - R. B. Mannon
- University of Alabama, Division of Nephrology, Birmingham, AL
| | - B. Herrera
- University of California, San Francisco, CA
| | - A. J. Matas
- University of Minnesota, Department of Surgery, Minneapolis, MN
| | | | - P.-Y. Kwok
- University of California, San Francisco, CA
| | - B. J. Keating
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - A. K. Israni
- Minneapolis Medical Research Foundation, Minneapolis, MN,University of Minnesota, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN,University of Minnesota, Department of Epidemiology and Community Health, Minneapolis, MN
| | - P. A. Jacobson
- University of Minnesota, Experimental and Clinical Pharmacology, Minneapolis, MN
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17
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Rostaing L, Bunnapradist S, Grinyó JM, Ciechanowski K, Denny JE, Silva HT, Budde K. Novel Once-Daily Extended-Release Tacrolimus Versus Twice-Daily Tacrolimus in De Novo Kidney Transplant Recipients: Two-Year Results of Phase 3, Double-Blind, Randomized Trial. Am J Kidney Dis 2015; 67:648-59. [PMID: 26717860 DOI: 10.1053/j.ajkd.2015.10.024] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 10/16/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND 1-year data from this trial showed the noninferiority of a novel once-daily extended-release tacrolimus (LCPT; Envarsus XR) to immediate-release tacrolimus (IR-Tac) twice daily after kidney transplantation. STUDY DESIGN Final 24-month analysis of a 2-armed, parallel-group, randomized, double-blind, double-dummy, multicenter, phase 3 trial. SETTING & PARTICIPANTS 543 de novo kidney recipients randomly assigned to LCPT (n=268) or IR-Tac (n=275); 507 (93.4%) completed the 24-month study. INTERVENTION LCPT tablets once daily at 0.17 mg/kg/d or IR-Tac twice daily at 0.1 mg/kg/d; subsequent doses were adjusted to maintain target trough ranges (first 30 days, 6-11 ng/mL; thereafter, 4-11 ng/mL). The intervention was 24 months; the study was double blinded for the entirety. OUTCOMES & MEASUREMENTS Treatment failure (death, transplant failure, biopsy-proven acute rejection, or loss to follow up) within 24 months. Safety end points included adverse events, serious adverse events, new-onset diabetes, kidney function, opportunistic infections, and malignancies. Pharmacokinetic measures included total daily dose (TDD) of study drugs and tacrolimus trough levels. RESULTS 24-month treatment failure was LCPT, 23.1%; IR-Tac, 27.3% (treatment difference, -4.14% [95% CI, -11.38% to +3.17%], well below the +10% noninferiority criterion defined for the primary 12-month end point). Subgroup analyses showed fewer treatment failures for LCPT versus IR-Tac among black, older, and female recipients. Safety was similar between groups. From month 1, TDD was lower for LCPT; the difference increased over time. At month 24, mean TDD for LCPT was 24% lower than for the IR-Tac group (P<0.001), but troughs were similar (means at 24 months: LCPT, 5.47 ± 0.17 ng/mL; IR-Tac, 5.8 ± 0.30 ng/mL; P=0.4). LIMITATIONS Trial participant eligibility criteria may limit the generalizability of results to the global population of de novo kidney transplant recipients. CONCLUSIONS Results suggest that once-daily LCPT in de novo kidney transplantation has comparable efficacy and safety profile to that of IR-Tac. Lower TDD reflects LCPT's improved bioavailability and absorption.
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Affiliation(s)
| | | | | | | | | | | | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin, Berlin, Germany
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18
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Cohen JB, Bloom RD, Reese PP, Porrett PM, Forde KA, Sawinski DL. National outcomes of kidney transplantation from deceased diabetic donors. Kidney Int 2015; 89:S0085-2538(15)00047-2. [PMID: 26489026 PMCID: PMC4840104 DOI: 10.1038/ki.2015.325] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 07/30/2015] [Accepted: 09/03/2015] [Indexed: 11/24/2022]
Abstract
Use of deceased diabetic donor kidneys has increased over recent decades. However, scarce patient and allograft survival data are available taking into account recipient diabetes status. Here we performed a retrospective cohort study using data from the United Network of Organ Sharing in patients transplanted from 1994 to 2014. Multivariable Cox regression assessed recipient outcomes of 9074 diabetic vs. 152,555 non-diabetic donor kidneys. Recipients of diabetic donor kidneys had elevated rates of all-cause allograft failure (hazard ratio 1.21, 95% confidence interval 1.16-1.26) and death (1.19, 1.13-1.24) compared to recipients of kidneys from non-diabetic donors. Younger recipients of diabetic donor kidneys had worse allograft survival than older recipients of non-diabetic donor kidneys. There was significant interaction between donor and recipient diabetes status. To minimize the effect of unmeasured confounders, we used paired analyses of recipients of mate-kidneys from the same donor, with one diabetic recipient and the other non-diabetic. Among discordant recipient pairs of diabetic donor kidneys, diabetic recipients had significantly higher risk of allograft failure (1.27, 1.05-1.53) and death (1.53, 1.22-1.93) than non-diabetic recipients. After stratifying by Kidney Donor Profile Index risk category, diabetic recipients of diabetic donor kidneys continued to have worse allograft survival compared to all other patients. Thus, risks are associated with the use of diabetic donor kidneys. Understanding these risks will enable clinicians to better educate potential recipients.Kidney International advance online publication, 21 October 2015; doi:10.1038/ki.2015.325.
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Affiliation(s)
- Jordana B. Cohen
- Renal, Electrolyte and Hypertension Division. Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Roy D. Bloom
- Renal, Electrolyte and Hypertension Division. Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Peter P. Reese
- Renal, Electrolyte and Hypertension Division. Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paige M. Porrett
- Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Kimberly A. Forde
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Deirdre L. Sawinski
- Renal, Electrolyte and Hypertension Division. Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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19
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Abstract
BACKGROUND The waiting time for deceased donor renal transplantation in the United States continues to grow. Retransplant candidates make up a small but growing percentage of the overall transplant waiting list and raise questions about the stewardship of scarce resources. The utility of renal transplantation among individuals with two prior renal transplants is not described in the literature, and we thus sought to determine the survival benefit associated with a third kidney transplant (3KT). METHODS Multivariable Cox regression models were created to determine characteristics associated with 3KT outcomes and the survival benefit of 3KT among recipients wait listed and transplanted within the United States between 1995 and 2009. RESULTS A total of 4,334 patients were waitlisted for a 3KT and 2,492 patients received a 3KT. In a multivariate analysis, 3KT demonstrated an overall patient survival benefit compared to the waitlist (hazards ratio, 0.379; 95% confidence interval, 0.302-0.475; P<0.001) for those awaiting their first, second, or third kidney transplants, although an inferior graft outcome compared to first kidney transplants. The time to survival benefit did not accrue until 8 months after transplantation. In addition, we found that the duration of second graft survival was predictive of third graft survival, such that second graft survival beyond 5 years is associated with superior 3KT graft survival. Second graft loss in 30 days or less was not associated with inferior 3KT graft survival. CONCLUSION A 3KT achieves a survival benefit over remaining on the waitlist, although is associated with inferior graft outcomes compared to first kidney transplants. Graft survival of the second transplant beyond 5 years is associated with superior 3KT graft survival.
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