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Wilk AS, Drewry KM, Escoffery C, Lea JP, Pastan SO, Patzer RE. Kidney Transplantation Contraindications: Variation in Nephrologist Practice and Training Vintage. Kidney Int Rep 2024; 9:888-897. [PMID: 38765582 PMCID: PMC11101805 DOI: 10.1016/j.ekir.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/08/2023] [Accepted: 01/08/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Health system leaders aim to increase access to kidney transplantation in part by encouraging nephrologists to refer more patients for transplant evaluation. Little is known about nephrologists' referral decisions and whether nephrologists with older training vintage weigh patient criteria differently (e.g., more restrictively). Methods Using a novel, iteratively validated survey of US-based nephrologists, we examined how nephrologists assess adult patients' suitability for transplant, focusing on established, important criteria: 7 clinical (e.g., overweight) and 7 psychosocial (e.g., insurance). We quantified variation in nephrologist restrictiveness-proportion of criteria interpreted as absolute or partial contraindications versus minor or negligible concerns-and tested associations between restrictiveness and nephrologist age (proxy for training vintage) in logistic regression models, controlling for nephrologist-level and practice-level factors. Results Of 144 nephrologists invited, 42 survey respondents (29% response rate) were 85% male and 54% non-Hispanic White, with mean age 52 years, and 67% spent ≥1 day/wk in outpatient dialysis facilities. Nephrologists interpreted patient criteria inconsistently; consistency was lower for psychosocial criteria (intraclass correlation coefficient: 0.28) than for clinical criteria (intraclass correlation coefficient: 0.43; P < 0.01). With each additional 10 years of age, nephrologists' odds of interpreting criteria restrictively (top tertile) doubled (adjusted odds ratio [aOR] 1.96; 95% confidence interval [CI]: 0.95-4.07), with marginal statistical significance. This relationship was significant when interpreting psychosocial criteria (aOR: 3.18; 95% CI: 1.16-8.71) but not when interpreting clinical criteria (aOR: 1.12; 95% CI: 0.52-2.38). Conclusion Nephrologists interpret evaluation criteria variably when assessing patient suitability for transplant. Guideline-based educational interventions could influence nephrologists' referral decision-making differentially by age.
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Affiliation(s)
- Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kelsey M. Drewry
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cam Escoffery
- Behavioral Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Janice P. Lea
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen O. Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory University Transplant Center, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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2
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Patel J, Martinchek M, Mills D, Hussain S, Kyeso Y, Huisingh-Scheetz M, Rubin D, Landi AJ, Cimeno A, Madariaga MLL. Comprehensive geriatric assessment predicts listing for kidney transplant in patients with end-stage renal disease: a retrospective cohort study. BMC Geriatr 2024; 24:148. [PMID: 38350846 PMCID: PMC10865555 DOI: 10.1186/s12877-024-04734-7] [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: 05/16/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) involves a formal broad approach to assess frailty and creating a plan for management. However, the impact of CGA and its components on listing for kidney transplant in older adults has not been investigated. METHODS We performed a single-center retrospective study of patients with end-stage renal disease who underwent CGA during kidney transplant candidacy evaluation between 2017 and 2021. All patients ≥ 65 years old and those under 65 with any team member concern for frailty were referred for CGA, which included measurements of healthcare utilization, comorbidities, social support, short physical performance battery, Montreal Cognitive Assessment (MoCA), and Physical Frailty Phenotype (FPP), and estimate of surgical risk by the geriatrician. RESULTS Two hundred and thirty patients underwent baseline CGA evaluation; 58.7% (135) had high CGA ("Excellent" or "Good" rating for transplant candidacy) and 41.3% (95) had low CGA ratings ("Borderline," "Fair," or "Poor"). High CGA rating (OR 8.46; p < 0.05), greater number of CGA visits (OR 4.93; p = 0.05), younger age (OR 0.88; p < 0.05), higher MoCA scores (OR 1.17; p < 0.05), and high physical activity (OR 4.41; p < 0.05) were all associated with listing on transplant waitlist. CONCLUSIONS The CGA is a useful, comprehensive tool to help select older adults for kidney transplantation. Further study is needed to better understand the predictive value of CGA in predicting post-operative outcomes.
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Affiliation(s)
- Jay Patel
- Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave. MC5047, 60637, Chicago, IL, USA.
| | - Michelle Martinchek
- Geriatrics and Extended Care and New England Geriatrics Research Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Dawson Mills
- Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave. MC5047, 60637, Chicago, IL, USA
| | - Sheraz Hussain
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Yousef Kyeso
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Megan Huisingh-Scheetz
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Daniel Rubin
- Department of Anesthesia, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Andrea J Landi
- Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, USA
| | - Arielle Cimeno
- Department of Surgery, University of Chicago Medicine & Biological Sciences, Chicago, USA
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3
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Lentine KL, Amanda M, Xiao H, Wisniewski A, Levan M, Al Ammary F, Sharfuddin A, Axelrod DA, Waterman AD, Kasiske B. Factors enabling transplant program participation in the Scientific Registry of Transplant Recipients (SRTR) Living Donor Collective: A national survey. Clin Transplant 2023; 37:e14908. [PMID: 36622257 PMCID: PMC10423496 DOI: 10.1111/ctr.14908] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Scientific Registry of Transplant Recipients (SRTR) Living Donor Collective (LDC), the first effort to create a lifetime registry for living donor candidates in the United States, requires transplant programs to register donor candidates while the SRTR conducts follow-up. METHODS To better understand facilitators and barriers to program participation, we conducted a brief electronic survey of U.S. transplant program staff from October 26, 2021 to December 17, 2021. RESULTS We received 132 responses, with at least one response from 87 living donor programs (46 kidney programs, 33 kidney and liver programs, and eight liver programs alone). We found 86% of program representatives strongly agreed or agreed that funding adequate to cover the cost of data collection would facilitate LDC participation, 92% agreed or strongly agreed with importance of electronic data submission options, and 74% reported that elimination of requirements to submit duplicative pre-operative information to the Organ Procurement and Transplantation Network (OPTN) would be helpful. Other potentially enabling factors include reduction in duration of OPTN postdonation follow-up requirements, ease-of-use, protection from data use for regulation, adequate data security, and equity in data access. CONCLUSION This survey identifies potential targets to strengthen participation in the effort to create a national living donor registry in the United States. Collaboration and investment to overcome barriers to LDC participation among transplant programs are vital to generate long-term data on living donation for donor candidates, donors, and patients in need of transplant.
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Affiliation(s)
- Krista L. Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis Univeristy Hospital, St. Louis, MO
| | | | - Huiling Xiao
- Saint Louis University Transplant Center, SSM-Saint Louis Univeristy Hospital, St. Louis, MO
| | - Addie Wisniewski
- Saint Louis University Transplant Center, SSM-Saint Louis Univeristy Hospital, St. Louis, MO
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4
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Shrestha P, Van Pilsum Rasmussen SE, King EA, Gordon EJ, Faden RR, Segev DL, Humbyrd CJ, McAdams-DeMarco M. Defining the ethical considerations surrounding kidney transplantation for frail and cognitively impaired patients: a Delphi study of geriatric transplant experts. BMC Geriatr 2022; 22:566. [PMID: 35804289 PMCID: PMC9264705 DOI: 10.1186/s12877-022-03209-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/06/2022] [Indexed: 01/22/2023] Open
Abstract
Background Among adult kidney transplant (KT) candidates, 21% are frail and 55% have cognitive impairment, increasing the risk of pre- and post-KT mortality. Centers often assess frailty status and cognitive function during transplant evaluation to help identify appropriate candidate. Yet, there are no ethical guidelines regarding the use of frailty and cognitive function during this evaluation. We seek to develop a clinical consensus on balancing utility and justice in access to KT for frail and cognitively impaired patients. Methods Twenty-seven experts caring for ESRD patients completed a two-round Delphi panel designed to facilitate consensus (> 80% agreement). Results Experts believed that denying patients transplantation based solely on expected patient survival was inequitable to frail or cognitively impaired candidates; 100% agreed that frailty and cognitive impairment are important factors to consider during KT evaluation. There was consensus that health related quality of life and social support are important to consider before waitlisting frail or cognitively impaired patients. Experts identified important factors to consider before waitlisting frail (likely to benefit from KT, frailty reversibility, age, and medical contraindications) and cognitively impaired (degree of impairment and medication adherence) patients. Conclusions Clinical experts believed it was ethically unacceptable to allocate organs solely based on patients’ expected survival; frailty and cognitive impairment should be measured at evaluation when weighed against other clinical factors. Ethical guidelines regarding the use of frailty and cognitive function during KT evaluation ought to be developed. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03209-x.
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Affiliation(s)
- Prakriti Shrestha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Elizabeth A King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elisa J Gordon
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ruth R Faden
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA.,Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Surgery, New York University, New York, USA.
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5
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Evolving Metrics of Quality for Kidney Transplant Candidates: Transplant Center Variability in Delisting and 1-Year Mortality. J Am Coll Surg 2022; 234:1075-1081. [PMID: 35703800 DOI: 10.1097/xcs.0000000000000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Management of patients on the kidney transplant waitlist lacks oversight, and transplant centers can delist candidates without consequence. To better understand between-center differences in waitlist management, we examined delisting rates and mortality after delisting within 3 years of removal from the kidney transplant waitlist. STUDY DESIGN This is a retrospective cohort study using data from the Scientific Registry of Transplant Recipients of adults listed for deceased donor kidney transplant in 2015 and followed until the end of 2018. Patients of interest were those delisted for reasons other than transplant, death, or transfer. Centers were excluded if they had fewer than 20 waitlisted patients per year. We calculated probability of delisting and death after delisting using multivariable competing risk models. RESULTS During follow-up, 14.2% of patients were delisted. The median probability of delisting within 3 years, adjusted for center-level variability, was 7.0% (interquartile range [IQR]: 3.9% to 10.6%). Median probability of death was 58.2% (IQR: 40% to 73.4%). There was no meaningful correlation between probability of delisting and death (τ = -0.05, p = 0.34). CONCLUSIONS There is significant variability in the rate of death after delisting across kidney transplant centers. Likelihood of transplant is extremely important to candidates, and improved data collection efforts are needed to inform whether current delisting practices are successfully removing patients who could not meaningfully benefit from transplant, or whether certain populations may benefit from remaining on the list and maintaining eligibility.
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6
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Whelan AM, Johansen KL, Copeland T, McCulloch CE, Nallapothula D, Lee BK, Roll GR, Weir MR, Adey DB, Ku E. Kidney transplant candidacy evaluation and waitlisting practices in the United States and their association with access to transplantation. Am J Transplant 2022; 22:1624-1636. [PMID: 35289082 PMCID: PMC9177783 DOI: 10.1111/ajt.17031] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 02/20/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023]
Abstract
There are limited data on the degree of variability in practices surrounding prioritization of referrals for transplant evaluation and criteria for transplant candidacy and their association with transplantation rates. We surveyed transplant programs across the United States between January 2020 and May 2020 to determine current pre-transplantation practices. We examined the relation between these reported practices and the outcomes of waitlisted patients at responding programs between January 2015 and March 2021 using Scientific Registry of Transplant Recipients data. We used adjusted Cox models with random effects to accommodate clustering by program. Primary outcomes included living or deceased donor transplantation. Of 172 surveyed programs, 90 participated. Substantial variations were noted in when the candidacy evaluation began (13% reported when eGFR was <30 mL/min/1.73 m2 and 17% reported no set policy) and the approach to pre-transplantation cardiac workup (multi-modality [58%], stress echocardiogram [20%]). Using adjusted models, a program policy of using other measures of body habitus to determine transplant candidacy rather than requiring patients to meet a body mass index (BMI) threshold of ≤35 kg/m2 (reference group) for candidacy was associated with a higher hazard of living donor transplantation (HR 1.83 [95% CI 1.10-3.03]). Pre-transplant practices vary substantially across the United States, and select practices were associated with transplantation rates.
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Affiliation(s)
- Adrian M. Whelan
- University of California, San Francisco, Division of Nephrology, Department of Medicine
| | - Kirsten L. Johansen
- Hennepin County Medical Center and University of Minnesota, Division of Nephrology, Department of Medicine
| | - Timothy Copeland
- University of California, San Francisco, Division of Nephrology, Department of Medicine
| | - Charles E. McCulloch
- University of California, San Francisco, Department of Epidemiology and Biostatistics
| | | | - Brian K. Lee
- University of California, San Francisco, Division of Nephrology, Department of Medicine,University of Texas at Austin, Department of Internal Medicine
| | - Garrett R. Roll
- University of California, San Francisco, Division of Transplant Surgery, Department of Surgery
| | - Matthew R. Weir
- University of Maryland, Division of Nephrology, Department of Medicine
| | - Deborah B. Adey
- University of California, San Francisco, Division of Nephrology, Department of Medicine
| | - Elaine Ku
- University of California, San Francisco, Division of Nephrology, Department of Medicine,University of California, San Francisco, Department of Epidemiology and Biostatistics,University of California, San Francisco, Division of Pediatric Nephrology, Department of Pediatrics
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7
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Lentine KL, Fleetwood VA, Caliskan Y, Randall H, Wellen JR, Lichtenberger M, Dedert C, Rothweiler R, Marklin G, Brockmeier D, Schnitzler MA, Husain SA, Mohan S, Kasiske BL, Cooper M, Mannon RB, Axelrod DA. Deceased Donor Procurement Biopsy Practices, Interpretation, and Histology-Based Decision Making: A Survey of U.S. Transplant Centers. Kidney Int Rep 2022; 7:1268-1277. [PMID: 35685316 PMCID: PMC9171615 DOI: 10.1016/j.ekir.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/13/2022] [Accepted: 03/21/2022] [Indexed: 10/31/2022] Open
Abstract
Introduction Methods Results Conclusion
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8
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Doshi MD, Singh N, Hippen BE, Woodside KJ, Mohan P, Byford HL, Cooper M, Dadhania DM, Ainapurapu S, Lentine KL. Transplant Clinician Opinions on Use of Race in the Estimation of Glomerular Filtration Rate. Clin J Am Soc Nephrol 2021; 16:1552-1559. [PMID: 34620650 PMCID: PMC8499001 DOI: 10.2215/cjn.05490421] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Current race-based eGFR calculators assign a higher eGFR value to Black patients, which could affect the care of kidney transplant candidates and potential living donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a survey of staff at adult kidney transplant centers in the United States (December 17, 2020 to February 28, 2021) to assess opinions on use of race-based eGFR equations for waitlisting and living donor candidate evaluation, availability of serum cystatin C testing and measured GFR, and related practices. RESULTS Respondents represented 57% (124 of 218) of adult kidney transplant programs, and the responding centers conducted 70% of recent kidney transplant volume. Most (93%) programs use serum creatinine-based eGFR for listing candidates. However, only 6% of respondents felt that current race-based eGFR calculators are appropriate, with desire for change grounded in concerns for promotion of health care disparities by current equations and inaccuracies in reporting of race. Most respondents (70%) believed that elimination of race would allow more preemptive waitlisting for Black patients, but a majority (79%) also raised concerns that such an approach could incur harms. More than one third of the responding programs lacked or were unsure of availability of testing for cystatin C or measured GFR. At this time, 40% of represented centers did not plan to remove race from eGFR calculators, 46% were planning to remove, and 15% had already done so. There was substantial variability in eGFR reporting and listing of multiracial patients with some Black ancestry. There was no difference in GFR acceptance thresholds for Black versus non-Black living donors. CONCLUSIONS This national survey highlights a broad consensus that extant approaches to GFR estimation are unsatisfactory, but it also identified a range of current opinions.
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Affiliation(s)
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | | | | | - Prince Mohan
- Geisinger Medical Center, Danville, Pennsylvania
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9
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Axelrod DA, Ince D, Harhay MN, Mannon RB, Alhamad T, Cooper M, Josephson MA, Caliskan Y, Sharfuddin A, Kumar V, Guenette A, Schnitzler MA, Ainapurapu S, Lentine KL. Operational challenges in the COVID era: Asymptomatic infections and vaccination timing. Clin Transplant 2021; 35:e14437. [PMID: 34297878 PMCID: PMC8420523 DOI: 10.1111/ctr.14437] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/23/2021] [Accepted: 07/08/2021] [Indexed: 11/28/2022]
Abstract
The coronavirus disease 2019 (COVID‐19) pandemic has created unprecedented challenges for solid organ transplant programs. While transplant activity has largely recovered, appropriate management of deceased donor candidates who are asymptomatic but have positive nucleic acid testing (NAT) for SARS‐CoV‐2 is unclear, as this result may reflect active infection or prolonged viral shedding. Furthermore, candidates who are unvaccinated or partially vaccinated continue to receive donor offers. In the absence of robust outcomes data, transplant professionals at US adult kidney transplant centers were surveyed (February 13, 2021 to April 29, 2021) to determine community practice (N: 92 centers, capturing 41% of centers and 57% of transplants performed). The majority (97%) of responding centers declined organs for asymptomatic NAT+ patients without documented prior infection. However, 32% of centers proceed with kidney transplant in NAT+ patients who were at least 30 days from initial diagnosis with negative chest imaging. Less than 7% of programs reported inactivating patients who were unvaccinated or partially vaccinated. In conclusion, despite national recommendations to wait for negative testing, many centers are proceeding with kidney transplant in patients with positive SARS‐CoV‐2 NAT results due to presumed viral shedding. Furthermore, few centers are requiring COVID‐19 vaccination prior to transplantation at this time.
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Affiliation(s)
| | - Dilek Ince
- University of Iowa/Transplant Institute, Iowa City, IA, USA
| | - Meera N Harhay
- Drexel University Tower Health Transplant Institute, Philadelphia, USA
| | | | | | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, DC, USA
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | | | - Vineeta Kumar
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexis Guenette
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | - Mark A Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | - Sruthi Ainapurapu
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
| | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
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10
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Parsons RF, Matar A, Lentine KL, Woodside KJ, Singh N, Alhamad T, Basu A, Cabeza Rivera FH, Cheungpasitporn W, Romeo G, Rao S, Kensinger CD, Parajuli S, Sultan S, Tantisattamo E, Pavlakis M, Cooper M. Pancreas transplantation perceptions and practice: Results from a national US survey. Clin Transplant 2021; 35:e14432. [PMID: 34291503 DOI: 10.1111/ctr.14432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/28/2021] [Accepted: 07/14/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Due to a substantial decline in pancreas transplantation (PT) across the United States over the past 15 years, we sought to understand the perceptions and practices of US PT programs. METHODS Surveys were sent to members of the American Society of Transplantation Surgeons and the American Society of Transplantation by email and professional society postings between August 2019 and November 2019. RESULTS One hundred twenty three responses were recorded from 56 unique programs. Program characteristics were obtained from the Scientific Registry of Transplant Recipients. Respondents were transplant surgeons (71%), transplant nephrologists (17%), trainees (9%), and allied professionals (3%). Programs were defined according to annual volume as: low (<5 PT/year), intermediate (6-20), or high (>20). High-volume programs reported that these factors were most important for increased PT: expansion of recipient selection, more aggressive donor utilization, and hiring of PT program-specific personnel. At both the program and national level, the vast majority (82% and 79%, respectively) felt the number of PTs currently performed are not in balance with patients' needs. CONCLUSIONS Overall, programs reported that the option of PT is not offered adequately to diabetic patients and that strategies to maintain higher PT volume are most evident at intermediate, and especially, high-volume programs.
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Affiliation(s)
| | - Abraham Matar
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Krista L Lentine
- Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, John C. McDonald Regional Transplant Center, Shreveport, Louisiana, USA
| | - Tarek Alhamad
- John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arpita Basu
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Mayo Clinic, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Giulio Romeo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Swati Rao
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Clark D Kensinger
- Piedmont Healthcare, Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Samuel Sultan
- Division of Transplantation Surgery, Weill Cornell Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Ekamol Tantisattamo
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
| | - Martha Pavlakis
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Cooper
- Department of Surgery, Medstar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia, USA
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11
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Butler CR, Wightman A, Richards CA, Laundry RS, Taylor JS, Hebert PL, Liu CF, O'Hare AM. Thematic Analysis of the Health Records of a National Sample of US Veterans With Advanced Kidney Disease Evaluated for Transplant. JAMA Intern Med 2021; 181:212-219. [PMID: 33226419 PMCID: PMC7684522 DOI: 10.1001/jamainternmed.2020.6388] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE To be considered for a kidney transplant, patients with advanced kidney disease must participate in a formal evaluation and selection process. Little is known about how this process proceeds in real-world clinical settings. OBJECTIVE To characterize the transplant evaluation process among a representative national sample of US veterans with advanced kidney disease who were referred to a kidney transplant center. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was a thematic analysis of clinician notes in the electronic health records of US veterans referred for kidney transplant evaluation. In a random sample of 4000 patients with advanced kidney disease between January 1, 2004, and December 31, 2014, cared for in the US Department of Veterans Affairs (VA) health care system, there were 211 patients who were referred to a transplant center during the follow-up period. This group was included in the qualitative analysis and was followed up until their date of death or the end of the follow-up period on October 8, 2019. MAIN OUTCOMES AND MEASURES Dominant themes pertaining to the kidney transplant evaluation and selection process identified through thematic analysis. RESULTS Among 211 study patients, the mean (SD) age was 57.9 (9.5) years, and 202 patients (95.7%) were male. The following 4 dominant themes regarding the transplant evaluation process emerged: (1) far-reaching and inflexible medical evaluation, in which patients were expected to complete an extensive evaluation that could have substantial physical and emotional consequences, made little accommodation for their personal values and needs, and impacted other aspects of their care; (2) psychosocial valuation, in which the psychosocial component of the transplant assessment could be subjective and intrusive and could place substantial demands on patients' family members; (3) surveillance over compliance, in which the patients' ability and willingness to follow medical recommendations was an important criterion for transplant candidacy and their adherence to a wide range of recommendations and treatments was closely monitored; and (4) disempowerment and lack of transparency, in which patients and their local clinicians were often unsure about what to expect during the evaluation process or about the rationale for selection decisions. For the evaluation process to proceed, local clinicians had to follow transplant center requirements even when they believed the requirements did not align with best practices or the patients' needs. CONCLUSIONS AND RELEVANCE In this qualitative study of US veterans with advanced kidney disease evaluated for transplant, clinician documentation in the medical record indicated that, to be considered for a kidney transplant, patients were required to participate in a rigid, demanding, and opaque evaluation and selection process over which they and their local clinicians had little control. These findings highlight the need for a more evidence-based, individualized, and collaborative approach to kidney transplant evaluation.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington
| | - Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington
| | - Claire A Richards
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington.,School of Nursing, University of Washington, Seattle
| | - Ryan S Laundry
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington
| | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - Paul L Hebert
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services Research, University of Washington, Seattle
| | - Chuan-Fen Liu
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services Research, University of Washington, Seattle
| | - Ann M O'Hare
- Division of Nephrology, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington
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12
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Salvalaggio PR, Ferreira GF, Caliskan Y, Vest LS, Schnitzler MA, de Sandes-Freitas TV, Moura LR, Lam NN, Maldonado RA, Loupy A, Axelrod DA, Lentine KL. An International survey on living kidney donation and transplant practices during the COVID-19 pandemic. Transpl Infect Dis 2020; 23:e13526. [PMID: 33245844 PMCID: PMC7744917 DOI: 10.1111/tid.13526] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/14/2020] [Accepted: 11/08/2020] [Indexed: 12/23/2022]
Abstract
The scope of the impact of the Coronavirus disease 19 (COVID‐19) pandemic on living donor kidney transplantation (LDKT) practices across the world is not well‐defined. We received survey responses from 204 transplant centers internationally from May to June 2020 regarding the impact of the COVID‐19 pandemic on LDKT practices. Respondents represented 16 countries on five continents. Overall, 75% of responding centers reported that LDKT surgery was on hold (from 67% of North American centers to 91% of European centers). The majority (59%) of centers reported that new donor evaluations were stopped (from 46% of North American centers to 86% of European centers), with additional 23% of centers reporting important decrease in evaluations. Only 10% of centers reported slight variations on their evaluations. For the centers that continued donor evaluations, 40% performed in‐person visits, 68% by video, and 42% by telephone. Center concerns for donor (82%) and recipient (76%) safety were the leading barriers to LDKT during the pandemic, followed by patients concerns (48%), and government restrictions (46%). European centers reported more barriers related to staff limitations while North and Latin American centers were more concerned with testing capacity and insufficient resources including protective equipment. As LDKT resumes, 96% of the programs intend to screen donor and recipient pairs for coronavirus infection, most of them with polymerase chain reaction testing of nasopharyngeal swab samples. The COVID‐19 pandemic has had broad impact on all aspects of LDKT practice. Ongoing research and consensus‐building are needed to guide safe reopening of LDKT programs.
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Affiliation(s)
| | - Gustavo F Ferreira
- Department of Medicine, Santa Casa de Juiz de Fora, Juiz de Fora, Brazil
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, Saint Louis University, St. Louis, MO, USA
| | - Luke S Vest
- Saint Louis University Center for Abdominal Transplantation, Saint Louis University, St. Louis, MO, USA
| | - Mark A Schnitzler
- Saint Louis University Center for Abdominal Transplantation, Saint Louis University, St. Louis, MO, USA
| | | | - Lucio R Moura
- Department of Medicine, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Ngan N Lam
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rafael A Maldonado
- Department of Medicine, Clinica Privada Vélez Sarsfield, Córdoba, Argentina
| | | | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, IA, USA
| | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, Saint Louis University, St. Louis, MO, USA
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13
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Lentine KL, Peipert JD, Alhamad T, Caliskan Y, Concepcion BP, Forbes R, Schnitzler M, Chang SH, Cooper M, Bloom RD, Mannon RB, Axelrod DA. Survey of Clinician Opinions on Kidney Transplantation from Hepatitis C Virus Positive Donors: Identifying and Overcoming Barriers. ACTA ACUST UNITED AC 2020; 1:1291-1299. [PMID: 33251523 DOI: 10.34067/kid.0004592020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Transplant practices related to use of organs from Hepatitis C virus infected donors (DHCV+) is evolving rapidly. Methods We surveyed U.S. kidney transplant programs by email and professional society listserv postings between 7/19-1/20 to assess attitudes, management strategies, and barriers related to use of viremic (nucleic acid testing (NAT)+) donor organs in HCV uninfected recipients. Results Staff at 112 unique programs responded, representing 54% of U.S. adult kidney transplant programs and 69% of adult deceased donor kidney transplant volume in 2019. Most survey respondents were transplant nephrologists (46%) or surgeons (43%). Among responding programs, 67% currently transplant DHCV antibody+/NAT- organs under a clinical protocol or as standard of care. By comparison, only 58% offer DHCV NAT+ kidney transplant to HCV- recipients, including 35% under clinical protocols, 14% as standard of care, and 9% under research protocols. Following transplant of DHCV NAT+ organs to uninfected recipients, 53% start direct acting antiviral agent (DAA) therapy after discharge and documented viremia. Viral monitoring protocols after DHCV NAT+ to HCV uninfected recipient kidney transplantation varied substantially. 56% of programs performing these transplants report having an institutional plan to provide DAA treatment if declined by the recipient's insurance. Respondents felt a mean decrease in waiting time of ≥18 months (range 0-60) justifies the practice. Program concerns related to use of DHCV NAT+ kidneys include insurance coverage concerns (72%), cost (60%), and perceived risk of transmitting resistant infection (44%). Conclusions Addressing knowledge about safety and logistical/financial barriers related to use of DHCV NAT+ kidney transplantation for HCV uninfected recipients may help reduced discards and expand the organ supply.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | - John D Peipert
- Northwestern University, Feinberg School of Medicine, Chicago, IL.,Northwestern University Transplant Outcomes Research Core, Chicago, IL
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | | | | | - Mark Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | | | | | - Roy D Bloom
- University of Pennsylvania, Philadelphia, PA
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14
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Lentine KL, Vest LS, Schnitzler MA, Mannon RB, Kumar V, Doshi MD, Cooper M, Mandelbrot DA, Harhay MN, Josephson MA, Caliskan Y, Sharfuddin A, Kasiske BL, Axelrod DA. Survey of US Living Kidney Donation and Transplantation Practices in the COVID-19 Era. Kidney Int Rep 2020; 5:1894-1905. [PMID: 32864513 PMCID: PMC7445484 DOI: 10.1016/j.ekir.2020.08.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The scope of the impact of the coronavirus disease 2019 (COVID-19) pandemic on living donor kidney transplantation (LDKT) practices is not well defined. METHODS We surveyed US transplant programs to assess practices, strategies, and barriers to living LDKT during the COVID-19 pandemic. After institutional review board approval, the survey was distributed from 9 May 2020 to 30 May 2020 by e-mail and postings to professional society list-servs. Responses were stratified based on state COVID-19 cumulative incidence levels. RESULTS Staff at 118 unique centers responded, representing 61% of US living donor recovery programs and 75% of LKDT volume in the prepandemic year. Overall, 66% reported that LDKT surgery was on hold (81% in "high" vs. 49% in "low" COVID-19 cumulative incidence states). A total of 36% reported that evaluation of new donor candidates had paused, 27% reported that evaluations were very much decreased (>0% to <25% typical), and 23% reported that evaluations were moderately decreased (25% to <50% typical). Barriers to LDKT surgery included program concerns for donor (85%) and recipient (75%) safety, patient concerns (56%), elective case restrictions (47%), and hospital administrative restrictions (48%). Programs with higher local COVID-19 cumulative incidence reported more barriers related to staff and resource diversion. Most centers continuing donor evaluations used remote strategies (video, 82%; telephone, 43%). As LDKT resumes, all programs will screen for COVID-19, although timeframe and modalities will vary. Recommendations for presurgical self-quarantine are also variable. CONCLUSION The COVID-19 pandemic has had broad impacts on LDKT practice. Ongoing research and consensus building are needed to reduce barriers, to guide optimal practices, and to support safe restoration of LDKT across centers.
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Affiliation(s)
- Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Luke S. Vest
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Mark A. Schnitzler
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Roslyn B. Mannon
- Department of Medicine, University of Nebraska, Omaha, Nebraska, USA
| | - Vineeta Kumar
- University of Alabama Comprehensive Transplant Center, Birmingham, Alabama, USA
| | - Mona D. Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, DC, USA
| | - Didier A. Mandelbrot
- Comprehensive Transplant Program, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Meera N. Harhay
- Department of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Asif Sharfuddin
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Bertram L. Kasiske
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - David A. Axelrod
- Organ Transplant Center, University of Iowa, Iowa City, Iowa, USA
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15
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Lentine KL, Motter JD, Henderson ML, Hays RE, Shukhman E, Hunt J, Al Ammary F, Kumar V, LaPointe Rudow D, Van Pilsum Rasmussen SE, Nishio-Lucar AG, Schaefer HM, Cooper M, Mandelbrot DA. Care of international living kidney donor candidates in the United States: A survey of contemporary experience, practice, and challenges. Clin Transplant 2020; 34:e14064. [PMID: 32808320 DOI: 10.1111/ctr.14064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/08/2020] [Accepted: 08/13/2020] [Indexed: 12/25/2022]
Abstract
The evaluation and care of non-US citizen, non-US residents who wish to come to the United States to serve as international living kidney donors (ILKDs) can pose unique challenges. We surveyed US transplant programs to better understand practices related to ILKD care. We distributed the survey by email and professional society list-servs (Fall 2018, assessing 2017 experience). Eighty-five programs responded (36.8% program response rate), of which 80 considered ILKD candidates. Only 18 programs had written protocols for ILKD evaluation. Programs had a median of 3 (range: 0,75) ILKD candidates who initiated contact during the year, from origin countries spanning 6 continents. Fewer (median: 1, range: 0,25) were approved for donation. Program-reported reasons for not completing ILKD evaluations included visa barriers (58.6%), inability to complete evaluation (34.3%), concerns regarding follow-up (31.4%) or other healthcare access (28.6%), and financial impacts (21.4%). Programs that did not evaluate ILKDs reported similar concerns. Staff time required to evaluate ILKDs was estimated as 1.5-to-3-times (47.9%) or >3-times (32.9%) that needed for domestic candidates. Among programs accepting ILKDs, on average 55% reported successful completion of 1-year follow-up. ILKD evaluation is a resource-intensive process with variable outcomes. Planning and commitment are necessary to care for this unique candidate group.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri, USA
| | - Jennifer D Motter
- Johns Hopkins Comprehensive Transplant Center, Baltimore, Maryland, USA
| | - Macey L Henderson
- Johns Hopkins Comprehensive Transplant Center, Baltimore, Maryland, USA
| | - Rebecca E Hays
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Ellen Shukhman
- Cedars-Sinai Comprehensive Transplant Center, Los Angeles, California, USA
| | - Julia Hunt
- Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Fawaz Al Ammary
- Johns Hopkins Comprehensive Transplant Center, Baltimore, Maryland, USA
| | - Vineeta Kumar
- University of Alabama Comprehensive Transplant Center, Birmingham, Alabama, USA
| | | | | | | | | | - Matthew Cooper
- MedStar Georgetown Transplant Institute, Washington, District of Columbia, USA
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16
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Sonnenberg EM, Cohen JB, Hsu JY, Potluri VS, Levine MH, Abt PL, Reese PP. Association of Kidney Transplant Center Volume With 3-Year Clinical Outcomes. Am J Kidney Dis 2019; 74:441-451. [PMID: 31076173 DOI: 10.1053/j.ajkd.2019.02.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 02/26/2019] [Indexed: 12/29/2022]
Abstract
RATIONALE & OBJECTIVE A robust relationship between procedure volume and clinical outcomes has been demonstrated across many surgical fields. This study assessed whether a center volume-outcome relationship exists for contemporary kidney transplantation, specifically for diabetic recipients, older recipients (aged ≥65 years), and recipients of high kidney donor profile index (KDPI ≥ 85) kidneys. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adult kidney-only transplant recipients who underwent transplantation between 2009 and 2013 (N = 79,581). EXPOSURES The primary exposure variable was center volume, categorized into quartiles based on the total kidney transplantation volume. Quartile 1 (Q1) centers performed a mean of fewer than 66 kidney transplantations per year, whereas Q4 centers performed a mean of more than 196 kidney transplantations per year. OUTCOMES All-cause graft failure and mortality within 3 years of transplantation. ANALYTICAL APPROACH Multivariable Cox frailty models were used to adjust for donor characteristics, recipient characteristics, and cold ischemia time. RESULTS Minor differences in rates of 3-year deceased donor all-cause graft failure across quartiles of center volume were observed (14.9% for Q1 vs 16.7% for Q4), including in subgroups (diabetic recipients, 18.4% for Q1 vs 19.7% for Q4; older recipients, 19.4% for Q1 vs 22.5% for Q4; recipients of high KDPI kidneys, 26.5% for Q1 vs 26.5% for Q4). Results were similar for 3-year mortality. After adjustment for donor, recipient, and graft characteristics using Cox regression, center volume was not significantly associated with all-cause graft failure or mortality within 3 years, except that diabetic recipients at Q3 centers had slightly lower mortality (compared with Q1 centers, adjusted HR of 0.85 [95% CI, 0.73-0.99]). LIMITATIONS Potential unmeasured confounding from patient comorbid conditions and organ selection. CONCLUSIONS These findings provide little evidence that care in higher volume centers is associated with better adjusted outcomes for kidney transplant recipients, even in populations anticipated to be at increased risk for graft failure or death.
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Affiliation(s)
- Elizabeth M Sonnenberg
- Department of Surgery, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Jesse Y Hsu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Vishnu S Potluri
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Matthew H Levine
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA.
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17
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Single-center analysis of infectious complications in older adults during the first year after kidney transplantation. Eur J Clin Microbiol Infect Dis 2018; 38:141-148. [PMID: 30353487 DOI: 10.1007/s10096-018-3405-5] [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: 07/20/2018] [Accepted: 10/15/2018] [Indexed: 12/29/2022]
Abstract
Infections are among the top three causes of death of older adults in the first year after kidney transplantation (KT). Our aim was to describe infectious complications among KT recipients aged ≥ 65 during the first 12 months post-transplant. Single-center retrospective cohort study. Ninety-one KTs had been performed in patients ≥ 65 years of age between 2011 and 2015. 92.3% of the patients developed at least one infection. Infectious episodes increased the risk of future infection by 10% (p = 0.0018) with each infection portending a greater risk. At a patient level, viral (71.4%) and bacterial (70.2%) infections predominated. Urinary tract infections were the most frequent complication (30.3%), followed by cytomegalovirus infections (22.7%). Infections were the main reason for readmission. 7.7% of the patients developed rejection; and overall 3.3% lost their graft. Mortality at 1 year was 9.9%. Older KT recipients have a high incidence of infectious complications the first year after KT. Infections were the number one reason for readmission, and an infection episode predicted future infections for the individual patient. Despite these complications, the majority of older KT recipients were alive with a functioning graft at 1 year.
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