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Bamforth RJ, Trachtenberg A, Ho J, Wiebe C, Ferguson TW, Rigatto C, Forget E, Dodd N, Tangri N. Expanding Access to High KDPI Kidney Transplant for Recipients Aged 60 y and Older: Cost Utility and Survival. Transplant Direct 2024; 10:e1629. [PMID: 38757046 PMCID: PMC11098249 DOI: 10.1097/txd.0000000000001629] [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: 11/28/2023] [Revised: 02/05/2024] [Accepted: 02/21/2024] [Indexed: 05/18/2024] Open
Abstract
Background Modern organ allocation systems are tasked with equitably maximizing the utility of transplanted organs. Increasing the use of deceased donor organs at risk of discard may be a cost-effective strategy to improve overall transplant benefit. We determined the survival implications and cost utility of increasing the use of marginal kidneys in an older adult Canadian population of patients with end-stage kidney disease. Methods We constructed a cost-utility model with microsimulation from the perspective of the Canadian single-payer health system for incident transplant waitlisted patients aged 60 y and older. A kidney donor profile index score of ≥86 was considered a marginal kidney. Donor- and recipient-level characteristics encompassed in the kidney donor profile index and estimated posttransplant survival scores were used to derive survival posttransplant. Patients were followed up for 10 y from the date of waitlist initiation. Our analysis compared the routine use of marginal kidneys (marginal kidney scenario) with the current practice of limited use (status quo scenario). Results The 10-y mean cost and quality-adjusted life-years per patient in the marginal kidney scenario were estimated at $379 485.33 (SD: $156 872.49) and 4.77 (SD: 1.87). In the status quo scenario, the mean cost and quality-adjusted life-years per patient were $402 937.68 (SD: $168 508.85) and 4.37 (SD: 1.87); thus, the intervention was considered dominant. At 10 y, 62.8% and 57.0% of the respective cohorts in the marginal kidney and status quo scenarios remained alive. Conclusions Increasing the use of marginal kidneys in patients with end-stage kidney disease aged 60 y and older may offer cost savings, improved quality of life, and greater patient survival in comparison with usual care.
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Affiliation(s)
- Ryan J. Bamforth
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Aaron Trachtenberg
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Julie Ho
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Chris Wiebe
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Thomas W. Ferguson
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Claudio Rigatto
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Evelyn Forget
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nancy Dodd
- Transplant Manitoba Adult Kidney Program, Winnipeg, MB, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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Wen Y, Mansour SG, Srialluri N, Hu D, Thiessen Philbrook H, Hall IE, Doshi MD, Mohan S, Reese PP, Parikh CR. Kidney Transplant Outcomes From Deceased Donors Who Received Dialysis. JAMA 2024:2819312. [PMID: 38780515 PMCID: PMC11117155 DOI: 10.1001/jama.2024.8469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 04/21/2024] [Indexed: 05/25/2024]
Abstract
Importance Recipient outcomes after kidney transplant from deceased donors who received dialysis prior to kidney donation are not well described. Objective To compare outcomes of transplant recipients who received kidneys from deceased donors who underwent dialysis prior to kidney donation vs recipients of kidneys from deceased donors who did not undergo dialysis. Design, Setting, and Participants A retrospective cohort study was conducted including data from 58 US organ procurement organizations on deceased kidney donors and kidney transplant recipients. From 2010 to 2018, 805 donors who underwent dialysis prior to kidney donation were identified. The donors who underwent dialysis prior to kidney donation were matched 1:1 with donors who did not undergo dialysis using a rank-based distance matrix algorithm; 1944 kidney transplant recipients were evaluated. Exposure Kidney transplants from deceased donors who underwent dialysis prior to kidney donation compared with kidney transplants from deceased donors who did not undergo dialysis. Main Outcomes and Measures The 4 study outcomes were delayed graft function (defined as receipt of dialysis by the kidney recipient ≤1 week after transplant), all-cause graft failure, death-censored graft failure, and death. Results From 2010 to 2018, 1.4% of deceased kidney donors (805 of 58 155) underwent dialysis prior to kidney donation. Of these 805 individuals, 523 (65%) donated at least 1 kidney. A total of 969 kidneys (60%) were transplanted and 641 kidneys (40%) were discarded. Among the donors with kidneys transplanted, 514 (mean age, 33 years [SD, 10.8 years]; 98 had hypertension [19.1%] and 36 had diabetes [7%]) underwent dialysis prior to donation and were matched with 514 (mean age, 33 years [SD, 10.9 years]; 98 had hypertension [19.1%] and 36 had diabetes [7%]) who did not undergo dialysis. Kidney transplants from donors who received dialysis prior to donation (n = 954 kidney recipients) were associated with a higher risk of delayed graft function compared with kidney transplants from donors who did not receive dialysis (n = 990 kidney recipients) (59.2% vs 24.6%, respectively; adjusted odds ratio, 4.17 [95% CI, 3.28-5.29]). The incidence rates did not significantly differ at a median follow-up of 34.1 months for all-cause graft failure (43.1 kidney transplants per 1000 person-years from donors who received dialysis prior to donation vs 46.9 kidney transplants per 1000 person-years from donors who did not receive dialysis; adjusted hazard ratio [HR], 0.90 [95% CI, 0.70-1.15]), for death-censored graft failure (22.5 vs 20.6 per 1000 person-years, respectively; adjusted HR, 1.18 [95% CI, 0.83-1.69]), or for death (24.6 vs 30.8 per 1000 person-years; adjusted HR, 0.76 [95% CI, 0.55-1.04]). Conclusions and Relevance Compared with receiving a kidney from a deceased donor who did not undergo dialysis, receiving a kidney from a deceased donor who underwent dialysis prior to kidney donation was associated with a significantly higher incidence of delayed graft function, but no significant difference in graft failure or death at follow-up.
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Affiliation(s)
- Yumeng Wen
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sherry G. Mansour
- Section of Nephrology, Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Nityasree Srialluri
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David Hu
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Heather Thiessen Philbrook
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Isaac E. Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Mona D. Doshi
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chirag R. Parikh
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Nishio Lucar AG, Patel A, Mehta S, Yadav A, Doshi M, Urbanski MA, Concepcion BP, Singh N, Sanders ML, Basu A, Harding JL, Rossi A, Adebiyi OO, Samaniego-Picota M, Woodside KJ, Parsons RF. Expanding the access to kidney transplantation: Strategies for kidney transplant programs. Clin Transplant 2024; 38:e15315. [PMID: 38686443 DOI: 10.1111/ctr.15315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/05/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.
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Affiliation(s)
- Angie G Nishio Lucar
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Ankita Patel
- Recanati-Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shikha Mehta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anju Yadav
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mona Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan A Urbanski
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - M Lee Sanders
- Department of Internal Medicine, Division of Nephrology, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Arpita Basu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Oluwafisayo O Adebiyi
- Department of Medicine, Indiana University Health Hospital, Indianapolis, Indiana, USA
| | | | | | - Ronald F Parsons
- Department of Surgery, University of Pennsylvannia, Philadelphia, Pennsylvania, USA
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McCracken EK, Jay CL, Garner M, Webb C, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta RJ. The Kidney Not Taken: Single-Kidney Use in Deceased Donors. J Am Coll Surg 2024; 238:492-504. [PMID: 38224100 DOI: 10.1097/xcs.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND The nonuse rate for kidneys recovered from deceased donors is increasing, rising to 27% in 2023. In 10% of these cases, 1 kidney is transplanted but the mate kidney is not. STUDY DESIGN We conducted a retrospective, single-center cohort study from December 2001 to May 2023 comparing single kidneys transplanted at our center (where the contralateral kidney was not used) to kidneys where both were transplanted separately, at least 1 of which was at our center. RESULTS We performed 395 single deceased-donor kidney transplants in which the mate kidney was not transplanted. Primary reasons for mate kidney nonuse were as follows: no recipient located or list exhausted (33.4%), kidney trauma or injury or anatomic abnormalities (18.7%), biopsy findings (16.7%), and poor renal function (13.7%). Mean donor and recipient ages were 51.5 ± 14.2 and 60 ± 12.6 years, respectively. Mean kidney donor profile index was 73% ± 22%, and 104 donors (26.3%) had kidney donor profile index >85%. Mean cold ischemia was 25.6 ± 7.4 hours, and 280 kidneys (70.7%) were imported. Compared with 2,303 concurrent control transplants performed at our center, primary nonfunction or thrombosis (5.1% single vs 2.8% control) and delayed graft function (35.4% single vs 30.1% control) were greater with single-kidney use (both p < 0.05). Median patient and death-censored graft survival were shorter in the single group (11.6 vs 13.5 years, p = 0.03 and 11.6 vs 19 years, p = 0.003), although the former was at least double median survival on the waiting list. In patients with functioning grafts in the single-kidney group, 1-year mean serum creatinine was 1.77 ± 0.8 mg/dL and estimated glomerular filtration rate was 44.8 ± 20 mL/min/1.73 m 2 . CONCLUSIONS These findings suggest that many mate kidneys are being inappropriately rejected, given the acceptable outcomes that can be achieved by transplanting the single kidney in appropriately selected recipients.
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Affiliation(s)
- Emily Ke McCracken
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Colleen L Jay
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Matthew Garner
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Christopher Webb
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Alan C Farney
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Giuseppe Orlando
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Alejandra Mena-Gutierrez
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Natalia Sakhovskaya
- Department of Internal Medicine, Section of Nephrology (Reeves-Daniel, Mena-Gutierrez, Sakhovskaya), Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Robert J Stratta
- From the Department of Surgery, Section of Transplantation (McCracken, Jay, Garner, Webb, Farney, Orlando, Stratta)
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5
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Lu Y, Coromina Hernandez L, Woodside KJ. Donor Resuscitation Time, Kidney Transplant, and Selection Bias: Les reins ont des raisons que la raison ne connaît pas (with Apologies to Blaise Pascal). Transplantation 2024; 108:612-613. [PMID: 37817308 DOI: 10.1097/tp.0000000000004826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Affiliation(s)
- Yee Lu
- University of Michigan, Ann Arbor, MI
| | | | - Kenneth J Woodside
- Sharing Hope of South Carolina, Charleston, SC
- Gift of Life Michigan, Ann Arbor, MI
- Academia Invisus LLC, Ann Arbor, MI
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6
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Woelfel I, Schenk A, Limkemann A, Huang E, Syed S. Missing the Match: A National Survey Investigating Education in Renal Donor-Recipient Matching. Transplant Proc 2024; 56:267-277. [PMID: 38341297 DOI: 10.1016/j.transproceed.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/07/2023] [Accepted: 01/16/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE Clinical judgment in renal donor organ and recipient selection is gained through fellowship and mentorship in early career. We aim to understand the past and current state of organ acceptance education. METHODS We developed and distributed an anonymous, national survey to American Society of Transplant Surgeons faculty members and transplant surgery fellows in 2022. Survey questions explored in detail the evaluation of organ offers, the extent of formal education in organ evaluation, and attitudes regarding training adequacy. FINDINGS Ninety-eight attending surgeons (65 men, 25 women, and 3 nonbinary) and 38 fellows (25 men, 6 women, and 2 nonbinary) responded. Seventy-eight percent of attending surgeons and 6% of fellows take primary organ offers. Forty-four percent of fellows report no didactic education in donor evaluation and recipient selection. Fellows report that discussion with attending surgeons (37.2%) and independent study of the literature (35.4%) are their primary modes of learning. Fellows call for additional clinical decision-making experience (47.3%), further didactic sessions (44.7%), and additional discussions with faculty (44.7%). Sixty-four percent of fellows and 55% of attendings felt their training provided adequate education about donor selection. CONCLUSION Our responses suggest gaps in education regarding donor and recipient selection. Increased clinical experience and standardized education at the national level represent opportunities for improvement.
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Affiliation(s)
- Ingrid Woelfel
- Ohio State University, Department of Surgery, Columbus, Ohio.
| | - Austin Schenk
- Ohio State University, Department of Surgery, Columbus, Ohio
| | | | - Emily Huang
- Ohio State University, Department of Surgery, Columbus, Ohio
| | - Shareef Syed
- University of California San Francisco, Department of Surgery, Division of Transplantation, San Francisco, California
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Warner RM, Yang J, Drake A, Lee Y, Nemanic S, Scott D, Higgins AZ. Osmotic response during kidney perfusion with cryoprotectant in isotonic or hypotonic vehicle solution. PeerJ 2023; 11:e16323. [PMID: 38025736 PMCID: PMC10668850 DOI: 10.7717/peerj.16323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023] Open
Abstract
Organ cryopreservation would revolutionize transplantation by overcoming the shelf-life limitations of conventional organ storage. To prepare an organ for cryopreservation, it is first perfused with cryoprotectants (CPAs). These chemicals can enable vitrification during cooling, preventing ice damage. However, CPAs can also cause toxicity and osmotic damage. It is a major challenge to find the optimal balance between protecting the cells from ice and avoiding CPA-induced damage. In this study, we examined the organ perfusion process to shed light on phenomena relevant to cryopreservation protocol design, including changes in organ size and vascular resistance. In particular, we compared perfusion of kidneys (porcine and human) with CPA in either hypotonic or isotonic vehicle solution. Our results demonstrate that CPA perfusion causes kidney mass changes consistent with the shrink-swell response observed in cells. This response was observed when the kidneys were relatively fresh, but disappeared after prolonged warm and/or cold ischemia. Perfusion with CPA in a hypotonic vehicle solution led to a significant increase in vascular resistance, suggesting reduced capillary diameter due to cell swelling. This could be reversed by switching to perfusion with CPA in isotonic vehicle solution. Hypotonic vehicle solution did not cause notable osmotic damage, as evidenced by low levels of lactate dehydrogenase (LDH) in the effluent, and it did not have a statistically significant effect on the delivery of CPA into the kidney, as assessed by computed tomography (CT). Overall, our results show that CPA vehicle solution tonicity affects organ size and vascular resistance, which may have important implications for cryopreservation protocol design.
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Affiliation(s)
- Ross M. Warner
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon, United States
| | - Jun Yang
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon, United States
| | - Andrew Drake
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon, United States
| | - Youngjoo Lee
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon, United States
| | - Sarah Nemanic
- Veterinary Radiology Consulting LLC, Lebanon, Oregon, United States
| | - David Scott
- Department of Abdominal Transplantation, Oregon Health & Science University, Portland, Oregon, United States
| | - Adam Z. Higgins
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon, United States
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Kilambi V, Barah M, Formica RN, Friedewald JJ, Mehrotra S. Evaluation of Opening Offers Early for Deceased Donor Kidneys at Risk of Nonutilization. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00287. [PMID: 37943856 PMCID: PMC10861110 DOI: 10.2215/cjn.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Reducing nonutilization of kidneys recovered from deceased donors is a current policy concern for kidney allocation in the United States. The likelihood of nonutilization is greater with a higher kidney donor risk index (KDRI) offer. We examine how opening offers for organs with KDRI >1.75 to the broader waitlist at varying points of time affects usage rates. METHODS We simulate kidney allocation using data for January 2018 to June 2019 from Organ Procurement and Transplantation Network. For the simulation experiment, allocation policy is modified so that KDRI >1.75 organs are offered to all local candidates (same donation service area) after a set amount of cold time simultaneously. Open offers to candidates nationally are similarly examined. RESULTS Simulation results ( n =50 replications) estimate that opening offers locally for KDRI >1.75 after 10 hours yields a nonutilization rate of 38% (range: 35%-42%), less than the prevailing rate of 55% of KDRI >1.75 kidneys. Opening offers after 5 hours yields 30% (range: 26%-34%), reducing the prevailing nonutilization rate by 45%. Opening offers nationally after 10 and 5 hours yields nonutilization rates of 11% (range: 8%-15%) and 6% (range: 4%-9%) for KDRI >1.75 kidneys, respectively. CONCLUSIONS Simulation findings indicate that opening offers and adjusting their timing can significantly reduce nonutilization of high-KDRI kidneys.
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Affiliation(s)
- Vikram Kilambi
- Department of Engineering and Applied Sciences, RAND Corporation, Arlington, Virginia
- RAND Health Care, Access and Delivery Program, RAND Corporation, Arlington, Virginia
| | - Masoud Barah
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
| | - Richard N. Formica
- Department of Nephrology, Yale School of Medicine, New Haven, Connecticut
| | - John J. Friedewald
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjay Mehrotra
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, Illinois
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
- Center for Engineering and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Jadlowiec CC, Ohara SY, Punukollu R, Wagler J, Ruch B, Kumm K, Budhiraja P, Me HM, Mathur AK, Reddy KS, Khamash H, Heilman R. Outcomes with transplanting kidneys offered through expedited allocation. Clin Transplant 2023; 37:e15094. [PMID: 37563488 DOI: 10.1111/ctr.15094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Expedited out-of-sequence deceased donor kidney allocation is a strategy to avoid discards after early placement attempts have been unsuccessful. Our study aimed to assess outcomes and characteristics of these transplanted kidneys. METHODS KDPI matching was performed between expedited allocation (EA) and standard allocation (SA) deceased donor kidney transplants performed at our center. RESULTS Between 2018 and 2021, there were 225 EA offers, and 189 (84%) were transplanted. EA recipients were older (p = .007) and had shorter dialysis vintage (p < .0001). EA kidneys were likely to be nationally allocated (p < .001), have AKI (p < .0001) and longer CIT (p < .0001). There were no differences in EA and SA time-zero kidney biopsies (ci, p = .07; ct, p = .89; cv, p = .95; ah, p = .79). EA kidneys had more DGF (p = .0006), but there were no differences in DGF duration (p = .83), hospital length of stay (p = .43), 1- and 2-year eGFR (p = .16, p = .99), patient (p = .34), or death-censored graft (p = .66) survival. CONCLUSION During this study period, our center transplanted 189 kidneys through EA following local-regional declines. These kidneys often came from AKI donors and had more DGF but had similar outcomes to KDPI-matched SA kidneys. Although it has been suggested that EA has the potential to worsen transplant disparities, transplant center level decisions on organ acceptance contribute to these variations.
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Affiliation(s)
- Caroline C Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Stephanie Y Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, Arizona, USA
| | - Rachana Punukollu
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Josiah Wagler
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Brianna Ruch
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kayla Kumm
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Hay Me Me
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Amit K Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Kunam S Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Hasan Khamash
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
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10
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Webb CJ, McCracken E, Jay CL, Sharda B, Garner M, Farney AC, Orlando G, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Single center experience and literature review of kidney transplantation from non-ideal donors with acute kidney injury: Risk and reward. Clin Transplant 2023; 37:e15115. [PMID: 37646473 DOI: 10.1111/ctr.15115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION There is limited experience transplanting kidneys from either expanded criteria donors (ECD) or donation after circulatory death (DCD) deceased donors with terminal acute kidney injury (AKI). METHODS AKI kidneys were defined by a donor terminal serum creatinine level >2.0 mg/dL whereas non-ideal deceased donor (NIDD) kidneys were defined as AKI/DCD or AKI/ECDs. RESULTS From February 2007 to March 2023, we transplanted 266 single AKI donor kidneys including 29 from ECDs, 29 from DCDs (n = 58 NIDDs), and 208 from brain-dead standard criteria donors (SCDs). Mean donor age (43.7 NIDD vs. 33.5 years SCD), KDPI (66% NIDD vs. 45% SCD), and recipient age (57 NIDD vs. 51 years SCD) were higher in the NIDD group (all p < .01). Mean waiting times (17.8 NIDD vs. 24.2 months SCD) and dialysis duration (34 NIDD vs. 47 months SCD) were shorter in the NIDD group (p < .05). Delayed graft function (DGF, 48%) and 1-year graft survival (92.7% NIDD vs. 95.9% SCD) was similar in both groups. Five-year patient and kidney graft survival rates were 82.1% versus 89.9% and 82.1% versus 75.2% (both p = NS) in the NIDD versus SCD groups, respectively. CONCLUSIONS The use of kidneys from AKI donors can be safely liberalized to include selected ECD and DCD donors.
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Affiliation(s)
- Christopher J Webb
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Emily McCracken
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Matthew Garner
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation and the Section of Nephrology, Winston-Salem, North Carolina, USA
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11
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Punukollu R, Ryan M, Misra S, Budhiraja P, Ohara S, Kumm K, Guerra G, Reddy KS, Heilman R, Jadlowiec CC. Past, Current, and Future Perspectives on Transplanting Acute Kidney Injury Kidneys. Clin Pract 2023; 13:944-958. [PMID: 37623267 PMCID: PMC10453697 DOI: 10.3390/clinpract13040086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
(1) Background: Acute kidney injury (AKI) kidneys have high non-utilization rates due to concerns regarding unfavorable outcomes. In this paper, we aimed to review the past, present, and future opinions on AKI kidneys. (2) Methods: A PubMed search was conducted for topics relevant to AKI kidney transplantation. (3) Results: Current short- and long-term data on AKI kidneys have demonstrated good outcomes including favorable graft function and survival. The role of procurement biopsies is controversial, but they have been shown to be beneficial in AKI kidneys by allowing clinicians to differentiate between reversible tubular injury and irreversible cortical necrosis. Machine perfusion has also been applied to AKI kidneys and has been shown to reduce delayed graft function (DGF). The incidence of DGF increases with AKI severity and its management can be challenging. Strategies employed to counteract this have included early initiation of dialysis after kidney transplantation, early targeting of adequate immunosuppression levels to minimize rejection risk, and establishment of outpatient dialysis. (4) Conclusions: Despite good outcomes, there continue to be barriers that impact AKI kidney utilization. Successful strategies have included use of procurement biopsies or machine perfusion and expectant management of DGF. With increasing experience, better use of AKI kidneys can result in additional opportunities to expand the donor pool.
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Affiliation(s)
- Rachana Punukollu
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Margaret Ryan
- Division of Anatomic Pathology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Suman Misra
- Division of Nephrology, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Stephanie Ohara
- Division of Surgery, Valleywise Health Medical Center, Creighton University, Phoenix, AZ 85008, USA
| | - Kayla Kumm
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Giselle Guerra
- Division of Nephrology, Miami Transplant Institute, Miami, FL 33136, USA
| | - Kunam S. Reddy
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Caroline C. Jadlowiec
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
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12
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Bunnapradist S, Rosenthal JT, Huang E, Dafoe D, Seto T, Cohen A, Danovitch G. Deceased Donor Kidney Nonuse: A Systematic Approach to Improvement. Transplant Direct 2023; 9:e1491. [PMID: 37250491 PMCID: PMC10219747 DOI: 10.1097/txd.0000000000001491] [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: 09/26/2022] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 05/31/2023] Open
Abstract
A large number of procured kidneys continue not to be transplanted, while the waiting list remains high. Methods We analyzed donor characteristics for unutilized kidneys in our large organ procurement organization (OPO) service area in a single year to determine the reasonableness of their nonuse and to identify how we might increase the transplant rate of these kidneys. Five experienced local transplant physicians independently reviewed unutilized kidneys to identify which kidneys they would consider transplanting in the future. Biopsy results, donor age, kidney donor profile index, positive serologies, diabetes, and hypertension were risk factors for nonuse. Results Two-thirds of nonused kidneys had biopsies with high degree of glomerulosclerosis and interstitial fibrosis. Reviewers identified 33 kidneys as potentially transplantable (12%). Conclusions Reducing the rate of unutilized kidneys in this OPO service area will be achieved by setting acceptable expanded donor characteristics, identifying suitable well-informed recipients, defining acceptable outcomes, and systematically evaluating the results of these transplants. Because the improvement opportunity will vary by region, to achieve a significant impact on improving the national nonuse rate, it would be useful for all OPOs, in collaboration with their transplant centers, to conduct a similar analysis.
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Affiliation(s)
- Suphamai Bunnapradist
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
| | - J. Thomas Rosenthal
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
| | - Edmund Huang
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | - Donald Dafoe
- Department of Surgery, University of California Irvine, Irvine, CA
| | | | | | - Gabriel Danovitch
- David Geffen School of Mesdicine, University of California Los Angeles, Los Angeles, CA
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13
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Ibrahim M, Mehew J, Martin K, Forsythe J, Johnson RJ, Callaghan C. Outcomes of Declined Deceased Donor Kidney Offers That Are Subsequently Implanted: A UK Registry Study. Transplantation 2023; 107:1348-1358. [PMID: 36706063 DOI: 10.1097/tp.0000000000004467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Deceased donor kidneys are often declined for ≥1 patients but then implanted into another. Studies are needed to guide transplant clinicians and patients, especially given the increasing age and comorbidity of donors. This study compares outcomes of recipients of transplanted kidneys that were initially declined with outcomes of patients who remained on the waiting list. METHODS This UK Transplant Registry study examined named-patient, adult donation after brain death donor single kidney-only offers that were declined for donor- or organ-related reasons (DORRs), in which the kidney was subsequently transplanted from January 1, 2010, to December 31, 2018. Outcomes included graft function and survival of kidneys transplanted following DORR decline, survival and transplant status of patients who had a kidney declined, and intercenter decline rates. RESULTS A total of 4722 kidneys declined for DORRs, which eventually resulted in single kidney-only transplants, were examined. One year after the offer decline, 35% of patients for whom the organ was declined remained on the list, 55% received a deceased donor transplant at a median of 174 d after the initial offer decline, and 4% had been removed or died. For patients transplanted following offer decline, there was no significant difference in 5-y graft survival when comparing the outcomes to those recipients who received the declined kidney. There was significant variation in DORR decline rates between UK transplant units (17%-54%). CONCLUSIONS This study shows reasonable outcomes of kidneys previously declined for DORRs and supports the utilization of those considered to be of higher risk for carefully selected recipients.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Jennifer Mehew
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Kate Martin
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - John Forsythe
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Rachel J Johnson
- NHS Blood and Transplant, Stoke Gifford, Bristol, United Kingdom
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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14
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Liu RX, Koyawala N, Thiessen-Philbrook HR, Doshi MD, Reese PP, Hall IE, Mohan S, Parikh CR. Untargeted metabolomics of perfusate and their association with hypothermic machine perfusion and allograft failure. Kidney Int 2023; 103:762-771. [PMID: 36549364 DOI: 10.1016/j.kint.2022.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/28/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022]
Abstract
Although hypothermic machine perfusion (HMP) is associated with improved kidney graft viability and function, the underlying biological mechanisms are unknown. Untargeted metabolomic profiling may identify potential metabolites and pathways that can help assess allograft viability and contribute to organ preservation. Therefore, in this multicenter study, we measured all detectable metabolites in perfusate collected at the beginning and end of deceased-donor kidney perfusion and evaluated their associations with graft failure. In our cohort of 190 kidney transplants, 33 (17%) had death-censored graft failure over a median follow-up of 5.0 years (IQR 3.0-6.1 years). We identified 553 known metabolites in perfusate and characterized their experimental and biological consistency through duplicate samples and unsupervised clustering. After perfusion-time adjustment and false discovery correction, six metabolites in post-HMP perfusate were significantly associated with death-censored graft failure, including alpha-ketoglutarate, 3-carboxy-4-methyl-5-propyl-2-furanpropanoate, 1-carboxyethylphenylalanine, and three glycerol-phosphatidylcholines. All six metabolites were associated with an increased risk of graft failure (Hazard Ratio per median absolute deviation range 1.04-1.45). Four of six metabolites also demonstrated significant interaction with donation after cardiac death with notably greater risk in the donation after cardiac death group (Hazard Ratios up to 1.69). Discarded kidneys did not have significantly different levels of any death-censored graft failure-associated metabolites. On interrogation of pathway analysis, production of reactive oxygen species and increased metabolism of fatty acids were upregulated in kidneys that subsequently developed death-censored graft failure. Thus, further understanding the role of these metabolites may inform the HMP process and help improve the objective evaluation of allograft offers, thereby reducing the discard of potentially viable organs.
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Affiliation(s)
- Richard X Liu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Neel Koyawala
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Mona D Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Isaac E Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Chirag R Parikh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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15
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Wood EL, Kwan L, Burrows JE, Singh G, Veale J, Lum EL. Early recurrence of Focal Segmental Glomerulosclerosis in kidney transplant recipients: When to consider regifting. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2023.100130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
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16
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Garner M, Jay CL, Sharda B, Webb C, Farney AC, Orlando G, Rogers J, Reeves-Daniel A, Mena-Gutierrez A, Sakhovskaya N, Stratta B, Stratta RJ. Long-term outcomes of kidney transplantation from deceased donors with terminal acute kidney injury: Single center experience and literature review. Clin Transplant 2023; 37:e14886. [PMID: 36524320 DOI: 10.1111/ctr.14886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/05/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Long-term outcomes of kidney transplantation from deceased donors (DDKTs) with terminal acute kidney injury (AKI) are not well defined. METHODS Single center retrospective review of DDKTs from 1/31/07-12/31/19. AKI kidneys were defined by a doubling of the donor's admission serum creatinine (SCr) level AND a terminal SCr ≥2.0 mg/dl. RESULTS A total of 188 AKI DDKTs were performed, including 154 from brain-dead standard criteria donors (SCD). Mean donor age was 36 years and mean Kidney Donor Profile Index was 50%; mean admission and terminal SCr levels were 1.3 and 3.1 mg/dl, respectively. With a mean follow-up of 94 months (median 89 months), overall patient (both 71.3%) and graft survival (54% AKI vs. 57% non-AKI) rates were comparable to concurrent DDKTs from brain-dead non-AKI SCDs (n = 769). Delayed graft function (DGF) was higher in AKI kidney recipients (47% vs. 20% non-AKI DDKTs, p < .0001). DGF was associated with lower graft survival in recipients of both AKI and non-AKI SCD kidneys but the impact was earlier and more pronounced in non-AKI recipients. CONCLUSIONS Despite having more than twice the incidence of DGF, kidneys from deceased donors with terminal AKI have long-term outcomes comparable to non-AKI SCD kidneys and represent a safe and effective method to expand the donor pool.
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Affiliation(s)
- Matthew Garner
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Colleen L Jay
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher Webb
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alan C Farney
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeffrey Rogers
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amber Reeves-Daniel
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandra Mena-Gutierrez
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Natalia Sakhovskaya
- Department of Medicine, Section of Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bobby Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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17
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Akalay S, Hosgood SA. How to Best Protect Kidneys for Transplantation-Mechanistic Target. J Clin Med 2023; 12:jcm12051787. [PMID: 36902572 PMCID: PMC10003664 DOI: 10.3390/jcm12051787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
The increasing number of patients on the kidney transplant waiting list underlines the need to expand the donor pool and improve kidney graft utilization. By protecting kidney grafts adequately from the initial ischemic and subsequent reperfusion injury occurring during transplantation, both the number and quality of kidney grafts could be improved. The last few years have seen the emergence of many new technologies to abrogate ischemia-reperfusion (I/R) injury, including dynamic organ preservation through machine perfusion and organ reconditioning therapies. Although machine perfusion is gradually making the transition to clinical practice, reconditioning therapies have not yet progressed from the experimental setting, pointing towards a translational gap. In this review, we discuss the current knowledge on the biological processes implicated in I/R injury and explore the strategies and interventions that are being proposed to either prevent I/R injury, treat its deleterious consequences, or support the reparative response of the kidney. Prospects to improve the clinical translation of these therapies are discussed with a particular focus on the need to address multiple aspects of I/R injury to achieve robust and long-lasting protective effects on the kidney graft.
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Affiliation(s)
- Sara Akalay
- Department of Development and Regeneration, Laboratory of Pediatric Nephrology, KU Leuven, 3000 Leuven, Belgium
| | - Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence:
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18
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Stratta RJ. Kidney utility and futility. Clin Transplant 2022; 36:e14847. [PMID: 36321653 DOI: 10.1111/ctr.14847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/01/2022] [Accepted: 10/29/2022] [Indexed: 11/25/2022]
Abstract
Changes in kidney allocation coupled with the COVID-19 pandemic have placed tremendous strain on current systems of organ distribution and logistics. Although the number of deceased donors continues to rise annually in the United States, the proportion of marginal deceased donors (MDDs) is disproportionately growing. Cold ischemia times and kidney discard rates are rising in part related to inadequate planning, resources, and shortages. Complexity in kidney allocation and distribution has contributed to this dilemma. Logistical issues and the ability to reperfuse the kidney within acceptable time constraints increasingly determine clinical decision-making for organ acceptance. We have a good understanding of the phenotype of "hard to place" MDD kidneys, yet continue to promote a "one size fits all" approach to organ allocation. Allocation and transportation systems need to be agile, mobile, and flexible in order to accommodate the expanding numbers of MDD organs. By identifying "hard to place" MDD kidneys early and implementing a "fast-track" or open offer policy to expedite placement, the utilization rate of MDDs would improve dramatically. Organ allocation and distribution based on location, motivation, and innovation must lead the way. In the absence of change, we are sacrificing utility for futility and discard rates will continue to escalate.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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19
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Stewart D, Tanriover B, Gupta G. Oversimplification and Misplaced Blame Will Not Solve the Complex Kidney Underutilization Problem. KIDNEY360 2022; 3:2143-2147. [PMID: 36591359 PMCID: PMC9802557 DOI: 10.34067/kid.0005402022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Darren Stewart
- Department of Surgery, New York University Langone Health, New York, New York
| | - Bekir Tanriover
- Division of Nephrology, The University of Arizona, Tucson, Arizona
| | - Gaurav Gupta
- Division of Nephrology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia,Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
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20
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Husain SA, King KL, Cron DC, Neidlinger NA, Ng H, Mohan S, Adler JT. Association of transplant center market concentration and local organ availability with deceased donor kidney utilization. Am J Transplant 2022; 22:1603-1613. [PMID: 35213789 PMCID: PMC9177771 DOI: 10.1111/ajt.17010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/30/2022] [Accepted: 02/20/2022] [Indexed: 01/25/2023]
Abstract
Although there is a shortage of kidneys available for transplantation, many transplantable kidneys are not procured or are discarded after procurement. We investigated whether local market competition and/or organ availability impact kidney procurement/utilization. We calculated the Herfindahl-Hirschman Index (HHI) for deceased donor kidney transplants (2015-2019) for 58 US donation service areas (DSAs) and defined 4 groups: HHI ≤ 0.32 (high competition), HHI = 0.33-0.51 (medium), HHI = 0.53-0.99 (low), and HHI = 1 (monopoly). We calculated organ availability for each DSA as the number kidneys procured per incident waitlisted candidate, grouped as: <0.42, 0.42-0.69, >0.69. Characteristics of procured organs were similar across groups. In adjusted logistic regression, the HHI group was inconsistently associated with composite export/discard (reference: high competition; medium: OR 1.16, 95% CI 1.11-1.20; low 1.01, 0.96-1.06; monopoly 1.19, 1.13-1.26) and increasing organ availability was associated with export/discard (reference: availability <0.42; 0.42-0.69: OR 1.35, 95% CI 1.30-1.40; >0.69: OR 1.83, 95% CI 1.73-1.93). When analyzing each endpoint separately, lower competition was associated with higher export and only market monopoly was weakly associated with lower discard, whereas higher organ availability was associated with export and discard. These results indicate that local organ utilization is more strongly influenced by the relative intensity of the organ shortage than by market competition between centers.
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Affiliation(s)
- Syed A. Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Han Ng
- Department of Economics, Pennsylvania State University, State College, Pennsylvania
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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21
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King KL, Husain SA, Perotte A, Adler JT, Schold JD, Mohan S. Deceased donor kidneys allocated out of sequence by organ procurement organizations. Am J Transplant 2022; 22:1372-1381. [PMID: 35000284 PMCID: PMC9081167 DOI: 10.1111/ajt.16951] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 01/25/2023]
Abstract
Deceased donor kidney allocation follows a ranked match-run of potential recipients. Organ procurement organizations (OPOs) are permitted to deviate from the mandated match-run in exceptional circumstances. Using match-run data for all deceased donor kidney transplants (Ktx) in the US between 2015 and 2019, we identified 1544 kidneys transplanted from 933 donors with an OPO-initiated allocation exception. Most OPOs (55/58) used this process at least once, but 3 OPOs performed 64% of the exceptions and just 2 transplant centers received 25% of allocation exception Ktx. At 2 of 3 outlier OPOs these transplants increased 136% and 141% between 2015 and 2019 compared to only a 35% increase in all Ktx. Allocation exception donors had less favorable characteristics (median KDPI 70, 41% with history of hypertension), but only 29% had KDPI ≥ 85% and the majority did not meet the traditional threshold for marginal kidneys. Allocation exception kidneys went to larger centers with higher offer acceptance ratios and to recipients with 2 fewer priority points-equivalent to 2 less years of waiting time. OPO-initiated exceptions for kidney allocation are growing increasingly frequent and more concentrated at a few outlier centers. Increasing pressure to improve organ utilization risks increasing out-of-sequence allocations, potentially exacerbating disparities in access to transplantation.
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Affiliation(s)
- Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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22
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Stewart DE, Foutz J, Kamal L, Weiss S, McGehee HS, Cooper M, Gupta G. The Independent Effects of Procurement Biopsy Findings on Ten-Year Outcomes of Extended Criteria Donor Kidney Transplants. Kidney Int Rep 2022; 7:1850-1865. [PMID: 35967103 PMCID: PMC9366372 DOI: 10.1016/j.ekir.2022.05.027] [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: 04/12/2022] [Accepted: 05/23/2022] [Indexed: 11/01/2022] Open
Abstract
Introduction Methods Results Conclusion
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23
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Liu C, Alasfar S, Reese PP, Mohan S, Doshi MD, Hall IE, Thiessen Philbrook H, Jia Y, Stewart D, Parikh CR. Trends in the procurement and discard of kidneys from deceased donors with acute kidney injury. Am J Transplant 2022; 22:898-908. [PMID: 34897982 DOI: 10.1111/ajt.16920] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 11/11/2021] [Accepted: 12/02/2021] [Indexed: 01/25/2023]
Abstract
Kidney allocation trends from deceased donors with acute kidney injury (AKI) have not been characterized since initial Kidney Donor Profile Index reporting in 2012 and its use under the revised Kidney Allocation System (KAS) in 2014. We conducted a retrospective analysis of US registry data to characterize kidney procurement and discard trends in deceased donors with AKI, defined by ≥50% or ≥0.3 mg/dl (≥4.0 mg/dl or ≥200% for stage 3) increase in terminal serum creatinine from admission. From 2010 to 2020, 172 410 kidneys were procured from 93 341 deceased donors 16 years or older; 34 984 kidneys were discarded (17 559 from AKI donors). The proportion of stage 3 AKI donors doubled from 6% (412/6841) in 2010 to 12% (1365/11493) in 2020. Procurement of stage 3 AKI kidneys increased from 51% (423/824) to 80% (2183/2730). While discard of stage 3 AKI kidneys increased from 41% (175/423) in 2010 to 44% (960/2183) in 2020, this increase was not statistically significant in interrupted time-series analysis following KAS implementation (slope difference -0.41 [-3.22, 2.4], and level change 3.09 [-6.4, 12.6]). In conclusion, the absolute number of stage 3 AKI kidneys transplanted has increased. Ongoing high discard rates of these kidneys suggest opportunities for improved utilization.
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Affiliation(s)
- Caroline Liu
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sami Alasfar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter P Reese
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Mona D Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Isaac E Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Heather Thiessen Philbrook
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yaqi Jia
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Darren Stewart
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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24
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. The use of marginal kidneys in dual kidney transplantation to expand kidney graft utilization. Curr Opin Organ Transplant 2022; 27:75-85. [PMID: 34939967 DOI: 10.1097/mot.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to chronicle the history of dual kidney transplantation (DKT) and identify opportunities to improve utilization of marginal deceased donor (MDD) kidneys through DKT. RECENT FINDINGS The practice of DKT from adult MDDs dates back to the mid-1990s, at which time the primary indication was projected insufficient nephron mass from older donors. Multiple subsequent studies of short- and long-term success have been reported focusing on three major aspects: Identifying appropriate selection criteria/scoring systems based on pre- and postdonation factors; refining technical aspects; and analyzing longer-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. MDDs with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or nonrecovery. SUMMARY DKT may reduce organ discard and optimize the use of kidneys from MDDs. New and innovative technologies targeting ex vivo organ assessment, repair, and regeneration may have a major impact on the decision whether or not to use recovered kidneys for single or DKT.
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Affiliation(s)
- Robert J Stratta
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Harriman
- The Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Venkat Gurram
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Komal Gurung
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Berjesh Sharda
- The Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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25
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A Review of Current and Emerging Trends in Donor Graft-Quality Assessment Techniques. J Clin Med 2022; 11:jcm11030487. [PMID: 35159939 PMCID: PMC8836899 DOI: 10.3390/jcm11030487] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 02/07/2023] Open
Abstract
The number of patients placed on kidney transplant waiting lists is rapidly increasing, resulting in a growing gap between organ demand and the availability of kidneys for transplantation. This organ shortage has forced medical professionals to utilize marginal kidneys from expanded criteria donors (ECD) to broaden the donor pool and shorten wait times for patients with end-stage renal disease. However, recipients of ECD kidney grafts tend to have worse outcomes compared to those receiving organs from standard criteria donors (SCD), specifically increased risks of delayed graft function (DGF) and primary nonfunction incidence. Thus, representative methods for graft-quality assessment are strongly needed, especially for ECDs. Currently, graft-quality evaluation is limited to interpreting the donor’s recent laboratory tests, clinical risk scores, the visual evaluation of the organ, and, in some cases, a biopsy and perfusion parameters. The last few years have seen the emergence of many new technologies designed to examine organ function, including new imaging techniques, transcriptomics, genomics, proteomics, metabolomics, lipidomics, and new solutions in organ perfusion, which has enabled a deeper understanding of the complex mechanisms associated with ischemia-reperfusion injury (IRI), inflammatory process, and graft rejection. This review summarizes and assesses the strengths and weaknesses of current conventional diagnostic methods and a wide range of new potential strategies (from the last five years) with respect to donor graft-quality assessment, the identification of IRI, perfusion control, and the prediction of DGF.
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26
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Godwin M. Nephrology Policy: Kidney Transplantation. Adv Chronic Kidney Dis 2022; 29:59-64. [PMID: 35690406 DOI: 10.1053/j.ackd.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Kidney transplant policy has not historically been considered a domain of nephrology policy; despite that, the US transplant system is marked by missed opportunities that prevent patients from accessing a kidney transplant. Policymakers in the federal government are focused on growing the inadequate supply of kidneys, especially on increasing procurement of deceased donor organs, and reducing kidney discards. There are many more challenges in transplantation that require the attention of experts in nephrology policy, whether in the Administration, Congress, advocacy organizations, or clinical practice. Thoughtful policy solutions are needed to improve transplant equity, balance competing patient desires, increase living donation, develop and implement measures of transplant center performance, and create an infrastructure for the long-term management of transplant recipients.
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27
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Noreen SM, Klassen D, Brown R, Becker Y, O'Connor K, Prinz J, Cooper M. Kidney accelerated placement project: Outcomes and lessons learned. Am J Transplant 2022; 22:210-221. [PMID: 34582630 DOI: 10.1111/ajt.16859] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 01/25/2023]
Abstract
Opportunities continue to be lost with a high rate of kidneys recovered for transplant but not utilized, particularly those considered less than ideal quality. The Organ Procurement and Transplantation Network (OPTN) Organ Center is tasked with allocating arguably the most difficult-to-place kidneys, and we hypothesized an accelerated placement pathway would increase utilization of kidneys placed by the Organ Center. The Kidney Accelerated Placement (KAP) project, implemented by the Organ Center from July 18, 2019 to July 15, 2020, aimed to offer kidneys with a high kidney donor profile index to programs that had a history of accepting such organs. We compared OPTN kidney match run, donor, and transplant recipient data during the project period and 1 year prior. There was no statistically significant change in the percentage of KAP-eligible donors accepted during the project period (16.4%) compared to the prior year (17.5%). Conversion from acceptance to transplant was higher under KAP (72.7% vs. 71.2%), though not significant. Waiting to accelerate placement after kidneys have been declined by multiple transplant programs locally and regionally is an intervention that may come too late to effectively increase utilization. Transplant rates of nationally shared and marginal kidneys remain a challenge, and future iterations of this project should be investigated.
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Affiliation(s)
| | - David Klassen
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Roger Brown
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Yolanda Becker
- University of Chicago Medical Center, Chicago, Illinois, USA
| | | | | | - Matthew Cooper
- MedStar Georgetown Transplant Institute, Washington, District of Columbia, USA
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28
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Stratta RJ, Harriman D, Gurram V, Gurung K, Sharda B. Dual kidney transplants from adult marginal donors: Review and perspective. Clin Transplant 2021; 36:e14566. [PMID: 34936135 DOI: 10.1111/ctr.14566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/08/2021] [Accepted: 12/13/2021] [Indexed: 11/28/2022]
Abstract
The practice of dual kidney transplantation (DKT) from adult marginal deceased donors (MDDs) dates back to the mid-1990s with initial pioneering experiences reported by the Stanford and Maryland groups, at which time the primary indication was estimated insufficient nephron mass from older donors. Multiple subsequent studies of short and long-term success have been reported focusing on three major aspects of DKT: Identifying appropriate selection criteria and developing scoring systems based on pre- and post-donation factors; refining technical aspects; and analyzing mid-term outcomes. The number of adult DKTs performed in the United States has declined in the past decade and only about 60 are performed annually. For adult deceased donor kidneys meeting double allocation criteria, >60% are ultimately not transplanted. Deceased donors with limited renal functional capacity represent a large proportion of potential kidneys doomed to either discard or non-recovery. However, DKT may reduce organ discard and optimize the use of kidneys from MDDs. In an attempt to promote utilization of MDD kidneys, the United Network for Organ Sharing introduced new allocation guidelines pursuant to DKT in 2019. The purpose of this review is to chronicle the history of DKT and identify opportunities to improve utilization of MDD kidneys through DKT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert J Stratta
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - David Harriman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, V5Z1M9, Canada
| | - Venkat Gurram
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Komal Gurung
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
| | - Berjesh Sharda
- Department of Surgery, Section of Transplantation, Wake Forest School of Medicine, One Medical Center Blvd., Winston-Salem, NC, 27157, United States
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29
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Stewart D. Moving Toward Continuous Organ Distribution. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00352-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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Shepherd S, Formica RN. Improving Transplant Program Performance Monitoring. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00344-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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31
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Kayler LK, Nie J, Noyes K. Hardest-to-place kidney transplant outcomes in the United States. Am J Transplant 2021; 21:3663-3672. [PMID: 34212471 DOI: 10.1111/ajt.16739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 01/25/2023]
Abstract
The outcomes of hardest-to-place kidney transplants-accepted last in the entire match run after being refused by previous centers-are unclear, potentially translating to risk aversion and unnecessary organ discard. We aimed to determine the outcomes of hardest-to-place kidney transplants and whether the organ acceptance position on the match run sufficiently captures the risk. This is a cohort study of the United Network for Organ Sharing data of all adult kidney-only transplant recipients from deceased donors between 2007 and 2018. Multiple regression models assessed delayed graft function, graft survival, and patient survival stratified by share type: local versus shared kidney acceptance position scaled by tertile. Among 127 028 kidney transplant recipients, 92 855 received local kidneys. The remaining received shared kidneys at sequence number 1-4 (n = 12 322), 5-164 (n = 10 485) and >164 (n = 11 366). Hardest-to-place kidneys, defined as the latest acceptance group in the match-run, were associated with delayed graft function (adjusted odds ratio 1.83, 95% confidence interval [CI] 1.74-1.92) and all-cause allograft failure (adjusted hazard ratio [aHR] 1.11, 95% CI 1.04-1.17). Results of this IRB-approved study were robust to the exclusion of operational allocation bypass and mandatory shares. The hardest-to-place kidneys accepted later in the match run were associated with higher graft failure and delayed graft function.
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Affiliation(s)
- Liise K Kayler
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Jing Nie
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
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32
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Lentine KL, Pastan S, Mohan S, Reese PP, Leichtman A, Delmonico FL, Danovitch GM, Larsen CP, Harshman L, Wiseman A, Kramer HJ, Vassalotti J, Joseph J, Longino K, Cooper M, Axelrod DA. A Roadmap for Innovation to Advance Transplant Access and Outcomes: A Position Statement From the National Kidney Foundation. Am J Kidney Dis 2021; 78:319-332. [PMID: 34330526 DOI: 10.1053/j.ajkd.2021.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023]
Abstract
Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St Louis, MO.
| | - Stephen Pastan
- Department of Medicine, Emory Transplant Center, Atlanta, GA
| | - Sumit Mohan
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Alan Leichtman
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa Transplant Institute, Iowa City, IA
| | - Alexander Wiseman
- Department of Medicine, Centura Health-Porter Adventist Hospital, Aurora, CO
| | | | - Joseph Vassalotti
- National Kidney Foundation, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Matthew Cooper
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, DC
| | - David A Axelrod
- Department of Surgery, University of Iowa Transplant Institute, Iowa City, IA
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33
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Hamroun A, Gibier JB, Maanaoui M, Lionet A, Gnemmi V, Bouyé S, Fantoni JC, Averland B, Antoine C, Lenain R, Hazzan M, Provôt F. Successful Reuse of Kidney Graft After Early Recurrence of Primary Focal and Segmental Glomerulosclerosis. Am J Kidney Dis 2021; 78:897-901. [PMID: 34118304 DOI: 10.1053/j.ajkd.2021.03.028] [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: 10/07/2020] [Accepted: 03/26/2021] [Indexed: 11/11/2022]
Abstract
Primary focal and segmental glomerulosclerosis (FSGS) frequently recurs after transplantation and is associated with a poor prognosis. We describe here the successful kidney graft reuse in an adult recipient, 8 months after early primary FSGS recurrence resistant to all available therapeutics. Patient 1, a 23-year-old man, followed for kidney failure secondary to primary FSGS, was first transplanted in 2018 with a deceased donor graft. Unfortunately, we observed an immediate recurrence of biopsy-proven primary FSGS. After 4 lines of treatment (intravenous cyclosporine+corticosteroids, plasma exchanges, immunoadsorption, and rituximab), the patient was still highly nephrotic and kidney function was slowly deteriorating. After approval from both the patient and the health authority (Biomedicine Agency), the graft was detransplanted 8 months after transplantation and reimplanted in patient 2, a 78-year-old nonimmunized and anephric recipient (bi-nephrectomy 2 years previously for bilateral renal carcinoma). We observed immediate kidney function and progressive resolution of proteinuria (serum creatinine of 1.2mg/dL and proteinuria of 0.1 g/d 1 year later). Biopsies performed after surgery showed persistent FSGS lesions with a decrease in overall foot-process effacement. To our knowledge, this is the first reported case showing that kidney graft transfer may still be a viable option for refractory primary FSGS several months after transplantation.
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Affiliation(s)
- Aghilès Hamroun
- Departments of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Regional and University Hospital Center of Lille, Lille, France; Paris-Saclay University, Versailles Saint Quentin University, Inserm, Clinical Epidemiology Team, CESP, Centre for Research in Epidemiology and Population Health, Villejuif, France.
| | - Jean-Baptiste Gibier
- Department of Pathology, Pathology Institute, Lille University, Regional and University Hospital Center of Lille, Inserm UMR-S1172 Lille, JPARC-Jean-Pierre Aubert Research Center, Team "Mucins, Epithelial Differentiation and Carcinogenesis," F-59037 Lille, France
| | - Mehdi Maanaoui
- Departments of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Regional and University Hospital Center of Lille, Lille, France; INSERM U1190, Translational Research for Diabetes, Lille, France
| | - Arnaud Lionet
- Departments of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Regional and University Hospital Center of Lille, Lille, France
| | - Viviane Gnemmi
- Department of Pathology, Pathology Institute, Lille University, Regional and University Hospital Center of Lille, Inserm UMR-S1172 Lille, JPARC-Jean-Pierre Aubert Research Center, Team "Mucins, Epithelial Differentiation and Carcinogenesis," F-59037 Lille, France
| | - Sébastien Bouyé
- Urology, Lille University, Regional and University Hospital Center of Lille, Lille, France
| | | | | | - Corinne Antoine
- Agence de la Biomédecine, Saint-Denis, France; Nephrology and Kidney Transplantation, Hospital Saint Louis, Paris, France
| | - Rémi Lenain
- Departments of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Regional and University Hospital Center of Lille, Lille, France; INSERM UMR1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Marc Hazzan
- Departments of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Regional and University Hospital Center of Lille, Lille, France
| | - François Provôt
- Departments of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Regional and University Hospital Center of Lille, Lille, France
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34
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Adler JT, Husain SA, King KL, Mohan S. Greater complexity and monitoring of the new Kidney Allocation System: Implications and unintended consequences of concentric circle kidney allocation on network complexity. Am J Transplant 2021; 21:2007-2013. [PMID: 33314637 DOI: 10.1111/ajt.16441] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 01/25/2023]
Abstract
The deceased donor kidney allocation system in the United States has undergone several rounds of iterative changes, but these changes were not explicitly designed to address the geographic variation in access to transplantation. The new allocation system, expected to start in December 2020, changes the definition of "local allocation" from the Donation Service Area to 250 nautical mile circles originating from the donor hospital. While other solid organs have adopted a similar approach, the larger number of both kidney transplant centers and transplant candidates is likely to have different consequences. Here, we discuss the incredible increase in complexity in allocation, discuss some of the likely intended and unintended consequences, and propose metrics to monitor the new system.
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Affiliation(s)
- Joel T Adler
- Department of Surgery, Division of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, Massachusetts
| | - Syed A Husain
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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35
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Schold JD, Mohan S, Huml A, Buccini LD, Sedor JR, Augustine JJ, Poggio ED. Failure to Advance Access to Kidney Transplantation over Two Decades in the United States. J Am Soc Nephrol 2021; 32:913-926. [PMID: 33574159 PMCID: PMC8017535 DOI: 10.1681/asn.2020060888] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/02/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Extensive research and policies have been developed to improve access to kidney transplantation among patients with ESKD. Despite this, wide variation in transplant referral rates exists between dialysis facilities. METHODS To evaluate the longitudinal pattern of access to kidney transplantation over the past two decades, we conducted a retrospective cohort study of adult patients with ESKD initiating ESKD or placed on a transplant waiting list from 1997 to 2016 in the United States Renal Data System. We used cumulative incidence models accounting for competing risks and multivariable Cox models to evaluate time to waiting list placement or transplantation (WLT) from ESKD onset. RESULTS Among the study population of 1,309,998 adult patients, cumulative 4-year WLT was 29.7%, which was unchanged over five eras. Preemptive WLT (prior to dialysis) increased by era (5.2% in 1997-2000 to 9.8% in 2013-2016), as did 4-year WLT incidence among patients aged 60-70 (13.4% in 1997-2000 to 19.8% in 2013-2016). Four-year WLT incidence diminished among patients aged 18-39 (55.8%-48.8%). Incidence of WLT was substantially lower among patients in lower-income communities, with no improvement over time. Likelihood of WLT after dialysis significantly declined over time (adjusted hazard ratio, 0.80; 95% confidence interval, 0.79 to 0.82) in 2013-2016 relative to 1997-2000. CONCLUSIONS Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations. Improving access to transplantation may require more substantial interventions.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, New York,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Anne Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Laura D. Buccini
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Emilio D. Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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36
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Karami F, Kernodle AB, Ishaque T, Segev DL, Gentry SE. Allocating kidneys in optimized heterogeneous circles. Am J Transplant 2021; 21:1179-1185. [PMID: 32808468 DOI: 10.1111/ajt.16274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/19/2020] [Accepted: 08/12/2020] [Indexed: 01/25/2023]
Abstract
Recently, the Organ Procurement and Transplant Network approved a plan to allocate kidneys within 250-nm circles around donor hospitals. These homogeneous circles might not substantially reduce geographic differences in transplant rates because deceased donor kidney supply and demand differ across the country. Using Scientific Registry of Transplant Recipients data from 2016-2019, we used an integer program to design unique, heterogeneous circles with sizes between 100 and 500 nm that reduced supply/demand ratio variation across transplant centers. We weighted demand according to wait time because candidates who have waited longer have higher priority. We compared supply/demand ratios and average travel distance of kidneys, using heterogeneous circles and 250 and 500-nm fixed-distance homogeneous circles. We found that 40% of circles could be 250 nm or smaller, while reducing supply/demand ratio variation more than homogeneous circles. Supply/demand ratios across centers for heterogeneous circles ranged from 0.06 to 0.13 kidneys per wait-year, compared to 0.04 to 0.47 and 0.05 to 0.15 kidneys per wait-year for 250-nm and 500-nm homogeneous circles, respectively. The average travel distance for kidneys using heterogeneous, and 250-nm and 500-nm fixed-distance circles was 173 nm, 134 nm, and 269 nm, respectively. Heterogeneous circles reduce geographic disparity compared to homogeneous circles, while maintaining reasonable travel distances.
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Affiliation(s)
- Fatemeh Karami
- Industrial Engineering Department, University of Louisville, Louisville, Kentucky, USA.,Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amber B Kernodle
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Tanveen Ishaque
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.,Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Sommer E Gentry
- Department of Mathematics, United States Naval Academy, Annapolis, Maryland, USA
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37
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Reese PP, Aubert O, Naesens M, Huang E, Potluri V, Kuypers D, Bouquegneau A, Divard G, Raynaud M, Bouatou Y, Vo A, Glotz D, Legendre C, Lefaucheur C, Jordan S, Empana JP, Jouven X, Loupy A. Assessment of the Utility of Kidney Histology as a Basis for Discarding Organs in the United States: A Comparison of International Transplant Practices and Outcomes. J Am Soc Nephrol 2021; 32:397-409. [PMID: 33323474 PMCID: PMC8054891 DOI: 10.1681/asn.2020040464] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/28/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Many kidneys donated for transplant in the United States are discarded because of abnormal histology. Whether histology adds incremental value beyond usual donor attributes in assessing allograft quality is unknown. METHODS This population-based study included patients who received a deceased donor kidney that had been biopsied before implantation according to a prespecified protocol in France and Belgium, where preimplantation biopsy findings are generally not used for decision making in the allocation process. We also studied kidneys that had been acquired from deceased United States donors for transplantation that were biopsied during allocation and discarded because of low organ quality. Using donor and recipient characteristics, we fit multivariable Cox models for death-censored graft failure and examined whether predictive accuracy (C index) improved after adding donor histology. We matched the discarded United States kidneys to similar kidneys transplanted in Europe and calculated predicted allograft survival. RESULTS In the development cohort of 1629 kidney recipients at two French centers, adding donor histology to the model did not significantly improve prediction of long-term allograft failure. Analyses using an external validation cohort from two Belgian centers confirmed the lack of improved accuracy from adding histology. About 45% of 1103 United States kidneys discarded because of histologic findings could be accurately matched to very similar kidneys that had been transplanted in France; these discarded kidneys would be expected to have allograft survival of 93.1% at 1 year, 80.7% at 5 years, and 68.9% at 10 years. CONCLUSIONS In this multicenter study, donor kidney histology assessment during allocation did not provide substantial incremental value in ascertaining organ quality. Many kidneys discarded on the basis of biopsy findings would likely benefit United States patients who are wait listed.
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Affiliation(s)
- Peter P. Reese
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France,Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Olivier Aubert
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France,Department of Kidney Transplantation, Necker Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Edmund Huang
- Division of Nephrology, Department of Medicine, Comprehensive Transplant Center, Cedars Sinai Medical Center, West Hollywood, California
| | - Vishnu Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Antoine Bouquegneau
- Department of Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Liege, Liege, Belgium
| | - Gillian Divard
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France
| | - Marc Raynaud
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France
| | - Yassine Bouatou
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France
| | - Ashley Vo
- Division of Nephrology, Department of Medicine, Comprehensive Transplant Center, Cedars Sinai Medical Center, West Hollywood, California
| | - Denis Glotz
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France,Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France,Department of Kidney Transplantation, Necker Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Carmen Lefaucheur
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France,Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Stanley Jordan
- Division of Nephrology, Department of Medicine, Comprehensive Transplant Center, Cedars Sinai Medical Center, West Hollywood, California
| | - Jean-Philippe Empana
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France
| | - Xavier Jouven
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France,Cardiology and Heart Transplant Department, Pompidou Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France,Department of Kidney Transplantation, Necker Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
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Swinarska JT, Stratta RJ, Rogers J, Chang A, Farney AC, Orlando G, Reeves-Daniel A, Gurram V, Gautreaux MD, Jay CL. Early Graft Loss after Deceased-Donor Kidney Transplantation: What Are the Consequences? J Am Coll Surg 2020; 232:493-502. [PMID: 33348013 DOI: 10.1016/j.jamcollsurg.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Decreasing kidney discards continues to be of paramount importance for improving organ transplant access, but transplantation of nonideal deceased donor kidneys may have higher inherent risks of early graft loss (EGL). Patients with EGL (defined as graft failure within 90 days after transplant) are allowed reinstatement of waiting time according to United Network for Organ Sharing (UNOS) policy. The purpose of this study was to examine outcomes for patients experiencing EGL. STUDY DESIGN We performed a single center retrospective review of adult deceased donor kidney transplant (DDKT)-alone recipients from 2001 to 2018, comparing those with EGL (including primary nonfunction [PNF]) to those without. RESULTS EGL occurred in 103 (5.5%) of 1,868 patients, including 57 (55%) PNF, 25 (24%) deaths, 16 (16%) thrombosis, 3 (3%) rejection, and 2 (2%) disease recurrence. Kidney Donor Profile Index (KDPI) > 85% and donation after circulatory death (DCD) DDKTs did not increase risk of either EGL or PNF unless combined with prolonged cold ischemic time (CIT). For KDPI >85% with CIT >24 hours, the risk of EGL or PNF was tripled (EGL odds ratio [OR] 2.9, 95% CI 1.6-5.2; PNF OR3.6, 95% CI1.7-7.7). For DCD with CIT > 24 hours, increased risks were likewise seen for EGL (OR 2.4, 95% CI 1.3-4.3), and PNF (OR 3.2, 95% CI 1.5-7). One-year and 5-year patient survival rates were 60% and 50% after EGL, 80% and 73% after PNF, and 99% and 87% for controls, respectively. Only 24% of either EGL or PNF patients underwent retransplantation. CONCLUSIONS EGL and PNF were associated with low retransplantation rates and inferior patient survival. Prolonged CIT compounds risks associated with KDPI > 85% and DCD donor kidneys. Therefore, policies promoting rapid allocation and increased local use of these kidneys should be considered.
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Affiliation(s)
| | - Robert J Stratta
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jeffrey Rogers
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amy Chang
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Alan C Farney
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Giuseppe Orlando
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Amber Reeves-Daniel
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Venkat Gurram
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Colleen L Jay
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC.
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Development and external validation study combining existing models and recent data into an up-to-date prediction model for evaluating kidneys from older deceased donors for transplantation. Kidney Int 2020; 99:1459-1469. [PMID: 33340517 DOI: 10.1016/j.kint.2020.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/11/2020] [Accepted: 11/05/2020] [Indexed: 11/20/2022]
Abstract
With a rising demand for kidney transplantation, reliable pre-transplant assessment of organ quality becomes top priority. In clinical practice, physicians are regularly in doubt whether suboptimal kidney offers from older donors should be accepted. Here, we externally validate existing prediction models in a European population of older deceased donors, and subsequently developed and externally validated an adverse outcome prediction tool. Recipients of kidney grafts from deceased donors 50 years of age and older were included from the Netherlands Organ Transplant Registry (NOTR) and United States organ transplant registry from 2006-2018. The predicted adverse outcome was a composite of graft failure, death or chronic kidney disease stage 4 plus within one year after transplantation, modelled using logistic regression. Discrimination and calibration were assessed in internal, temporal and external validation. Seven existing models were validated with the same cohorts. The NOTR development cohort contained 2510 patients and 823 events. The temporal validation within NOTR had 837 patients and the external validation used 31987 patients in the United States organ transplant registry. Discrimination of our full adverse outcome model was moderate in external validation (C-statistic 0.63), though somewhat better than discrimination of the seven existing prediction models (average C-statistic 0.57). The model's calibration was highly accurate. Thus, since existing adverse outcome kidney graft survival models performed poorly in a population of older deceased donors, novel models were developed and externally validated, with maximum achievable performance in a population of older deceased kidney donors. These models could assist transplant clinicians in deciding whether to accept a kidney from an older donor.
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40
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Yu K, King K, Husain SA, Dube GK, Stevens JS, Ratner LE, Cooper M, Parikh CR, Mohan S. Kidney nonprocurement in solid organ donors in the United States. Am J Transplant 2020; 20:3413-3425. [PMID: 32342627 PMCID: PMC8448558 DOI: 10.1111/ajt.15952] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/29/2020] [Accepted: 04/13/2020] [Indexed: 01/25/2023]
Abstract
There are limited data on the nonprocurement of kidneys from solid organ donors. Analysis of Standard Transplant Analysis and Research files was undertaken on all deceased donors in the United States with at least 1 solid organ recovered. From 2000 to 2018, 21 731 deceased donor kidneys (averaging 1144 kidneys per year) were not procured. No kidneys were procured from 8% of liver donors, 3% of heart donors, and 3% of lung donors. Compared to donors with all kidneys procured, those with none procured were older and more likely obese, black, hypertensive, diabetic, hepatitis C positive, smokers, Public Health Service - Increased Risk designated, deceased after cardiac death, or deceased after cerebrovascular accident. Although these donors had lower quality kidneys (median Kidney Donor Risk Index (interquartile range) 1.9 (1.0) vs 1.2 (0.7)), there was substantial overlap in quality between nonprocured and procured kidneys. Nearly one third of nonprocurements were attributed to donor history. Donors with elevated terminal creatinine likely resulting from acute kidney injury (AKI) had higher odds of kidney nonprocurement. Nonprocurement odds varied widely across Organ Procurement and Transplantation Network regions, with a positive correlation between donor kidney nonprocurements and kidney discards at the donation service area level. These findings suggest current discard rates underestimate the underutilization of deceased donor kidneys and more research is needed to optimize safe procurement and utilization of kidneys from donors with AKI.
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Affiliation(s)
- Kathleen Yu
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Syed A. Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Geoffrey K. Dube
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Jacob S. Stevens
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Lloyd E. Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York
| | - Matthew Cooper
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Chirag R. Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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41
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Financial Evaluation of Kidney Transplant With Hepatitis C Viremic Donors to Uninfected Recipients. Transplant Direct 2020; 6:e627. [PMID: 33204825 PMCID: PMC7665247 DOI: 10.1097/txd.0000000000001056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 02/07/2023] Open
Abstract
Kidney transplantation with hepatitis C viremic (dHCV+) donors appears safe for recipients without HCV when accompanied by direct acting antiviral (DAA) treatment. However, US programs have been reluctant to embrace this approach due to concern about insurance coverage. While the cost of DAA treatment is currently offset by the reduction in waiting time, increased competition for dHCV+ organs may reduce this advantage. This analysis sought to demonstrate the financial benefit of dHCV+ transplant for third-party health insurers to expand coverage availability. Methods An economic analysis was developed using a Markov model for 2 decisions: first, to accept a dHCV+ organ versus wait for a dHCV uninfected organ; or second, accept a high kidney donor profile index (KDPI) (>85) organ versus wait for a better quality dHCV+ organ. The analysis used Medicare payments, historical survival data, cost report data, and an estimated cost of DAA of $29 874. Results In the first analysis, using dHCV+ kidneys reduced the cost of end-stage kidney disease care if the wait for a dHCV uninfected organ exceeded 11.5 months. The financial breakeven point differed according to the cost of DAA treatment. In the second analysis, declining a high-KDPI organ in favor of a waiting dHCV+ organ was marginally clinically beneficial if waiting times were <12 months but not cost effective. Conclusions dHCV+ transplant appears to be economically and clinically advantageous compared with waiting for dHCV-uninfected transplant but should not replace high-KDPI transplant when appropriate. Despite the high cost of DAA therapy, health insurers benefit financially from dHCV+ transplant within 1 year.
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42
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Abstract
PURPOSE OF REVIEW Deceased donation represents the largest supply of organs for transplant in the United States. Organs with suboptimal characteristics related to donor disease or recovery-related issues are increasingly discarded at the time of recovery, prompting late allocation to candidates later in the match sequence. Late allocation contributes to organ injury by prolonging cold ischemia, which may further lead to the risk of organ discard, despite the potential to provide benefit to certain transplant candidates. RECENT FINDINGS Expedited placement of marginal organs has emerged as a strategy to address the growing problem of organ discard of marginal organs that have been declined late after recovery. In this review, we describe the basis for expedited organ placement, and approaches to facilitating placement of these grafts, drawing examples from kidney and liver donation and transplantation globally. SUMMARY There is significant global variation in practice related to late allocation. Multiple policy mechanisms exist to facilitate expedited placement, including simultaneous offers to multiple centers, predesignation of aggressive centers, and increasing organ procurement organization autonomy in late allocation. Optimizing late allocation of deceased donor organs holds significant promise to increase the number of transplants.
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43
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Abstract
BACKGROUND Kidneys transplanted from deceased donors with serum creatinine-defined acute kidney injury (AKI) have similar allograft survival as non-AKI kidneys but are discarded at a higher rate. Urine injury biomarkers are sensitive markers of structural kidney damage and may more accurately predict graft outcomes. METHODS In the 2010-2013 multicenter Deceased Donor Study of 2430 kidney transplant recipients from 1298 donors, we assessed the association of donor urine injury biomarkers microalbumin, neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, IL-18, and liver-type fatty acid binding protein with graft failure (GF) and death-censored GF (dcGF) using Cox proportional hazard models (median follow-up 4 y). We examined if serum creatinine-defined donor AKI modified this association to assess the relationship between subclinical donor AKI (elevated biomarkers without creatinine-defined AKI) and GF. Through chart review of a subcohort (1137 recipients), we determined associations between donor injury biomarkers and a 3-year composite outcome of GF, mortality, or estimated glomerular filtration rate ≤ 20mL/min/1.73m. RESULTS Risk of GF, dcGF, and 3-year composite outcome did not vary with donor injury biomarker concentrations after adjusting for donor, transplant, and recipient characteristics (adjusted hazard ratio ranged from 0.96 to 1.01 per log-2 increase in biomarker). Subclinical injury in transplanted kidneys without AKI was not associated with GF. CONCLUSIONS AKI measured using injury biomarkers was not associated with posttransplant graft outcomes (at median 4 y posttransplant). When assessing posttransplant graft viability, clinicians can prioritize other donor and recipient factors over donor kidney injury, measured by either serum creatinine or urine injury biomarkers.
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44
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Mehrotra S, Schantz K, Friedewald JJ, Ladner DP, Becker Y, Formica R, Barah M, Gu J, Gordon EJ. Physician and patient acceptance of policies to reduce kidney discard. Clin Transplant 2020; 34:e14054. [PMID: 32738167 PMCID: PMC7929781 DOI: 10.1111/ctr.14054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Despite the shortage of kidneys for transplantation in the United States, approximately 18%‐20% of deceased donor kidneys are discarded each year. These discarded kidneys can offer a survival benefit to suitable patients. Revisions to the current kidney allocation policy may be needed to reduce deceased donor kidney discard. We surveyed transplant physicians and patients to assess their perceived acceptability of policy proposals to reduce the discard of deceased donor kidneys. Members of professional societies (AST, ASTS) and a patient organization (AAKP) were invited to complete the survey. Responses were obtained from 97 physicians and 107 patients. The majority of physicians (73.4%) and patients (73.8%) "somewhat" or "completely" accepted a policy for fast‐tracking kidneys at risk of discard. Physicians and patients also supported returning a proportion of waiting time to patients who accept KDPI >85 kidneys and experience graft failure within the first 12 months, with 36% of physicians and 50% of patients electing to return 100% of the waiting time. The majority of physicians (75%) "somewhat or completely" accepted a policy to skip less aggressive centers for KDPI 90 + offers. Physicians and patients provided insights into factors researchers, and policymakers should consider in the design and implementation of these policies.
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Affiliation(s)
- Sanjay Mehrotra
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Karolina Schantz
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - John J Friedewald
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Daniela P Ladner
- Comprehensive Transplant Center Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Masoud Barah
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Jiayi Gu
- Department of Engineering and Management Sciences, Northwestern University, Evanston, IL, USA
| | - Elisa J Gordon
- Comprehensive Transplant Center Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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45
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Ibrahim M, Greenhall GHB, Summers DM, Mumford L, Johnson R, Baker RJ, Forsythe J, Pettigrew GJ, Ahmad N, Callaghan CJ. Utilization and Outcomes of Single and Dual Kidney Transplants from Older Deceased Donors in the United Kingdom. Clin J Am Soc Nephrol 2020; 15:1320-1329. [PMID: 32690721 PMCID: PMC7480543 DOI: 10.2215/cjn.02060220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Kidneys from elderly deceased donors are often discarded after procurement if the expected outcomes from single kidney transplantation are considered unacceptable. An alternative is to consider them for dual kidney transplantation. We aimed to examine the utilization of kidneys from donors aged ≥60 years in the United Kingdom and compare clinical outcomes of dual versus single kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from the United Kingdom Transplant Registry from 2005 to 2017 were analyzed. We examined utilization rates of kidneys retrieved from deceased donors aged ≥60 years, and 5-year patient and death-censored graft survival of recipients of dual and single kidney transplants. Secondary outcomes included eGFR. Multivariable analyses and propensity score analysis were used to correct for differences between the groups. RESULTS During the study period, 7841 kidneys were procured from deceased donors aged ≥60 years, of which 1338 (17%) were discarded; 356 dual and 5032 single kidneys were transplanted. Donors of dual transplants were older (median, 73 versus 66 years; P<0.001) and had higher United States Kidney Donor Risk Indices (2.48 versus 1.98; P<0.001). Recipients of dual transplants were also older (64 versus 61 years; P<0.001) and had less favorable human leukocyte antigen matching (P<0.001). After adjusting for confounders, dual and single transplants had similar 5-year graft survival (hazard ratio, 0.81; 95% CI, 0.59 to 1.12). No difference in patient survival was demonstrated. Similar findings were observed in a matched cohort with a propensity score analysis method. Median 12-month eGFR was significantly higher in the dual kidney transplant group (40 versus 36 ml/min per 1.73 m2; P<0.001). CONCLUSIONS Recipients of kidneys from donors aged ≥60 years have similar 5-year graft survival and better graft function at 12 months with dual compared with single deceased donor kidney transplants.
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Affiliation(s)
- Maria Ibrahim
- Department of Nephrology and Transplantation, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom .,National Health Service Blood and Transplant, Bristol, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - George H B Greenhall
- Department of Nephrology and Transplantation, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom.,National Health Service Blood and Transplant, Bristol, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Dominic M Summers
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Lisa Mumford
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Rachel Johnson
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Richard J Baker
- Department of Nephrology, St James's University Hospital, The Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom
| | - John Forsythe
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Gavin J Pettigrew
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Niaz Ahmad
- Department of Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom.,National Health Service Blood and Transplant, Bristol, United Kingdom
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DiRito JR, Hosgood SA, Reschke M, Albert C, Bracaglia LG, Ferdinand JR, Stewart BJ, Edwards CM, Vaish AG, Thiru S, Mulligan DC, Haakinson DJ, Clatworthy MR, Saltzman WM, Pober JS, Nicholson ML, Tietjen GT. Lysis of cold-storage-induced microvascular obstructions for ex vivo revitalization of marginal human kidneys. Am J Transplant 2020; 21:161-173. [PMID: 32627324 PMCID: PMC7775334 DOI: 10.1111/ajt.16148] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/15/2020] [Accepted: 06/08/2020] [Indexed: 01/25/2023]
Abstract
Thousands of kidneys from higher-risk donors are discarded annually because of the increased likelihood of complications posttransplant. Given the severe organ shortage, there is a critical need to improve utilization of these organs. To this end, normothermic machine perfusion (NMP) has emerged as a platform for ex vivo assessment and potential repair of marginal organs. In a recent study of 8 transplant-declined human kidneys on NMP, we discovered microvascular obstructions that impaired microvascular blood flow. However, the nature and physiologic impact of these lesions were unknown. Here, in a study of 39 human kidneys, we have identified that prolonged cold storage of human kidneys induces accumulation of fibrinogen within tubular epithelium. Restoration of normoxic conditions-either ex vivo during NMP or in vivo following transplant-triggered intravascular release of fibrinogen correlating with red blood cell aggregation and microvascular plugging. Combined delivery of plasminogen and tissue plasminogen activator during NMP lysed the plugs leading to a significant reduction in markers of renal injury, improvement in indicators of renal function, and improved delivery of vascular-targeted nanoparticles. Our study suggests a new mechanism of cold storage injury in marginal organs and provides a simple treatment with immediate translational potential.
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Affiliation(s)
- Jenna R. DiRito
- Department of Surgery, University of Cambridge, Cambridge, UK,Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Melanie Reschke
- Department of Molecular Biophysics & Biochemistry, Yale University, New Haven, Connecticut
| | - Claire Albert
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
| | - Laura G. Bracaglia
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
| | - John R. Ferdinand
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Benjamin J. Stewart
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Anand G. Vaish
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Sathia Thiru
- Department of Pathology, University of Cambridge, Cambridge, UK
| | - David C. Mulligan
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Menna R. Clatworthy
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, Cambridge, UK
| | - W. Mark Saltzman
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
| | - Jordan S. Pober
- Department of Immunobiology, Yale University, New Haven, Connecticut
| | | | - Gregory T. Tietjen
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut,Department of Biomedical Engineering, Yale University, New Haven, Connecticut
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47
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Kim DW, Tsapepas D, King KL, Husain SA, Corvino FA, Dillon A, Wang W, Mayne TJ, Mohan S. Financial impact of delayed graft function in kidney transplantation. Clin Transplant 2020; 34:e14022. [PMID: 32573812 DOI: 10.1111/ctr.14022] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Abstract
Increased utilization of suboptimal organs in response to organ shortage has resulted in increased incidence of delayed graft function (DGF) after transplantation. Although presumed increased costs associated with DGF are a deterrent to the utilization of these organs, the financial burden of DGF has not been established. We used the Premier Healthcare Database to conduct a retrospective analysis of healthcare resource utilization and costs in kidney transplant patients (n = 12 097) between 1/1/2014 and 12/31/2018. We compared cost and hospital resource utilization for transplants in high-volume (n = 8715) vs low-volume hospitals (n = 3382), DGF (n = 3087) vs non-DGF (n = 9010), and recipients receiving 1 dialysis (n = 1485) vs multiple dialysis (n = 1602). High-volume hospitals costs were lower than low-volume hospitals ($103 946 vs $123 571, P < .0001). DGF was associated with approximately $18 000 (10%) increase in mean costs ($130 492 vs $112 598, P < .0001), 6 additional days of hospitalization (14.7 vs 8.7, P < .0001), and 2 additional ICU days (4.3 vs 2.1, P < .0001). Multiple dialysis sessions were associated with an additional $10 000 compared to those with only 1. In conclusion, DGF is associated with increased costs and length of stay for index kidney transplant hospitalizations and payment schemes taking this into account may reduce clinicians' reluctance to utilize less-than-ideal kidneys.
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Affiliation(s)
- Daniel W Kim
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Demetra Tsapepas
- Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, NY, USA.,Department of Analytics, New York Presbyterian Hospital, New York, NY, USA
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | | | | | | | | | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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48
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King KL, Husain SA, Mohan S. Trends in Transplantation Center Use of Kidneys From Deceased Donors With Positive Hepatitis C Virus Nucleic Acid Testing. Am J Kidney Dis 2020; 76:743-746. [PMID: 32479923 DOI: 10.1053/j.ajkd.2020.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/29/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY; Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY; Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY; Columbia University Renal Epidemiology (CURE) Group, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.
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49
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Placona AM, Martinez C, McGehee H, Carrico B, Klassen DK, Stewart D. Can donor narratives yield insights? A natural language processing proof of concept to facilitate kidney allocation. Am J Transplant 2020; 20:1095-1104. [PMID: 31736193 DOI: 10.1111/ajt.15705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/04/2019] [Accepted: 10/30/2019] [Indexed: 01/25/2023]
Abstract
Although expedited placement could ameliorate stagnant kidney utilization, precisely identifying difficult-to-place organs is crucial to mitigate potential harms associated with this policy. Existing algorithms have only leveraged structured data from the Organ Procurement and Transplantation Network (OPTN); however, detailed, free text case information about a donor exists. No known research exists about the utility of these data. We developed a model to predict the probability of delay or discard for adult deceased kidney donors between 2010 and 2018, leveraging donor free text data. The resultant model had a c-statistic of 0.75 compared to 0.80 ( Reduced Probability of Delay or Discard [model], r-PODD) and 0.77 ( Kidney Donor Profile Index, KDPI) on the test dataset. Analysis of the top predictive words suggest both known and potentially novel clinical factors (ie, a known factor such as hypertension vs a novel factor such as stents), and nuanced social factors (intravenous drug use) could negatively affect kidney utilization. These findings suggest that donor narratives have utility; the natural language processing (NLP) model is only moderately correlated with existing indices and provides directional evidence about additional cardiovascular risk factors that may affect kidney utilization. More research is needed to understand the potential to enhance existing indices of kidney utilization to better enable and mitigate the effects of policy interventions such as expedited placement.
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Affiliation(s)
- Andrew M Placona
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Carlos Martinez
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Harrison McGehee
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Bob Carrico
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - David K Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing, Richmond, Virginia
| | - Darren Stewart
- Research Department, United Network for Organ Sharing, Richmond, Virginia
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50
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Kidney Perfusion as an Organ Quality Assessment Tool-Are We Counting Our Chickens Before They Have Hatched? J Clin Med 2020; 9:jcm9030879. [PMID: 32210197 PMCID: PMC7141526 DOI: 10.3390/jcm9030879] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 02/07/2023] Open
Abstract
The final decision to accept an organ for transplantation remains a subjective one. With “poor organ quality” commonly cited as a major reason for kidney discard, accurate, objective, and reliable quality assessment is essential. In an era of increasingly higher-risk deceased donor kidneys, the catch is to accept those where the risk–benefit scale will tip in the right direction. Currently available assessment tools, such as risk-scores predicting outcome and zero-time biopsy, perform unsatisfactory, and assessment options during static cold storage are limited. Kidney perfusion technologies are finding their way into clinical practice, and they bring a new opportunity to assess kidney graft viability and quality, both in hypothermic and normothermic conditions. We give an overview of the current understanding of kidney viability assessment during ex situ kidney perfusion. A pragmatic framework to approach viability assessment is proposed as an interplay of three different compartments: the nephron, the vascular compartment, and the immune compartment. Although many interesting ways to assess kidney injury and function during perfusion have been proposed, none have reached the stage where they can reliably predict posttransplant outcome. Larger well-designed studies and validation cohorts are needed to provide better guidance.
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