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Elalouf A, Yaniv-Rosenfeld A, Maoz H. Immune response against bacterial infection in organ transplant recipients. Transpl Immunol 2024; 86:102102. [PMID: 39094907 DOI: 10.1016/j.trim.2024.102102] [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: 05/17/2024] [Revised: 07/30/2024] [Accepted: 07/30/2024] [Indexed: 08/04/2024]
Abstract
This comprehensive review delves into the intricate dynamics between the immune system and bacterial infections in organ transplant recipients. Its primary objective is to fill existing knowledge gaps while critically assessing the strengths and weaknesses of current research. The paper accentuates the delicate balance that must be struck between preventing graft rejection through immunosuppression and maintaining robust immunity against bacterial threats. In this context, personalized medicine emerges as a transformative concept, offering the potential to revolutionize clinical outcomes by tailoring immunosuppressive regimens and vaccination strategies to the unique profiles of transplant recipients. By emphasizing the pivotal role of continuous monitoring, the review underscores the necessity for vigilant surveillance of transplant recipients to detect bacterial infections and associated immune responses early, thereby reducing the risk of severe infections and ultimately improving patient outcomes. Furthermore, the study highlights the significance of the host microbiome in shaping immune responses, suggesting that interventions targeting the microbiome hold promise for enhancing bacterial immunity in transplant recipients, both in research and clinical practice. In terms of future research directions, the review advocates for large-scale, longitudinal studies encompassing diverse patient cohorts to provide more comprehensive insights into post-transplant immune responses. It also advocates integrating multi-omics approaches, including genomics, transcriptomics, proteomics, and microbiome data, to understand immune responses and their underlying mechanisms. In conclusion, this review significantly enriches our understanding of immune responses in transplant recipients. It paves the way for more effective and personalized approaches to managing infections in this complex setting.
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Affiliation(s)
- Amir Elalouf
- Bar-Ilan University, Department of Management, Ramat Gan 5290002, Israel.
| | | | - Hanan Maoz
- Bar-Ilan University, Department of Management, Ramat Gan 5290002, Israel
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Akinyemi OA, Weldeslase TA, Odusanya EA, Hughes K, Cornwell EE, Callender CO. Impact of the Kidney Allocation Revision on Access to Kidney Transplantation and Outcomes in the United States. Am Surg 2024; 90:1886-1891. [PMID: 38531806 DOI: 10.1177/00031348241241628] [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] [Indexed: 03/28/2024]
Abstract
BACKGROUND The 2014 Kidney Allocation System (KAS) revision aimed to enhance equity in organ allocation and improve patient outcomes. This study assesses the impacts of the KAS revision on renal transplantation demographics and outcomes in the United States. METHODS We conducted a retrospective study utilizing the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) database from 1998 to 2022. We compared recipient and donor characteristics, and outcomes (graft failure and recipient survival) pre- and post-KAS revision. RESULTS Post-KAS, recipients were significantly older (53 vs 48, P < .001) with an increase in Medicaid beneficiaries (7.3% vs 5.5%, P < .001). Despite increased graft survival, HR = .91 (95% CI 0.80-.92, P < .001), overall recipient survival decreased, HR = 1.06 (95% CI 1.04-1.09, P < .001). KAS revision led to greater racial diversity among recipients and donors, enhancing equity in organ allocation. However, disparities persist in graft failure rates and recipient survival across racial groups. DISCUSSION The 2014 Kidney Allocation System revision has led to important changes in the renal transplantation landscape. While progress has been made towards increasing racial equity in organ allocation, further refinements are needed to address ongoing disparities. Recognizing the changing patient profiles and socio-economic factors will be crucial in shaping future policy modifications.
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Affiliation(s)
- Oluwasegun A Akinyemi
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
- Department of Health Policy and Management, University of Maryland, College Park, MD, USA
| | - Terhas A Weldeslase
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Eunice A Odusanya
- Department of Surgery Outcomes Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Kakra Hughes
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Edward E Cornwell
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Clive O Callender
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
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Santos AH, Mehta R, Alquadan K, Ibrahim H, Leghrouz MA, Belal A, Wen X. Age-modified risk factors for mortality of non-elderly adult kidney transplant recipients: a retrospective database analysis. Int Urol Nephrol 2024:10.1007/s11255-024-04132-3. [PMID: 38922533 DOI: 10.1007/s11255-024-04132-3] [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: 06/08/2024] [Accepted: 06/18/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE We aimed to investigate the role of the recipient's age strata in modifying the associations between risk factors and mortality in non-elderly adult kidney transplant (KT) recipients (KTR). METHODS We stratified 108,695 adult KTRs between 2000 and 2016 with conditional 1-year survival after KT into cohorts based on age at transplant: 18-49 years and 50-64 years. We excluded KTRs aged < 18 years or > / = 65 years. KTRs were observed for 5 years during the 2nd through 6th years post-KT for the outcome, all-cause mortality. RESULTS Increasing recipient age strata (18-49-year-old and 50-64-year-old) correlated with decreasing 6-year post-KT survival rates conditional on 1-year survival (79% and 57%, respectively, p < 0.0001). Middle adult age stratum was associated with a higher risk of all-cause mortality than young adult age stratum in KTRs of Hispanic/Latino and other races [HR = 1.23, 95% CI = 1.04-1.45 and HR = 1.51, 95% CI = 1.16-1.97, respectively] and with a primary native renal diagnosis of hypertension or glomerulonephritis [HR = 1.32, 95% CI = 1.12-1.55 and HR = 1.29, 95% CI = 1.10-151, respectively]. When compared with the young adult age stratum, the middle adult age stratum had a mitigating effect on the higher risk of mortality associated with sirolimus-mycophenolate or sirolimus-tacrolimus than the standard calcineurin inhibitor-mycophenolate regimen [HR = 0.75, 95% CI = 0.57-0.99 and HR = 0.71, 95% CI = 0.57-0.89, respectively]. CONCLUSION Among adult non-elderly KTRs, the age strata, 18-49 years, and 50-64 years, have varying modifying effects on the strength and direction of associations between some specific risk factors and all-cause mortality.
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Affiliation(s)
- Alfonso H Santos
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA.
| | - Rohan Mehta
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Kawther Alquadan
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Hisham Ibrahim
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Muhannad A Leghrouz
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Amer Belal
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Medical Science Bldg., Room NG-4, Gainesville, FL, 32610, USA
| | - Xuerong Wen
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
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Sandal S, Ahn J, Chen Y, Thompson V, Purnell TS, Cantarovich M, Clark-Cutaia MN, Wu W, Suri R, Segev DL, McAdams-DeMarco M. Differences in Racial and Ethnic Disparities Between First and Repeat Kidney Transplantation. Transplantation 2024:00007890-990000000-00761. [PMID: 38771099 DOI: 10.1097/tp.0000000000005051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Recent data suggest patients with graft failure had better access to repeat kidney transplantation (re-KT) than transplant-naive dialysis accessing first KT. This was postulated to be because of better familiarity with the transplant process and healthcare system; whether this advantage is equitably distributed is not known. We compared the magnitude of racial/ethnic disparities in access to re-KT versus first KT. METHODS Using United States Renal Data System, we identified 104 454 White, Black, and Hispanic patients with a history of graft failure from 1995 to 2018, and 2 357 753 transplant-naive dialysis patients. We used adjusted Cox regression to estimate disparities in access to first and re-KT and whether the magnitude of these disparities differed between first and re-KT using a Wald test. RESULTS Black patients had inferior access to both waitlisting and receiving first KT and re-KT. However, the racial/ethnic disparities in waitlisting for (adjusted hazard ratio [aHR] = 0.77; 95% confidence interval [CI], 0.74-0.80) and receiving re-KT (aHR = 0.61; 95% CI, 0.58-0.64) was greater than the racial/ethnic disparities in first KT (waitlisting: aHR = 0.91; 95% CI, 0.90-0.93; Pinteraction = 0.001; KT: aHR = 0.68; 95% CI, 0.64-0.72; Pinteraction < 0.001). For Hispanic patients, ethnic disparities in waitlisting for re-KT (aHR = 0.83; 95% CI, 0.79-0.88) were greater than for first KT (aHR = 1.14; 95% CI, 1.11-1.16; Pinteraction < 0.001). However, the disparity in receiving re-KT (aHR = 0.76; 95% CI, 0.72-0.80) was similar to that for first KT (aHR = 0.73; 95% CI, 0.68-0.79; Pinteraction = 0.55). Inferences were similar when restricting the cohorts to the Kidney Allocation System era. CONCLUSIONS Unlike White patients, Black and Hispanic patients with graft failure do not experience improved access to re-KT. This suggests that structural and systemic barriers likely persist for racialized patients accessing re-KT, and systemic changes are needed to achieve transplant equity.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - JiYoon Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yusi Chen
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Valerie Thompson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Wenbo Wu
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Rita Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine and Langone Health, New York, NY
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Buford J, Retzloff S, Wilk AS, McPherson L, Harding JL, Pastan SO, Patzer RE. Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States. Kidney Med 2023; 5:100706. [PMID: 37753250 PMCID: PMC10518364 DOI: 10.1016/j.xkme.2023.100706] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Rationale & Objective Patients with kidney failure from racial and ethnic minority groups and older patients have reduced access to the transplant waitlist relative to White and younger patients. Although racial disparities in the waitlisting group have declined after the 2014 kidney allocation system change, whether there is intersectionality of race and age in waitlisting access is unknown. Study Design Retrospective cohort study. Setting & Participants 439,455 non-Hispanic White and non-Hispanic Black US adults initiating dialysis between 2015 and 2019 were identified from the United States Renal Data System, and followed through 2020. Exposures Patient race and ethnicity (non-Hispanic White and non-Hispanic Black) and age group (18-29, 30-49, 50-64, and 65-80 years). Outcomes Placement on the United Network for Organ Sharing deceased donor waitlist. Analytical Approach Age- and race-stratified waitlisting rates were compared. Multivariable Cox proportional hazards models, censored for death, examined the association between race and waitlisting, and included interaction term for race and age. Results Over a median follow-up period of 1 year, the proportion of non-Hispanic White and non-Hispanic Black patients waitlisted was 20.7% and 20.5%, respectively. In multivariable models, non-Hispanic Black patients were 14% less likely to be waitlisted (aHR, 0.86, 95% CI, 0.77-0.95). Relative differences between non-Hispanic Black and non-Hispanic White patients were different by age group. Non-Hispanic Black patients were 27%, 12%, and 20% less likely to be waitlisted than non-Hispanic White patients for ages 18-29 years (aHR, 0.73; 95% CI, 0.61-0.86), 50-64 (aHR, 0.88; 95% CI, 0.80-0.98), and 65-80 years (aHR, 0.80; 95% CI, 0.71-0.90), respectively, but differences were attenuated among patients aged 30-49 years (aHR, 0.89; 95% CI, 0.77-1.02). Limitations Race and ethnicity data is physician reported, residual confounding, and analysis is limited to non-Hispanic White and non-Hispanic Black patients. Conclusions Racial disparities in waitlisting exist between non-Hispanic Black and non-Hispanic White individuals and are most pronounced among younger patients with kidney failure. Results suggest that interventions to address inequalities in waitlisting may need to be targeted to younger patients with kidney failure. Plain-Language Summary Research has shown that patients from racial and ethnic minority groups and older patients have reduced access to transplant waitlisting relative to White and younger patients; nevertheless, how age impacts racial disparities in waitlisting is unknown. We compared waitlisting between non-Hispanic Black and non-Hispanic White patients with incident kidney failure, within age strata, using registry data for 439,455 US adults starting dialysis (18-80 years) during 2015-2019. Overall, non-Hispanic Black patients were less likely to be waitlisted and relative differences between the two racial groups differed by age. After adjusting for patient-level factors, the largest disparity in waitlisting was observed among adults aged 18-29 years. These results suggest that interventions should target younger adults to reduce disparities in access to kidney transplant waitlisting.
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Affiliation(s)
- Jade Buford
- Regenstrief Institute, Indianapolis, Indiana
| | - Samantha Retzloff
- HIV Surveillance Branch (HSB), Division of HIV Prevention (DHP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Health Services Research Center, Emory University School of Medicine, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Reis de Souza V, Kelly S, Cerdeira Sabino E, Mendes de Oliveira F, Silva T, Miranda Teixeira C, Máximo C, Loureiro P, Barbara de Freitas Carneiro-Proietti A, Gomes I, Custer B, de Almeida-Neto C. Factors Associated with Leg Ulcers in Adults with Sickle Cell Disease in Brazil. Adv Skin Wound Care 2023; 36:98-105. [PMID: 36662043 DOI: 10.1097/01.asw.0000911152.41719.e5] [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: 01/21/2023]
Abstract
OBJECTIVE To define the prevalence of leg ulcers and identify the clinical and laboratory factors associated with leg ulcers in adult participants. METHODS The authors conducted a cross-sectional study of 1,109 patients who were 18 years or older with SS or Sβ0-thalassemia genotypes from a Brazilian cohort. Investigators assessed the prevalence of factors associated with leg ulcers from 2013 to 2017. RESULTS The prevalence of leg ulcers was 21%. Increasing age (odds ratio [OR], 1.07; range, 1.06-1.09), male sex (OR, 2.03; range, 1.44-2.87), treatment with chronic transfusion therapy (OR, 1.88; range, 1.15-3.03), higher indirect bilirubin levels (OR, 1.48; range, 1.02-2.16), and low hemoglobin levels (OR, 2.17; range, 1.52-3.11) were associated with leg ulcers. Participants who self-reported as Black (OR, 6.75; range, 2.63-21.32), mixed (OR, 3.91; range, 1.55-12.20), and other/unknown (OR, 3.84; range, 1.04-15.24) were more likely to have leg ulcers compared with those who self-reported as White. CONCLUSIONS The prevalence of leg ulcers in this Brazilian cohort was higher than the prevalence reported in developed countries. Known factors such as age and male sex were corroborated. The increased bilirubin level and decreased hemoglobin levels among participants with leg ulcers support the hypothesis that hemolysis is correlated with leg ulcer pathogenesis. Self-reported black skin color was an independent predictor of leg ulcers and warrants further study to understand the etiology and implications of this finding.
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Affiliation(s)
- Valquíria Reis de Souza
- Valquíria Reis de Souza, MSc, is Biologist, Instituto de Medicina Tropical, University of São Paulo, Brazil. Shannon Kelly, MD, is Associate Professor, Pediatrics, Vitalant Research Institute, San Francisco, California. Also at Instituto de Medicina Tropical, University of São Paulo, Ester Cerdeira Sabino, MD, PhD, is Associate Professor and Franciane Mendes de Oliveira, BSc, is Master's Degree Student. Tassila Silva, PhD, is Assistant Professor, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte. Carolina Miranda Teixeira, MSc, is Biologist and Master, Faculdade de Medicina, Universidade Federal de Minas Gerais. Claudia Máximo, MD, is Hematologist at Hemorio, Hemocentro do Rio de Janeiro. Paula Loureiro, MD, PhD, is Adjunct Professor and Researcher at Hemope and Universidade de Pernambuco, Recife. Also at Fundação Hemominas, Hemocentro de Minas Gerais, Anna Barbara de Freitas Carneiro-Proietti, MD, PhD, is Senior Researcher. Isabel Gomes, PhD, is Researcher at Universidade Federal de Minas Gerais. Brian Custer, PhD, MPH, is Director, Vitalant Research Institute, San Francisco, California and Professor of Laboratory Medicine, University of California, San Francisco. Cesar de Almeida-Neto, MD, PhD, is Associate Professor at Faculdade de Medicina da Universidade de São Paulo and Chief of Apheresis Department at Fundação Pró-Sangue Hemocentro de São Paulo. Acknowledgment: This work was supported by the National Institutes of Health National Heart, Lung, and Blood Institute by grant HHSN268201100007I. Recipient Epidemiology and Donor Evaluation Study-III: International Component (Brazil), with the participation of the following centers and investigators. Brazilian participants: Instituto de Medicina Tropical de São Paulo (USP): Ester C. Sabino, Cecilia Alencar; Fundação Pró-Sangue (São Paulo): Alfredo Mendrone, Jr, Cesar de Almeida Neto, Ligia Capuani; Instituto de Tratamento do Câncer Infantil (São Paulo): Miriam Park; Faculdade de Medicina da Universidade de São Paulo (São Paulo): Paula Blatyta; Hemominas-Belo Horizonte (Minas Gerais): Anna Bárbara de Freitas Carneiro-Proietti, Andre Belisario, Carolina Miranda Teixeira, Tassila Salomon, Franciane Mendes de Oliveira, Valquíria Reis. Hemominas; Montes Claros (Minas Gerais): Rosemere Afonso Mota, José Wilson Sales; Hemominas-Juiz de Fora (Minas Gerais): Daniela de Oliveira Werneck; Fundação Hemope-Recife (Pernambuco): Paula Loureiro, Aderson Araújo, Dahra Teles Hemorio (Rio de Janeiro): Clarisse Lobo, Claudia Máximo, Luiz Amorin; Instituto de Matemática e Estatística da Universidade de São Paulo-USP (São Paulo): João Eduardo Ferreira, Márcio Katsumi Oikawa, Pedro Losco Takecian, Mina Cintho Ozahata, Rodrigo Muller de Carvalho. US Investigators: Vitalant Research Institute and University of California San Francisco: Brian Scott Custer, Michael P. Busch, and Thelma Therezinha Gonçalez; Research Triangle Institute: Donald Brambilla, Liliana R. Preiss, Christopher McClure; UCSF Benioff Children's Hospital Oakland: Shannon Kelly; National Heart, Lung, and Blood Institute-Simone A. Glynn. The authors have disclosed no other financial relationships related to this article. Submitted February 16, 2022; accepted in revised form August 12, 2022
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Adedinsewo DA, Porter IE, White RO, Hickson LJ. Racial and Ethnic Disparities in Cardiovascular Disease Risk Among Patients with Chronic Kidney Disease. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00701-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Schold JD, Augustine JJ, Huml AM, Fatica R, Nurko S, Wee A, Poggio ED. Effects of body mass index on kidney transplant outcomes are significantly modified by patient characteristics. Am J Transplant 2021; 21:751-765. [PMID: 32654372 PMCID: PMC8905683 DOI: 10.1111/ajt.16196] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/23/2020] [Accepted: 06/28/2020] [Indexed: 02/06/2023]
Abstract
Body mass index (BMI) is a known risk factor associated with kidney transplant outcomes and is incorporated for determining transplant candidate eligibility. However, BMI is a coarse health measure and risks associated with BMI may vary by patient characteristics. We evaluated 296 807 adult (age > 17) solitary kidney transplant recipients from the Scientific Registry of Transplant Recipients (2000-2019). We examined effects of BMI using survival models and tested interactions with recipient characteristics. Overall, BMI demonstrated a "J-Shaped" risk profile with elevated risks for overall graft loss with low BMI and obesity. However, multivariable models indicated interactions between BMI with recipient age, diagnosis, gender, and race/ethnicity. Low BMI was relatively higher risk for older recipients (>60 years), people with type I diabetes, and males and demonstrated no additional risk among younger (18-39) and Hispanic recipients. High BMI was associated with elevated risk for Caucasians and attenuated risk among African Americans and people with type II diabetes. Effects of BMI had variable risks for mortality vs graft loss by recipient characteristics in competing risks models. The association of BMI with posttransplant outcomes is highly variable among kidney transplant recipients. Results are important considerations for personalized care and risk stratification. Findings suggest that transplant contraindications should not be based on absolute BMI thresholds but modified based on patient characteristics.
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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
| | | | - Anne M. Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard Fatica
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Saul Nurko
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alvin Wee
- 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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9
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Ross LF. Ethical Issues Raised by the Media Portrayal of Adolescent Transplant Refusals. Pediatrics 2020; 146:S33-S41. [PMID: 32737230 DOI: 10.1542/peds.2020-0818h] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 11/24/2022] Open
Abstract
Cases of adolescents in organ failure who refuse solid organ transplant are not common, but several have been discussed in the media in the United States and the United Kingdom. Using the framework developed by Buchanan and Brock for surrogate decision-making, I examine what role the adolescent should morally play when deciding about therapy for life-threatening conditions. I argue that the greater the efficacy of treatment, the less voice the adolescent (and the parent) should have. I then consider how refusals of highly effective transplant cases are similar to and different from refusals of other lifesaving therapies (eg, chemotherapy for leukemia), which is more commonly discussed in the media and medical literature. I examine whether organ scarcity and the need for lifelong immunosuppression justify differences in whether the state intervenes when an adolescent and his or her parents refuse a transplant. I argue that the state, as parens patriae, has an obligation to provide the social supports needed for a successful transplant and follow-up treatment plan, although family refusals may be permissible when the transplant is experimental or of low efficacy because of comorbidities or other factors. I conclude by discussing the need to limit media coverage of pediatric treatment refusals.
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Affiliation(s)
- Lainie Friedman Ross
- Departments of Pediatrics, Medicine, and Surgery, University of Chicago, Chicago, Illinois
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Aleksic S, Eisenberg R, Tsomos E, Zahedpour Anaraki S, Japp E, Upadhyay L, Mowrey WB, Akalin E, Zonszein J. Glycemic management and clinical outcomes in underserved minority kidney transplant recipients with type 2 and posttransplantation diabetes: A single-center retrospective study. Diabetes Res Clin Pract 2020; 165:108221. [PMID: 32442553 PMCID: PMC7415727 DOI: 10.1016/j.diabres.2020.108221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/28/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023]
Abstract
AIMS Little is known about glycemic management, particularly with novel cardio-nephroprotecive agents, in underserved minority kidney transplant recipients with pre-transplant type 2 (T2DM) and posttransplantation diabetes mellitus (PTDM). We assessed glycemic management and outcomes in this high-risk population. METHODS We reviewed records of patients who received kidney transplants between June 2012 and December 2014 at a single center. Hemoglobin A1c (HbA1c) and prescribed glucose-lowering medications were examined, and mortality was compared between T2DM, PTDM, and no diabetes (NoDM) patients. RESULTS We followed 302 patient records (41.1% Hispanic, 41.1% non-Hispanic black) for a median (IQR) of 45.5 (37.0, 53.0) months post-transplant. Pre-transplant T2DM was present in 152 (50.3%), while 58 (19.2%) developed PTDM and 92 (30.4%) remained NoDM. At 1-year post-transplant, the average HbA1c was 8.1 ± 1.8% in T2DM and 6.6 ± 1.3% in PTDM. No glucose-lowering agents were prescribed in 3.4% of T2DM and 44.8% of PTDM. When treated, both received mostly insulin and metformin. Diabetes, HbA1c and insulin therapy were not independently associated with risk of mortality. CONCLUSIONS Glycemic management was suboptimal and relied on older medications. Further studies are needed to assess longer-term outcomes of more rigorous glycemic management, and the value of novel cardio-nephroprotective agents in kidney transplant recipients.
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Affiliation(s)
- Sandra Aleksic
- Department of Medicine, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, NY, United States.
| | - Ruth Eisenberg
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Effie Tsomos
- Department of Medicine, Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai Medical Center, New York, NY, United States
| | - Sara Zahedpour Anaraki
- Department of Medicine, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, Bronx, NY, United States
| | - Emily Japp
- Department of Medicine, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, Bronx, NY, United States
| | - Laxmi Upadhyay
- Department of Medicine, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, Bronx, NY, United States
| | - Wenzhu Bi Mowrey
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Enver Akalin
- Montefiore-Einstein Center for Transplantation, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, Bronx, NY, United States
| | - Joel Zonszein
- Department of Medicine, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, NY, United States
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Foroutan F, Friesen EL, Clark KE, Motaghi S, Zyla R, Lee Y, Kamran R, Ali E, De Snoo M, Orchanian-Cheff A, Ribic C, Treleaven DJ, Guyatt G, Meade MO. Risk Factors for 1-Year Graft Loss After Kidney Transplantation: Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2019; 14:1642-1650. [PMID: 31540931 PMCID: PMC6832056 DOI: 10.2215/cjn.05560519] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 08/05/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES With expansion of the pool of kidney grafts, through the use of higher-risk donors, and increased attention to donor management strategies, the 1-year graft survival rate is subject to change. It is, therefore, useful to elucidate 1-year graft survival rates by dissecting the characteristics of the low-risk and high-risk kidney transplant cases. The objective of our study was to evaluate factors purported to influence the risk of 1-year graft loss in kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched bibliographic databases from 2000 to 2017 and included observational studies that measured the association between donor, recipient, the transplant operation, or early postoperative complications, and 1-year death-censored graft loss. RESULTS We identified 35 eligible primary studies, with 20 risk factors amenable to meta-analysis. Six factors were associated with graft loss, with moderate to high degree of certainty: donor age (hazard ratio [HR], 1.11 per 10-year increase; 95% confidence interval [95% CI], 1.04 to 1.18), extended criteria donors (HR, 1.35; 95% CI, 1.28 to 1.42), deceased donors (HR, 1.54; 95% CI, 1.32 to 1.82), number of HLA mismatches (HR, 1.08 per one mismatch increase; 95% CI, 1.07 to 1.09), recipient age (HR, 1.17 per 10-year increase; 95% CI, 1.09 to 1.25), and delayed graft function (HR, 1.89; 95% CI, 1.46 to 2.47) as risk factors for 1-year graft loss. Pooled analyses also excluded, with a high degree of certainty, any associations of cold ischemia time, recipient race, pretransplant body mass index, diabetes, and hypertension with 1-year graft loss. CONCLUSIONS Recipient age, donor age, standard versus extended criteria donor, living versus deceased donor, HLA mismatch, and delayed graft function all predicted 1-year graft survival. The effect of each risk factor is small.
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Affiliation(s)
- Farid Foroutan
- Ted Rogers Centre for Heart Research, Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact and
| | - Erik Loewen Friesen
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Elizabeth Clark
- Ted Rogers Centre for Heart Research, Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Roman Zyla
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Yung Lee
- Department of Health Research Methods, Evidence, and Impact and
| | - Rakhshan Kamran
- Department of Health Research Methods, Evidence, and Impact and
| | - Emir Ali
- Department of Health Research Methods, Evidence, and Impact and
| | - Mitch De Snoo
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | | | - Christine Ribic
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Darin J. Treleaven
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact and
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Wilkinson E, Brettle A, Waqar M, Randhawa G. Inequalities and outcomes: end stage kidney disease in ethnic minorities. BMC Nephrol 2019; 20:234. [PMID: 31242862 PMCID: PMC6595597 DOI: 10.1186/s12882-019-1410-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 06/06/2019] [Indexed: 02/08/2023] Open
Abstract
Background The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers. Methods Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature. Results Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity. Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning. Conclusions Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.
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Affiliation(s)
- Emma Wilkinson
- Institute for Health Research, University of Bedfordshire, Luton, Bedfordshire, UK
| | - Alison Brettle
- School of Health and Society, University of Salford, Manchester, UK
| | - Muhammad Waqar
- Institute for Health Research, University of Bedfordshire, Luton, Bedfordshire, UK
| | - Gurch Randhawa
- Institute for Health Research, University of Bedfordshire, Luton, Bedfordshire, UK.
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A Clinical Prediction Score to Guide Referral of Elderly Dialysis Patients for Kidney Transplant Evaluation. Kidney Int Rep 2017; 2:645-653. [PMID: 28845472 PMCID: PMC5568833 DOI: 10.1016/j.ekir.2017.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Dialysis patients aged ≥70 years derive improved life expectancy through kidney transplantation compared to their waitlisted counterparts, but guidelines are not clear about how to identify appropriate transplantation candidates. We developed a clinical prediction score to identify elderly dialysis patients with expected 5-year survival appropriate for kidney transplantation (>5 years). METHODS Incident dialysis patients in 2006-2009 aged ≥70 were identified from the United States Renal Data System database and divided into derivation and validation cohorts. Using the derivation cohort, candidate variables with a significant crude association with 5-year all-cause mortality were included in a multivariable logistic regression model to generate a scoring system. The scoring system was tested in the validation cohort and a cohort of elderly transplant recipients. RESULTS Characteristics most predictive of 5-year mortality included age >80, body mass index (BMI) <18, the presence of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), immobility, and being institutionalized. Factors associated with increased 5-year survival were non-white race, a primary cause of end stage renal disease (ESRD) other than diabetes, employment within 6 months of dialysis initiation, and dialysis start via arteriovenous fistula (AVF). 5-year mortality was 47% for the lowest risk score group (3.6% of the validation cohort) and >90% for the highest risk cohort (42% of the validation cohort). CONCLUSION This clinical prediction score could be useful for physicians to identify potentially suitable candidates for kidney transplantation.
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