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Li Y, Menon G, Kim B, Clark-Cutaia MN, Long JJ, Metoyer GT, Mohottige D, Strauss AT, Ghildayal N, Quint EE, Wu W, Segev DL, McAdams-DeMarco MA. Components of Residential Neighborhood Deprivation and Their Impact on the Likelihood of Live-Donor and Preemptive Kidney Transplantation. Clin Transplant 2024; 38:e15382. [PMID: 38973768 PMCID: PMC11232925 DOI: 10.1111/ctr.15382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/30/2024] [Accepted: 06/05/2024] [Indexed: 07/09/2024]
Abstract
INTRODUCTION Adults residing in deprived neighborhoods face various socioeconomic stressors, hindering their likelihood of receiving live-donor kidney transplantation (LDKT) and preemptive kidney transplantation (KT). We quantified the association between residential neighborhood deprivation index (NDI) and the likelihood of LDKT/preemptive KT, testing for a differential impact by race and ethnicity. METHODS We studied 403 937 adults (age ≥ 18) KT candidates (national transplant registry; 2006-2021). NDI and its 10 components were averaged at the ZIP-code level. Cause-specific hazards models were used to quantify the adjusted hazard ratio (aHR) of LDKT and preemptive KT across tertiles of NDI and its 10 components. RESULTS Candidates residing in high-deprivation neighborhoods were more likely to be female (40.1% vs. 36.2%) and Black (41.9% vs. 17.7%), and were less likely to receive both LDKT (aHR = 0.66, 95% confidence interval [CI]: 0.64-0.67) and preemptive KT (aHR = 0.60, 95% CI: 0.59-0.62) than those in low-deprivation neighborhoods. These associations differedby race and ethnicity (Black: aHRLDKT = 0.58, 95% CI: 0.55-0.62; aHRpreemptive KT = 0.68, 95% CI: 0.63-0.73; Pinteractions: LDKT < 0.001; Preemptive KT = 0.002). All deprivation components were associated with the likelihood of both LDKT and preemptive KT (except median home value): for example, higher median household income (LDKT: aHR = 1.08, 95% CI: 1.07-1.09; Preemptive KT: aHR = 1.10, 95% CI: 1.08-1.11) and educational attainments (≥high school [LDKT: aHR = 1.17, 95% CI: 1.15-1.18; Preemptive KT: aHR = 1.23, 95% CI: 1.21-1.25]). CONCLUSION Residence in socioeconomically deprived neighborhoods is associated with a lower likelihood of LDKT and preemptive KT, differentially impacting minority candidates. Identifying and understanding which neighborhood-level socioeconomic status contributes to these racial disparities can be instrumental in tailoring interventions to achieve health equity in LDKT and preemptive KT.
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Affiliation(s)
- Yiting Li
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Gayathri Menon
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Byoungjun Kim
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Maya N Clark-Cutaia
- Rory Meyers College of Nursing, New York University, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Jane J Long
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Garyn T Metoyer
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Dinushika Mohottige
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexandra T Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nidhi Ghildayal
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Evelien E Quint
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wenbo Wu
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
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Chiou D, Mooney BH, Shi B, Upfill-Brown A, Kallini J, SooHoo N, Johnson EE. Postoperative Care and Outcomes in Solid-Organ Transplant Patients Undergoing Lower Extremity Fracture Treatment. J Orthop Trauma 2024; 38:e238-e244. [PMID: 38358830 DOI: 10.1097/bot.0000000000002788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVES To determine the postoperative outcomes in solid-organ transplant (SOT) patients undergoing operative treatment of lower extremity fractures. METHODS DESIGN Retrospective comparative study. SETTING Academic Level 1 trauma center. PATIENT SELECTION CRITERIA Patients who underwent SOT and operative treatment of lower extremity fracture from 2013 to 2021 were identified, excluding pathologic fractures. OUTCOME MEASURES AND COMPARISONS Postoperative complications, length of stay, time to death, 90-day and 1-year readmission rates, readmission causes, discharge location, and immunosuppressive regiments. RESULTS Sixty-one patients with an average age of 67 years (range 29-88) were included. The mortality rate was 37.7%. The average follow-up was 15.2 months (range of 2 weeks-10 years). The majority of patients (32.8%) had received a liver transplant, and femoral neck fractures constituted the largest fracture group. The average length of stay was 10 days, with the shortest being 1 day and the longest being 126 days (SD 18). The majority of patients (57.3%) were not discharged home. Only 2 suffered from a postoperative complication requiring another procedure: hardware removal and liner exchange for periprosthetic joint infection, respectively. There was a 27.9% 90-day readmission rate with 2 deaths within that period with the most common being altered mental status (29.4%), genitourinary infections (17.6%), repeat falls (11.8%), and low hemoglobin requiring transfusion (11.8%). The longest average time to death analyzed by transplant type was found among lung transplant patients (1076 days, 62.5% mortality), followed by liver transplant patients (949 days, 35.0% mortality), and then kidney transplant patients (834 days, 38.9% mortality). The shortest time to death was 71 days from index procedure. CONCLUSIONS Family members of SOT patients undergoing operative treatment of lower extremity fractures should be made aware of the high risk for 90-day readmission postoperatively (27.9%) and overall mortality (12.5%). Providers should be aware of the need for multidisciplinary involvement for inpatient care, monitoring postoperative complications, and facilitating discharge planning. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel Chiou
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Bailey H Mooney
- David Geffen School of Medicine, University of California Los Angeles California, Los Angeles, CA
| | - Brendan Shi
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Jennifer Kallini
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Nelson SooHoo
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Eric E Johnson
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
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Jaikaransingh V. Bone health and fracture prevention after kidney transplantation. J Clin Transl Endocrinol 2024; 36:100345. [PMID: 38737624 PMCID: PMC11081796 DOI: 10.1016/j.jcte.2024.100345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024] Open
Abstract
Changes in bone health and strength are common after kidney transplantation and can lead to an increased risk of fracture. This has implications for morbidity, mortality and renal allograft survival. This review will focus on the changes that occur in bone health and fracture risk after kidney transplantation and examine the evidence available to guide diagnostic and therapeutic decisions with the aim of fracture prevention.
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Affiliation(s)
- Vishal Jaikaransingh
- University of Florida College of Medicine – Jacksonville, Department of Medicine, Division of Nephrology, United States
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Jia L, Chao S, Yang Q, Chen Q, Yuan Z, Chen L, Zhang T, Zhu K, Niu Y. The comprehensive incidence and risk factors of fracture in kidney transplant recipients: A meta-analysis. Nephrology (Carlton) 2024. [PMID: 38689467 DOI: 10.1111/nep.14301] [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: 01/14/2024] [Revised: 03/08/2024] [Accepted: 03/26/2024] [Indexed: 05/02/2024]
Abstract
AIM Kidney transplant recipients are at high risk of fracture due to many factors such as nutritional status, hyperparathyroidism, acidosis and steroid administration. The current meta-analysis aimed to comprehensively analyse the incidence and risk factors of fracture in kidney transplant recipients. METHODS A systematic search on Embase, Web of Science, PubMed and Cochrane Library until November 2023 was performed. RStudio software was used to analyse data. RESULTS Twenty-eight eligible studies containing 310 530 kidney transplant recipients were included in the analysis. The pooled incidence of fracture was 10% (95% confidence interval [CI]: 7%-13%) generally. When divided by regions, it was further observed that the pooled incidence of fracture was 13% (95% CI: 9%-17%) in Europe, 11% (95% CI: 6%-16%) in North America, 7% (95% CI: 3%-11%) in Asia. Regarding the risk factors, pooled analysis revealed that age of recipient (hazard ratio [HR] = 1.50, 95% CI: 1.17-1.91), female sex (HR = 1.45, 95% CI: 1.36-1.53), pretransplantation diabetes (HR = 1.76, 95% CI: 1.58-1.97), pretransplantation fracture history (HR = 2.28, 95% CI: 1.86-2.78), dialysis duration (HR = 1.09, 95% CI: 1.01-1.17) and deceased donor (HR = 1.21, 95% CI: 1.05-1.39) related to higher risk of fracture. The general quality of included studies was acceptable, and no publication bias existed except for the analysis between age of recipient and fracture incidence; further trim and fill method indicated age of recipient showed a correlation trend with the fracture incidence without the statistical significance. CONCLUSION The pooled incidence of fracture reaches 10% in kidney transplant recipients, which relates to age of recipient, female sex, pretransplantation diabetes or fracture history, dialysis duration and decease donor.
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Affiliation(s)
- Lei Jia
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Sheng Chao
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Qizhen Yang
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Qian Chen
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Zhihui Yuan
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Luobei Chen
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Tao Zhang
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Kejing Zhu
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Yulin Niu
- Organ Transplantation Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
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Kim S, Jung JH, Lee K, Jeon J, Shin DW, Jang HR, Lee JE, Han K, Huh W. Association of physical activity with fractures in kidney transplant recipients: A Korean nationwide cohort study. Clin Transplant 2024; 38:e15308. [PMID: 38581296 DOI: 10.1111/ctr.15308] [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: 12/07/2023] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 04/08/2024]
Abstract
Kidney transplant recipients are at high risk for fractures, primarily due to post-transplant bone disease. This retrospective cohort study analyzed data from the Korean National Health Insurance Service, including 10 083 kidney transplant recipients examined from 2009 to 2017. We assessed fracture incidence, emphasizing vertebral and hip fractures, and the association of physical activity and traditional risk factors with fracture risk. Kidney transplant recipients were categorized into three groups according to physical activity levels: non-activity, metabolic equivalent of task (MET) 1-499, and MET ≥500. Physical activity was associated with a decreased risk of all types of fractures: any (MET 1-499: adjusted hazard ratio (aHR) .75; 95% confidence interval (CI) .62-.92, MET ≥500: aHR .84; 95% CI .70-1.00), vertebral (MET 1-499: aHR .69; 95% CI .49-.98, MET ≥500: aHR .67; 95% CI .49-.91), and hip (MET 1-499: aHR .43; 95% CI .23-.81) fractures. Additionally, older age, female sex, and diabetes were associated with an increased fracture risk. The assessment of physical activity and traditional risk factors could improve fracture risk prediction. Our findings emphasize the need for further research to establish optimal physical activity recommendations for fracture prevention in kidney transplant recipients.
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Affiliation(s)
- Sungmi Kim
- Division of nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Hyung Jung
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Kyungho Lee
- Division of nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Junseok Jeon
- Division of nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Wook Shin
- Department of Family Medicine, Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Division of nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Eun Lee
- Division of nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Wooseong Huh
- Division of nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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McPherson LJ, Di M, Adams AA, Plantinga L, Pastan SO, Patzer RE. Geographic Differences in Racial Disparities in Access to Kidney Transplantation. Kidney Int Rep 2023; 8:2474-2477. [PMID: 38025234 PMCID: PMC10658202 DOI: 10.1016/j.ekir.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/17/2023] [Accepted: 08/02/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Laura J. McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mengyu Di
- Regenstrief Institute, Indianapolis, Indiana, USA
| | - Ayrenne A. Adams
- Department of Medicine, Division of General Internal Medicine and Innovation, New York University Grossman School of Medicine, New York, New York, USA
| | - Laura Plantinga
- Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Elder GJ. Current Status of Mineral and Bone Disorders in Transplant Recipients. Transplantation 2023; 107:2107-2119. [PMID: 36788445 DOI: 10.1097/tp.0000000000004538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Most patients with end-stage kidney disease undergoing kidney transplantation are affected by the chronic kidney disease-mineral and bone disorder. This entity encompasses laboratory abnormalities, calcification of soft tissues, and the bone abnormalities of renal osteodystrophy that together result in an increased risk of fracture, cardiovascular events, and mortality. Although many biochemical disturbances associated with end-stage kidney disease improve in the first year after transplantation, hyperparathyroidism commonly persists, and residual changes of renal osteodystrophy are slow to resolve. When superimposed on common, traditional risk factors, post-transplant glucocorticoid treatment, the possibility of tubular disturbances and post-transplant chronic kidney disease, rates of incident fracture remain high. This review examines hormonal and biochemical changes before and after kidney transplantation, fracture risk assessment tools and imaging modalities, a staged approach to management and concerns associated with antiresorptive and anabolic therapies. A multidisciplinary approach is proposed as the best means to improve patient-level outcomes.
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Affiliation(s)
- Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
- Skeletal Biology Program, Garvan Institute of Medical Research, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
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Andrian T, Siriteanu L, Covic AS, Ipate CA, Miron A, Morosanu C, Caruntu ID, Covic A. Non-Traditional Non-Immunological Risk Factors for Kidney Allograft Loss-Opinion. J Clin Med 2023; 12:jcm12062364. [PMID: 36983364 PMCID: PMC10051358 DOI: 10.3390/jcm12062364] [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: 12/28/2022] [Revised: 02/16/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Rates of late allograft loss have improved slowly in the last decades. Well described traditional risk factors that influence allograft survival include cardiovascular events, rejection, infections and post-transplant neoplasia. Here, we critically evaluate the influence of several non-immunological, non-traditional risk factors and describe their impact on allograft survival and cardiovascular health of kidney transplant recipients. We assessed the following risk factors: arterial stiffness, persistent arteriovenous access, mineral bone disease, immunosuppressive drugs residual levels variability, hypomagnesemia, glomerular pathological alterations not included in Banff criteria, persistent inflammation and metabolic acidosis.
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Affiliation(s)
- Titus Andrian
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Lucian Siriteanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Andreea Simona Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Cristina Alexandra Ipate
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
| | - Adelina Miron
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Corneliu Morosanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
| | - Irina-Draga Caruntu
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
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Time-Varying Risk Factors for Incident Fractures in Kidney Transplant Recipients: A Nationwide Cohort Study in South Korea. J Clin Med 2023; 12:jcm12062337. [PMID: 36983337 PMCID: PMC10058856 DOI: 10.3390/jcm12062337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Little is known about the time-varying risk factors for fractures in kidney transplant recipients (KTRs). Using the Korea Organ Transplantation Registry, a nationwide cohort study of KTRs, the incidence, locations, and time-varying predictors of fractures were analyzed, including at baseline and post-transplant 6-month variables in KTRs who underwent KT between January 2014 and June 2019. Among 4134 KTRs, with a median follow-up of 2.94 years (12,441.04 person-years), 63 patients developed fractures. The cumulative 5-year incidence was 2.10%. The most frequent locations were leg (25.40%) and foot/ankle (22.22%). In multivariable analysis, older recipient age at baseline (hazard ratio [HR], 1.035; 95% confidence interval [CI], 1.007–1.064; p = 0.013) and higher tacrolimus trough level (HR, 1.112; 95% CI, 1.029–1.202; p = 0.029) were associated with higher risks for fractures. Pretransplant diabetes mellitus had a time-dependent impact on fractures, with increasing risk as time elapses (HR for diabetes mellitus 1.115; 95% CI, 0.439–2.832; HR for diabetes mellitus × time, 1.049; 95% CI, 1.007–1.094; p = 0.022). In conclusion, KTRs had a high risk of peripheral skeletal fractures in the first 5 years. At baseline recipient age, pretransplant diabetes mellitus and tacrolimus trough level after KT were responsible for the fractures in KTRs.
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Atagu N, Mihilli S, Nguyen HT, Wu A, Famure O, Li Y, Kim SJ. Risk Factors for First and Recurrent Fractures among Kidney Transplant Recipients. Prog Transplant 2023; 33:16-24. [PMID: 36514897 PMCID: PMC9975818 DOI: 10.1177/15269248221145034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Kidney transplantation is associated with increased risk of bone fracture. Current literature reports widely variable fracture burden and contains limited data on risk factors for recurrent fractures. Methods: The incidence of all and major osteoporotic fractures (hip, forearm, thoracolumbar, and proximal humerus) were assessed. The risk factors for first and recurrent fractures among 1285 Canadian kidney transplant recipients transplanted between January 1, 2004, and December 31, 2013 were also identified. Results: The 10-year cumulative incidence of all fractures and major osteoporotic fractures in this population was 27.1% (95% CI: 22.5, 32.4) and 17.8% (95% CI: 13.4, 23.5), respectively. On multivariable analysis, female sex (HR = 1.64 [95% CI: 1.20, 2.26]), history of fracture (HR = 1.54 [95% CI: 1.12, 2.11]), and pretransplant diabetes (HR = 1.85 [95% CI: 1.29, 2.65]) were recipient factors found to increase the risk for any first fracture posttransplant. These risk factors persist in analysis with the time origin 3-months posttransplant, where transplant age (HR = 1.01 [95% CI: 1.00, 1.03]) and increased time on pretransplant dialysis (HR = 1.06 [95% CI: 1.00, 1.12]) also emerge as risk factors for first fracture. On multivariable shared frailty model analysis, increased risk of recurrent fractures was associated with recipient female sex (HR = 1.74 [95% CI: 1.21, 2.51]) and history of diabetes (HR = 1.76 [95% CI: 1.17, 2.66]). Discussion: The results suggested that some risk factors for first fracture may not inform risk of recurrent fractures. As such, fracture risk should be assessed accordingly to optimize long-term care and implement preventive measures.
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Affiliation(s)
- Norman Atagu
- Russell H. Morgan Department of Radiology and Radiological Science, 1500Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stefani Mihilli
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Huong Thao Nguyen
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Alicia Wu
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Olusegun Famure
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
| | - Yanhong Li
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada.,Department of Medicine (Nephrology), 12366University of Toronto, Medical, Toronto, Ontario, Canada
| | - S Joseph Kim
- Ajmera Transplant Centre, Toronto General Hospital, 7989University Health Network, Toronto, Ontario, Canada
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Pinto-Ramirez J, Garcia-Lopez A, Salcedo-Herrera S, Patino-Jaramillo N, Garcia-Lopez J, Barbosa-Salinas J, Riveros-Enriquez S, Hernandez-Herrera G, Giron-Luque F. Risk factors for graft loss and death among kidney transplant recipients: A competing risk analysis. PLoS One 2022; 17:e0269990. [PMID: 35834500 PMCID: PMC9282472 DOI: 10.1371/journal.pone.0269990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 06/01/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Kidney transplantation is the best therapeutical option for CKD patients. Graft loss risk factors are usually estimated with the cox method. Competing risk analysis could be useful to determine the impact of different events affecting graft survival, the occurrence of an outcome of interest can be precluded by another. We aimed to determine the risk factors for graft loss in the presence of mortality as a competing event. METHODS A retrospective cohort of 1454 kidney transplant recipients who were transplanted between July 1, 2008, to May 31, 2019, in Colombiana de Trasplantes, were analyzed to determine risk factors of graft loss and mortality at 5 years post-transplantation. Kidney and patient survival probabilities were estimated by the competing risk analysis. The Fine and Gray method was used to fit a multivariable model for each outcome. Three variable selection methods were compared, and the bootstrapping technique was used for internal validation as split method for resample. The performance of the final model was assessed calculating the prediction error, brier score, c-index and calibration plot. RESULTS Graft loss occurred in 169 patients (11.6%) and death in 137 (9.4%). Cumulative incidence for graft loss and death was 15.8% and 13.8% respectively. In a multivariable analysis, we found that BKV nephropathy, serum creatinine and increased number of renal biopsies were significant risk factors for graft loss. On the other hand, recipient age, acute cellular rejection, CMV disease were risk factors for death, and recipients with living donor had better survival compared to deceased-donor transplant and coronary stent. The c-index were 0.6 and 0.72 for graft loss and death model respectively. CONCLUSION We developed two prediction models for graft loss and death 5 years post-transplantation by a unique transplant program in Colombia. Using a competing risk multivariable analysis, we were able to identify 3 significant risk factors for graft loss and 5 significant risk factors for death. This contributes to have a better understanding of risk factors for graft loss in a Latin-American population. The predictive performance of the models was mild.
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Affiliation(s)
| | - Andrea Garcia-Lopez
- Department of Transplant Research, Colombiana de Trasplantes, Bogotá, Colombia
| | | | | | - Juan Garcia-Lopez
- Departmento of Technology and Informatics, Colombiana de Trasplantes, Bogotá, Colombia
| | | | | | - Gilma Hernandez-Herrera
- Postgraduate Program in Epidemiology, Universidad del Rosario – Universidad CES, Bogotá-Medellín, Colombia
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12
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Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DR, Cavalier E, D’Haese P, Evenepoel P. Natural History of Bone Disease following Kidney Transplantation. J Am Soc Nephrol 2022; 33:638-652. [PMID: 35046132 PMCID: PMC8975071 DOI: 10.1681/asn.2021081081] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/09/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Knowledge of the effect of kidney transplantation on bone is limited and fragmentary. The aim of this study was to characterize the evolution of bone disease in the first post-transplant year. METHODS We performed a prospective, observational cohort study in patients referred for kidney transplantation under a steroid-sparing immunosuppressive protocol. Bone phenotyping was done before, or at the time of, kidney transplantation, and repeated at 12 months post-transplant. The phenotyping included bone histomorphometry, bone densitometry by dual-energy x-ray absorptiometry, and biochemical parameters of bone and mineral metabolism. RESULTS Paired data were obtained for 97 patients (median age 55 years; 72% male; 21% of patients had diabetes). Bone turnover remained normal or improved in the majority of patients (65%). Bone histomorphometry revealed decreases in bone resorption (eroded perimeter, mean 4.6% pre- to 2.3% post-transplant; P<0.001) and disordered bone formation (fibrosis, 27% pre- versus 2% post-transplant; P<0.001). Whereas bone mineralization was normal in all but one patient pretransplant, delayed mineralization was seen in 15% of patients at 1 year post-transplant. Hypophosphatemia was associated with deterioration in histomorphometric parameters of bone mineralization. Changes in bone mineral density were highly variable, ranging from -18% to +17% per year. Cumulative steroid dose was related to bone loss at the hip, whereas resolution of hyperparathyroidism was related to bone gain at both spine and hip. CONCLUSIONS Changes in bone turnover, mineralization, and volume post-transplant are related both to steroid exposure and ongoing disturbances of mineral metabolism. Optimal control of mineral metabolism may be key to improving bone quality in kidney transplant recipients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Evolution of Bone Histomorphometry and Vascular Calcification Before and After Renal Transplantation, NCT01886950.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk R.J. Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, Liège, Belgium
| | - Patrick D’Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium .,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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13
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Abstract
After kidney transplantation, mineral and bone disorders are associated with higher risk of fractures and consequent morbidity and mortality. Disorders of calcium and phosphorus, vitamin D deficiency, and hyperparathyroidism are also common. The epidemiology of bone disease has evolved over the past several decades due to changes in immunosuppressive regimens, mainly glucocorticoid minimization or avoidance. The assessment of bone disease in kidney transplant recipients relies on risk factor recognition and bone mineral density assessment. Several drugs have been trialed for the treatment of post-transplant mineral and bone disorders. This review will focus on the epidemiology, effect, and treatment of metabolic and skeletal derangements in the transplant recipient.
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Affiliation(s)
- Pascale Khairallah
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
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14
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Competing Risk Analysis in Renal Allograft Survival: A New Perspective to an Old Problem. Transplantation 2021; 105:668-676. [PMID: 32332421 DOI: 10.1097/tp.0000000000003285] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Graft survival after kidney transplant (KTX) is often estimated by the Kaplan-Meier (KM) method censoring for competing endpoints, primarily death. This method overestimates the incidence of graft loss. METHODS In 3157 adult KTX recipients followed for a mean of 79.2 months, we compared kidney and patient survival probabilities by KM versus competing risk analysis (CRA). These methods are extended to comparing different regression methods. RESULTS Compared with CRA, the probabilities of death and graft loss (censored for the other outcome) were substantially higher by KM. These differences increased with increasing follow-up time. Importantly, differences in graft losses were magnified in subgroups with greater probabilities of death. Among recipients with diabetes, the probabilities of graft loss at 20 years were 57% by KM and 32% by CRA, while for non-diabetes mellitus corresponding values were 44% and 35%. Similar results are noted when comparing older versus younger recipients. Finally, we find that the Fine-Gray method assumptions are violated when using age and gender as covariates and that the alternative method of Aalen-Johansen may be more appropriate. CONCLUSIONS CRA provides more accurate estimates of long-term graft survival and death, particularly in subgroups of recipients with higher rates of the competing event. Overestimation of risk by KM leads to both quantitative and qualitative misinterpretations of long-term KTX outcomes. When using regression analyses, care should be taken to check assumptions to guide the choice of appropriate method.
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15
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Iseri K, Carrero JJ, Evans M, Felländer-Tsai L, Berg HE, Runesson B, Stenvinkel P, Lindholm B, Qureshi AR. Fractures after kidney transplantation: Incidence, predictors, and association with mortality. Bone 2020; 140:115554. [PMID: 32730931 DOI: 10.1016/j.bone.2020.115554] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Major fractures (MF) are associated with increased mortality in the general population and represent an even higher risk in patients with chronic kidney disease. We investigated incidence, predictors and clinical outcomes associated with first MF (MFfirst) following kidney transplantation (KT). METHODS We used the Swedish National Renal Registry of 3992 first KT recipients (2005-2016) (median age 53 years, 65% men) and identified all MFfirst in hip, spine, humerus and forearm following KT. We estimated incidence rates and predictors of MFfirst using flexible parametric hazard models and Fine-Gray analysis accounting for competing risk of death, and risk of all-cause mortality following MFfirst using Cox proportional hazards models with fracture as time-varying exposure. RESULTS During median follow-up of 4.8 years (IQR 2.2-7.9 years), there were 279 fractures of which 139 were forearm fractures. The crude incidence rate of MFfirst (n = 279) was 13.5/1000 patient-years and that of hip fractures (n = 69) 3.4/1000 patient-years. The multivariate-adjusted fracture incidence rates were highest during the first 6 months following KT, and 86% higher in women than in men. High age, female sex, previous history of MF, diabetes nephropathy, pretransplant dialysis therapy and acute rejection were associated with increased risk for MFfirst, whereas pre-emptive KT was associated with lower risk of MFfirst. Spline curves showed markedly higher impact of higher age on risk of MFfirst in women than in men. MFfirst (n = 279) independently predicted increased all-cause mortality risk (hazard ratio, HR, 1.78(95%CI 1.35-2.36)). Among MFfirst, with humerus fracture as reference, hip fracture (HR, 4.68(95%CI 1.56-14.06)) and spine fracture (HR, 4.02(95%CI 1.19-13.54)), but not forearm fracture (HR, 1.17 (95%CI 0.38-3.53)), were associated with increased all-cause mortality risk. CONCLUSIONS The initial 6 months following kidney transplantation is a high-risk period for MF. Among MF, hip fracture and spine fracture associate with substantially increased all-cause mortality risk.
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Affiliation(s)
- Ken Iseri
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.
| | - Juan Jesús Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Marie Evans
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hans E Berg
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Runesson
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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16
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McAdams-DeMarco MA, Chu NM, Segev DL. Frailty and Long-Term Post-Kidney Transplant Outcomes. CURRENT TRANSPLANTATION REPORTS 2019; 6:45-51. [PMID: 31768307 PMCID: PMC6876846 DOI: 10.1007/s40472-019-0231-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To highlight recent research about frailty and its role as a predictor of adverse, long-term post-kidney transplant (KT) outcomes. RECENT FINDINGS Frailty is easily measured using the physical frailty phenotype (PFP) developed by gerontologist Dr. Linda Fried and colleagues. In recent studies, >50% of KT recipients were frail (20%) or intermediately frail (32%) at KT admission. Frail recipients were at 1.3-times higher risk of immunosuppression intolerance and 2.2-times higher risk of mortality, even after accounting for recipient, donor, and transplant factors; these findings were consistent with those on short-term post-KT outcomes. Pilot data suggests that prehabilitation may be an intervention that increases physiologic reserve in frail KT recipients. SUMMARY The PFP is a effective tool to measure frailty in ESRD that improves risk stratification for short-term and long-term post-KT outcomes. Interventions to improve physiologic reserve and prevent adverse KT outcomes, particularly among frail KT recipients, are needed.
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Affiliation(s)
- Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD
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