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Zhang Y, Long Y, Li Y, Liao D, Hu L, Peng K, Liu H, Ji F, Shan X. Remote ischemic conditioning may improve graft function following kidney transplantation: a systematic review and meta-analysis with trial sequential analysis. BMC Anesthesiol 2024; 24:168. [PMID: 38702625 PMCID: PMC11067269 DOI: 10.1186/s12871-024-02549-y] [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: 02/21/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Remote ischemic conditioning (RIC) has the potential to benefit graft function following kidney transplantation by reducing ischemia-reperfusion injury; however, the current clinical evidence is inconclusive. This meta-analysis with trial sequential analysis (TSA) aimed to determine whether RIC improves graft function after kidney transplantation. METHODS A comprehensive search was conducted on PubMed, Cochrane Library, and EMBASE databases until June 20, 2023, to identify all randomized controlled trials that examined the impact of RIC on graft function after kidney transplantation. The primary outcome was the incidence of delayed graft function (DGF) post-kidney transplantation. The secondary outcomes included the incidence of acute rejection, graft loss, 3- and 12-month estimated glomerular filtration rates (eGFR), and the length of hospital stay. Subgroup analyses were conducted based on RIC procedures (preconditioning, perconditioning, or postconditioning), implementation sites (upper or lower extremity), and graft source (living or deceased donor). RESULTS Our meta-analysis included eight trials involving 1038 patients. Compared with the control, RIC did not significantly reduce the incidence of DGF (8.8% vs. 15.3%; risk ratio = 0.76, 95% confidence interval [CI], 0.48-1.21, P = 0.25, I2 = 16%), and TSA results showed that the required information size was not reached. However, the RIC group had a significantly increased eGFR at 3 months after transplantation (mean difference = 2.74 ml/min/1.73 m2, 95% CI: 1.44-4.05 ml/min/1.73 m2, P < 0.0001, I2 = 0%), with a sufficient evidence suggested by TSA. The secondary outcomes were comparable between the other secondary outcomes. The treatment effect of RIC did not differ between the subgroup analyses. CONCLUSION In this meta-analysis with trial sequential analysis, RIC did not lead to a significant reduction in the incidence of DGF after kidney transplantation. Nonetheless, RIC demonstrated a positive correlation with 3-month eGFR. Given the limited number of patients included in this study, well-designed clinical trials with large sample sizes are required to validate the renoprotective benefits of RIC. TRIAL REGISTRATION This systematic review and meta-analysis was registered at the International Prospective Register of Systematic Reviews (Number CRD42023464447).
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Affiliation(s)
- Yang Zhang
- Department of Anesthesiology, Institute of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Yuqin Long
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongjun Li
- Department of Anesthesiology, Lianshui County People's Hospital, Huaian, China
| | - Dawei Liao
- Department of Anesthesiology, Tongren People's Hospital, Tongren, Guizhou, China
| | - Linkun Hu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ke Peng
- Department of Anesthesiology, Institute of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Fuhai Ji
- Department of Anesthesiology, Institute of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu, China.
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China.
| | - Xisheng Shan
- Department of Anesthesiology, Institute of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu, China.
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China.
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Zhang R, Trotter PB, McCaffrey J, Fitzroy R, Trivioli G, Stewart BJ, Ferdinand JR, Loudon KW, Riding A, West J, Ferro A, Clatworthy MR. Assessment of biological organ age using molecular pathology in pre-transplant kidney biopsies. Kidney Int 2024:S0085-2538(24)00311-9. [PMID: 38692408 DOI: 10.1016/j.kint.2024.03.028] [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: 01/31/2023] [Revised: 01/21/2024] [Accepted: 03/18/2024] [Indexed: 05/03/2024]
Abstract
Organ shortage is a major challenge in kidney transplantation but the use of older donors, often with co-morbidities, is hampered by inconsistent outcomes. Methods of accurately stratifying marginal donor organs by clinical and histological assessment are lacking. To better understand organ variability, we profiled the transcriptomes of 271 kidneys from deceased donors at retrieval. Following correction for biopsy composition, we assessed molecular pathways that associated with delayed, and sub-optimal one-year graft function. Analysis of cortical biopsies identified an adaptive immune gene-rich module that significantly associated with increasing age and worse outcomes. Cellular deconvolution using human kidney reference single cell transcriptomes confirmed an increase in kidney-specific B and T cell signatures, as well as kidney macrophage, myofibroblast and fibroblast gene sets in this module. Surprisingly, innate immune pathway and neutrophil gene signature enrichment was associated with better outcomes. Thus, our work uncovers cellular molecular features of pathological organ ageing, identifiable at kidney retrieval, with translational potential.
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Affiliation(s)
- Roy Zhang
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Patrick B Trotter
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - James McCaffrey
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK; Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rory Fitzroy
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Giorgio Trivioli
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Benjamin J Stewart
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK; Cellular Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - John R Ferdinand
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Kevin W Loudon
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Alexandra Riding
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Jonathan West
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Ashley Ferro
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | - Menna R Clatworthy
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK; Cellular Genetics, Wellcome Sanger Institute, Hinxton, UK.
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3
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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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4
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Husain SA, Khanna S, Yu M, Adler JT, Cron DC, King KL, Schold JD, Mohan S. Cold Ischemia Time and Delayed Graft Function in Kidney Transplantation: A Paired Kidney Analysis. Transplantation 2024:00007890-990000000-00713. [PMID: 38557641 DOI: 10.1097/tp.0000000000005006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND We aimed to understand the association between cold ischemia time (CIT) and delayed graft function (DGF) after kidney transplantation and the impact of organ pumping on that association. METHODS Retrospective cohort study using US registry data. We identified kidney pairs from the same donor where both kidneys were transplanted but had a CIT difference >0 and ≤20 h. We determined the frequency of concordant (both kidneys with/without DGF) or discordant (only 1 kidney DGF) DGF outcomes. Among discordant pairs, we computed unadjusted and adjusted relative risk of DGF associated with longer-CIT status, when then repeated this analysis restricted to pairs where only the longer-CIT kidney was pumped. RESULTS Among 25 831 kidney pairs included, 71% had concordant DGF outcomes, 16% had only the longer-CIT kidney with DGF, and 13% had only the shorter-CIT kidney with DGF. Among discordant pairs, longer-CIT status was associated with a higher risk of DGF in unadjusted and adjusted models. Among pairs where only the longer-CIT kidney was pumped, longer-CIT kidneys that were pumped had a lower risk of DGF than their contralateral shorter-CIT kidneys that were not pumped regardless of the size of the CIT difference. CONCLUSIONS Most kidney pairs have concordant DGF outcomes regardless of CIT difference, but even small increases in CIT raise the risk of DGF. Organ pumping may mitigate and even overcome the adverse consequences of prolonged CIT on the risk of DGF, but prospective studies are needed to better understand this relationship.
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Affiliation(s)
- Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Sohil Khanna
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
| | - Jesse D Schold
- Department of Surgery, University of Colorado-Anschutz Medical Campus, Aurora, CO
- Department of Epidemiology, School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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5
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Saben JL, Kaplan B, Burton JR, Cooper JE, Pomposelli JJ, Schold JD, Pomfret EA. Highlights From Controversies in Transplantation 2023 Conference. Transplantation 2024; 108:598-600. [PMID: 37314449 DOI: 10.1097/tp.0000000000004699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Jessica L Saben
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Bruce Kaplan
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James R Burton
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James E Cooper
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO
| | - James J Pomposelli
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Jesse D Schold
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
| | - Elizabeth A Pomfret
- University of Colorado Anschutz Medical Campus, Department of Surgery, Aurora, CO
- Colorado Center for Transplantation Care, Research and Education, Aurora, CO
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Gonzalez Sepulveda JM, Mehrotra S, Yang JC, Schantz KJ, Becker Y, Formica R, Ladner DP, Kaufman D, Friedewald J. Physician Preferences when Selecting Candidates for Lower-Quality Kidney Offers. Clin J Am Soc Nephrol 2023; 18:1599-1609. [PMID: 37729938 PMCID: PMC10723918 DOI: 10.2215/cjn.0000000000000302] [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: 03/09/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND In the United States, more than 50% of kidneys in the lowest 15% quality range (those with Kidney Donor Profile Index >85) are discarded. Studies suggest that using more of these kidneys could benefit patients waiting for a transplant. This study assesses the trade-offs physicians make when selecting recipients for lower-quality kidneys. METHODS A discrete choice experiment (DCE) was administered to surgeons and nephrologists in the United States who are involved in kidney acceptance decisions. The DCE presented kidneys that varied in terms of Kidney Donor Profile Index, expected cold ischemia time, donor age, pump parameters, serum creatinine levels, glomerulosclerosis, donor diabetes status, and whether donation was made after circulatory death. Candidate characteristics included recipients' age, diabetes history, time on dialysis, ejection fraction, HLA mismatch, calculated panel reactive antibody, and Karnofsky performance score. Regression analysis was used to estimate acceptability weights associated with kidney and recipient characteristics. RESULTS A total of 108 physicians completed the DCE. The likelihood of acceptance was significantly lower with deterioration of kidney quality, expected cold ischemia time at transplantation, and missing biopsy and pump information. Acceptance was prioritized for patients who were higher on the waiting list, younger recipients, those who have spent less time on dialysis, and those without a history of diabetes. Performance status (Karnofsky score) and calculated panel reactive antibody also had a statistically significant but smaller association. Finally, ejection fraction had a marginally significant association, and HLA match had no significant association with the acceptance of marginal kidneys. A group of respondents were found to be primarily concerned about cold ischemia time. CONCLUSIONS In this DCE, physicians considered the recipient characteristics that inform expected post-transplant survival score when they decided whether to accept a marginal kidney for a given recipient.
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Affiliation(s)
- Juan M. Gonzalez Sepulveda
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sanjay Mehrotra
- Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Jui-Chen Yang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Yolanda Becker
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Richard Formica
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Daniela P. Ladner
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dixon Kaufman
- University of Wisconsin School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - John Friedewald
- Feinberg School of Medicine, Northwestern University, 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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8
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Josephson MA, Meyer RN. Transforming Transplant in the United States. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00197. [PMID: 37494013 PMCID: PMC10861102 DOI: 10.2215/cjn.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/21/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Michelle A. Josephson
- University of Chicago, Section of Nephrology, Department of Medicine, and Transplant Institute, Chicago, Illinois
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9
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Ayorinde JOO, Citterio F, Landrò M, Peruzzo E, Islam T, Tilley S, Taylor G, Bardsley V, Liò P, Samoshkin A, Pettigrew GJ. Artificial Intelligence You Can Trust: What Matters Beyond Performance When Applying Artificial Intelligence to Renal Histopathology? J Am Soc Nephrol 2022; 33:2133-2140. [PMID: 36351761 PMCID: PMC9731632 DOI: 10.1681/asn.2022010069] [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] [Indexed: 11/11/2022] Open
Abstract
Although still in its infancy, artificial intelligence (AI) analysis of kidney biopsy images is anticipated to become an integral aspect of renal histopathology. As these systems are developed, the focus will understandably be on developing ever more accurate models, but successful translation to the clinic will also depend upon other characteristics of the system.In the extreme, deployment of highly performant but "black box" AI is fraught with risk, and high-profile errors could damage future trust in the technology. Furthermore, a major factor determining whether new systems are adopted in clinical settings is whether they are "trusted" by clinicians. Key to unlocking trust will be designing platforms optimized for intuitive human-AI interactions and ensuring that, where judgment is required to resolve ambiguous areas of assessment, the workings of the AI image classifier are understandable to the human observer. Therefore, determining the optimal design for AI systems depends on factors beyond performance, with considerations of goals, interpretability, and safety constraining many design and engineering choices.In this article, we explore challenges that arise in the application of AI to renal histopathology, and consider areas where choices around model architecture, training strategy, and workflow design may be influenced by factors beyond the final performance metrics of the system.
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Affiliation(s)
- John O O Ayorinde
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | | | | | | | | | | | - Victoria Bardsley
- Department of Histopathology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Pietro Liò
- Department of Computer Science and Technology, University of Cambridge, Cambridge, United Kingdom
| | - Alex Samoshkin
- Office for Translational Research, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Gavin J Pettigrew
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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10
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Husain SA, King KL, Cron DC, Lentine KL, Adler JT, Mohan S. Influence of organ quality on the observed association between deceased donor kidney procurement biopsy findings and graft survival. Am J Transplant 2022; 22:2842-2854. [PMID: 35946600 DOI: 10.1111/ajt.17167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/17/2022] [Accepted: 08/05/2022] [Indexed: 01/25/2023]
Abstract
Deceased donor kidney procurement biopsies findings are the most common reason for kidney discard. Retrospective studies have found inconsistent associations with post-transplant outcomes but may have been limited by selection bias because kidneys with advanced nephrosclerosis from high-risk donors are typically discarded. We conducted a retrospective cohort study of kidneys transplanted in the United States from 2015 to 2019 with complete biopsy data available, defining "suboptimal histology" as glomerulosclerosis ≥11%, IFTA ≥mild, and/or vascular disease ≥mild. We used time-to-event analyses to determine the association between suboptimal histology and death-censored graft failure after stratification by kidney donor profile index (KDPI) (≤35%, 36%-84%, ≥85%) and final creatinine (<1 mg/dl, 1-2 mg/dl, >2 mg/dl). Among 30 469 kidneys included, 36% had suboptimal histology. In adjusted analyses, suboptimal histology was associated with death-censored graft failure among kidneys with KDPI 36-84% (HR 1.22, 95% CI 1.09-1.36), but not KDPI≤35% (HR 1.24, 0.94-1.64) or ≥ 85% (HR 0.99, 0.81-1.22). Similarly, suboptimal histology was associated with death-censored graft failure among kidneys from donors with creatinine 1-2 mg/dl (HR 1.39, 95% CI 1.20-1.60) but not <1 mg/dl (HR 1.07, 0.93-1.23) or >2 mg/dl (HR 0.95, 0.75-1.20). The association of procurement histology with graft longevity among intermediate-quality kidneys that were likely to be both biopsied and transplanted suggests biopsies provide independent organ quality assessments.
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Affiliation(s)
- S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Krista L Lentine
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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11
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Scurt FG, Ernst A, Hammoud B, Wassermann T, Mertens PR, Schwarz A, Becker JU, Chatzikyrkou C. Effect of creatinine metrics on outcome after transplantation of marginal donor kidneys. Nephrology (Carlton) 2022; 27:973-982. [PMID: 36043436 DOI: 10.1111/nep.14108] [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: 04/05/2022] [Revised: 07/10/2022] [Accepted: 08/20/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Predicting outcome after transplantation of marginal kidneys is a challenging task. Donor creatinine or estimated glomerular filtration rate (eGFR) are integral components of the respective risk scores. However, there is uncertainty on which of their values obtained successively during procurement is the most suitable. MATERIAL AND METHODS This is a retrospective study of 221 adult brain death donors with marginal kidneys, transplanted in 223 recipients. We applied logistic regression analysis to investigate the association between initial (at hospital admission), nadir (lowest), zenith (highest) and terminal (at recovery) donor eGFR with primary non-function (PNF), delayed graft function (DGF), 3- and 12-month graft function and 1- and 3-year patient- and death-censored graft survival. RESULTS In the multivariate analysis, admission, terminal, and the lowest donor eGFR could most accurately predict DGF. The respective ORs [95% CI] were: 0.875 [0.771-0.993], 0.818 [95% CI: 0.726-0.922] and 0.793 [0.689-0.900]. Although not being significant for DGF (OR 0.931 [95% CI: 0.817-1.106]), the highest eGFR was the best predictor of 3-month graft function (adjusted b coefficient 1.161 [95% CI: 0.355-1.968]). Analysis of primary nonfunction showed that determination of initial and the highest eGFR proved to be the best predictors. The respective ORs [95% CI] were: 0.804 [0.667-0.968] and 0.750 [0.611-0.919]. There were no differences in the risk associations of each of the four eGFR recordings with patient- and graft survival. CONCLUSION The various eGFR recordings determined during the procurement process of marginal donors can predict PNF, DGF and 3- and 12-month graft function. Regarding short-term patient- and graft survival, there appears to be impacted by recipient factors rather than donor kidney function.
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Affiliation(s)
- Florian G Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany
| | - Angela Ernst
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Ben Hammoud
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany
| | - Tamara Wassermann
- Department of Pneumology, Medical Faculty, Otto-von Guericke University Magdeburg, Germany
| | - Peter R Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany
| | - Anke Schwarz
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Jan U Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.,PHV Dialysis Center, Halberstadt, Germany
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12
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Batra RK, Ariyamuthu VK, MacConmara MP, Gupta G, Gungor AB, Tanriover B. Outcomes of Simultaneous Liver-Kidney Transplantation Using Kidneys of Deceased Donors With Acute Kidney Injury. Liver Transpl 2022; 28:983-997. [PMID: 35006615 DOI: 10.1002/lt.26406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 12/24/2021] [Accepted: 01/07/2022] [Indexed: 01/13/2023]
Abstract
Outcomes from simultaneous liver-kidney transplantation (SLKT) when using kidneys from donors with acute kidney injury (AKI) have not been studied. We studied 5344 SLKTs between May 1, 2007, and December 31, 2019, by using Organ Procurement and Transplantation Network registry data supplemented with United Network for Organ Sharing-DonorNet data. Designating a donor as having AKI required by definition that the following criteria were met: (1) the donor's condition aligned with the Kidney Disease: Improving Global Outcomes (KDIGO) international consensus guidelines and the terminal serum creatinine (Scr) level was ≥1.5 times the minimum Scr level for deceased donors before organ recovery and (2) the terminal Scr level was ≥1.5 mg/dL (a clinically meaningful and intuitive Scr threshold for defining AKI for transplant providers). The primary outcomes were liver transplant all-cause graft failure (ACGF; defined as graft failures and deaths) and kidney transplant death-censored graft failure (DCGF) at 1 year after transplant. The donors with AKI were young, had good organ quality, and had a short cold ischemia time. In the study cohort, 4482 donors had no AKI, whereas 862 had AKI (KDIGO AKI stages: 1, n = 521; 2, n = 202; and 3, n = 138). In the group with AKI and the group with no AKI, respectively, liver ACGF at 1 year (11.1% versus 12.9% [P = 0.13]; hazard ratio [HR], 1.20; 95% confidence interval [CI], 0.97-1.49) and kidney DCGF at 1 year (4.6% versus 5.7% [P = 0.18]; HR, 1.27; 95% CI, 0.95-1.70) did not differ in the full multivariable Cox proportional hazard models. Selected kidneys from deceased donors with AKI can be considered for SLKT.
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Affiliation(s)
- Ramesh K Batra
- Department of Surgery, School of Medicine, Yale University, New Haven, CT
| | | | | | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA
| | - Ahmet B Gungor
- Division of Nephrology, Banner University Medical Group, Tucson, AZ
| | - Bekir Tanriover
- Division of Nephrology, College of Medicine, University of Arizona, Tucson, AZ
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13
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Shan XS, Hu LK, Wang Y, Liu HY, Chen J, Meng XW, Pu JX, Huang YH, Hou JQ, Feng XM, Liu H, Meng L, Peng K, Ji FH. Effect of Perioperative Dexmedetomidine on Delayed Graft Function Following a Donation-After-Cardiac-Death Kidney Transplant: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2215217. [PMID: 35657627 PMCID: PMC9166619 DOI: 10.1001/jamanetworkopen.2022.15217] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE Delayed graft function (DGF) is a risk factor for acute rejection and graft failure after kidney transplant. Previous studies have suggested that dexmedetomidine may be renoprotective, but whether the use of dexmedetomidine would improve kidney allograft function is unknown. OBJECTIVE To investigate the effects of perioperative dexmedetomidine on DGF following a donation-after-cardiac-death (DCD) kidney transplant. DESIGN, SETTING, AND PARTICIPANTS This single-center, double-blind, placebo-controlled randomized clinical trial was conducted at The First Affiliated Hospital of Soochow University in Suzhou, China. Adults (18 years or older) who were scheduled for DCD kidney transplant were enrolled between September 1, 2019, and January 28, 2021, and then randomized to receive either dexmedetomidine or normal saline (placebo). One-year postoperative outcomes were recorded. All analyses were based on the modified intention-to-treat population. INTERVENTIONS Patients who were randomized to the dexmedetomidine group received a 24-hour perioperative dexmedetomidine intravenous infusion (0.4 μg/kg/h intraoperatively and 0.1 μg/kg/h postoperatively). Patients who were randomized to the normal saline group received an intravenous infusion of the placebo with the same dose regimen as the dexmedetomidine. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of DGF, defined as the need for dialysis in the first posttransplant week. The prespecified secondary outcomes were in-hospital repeated dialysis in the first posttransplant week, in-hospital acute rejection, and serum creatinine, serum cystatin C, estimated glomerular filtration rate, need for dialysis, and patient survival on posttransplant day 30. RESULTS Of the 114 patients enrolled, 111 completed the study (mean [SD] age, 43.4 [10.8] years; 64 male patients [57.7%]), of whom 56 were randomized to the dexmedetomidine group and 55 to the normal saline group. Dexmedetomidine infusion compared with normal saline reduced the incidence of DGF (17.9% vs 34.5%; odds ratio [OR], 0.41; 95% CI, 0.17-0.98; P = .04) and repeated dialysis (12.5% vs 30.9%; OR, 0.32; 95% CI, 0.13-0.88; P = .02, which was not statistically significant after multiple testing corrections), without significant effect on other secondary outcomes. Dexmedetomidine vs normal saline infusion led to a higher median (IQR) creatinine clearance rate on postoperative days 1 (9.9 [4.9-21.2] mL/min vs 7.9 [2.0-10.4] mL/min) and 2 (29.6 [9.7-67.4] mL/min vs 14.6 [3.8-45.1] mL/min) as well as increased median (IQR) urine output on postoperative days 2 (106.5 [66.3-175.6] mL/h vs 82.9 [27.1-141.9] mL/h) and 7 (126.1 [98.0-151.3] mL/h vs 107.0 [82.5-137.5] mL/h) and at hospital discharge discharge (110.4 [92.8-121.9] mL/h vs 97.1 [77.5-113.8] mL/h). Three patients (5.5%) from the normal saline group developed allograft failure by the post hoc 1-year follow-up visit. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that 24-hour perioperative dexmedetomidine decreased the incidence of DGF after DCD kidney transplant. The findings support the use of dexmedetomidine in kidney transplants. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR1900025493.
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Affiliation(s)
- Xi-sheng Shan
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Lin-kun Hu
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yiqing Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hua-yue Liu
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jun Chen
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Xiao-wen Meng
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jin-xian Pu
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yu-hua Huang
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jian-quan Hou
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiao-mei Feng
- Department of Anesthesiology, University of Utah Health, Salt Lake City
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California, Davis Health, Sacramento
| | - Lingzhong Meng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ke Peng
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Fu-hai Ji
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
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14
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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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15
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Rosaasen C, Rosaasen N, Mainra R, Trachtenberg A, Ho J, Parsons C, Delaney S, Mansell H. Waitlisted and Transplant Patient Perspectives on Expanding Access to Deceased-Donor Kidney Transplant: A Qualitative Study. Can J Kidney Health Dis 2022; 9:20543581221100291. [PMID: 35615070 PMCID: PMC9125065 DOI: 10.1177/20543581221100291] [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: 12/07/2021] [Accepted: 03/27/2022] [Indexed: 11/17/2022] Open
Abstract
Background: A concerning number of kidneys (eg, expanded donor criteria, extended criteria, or marginal kidneys) are discarded yearly while patients experience significant morbidity and mortality on the transplant waitlist. Novel solutions are needed to solve the shortage of kidneys available for transplant. Patient perceptions regarding the use of these less than ideal kidneys remain unexplored. Objective: To explore the perspectives of patients who have previously received a less than ideal kidney in the past and patients awaiting transplant who could potentially benefit from one. Design: Qualitative description study. Setting: 2 provinces in Canada participated (Saskatchewan and Manitoba). Patients: Patients with end-stage kidney disease who were awaiting kidney transplant and were either (a) aged 65 years and older, or (b) 55 years and older with other medical conditions (eg, diabetes). Methods: Criterion sampling was used to identify participants. Semi-structured, one-on-one interviews were conducted virtually, which explored perceived quality of life, perceptions of less than ideal kidneys, risk tolerance for accepting one, and educational needs to make such a choice. The interviews were transcribed verbatim and thematic analysis was used to analyze the data. Results: 15 interviews were conducted with usable data (n = 10 pretransplant; n = 5 posttransplant). Participants were a mean of 65.5 ± 8.8 years old. Four interrelated themes became prominent including (1) patient awareness and understanding of their situation or context, (2) a desire for information, (3) a desire for freedom from dialysis, and (4) trust. Subthemes of transparency, clarity, standardization, and autonomy were deemed important for participant education. The majority of pretransplant participants (n = 8/10) indicated that between 3 and 5 years off of dialysis would make the risk of accepting a less than ideal kidney feel worthwhile. Limitation: The study setting was limited to 2 Canadian provinces, which limits the generalizability. Furthermore, the participants were homogenous in demographics such as ethnicity. Conclusion: These findings indicate that patients are comfortable to accept a less than ideal kidney for transplant in situations where their autonomy is respected, they are provided clear, standardized, and transparent information, and when they trust their physician. These results will be used to inform the development of a new national registry for expanding access to deceased-donor kidney transplant. Trial Registration: Not registered.
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Affiliation(s)
- Canute Rosaasen
- Johnson Shoyama Graduate School of Public Policy, University of Saskatchewan, Saskatoon, Canada
| | - Nicola Rosaasen
- Saskatchewan Transplant Program, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Rahul Mainra
- Division of Nephrology, Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Aaron Trachtenberg
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Julie Ho
- Department of Internal Medicine and Department of Immunology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | | | | | - Holly Mansell
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
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16
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Computer-assisted evaluation enhances the quantification of interstitial fibrosis in renal implantation biopsies, measures differences between frozen and paraffin sections, and predicts delayed graft function. J Nephrol 2022; 35:1819-1829. [PMID: 35438423 PMCID: PMC9458593 DOI: 10.1007/s40620-022-01315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 03/19/2022] [Indexed: 11/24/2022]
Abstract
Background (Pre-)Implantation biopsies provide important data on the quality of donor kidneys. Interstitial fibrosis, as a known predictor for kidney disease progression, is an essential feature of this evaluation. However, the assessment of frozen sections of implantation biopsies is challenging and can result in the disposal of candidate organs. We sought to apply digital image analysis (DIA) to quantify the differences between frozen and paraffin sections when evaluating interstitial fibrosis, identify factors that influence these variations and test the predictive value of the computerised measures. Methods We quantified the differences between frozen and paraffin sections in the same biopsy samples by measuring Sirius red-stained interstitial areas (SRIA) in DIA. We compared them to the original reports, and retrospectively correlated our findings to clinical data, graft function and outcome in 73 patients. Results Frozen sections display a broader interstitial area than paraffin sections, in some cases up to one-third more (mean difference + 7.8%, range − 7 to 29%). No donor-related factors (age or gender, cold ischemia time, or non-heart-beating donor) influenced significantly this difference. Compared to the original assessment of frozen vs paraffin sections in optical microscopy, the DIA of interstitial fibrosis shows a higher consistency (ICC 0.69). Our approach further allows to distinguish SRIA in paraffin sections as an independent predictor for delayed graft function (OR = 1.1; p = 0.028). Conclusions DIA is superior to and more consistent than routine optic microscopy for interstitial fibrosis evaluation. This method could improve implantation biopsy diagnostics and help to reduce disposal of organs. Graphical abstract Supplementary Information The online version contains supplementary material available at 10.1007/s40620-022-01315-y.
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17
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Husain SA, King KL, Adler JT, Mohan S, Perotte R. Impact of Extending Eligibility for Reinstatement of Waiting Time After Early Allograft Failure: A Decision Analysis. Am J Kidney Dis 2022; 79:354-361. [PMID: 34562524 PMCID: PMC8881308 DOI: 10.1053/j.ajkd.2021.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/31/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE The shortage of deceased donor kidneys identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys being discarded after procurement. We estimated the impact of a policy proposal aiming to increase organ utilization by extending eligibility for waiting time reinstatement for recipients experiencing early allograft failure after transplantation. STUDY DESIGN Decision analysis informed by clinical registry data. SETTING & POPULATION We used Organ Procurement and Transplantation Network data to identify 76,044 deceased-donor kidneys procured in the United States from 2013 to 2017, 80% of which were transplanted and 20% discarded. INTERVENTION Extend waiting time reinstatement for recipients experiencing allograft failure from the current 90 days to 1 year after transplantation. OUTCOME Net impact to the waitlist, defined as the estimated number of additional transplants minus estimated increase in waiting list reinstatements. MODEL, PERSPECTIVE, & TIMEFRAME We estimated (1) the number of additional deceased donor kidneys that would be transplanted if there was a 5%-25% relative reduction in discards, and (2) the number of recipients who would regain waiting time under a 6-, 12-, 18-, and 24-month reinstatement policy. RESULTS Reinstating a waiting time for recipients experiencing allograft failure up to 1 year after transplantation yielded more additional transplants than growth in additions to the waiting list for all model assumptions except the combination of a very low relative reduction in discards (5%) and a very high failure rate of transplanted kidneys that would previously have been discarded (≥5 times the rate of currently transplanted kidneys). LIMITATIONS Lack of empirical evidence supporting the proposed impact of such a policy change. CONCLUSIONS A policy change reinstating waiting time for deceased donor kidneys recipients with allograft failure up to 1 year after transplantation should explored as a decision science-based intervention to improve organ utilization.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY,The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Joel T. Adler
- Department of Surgery, Division of Transplant Surgery, Brigham and Women’s Hospital, Boston, MA,Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, 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
| | - Rimma Perotte
- Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, NJ,Department of Biomedical Informatics, Columbia University Medical Center, New York, NY
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18
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Mohan S, Schold JD. Accelerating deceased donor kidney utilization requires more than accelerating placement. Am J Transplant 2022; 22:7-8. [PMID: 34637595 DOI: 10.1111/ajt.16866] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.,Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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19
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Husain SA, King KL, Robbins-Juarez S, Adler JT, McCune KR, Mohan S. Number of Donor Renal Arteries and Early Outcomes after Deceased Donor Kidney Transplantation. KIDNEY360 2021; 2:1819-1826. [PMID: 35373010 PMCID: PMC8785844 DOI: 10.34067/kid.0005152021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/07/2021] [Indexed: 02/07/2023]
Abstract
Background Anatomic abnormalities increase the risk of deceased donor kidney discard, but their effect on transplant outcomes is understudied. We sought to determine the effect of multiple donor renal arteries on early outcomes after deceased donor kidney transplantation. Methods For this retrospective cohort study, we identified 1443 kidneys from 832 deceased donors with ≥1 kidney transplanted at our center (2006-2016). We compared the odds of delayed graft function and 90-day graft failure using logistic regression. To reduce potential selection bias, we then repeated the analysis using a paired-kidney cohort, including kidney pairs from 162 donors with one single-artery kidney and one multiartery kidney. Results Of 1443 kidneys included, 319 (22%) had multiple arteries. Multiartery kidneys experienced longer cold ischemia time, but other characteristics were similar between groups. Delayed graft function (50% multiartery versus 45% one artery, P=0.07) and 90-day graft failure (3% versus 3%, P=0.83) were similar between groups before and after adjusting for donor and recipient characteristics. In the paired kidney analysis, cold ischemia time was significantly longer for multiartery kidneys compared with single-artery kidneys from the same donor (33.5 versus 26.1 hours, P<0.001), but delayed graft function and 90-day graft failure were again similar between groups. Conclusions Compared with single-artery deceased donor kidneys, those with multiple renal arteries are harder to place, but experience similar delayed graft function and early graft failure.
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Affiliation(s)
- S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Shelief Robbins-Juarez
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
| | - Joel T Adler
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health at Brigham and Women's Hospital, Boston, Massachusetts
| | - Kasi R McCune
- Department of Surgery, Kidney and Pancreas Transplant Program, Columbia University College of Physicians & Surgeons, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, New York, New York
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20
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King KL, Chaudhry SG, Ratner LE, Cohen DJ, Husain SA, Mohan S. Declined Offers for Deceased Donor Kidneys Are Not an Independent Reflection of Organ Quality. KIDNEY360 2021; 2:1807-1818. [PMID: 35372993 PMCID: PMC8785847 DOI: 10.34067/kid.0004052021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/06/2021] [Indexed: 02/04/2023]
Abstract
Background Deceased donor kidney offers are frequently declined multiple times before acceptance for transplantation, despite significant organ shortage and long waiting times. Whether the number of times a kidney has been declined, reflecting cumulative judgments of clinicians, is associated with long-term transplant outcomes remains unclear. Methods In this national, retrospective cohort study of deceased donor kidney transplants in the United States from 2008 to 2015 (n=78,940), we compared donor and recipient characteristics and short- and long-term graft and patient survival outcomes grouping by the sequence number at which the kidney was accepted for transplantation. We compared outcomes for kidneys accepted within the first seven offers in the match-run, after 8-100 offers, and for hard-to-place kidneys distinguishing those requiring >100 and >1000 offers before acceptance. Results Harder-to-place kidneys had lower donor quality and higher rates of delayed graft function (46% among kidneys requiring >1000 offers before acceptance versus 23% among kidneys with ≤7 offers). In unadjusted models, later sequence groups had higher hazard of all-cause graft failure, death-censored graft failure, and patient mortality; however, these associations were attenuated after adjusting for Kidney Donor Risk Index (KDRI). After adjusting for donor factors already taken into consideration during allocation, and recipient factors associated with long-term outcomes, graft, and patient survival outcomes were not significantly different for the hardest-to-place kidneys compared with the easiest-to-place kidneys, with the exception of death-censored graft failure (adjusted hazard ratio, 1.16, 95% CI, 1.05 to 1.28). Conclusion Late sequence offers may represent missed opportunities for earlier successful transplant for the higher-priority waitlisted candidates for whom the offers were declined.
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Affiliation(s)
- Kristen L King
- Department of Medicine, Columbia University Irving Medical Center, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Sulemon G Chaudhry
- Division of Transplant Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Lloyd E Ratner
- Division of Transplant Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - David J Cohen
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - S Ali Husain
- Department of Medicine, Columbia University Irving Medical Center, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York
| | - Sumit Mohan
- Department of Medicine, Columbia University Irving Medical Center, New York, New York.,The Columbia University Renal Epidemiology Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, New York, New York
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21
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Abstract
PURPOSE OF REVIEW The Final Rule clearly states that geography should not be a determinant of a chance of a potential candidate being transplanted. There have been multiple concerns about geographic disparities in patients in need of solid organ transplantation. Allocation policy adjustments have been designed to address these concerns, but there is little evidence that the disparities have been solved. The purpose of this review is to describe the main drivers of geographic disparities in solid organ transplantation and how allocation policy changes and other potential actions could impact these inequalities. RECENT FINDINGS Geographical disparities have been reported in kidney, pancreas, liver, and lung transplantation. Organ Procurement and Transplant Network has modified organ allocation rules to underplay geography as a key determinant of a candidates' chance of receiving an organ. Thus, heart, lung, and more recently liver and Kidney Allocation Systems have incorporated broader organ sharing to reduce geographical disparities. Whether these policy adjustments will indeed eliminate geographical disparities are still unclear. SUMMARY Modern allocation policy focus in patients need, regardless of geography. Innovative actions to further reduce geographical disparities are needed.
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22
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Emmons BR, Husain SA, King KL, Adler JT, Mohan S. Variations in deceased donor kidney procurement biopsy practice patterns: A survey of U.S. organ procurement organizations. Clin Transplant 2021; 35:e14411. [PMID: 34196034 PMCID: PMC8556234 DOI: 10.1111/ctr.14411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Procurement biopsies have become a common practice in the evaluation and allocation of deceased donor kidneys in the United States despite questions about their value and reproducibility. We sought to determine the extent of OPO-level differences in criteria used to decide which deceased donor kidneys undergo a procurement biopsy and to assess the degree of variability in procurement biopsy technique and interpretation across OPOs. METHODS Each of the country's 58 OPOs were invited to participate in the survey. OPOs were divided into two groups based on organ availability ratio and deceased donor kidney discard rate. RESULTS AND CONCLUSIONS Fifty-out-of-fifty-eight invited OPOs (86% response rate) responded to the survey between November 2020 and December 2020. Thirty (60%) OPOs reported that they have formal criteria for performing kidney procurement biopsy, but for 29 of these OPOs, transplant centers can request biopsy on kidneys that do not meet criteria. OPOs used a total of seven different variables and 12 different numerical thresholds to define impaired kidney function that would prompt a procurement biopsy. Additionally, wide variability was seen in biopsy technique and procedures for biopsy interpretation and reporting of findings to transplant programs. These findings identify a clear opportunity for standardization of procurement biopsies to best practices.
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Affiliation(s)
- Brendan R. Emmons
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
| | - S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Joel T. Adler
- Department of Surgery, Division of Transplant Surgery, Brigham and Women’s Hospital, Boston, MA
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, MA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, 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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23
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Batal I, Serban G, Mohan S, Husain SA, Vasilescu ER, Crew RJ, Dube G, Sandoval PR, Coley SM, Santoriello D, Stokes MB, D'Agati VD, Cohen DJ, Markowitz G, Hardy MA, Ratner LE. The clinical significance of receiving a kidney allograft from deceased donor with chronic histologic changes. Mod Pathol 2021; 34:1795-1805. [PMID: 33986461 DOI: 10.1038/s41379-021-00815-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 12/22/2022]
Abstract
Allograft survival of deceased donor kidneys with suboptimal histology (DRTx/suboptimal histology: >10% glomerulosclerosis, >10% tubulointerstitial scarring, or >mild vascular sclerosis) is inferior to both DRTx with optimal histology (DRTx/optimal histology) and living donor kidneys irrespective of histologic changes (LRTx). In this report, we explored the reasons behind this guarded outcome with a special focus on the role of alloimmunity. We initially assessed gene expression in 39 time-zero allograft biopsies using the Nanostring 770 genes PanCancer Immune Profiling Panel. Subsequently, we studied 696 consecutive adult kidney allograft recipients that were grouped according to allograft type and histology at time-zero biopsy [DRTx/suboptimal histology (n = 194), DRTx/optimal histology (n = 166), and LRTx (n = 336)]. Part-1: Several immune pathways were upregulated in time-zero biopsies from DRTx/suboptimal histology (n = 11) compared to LRTx (n = 17) but not to DRTx/optimal histology (n = 11). Part-2: Amongst the three groups of recipients, DRTx/suboptimal histology had the highest incidence of acute rejection episodes, most of which occurred during the first year after transplantation (early rejection). This increase was mainly attributed to T cell mediated rejection, while the incidence of antibody-mediated rejection was similar amongst the three groups. Importantly, early acute T cell mediated rejection was a strong independent predictor for allograft failure in DRTx/suboptimal histology (adjusted HR: 2.13, P = 0.005) but not in DRTx/optimal histology nor in LRTx. Our data highlight an increased baseline immunogenicity in DRTx/suboptimal histology compared to LRTx but not to DRTx/optimal histology. However, our results suggest that donor chronic histologic changes in DRTx may help transfer such increased baseline immunogenicity into clinically relevant acute rejection episodes that have detrimental effects on allograft survival. These findings may provide a rationale for enhanced immunosuppression in recipients of DRTx with baseline chronic histologic changes to minimize subsequent acute rejection and to prolong allograft survival.
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Affiliation(s)
- Ibrahim Batal
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA.
| | - Geo Serban
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Sumit Mohan
- Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA.,Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Syed A Husain
- Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Elena-Rodica Vasilescu
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Russel J Crew
- Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Geoffrey Dube
- Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - P Rodrigo Sandoval
- Surgery, Division of Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Shana M Coley
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dominick Santoriello
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael B Stokes
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Vivette D D'Agati
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - David J Cohen
- Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Glen Markowitz
- Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mark A Hardy
- Surgery, Division of Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Lloyd E Ratner
- Surgery, Division of Transplantation, Columbia University Irving Medical Center, New York, NY, USA
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24
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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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25
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Mühle R, Markgraf W, Hilsmann A, Malberg H, Eisert P, Wisotzky EL. Comparison of different spectral cameras for image-guided organ transplantation. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-210076RR. [PMID: 34304399 PMCID: PMC8305772 DOI: 10.1117/1.jbo.26.7.076007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/24/2021] [Indexed: 06/13/2023]
Abstract
SIGNIFICANCE Hyperspectral and multispectral imaging (HMSI) in medical applications provides information about the physiology, morphology, and composition of tissues and organs. The use of these technologies enables the evaluation of biological objects and can potentially be applied as an objective assessment tool for medical professionals. AIM Our study investigates HMSI systems for their usability in medical applications. APPROACH Four HMSI systems (one hyperspectral pushbroom camera and three multispectral snapshot cameras) were examined and a spectrometer was used as a reference system, which was initially validated with a standardized color chart. The spectral accuracy of the cameras reproducing chemical properties of different biological objects (porcine blood, physiological porcine tissue, and pathological porcine tissue) was analyzed using the Pearson correlation coefficient. RESULTS All the HMSI cameras examined were able to provide the characteristic spectral properties of blood and tissues. A pushbroom camera and two snapshot systems achieve Pearson coefficients of at least 0.97 compared to the ground truth, indicating a very high positive correlation. Only one snapshot camera performs moderately to high positive correlation (0.59 to 0.85). CONCLUSION The knowledge of the suitability of HMSI cameras for accurate measurement of chemical properties of biological objects offers a good opportunity for the selection of the optimal imaging tool for specific medical applications, such as organ transplantation.
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Affiliation(s)
- Richard Mühle
- Technische Universität Dresden, Institute of Biomedical Engineering, Dresden, Germany
- Technische Universität Dresden, Department of Neurosurgery, Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - Wenke Markgraf
- Technische Universität Dresden, Institute of Biomedical Engineering, Dresden, Germany
| | - Anna Hilsmann
- Fraunhofer Heinrich-Hertz-Institute, Department of Vision and Imaging Technologies, Berlin, Germany
| | - Hagen Malberg
- Technische Universität Dresden, Institute of Biomedical Engineering, Dresden, Germany
| | - Peter Eisert
- Fraunhofer Heinrich-Hertz-Institute, Department of Vision and Imaging Technologies, Berlin, Germany
- Humboldt Universität zu Berlin, Department of Visual Computing, Berlin, Germany
| | - Eric L. Wisotzky
- Fraunhofer Heinrich-Hertz-Institute, Department of Vision and Imaging Technologies, Berlin, Germany
- Humboldt Universität zu Berlin, Department of Visual Computing, Berlin, Germany
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26
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Husain SA, King KL, Coley S, Natarajan K, Perotte A, Mohan S. Association between procurement biopsy findings and deceased donor kidney outcomes: a paired kidney analysis. Transpl Int 2021; 34:1239-1250. [PMID: 33964036 DOI: 10.1111/tri.13899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/06/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
Unfavourable procurement biopsy findings are the most common reason for deceased donor kidney discard in the United States. We sought to assess the association between biopsy findings and post-transplant outcomes when donor characteristics are accounted for. We used registry data to identify 1566 deceased donors of 3132 transplanted kidneys (2015-2020) with discordant right/left procurement biopsy classification and performed time-to-event analyses to determine the association between optimal histology and hazard of death-censored graft failure or death. We then repeated all analyses using a local cohort of 147 donors of kidney pairs with detailed procurement histology data available (2006-2016). Among transplanted kidney pairs in the national cohort, there were no significant differences in incidence of delayed graft function or primary nonfunction. Time to death-censored graft failure was not significantly different between recipients of optimal versus suboptimal kidneys. Results were similar in analyses using the local cohort. Regarding recipient survival, analysis of the national, but not local, cohort showed optimal kidneys were associated with a lower hazard of death (adjusted HR 0.68, 95% CI 0.52-0.90, P = 0.006). In conclusion, in a large national cohort of deceased donor kidney pairs with discordant right/left procurement biopsy findings, we found no association between histology and death-censored graft survival.
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Affiliation(s)
- Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Shana Coley
- Department of Pathology, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, NY, USA
| | - Karthik Natarajan
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, NY, USA.,The 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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27
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Husain SA, King KL, Mohan S. Left-digit bias and deceased donor kidney utilization. Clin Transplant 2021; 35:e14284. [PMID: 33705569 DOI: 10.1111/ctr.14284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/04/2021] [Indexed: 11/29/2022]
Abstract
Cognitive biases shown to impact medical decision-making include left-digit bias, the tendency to focus on a continuous variable's leftmost digit. We hypothesized that left-digit bias impacts deceased donor kidney utilization through heuristic processing of donor age and creatinine. We used US registry data to identify 87 019 kidneys recovered (2015-2019) and compared the proportion around thresholds for donor age (69 vs. 70 years) and creatinine (1.9 vs. 2.0 mg/dl), then compared the risk of kidney discard. Kidneys from donors aged 70 vs. 69 years were more frequently discarded (77% vs. 65%, p < .001), with higher risk of discard even after adjusting for KDRI (adjusted RR 1.11, 95% CI 1.02-1.21, p = .018). Similarly, kidneys from donors with final creatinine 2.0 vs. 1.9 mg/dl were more frequently discarded (37% vs. 29%, p < .001), with higher risk of discard after adjusting for KDRI (adjusted RR 1.19, 95% CI 1.07-1.33, p = .001). However, no significant left-digit effect was found when examining other donor age (39/40, 49/50, 59/60 years) or creatinine (0.9/1.0, 2.9/3.0 mg/dl) thresholds. The findings suggest a possible left-digit effect affecting kidney utilization at specific thresholds. Additional investigations of the impact of this and other heuristics on organ utilization are needed to identify potential areas for decision-making interventions aimed at reducing kidney discard.
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Affiliation(s)
- S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,The Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Kristen L King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA.,The 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.,The 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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28
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Dabare D, Hodson J, Nath J, Sharif A, Kalia N, Inston N. Macroscopic assessment of the quality of cold perfusion after deceased-donor kidney procurement: A United Kingdom population-based cohort study. Clin Transplant 2021; 35:e14272. [PMID: 33638883 DOI: 10.1111/ctr.14272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 11/29/2022]
Abstract
Concern regarding the quality of cold perfusion (QOP) during macroscopic assessment of procured kidneys is a common reason for discard. In the UK, QOP is routinely graded by both retrieving and implanting teams during back-bench surgery as: 1 (good), 2 (fair), 3 (poor) or 4 (patchy). We evaluated the association of this grading with organ utilization, graft outcomes, and agreement between teams. Data on all deceased-donor kidneys procured between January 2000 and December 2016 were analyzed for discard rates, while association with graft outcomes was studied in single adult transplants. Of 31,167 kidneys procured, 90.6%, 5.7%, 1.7%, and 2.1% were assigned grades 1, 2, 3, and 4, respectively, at retrieval. QOP was an independent risk factor of discard, with the highest rates observed in grade 3 kidneys (41.8%), compared to 6.5% in grade 1 (aOR 7.67, 95% CI 5.44-10.82, p < .001). Grading at retrieval was an independent predictor of delayed graft function (p = .019) and primary non-function (p = .001), but not long-term graft survival (p = .111). Implanting grade was an independent predictor of all three outcomes (p < .001, p < .001, and p = .002, respectively). Consistency of grading between teams was poor (Kappa = 0.179). QOP influences utilization and predicts outcomes, but a standardized and validated scoring system is required.
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Affiliation(s)
- Dilan Dabare
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jay Nath
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Neena Kalia
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Nicholas Inston
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
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29
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Marsh JN, Liu TC, Wilson PC, Swamidass SJ, Gaut JP. Development and Validation of a Deep Learning Model to Quantify Glomerulosclerosis in Kidney Biopsy Specimens. JAMA Netw Open 2021; 4:e2030939. [PMID: 33471115 PMCID: PMC7818108 DOI: 10.1001/jamanetworkopen.2020.30939] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE A chronic shortage of donor kidneys is compounded by a high discard rate, and this rate is directly associated with biopsy specimen evaluation, which shows poor reproducibility among pathologists. A deep learning algorithm for measuring percent global glomerulosclerosis (an important predictor of outcome) on images of kidney biopsy specimens could enable pathologists to more reproducibly and accurately quantify percent global glomerulosclerosis, potentially saving organs that would have been discarded. OBJECTIVE To compare the performances of pathologists with a deep learning model on quantification of percent global glomerulosclerosis in whole-slide images of donor kidney biopsy specimens, and to determine the potential benefit of a deep learning model on organ discard rates. DESIGN, SETTING, AND PARTICIPANTS This prognostic study used whole-slide images acquired from 98 hematoxylin-eosin-stained frozen and 51 permanent donor biopsy specimen sections retrieved from 83 kidneys. Serial annotation by 3 board-certified pathologists served as ground truth for model training and for evaluation. Images of kidney biopsy specimens were obtained from the Washington University database (retrieved between June 2015 and June 2017). Cases were selected randomly from a database of more than 1000 cases to include biopsy specimens representing an equitable distribution within 0% to 5%, 6% to 10%, 11% to 15%, 16% to 20%, and more than 20% global glomerulosclerosis. MAIN OUTCOMES AND MEASURES Correlation coefficient (r) and root-mean-square error (RMSE) with respect to annotations were computed for cross-validated model predictions and on-call pathologists' estimates of percent global glomerulosclerosis when using individual and pooled slide results. Data were analyzed from March 2018 to August 2020. RESULTS The cross-validated model results of section images retrieved from 83 donor kidneys showed higher correlation with annotations (r = 0.916; 95% CI, 0.886-0.939) than on-call pathologists (r = 0.884; 95% CI, 0.825-0.923) that was enhanced when pooling glomeruli counts from multiple levels (r = 0.933; 95% CI, 0.898-0.956). Model prediction error for single levels (RMSE, 5.631; 95% CI, 4.735-6.517) was 14% lower than on-call pathologists (RMSE, 6.523; 95% CI, 5.191-7.783), improving to 22% with multiple levels (RMSE, 5.094; 95% CI, 3.972-6.301). The model decreased the likelihood of unnecessary organ discard by 37% compared with pathologists. CONCLUSIONS AND RELEVANCE The findings of this prognostic study suggest that this deep learning model provided a scalable and robust method to quantify percent global glomerulosclerosis in whole-slide images of donor kidneys. The model performance improved by analyzing multiple levels of a section, surpassing the capacity of pathologists in the time-sensitive setting of examining donor biopsy specimens. The results indicate the potential of a deep learning model to prevent erroneous donor organ discard.
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Affiliation(s)
- Jon N Marsh
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics (I 2 ), Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Ta-Chiang Liu
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Parker C Wilson
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - S Joshua Swamidass
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics (I 2 ), Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joseph P Gaut
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
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30
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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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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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Husain SA, Shah V, Alvarado Verduzco H, King KL, Brennan C, Batal I, Coley SM, Hall IE, Stokes MB, Dube GK, Crew RJ, Perotte A, Natarajan K, Carpenter D, Sandoval PR, Santoriello D, D’Agati V, Cohen DJ, Ratner L, Markowitz G, Mohan S. Impact of Deceased Donor Kidney Procurement Biopsy Technique on Histologic Accuracy. Kidney Int Rep 2020; 5:1906-1913. [PMID: 33163711 PMCID: PMC7609887 DOI: 10.1016/j.ekir.2020.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/27/2020] [Accepted: 08/04/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction The factors that influence deceased donor kidney procurement biopsy reliability are not well established. We examined the impact of biopsy technique and pathologist training on procurement biopsy accuracy. Methods We retrospectively identified all deceased donor kidney-only transplants at our center from 2006 to 2016 with both procurement and reperfusion biopsies performed and information available on procurement biopsy technique and pathologist (n = 392). Biopsies were scored using a previously validated system, classifying “suboptimal” histology as the presence of at least 1 of the following: glomerulosclerosis ≥11%, moderate/severe interstitial fibrosis/tubular atrophy, or moderate/severe vascular disease. We calculated relative risk ratios (RRR) to determine the influence of technique (core vs. wedge) and pathologist (renal vs. nonrenal) on concordance between procurement and reperfusion biopsy histologic classification. Results A total of 171 (44%) procurement biopsies used wedge technique, and 221 (56%) used core technique. Results of only 36 biopsies (9%) were interpreted by renal pathologists. Correlation between procurement and reperfusion glomerulosclerosis was poor for both wedge (r2 = 0.11) and core (r2 = 0.14) biopsies. Overall, 34% of kidneys had discordant classification on procurement versus reperfusion biopsy. Neither biopsy technique nor pathologist training was associated with concordance between procurement and reperfusion histology, but a larger number of sampled glomeruli was associated with a higher likelihood of concordance (adjusted RRR = 1.12 per 10 glomeruli, 95% confidence interval = 1.04−1.22). Conclusions Biopsy technique and pathologist training were not associated with procurement biopsy histologic accuracy in this retrospective study. Prospective trials are needed to determine how to optimize procurement biopsy practices.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Correspondence: S. Ali Husain, Division of Nephrology, Department of Medicine, 622 West 168th Street PH4-124, New York, New York 10032, USA.
| | - Vaqar Shah
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Hector Alvarado Verduzco
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Corey Brennan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Shana M. Coley
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Isaac E. Hall
- Department of Medicine, Division of Nephrology and Hypertension, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - M. Barry Stokes
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Geoffrey K. Dube
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - R. John Crew
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Karthik Natarajan
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Dustin Carpenter
- Department of Surgery, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - P. Rodrigo Sandoval
- Department of Surgery, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Vivette D’Agati
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - David J. Cohen
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Lloyd Ratner
- Department of Surgery, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Glen Markowitz
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Utilization of Donor Kidneys With Acute Kidney Injury in Pediatric Kidney Transplant Recipients. Transplantation 2020; 104:597-602. [PMID: 32238780 DOI: 10.1097/tp.0000000000002827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND An elevated terminal creatinine is frequently used as a reason for organ refusal in pediatric kidney transplantation. There is increasing evidence that adults who receive kidneys from donors with moderate to severe acute kidney injury (AKI) have similar outcomes to recipients who receive kidneys from donors with none to mild AKI. METHODS We used the Scientific Registry of Transplant Recipients to determine how many pediatric kidney transplant recipients developed delayed graft function (DGF) between 2000 and 2010. RESULTS When stratified by the donor terminal creatinine, there was no significant difference in the recipient discharge creatinine or the likelihood of developing DGF. In a logistic regression model, older donor age, male donors, and a longer cold ischemia time but not donor terminal creatinine were independent predictors of DGF. There were very few graft loss events documented in this study. CONCLUSIONS Our results are in agreement with previously published data; a high donor terminal creatinine is not significantly associated with DGF in pediatric renal transplant recipients. Additional studies investigating the risk of rejection and long-term graft function are needed before adopting the practice of accepting kidneys with moderate to severe AKI in pediatric kidney transplant recipients.
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Ayorinde JOO, Hamed M, Goh MA, Summers DM, Dare A, Chen Y, Saeb‐Parsy K. Development of an objective, standardized tool for surgical assessment of deceased donor kidneys: The Cambridge Kidney Assessment Tool. Clin Transplant 2020; 34:e13782. [DOI: 10.1111/ctr.13782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/05/2020] [Accepted: 01/08/2020] [Indexed: 11/26/2022]
Affiliation(s)
- John O. O. Ayorinde
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Mazin Hamed
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Mingzheng Aaron Goh
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Dominic M. Summers
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Anna Dare
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
| | - Yining Chen
- Department of Statistics London School of Economics London UK
| | - Kourosh Saeb‐Parsy
- Department of Surgery Addenbrooke's Hospital University of Cambridge Cambridge UK
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Husain SA, King KL, Batal I, Dube GK, Hall IE, Brennan C, Stokes MB, Crew RJ, Carpenter D, Alvarado Verduzco H, Rosen R, Coley S, Campenot E, Santoriello D, Perotte A, Natarajan K, D'Agati VD, Cohen DJ, Ratner LE, Markowitz G, Mohan S. Reproducibility of Deceased Donor Kidney Procurement Biopsies. Clin J Am Soc Nephrol 2020; 15:257-264. [PMID: 31974289 PMCID: PMC7015101 DOI: 10.2215/cjn.09170819] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/05/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Unfavorable histology on procurement biopsies is the most common reason for deceased donor kidney discard. We sought to assess the reproducibility of procurement biopsy findings. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We compiled a continuous cohort of deceased donor kidneys transplanted at our institution from 1/1/2006 to 12/31/2016 that had at least one procurement biopsy performed, and excluded cases with missing biopsy reports and those used in multiorgan transplants. Suboptimal histology was defined as the presence of advanced sclerosis in greater than or equal to one biopsy compartment (glomeruli, tubules/interstitium, vessels). We calculated κ coefficients to assess agreement in optimal versus suboptimal classification between sequential biopsy reports for kidneys that underwent multiple procurement biopsies and used time-to-event analysis to evaluate the association between first versus second biopsies and patient and allograft survival. RESULTS Of the 1011 kidneys included in our cohort, 606 (60%) had multiple procurement biopsies; 98% had first biopsy performed at another organ procurement organization and their second biopsy performed locally. Categorical agreement was highest for vascular disease (κ=0.17) followed by interstitial fibrosis and tubular atrophy (κ=0.12) and glomerulosclerosis (κ=0.12). Overall histologic agreement (optimal versus suboptimal) was κ=0.15. First biopsy histology had no association with allograft survival in unadjusted or adjusted analyses. However, second biopsy optimal histology was associated with a higher probability of death-censored allograft survival, even after adjusting for donor and recipient factors (adjusted hazard ratio, 0.50; 95% confidence interval, 0.34 to 0.75; P=0.001). CONCLUSIONS Deceased donor kidneys that underwent multiple procurement biopsies often displayed substantial differences in histologic categorization in sequential biopsies, and there was no association between first biopsy findings and post-transplant outcomes.
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Affiliation(s)
- S Ali Husain
- Division of Nephrology, Department of Medicine and .,The Columbia University Renal Epidemiology Group, New York, New York
| | - Kristen L King
- Division of Nephrology, Department of Medicine and.,The Columbia University Renal Epidemiology Group, New York, New York
| | | | | | - Isaac E Hall
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Corey Brennan
- The Columbia University Renal Epidemiology Group, New York, New York.,Kidney and Pancreas Transplant Program, New York Presbyterian Hospital, New York, New York
| | | | - R John Crew
- Division of Nephrology, Department of Medicine and
| | - Dustin Carpenter
- Surgery, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | | | | | | | | | | | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, New York; and
| | - Karthik Natarajan
- Department of Biomedical Informatics, Columbia University, New York, New York; and
| | | | | | - Lloyd E Ratner
- Surgery, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, New York
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine and.,The Columbia University Renal Epidemiology Group, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Locke JE, Sellers MT. Get on with it!-A novel allocation strategy to reduce kidney discards. Am J Transplant 2019; 19:2971-2972. [PMID: 31119845 DOI: 10.1111/ajt.15471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 04/28/2019] [Accepted: 04/28/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Jayme E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, Alabama
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King KL, Husain SA, Mohan S. Geographic Variation in the Availability of Deceased Donor Kidneys per Wait-Listed Candidate in the United States. Kidney Int Rep 2019; 4:1630-1633. [PMID: 31891004 PMCID: PMC6933455 DOI: 10.1016/j.ekir.2019.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 01/30/2023] Open
Affiliation(s)
- Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
- Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
- Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
- Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Brennan C, Husain SA, King KL, Tsapepas D, Ratner LE, Jin Z, Schold JD, Mohan S. A Donor Utilization Index to Assess the Utilization and Discard of Deceased Donor Kidneys Perceived as High Risk. Clin J Am Soc Nephrol 2019; 14:1634-1641. [PMID: 31624140 PMCID: PMC6832051 DOI: 10.2215/cjn.02770319] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/24/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES An increasing number of patients on the waitlist for a kidney transplant indicates a need to effectively utilize as many deceased donor kidneys as possible while ensuring acceptable outcomes. Assessing regional and center-level organ utilization with regards to discard can reveal regional variation in suboptimal deceased donor kidney acceptance patterns stemming from perceptions of risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We created a weighted donor utilization index from a logistic regression model using high-risk donor characteristics and discard rates from 113,640 deceased donor kidneys procured for transplant from 2010 to 2016, and used it to examine deceased donor kidney utilization in 182 adult transplant centers with >15 annual deceased donor kidney transplants. Linear regression and correlation were used to analyze differences in donor utilization indexes. RESULTS The donor utilization index was found to significantly vary by Organ Procurement and Transplantation Network region (P<0.001), revealing geographic trends in kidney utilization. When investigating reasons for this disparity, there was no significant correlation between center volume and donor utilization index, but the percentage of deceased donor kidneys imported from other regions was significantly associated with donor utilization for all centers (rho=0.39; P<0.001). This correlation was found to be particularly strong for region 4 (rho=0.83; P=0.001) and region 9 (rho=0.82; P=0.001). Additionally, 25th percentile time to transplant was weakly associated with the donor utilization index (R 2=0.15; P=0.03). CONCLUSIONS There is marked center-level variation in the use of deceased donor kidneys with less desirable characteristics both within and between regions. Broader utilization was significantly associated with shorter time to transplantation.
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Affiliation(s)
- Corey Brennan
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Department of Transplant Surgery, New York-Presbyterian Hospital, New York, New York
| | - Syed Ali Husain
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Kristen L King
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Demetra Tsapepas
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Department of Transplant Surgery, New York-Presbyterian Hospital, New York, New York
| | - Lloyd E Ratner
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Jesse D Schold
- Department of Quantitative Health Sciences and.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York; .,Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York; and
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Husain SA, King KL, Pastan S, Pazter RE, Cohen DJ, Radhakrishnan J, Mohan S. Association Between Declined Offers of Deceased Donor Kidney Allograft and Outcomes in Kidney Transplant Candidates. JAMA Netw Open 2019; 2:e1910312. [PMID: 31469394 PMCID: PMC6724162 DOI: 10.1001/jamanetworkopen.2019.10312] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE In the United States, substantial disparities in access to kidney transplant exist for wait-listed candidates with end-stage renal disease. The implications of transplant centers' willingness to accept kidney offers for access to transplant and mortality outcomes are unknown. OBJECTIVE To determine the outcomes for wait-listed kidney transplant candidates after the transplant center's refusal of a deceased donor kidney offer. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from the United Network for Organ Sharing Potential Transplant Recipient data set on all deceased donor kidney offers in the United States made between January 1, 2008, and December 31, 2015. The final study cohort included adult patients who were wait-listed for kidney transplant and received at least 1 allograft offer during the study period (N = 280 041). Data analysis was conducted from June 1, 2018, to March 30, 2019. EXPOSURE Candidate state of residence. MAIN OUTCOMES AND MEASURES Waiting list outcome event groups included received deceased donor allograft, received living donor allograft, died while on the waiting list, removed from the waiting list without a transplant, or still on the waiting list at the end of follow-up. RESULTS Among the 280 041 kidney transplant candidates included in the study, the mean (SD) age at wait-listing was 51.1 (13.1) years, and male patients were predominant (171 517 [61.2%]). In this cohort, 81 750 candidates (29.2%) received a deceased donor kidney allograft, 30 870 (11.0%) received a living donor allograft, 25 967 (9.3%) died while on the waiting list, and 59 359 (21.2%) were removed from the waiting list. Overall, 10 candidates with at least 1 previous allograft offer died each day during the study period. Time to first offer was similar for candidates who received deceased donor kidney allograft compared with those who died while waiting (median [interquartile range {IQR}] time, 79 [16-426] days vs 78 [17-401] days, respectively). Deceased donor allograft recipients had a median of 17 offers (IQR, 6-44) over 422 days (IQR, 106-909 days), whereas candidates who died while waiting received a median of 16 offers (IQR, 6-41) over 651 days (IQR, 304-1117 days). Most kidneys (84%) were declined on behalf of at least 1 candidate before being accepted for transplant. As reported by centers, organ or donor quality concerns accounted for 8 416 474 (92.6%) of all declined offers, whereas offers were infrequently refused because of patient-related factors (232 193 [2.6%]), logistical limitations (49 492 [0.5%]), or other concerns. The odds of death after an offer and the median number of offers received prior to death varied considerably by state. CONCLUSIONS AND RELEVANCE This study found that transplant candidates appeared to receive a large number of viable deceased donor kidney offers that were refused on their behalf by transplant centers, potentially exacerbating the detrimental consequences of the organ shortage; increased transparency in organ allocation process and decisions may improve patient-centered care and access to kidney transplant.
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Affiliation(s)
- S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Stephen Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Pazter
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - David J. Cohen
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, 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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Moeckli B, Sun P, Lazeyras F, Morel P, Moll S, Pascual M, Bühler LH. Evaluation of donor kidneys prior to transplantation: an update of current and emerging methods. Transpl Int 2019; 32:459-469. [PMID: 30903673 DOI: 10.1111/tri.13430] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023]
Abstract
The lack of suitable kidney donor organs has led to rising numbers of patients with end stage renal disease waiting for kidney transplantation. Despite decades of clinical experience and research, no evaluation process that can reliably predict the outcome of an organ has yet been established. This review is an overview of current methods and emerging techniques in the field of donor kidney evaluation prior to transplantation. Established techniques like histological evaluation, clinical scores, and machine perfusion systems offer relatively reliable predictions of delayed graft function but are unable to consistently predict graft survival. Emerging techniques including molecular biomarkers, new imaging technologies, and normothermic machine perfusion offer innovative approaches toward a more global evaluation of an organ with better outcome prediction and possibly even identification of targets for therapeutic interventions prior to transplantation. These techniques should be studied in randomized controlled trials to determine whether they can be safely used in routine clinical practice to ultimately reduce the discard rate and improve graft outcomes.
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Affiliation(s)
- Beat Moeckli
- Department of Surgery and Transplantation, Zurich University Hospital, Zurich, Switzerland
| | - Pamela Sun
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - François Lazeyras
- Department of Radiology and Medical Informatics, CIBM, Geneva University Hospital, Geneva, Switzerland
| | - Philippe Morel
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Solange Moll
- Department of Pathology, Geneva University Hospital, Geneva, Switzerland
| | - Manuel Pascual
- Transplantation Center Lausanne, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Léo H Bühler
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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Dube GK, Brennan C, Husain SA, Crew RJ, Chiles MC, Cohen DJ, Mohan S. Outcomes of kidney transplant from deceased donors with acute kidney injury and prolonged cold ischemia time - a retrospective cohort study. Transpl Int 2019; 32:646-657. [DOI: 10.1111/tri.13406] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/03/2019] [Accepted: 01/29/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Geoffrey K. Dube
- Division of Nephrology; Department of Medicine; Columbia University Irving Medical Center; New York NY USA
| | - Corey Brennan
- Division of Nephrology; Department of Medicine; Columbia University Irving Medical Center; New York NY USA
| | - Syed Ali Husain
- Division of Nephrology; Department of Medicine; Columbia University Irving Medical Center; New York NY USA
| | - Russell J. Crew
- Division of Nephrology; Department of Medicine; Columbia University Irving Medical Center; New York NY USA
| | - Mariana C. Chiles
- Division of Nephrology; Department of Medicine; Columbia University Irving Medical Center; New York NY USA
| | - David J. Cohen
- Division of Nephrology; Department of Medicine; Columbia University Irving Medical Center; New York NY USA
| | - Sumit Mohan
- Division of Nephrology; Department of Medicine; Columbia University Irving Medical Center; New York NY USA
- Department of Epidemiology; Columbia University Irving Medical Center; New York NY USA
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42
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Carpenter D, Husain SA, Brennan C, Batal I, Hall IE, Santoriello D, Rosen R, Crew RJ, Campenot E, Dube GK, Radhakrishnan J, Stokes MB, Sandoval PR, D’Agati V, Cohen DJ, Ratner LE, Markowitz G, Mohan S. Procurement Biopsies in the Evaluation of Deceased Donor Kidneys. Clin J Am Soc Nephrol 2018; 13:1876-1885. [PMID: 30361336 PMCID: PMC6302333 DOI: 10.2215/cjn.04150418] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 09/07/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Biopsies taken at deceased donor kidney procurement continue to be cited as a leading reason for discard; however, the reproducibility and prognostic capability of these biopsies are controversial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We compiled a retrospective, single-institution, continuous cohort of deceased donor kidney transplants performed from 2006 to 2009. Procurement biopsy information-percentage of glomerulosclerosis, interstitial fibrosis/tubular atrophy, and vascular disease-was obtained from the national transplant database. Using univariable, multivariable, and time-to-event analyses for death-censored graft survival, we compared procurement frozen section biopsy reports with reperfusion paraffin-embedded biopsies read by trained kidney pathologists (n=270). We also examined agreement for sequential procurement biopsies performed on the same kidney (n=116 kidneys). RESULTS For kidneys on which more than one procurement biopsy was performed (n=116), category agreement was found in only 64% of cases (κ=0.14). For all kidneys (n=270), correlation between procurement and reperfusion biopsies was poor: overall, biopsies were classified into the same category (optimal versus suboptimal) in only 64% of cases (κ=0.25). This discrepancy was most pronounced when categorizing percentage of glomerulosclerosis, which had 63% agreement (κ=0.15). Interstitial fibrosis/tubular atrophy and vascular disease had agreement rates of 82% (κ=0.13) and 80% (κ=0.15), respectively. Ninety-eight (36%) recipients died, and 56 (21%) allografts failed by the end of follow-up. Reperfusion biopsies were more prognostic than procurement biopsies (hazard ratio for graft failure, 2.02; 95% confidence interval, 1.09 to 3.74 versus hazard ratio for graft failure, 1.30; 95% confidence interval, 0.61 to 2.76), with procurement biopsies not significantly associated with graft failure. CONCLUSIONS We found that procurement biopsies are poorly reproducible, do not correlate well with paraffin-embedded reperfusion biopsies, and are not significantly associated with transplant outcomes.
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Affiliation(s)
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- The Columbia University Renal Epidemiology Group, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Corey Brennan
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York; and
| | | | - Isaac E. Hall
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Dominick Santoriello
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Raphael Rosen
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - R. John Crew
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Geoffrey K. Dube
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | | | | | - David J. Cohen
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | | | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- The Columbia University Renal Epidemiology Group, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York; and
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Cooper M, Formica R, Friedewald J, Hirose R, O’Connor K, Mohan S, Schold J, Axelrod D, Pastan S. Report of National Kidney Foundation Consensus Conference to Decrease Kidney Discards. Clin Transplant 2018; 33:e13419. [DOI: 10.1111/ctr.13419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute; Georgetown University; Washington District of Columbia
| | - Richard Formica
- Department of Medicine, Section of Nephrology; Yale School of Medicine; New Haven Connecticut
| | - John Friedewald
- Northwestern University Comprehensive Transplant Center; Chicago Illinois
| | - Ryutaro Hirose
- Department of Surgery; University of California San Francisco; San Francisco California
| | | | - Sumit Mohan
- Division of Nephrology, Department of Medicine; Vagelos College of Physicians & Surgeons, Columbia University; New York New York
- Department of Epidemiology, Mailman School of Public Health; Columbia University; New York New York
| | - Jesse Schold
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland Ohio
| | - David Axelrod
- Department of Surgery; Lahey Hospital and Medical Center; Burlington Massachusetts
| | - Stephen Pastan
- Renal Division, Department of Medicine; Emory University School of Medicine; Atlanta Georgia
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44
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Mannon RB. Delayed Graft Function: The AKI of Kidney Transplantation. Nephron Clin Pract 2018; 140:94-98. [PMID: 30007955 PMCID: PMC6165700 DOI: 10.1159/000491558] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/25/2018] [Indexed: 01/06/2023] Open
Abstract
With the growing wait list of individuals waiting for kidney transplantation, there has been renewed interest in the quality and function of donor organs. In particular, concern about the development of delayed allograft function (DGF) after transplantation continues to lead to the avoidance of donor organs offered to a transplant center. DGF is associated with worse short-and long-term outcomes and associated with higher rejection rates. There are no FDA-approved therapies to mitigate the ischemic injury that occurs. Risk factors include both donor and recipient characteristics, although their prediction is not precise. With new understanding about mechanisms of injury and new focus on the function of the deceased donor, there is opportunity to identify not only novel therapies to improve allograft function but to identify potential biomarkers of DGF. DGF remains a significant factor in impacting kidney transplant outcome, and finding biomarkers will assist in the development and approval of novel agents to ameliorate early and later injury. This mini-review highlights our presentation at the 23rd International Conference on Advances in Critical Care Nephrology and UAB/UCSD O'Brien Center Acute Kidney Injury (AKI) Pre-Meeting.
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45
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Mohan S, Chiles MC, Patzer RE, Pastan SO, Husain SA, Carpenter DJ, Dube GK, Crew RJ, Ratner LE, Cohen DJ. Factors leading to the discard of deceased donor kidneys in the United States. Kidney Int 2018; 94:187-198. [PMID: 29735310 PMCID: PMC6015528 DOI: 10.1016/j.kint.2018.02.016] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 01/31/2018] [Accepted: 02/01/2018] [Indexed: 01/22/2023]
Abstract
The proportion of deceased donor kidneys procured for transplant but subsequently discarded has been growing steadily in the United States, but factors contributing to the rising discard rate remain unclear. To assess the reasons for and probability of organ discard we assembled a cohort of 212,305 deceased donor kidneys recovered for transplant from 2000-2015 in the SRTR registry that included 36,700 kidneys that were discarded. 'Biopsy Findings' (38.2%) was the most commonly reported reason for discard. The median Kidney Donor Risk Index of discarded kidneys was significantly higher than transplanted organs (1.78 vs 1.12), but a large overlap in the quality of discarded and transplanted kidneys was observed. Kidneys of donors who were older, female, Black, obese, diabetic, hypertensive or HCV-positive experienced a significantly increased odds of discard. Kidneys from donors with multiple unfavorable characteristics were more likely to be discarded, whereas unilaterally discarded kidneys had the most desirable donor characteristics and the recipients of their partner kidneys experienced a one-year death-censored graft survival rate over 90%. There was considerable geographic variation in the odds of discard across the United States, which further supports the notion that factors beyond organ quality contributed to kidney discard. Thus, while the discard of a small fraction of organs procured from donors may be inevitable, the discard of potentially transplantable kidneys needs to be avoided. This will require a better understanding of the factors contributing to organ discard in order to remove the disincentives to utilize less-than-ideal organs for transplantation.
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Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA.
| | - Mariana C Chiles
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Dustin J Carpenter
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Geoffrey K Dube
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - R John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - David J Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
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Kadatz M, Gill JS. Compelling Evidence of the Need for Policy Change to Decrease Deceased Donor Kidney Discard in the United States: Waste Not Want Less. Clin J Am Soc Nephrol 2018; 13:13-15. [PMID: 29217538 PMCID: PMC5753327 DOI: 10.2215/cjn.12671117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Matthew Kadatz
- Division of Nephrology, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - John S. Gill
- Division of Nephrology, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
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