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Jaure A, Vastani RT, Teixeira-Pinto A, Ju A, Craig JC, Viecelli AK, Scholes-Robertson N, Josephson MA, Ahn C, Butt Z, Caskey FJ, Dobbels F, Fowler K, Jowsey-Gregoire S, Jha V, Tan JC, Sautenet B, Howell M. Validation of a Core Patient-Reported Outcome Measure for Life Participation in Kidney Transplant Recipients: the SONG Life Participation Instrument. Kidney Int Rep 2024; 9:87-95. [PMID: 38312789 PMCID: PMC10831350 DOI: 10.1016/j.ekir.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Life participation has been established as a critically important core for trials in kidney transplantation. We aimed to validate a patient-reported outcome measure for life participation in kidney transplant recipients. Methods A psychometric evaluation of the Standardized Outcomes in Nephrology life participation (SONG-LP) measure was conducted in adult kidney transplant recipients. The measure includes 4 items of life participation (leisure, family, work, and social) each with a 5-point Likert scale. Each item is scored from 0 (never) to 4 (always) and the summary measure score the average of each item. Results A total of 249 adult kidney transplant recipients from 20 countries participated. The SONG-LP instrument demonstrated internal consistency (Cronbach's α = 0.87; 95% confidence intervals [CI]: 0.83-0.90, baseline) and test-retest reliability over 1 week (intraclass correlation coefficient of 0.62; 95% CI: 0.54-0.70). There was moderate to high correlation (0.65; 95% CI: 0.57-0.72) with the PROMIS Ability to Participate in Social Roles and Activities Short Form 8a that assessed a similar construct, and moderate correlation with measures that assessed related concepts (i.e., EQ5D 0.57; 95% CI: 0.49-0.65), PROMIS Cognitive Functional Abilities Subset Short Form 4a (0.40; 95% CI: 0.29-0.50). Conclusion The SONG-LP instrument is a simple, internally consistent, reliable measure for kidney transplant recipients and correlates with similar measures. Routine incorporation in clinical trials will ensure consistent and appropriate assessment of life participation for informed patient-centered decision-making.
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Affiliation(s)
- Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Rahim T. Vastani
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Angela Ju
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Andrea K. Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Michelle A. Josephson
- Department of Medicine (Section of Nephrology), The University of Chicago, Chicago, Illinois, USA
| | - Curie Ahn
- Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Zeeshan Butt
- Departments of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Phreesia, Inc., Wilmington, Delaware, USA
| | - Fergus J. Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, KU Leuven, Belgium
| | - Kevin Fowler
- The Voice of the Patient, Saint Louis, Missouri, USA
| | | | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Jane C. Tan
- Department of Medicine, Stanford University, Stanford, California, USA
| | | | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
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Kaufmann MB, Tan JC, Chertow GM, Goldhaber-Fiebert JD. Deceased Donor Kidney Transplantation for Older Transplant Candidates: A New Microsimulation Model for Determining Risks and Benefits. Med Decis Making 2023; 43:576-586. [PMID: 37170943 PMCID: PMC10330392 DOI: 10.1177/0272989x231172169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Under the current US kidney allocation system, older candidates receive a disproportionately small share of deceased donor kidneys despite a reserve of potentially usable kidneys that could shorten their wait times. To consider potential health gains from increasing access to kidneys for these candidates, we developed and calibrated a microsimulation model of the transplantation process and long-term outcomes for older deceased donor kidney transplant candidates. METHODS We estimated risk equations for transplant outcomes using the Scientific Registry of Transplant Recipients (SRTR), which contains data on all US transplants (2010-2019). A microsimulation model combined these equations to account for competing events. We calibrated the model to key transplant outcomes and used acceptance sampling, retaining the best-fitting 100 parameter sets. We then examined life expectancy gains from allocating kidneys even of lower quality across patient subgroups defined by age and designated race/ethnicity. RESULTS The best-fitting 100 parameter sets (among 4,000,000 sampled) enabled our model to closely match key transplant outcomes. The model demonstrated clear survival benefits for those who receive a deceased donor kidney, even a lower quality one, compared with remaining on the waitlist where there is a risk of removal. The expected gain in survival from receiving a lower quality donor kidney was consistent gains across age and race/ethnic subgroups. LIMITATIONS Limited available data on socioeconomic factors. CONCLUSIONS Our microsimulation model accurately replicates a range of key kidney transplant outcomes among older candidates and demonstrates that older candidates may derive substantial benefits from transplantation with lower quality kidneys. This model can be used to evaluate policies that have been proposed to address concerns that the current system disincentivizes deceased donor transplants for older patients. HIGHLIGHTS The microsimulation model was consistent with the data after calibration and accurately simulated the transplantation process for older deceased donor kidney transplant candidates.There are clear survival benefits for older transplant candidates who receive deceased donor kidneys, even lower quality ones, compared with remaining on the waitlist.This model can be used to evaluate policies aimed at increasing transplantation among older candidates.
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Affiliation(s)
- Matthew B Kaufmann
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Abstract
Solid organ transplantation is a life-saving treatment for people with end-stage organ disease. Immune-mediated transplant rejection is a common complication that decreases allograft survival. Although immunosuppression is required to prevent rejection, it also increases the risk of infection. Some infections, such as cytomegalovirus and BK virus, can promote inflammatory gene expression that can further tip the balance toward rejection. BK virus and other infections can induce damage that resembles the clinical pathology of rejection, and this complicates accurate diagnosis. Moreover, T cells specific for viral infection can lead to rejection through heterologous immunity to donor antigen directly mediated by antiviral cells. Thus, viral infections and allograft rejection interact in multiple ways that are important to maintain immunologic homeostasis in solid organ transplant recipients. Better insight into this dynamic interplay will help promote long-term transplant survival.
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Affiliation(s)
- Lauren E Higdon
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
| | - Jane C Tan
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
| | - Jonathan S Maltzman
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
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Cheng XS, Liu S, Han J, Stedman MR, Baiocchi M, Tan JC, Chertow GM, Fearon WF. Association of Pretransplant Coronary Heart Disease Testing With Early Kidney Transplant Outcomes. JAMA Intern Med 2023; 183:134-141. [PMID: 36595271 PMCID: PMC9857067 DOI: 10.1001/jamainternmed.2022.6069] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/07/2022] [Indexed: 01/04/2023]
Abstract
Importance Testing for coronary heart disease (CHD) in asymptomatic kidney transplant candidates before transplant is widespread and endorsed by various professional societies, but its association with perioperative outcomes is unclear. Objective To estimate the association of pretransplant CHD testing with rates of death and myocardial infarction (MI). Design, Setting, and Participants This retrospective cohort study included all adult, first-time kidney transplant recipients from January 2000 through December 2014 in the US Renal Data System with at least 1 year of Medicare enrollment before and after transplant. An instrumental variable (IV) analysis was used, with the program-level CHD testing rate in the year of the transplant as the IV. Analyses were stratified by study period, as the rate of CHD testing varied over time. A combination of US Renal Data System variables and Medicare claims was used to ascertain exposure, IV, covariates, and outcomes. Exposures Receipt of nonurgent invasive or noninvasive CHD testing during the 12 months preceding kidney transplant. Main Outcomes and Measures The primary outcome was a composite of death or acute MI within 30 days of after kidney transplant. Results The cohort comprised 79 334 adult, first-time kidney transplant recipients (30 147 women [38%]; 25 387 [21%] Black and 48 394 [61%] White individuals; mean [SD] age of 56 [14] years during 2012 to 2014). The primary outcome occurred in 4604 patients (244 [5.3%]; 120 [2.6%] death, 134 [2.9%] acute MI). During the most recent study period (2012-2014), the CHD testing rate was 56% in patients in the most test-intensive transplant programs (fifth IV quintile) and 24% in patients at the least test-intensive transplant program (first IV quintile, P < .001); this pattern was similar across other study periods. In the main IV analysis, compared with no testing, CHD testing was not associated with a change in the rate of primary outcome (rate difference, 1.9%; 95% CI, 0%-3.5%). The results were similar across study periods, except for 2000 to 2003, during which CHD testing was associated with a higher event rate (rate difference, 6.8%; 95% CI, 1.8%-12.0%). Conclusions and Relevance The results of this cohort study suggest that pretransplant CHD testing was not associated with a reduction in early posttransplant death or acute MI. The study findings potentially challenge the ubiquity of CHD testing before kidney transplant and should be confirmed in interventional studies.
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Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Margaret R. Stedman
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Michael Baiocchi
- Department of Statistics, Stanford University, Stanford, California
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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Cheng XS, Han J, Braggs-Gresham JL, Held PJ, Busque S, Roberts JP, Tan JC, Scandling JD, Chertow GM, Dor A. Trends in Cost Attributable to Kidney Transplantation Evaluation and Waiting List Management in the United States, 2012-2017. JAMA Netw Open 2022; 5:e221847. [PMID: 35267033 PMCID: PMC8914579 DOI: 10.1001/jamanetworkopen.2022.1847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE While recent policy reforms aim to improve access to kidney transplantation for patients with end-stage kidney disease, the cost implications of kidney waiting list expansion are not well understood. The Organ Acquisition Cost Center (OACC) is the mechanism by which Medicare reimburses kidney transplantation programs, at cost, for costs attributable to kidney transplantation evaluation and waiting list management, but these costs have not been well described to date. OBJECTIVES To describe temporal trends in mean OACC costs per kidney transplantation and to identify factors most associated with cost. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation included all kidney transplantation waiting list candidates and recipients in the United States from 2012 to 2017. A population-based study of cost center reports was conducted using data from all Center of Medicare & Medicaid-certified transplantation hospitals. Data analysis was conducted from June to August 2021. EXPOSURES Year, local price index, transplantation and waiting list volume of transplantation program, and comorbidity burden. MAIN OUTCOMES AND MEASURES Mean OACC costs per kidney transplantation. RESULTS In 1335 hospital-years from 2012 through 2017, Medicare's share of OACC costs increased from $0.95 billion in 2012 to $1.32 billion in 2017 (3.7% of total Medicare End-Stage Renal Disease program expenditure). Median (IQR) OACC costs per transplantation increased from $81 000 ($66 000 to $103 000) in 2012 to $100 000 ($82 000 to $125 000) in 2017. Kidney organ procurement costs contributed to 36% of mean OACC costs per transplantation throughout the study period. During the study period, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, kidney transplantation volume, and comorbidity burden. For a median-sized transplantation program, mean OACC costs per transplantation decreased with more transplants (-$3500 [95% CI, -$4300 to -$2700] per 10 transplants; P < .001) and increased with year ($4400 [95% CI, $3500 to $5300] per year; P < .001), local price index ($1900 [95% CI, $200 to $3700] per 10-point increase; P = .03), patients listed active on the waiting list ($3100 [95% CI, $1700 to $4600] per 100 patients; P < .001), and patients on the waiting list with high comorbidities ($1500 [9% CI, $600 to $2500] per 1% increase in proportion of waitlisted patients with the highest comorbidity score; P = .002). CONCLUSIONS AND RELEVANCE In this study, OACC costs increased at 4% per year from 2012 to 2017 and were not solely attributable to the cost of organ procurement. Expanding the waiting list will likely contribute to further increases in the mean OACC costs per transplantation and substantially increase Medicare liability.
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Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | - Philip J. Held
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Stephan Busque
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - John P. Roberts
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - John D. Scandling
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Avi Dor
- George Washington University, Milken Institute School of Public Health, Washington, DC
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6
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Cheng XS, Liu S, Han J, Stedman MR, Chertow GM, Tan JC, Fearon WF. Trends in Coronary Artery Disease Screening before Kidney Transplantation. Kidney360 2021; 3:516-523. [PMID: 35582172 PMCID: PMC9034804 DOI: 10.34067/kid.0005282021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/09/2021] [Indexed: 01/10/2023]
Abstract
Background Coronary artery disease (CAD) screening in asymptomatic kidney transplant candidates is widespread but not well supported by contemporary cardiology literature. In this study we describe temporal trends in CAD screening before kidney transplant in the United States. Methods Using the United States Renal Data System, we examined Medicare-insured adults who received a first kidney transplant from 2000 through 2015. We stratified analysis on the basis of whether the patient's comorbidity burden met guideline definitions of high risk for CAD. We examined temporal trends in nonurgent CAD tests within the year before transplant and the composite of death and nonfatal myocardial infarction in the 30 days after transplant. Results Of 94,832 kidney transplant recipients, 37,139 (39%) underwent at least one nonurgent CAD test in the 1 year before transplant. From 2000 to 2015, the transplant program waitlist volume had increased as transplant volume stayed constant, whereas patients in the later eras had a slightly higher comorbidity burden (older, longer dialysis vintage, and a higher prevalence of diabetes mellitus and CAD). The likelihood of CAD test in the year before transplant increased from 2000 through 2003 and remained relatively stable thereafter. When stratified by CAD risk status, test rates decreased modestly in patients who were high risk but remained constant in patients who were low risk after 2008. Death or nonfatal myocardial infarction within 30 days after transplant decreased from 3% in 2000 to 2% in 2015. Nuclear perfusion scan was the most frequent modality of testing throughout the examined time periods. Conclusions CAD testing rates before kidney transplantation have remained constant from 2000 through 2015, despite widespread changes in cardiology guidelines and practice.
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Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Jialin Han
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Margaret R. Stedman
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Jane C. Tan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - William F. Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
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7
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Krissberg JR, Kaufmann MB, Gupta A, Bendavid E, Stedman M, Cheng XS, Tan JC, Grimm PC, Chaudhuri A. Racial Disparities in Pediatric Kidney Transplantation under the New Kidney Allocation System in the United States. Clin J Am Soc Nephrol 2021; 16:1862-1871. [PMID: 34670797 PMCID: PMC8729489 DOI: 10.2215/cjn.06740521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES In December 2014, the Kidney Allocation System (KAS) was implemented to improve equity in access to transplantation, but preliminary studies in children show mixed results. Thus, we aimed to assess how the 2014 KAS policy change affected racial and ethnic disparities in pediatric kidney transplantation access and related outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study of children <18 years of age active on the kidney transplant list from 2008 to 2019 using the Scientific Registry of Transplant Recipients. Log-logistic accelerated failure time models were used to determine the time from first activation on the transplant list and the time on dialysis to deceased donor transplant, each with KAS era or race and ethnicity as the exposure of interest. We used logistic regression to assess odds of delayed graft function. Log-rank tests assessed time to graft loss within racial and ethnic groups across KAS eras. RESULTS All children experienced longer wait times from activation to transplantation post-KAS. In univariable analysis, Black and Hispanic children and other children of color experienced longer times from activation to transplant compared with White children in both eras; this finding was largely attenuated after multivariable analysis (time ratio, 1.16; 95% confidence interval, 1.01 to 1.32; time ratio, 1.13; 95% confidence interval, 1.00 to 1.28; and time ratio, 1.17; 95% confidence interval, 0.96 to 1.41 post-KAS, respectively). Multivariable analysis also showed that racial and ethnic disparities in time from dialysis initiation to transplantation in the pre-KAS era were mitigated in the post-KAS era. There were no disparities in odds of delayed graft function. Black and Hispanic children experienced longer times with a functioning graft in the post-KAS era. CONCLUSIONS No racial and ethnic disparities from activation to deceased donor transplantation were seen before or after implementation of the KAS in multivariable analysis, whereas time on dialysis to transplantation and odds of short-term graft loss improved in equity after the implementation of the KAS, without compromising disparities in delayed graft function. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_07_CJN06740521.mp3.
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Affiliation(s)
- Jill R. Krissberg
- Department of Pediatrics, Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Department of Nephrology, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Matthew B. Kaufmann
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Anshal Gupta
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Eran Bendavid
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Margaret Stedman
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Xingxing S. Cheng
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jane C. Tan
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Paul C. Grimm
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Abanti Chaudhuri
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, California
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8
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Cheng XS, Held PJ, Dor A, Bragg-Gresham JL, Tan JC, Scandling JD, Chertow GM, Roberts JP. The organ procurement costs of expanding deceased donor organ acceptance criteria: Evidence from a cost function model. Am J Transplant 2021; 21:3694-3703. [PMID: 33884757 DOI: 10.1111/ajt.16617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/25/2021] [Accepted: 04/14/2021] [Indexed: 01/25/2023]
Abstract
A potential solution to the deceased donor organ shortage is to expand donor acceptability criteria. The procurement cost implications of using nonstandard donors is unknown. Using 5 years of US organ procurement organization (OPO) data, we built a cost function model to make cost projections: the total cost was the dependent variable; production outputs, including the number of donors and organs procured, were the independent variables. In the model, procuring one kidney or procuring both kidneys from double/en bloc transplantation from a single-organ donor resulted in a marginal cost of $55 k (95% confidence interval [CI] $28 k, $99 k) per kidney, and procuring only the liver from a single-organ donor results in a marginal cost of $41 k (95% CI $12 k, $69 k) per liver. Procuring two kidneys for two candidates from a donor lowered the marginal cost to $36 k (95% CI $22 k, $66 k) per kidney, and procuring two kidneys and a liver lowers the marginal cost to $24 k (95% CI $17 k, $45 k) per organ. Economies of scale were observed, where high OPO volume was correlated with lower costs. Despite higher cost per organ than for standard donors, kidney transplantation from nonstandard donors remained cost-effective based on contemporary US data.
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Affiliation(s)
- Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Philip J Held
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Avi Dor
- Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | | | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - John D Scandling
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - John P Roberts
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, California
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9
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Higdon LE, Schaffert S, Cohen RH, Montez-Rath ME, Lucia M, Saligrama N, Margulies KB, Martinez OM, Tan JC, Davis MM, Khatri P, Maltzman JS. Functional Consequences of Memory Inflation after Solid Organ Transplantation. J Immunol 2021; 207:2086-2095. [PMID: 34551963 DOI: 10.4049/jimmunol.2100405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
CMV is a major infectious complication following solid organ transplantation. Reactivation of CMV leads to memory inflation, a process in which CD8 T cells expand over time. Memory inflation is associated with specific changes in T cell function, including increased oligoclonality, decreased cytokine production, and terminal differentiation. To address whether memory inflation during the first year after transplantation in human subjects alters T cell differentiation and function, we employed single-cell-matched TCRαβ and targeted gene expression sequencing. Expanded T cell clones exhibited a terminally differentiated, immunosenescent, and polyfunctional phenotype whereas rare clones were less differentiated. Clonal expansion occurring between pre- and 3 mo posttransplant was accompanied by enhancement of polyfunctionality. In contrast, polyfunctionality and differentiation state were largely maintained between 3 and 12 mo posttransplant. Highly expanded clones had a higher degree of polyfunctionality than rare clones. Thus, CMV-responsive CD8 T cells differentiated during the pre- to posttransplant period then maintained their differentiation state and functional capacity despite posttransplant clonal expansion.
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Affiliation(s)
- Lauren E Higdon
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
| | - Steven Schaffert
- Institute for Immunity, Transplantation and Infection, Stanford University, Stanford, CA.,Department of Medicine/Biomedical Informatics, Stanford University, Stanford, CA; and
| | - Rachel H Cohen
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
| | | | - Marc Lucia
- Department of Surgery, Stanford University, Stanford, CA
| | - Naresha Saligrama
- Department of Microbiology and Immunology, Stanford University, Stanford CA
| | - Kenneth B Margulies
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Jane C Tan
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
| | - Mark M Davis
- Institute for Immunity, Transplantation and Infection, Stanford University, Stanford, CA.,Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA; and
| | - Purvesh Khatri
- Institute for Immunity, Transplantation and Infection, Stanford University, Stanford, CA.,Department of Medicine/Biomedical Informatics, Stanford University, Stanford, CA; and
| | - Jonathan S Maltzman
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA; .,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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10
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Myers J, Chan KN, Chen Y, Lit Y, Massaband P, Kiratli BJ, Tan JC, Rabkin R. Association of physical function and performance with peak VO 2 in elderly patients with end stage kidney disease. Aging Clin Exp Res 2021; 33:2797-2806. [PMID: 33686542 DOI: 10.1007/s40520-021-01801-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Physical function is impaired in end stage renal disease (ESRD). Various instruments have been used to assess the functional capabilities and health status of patients with ESRD, but it is not known which has the best association with peak VO2. AIMS To assess the association between functional measures in ESRD. METHODS Thirty nine elderly ESRD patients were evaluated with commonly used functional, health status, and quality of life measures, including maximal cardiopulmonary exercise testing (CPET), 6-min walk (6MWT), sit-to-stand test (STS), Veterans Specific Activity Questionnaire (VSAQ), upper and lower body strength, pulmonary function tests, and body composition determined by dual X-ray absorptiometry. The association between performance on these functional tools, clinical variables, and exercise test responses was assessed, and a non-exercise test multivariate model was developed to predict peak VO2. RESULTS Peak VO2 was modestly related to VSAQ score (r = 0.59, p < 0.01), indices of upper and lower body strength (r = 0.45, p < 0.01 for both), and FEV1 (r = 0.51, p < 0.01). Functional and quality of life questionnaires were generally poorly related to one another and to peak VO2. In a multivariate model, 6MWT performance, forced expiratory volume in 1 s (FEV1), and VSAQ score were the best predictors of peak VO2, yielding a multiple R = 0.82, accounting for 67% of the variance in peak VO2. CONCLUSION Exercise capacity can be reasonably estimated using non-exercise test variables in patients with ESRD, including a symptom questionnaire (VSAQ), 6MWT and FEV1. CLINICAL TRIAL INFORMATION ClinicalTrials.gov identifier: NCT01990495. Registered Nov 21, 2013.
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Affiliation(s)
- Jonathan Myers
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Cardiology 111C, 3801 Miranda Ave, Palo Alto, CA, 94304, USA.
- Cardiology Division, Stanford University, Stanford, CA, USA.
| | - Khin N Chan
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Cardiology 111C, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
- Nephrology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Yu Chen
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Cardiology 111C, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
| | - Yiming Lit
- Nephrology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Nephrology Division, Stanford University, Stanford, CA, USA
| | - Payam Massaband
- Radiology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - B Jenny Kiratli
- Spinal Cord Injury Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ralph Rabkin
- Nephrology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Nephrology Division, Stanford University, Stanford, CA, USA
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11
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Cheungpasitporn W, Lentine KL, Tan JC, Kaufmann M, Caliskan Y, Bunnapradist S, Lam NN, Schnitzler M, Axelrod DA. Immunosuppression Considerations for Older Kidney Transplant Recipients. Curr Transplant Rep 2021; 8:100-110. [PMID: 34211822 PMCID: PMC8244945 DOI: 10.1007/s40472-021-00321-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW While kidney transplantation improves the long-term survival of the majority of patients with end-stage kidney disease (ESKD), age-related immune dysfunction and associated comorbidities make older transplant recipients more susceptible to complications related to immunosuppression. In this review, we discuss appropriate management of immunosuppressive agents in older adults to minimize adverse events, avoid acute rejection, and maximize patient and graft survival. RECENT FINDINGS Physiological changes associated with senescence can impact drug metabolism and increase the risk of posttransplant infection and malignancy. Clinical trials assessing the safety and efficacy of immunosuppressive agents in older adults are lacking. Recent findings from U.S. transplant registry-based studies suggest that risk-adjusted death-censored graft failure is higher among older patients who received antimetabolite avoidance, mammalian target of rapamycin inhibitor (mTORi)-based, and cyclosporine-based regimens. Observational data suggest that risk-adjusted mortality may be increased in older patients who receive mTORi-based and cyclosporine-based regimens but lower in those managed with T-cell induction and maintenance steroid avoidance/withdrawal. SUMMARY Tailored immunosuppression management to improve patient and graft survival in older transplant recipients is an important goal of personalized medicine. Lower intensity immunosuppression, such as steroid-sparing regimens, appear beneficial whereas mTORi- and cyclosporine-based maintenance are associated with greater potential for adverse effects. Prospective clinical trials to assess the safety and efficacy of immunosuppression agents in older recipients are urgently needed.
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12
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Cheng XS, Watford DJ, Arashi H, Stedman MR, Chertow GM, Tan JC, Fearon WF. Performance versus Risk Factor-Based Approaches to Coronary Artery Disease Screening in Waitlisted Kidney Transplant Candidates. Cardiorenal Med 2021; 11:140-150. [PMID: 34034263 DOI: 10.1159/000516158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/22/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Current screening algorithms for coronary artery disease (CAD) before kidney transplantation result in many tests but few interventions. OBJECTIVE The aim of this study was to study the utility of 6-minute walk test (6MWT), an office-based test of cardiorespiratory fitness, for risk stratification in this setting. METHODS We enrolled 360 patients who are near the top of the kidney transplant waitlist at our institution. All patients underwent CAD evaluation irrespective of 6MWT results. We examined the association between 6MWT and time to CAD-related events (defined as cardiac death, revascularization, nonfatal myocardial infarction, and removal from the waitlist for CAD), treating noncardiac death and waitlist removal for non-CAD reasons as competing events. RESULTS The 6MWT-based approach designated approximately 45% of patients as "low risk," whereas a risk factor- or symptom-based approach designated 14 and 81% of patients as "low risk," respectively. The 6MWT-based approach was not significantly associated with CAD-related events within 1 year (subproportional hazard ratio [sHR] 1.00 [0.90-1.11] per 50 m) but was significantly associated with competing events (sHR 0.70 [0.66-0.75] per 50 m). In a companion analysis, removing waitlist status from consideration, 6MWT result was associated with the development of CAD-related events (sHR 0.92 [0.84-1.00] per 50 m). CONCLUSIONS The 6MWT designates fewer patients as high risk and in need of further testing (compared to risk factor-based approaches), but its utility as a pure CAD risk stratification tool is modulated by the background waitlist removal rate. CAD screening before kidney transplant should be tailored according to a patient's actual chance of receiving a transplant.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel J Watford
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Hiroyuki Arashi
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Margaret R Stedman
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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13
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Ahearn P, Johansen KL, Tan JC, McCulloch CE, Grimes BA, Ku E. Sex Disparity in Deceased-Donor Kidney Transplant Access by Cause of Kidney Disease. Clin J Am Soc Nephrol 2021; 16:241-250. [PMID: 33500250 PMCID: PMC7863650 DOI: 10.2215/cjn.09140620] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Women with kidney failure have lower access to kidney transplantation compared with men, but the magnitude of this disparity may not be uniform across all kidney diseases. We hypothesized that the attributed cause of kidney failure may modify the magnitude of the disparities in transplant access by sex. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study of adults who developed kidney failure between 2005 and 2017 according to the United States Renal Data System. We used adjusted Cox models to examine the association between sex and either access to waitlist registration or deceased-donor kidney transplantation, and tested for interaction between sex and the attributed cause of kidney failure using adjusted models. RESULTS Among a total of 1,478,037 patients, 271,111 were registered on the waitlist and 89,574 underwent deceased-donor transplantation. The rate of waitlisting was 6.5 per 100 person-years in women and 8.3 per 100 person-years for men. In adjusted analysis, women had lower access to the waitlist (hazard ratio, 0.89; 95% confidence interval, 0.89 to 0.90) and to deceased-donor transplantation after waitlisting (hazard ratio, 0.96; 95% confidence interval, 0.94 to 0.98). However, there was an interaction between sex and attributed cause of kidney disease in adjusted models (P<0.001). Women with kidney failure due to type 2 diabetes had 27% lower access to the kidney transplant waitlist (hazard ratio, 0.73; 95% confidence interval, 0.72 to 0.74) and 11% lower access to deceased-donor transplantation after waitlisting compared with men (hazard ratio, 0.89; 95% confidence interval, 0.86 to 0.92). In contrast, sex disparities in access to either the waitlist or transplantation were not observed in kidney failure secondary to cystic disease. CONCLUSIONS The disparity in transplant access by sex is not consistent across all causes of kidney failure. Lower deceased-donor transplantation rates in women compared with men are especially notable among patients with kidney failure attributed to diabetes.
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Affiliation(s)
- Patrick Ahearn
- Division of Nephrology, Stanford University, Palo Alto, California
| | - Kirsten L. Johansen
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota,Division of Nephrology, University of Minnesota, Minneapolis, Minnesota
| | - Jane C. Tan
- Division of Nephrology, Stanford University, Palo Alto, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Barbara A. Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Elaine Ku
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California,Division of Nephrology, University of California, San Francisco, California,Division of Pediatric Nephrology, University of California, San Francisco, California
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14
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Cheng XS, Mohanty S, Turner V, Mastrodicasa D, Winther S, Fleischmann D, Tan JC, Fearon WF. Coronary Computed Tomography Angiography in Diagnosing Obstructive Coronary Artery Disease in Patients with Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Cardiorenal Med 2020; 11:44-51. [PMID: 33321489 DOI: 10.1159/000510402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/17/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Coronary computed tomography angiography (CCTA) is emerging as an important noninvasive testing modality for coronary angiography. The performance characteristic of CCTA in patients with advanced kidney disease is unknown. METHODS We performed a systematic review and meta-analysis of studies specifically investigating the sensitivity and specificity of CCTA compared to coronary angiogram as a reference standard in patients with advanced kidney disease, defined as dialysis dependence or nearing kidney transplantation. Two independent investigators assessed studies for inclusion/exclusion, quality, and characteristics, while a third investigator adjudicated. RESULTS We identified 4 studies including a total of 217 patients, of whom 159 were dialysis dependent. Three of the 4 studies had a high risk of bias in patient selection and study flow, while 1 study rated low in all areas of bias. The studies were heterogeneous in their patient selection and CCTA protocol but consistent in their definition of obstructive coronary artery disease. The pooled sensitivity and specificity for CCTA were 0.96 (0.87-0.99) and 0.66 (0.57-0.74), respectively. When we restricted the analysis to dialysis-dependent patients, the pooled sensitivity and specificity for CCTA were 0.99 (0.74-1.00) and 0.67 (0.49-0.82), respectively. CONCLUSIONS Based on limited data, CCTA appears to have comparable sensitivity but lower specificity relative to the non-kidney disease population.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA,
| | - Suman Mohanty
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Valery Turner
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Simon Winther
- Department of Cardiology, Regional Hospital Unit West, Herning, Denmark
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - William F Fearon
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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15
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Watford DJ, Cheng XS, Han J, Stedman MR, Chertow GM, Tan JC. Toward telemedicine-compatible physical functioning assessments in kidney transplant candidates. Clin Transplant 2020; 35:e14173. [PMID: 33247983 PMCID: PMC7906942 DOI: 10.1111/ctr.14173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
Frailty is associated with adverse kidney transplant outcomes and can be assessed by subjective and objective metrics. There is increasing recognition of the value of metrics obtainable remotely. We compared the self‐reported SF‐36 physical functioning subscale score (SF‐36 PF) with in‐person physical performance tests (6‐min walk and sit‐to‐stand) in a prospective cohort of kidney transplant candidates. We assessed each metric's ability to predict time to the composite outcome of waitlist removal or death, censoring at transplant. We built time‐dependent receiver operating characteristic curves and calculated the area under the curve [AUC(t)] at 1 year, using bootstrapping for internal validation. In 199 patients followed for a median of 346 days, 41 reached the composite endpoint. Lower SF‐36 PF scores were associated with higher risk of waitlist removal/death, with every 10‐point decrease corresponding to a 16% increase in risk. All models showed an AUC(t) of 0.83–0.84 that did not contract substantially after internal validation. Among kidney transplant candidates, SF‐36 PF, obtainable remotely, can help to stratify the risk of waitlist removal or death, and may be used as a screening tool for poor physical functioning in ongoing candidate evaluation, particularly where travel, increasing patient volume, or other restrictions challenge in‐person assessment.
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Affiliation(s)
- Daniel J Watford
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Margaret R Stedman
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
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16
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Harhay MN, Rao MK, Woodside KJ, Johansen KL, Lentine KL, Tullius SG, Parsons RF, Alhamad T, Berger J, Cheng XS, Lappin J, Lynch R, Parajuli S, Tan JC, Segev DL, Kaplan B, Kobashigawa J, Dadhania DM, McAdams-DeMarco MA. An overview of frailty in kidney transplantation: measurement, management and future considerations. Nephrol Dial Transplant 2020; 35:1099-1112. [PMID: 32191296 DOI: 10.1093/ndt/gfaa016] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Indexed: 02/07/2023] Open
Abstract
The construct of frailty was first developed in gerontology to help identify older adults with increased vulnerability when confronted with a health stressor. This article is a review of studies in which frailty has been applied to pre- and post-kidney transplantation (KT) populations. Although KT is the optimal treatment for end-stage kidney disease (ESKD), KT candidates often must overcome numerous health challenges associated with ESKD before receiving KT. After KT, the impacts of surgery and immunosuppression represent additional health stressors that disproportionately impact individuals with frailty. Frailty metrics could improve the ability to identify KT candidates and recipients at risk for adverse health outcomes and those who could potentially benefit from interventions to improve their frail status. The Physical Frailty Phenotype (PFP) is the most commonly used frailty metric in ESKD research, and KT recipients who are frail at KT (~20% of recipients) are twice as likely to die as nonfrail recipients. In addition to the PFP, many other metrics are currently used to assess pre- and post-KT vulnerability in research and clinical practice, underscoring the need for a disease-specific frailty metric that can be used to monitor KT candidates and recipients. Although frailty is an independent risk factor for post-transplant adverse outcomes, it is not factored into the current transplant program risk-adjustment equations. Future studies are needed to explore pre- and post-KT interventions to improve or prevent frailty.
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Affiliation(s)
- Meera N Harhay
- Department of Medicine, Division of Nephrology, Drexel University College of Medicine, Philadelphia, PA, USA.,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA.,Tower Health Transplant Institute, Tower Health System, West Reading, PA, USA
| | - Maya K Rao
- Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | | | | | - Krista L Lentine
- Center for Abdominal Transplantation, St Louis University School of Medicine, St Louis, MO, USA
| | - Stefan G Tullius
- Department of Surgery, Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald F Parsons
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, St Louis, MO, USA
| | - Joseph Berger
- Department of Internal Medicine, Division of Nephrology, UT Southwestern Medical Center, Dallas, TX, USA
| | - XingXing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bruce Kaplan
- Vice President System Office, Baylor Scott and White Health, Temple, TX, USA
| | - Jon Kobashigawa
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Darshana M Dadhania
- Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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17
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Hajhosseini B, Stewart B, Tan JC, Busque S, Melcher ML. Evaluating Deceased Donor Registries: Identifying Predictive Factors of Donor Designation. Am Surg 2020; 79:235-41. [DOI: 10.1177/000313481307900319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The objectives of this study were to evaluate and compare the performance of the deceased donor registries of the 50 states and the District of Columbia and to identify possible predictive factors of donor designation. Data were collected retrospectively by Donate Life America using a questionnaire sent to Donor Designation Collaborative state teams between 2007 and 2010. By the end of 2010, there were 94,669,081 designated donors nationwide. This accounted for 39.8 per cent of the U.S. population aged 18 years and over. The number of designated organ donors and registry-authorized recovered donors increased each year; however, the total number of recovered donors in 2010 was the lowest since 2004. Donor designation rate was significantly higher when license applicants were verbally questioned at the Department of Motor Vehicles (DMV) regarding their willingness to register as a donor and when DMV applicants were not given an option on DMV application forms to contribute money to support organ donation, compared with not being questioned verbally, and being offered an option to contribute money. State registries continue to increase the total number of designated organ donors; however, the current availability of organs remains insufficient to meet the demand. These data suggest that DMV applicants who are approached verbally regarding their willingness to register as a donor and not given an option on DMV application forms to contribute money to support organ donation might be more likely to designate themselves to be a donor.
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Affiliation(s)
- Babak Hajhosseini
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Bryan Stewart
- Donate Life America, Richmond, VA and Donate Life California Board of Directors, San Diego, CA
| | - Jane C. Tan
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Stephan Busque
- Division of Abdominal Transplantation, Stanford University School of Medicine, Stanford, California
| | - Marc L. Melcher
- Division of Abdominal Transplantation, Stanford University School of Medicine, Stanford, California
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18
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Cheng XS, Myers J, Han J, Stedman MR, Watford DJ, Lee J, Discipulo KV, Chan KN, Chertow GM, Tan JC. Physical Performance Testing in Kidney Transplant Candidates at the Top of the Waitlist. Am J Kidney Dis 2020; 76:815-825. [PMID: 32512039 DOI: 10.1053/j.ajkd.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/08/2020] [Indexed: 02/08/2023]
Abstract
RATIONALE & OBJECTIVE Frailty and poor physical function are associated with adverse kidney transplant outcomes, but how to incorporate this knowledge into clinical practice is uncertain. We studied the association between measured physical performance and clinical outcomes among patients on kidney transplant waitlists. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS We studied consecutive patients evaluated in our Transplant Readiness Assessment Clinic, a top-of-the-waitlist management program, from May 2017 through December 2018 (N=305). We incorporated physical performance testing, including the 6-minute walk test (6MWT) and the sit-to-stand (STS) test, into routine clinical assessments. EXPOSURES 6MWT and STS test results. OUTCOMES The primary outcome was time to adverse waitlist outcomes (removal from waitlist or death); secondary outcomes were time to transplantation and time to death. ANALYTICAL APPROACH We used linear regression to examine the relationship between clinical characteristics and physical performance test results. We used subdistribution hazards models to examine the association between physical performance test results and outcomes. RESULTS Median 6MWT and STS results were 393 (IQR, 305-455) m and 17 (IQR, 12-21) repetitions, respectively. Clinical characteristics and Estimated Post-Transplant Survival scores accounted for only 14% to 21% of the variance in 6MWT/STS results. Physical performance test results were associated with adverse waitlist outcomes (adjusted subdistribution hazard ratio [sHR] of 1.42 [95% CI, 1.30-1.56] per 50-m lower 6MWT test result and 1.53 [95% CI, 1.33-1.75] per 5-repetition lower STS test result) and with transplantation (adjusted sHR of 0.80 [95% CI, 0.72-0.88] per 50-m lower 6MWT test result and 0.80 [95% CI, 0.71-0.89] per 5-repetition lower STS test result). Addition of either STS or 6MWT to survival models containing clinical characteristics enhanced fit (likelihood ratio test P<0.001). LIMITATIONS Single-center observational study. Other measures of global health status (eg, Fried Frailty Index or Short Physical Performance Battery) were not examined. CONCLUSIONS Among waitlisted kidney transplant candidates with high kidney allocation scores, standardized and easily performed physical performance test results are associated with waitlist outcomes and contain information beyond what is currently routinely collected in clinical practice.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Jonathan Myers
- Veterans Administration Palo Alto Health Care System/Stanford University, Palo Alto, CA
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Margaret R Stedman
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Daniel J Watford
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Jenny Lee
- Stanford Hospital and Clinics, Palo Alto, CA
| | | | - Khin N Chan
- Veterans Administration Palo Alto Health Care System/Stanford University, Palo Alto, CA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA.
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19
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Cheng XS, Khush KK, Wiseman A, Teuteberg J, Tan JC. To kidney or not to kidney: Applying lessons learned from the simultaneous liver-kidney transplant policy to simultaneous heart-kidney transplantation. Clin Transplant 2020; 34:e13878. [PMID: 32279361 DOI: 10.1111/ctr.13878] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 12/15/2022]
Abstract
As the medical community is increasingly offering transplantation to patients with increasing comorbidity burdens, the number of simultaneous heart-kidney (SHK) transplants is rising in the United States. How to determine eligibility for SHK transplant versus heart transplant alone is unknown. In this review, we situate this problem in the broader picture of organ shortage. We critically appraise available literature on outcomes in SHK versus heart transplant alone. We posit staged kidney-after-heart transplantation as a plausible alternative to SHK transplantation and review the pros and cons. Drawing lessons from the field of simultaneous liver-kidney transplant, we argue for an analogous policy for SHK transplant with standardized minimal eligibility criteria and a modified Safety Net provision. The new policy will serve as a starting point for comparing simultaneous versus staged approaches and refining the medical eligibility criteria for SHK.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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20
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Tan SK, Huang C, Sahoo MK, Weber J, Kurzer J, Stedman MR, Concepcion W, Gallo AE, Alonso D, Srinivas T, Storch GA, Subramanian AK, Tan JC, Pinsky BA. Impact of Pretransplant Donor BK Viruria in Kidney Transplant Recipients. J Infect Dis 2020; 220:370-376. [PMID: 30869132 DOI: 10.1093/infdis/jiz114] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/12/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND BK virus (BKV) is a significant cause of nephropathy in kidney transplantation. The goal of this study was to characterize the course and source of BKV in kidney transplant recipients. METHODS We prospectively collected pretransplant plasma and urine samples from living and deceased kidney donors and performed BKV polymerase chain reaction (PCR) and immunoglobulin G (IgG) testing on pretransplant and serially collected posttransplant samples in kidney transplant recipients. RESULTS Among deceased donors, 8.1% (17/208) had detectable BKV DNA in urine prior to organ procurement. BK viruria was observed in 15.4% (6/39) of living donors and 8.5% (4/47) of deceased donors of recipients at our institution (P = .50). BKV VP1 sequencing revealed identical virus between donor-recipient pairs to suggest donor transmission of virus. Recipients of BK viruric donors were more likely to develop BK viruria (66.6% vs 7.8%; P < .001) and viremia (66.6% vs 8.9%; P < .001) with a shorter time to onset (log-rank test, P < .001). Though donor BKV IgG titers were higher in recipients who developed BK viremia, pretransplant donor, recipient, and combined donor/recipient serology status was not associated with BK viremia (P = .31, P = .75, and P = .51, respectively). CONCLUSIONS Donor BK viruria is associated with early BK viruria and viremia in kidney transplant recipients. BKV PCR testing of donor urine may be useful in identifying recipients at risk for BKV complications.
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Affiliation(s)
- Susanna K Tan
- Division of Infectious Diseases, Department of Medicine, California
| | - Chunhong Huang
- Department of Pathology, Department of Medicine, California
| | - Malaya K Sahoo
- Department of Pathology, Department of Medicine, California
| | - Jenna Weber
- Department of Pathology, Department of Medicine, California
| | - Jason Kurzer
- Department of Pathology, Department of Medicine, California
| | | | - Waldo Concepcion
- Department of Transplant Surgery, Stanford University School of Medicine, California
| | - Amy E Gallo
- Department of Transplant Surgery, Stanford University School of Medicine, California
| | - Diane Alonso
- Department of General Surgery, Intermountain Healthcare, Salt Lake City, Utah
| | - Titte Srinivas
- Division of Nephrology, Department of Medicine, Intermountain Healthcare, Salt Lake City, Utah
| | - Gregory A Storch
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St Louis, Missouri
| | | | - Jane C Tan
- Division of Nephrology, Department of Medicine, California
| | - Benjamin A Pinsky
- Division of Infectious Diseases, Department of Medicine, California.,Department of Pathology, Department of Medicine, California
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21
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McAdams-DeMarco MA, Van Pilsum Rasmussen SE, Chu NM, Agoons D, Parsons RF, Alhamad T, Johansen KL, Tullius SG, Lynch R, Harhay MN, Rao MK, Berger J, Cooper M, Tan JC, Cheng XS, Woodside KJ, Parajuli S, Lentine KL, Kaplan B, Segev DL, Kobashigawa JA, Dadhania D. Perceptions and Practices Regarding Frailty in Kidney Transplantation: Results of a National Survey. Transplantation 2020; 104:349-356. [PMID: 31343576 PMCID: PMC6834867 DOI: 10.1097/tp.0000000000002779] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Given the potential utility of frailty, a clinical phenotype of decreased physiologic reserve and resistance to stressors, to predict postkidney transplant (KT) outcomes, we sought to understand the perceptions and practices regarding frailty measurement in US KT programs. METHODS Surveys were emailed to American Society of Transplantation Kidney/Pancreas Community of Practice members and 202 US transplant programs (November 2017 to April 2018). Program characteristics were gleaned from Scientific Registry of Transplant Recipients. RESULTS The 133 responding programs (response rate = 66%) represented 77% of adult KTs and 79% of adult KT candidates in the United States. Respondents considered frailty to be a useful concept in evaluating candidacy (99%) and endorsed a need to develop a frailty measurement specific to KT (92%). Frailty measurement was more common during candidacy evaluation (69%) than during KT admission (28%). Of the 202 programs, 38% performed frailty assessments in all candidates while 23% performed assessments only for older candidates. There was heterogeneity in the frailty assessment method; 18 different tools were utilized to measure frailty. The most common tool was a timed walk test (19%); 67% reported performing >1 tool. Among programs that measure frailty, 53% reported being less likely to list frail patients for KT. CONCLUSIONS Among US KT programs, frailty is recognized as a clinically relevant construct and is commonly measured at evaluation. However, there is considerable heterogeneity in the tools used to measure frailty. Efforts to identify optimal measurement of frailty using either an existing or a novel tool and subsequent standardization of its measurement and application across KT programs should be considered.
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Affiliation(s)
- Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dayawa Agoons
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald F Parsons
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, MO
| | | | - Stefan G Tullius
- Department of Surgery, Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Meera N Harhay
- Department of Medicine, Division of Nephrology, Drexel University College of Medicine, Philadelphia, PA
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA
| | - Maya K Rao
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Joseph Berger
- Division of Nephrology, University of Texas Southwestern Medical School, Dallas, TX
| | - Matthew Cooper
- Department of Surgery, Georgetown University School of Medicine, Washington, DC
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA
| | - XingXing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA
| | - Kenneth J Woodside
- Department of Surgery, Medical School, University of Michigan, Ann Arbor, MI
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jon A Kobashigawa
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Darshana Dadhania
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY
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22
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Ju A, Chow BY, Ralph AF, Howell M, Josephson MA, Ahn C, Butt Z, Dobbels F, Fowler K, Jowsey-Gregoire S, Jha V, Locke JE, Tan JC, Taylor Q, Rutherford C, Craig JC, Tong A. Patient-reported outcome measures for life participation in kidney transplantation: A systematic review. Am J Transplant 2019; 19:2306-2317. [PMID: 30664327 DOI: 10.1111/ajt.15267] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/07/2019] [Accepted: 01/13/2019] [Indexed: 01/25/2023]
Abstract
For many patients with end-stage kidney disease, transplantation improves survival and quality of life compared with dialysis. However, complications and side effects in kidney transplant recipients can limit their ability to participate in activities of daily living including work, study, and recreational activities. The aim of this study was to identify the characteristics, content, and psychometric properties of the outcome measures used to assess life participation in kidney transplant recipients. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018 for all studies that reported life participation in kidney transplant recipients. Two authors identified instruments measuring life participation and reviewed for characteristics. In total, 230 studies were included: 19 (8%) randomized trials, 17 (7%) nonrandomized trials, and 194 (85%) observational studies. Across these studies, we identified 29 different measures that were used to assess life participation. Twelve (41%) measures specifically assessed aspects of life participation (eg, disability assessment, daily activities of living), while 17 (59%) assessed other constructs (eg, quality of life) that included questions on life participation. Validation data to support the use of these measures in kidney transplant recipients were available for only 7 measures. A wide range of measures have been used to assess life participation in kidney transplant recipients, but validation data supporting the use of these measures in this population are sparse. A content relevant and validated measure to improve the consistency and accuracy of measuring life participation in research may inform strategies for transplant recipients to be better able to engage in their life activities.
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Affiliation(s)
- Angela Ju
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Bi Yang Chow
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Angelique F Ralph
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | | | - Curie Ahn
- Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Zeeshan Butt
- Departments of Medical Social Sciences and Surgery (Division of Organ Transplantation), Northwestern University, Chicago, Illinois
| | | | - Kevin Fowler
- Kidney Health Initiative, Patient Family Partnership Council, The Voice of the Patient, Elmhurst, Illinois
| | | | | | - Jayme E Locke
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Jane C Tan
- Department of Medicine, Stanford University, Stanford, California
| | | | - Claudia Rutherford
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia.,Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
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23
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Cheng XS, Lentine KL, Koraishy FM, Myers J, Tan JC. Correction to: Implications of Frailty for Peritransplant Outcomes in Kidney Transplant Recipient. Curr Transpl Rep 2019. [DOI: 10.1007/s40472-019-00245-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Itakura T, Webster A, Chintala SK, Wang Y, Gonzalez JM, Tan JC, Vranka JA, Acott T, Craft CM, Sibug Saber ME, Jeong S, Stamer WD, Martemyanov KA, Fini ME. GPR158 in the Visual System: Homeostatic Role in Regulation of Intraocular Pressure. J Ocul Pharmacol Ther 2019; 35:203-215. [PMID: 30855200 DOI: 10.1089/jop.2018.0135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose: GPR158 is a newly characterized family C G-protein-coupled receptor, previously identified in functional screens linked with biological stress, including one for susceptibility to ocular hypertension/glaucoma induced by glucocorticoid stress hormones. In this study, we investigated GPR158 function in the visual system. Methods: Gene expression and protein immunolocalization analyses were performed in mouse and human brain and eye to identify tissues where GPR158 might function. Gene expression was perturbed in mice, and in cultures of human trabecular meshwork cells of the aqueous outflow pathway, to investigate function and mechanism. Results: GPR158 is highly expressed in the brain, and in this study, we show prominent expression specifically in the visual center of the cerebral cortex. Expression was also observed in the eye, including photoreceptors, ganglion cells, and trabecular meshwork. Protein was also localized to the outer plexiform layer of the neural retina. Gpr158 deficiency in knockout (KO) mice conferred short-term protection against the intraocular pressure increase that occurred with aging, but this was reversed over time. Most strikingly, the pressure lowering effect of the acute stress hormone, epinephrine, was negated in KO mice. In contrast, no disruption of the electroretinogram was observed. Gene overexpression in cell cultures enhanced cAMP production in response to epinephrine, suggesting a mechanism for intraocular pressure regulation. Overexpression also increased survival of cells subjected to oxidative stress linked to ocular hypertension, associated with TP53 pathway activation. Conclusions: These findings implicate GPR158 as a homeostatic regulator of intraocular pressure and suggest GPR158 could be a pharmacological target for managing ocular hypertension.
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Affiliation(s)
- Tatsuo Itakura
- 1 USC Institute for Genetic Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Andrew Webster
- 1 USC Institute for Genetic Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Shravan K Chintala
- 1 USC Institute for Genetic Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Yuchen Wang
- 2 Department of Neuroscience, The Scripps Research Institute, Jupiter, Florida
| | - Jose M Gonzalez
- 3 Doheny Eye Institute and Department of Ophthalmology, University of California Los Angeles, Los Angeles, California
| | - J C Tan
- 3 Doheny Eye Institute and Department of Ophthalmology, University of California Los Angeles, Los Angeles, California
| | - Janice A Vranka
- 4 Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
| | - Ted Acott
- 4 Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
| | - Cheryl Mae Craft
- 5 USC Roski Eye Institute, Department of Ophthalmology, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.,6 Department of Integrative Anatomical Sciences, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Maria E Sibug Saber
- 7 Department of Pathology, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Shinwu Jeong
- 8 USC Institute for Genetic Medicine, Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - W Daniel Stamer
- 9 Department of Ophthalmology, Duke University, Durham, North Carolina
| | | | - M Elizabeth Fini
- 1 USC Institute for Genetic Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
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25
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Abstract
Purpose of Review Research over the past few decades points to the importance of frailty, or the lack of physiologic reserve, in the natural history of chronic diseases and in modifying the impact of potential interventions. End-stage kidney disease (ESKD) and the intervention of kidney transplantation are no exception. We review the recent epidemiologic and cohort-based evidence on the association between frailty and kidney transplant outcomes and provide a framework of questions with which to approach future research endeavors and clinical practice. Recent Findings Frailty in kidney transplant candidates can be measured in numerous ways, including descriptive phenotype, description scores, functional testing, and surrogate measures. Regardless of the metric, the presence of frailty is strongly associated with inferior pre- and posttransplant outcomes compared to the absence of frailty. However, some frail patients with ESKD can benefit from transplant over chronic dialysis. Evidence-based approaches for identifying frail ESKD patients who can benefit from transplant over dialysis, with acceptable posttransplant outcomes, are lacking. Interventional trials to improve frailty and physical function before transplant (prehabilitation) and after transplant (rehabilitation) are also lacking. Conclusion Frailty is increasingly recognized as highly relevant to peritransplant outcomes, but more work is needed to: 1) tailor management to the unique needs of frail patients, both pre- and posttransplant; 2) define phenotypes of frail patients who are expected to benefit from transplant over dialysis; and 3) develop interventions to reverse frailty, both pre- and post-transplant.
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Affiliation(s)
- Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University, Stanford CA
| | - Krista L Lentine
- Department of Medicine, Division of Nephrology, Saint Louis University, St. Louis MO
| | - Farrukh M Koraishy
- Department of Medicine, Division of Nephrology, Saint Louis University, St. Louis MO
| | - Jonathan Myers
- Department of Medicine, Division of Cardiology, Palo Alto VA Hospital and Stanford University, Palo Alto CA
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University, Stanford CA
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26
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Taiwo AA, Khush KK, Stedman MR, Zheng Y, Tan JC. Longitudinal changes in kidney function following heart transplantation: Stanford experience. Clin Transplant 2018; 32:e13414. [PMID: 30240515 PMCID: PMC6265058 DOI: 10.1111/ctr.13414] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/08/2018] [Accepted: 09/13/2018] [Indexed: 11/30/2022]
Abstract
Many heart transplant recipients experience declining kidney function following transplantation. We aimed to quantify change in kidney function in heart transplant recipients stratified by pre-transplant kidney function. A total of 230 adult heart transplant recipients between May 1, 2008, and December 31, 2014, were evaluated for up to 5 years post-transplant (median 1 year). Using 19 398 total estimated glomerular filtration rate (eGFR) assessments, we evaluated trends in eGFR in recipients with normal/near-normal (eGFR ≥45 mL/min/1.73 m2 ) vs impaired (eGFR <45 mL/min/1.73 m2 ) kidney function and the likelihood of reaching an eGFR of 20 mL/min/1.73 m2 after heart transplant. Baseline characteristics were similar. Immediately following heart transplant, the impaired pre-transplant kidney function group showed a mean eGFR gain of 9.5 mL/min/1.73 m2 (n = 193) vs a mean decline of 4.9 mL/min/1.73 m2 (n = 37) in the normal/near-normal group. Subsequent rates of eGFR decline were 2.2 mL/min/1.73 m2 /y vs 2.9 mL/min/1.73 m2 /y, respectively. The probability of reaching an eGFR of 20 mL/min/1.73 m2 or less at 1, 5, and 10 years following heart transplant was 1%, 4%, and 30% in the impaired group, and <1%, <1%, and 10% in the normal/near-normal group. Estimates of expected recovery in kidney function and its decline over time will help inform decision making about kidney care after heart transplantation.
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Affiliation(s)
- Adetokunbo A Taiwo
- Division of Nephrology, Stanford Hospital & Clinics, Palo Alto, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford Hospital & Clinics, Palo Alto, California
| | - Margaret R Stedman
- Division of Nephrology, Stanford Hospital & Clinics, Palo Alto, California
| | - Yuanchao Zheng
- Division of Nephrology, Stanford Hospital & Clinics, Palo Alto, California
| | - Jane C Tan
- Division of Nephrology, Stanford Hospital & Clinics, Palo Alto, California
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27
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Cheng XS, Busque S, Lee J, Discipulo K, Hartley C, Tulu Z, Scandling JD, Tan JC. A new approach to kidney wait-list management in the kidney allocation system era: Pilot implementation and evaluation. Clin Transplant 2018; 32:e13406. [PMID: 30218580 DOI: 10.1111/ctr.13406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/23/2018] [Accepted: 09/10/2018] [Indexed: 11/29/2022]
Abstract
Kidney transplant wait-list management is becoming increasingly complex. We introduced a novel wait-list management strategy at our center, the Transplant Readiness Assessment Clinic (TRAC), whereby patients whose Kidney Allocation Scores surpass a threshold are actively managed. From January 1, 2016 through June 30, 2017, we evaluated 195 patients through TRAC. Compared to pre-TRAC systems at our institution, TRAC resulted in a higher proportion of activation at 18 months (38% vs 22%-26%, P < 0.0001), despite being enriched in patients with long dialysis duration. TRAC also resulted in a higher proportion of wait-list removal (15% vs 8%-9%, P < 0.05) although combined wait-list removal and death on wait-list did not differ (18% vs 16%-17%). Median time to activation was 356 days from TRAC evaluation. Of the transplant barriers, need for cardiovascular studies was the most common (31%), followed by other medical issues (23%), poor functional status (13%), and psychosocial issues (10%). By concentrating center resources on patients most likely to be transplanted after activation and performing active patient management close to the time of transplant, TRAC has the potential to significantly enhance kidney transplant success in regions with long wait-times.
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Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Stephan Busque
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jenny Lee
- Stanford Hospital and Clinics, Stanford, California
| | | | | | - Zeynep Tulu
- Stanford Hospital and Clinics, Stanford, California
| | - John D Scandling
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
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28
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Tan SK, Cheng XS, Kao CS, Weber J, Pinsky BA, Gill HS, Busque S, Subramanian AK, Tan JC. Native kidney cytomegalovirus nephritis and cytomegalovirus prostatitis in a kidney transplant recipient. Transpl Infect Dis 2018; 21:e12998. [PMID: 30203504 DOI: 10.1111/tid.12998] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/20/2018] [Accepted: 09/02/2018] [Indexed: 01/05/2023]
Abstract
We present a case of cytomegalovirus (CMV) native kidney nephritis and prostatitis in a CMV D+/R- kidney transplant recipient who had completed six months of CMV prophylaxis four weeks prior to the diagnosis of genitourinary CMV disease. The patient had a history of benign prostatic hypertrophy and urinary retention that required self-catheterization to relieve high post-voiding residual volumes. At 7 months post-transplant, he was found to have a urinary tract infection, moderate hydronephrosis of the transplanted kidney, and severe hydroureteronephrosis of the native left kidney and ureter, and underwent native left nephrectomy and transurethral resection of the prostate. Histopathologic examination of kidney and prostate tissue revealed CMV inclusions consistent with invasive CMV disease. This case highlights that CMV may extend beyond the kidney allograft to involve other parts of the genitourinary tract, including the native kidneys and prostate. Furthermore, we highlight the tissue-specific risk factors that preceded CMV tissue invasion. In addition to concurrent diagnoses, health care providers should have a low threshold for considering late-onset CMV disease in high-risk solid organ transplant recipients presenting with signs and symptoms of genitourinary tract pathology.
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Affiliation(s)
- Susanna K Tan
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
| | - Xingxing S Cheng
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Chia-Sui Kao
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Jenna Weber
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Benjamin A Pinsky
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California.,Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Harcharan S Gill
- Department of Urology, Stanford University School of Medicine, Stanford, California
| | - Stephan Busque
- Department of Surgery, Division of Abdominal Transplantation, Stanford University School of Medicine, Stanford, California
| | - Aruna K Subramanian
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
| | - Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
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29
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Li AA, Cholankeril G, Cheng XS, Tan JC, Kim D, Toll AE, Nair S, Ahmed A. Underutilization of Hepatitis C Virus Seropositive Donor Kidneys in the United States in the Current Opioid Epidemic and Direct-Acting Antiviral Era. Diseases 2018; 6:E62. [PMID: 29996536 PMCID: PMC6165210 DOI: 10.3390/diseases6030062] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/05/2018] [Accepted: 07/09/2018] [Indexed: 12/26/2022] Open
Abstract
In recent years, the opioid epidemic and new hepatitis C virus (HCV) treatments have changed the landscape of organ procurement and allocation. We studied national trends in solid organ transplantation (2000⁻2016), focusing on graft utilization from HCV seropositive deceased donors in the pre-2014 (2000⁻2013) versus current (2014⁻2016) eras with a retrospective analysis of the United Network for Organ Sharing database. During the study period, HCV seropositive donors increased from 181 to 661 donors/year. The rate of HCV seropositive donor transplants doubled from 2014 to 2016. Heart and lung transplantation data were too few to analyze. A higher number of HCV seropositive livers were transplanted into HCV seropositive recipients during the current era: 374 versus 124 liver transplants/year. Utilization rates for liver transplantation reached parity between HCV seropositive and non-HCV donors. While the number of HCV seropositive kidneys transplanted to HCV seropositive recipients increased from 165.4 to 334.7 kidneys/year from the pre-2014 era to the current era, utilization rates for kidneys remained lower in HCV seropositive than in non-HCV donors. In conclusion, relative underutilization of kidneys from HCV seropositive versus non-HCV donors has persisted, in contrast to trends in liver transplantation.
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Affiliation(s)
- Andrew A Li
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | - Xingxing S Cheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | - Jane C Tan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | - Alice E Toll
- United Network for Organ Sharing, Richmond, VA 23219, USA.
| | - Satheesh Nair
- Department of Transplant Surgery, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, TN 38104, USA.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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30
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Abstract
Purpose of Review The risks following living kidney donation has been the subject of rigorous investigation in the past several decades. How to utilize the burgeoning new knowledge base to better the risk assessment, education, and health maintenance of donors is unclear. We review the physiologic and epidemiologic evidences on the post-donation state and submit a multiple-hit hypothesis to reconcile the finite elevation in risk of kidney disease after donation with the benign course of most kidney donors. Recent Findings The risk of end-stage kidney disease is higher in kidney donors compared to similarly healthy non-kidney donors. Nonetheless, post-donation kidney disease is uncommon and arises mostly in the setting of other “hits”—either a “first hit” present at birth or a “second hit” acquired later in life. Summary The transplant community’s focus should be directed toward (1) personalized risk assessment to inform consent before donation and (2) preventing and treating development of “second hits” following kidney donation.
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Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Department of Medicine, Stanford University, 750 Welch Road, Suite 200, Mail code 5785, Palo Alto, CA 94304 USA
| | - Richard J. Glassock
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Krista L. Lentine
- Division of Nephrology, Saint Louis University Center for Abdominal Transplantation, Saint Louis, MO USA
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University, 750 Welch Road, Suite 200, Mail code 5785, Palo Alto, CA 94304 USA
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University, 750 Welch Road, Suite 200, Mail code 5785, Palo Alto, CA 94304 USA
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Cheng XS, Myers JN, Chertow GM, Rabkin R, Chan KN, Chen Y, Tan JC. Prehabilitation for kidney transplant candidates: Is it time? Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13020] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology; Department of Medicine; Stanford University; Palo Alto CA USA
| | - Jonathan N. Myers
- Division of Cardiology; Veterans Affairs Palo Alto Health Care System; Palo Alto CA USA
- Research Service; Veterans Administration Health Care System; Palo Alto CA USA
| | - Glenn M. Chertow
- Division of Nephrology; Department of Medicine; Stanford University; Palo Alto CA USA
| | - Ralph Rabkin
- Division of Nephrology; Department of Medicine; Stanford University; Palo Alto CA USA
- Research Service; Veterans Administration Health Care System; Palo Alto CA USA
| | - Khin N. Chan
- Division of Cardiology; Veterans Affairs Palo Alto Health Care System; Palo Alto CA USA
| | - Yu Chen
- Research Service; Veterans Administration Health Care System; Palo Alto CA USA
| | - Jane C. Tan
- Division of Nephrology; Department of Medicine; Stanford University; Palo Alto CA USA
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Cheng XS, Tan JC, Kim WR. Management of renal failure in end-stage liver disease: A critical appraisal. Liver Transpl 2016; 22:1710-1719. [PMID: 27875032 DOI: 10.1002/lt.24609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/09/2016] [Indexed: 01/13/2023]
Abstract
Renal failure is a late consequence of end-stage liver disease (ESLD). Even with liver transplantation, pretransplant renal impairment remains a strong predictor of posttransplant mortality. This review seeks to summarize and critically appraise common therapies used in this setting, including pharmacologic agents, procedures (transjugular intrahepatic portosystemic shunt, renal replacement therapy), and simultaneous liver-kidney transplantation. More experimental extracorporal modalities, eg, albumin dialysis or bioartificial livers, will not be discussed. A brief discussion on the definition and pathophysiologic underpinnings of renal failure in ESLD will be held at the beginning to lay the groundwork for the main section. Liver Transplantation 22 1710-1719 2016 AASLD.
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Affiliation(s)
| | - Jane C Tan
- Division of Nephrology, Stanford University, Palo Alto, CA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
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Abstract
One third of the kidney transplants performed in the USA come from living kidney donors. The long-term outcome of healthy individuals who donate kidneys is mostly excellent, although recent studies have suggested that living donation is associated with a small absolute increase in the risk of end stage renal failure. Much of our understanding about the progression of kidney disease comes from experimental models of nephron loss. For this reason, living kidney donation has long been of great interest to renal physiologists. This review will summarize the determinants of glomerular filtration and the physiology that underlies post-donation hyperfiltration. We describe the 'remnant kidney' model of kidney disease and the reasons why such progressive kidney disease very rarely ensues in healthy humans following uninephrectomy. We also review some of the methods used to determine glomerular number and size and outline their associations.
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Affiliation(s)
- Colin R. Lenihan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Bryan D. Myers
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
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34
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Tan JC, Gordon EJ, Dew MA, LaPointe Rudow D, Steiner RW, Woodle ES, Hays R, Rodrigue JR, Segev DL. Living Donor Kidney Transplantation: Facilitating Education about Live Kidney Donation--Recommendations from a Consensus Conference. Clin J Am Soc Nephrol 2015; 10:1670-7. [PMID: 25908792 DOI: 10.2215/cjn.01030115] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The Best Practice in Live Kidney Donation Consensus Conference held in June of 2014 included the Best Practices in Living Donor Education Workgroup, whose charge was to identify best practice strategies in education of living donors, community outreach initiatives, commercial media, solicitation, and state registries. The workgroup's goal was to identify critical content to include in living kidney donor education and best methods to deliver educational content. A detailed summary of considerations regarding educational content issues for potential living kidney donors is presented, including the consensus that was reached. Educational topics that may require updating on the basis of emerging studies on living kidney donor health outcomes are also presented. Enhancing the educational process is important for increasing living donor comprehension to optimize informed decision-making.
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Affiliation(s)
- Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California;
| | - Elisa J Gordon
- Center for Healthcare Studies and Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dianne LaPointe Rudow
- Recanati Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York
| | - Robert W Steiner
- Department of Medicine, University of California at San Diego, San Diego, California
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca Hays
- Transplant Center, University of Wisconsin Hospital, Madison, Wisconsin
| | - James R Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Rudow DL, Hays R, Baliga P, Cohen DJ, Cooper M, Danovitch GM, Dew MA, Gordon EJ, Mandelbrot DA, McGuire S, Milton J, Moore DR, Morgieivich M, Schold JD, Segev DL, Serur D, Steiner RW, Tan JC, Waterman AD, Zavala EY, Rodrigue JR. Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care. Am J Transplant 2015; 15:914-22. [PMID: 25648884 PMCID: PMC4516059 DOI: 10.1111/ajt.13173] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/07/2014] [Accepted: 12/21/2014] [Indexed: 01/25/2023]
Abstract
Live donor kidney transplantation is the best treatment option for most patients with late-stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. A consensus conference was held June 5-6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation.
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Affiliation(s)
| | - Rebecca Hays
- Transplant Center, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Prabhakar Baliga
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - David J. Cohen
- Department of Medicine, Columbia University Medical Center, New York, NY
| | | | - Gabriel M. Danovitch
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Elisa J. Gordon
- Comprehensive Transplant Center and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Suzanne McGuire
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Jennifer Milton
- Transplant Center, University of Texas at San Antonio, San Antonio, TX
| | - Deonna R. Moore
- Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - Marie Morgieivich
- The Living Donor Institute, Barnabas Health Transplant Division, Livingston, NJ
| | - Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Serur
- Department of Medicine, Cornell University, New York, NY
| | - Robert W. Steiner
- Department of Medicine, University of California at San Diego, San Diego, CA
| | - Jane C. Tan
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Amy D. Waterman
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Edward Y. Zavala
- Transplant Center, Vanderbilt University Medical Center, Nashville, TN
| | - James R. Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Geraci NS, Tan JC, McDowell MA. Characterization of microRNA expression profiles in Leishmania-infected human phagocytes. Parasite Immunol 2015; 37:43-51. [PMID: 25376316 DOI: 10.1111/pim.12156] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 10/29/2014] [Indexed: 12/14/2022]
Abstract
Leishmania are intracellular protozoa that influence host immune responses eliciting parasite species-specific pathologies. MicroRNAs (miRNAs) are short single-stranded ribonucleic acids that complement gene transcripts to block protein translation and have been shown to regulate immune system molecular mechanisms. Human monocyte-derived dendritic cells (DC) and macrophages (MP) were infected in vitro with Leishmania major or Leishmania donovani parasites. Small RNAs were isolated from total RNA and sequenced to identify mature miRNAs associated with leishmanial infections. Normalized sequence read count profiles revealed a global downregulation in miRNA expression among host cells following infection. Most identified miRNAs were expressed at higher levels in L. donovani-infected cells relative to L. major-infected cells. Pathway enrichments using in silico-predicted gene targets of differentially expressed miRNAs showed evidence of potentially universal MAP kinase signalling pathway effects. Whereas JAK-STAT and TGF-β signalling pathways were more highly enriched using targets of miRNAs upregulated in L. donovani-infected cells, these data provide evidence in support of a selective influence on host cell miRNA expression and regulation in response to differential Leishmania infections.
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Affiliation(s)
- N S Geraci
- Department of Biological Sciences, Eck Institute for Global Health, University of Notre Dame, Notre Dame, IN, USA
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Lenihan CR, Busque S, Derby G, Blouch K, Myers BD, Tan JC. Longitudinal study of living kidney donor glomerular dynamics after nephrectomy. J Clin Invest 2015; 125:1311-8. [PMID: 25689253 DOI: 10.1172/jci78885] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/11/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Over 5,000 living kidney donor nephrectomies are performed annually in the US. While the physiological changes that occur early after nephrectomy are well documented, less is known about the long-term glomerular dynamics in living donors. METHODS We enrolled 21 adult living kidney donors to undergo detailed long-term clinical, physiological, and radiological evaluation pre-, early post- (median, 0.8 years), and late post- (median, 6.3 years) donation. A morphometric analysis of glomeruli obtained during nephrectomy was performed in 19 subjects. RESULTS Donors showed parallel increases in single-kidney renal plasma flow (RPF), renocortical volume, and glomerular filtration rate (GFR) early after the procedure, and these changes were sustained through to the late post-donation period. We used mathematical modeling to estimate the glomerular ultrafiltration coefficient (Kf), which also increased early and then remained constant through the late post-donation study. Assuming that the filtration surface area (and hence, Kf) increased in proportion to renocortical volume after donation, we calculated that the 40% elevation in the single-kidney GFR observed after donation could be attributed exclusively to an increase in the Kf. The prevalence of hypertension in donors increased from 14% in the early post-donation period to 57% in the late post-donation period. No subjects exhibited elevated levels of albuminuria. CONCLUSIONS Adaptive hyperfiltration after donor nephrectomy is attributable to hyperperfusion and hypertrophy of the remaining glomeruli. Our findings point away from the development of glomerular hypertension following kidney donation. TRIAL REGISTRATION Not applicable. FUNDING. NIH (R01DK064697 and K23DK087937); Astellas Pharma US; the John M. Sobrato Foundation; the Satellite Extramural Grant Foundation; and the American Society of Nephrology.
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Lenihan CR, Busque S, Derby G, Blouch K, Myers BD, Tan JC. The association of predonation hypertension with glomerular function and number in older living kidney donors. J Am Soc Nephrol 2014; 26:1261-7. [PMID: 25525178 DOI: 10.1681/asn.2014030304] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 09/01/2014] [Indexed: 11/03/2022] Open
Abstract
The effect of preexisting hypertension on living donor nephron number has not been established. In this study, we determined the association between preexisting donor hypertension and glomerular number and volume and assessed the effect of predonation hypertension on postdonation BP, adaptive hyperfiltration, and compensatory glomerular hypertrophy. We enrolled 51 living donors to undergo physiologic, morphometric, and radiologic evaluations before and after kidney donation. To estimate the number of functioning glomeruli (NFG), we divided the whole-kidney ultrafiltration coefficient (Kf) by the single-nephron ultrafiltration coefficient (SNKf). Ten donors were hypertensive before donation. We found that, in donors ages >50 years old, preexisting hypertension was associated with a reduction in NFG. In a comparison of 10 age- and sex-matched hypertensive and normotensive donors, we observed more marked glomerulopenia in hypertensive donors (NFG per kidney, 359,499±128,929 versus 558,239±205,152; P=0.02). Glomerulopenia was associated with a nonsignificant reduction in GFR in the hypertensive group (89±12 versus 95±16 ml/min per 1.73 m(2)). We observed no difference in the corresponding magnitude of postdonation BP, hyperfiltration capacity, or compensatory renocortical hypertrophy between hypertensive and normotensive donors. Nevertheless, we propose that the greater magnitude of glomerulopenia in living kidney donors with preexisting hypertension justifies the need for long-term follow-up studies.
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Affiliation(s)
| | - Stephan Busque
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | | | | | | | - Jane C Tan
- Division of Nephrology, Department of Medicine and
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Abstract
Despite numerous studies that substantiate its long-term safety, barriers to kidney donation persist. These include issues of insurability after donation and its consequent financial and emotional burdens. We present 2 cases in which mislabeling of kidney donors as having chronic kidney disease shortly after kidney donation adversely affected their insurability. A concerted effort should be made to affect public policy such that insurability and the psychosocial well-being of living donors are protected.
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Affiliation(s)
- Colin R Lenihan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA.
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
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Lenihan CR, Lockridge JB, Tan JC. A new clinical prediction tool for 5-year kidney transplant outcome. Am J Kidney Dis 2014; 63:549-51. [PMID: 24670483 DOI: 10.1053/j.ajkd.2014.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 01/08/2014] [Indexed: 12/30/2022]
Affiliation(s)
- Colin R Lenihan
- Stanford University School of Medicine, Palo Alto, California
| | | | - Jane C Tan
- Stanford University School of Medicine, Palo Alto, California.
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Affiliation(s)
- E L Lum
- Department of Medicine, Division of Nephrology, Kidney Transplantation, UCLA David Geffen School of Medicine, Los Angeles, CA
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Lenihan CR, Tan JC, Kambham N. Acute transplant glomerulopathy with monocyte rich infiltrate. Transpl Immunol 2013; 29:114-7. [PMID: 24056179 DOI: 10.1016/j.trim.2013.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 10/26/2022]
Abstract
Acute transplant glomerulopathy refers to alloimmune mediated endothelial injury and glomerular inflammation that typically occurs early post-kidney transplantation. We report a case of a 48-year old woman with end stage renal disease from lupus nephritis who developed an unexplained rise in serum creatinine 2 months after renal transplant. As immunosuppression, she received alemtuzumab induction followed by a tacrolimus, mycophenolate mofetil and prednisone maintenance regimen. Her biopsy revealed severe glomerular endothelial injury associated with monocyte/macrophage-rich infiltrate in addition to mild acute tubulointerstitial cellular rejection. We briefly discuss acute transplant glomerulitis, its pathology and association with chronic/overt transplant glomerulopathy, C4d negative antibody-mediated rejection and the significance of monocytes in rejection. We also postulate that alemtuzumab induction may have contributed to the unusual pattern of monocyte-rich transplant glomerulitis.
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Affiliation(s)
- Colin R Lenihan
- Department of Medicine, Nephrology Division, Stanford University Medical Center, Stanford, CA, United States
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Abstract
BACKGROUND/AIMS The elderly are the fastest growing subpopulation with end-stage renal disease. The goal of our study was to define characteristics of elderly patients who were considered ineligible for transplantation compared to those who were listed. METHODS 984 patients were referred for evaluation during a 2-year period. Records of patients ≥65 years of age (n = 123) were reviewed. Patients who were listed versus not listed were characterized. Factors associated with waitlisting were determined using standard statistical tools. RESULTS Half of elderly transplant candidates were accepted for listing compared to 75.4% of those aged <65 years. In multivariable logistic regression, older age (OR 1.29 per year ≥65, 95% CI 1.14-1.45), coronary artery disease (OR 8.57, 95% CI 2.41-30.53), and poor mobility (OR 13.97, 95% CI 4.76-41.00) were independently associated with denial of listing. The receiver operating characteristic curve showed good discrimination for denial of listing (area under the receiver operating characteristic curve of 0.88). CONCLUSION Elderly candidates carry a heavy burden of comorbidities and over half of those evaluated are deemed unsuitable for waitlisting. Better delineation of characteristics associated with suitability for transplant candidacy in the elderly is warranted to facilitate appropriate referrals by physicians and management of expectations in potential candidates.
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Affiliation(s)
- Colin R Lenihan
- Department of Medicine, Stanford University, Palo Alto, CA 94304, USA.
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Tan JC, Kim JP, Chertow GM, Grumet FC, Desai M. Donor-recipient sex mismatch in kidney transplantation. ACTA ACUST UNITED AC 2012; 9:335-347.e2. [PMID: 22906727 DOI: 10.1016/j.genm.2012.07.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 07/12/2012] [Accepted: 07/16/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The lack of reliable human proxies for minor (ie, non-HLA) histocompatibility loci hampers the ability to leverage these factors toward improving transplant outcomes. Despite conflicting reports of the effect of donor-recipient sex mismatch on renal allografts, the association between acute rejection of renal allografts and the development of human alloantibodies to the male H-Y antigen suggested to us that donor-recipient sex mismatch deserved re-evaluation. OBJECTIVE To evaluate whether the relationships between donor sex and allograft failure differed by recipient sex. METHODS We studied recipients of deceased-donor (n = 125,369) and living-donor (n = 63,139) transplants in the United States Renal Data System. Using Cox proportional hazards models stratified by donor type, we estimated the association between donor-recipient sex mismatch and death-censored allograft failure with adjustment for known risk factors, with and without the use of multiple imputation methods to account for potential bias and/or loss of efficiency due to missing data. RESULTS The advantage afforded by male donor kidneys was more pronounced among male than among female recipients (8% vs 2% relative risk reduction; interaction P < 0.01). This difference is of the order of magnitude of several other risk factors affecting donor selection decisions. CONCLUSIONS Donor-recipient sex mismatch affects renal allograft survival in a direction consistent with immune responses to sexually determined minor histocompatibility antigens. Our study provides a paradigm for clinical detection of markers for minor histocompatibility loci.
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Affiliation(s)
- Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA.
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Munoz Mendoza J, Melcher ML, Daniel B, Tan JC. Multiple renal arteries and non-contrast magnetic resonance angiography in transplant renal artery stenosis. Clin Kidney J 2012; 5:272-5. [PMID: 26069784 PMCID: PMC4400505 DOI: 10.1093/ckj/sfs027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 02/21/2012] [Indexed: 12/04/2022] Open
Affiliation(s)
- Jair Munoz Mendoza
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Marc L Melcher
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Bruce Daniel
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
BACKGROUND Transplanted nephron mass is an important determinant of long-term allograft survival, but accurate assessment before organ retrieval is challenging. Newer radiologic imaging techniques allow for better determination of total kidney and cortical volumes. METHODS Using volume measurements reconstructed from magnetic resonance or computed tomography imaging from living donor candidates, we characterized total kidney (n=312) and cortical volumes (n=236) according to sex, age, weight, height, body mass index (BMI), and body surface area (BSA). RESULTS The mean cortical volume was 204 mL (range 105-355 mL) with no significant differences between left and right cortical volumes. The degree to which existing anthropomorphic surrogates predict nephron mass was quantified, and a diligent attempt was made to derive a better surrogate model for nephron mass. Cortical volumes were strongly associated with sex and BSA, but not with weight, height, or BMI. Four prediction models for cortical volume constructed using combinations of age, sex, race, weight, and height were compared with models including either BSA or BMI. CONCLUSIONS Among existing surrogate measures, BSA was superior to BMI in predicting renal cortical volume. We were able to construct a statistically superior proxy for cortical volume, but whether relevant improvements in predictive accuracy could be gained needs further evaluation in a larger population.
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Affiliation(s)
- Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Abstract
The presence of kidney stones has been a relative contraindication for living donation. With the widespread use of more sensitive imaging techniques as part of the routine living donor workup, kidney stones are more frequently detected, and their clinical significance in this setting is largely unknown. Records from 325 potential kidney donors who underwent MRA or CT-angiography were reviewed; 294 proceeded to donation. The prevalence of kidney stones found incidentally during donor evaluation was 7.4% (24 of 325). Sixteen donors with stones proceeded with kidney donation. All incidental calculi were nonobstructing and small (median 2 mm; range 1-9 mm). Eleven recipients were transplanted with allografts containing stones. One recipient developed symptomatic nephrolithasis after transplantation. This recipient was found to have newly formed stones secondary to hyperoxaluria, suggesting a recipient-driven propensity for stone formation. The remaining ten recipients have stable graft function, postoperative ultrasound negative for nephrolithiasis, and no sequelae from stones. No donor developed symptomatic nephrolithiasis following donation. Judicious use of allografts with small stones in donors with normal metabolic studies may be acceptable, and careful follow-up in recipients of such allografts is warranted.
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Affiliation(s)
- Irene K Kim
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Anand S, Yabu JM, Melcher ML, Kambham N, Laszik Z, Tan JC. Cytomegalovirus in the transplanted kidney: a report of two cases and review of prophylaxis. NDT Plus 2011; 4:342-5. [PMID: 25984184 PMCID: PMC4421734 DOI: 10.1093/ndtplus/sfr074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 05/26/2011] [Indexed: 12/02/2022] Open
Affiliation(s)
- Shuchi Anand
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Julie M Yabu
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Marc L Melcher
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Neeraja Kambham
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zoltan Laszik
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Pereira S, Perkins S, Lee JH, Shumway W, LeFor W, Lopez-Cepero M, Wong C, Connolly A, Tan JC, Grumet FC. Donor-specific antibody against denatured HLA-A1: clinically nonsignificant? Hum Immunol 2011; 72:492-8. [PMID: 21396421 DOI: 10.1016/j.humimm.2011.02.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 02/08/2011] [Accepted: 02/22/2011] [Indexed: 12/17/2022]
Abstract
Pre-transplant screening of a woman with end-stage renal disease (ESRD) showed no anti-human leukocyte antigen (HLA) alloantibodies by anti-human globulin-complement-dependent cytotoxicity (AHG-CDC; class I) or enzyme-linked immunosorbent assay (class II). Following a negative AHG-CDC crossmatch, an HLA*01:01+ deceased donor (DD) kidney was transplanted in September 2005. Subsequent screening of pre-transplant serum by LABScreen Single Antigen (SA) array showed strong reactivity versus A*01:01. Despite that reactivity, at 5 years post-transplant, the patient has a serum creatinine of 1.6 mg/dl and has never experienced humoral or cellular rejection. Retrospective flow-cytometric crossmatch of pre- and post-transplant sera versus DD cells was negative. Rescreening of multiple pre- and post-transplant sera revealed anti-A1 reactivity persisting from the first through the last samples tested. The patient's anti-A1 was almost two fold more reactive with denatured A*01:01 FlowPRA SA beads after denaturation with acid treatment (pH 2.7) than with untreated beads. Parallel results were observed with pH 2.7 treated versus untreated A1+ T cells in FXM. These data highlight the difficulty in interpreting screening results obtained using bead arrays, because of antibodies that appear to recognize denatured but not native class I HLA antigens. We suggest that such bead-positive, flow cytometric crossmatch negative antibodies are not associated with humoral rejection, may not necessarily be detrimental to a graft, and deserve further evaluation before becoming a barrier to transplantation.
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Affiliation(s)
- Shalini Pereira
- Seattle Cancer Care Alliance, Clinical Research Division, Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.
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Affiliation(s)
- Jane C Tan
- Department of Medicine, Division of Nephrology, Stanford University, Calif., USA.
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