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Yi Z, Xi C, Menon MC, Cravedi P, Tedla F, Soto A, Sun Z, Liu K, Zhang J, Wei C, Chen M, Wang W, Veremis B, Garcia-Barros M, Kumar A, Haakinson D, Brody R, Azeloglu EU, Gallon L, O'Connell P, Naesens M, Shapiro R, Colvin RB, Ward S, Salem F, Zhang W. A large-scale retrospective study enabled deep-learning based pathological assessment of frozen procurement kidney biopsies to predict graft loss and guide organ utilization. Kidney Int 2024; 105:281-292. [PMID: 37923131 PMCID: PMC10892475 DOI: 10.1016/j.kint.2023.09.031] [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] [Received: 01/02/2023] [Revised: 09/07/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023]
Abstract
Lesion scores on procurement donor biopsies are commonly used to guide organ utilization for deceased-donor kidneys. However, frozen sections present challenges for histological scoring, leading to inter- and intra-observer variability and inappropriate discard. Therefore, we constructed deep-learning based models to recognize kidney tissue compartments in hematoxylin & eosin-stained sections from procurement needle biopsies performed nationwide in years 2011-2020. To do this, we extracted whole-slide abnormality features from 2431 kidneys and correlated with pathologists' scores and transplant outcomes. A Kidney Donor Quality Score (KDQS) was derived and used in combination with recipient demographic and peri-transplant characteristics to predict graft loss or assist organ utilization. The performance on wedge biopsies was additionally evaluated. Our model identified 96% and 91% of normal/sclerotic glomeruli respectively; 94% of arteries/arterial intimal fibrosis; 90% of tubules. Whole-slide features of Sclerotic Glomeruli (GS)%, Arterial Intimal Fibrosis (AIF)%, and Interstitial Space Abnormality (ISA)% demonstrated strong correlations with corresponding pathologists' scores of all 2431 kidneys, but had superior associations with post-transplant estimated glomerular filtration rates in 2033 and graft loss in 1560 kidneys. The combination of KDQS and other factors predicted one- and four-year graft loss in a discovery set of 520 kidneys and a validation set of 1040 kidneys. By using the composite KDQS of 398 discarded kidneys due to "biopsy findings", we suggest that if transplanted, 110 discarded kidneys could have had similar survival to that of other transplanted kidneys. Thus, our composite KDQS and survival prediction models may facilitate risk stratification and organ utilization while potentially reducing unnecessary organ discard.
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Affiliation(s)
- Zhengzi Yi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Caixia Xi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Madhav C Menon
- Nephrology Division, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Fasika Tedla
- The Recanati/Miller Transplantation Institute (RMTI), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alan Soto
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zeguo Sun
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Keyu Liu
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Jason Zhang
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Chengguo Wei
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Man Chen
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Wenlin Wang
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Brandon Veremis
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Monica Garcia-Barros
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abhishek Kumar
- Nephrology Division, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Danielle Haakinson
- Nephrology Division, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rachel Brody
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evren U Azeloglu
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA
| | - Lorenzo Gallon
- Northwestern Medicine Organ Transplantation Center, Northwestern University, Chicago, Illinois, USA
| | - Philip O'Connell
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Maarten Naesens
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ron Shapiro
- The Recanati/Miller Transplantation Institute (RMTI), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital. Boston, Massachusetts, USA; Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Ward
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Fadi Salem
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Weijia Zhang
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York New York, USA.
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Albert C, Harris M, DiRito J, Shi A, Edwards C, Harkins L, Lysyy T, Kulkarni S, Mulligan DC, Hosgood SA, Watson CJE, Friend PJ, Nicholson ML, Haakinson D, Saeb-Parsy K, Tietjen GT. Honoring the gift: The transformative potential of transplant-declined human organs. Am J Transplant 2023; 23:165-170. [PMID: 36695696 DOI: 10.1016/j.ajt.2022.11.015] [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] [Received: 06/27/2022] [Revised: 10/24/2022] [Accepted: 11/13/2022] [Indexed: 01/09/2023]
Abstract
For decades, transplantation has been a life-saving treatment for those fortunate enough to gain access. Nevertheless, many patients die waiting for an organ and countless more never make it onto the waitlist because of a shortage of donor organs. Concurrently, thousands of donated organs are declined for transplant each year because of concerns about poor outcomes post-transplant. The decline of any donated organ-even if medically justified-is tragic for both the donor family and potential recipients. In this Personal Viewpoint, we discuss the need for a new mindset in how we honor the gift of organ donation. We believe that the use of transplant-declined human organs in translational research has the potential to hasten breakthrough discoveries in a multitude of scientific and medical areas. More importantly, such breakthroughs will allow us to properly value every donated organ. We further discuss the many practical challenges that such research presents and offer some possible solutions based on experiences in our own research laboratories. Finally, we share our perspective on what we believe are the necessary next steps to ensure a future where every donated organ realizes its full potential to impact the lives of current and future patients.
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Affiliation(s)
- Claire Albert
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA
| | - Matthew Harris
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Jenna DiRito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Audrey Shi
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | | | - Lauren Harkins
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA
| | - Taras Lysyy
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Sanjay Kulkarni
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - David C Mulligan
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Peter J Friend
- University of Oxford, Nuffield Department of Surgical Sciences and the Oxford Transplant Centre, Oxford, UK
| | - Michael L Nicholson
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Danielle Haakinson
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA
| | - Kourosh Saeb-Parsy
- Department of Surgery, University of Cambridge, and Cambridge NIHR Biomedical Research Centre, Cambridge, UK.
| | - Gregory T Tietjen
- Yale University, Department of Biomedical Engineering, New Haven, Connecticut, USA; Yale School of Medicine, Department of Surgery, New Haven, Connecticut, USA.
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3
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Albert C, Bracaglia L, Koide A, DiRito J, Lysyy T, Harkins L, Edwards C, Richfield O, Grundler J, Zhou K, Denbaum E, Ketavarapu G, Hattori T, Perincheri S, Langford J, Feizi A, Haakinson D, Hosgood SA, Nicholson ML, Pober JS, Saltzman WM, Koide S, Tietjen GT. Monobody adapter for functional antibody display on nanoparticles for adaptable targeted delivery applications. Nat Commun 2022; 13:5998. [PMID: 36220817 PMCID: PMC9553936 DOI: 10.1038/s41467-022-33490-8] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/20/2022] [Indexed: 11/08/2022] Open
Abstract
Vascular endothelial cells (ECs) play a central role in the pathophysiology of many diseases. The use of targeted nanoparticles (NPs) to deliver therapeutics to ECs could dramatically improve efficacy by providing elevated and sustained intracellular drug levels. However, achieving sufficient levels of NP targeting in human settings remains elusive. Here, we overcome this barrier by engineering a monobody adapter that presents antibodies on the NP surface in a manner that fully preserves their antigen-binding function. This system improves targeting efficacy in cultured ECs under flow by >1000-fold over conventional antibody immobilization using amine coupling and enables robust delivery of NPs to the ECs of human kidneys undergoing ex vivo perfusion, a clinical setting used for organ transplant. Our monobody adapter also enables a simple plug-and-play capacity that facilitates the evaluation of a diverse array of targeted NPs. This technology has the potential to simplify and possibly accelerate both the development and clinical translation of EC-targeted nanomedicines.
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Affiliation(s)
- C Albert
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - L Bracaglia
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - A Koide
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY, USA
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - J DiRito
- Department of Surgery, Yale University, New Haven, CT, USA
| | - T Lysyy
- Department of Surgery, Yale University, New Haven, CT, USA
| | - L Harkins
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - C Edwards
- Department of Surgery, Yale University, New Haven, CT, USA
| | - O Richfield
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
- Department of Surgery, Yale University, New Haven, CT, USA
| | - J Grundler
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - K Zhou
- Department of Molecular Biophysics and Biochemistry, Yale University, New Haven, CT, USA
| | - E Denbaum
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY, USA
| | - G Ketavarapu
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY, USA
| | - T Hattori
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY, USA
- Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY, USA
| | - S Perincheri
- Department of Pathology, Yale University, New Haven, CT, USA
| | - J Langford
- Department of Surgery, Yale University, New Haven, CT, USA
| | - A Feizi
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - D Haakinson
- Department of Surgery, Yale University, New Haven, CT, USA
| | - S A Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - M L Nicholson
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - J S Pober
- Department of Immunobiology, Yale University, New Haven, CT, USA
| | - W M Saltzman
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - S Koide
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY, USA.
- Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY, USA.
| | - G T Tietjen
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA.
- Department of Surgery, Yale University, New Haven, CT, USA.
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Merola J, Gan G, Stewart D, Noreen S, Mulligan D, Batra R, Haakinson D, Deng Y, Kulkarni S. Inactive status is an independent predictor of liver transplant waitlist mortality and is associated with a transplant centers median meld at transplant. PLoS One 2021; 16:e0260000. [PMID: 34793524 PMCID: PMC8601542 DOI: 10.1371/journal.pone.0260000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Approximately 30% of patients on the liver transplant waitlist experience at least one inactive status change which makes them temporarily ineligible to receive a deceased donor transplant. We hypothesized that inactive status would be associated with higher mortality which may differ on a transplant centers' or donor service areas' (DSA) Median MELD at Transplant (MMaT). METHODS Multi-state models were constructed (OPTN database;06/18/2013-06/08/2018) using DSA-level and transplant center-level data where MMaT were numerically ranked and categorized into tertiles. Hazards ratios were calculated between DSA and transplant center tertiles, stratified by MELD score, to determine differences in inactive to active transition probabilities. RESULTS 7,625 (30.2% of sample registrants;25,216 total) experienced at least one inactive status change in the DSA-level cohort and 7,623 experienced at least one inactive status change in the transplant-center level cohort (30.2% of sample registrants;25,211 total). Inactive patients with MELD≤34 had a higher probability of becoming re-activated if they were waitlisted in a low or medium MMaT transplant center or DSA. Transplant rates were higher and lower re-activation probability was associated with higher mortality for the MELD 26-34 group in the high MMaT tertile. There were no significant differences in re-activation, transplant probability, or waitlist mortality for inactivated patients with MELD≥35 regardless of a DSA's or center's MMaT. CONCLUSION This study shows that an inactive status change is independently associated with waitlist mortality. This association differs by a centers' and a DSAs' MMaT. Prioritization through care coordination to resolve issues of inactivity is fundamental to improving access.
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Affiliation(s)
- Jonathan Merola
- Department of Surgery, Division of Organ Transplantation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Geliang Gan
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, United States of America
| | - Samantha Noreen
- United Network for Organ Sharing, Richmond, Virginia, United States of America
| | - David Mulligan
- Department of Surgery, Division of Organ Transplantation, Yale School of Medicine, New Haven, Connecticut, United States of America
- United Network for Organ Sharing, Richmond, Virginia, United States of America
| | - Ramesh Batra
- Department of Surgery, Division of Organ Transplantation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Danielle Haakinson
- Department of Surgery, Division of Organ Transplantation, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Sanjay Kulkarni
- Department of Surgery, Division of Organ Transplantation, Yale School of Medicine, New Haven, Connecticut, United States of America
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Do V, Haakinson D, Belfort-DeAguiar R, Cohen E. Implementing a pharmacist-led transition of care model for posttransplant hyperglycemia. Am J Health Syst Pharm 2021; 78:1207-1215. [PMID: 33821878 PMCID: PMC8083386 DOI: 10.1093/ajhp/zxab151] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The implementation of a pharmacist-managed transition of care program for kidney transplant recipients with posttransplant hyperglycemia (PTHG) is described. Methods In September 2015, a collaborative practice agreement between pharmacists and transplant providers at an academic medical center for management of PTHG was developed. The goal of the pharmacist-run service was to reduce hospitalizations by providing care to patients in the acute phase of hyperglycemia while they transitioned back to their primary care provider or endocrinologist. For continuous quality improvement, preimplementation data were collected from August 2014 to August 2015 and compared to postimplementation data collected from August 2017 to August 2018. The primary endpoint was hospitalizations due to hyperglycemia within 90 days post transplantation. Secondary endpoints included emergency department (ED) visits due to hypoglycemia and the number of interventions performed, number of encounters completed, and number of ED visits or admissions for hypoglycemia. A Fisher’s exact test was used to compare categorical data, and a Student t test was used to compare continuous data. A P value of <0.05 was considered to be statistically significant. Results Forty-three patients in the preimplementation group were compared to 35 patients in the postimplementation group. There was a significant reduction in hospitalizations due to hyperglycemia in the postimplementation versus the preimplementation group (9 vs 1, P < 0.05); there was a reduction in ED visits due to hyperglycemia (5 vs 0, P = 0.06). There were no ED visits or hospitalizations due to hypoglycemia in either group. Clinical transplant pharmacists performed an average of 8.3 (SD, 4.4) encounters per patient per 90 days. Conclusion A collaborative practice agreement was created and successfully implemented. A pharmacist-managed PTHG program could be incorporated into the standard care of kidney transplant recipients to help minimize rehospitalizations due to hyperglycemia.
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Affiliation(s)
- Vincent Do
- Yale New Haven Hospital, New Haven CT, USA
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6
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Joyce M, Durant L, Emre S, Haakinson D, Hammers L, Hughes L, Ventura K, Wuerth D, Liapakis A. Expansion of Patient Education Programming Regarding Live Donor Liver Transplantation via Virtual Group Encounters During the COVID-19 Pandemic. Transplant Proc 2021; 53:1105-1111. [PMID: 33676742 DOI: 10.1016/j.transproceed.2021.01.038] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
During the coronavirus 2019 pandemic we converted our liver transplant waitlist candidate education and support program to a virtual format and expanded it to include ongoing engagement sessions aimed to educate and empower patients to maximize opportunity for live donor liver transplantation. Over a period of 6 months from April 2020 to Sept 2020 we included 21 patients in this pilot quality improvement program. We collected data regarding patient response and potential donor referral activity. Overall, patient response was positive, and some patients saw progress toward live donor liver transplantation by fostering inquiry of potential live liver donors. Optimization of logistical aspects of the program including program flow, technology access, and utilization is required to enhance patient experience. Long-term follow-up is needed to assess impact on the outcome of transplantation rates. Future data collection and analysis should focus on assessment of any potential disparity that may result from utilization of virtual programming. Herein we provide a framework for this type of virtual program and describe our experience.
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Affiliation(s)
- Michael Joyce
- Yale New Haven Transplantation Center, New Haven, Connecticut
| | - Luwan Durant
- Yale New Haven Transplantation Center, New Haven, Connecticut
| | - Sukru Emre
- Yale New Haven Transplantation Center, New Haven, Connecticut
| | | | - Lenore Hammers
- Yale New Haven Transplantation Center, New Haven, Connecticut
| | - Lisa Hughes
- Yale New Haven Transplantation Center, New Haven, Connecticut
| | - Kara Ventura
- Yale New Haven Transplantation Center, New Haven, Connecticut
| | - Diane Wuerth
- Yale New Haven Transplantation Center, New Haven, Connecticut
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Abstract
Metabolic disorders are highly prevalent in kidney transplant candidates and recipients and can adversely affect post-transplant graft outcomes. Management of diabetes, hyperparathyroidism, and obesity presents distinct opportunities to optimize patients both before and after transplant as well as the ability to track objective data over time to assess a patient's ability to partner effectively with the health care team and adhere to complex treatment regimens. Optimization of these particular disorders can most dramatically decrease the risk of surgical and cardiovascular complications post-transplant. Approximately 60% of nondiabetic patients experience hyperglycemia in the immediate post-transplant phase. Multiple risk factors have been identified related to development of new onset diabetes after transplant, and it is estimated that upward of 7%-30% of patients will develop new onset diabetes within the first year post-transplant. There are a number of medications studied in the kidney transplant population for diabetes management, and recent data and the risks and benefits of each regimen should be optimized. Secondary hyperparathyroidism occurs in most patients with CKD and can persist after kidney transplant in up to 66% of patients, despite an initial decrease in parathyroid hormone levels. Parathyroidectomy and medical management are the options for treatment of secondary hyperparathyroidism, but there is no randomized, controlled trial providing clear recommendations for optimal management, and patient-specific factors should be considered. Obesity is the most common metabolic disorder affecting the transplant population in both the pre- and post-transplant phases of care. Not only does obesity have associations and interactions with comorbid illnesses, such as diabetes, dyslipidemia, and cardiovascular disease, all of which increase morbidity and mortality post-transplant, but it also is intimately inter-related with access to transplantation for patients with kidney failure. We review these metabolic disorders and their management, including data in patients with kidney transplants.
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Affiliation(s)
- Elizabeth Cohen
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut
| | - Maria Korah
- Yale University School of Medicine, New Haven, Connecticut
| | - Glenda Callender
- Department of Surgery, Section of Endocrine Surgery, Yale University, New Haven, Connecticut
| | | | - Danielle Haakinson
- Department of Surgery, Section of Transplant, Yale University, New Haven, Connecticut
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Kulkarni S, Ladin K, Haakinson D, Greene E, Li L, Deng Y. Association of Racial Disparities With Access to Kidney Transplant After the Implementation of the New Kidney Allocation System. JAMA Surg 2020; 154:618-625. [PMID: 30942882 DOI: 10.1001/jamasurg.2019.0512] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Inactive patients on the kidney transplant wait-list have a higher mortality. The implications of this status change on transplant outcomes between racial/ethnic groups are unknown. Objectives To determine if activity status changes differ among races/ethnicities and levels of sensitization, and if these differences are associated with transplant probability after implementation of the Kidney Allocation System. Design, Setting, and Participants A multistate model was constructed from the Organ Procurement and Transplantation Network kidney transplant database (December 4, 2014, to September 8, 2016). The time interval followed Kidney Allocation System implementation and provided at least 1-year follow-up for all patients. The model calculated probabilities between active and inactive status and the following competing risk outcomes: living donor transplant, deceased donor transplant, and death/other. This retrospective cohort study included 42 558 patients on the Organ Procurement and Transplantation Network kidney transplant wait-list following Kidney Allocation System implementation. To rule out time-varying confounding from relisting, analysis was limited to first-time registrants. Owing to variations in listing practices, primary center listing data were used for dually listed patients. Individuals listed for another organ or pancreatic islets were excluded. Analysis began July 2017. Main Outcome and Measures Probabilities were determined for transitions between active and inactive status and the following outcome states: active to living donor transplant, active to deceased donor transplant, active to death/other, inactive to living donor transplant, inactive to deceased donor transplant, and inactive to death/other. Results The median (interquartile range) age at listing was 55.0 (18.0-89.0) years, and 26 535 of 42 558 (62.4%) were men. White individuals were 43.3% (n = 18 417) of wait-listed patients, while black and Hispanic individuals made up 27.8% (n = 11 837) and 19.5% (n = 8296), respectively. Patients in the calculated plasma reactive antibody categories of 0% or 1% to 79% showed no statistically significant difference in transplant probability among races/ethnicities. White individuals had an advantage in transplant probability over black individuals in calculated plasma reactive antibody categories of 80% to 89% (hazard ratio [HR], 1.8 [95% CI, 1.4-2.2]) and 90% or higher (HR, 2.4 [95% CI, 2.1-2.6]), while Hispanic individuals had an advantage over black individuals in the calculated plasma reactive antibody group of 90% or higher (HR, 2.5 [95% CI, 2.1-2.8]). Once on the inactive list, white individuals were more likely than Hispanic individuals (HR, 1.2 [95% CI, 1.17-1.3]) or black individuals (HR, 1.4 [95% CI, 1.3-1.4]) to resolve issues for inactivity resulting in activation. Conclusions and Relevance For patients who are highly sensitized, there continues to be less access to kidney transplant in the black population after the implementation of the Kidney Allocation System. Health disparities continue after listing where individuals from minority groups have greater difficulty in resolving issues of inactivity.
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Affiliation(s)
- Sanjay Kulkarni
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Keren Ladin
- Department of Community Medicine and Public Health, Tufts University, Boston, Massachusetts
| | | | - Erich Greene
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Luhang Li
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
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