Impact of cadaveric renal transplantation on survival in patients listed for transplantation

The aim of this study was to assess the magnitude of the survival benefit of renal transplantation compared with dialysis in patients selected for transplantation in Scotland. Longitudinal study of survival and mortality risk in all adult patients (1732) listed for a first transplant between January 1, 1989, and December 31, 1989, in Scotland. A time-dependent Cox regression analysis adjusted for comorbidity, sociodemographic and geographic factors, primary renal disease, time on dialysis, and year of listing compared the risk of death for patients receiving a first cadaveric transplant versus all patients on dialysis listed for transplantation. After adjustment for the covariates, the relative risk (RR) of death during the first 30 days after transplantation was 1.35 (95% confidence interval [CI], 0.63 to 2.86) compared with patients on dialysis (RR = 1). The long-term RR (at 18 mo) for the transplant recipients was 0.18 (95% CI, 0.08 to 0.42) when compared with patients on dialysis (RR = 1). This lower long-term risk of death was present in all patients undergoing transplantation, irrespective of their age group or primary renal disease. Similar results were seen when survival with a transplant was censored for graft failure. The projected life expectancy with a transplant was 17.19 yr compared with only 5.84 yr on dialysis. Despite an initial higher risk of death, long-term survival for patients who undergo transplantation is significantly better compared with patients who are listed but remain on dialysis. A successful transplant triples the life expectancy of a listed renal failure patient.

How great is the survival advantage of transplantation over dialysis in elderly patients?

BACKGROUND

Patients >60 years old represent 66% of all new patients starting renal replacement therapy in Scotland. The aim of this study was to investigate whether or not transplantation provides any survival benefit in this group of patients.

METHODS

325 patients >60 years old listed for transplantation in Scotland between 1 January 1989 and 31 December 1999 were followed up until 31 December 2000. Sociodemographic, comorbidity, listing and transplant data were obtained from the national renal and transplant databases and case-notes review. Survival was compared between those who received a transplant and those who were listed but did not receive a transplant by the end of the follow-up period. Mann-Whitney, chi(2), Fisher's exact and log-rank tests were used where appropriate.

RESULTS

Of the 325 patients listed, 128 (39.4%) received a first transplant within the study period and the remaining 197 (60.6%) continued to undergo dialysis. The transplant recipients were younger at listing (P<0.0001), lived closer to the transplant centre (P = 0.043) and spent less time on the active waiting list (P<0.0001) than patients who remained on dialysis. They had less ischaemic heart disease (P = 0.024), cerebrovascular disease (P = 0.03) and arrhythmias (P = 0.016). The overall mortality rate was 0.16 per patient-year for dialysis and 0.10 for transplantation. There was a significantly lower risk of death (RR = 0.35, 95% CI 0.22--0.54; P<0.0001, log-rank) and a longer life expectancy after listing with a transplant (8.17 vs 4.32 years).

CONCLUSIONS

Renal transplantation offers a significant survival advantage over dialysis in elderly patients with end-stage renal failure who are considered suitable for transplantation.

Equity of access to renal transplant waiting list and renal transplantation in Scotland: cohort study

OBJECTIVE

To examine the access to the renal transplant waiting list and renal transplantation in Scotland.

DESIGN

Cohort study.

SETTING

Renal and transplant units in Scotland.

PARTICIPANTS

4523 adults starting renal replacement therapy in Scotland between 1 January 1989 and 31 December 1999.

MAIN OUTCOME MEASURES

Impact of age, sex, social deprivation, primary renal disease, renal or transplant unit, and geography on access to the waiting list and renal transplantation.

RESULTS

1736 of 4523 (38.4%) patients were placed on the waiting list for renal transplantation and 1095 (24.2%) underwent transplantation up to 31 December 2000, the end of the study period. Patients were less likely to be placed on the list if they were female, older, had diabetes, were in a high deprivation category, and were treated in a renal unit in a hospital with no transplant unit. Patients living furthest away from the transplant centre were listed more quickly. The only factors governing access to transplantation once on the list were age, primary renal disease, and year of listing. A significant centre effect was found in access to the waiting list and renal transplantation.

CONCLUSIONS

A major disparity exists in access to the renal transplant waiting list and renal transplantation in Scotland. Comorbidity may be an important factor.

"Dirty little secrets"--endotoxin contamination of recombinant proteins

The identification of Toll-like receptors has revolutionised our understanding of innate immunity. TLR4 transduces the LPS signal and that of a number of structurally and functionally unrelated agonists. However, recent evidence adds to longstanding concerns that endotoxin contamination of bacterially derived recombinant TLR4 agonists is responsible for effects attributed to these molecules. We highlight key factors in differentiating specific agonist effects from those of endotoxin and emphasize why conventional methods of detecting and eliminating LPS may lead to erroneous results. We propose that considerable caution is needed in the investigation of TLR4 agonists, particularly when using proteins produced in a bacterium that also houses the most ideal TLR4 agonist, LPS.

Higher quality of life in living donor kidney transplantation: prospective cohort study

This prospective, longitudinal cohort study investigated the effect of donating or receiving a kidney on quality of life and relationship dynamics. Forty donors and 35 recipients from two UK transplantation centres completed the World Health Organisation quality of life questionnaire (WHOQOL) with additional questionnaires before, 6 weeks and one year after operation. Before donation the donor mean quality of life score in the physical domain was 18.8. This was significantly higher than the UK value for a healthy person of 16.4 (P < 0.001). Six weeks after operation, donor score reduced to UK normative levels however improved again at one year (17.7). Recipient mean physical domain score before was 11.4, significantly lower than the UK norm (P < 0.01), increasing to 16.0 one year after. Both donor (P < 0.009) and recipient (P < 0.05) experienced a significant improvement in their mutual relationship. Recipients expressed anxiety about the donor before operation. Donors were not concerned about living with one kidney. We concluded that living kidney donation has no detrimental effect on the physical or psychological well being of donors one year after donation. Transplantation results in a major improvement in quality of life for the recipient. Most donors would donate again, if this were possible.

Real-world Effectiveness of the Pfizer-BioNTech BNT162b2 and Oxford-AstraZeneca ChAdOx1-S Vaccines Against SARS-CoV-2 in Solid Organ and Islet Transplant Recipients

BACKGROUND

The clinical effectiveness of vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in immunosuppressed solid organ and islet transplant (SOT) recipients is unclear.

METHODS

We linked 4 national registries to retrospectively identify laboratory-confirmed SARS-CoV-2 infections and deaths within 28 d in England between September 1, 2020, and August 31, 2021, comparing unvaccinated adult SOT recipients and those who had received 2 doses of ChAdOx1-S or BNT162b2 vaccine. Infection incidence rate ratios were adjusted for recipient demographics and calendar month using a negative binomial regression model, with 95% confidence intervals. Case fatality rate ratios were adjusted using a Cox proportional hazards model to generate hazard ratio (95% confidence interval).

RESULTS

On August 31, 2021, it was found that 3080 (7.1%) were unvaccinated, 1141 (2.6%) had 1 vaccine dose, and 39 260 (90.3%) had 2 vaccine doses. There were 4147 SARS-CoV-2 infections and 407 deaths (unadjusted case fatality rate 9.8%). The risk-adjusted infection incidence rate ratio was 1.29 (1.03-1.61), implying that vaccination was not associated with reduction in risk of testing positive for SARS-CoV-2 RNA. Overall, the hazard ratio for death within 28 d of SARS-CoV-2 infection was 0.80 (0.63-1.00), a 20% reduction in risk of death in vaccinated patients (P = 0.05). Two doses of ChAdOx1-S were associated with a significantly reduced risk of death (hazard ratio, 0.69; 0.52-0.92), whereas vaccination with BNT162b2 was not (0.97; 0.71-1.31).

CONCLUSIONS

Vaccination of SOT recipients confers some protection against SARS-CoV-2-related mortality, but this protection is inferior to that achieved in the general population. SOT recipients require additional protective measures, including further vaccine doses, antiviral drugs, and nonpharmaceutical interventions.

Barriers to living donor kidney transplantation in the United Kingdom: a national observational study

Background. Living donor kidney transplantation (LDKT) provides more timely access to transplantation and better clinical outcomes than deceased donor kidney transplantation (DDKT). This study investigated disparities in the utilization of LDKT in the UK.

Methods. A total of 2055 adults undergoing kidney transplantation between November 2011 and March 2013 were prospectively recruited from all 23 UK transplant centres as part of the Access to Transplantation and Transplant Outcome Measures (ATTOM) study. Recipient variables independently associated with receipt of LDKT versus DDKT were identified.

Results. Of the 2055 patients, 807 (39.3%) received LDKT and 1248 (60.7%) received DDKT. Multivariable modelling demonstrated a significant reduction in the likelihood of LDKT for older age {odds ratio [OR] 0.11 [95% confidence interval (CI) 0.08–0.17], P < 0.0001 for 65–75 years versus 18–34 years}; Asian ethnicity [OR 0.55 (95% CI 0.39–0.77), P = 0.0006 versus White]; Black ethnicity [OR 0.64 (95% CI 0.42–0.99), P = 0.047 versus White]; divorced, separated or widowed [OR 0.63 (95% CI 0.46–0.88), P = 0.030 versus married]; no qualifications [OR 0.55 (95% CI 0.42–0.74), P < 0.0001 versus higher education qualifications]; no car ownership [OR 0.51 (95% CI 0.37–0.72), P = 0.0001] and no home ownership [OR 0.65 (95% CI 0.85–0.79), P = 0.002]. The odds of LDKT varied significantly between countries in the UK.

Conclusions. Among patients undergoing kidney transplantation in the UK, there are significant age, ethnic, socio-economic and geographic disparities in the utilization of LDKT. Further work is needed to explore the potential for targeted interventions to improve equity in living donor transplantation.

The Global Impact of COVID-19 on Solid Organ Transplantation: Two Years Into a Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a major global impact on solid organ transplantation (SOT). An estimated 16% global reduction in transplant activity occurred over the course of 2020, most markedly impacting kidney transplant and living donor programs, resulting in substantial knock-on effects for waitlisted patients. The increased severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection risk and excess deaths in transplant candidates has resulted in substantial effort to prioritize the safe restart and continuation of transplant programs over the second year of the pandemic, with transplant rates returning towards prepandemic levels. Over the past 2 y, COVID-19 mortality in SOT recipients has fallen from 20%-25% to 8%-10%, attributed to the increased and early availability of SARS-CoV-2 testing, adherence to nonpharmaceutical interventions, development of novel treatments, and vaccination. Despite these positive steps, transplant programs and SOT recipients continue to face challenges. Vaccine efficacy in SOT recipients is substantially lower than the general population and SOT recipients remain at an increased risk of adverse outcomes if they develop COVID-19. SOT recipients and transplant teams need to remain vigilant and ongoing adherence to nonpharmaceutical interventions appears essential. In this review, we summarize the global impact of COVID-19 on transplant activity, donor evaluation, and patient outcomes over the past 2 y, discuss the current strategies aimed at preventing and treating SARS-CoV-2 infection in SOT recipients, and based on lessons learnt from this pandemic, propose steps the transplant community could consider as preparation for future pandemics.

Renal transplantation in the United Kingdom for patients from ethnic minorities

BACKGROUND

To investigate any differences in access to transplant and post-transplant outcomes for ethnic minority patients in the United Kingdom, national data on ethnicity of patients on the waiting list, those receiving a transplant, and deceased donors were analyzed.

METHODS

Adult patients and donors were included. Ethnic origin was classified as white, Asian, black, or "other." National data were analyzed, and 2001 U.K. National census data were used for comparative purposes. Median waiting times to transplant were obtained from Kaplan-Meier estimates for patients registered 1998-2000. Transplant survival was estimated for patients transplanted from 1998 to 2003.

RESULTS

A total of 92% of the U.K. population was white, compared with 77% of waiting list patients, 88% of transplant recipients, and 97% of deceased donors. Median waiting time to transplantation for white patients was 719 days (95% confidence interval 680-758) compared with 1368 (1131-1605) days for Asian patients and 1419 (1165-1673) days for black patients. The degree of human leukocyte antigen matching achieved was inferior for Asian and black patients. There is some evidence of inferior 3-year transplant survival for black patients compared with white and Asian patients (P=0.03).

CONCLUSIONS

There are imbalances in the ethnic make up of the waiting list, the donor pool, and renal transplant recipients. There are significant differences in both post-transplant outcomes and time to transplantation between patients of different ethnic origin. Waiting times are influenced by allocation schemes, and the 2006 U.K. National Kidney Allocation Scheme is designed to achieve greater equity of access to transplant for all patients, regardless of geography, blood group, or ethnicity.

The incidence and importance of bacterial contaminants of cadaveric renal perfusion fluid

Infections represent a significant risk in the postoperative transplant recipient. The perfusion fluid used to perfuse and preserve the kidneys prior to transplantation represents a potential medium in which organisms can grow. The aim of this study was to determine the incidence and clinical relevance of bacterial contamination of perfusion fluid. A total of 4 centres participated in the study and 269 perfusion fluid samples were taken for microbiological analysis. Organisms were isolated from 38 out of 218 (17.4%) perfusion fluid samples taken prior to allograft implantation and 23 out of 51 (45%) samples taken at procurement. Low virulence organisms predominated although Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli were also isolated. Although infective complications were not seen in the allograft recipients, given the frequency with which contamination occurs and the variation in unit antibiotic protocols, we recommend the routine culturing of perfusion fluid to ensure that any potentially significant organisms are identified and treated appropriately.

Kidney and liver transplantation in the elderly

BACKGROUND

Transplant surgery is facing a shortage of deceased donor organs. In response, the criteria for organ donation have been extended, and an increasing number of organs from older donors are being used. For recipients, the benefits of transplantation are great, and the growing ageing population has led to increasing numbers of elderly patients being accepted for transplantation.

METHODS

The literature was reviewed to investigate the impact of age of donors and recipients in abdominal organ transplantation, and to highlight aspects of the fine balance in donor and recipient selection and screening, as well as allocation policies fair to young and old alike.

RESULTS

Overall, kidney and liver transplantation from older deceased donors have good outcomes, but are not as good as those from younger donors. Careful donor selection based on risk indices, and potentially biomarkers, special allocation schemes to match elderly donors with elderly recipients, and vigorous recipient selection, allows good outcomes with increasing age of both donors and recipients. The results of live kidney donation have been excellent for donor and recipient, and there is a trend towards inclusion of older donors. Future strategies, including personalized immunosuppression for older recipients as well as machine preservation and reconditioning of donor organs, are promising ways to improve the outcome of transplantation between older donors and older recipients.

CONCLUSION

Kidney and liver transplantation in the elderly is a clinical reality. Outcomes are good, but can be optimized by using strategies that modify donor risk factors and recipient co-morbidities, and personalized approaches to organ allocation and immunosuppression.

Uncovering a rare but critical complication following thyroid surgery: an audit across the UK and Ireland

OBJECTIVE

Serious wound infection after thyroidectomy is uncommon, but actual incidence is not well documented in the literature. In the past a patient in our unit died secondary to fulminant streptococcal sepsis after thyroidectomy for benign disease. This prompted us to audit experience of serious wound infection among British Association of Endocrine Surgery (BAES) members.

DESIGN

A questionnaire was posted to BAES members inquiring about experience of major wound infection following cervicotomy, incidence of minor wound infection, and prophylactic and therapeutic antibiotic usage.

MAIN OUTCOME

Eight respondents experienced a case of fulminant wound infection after cervicotomy (8% total respondents). Five patients died and, in 6 patients, cases of streptococci were cultured. Then, 9% of respondents used prophylactic antibiotics routinely, 16% sometimes and 75% never. The most commonly used antibiotic was augmentin, and the most common reasons for use among those with a selective policy were re-operative cases (38%) and immunocompromised patients (38%). Also, 40% of respondents experienced major wound infection requiring intravenous antibiotics or surgical drainage. The most common choices of antibiotic used before sensitivities were obtained were augmentin (43%) and flucloxacillin (35%).

CONCLUSIONS

Although rare, fulminant streptococcal wound infection after cervicotomy does occasionally occur and carries a high mortality.

The Role of Vascular Endothelial Growth Factor in the Kidney in Health and Disease

Vascular endothelial growth factor (VEGF) is a potent endothelial cell mitogen, angiogenic factor and enhancer of vascular permeability. Expressed in the epithelial cells of the developing glomerulus and tubular epithelium, VEGF plays an important role in the development and maintenance of the early vasculature of the kidney. Here, we review the available literature regarding the expression and function of VEGF both in the developing and healthy adult kidney. Furthermore, we highlight how VEGF expression is altered in the diseased kidney and how this modulated expression may impact on and reflect underlying functional changes occurring during the disease process. As discussed, many controversial issues remain, particularly concerning the role of VEGF in the diseased kidney. That VEGF has been proposed as a potential future therapeutic target for the management of some renal diseases requires first that the precise role of VEGF in the normal kidney and various renal pathologies be further and more clearly defined.

Changes in quality of life (QoL) and other patient-reported outcome measures (PROMs) in living-donor and deceased-donor kidney transplant recipients and those awaiting transplantation in the UK ATTOM programme: a longitudinal cohort questionnaire survey with additional qualitative interviews

OBJECTIVE

To examine quality of life (QoL) and other patient-reported outcome measures (PROMs) in kidney transplant recipients and those awaiting transplantation.

DESIGN

Longitudinal cohort questionnaire surveys and qualitative semi-structured interviews using thematic analysis with a pragmatic approach.

SETTING

Completion of generic and disease-specific PROMs at two time points, and telephone interviews with participants UK-wide.

PARTICIPANTS

101 incident deceased-donor (DD) and 94 incident living-donor (LD) kidney transplant recipients, together with 165 patients on the waiting list (WL) from 18 UK centres recruited to the Access to Transplantation and Transplant Outcome Measures (ATTOM) programme completed PROMs at recruitment (November 2011 to March 2013) and 1 year follow-up. Forty-one of the 165 patients on the WL received a DD transplant and 26 received a LD transplant during the study period, completing PROMs initially as patients on the WL, and again 1 year post-transplant. A subsample of 10 LD and 10 DD recipients participated in qualitative semi-structured interviews.

RESULTS

LD recipients were younger, had more educational qualifications and more often received a transplant before dialysis. Controlling for these and other factors, cross-sectional analyses at 12 months post-transplant suggested better QoL, renal-dependent QoL and treatment satisfaction for LD than DD recipients. Patients on the WL reported worse outcomes compared with both transplant groups. However, longitudinal analyses (controlling for pre-transplant differences) showed that LD and DD recipients reported similarly improved health status and renal-dependent QoL (p<0.01) pre-transplant to post-transplant. Patients on the WL had worsened health status but no change in QoL. Qualitative analyses revealed transplant recipients' expectations influenced their recovery and satisfaction with transplant.

CONCLUSIONS

While cross-sectional analyses suggested LD kidney transplantation leads to better QoL and treatment satisfaction, longitudinal assessment showed similar QoL improvements in PROMs for both transplant groups, with better outcomes than for those still wait-listed. Regardless of transplant type, clinicians need to be aware that managing expectations is important for facilitating patients' adjustment post-transplant.

Human leukocyte antigen and the allocation of kidneys from cadaver donors in the United Kingdom

The national scheme currently used for the allocation of cadaver kidneys in the United Kingdom includes factors demonstrated to improve transplant outcome and promote equity in organ allocation. Introduced in 1998, the scheme is based on human leukocyte antigen matching, gives priority to children and highly sensitized patients, and incorporates features to assist transplantation in patients who are difficult to match. The scheme is open and transparent and subject to continuous audit and review to address any inequities in access to transplant that become apparent.

Commercially available recombinant sonic hedgehog up-regulates Ptc and modulates the cytokine and chemokine expression of human macrophages: an effect mediated by endotoxin contamination?

The Sonic hedgehog (Shh) signalling pathway plays an important role in developmental patterning and proliferation. Recent evidence suggests that Shh also plays a role in the development of the immune system. Here, we demonstrate that components of the Shh signalling pathway are expressed in human macrophages and that the receptor for Shh, Ptc, is up-regulated by a commercially available recombinant preparation of Shh (CArShh). Further, we report that the addition of CArShh up-regulates the production of IL-6, IL-8, MCP-1, IP-10, MIG and RANTES by macrophages, an effect enhanced by the presence of fetal calf serum in the culture medium. In contrast, TGF-beta, TNF-alpha, IL-1b, IL-12 and IL-10 production were not modulated by CArShh and VEGF was minimally up-regulated even in the presence of serum. The up-regulation of these cytokines and chemokines was abrogated by CD14 inhibition and polymixin B, but not reliably inhibited by the specific Shh pathway inhibitor cyclopamine. These results suggest that, although components of the Shh signalling pathway are expressed in macrophages, the modulation of macrophage cytokine and chemokine effector function seen in response to commercially available rShh results from low levels of endotoxin contained within the CArShh preparations employed to explore the effects of Shh in vitro.

The Use of Marginal Heart Beating Donor Livers for Transplantation in the United Kingdom

BACKGROUND

This study investigated the use of deceased heart-beating donor livers offered for transplantation during a 10-year period, during which there has been an increasing disparity between organ supply and demand in the United Kingdom.

METHODS

Summary data from the National Transplant Database were analyzed on all 7107 heart-beating cadaveric donor livers offered for transplantation in the United Kingdom between 1996 and 2006, with particular attention to livers that were not retrieved, not transplanted, or that subsequently failed to function after transplantation.

RESULTS

The difference between the number of patients registered for liver transplantation in the United Kingdom and those transplanted increased from 132 in 1996 to 333 in 2006, leading to a 77% increase in the number of waiting list deaths. Mean donor age increased by 6.1 (5.7-6.6) years during the period studied, in part because of a reduction in the proportion of donors arising from road fatalities. Despite this, the rate of primary nonfunction remained low (1.7% during 1996-2006). The absolute risk increase of primary nonfunction arising from receipt of a moderately as opposed to mildly steatotic organ was 2.6%, which translates to a "number needed to harm" of 41 patients.

CONCLUSIONS

The decline in both the number and the quality of livers offered for transplantation in the United Kingdom during the past 10 years has not been associated with a change in the rate of primary nonfunction. In these times of acute donor shortage, these data may justify a more liberal use of marginal grafts.

Patient preferences, knowledge and beliefs about kidney allocation: qualitative findings from the UK-wide ATTOM programme

OBJECTIVE

To explore how patients who are wait-listed for or who have received a kidney transplant understand the current UK kidney allocation system, and their views on ways to allocate kidneys in the future.

DESIGN

Qualitative study using semistructured interviews and thematic analysis based on a pragmatic approach.

PARTICIPANTS

10 deceased-donor kidney transplant recipients, 10 live-donor kidney transplant recipients, 12 participants currently wait-listed for a kidney transplant and 4 participants whose kidney transplant failed.

SETTING

Semistructured telephone interviews conducted with participants in their own homes across the UK.

RESULTS

Three main themes were identified: uncertainty of knowledge of the allocation scheme; evaluation of the system and participant suggestions for future allocation schemes. Most participants identified human leucocyte anitgen matching as a factor in determining kidney allocation, but were often uncertain of the accuracy of their knowledge. In the absence of information that would allow a full assessment, the majority of participants consider that the current system is effective. A minority of participants were concerned about the perceived lack of transparency of the general decision-making processes within the scheme. Most participants felt that people who are younger and those better matched to the donor kidney should be prioritised for kidney allocation, but in contrast to the current scheme, less priority was considered appropriate for longer waiting patients. Some non-medical themes were also discussed, such as whether parents of dependent children should be prioritised for allocation, and whether patients with substance abuse problems be deprioritised.

CONCLUSIONS

Our participants held differing views about the most important factors for kidney allocation, some of which were in contrast to the current scheme. Patient participation in reviewing future allocation policies will provide insight as to what is considered acceptable to patients and inform healthcare staff of the kinds of information patients would find most useful.

Incentives to promote organ donation

The worldwide shortage of organs has led to the development of incentives to promote organ donation. These incentives vary widely in nature ranging from financial remuneration to preferential access to conditional donation. Such strategies to increase organ donation present a variety of ethical dilemmas challenging traditional concepts of justice and equity of access. In addition, there are legal and logistic considerations that must be discussed. The case is made that schemes using incentives to promote organ donation must meet the requirements of society for justice, equity of access, and avoidance of racial or other bias.

Impact of patient characteristics and comorbidity profile on activation of patients on the kidney transplantation waiting list

BACKGROUND

The aim of this study was to examine which demographic and comorbidity factors affected the activation of patients with end-stage renal disease on the national kidney transplantation waiting list.

METHODS

This was a prospective cohort study across 13 transplantation centers in the United Kingdom from October 1, 2006 to September 30, 2007. Data were collected for all new adult patients (n = 1530) referred to the renal transplantation assessment clinic. The proportion of patients who were activated to the waiting list after a minimum one year follow-up was estimated. Factors influencing activation of patients on the waiting list were examined.

RESULTS

A total of 872 (58.9%) patients were activated to the transplantation waiting list. The likelihood of activation to the transplantation waiting list was lower in patients older than 65 years (P = .021), nonwhite ethnicity (P < .0001), smokers (P < .0001), and those in whom diabetes was the cause of renal failure (P = .004). Multivariate analysis showed that there was an adverse impact of comorbidity such as ischemic heart disease (P = .003), diabetes (P = .006), and peripheral vascular disease (P = .007) on the likelihood of activation to the waiting list.

CONCLUSION

Patient characteristics and comorbidity are associated with the probability of activation of patients to the waiting list.

Does a kidney-sharing alliance have to sacrifice cold ischemic time for better HLA matching?

BACKGROUND

The Scotland-Northern Ireland Kidney Allocation Alliance was created in August 1998. The purpose was to optimize the transplant service through increased regional exchange, higher quality matched kidneys, and better organ distribution.

METHODS

An analysis was performed on prospectively collected data regarding retrieval and transplant activity. The degree of HLA matching, the cold ischemic time (CIT), the balance of exchange, and graft survival were analyzed for a 2-year period after the introduction of the new alliance and compared with the last year before alliance.

RESULTS

There was a 17.7% increase in the number of transplants performed. In the 2-year period, 78% of kidneys were exported from the retrieving center compared with 55% in the prealliance year, (P<0.05, chi2). The proportion of 000 mismatched transplants and other favorable matches increased from 9.5 to 21% and from 52.5 to 61%, respectively. There was no significant difference between the CIT for the three study periods, nor between the CIT for locally used kidneys versus those exchanged within the Alliance (P>0.05, Student's t test). The largest center was a net importer of kidneys, whereas small and medium-sized centers balanced their exchange within the 2-year period. The 1-year transplant survival rate improved from 81.5% in the prealliance year to 88.4% at the end of the second year.

CONCLUSIONS

The introduction of a regional kidney allocation alliance has improved the degree of HLA matching and increased the exchange of organs, without a significant increase in the CIT and any detrimental effect on graft survival.

Organ Transplants From Deceased Donors With Primary Brain Tumors and Risk of Cancer Transmission

Importance

Cancer transmission is a known risk for recipients of organ transplants. Many people wait a long time for a suitable transplant; some never receive one. Although patients with brain tumors may donate their organs, opinions vary on the risks involved.

Objective

To determine the risk of cancer transmission associated with organ transplants from deceased donors with primary brain tumors. Key secondary objectives were to investigate the association that donor brain tumors have with organ usage and posttransplant survival.

Design, Setting, and Participants

This was a cohort study in England and Scotland, conducted from January 1, 2000, to December 31, 2016, with follow-up to December 31, 2020. This study used linked data on deceased donors and solid organ transplant recipients with valid national patient identifier numbers from the UK Transplant Registry, the National Cancer Registration and Analysis Service (England), and the Scottish Cancer Registry. For secondary analyses, comparators were matched on factors that may influence the likelihood of organ usage or transplant failure. Statistical analysis of study data took place from October 1, 2021, to May 31, 2022.

Exposures

A history of primary brain tumor in the organ donor, identified from all 3 data sources using disease codes.

Main Outcomes and Measures

Transmission of brain tumor from the organ donor into the transplant recipient. Secondary outcomes were organ utilization (ie, transplant of an offered organ) and survival of kidney, liver, heart, and lung transplants and their recipients. Key covariates in donors with brain tumors were tumor grade and treatment history.

Results

This study included a total of 282 donors (median [IQR] age, 42 [33-54] years; 154 females [55%]) with primary brain tumors and 887 transplants from them, 778 (88%) of which were analyzed for the primary outcome. There were 262 transplants from donors with high-grade tumors and 494 from donors with prior neurosurgical intervention or radiotherapy. Median (IQR) recipient age was 48 (35-58) years, and 476 (61%) were male. Among 83 posttransplant malignancies (excluding NMSC) that occurred over a median (IQR) of 6 (3-9) years in 79 recipients of transplants from donors with brain tumors, none were of a histological type matching the donor brain tumor. Transplant survival was equivalent to that of matched controls. Kidney, liver, and lung utilization were lower in donors with high-grade brain tumors compared with matched controls.

Conclusions and Relevance

Results of this cohort study suggest that the risk of cancer transmission in transplants from deceased donors with primary brain tumors was lower than previously thought, even in the context of donors that are considered as higher risk. Long-term transplant outcomes are favorable. These results suggest that it may be possible to safely expand organ usage from this donor group.

Establishing a Transplant Coordinator-Led Living Kidney Donor Follow-up Clinic

Background

The long-term risks of renal failure and hypertension are statistically low for living kidney donors as a group, but can have serious consequences for the individual.

Objectives

To describe the experience with a transplant coordinator-led living donor follow-up clinic.

Method

Living kidney donors are reviewed on an annual basis by a designated coordinator (registered nurse). A 24-hour urine collection estimates renal function. Blood pressure and blood chemistry are measured and urinalysis performed. Current health status and wound discomfort are assessed. Any medical problems identified are referred to a specialist hospital department or to the donor's family practitioner.

Results

Fifty-nine appointments were booked and 12 (20%) donors did not attend. Renal function was within acceptable limits for all attending donors. Three donors had raised blood glucose levels and 8 donors were hypertensive; all were referred to family practitioners. Forty-seven donors (35 new, 12 return) completed a questionnaire on the follow-up provided. Thirty-eight (81%) were satisfied with the follow-up, and 47 (100%) agreed this clinic provided adequate follow-up. Thirty-three (70%) donors stated they preferred that the transplant coordinator performed the follow-up, 3 (6%) preferred the family practitioner, and 11 (23%) had no preference.

Conclusions

There are many possible solutions to the provision of lifelong care of living kidney donors. The model of a transplant coordinator-led clinic appears to have a high degree of patient acceptance, perhaps because of the continuity of care provided by a known member of the transplant team. Further work is required to identify reasons for nonattendance.