Simultaneous heart-kidney transplant in patients with borderline estimated glomerular filtration rate without dialysis dependency

BACKGROUND

Appropriate patient selection for simultaneous heart-kidney transplantation (sHK) in patients with moderate renal dysfunction remains challenging.

METHODS

From the United Network for Organ Sharing database (2003-2020), we identified 5678 adults with an estimated pre-transplant glomerular filtration rate (eGFR) between 30 and 45 mL/min/1.73 m2 and no pre-transplant dialysis. Patients undergoing sHK (n = 293) were compared with those undergoing heart transplantation alone (n = 5385) using 1:3 propensity score matching.

RESULTS

The sHK utilization rate increased from 1.8% in 2003 to 12.2% in 2020 (p < .001). After matching, 1 and 5-year survival was 87.7% (95% confidence interval [CI] 83.3-91.0) and 80.0% (95% CI 74.2-84.6) after sHK, and 87.3% (95% CI 85.2-89.1) and 71.8% (95% CI 68.4-74.9) after heart transplant alone (p = .04). In the subgroup analysis, sHK was associated with a 5-year survival benefit only in patients with 30 < eGFR ≤ 35 mL/min/1.73 m2 (p = .05) but not in those with 35 < eGFR < 45 mL/min/1.73 m2 (p = .45). Patients who underwent heart transplants alone also had a higher incidence of becoming chronic dialysis-dependent after transplant within 5-year follow-up (10.2%, 95% CI 8.0-12.6 vs. 3.8%, 95% CI 1.7-7.1, p = .004). The 5-year incidence of subsequent kidney waitlisting and transplants after heart transplants alone was 5.6% and 1.9%, respectively.

CONCLUSION

Among propensity-matched patients without pre-transplant dialysis, compared to heart transplants alone, sHK had improved 5-year survival in those with 30 < eGFR ≤ 35 but not in those with 35 < eGFR < 45 mL/min/1.73 m2 . One-year survival was similar irrespective of eGFR. Receiving a kidney after a heart transplant alone is rare under the current allocation system.

The state of global surgery assessment and data collection tools: A scoping review

BACKGROUND

There has been a proliferation of global surgery assessment tools designed for use in low- and middle-income countries. This scoping review sought to categorize and organize the breadth of global surgery assessment tools in the literature.

METHODS

The search was conducted using PubMed from October 2022 to April 2023 according to PRISMA extension for scoping review guidelines. The search terms were (("global surgery"[All Fields]) AND ("assessment"[All Fields]) OR (data collection)). Only tools published in English that detailed surgical assessment tools designed for low- and middle-income countries were included.

RESULTS

The search resulted in 963 papers and 46 texts described unique tools that were included for the final review. Of these, 30 (65%) tools were quantitative, 1 (2%) qualitative, and 15 (33%) employed mixed-methods. 25 (54%) tools evaluated surgery in general, whereas 21 (46%) were focused on various surgical subspecialties. Qualitatively, major themes among the tools were noted. There was significant overlap of many tools.

CONCLUSIONS

Nonspecialty surgery was represented more than any specialty surgery and many specialties had little or no representation in the literature. Ideally, local leadership should be involved in surgical assessment tools. Different methodologies, such as checklists and observational studies, aimed to target varying aspects of surgery and had distinct strengths and weaknesses. Further efforts should focus on expanding tools in neglected specialties.

Perceived Susceptibility to Chronic Kidney Disease and Hypertension Self-Management among Black and White Live Kidney Donors

Background

Despite the societal benefits of live kidney donation, Black donors may be more likely than White donors to develop hypertension (HTN) and chronic kidney disease after donation. Among live kidney donors diagnosed with post-donation HTN, little is known about potential racial/ethnic differences in HTN self-care behaviors and perceived susceptibility to developing kidney disease.

Methods

We ascertained electronic medical records and phone survey data from live donors enrolled in the multi-center Wellness and Health Outcomes of LivE Donors (WHOLE-Donor) Hypertension Care Study between May 2013 and April 2020. Using multivariable logistic regression models performed January through June 2021, we examined potential associations of donor race/ethnicity with perceived susceptibility to kidney disease and self-care behaviors (ie, Behavioral Risk Factor Surveillance System measure assessing self-reported actions to control high blood pressure).

Results

The study included 318 US-based live kidney donors who developed post-donation HTN (57.6% female; 78.9% White; 18.6% Black; and mean age 46.7 years at donation). Black donors were equally as likely as White donors to report being moderately or strongly concerned about developing kidney disease (adjusted odds ratio, aOR: 1.27, 95%CI: .66, 2.14, P=.57). Donors with diabetes were more likely than those without diabetes (aOR: 2.43, 95%CI: 1.03, 5.01, P=.04), while donors aged >50 years were less likely than younger donors (aOR: .39, 95%CI: .18, .85, P=.02) to report being moderately or strongly concerned about kidney disease. Overall, 87% of donors reported taking at least one action to help control blood pressure, with no significant differences by sociodemographic factors.

Conclusions

We found no substantial differences in perceived susceptibility to kidney disease among Black and White donors, despite published evidence that Black donors may experience greater risk of developing kidney disease than White donors. Behavioral interventions to enhance knowledge about future disease risk, attitudes, and self-care strategies among living kidney donors may be beneficial.

Piloting an Assessment Tool to Organize Surgical Care in Armed Conflicts: Findings From Cameroon

INTRODUCTION

Armed conflict is increasing globally and is dramatically disrupting surgical care more than ever before. To address this, the PIPESS (Personnel, Infrastructure, Procedures, Equipment, Supplies, and Standard) tool was designed to facilitate assessment of hospital capacity. It assesses 6 key categories at 3 timepoints: preconflict, during conflict, and postconflict. This tool was piloted to assess the impact of conflict and COVID-19 on surgical care delivery at the Buea Regional Hospital in Cameroon.

METHODS

This was a cross-sectional, qualitative study combining in-depth interviews and on-site observations of the surgical care unit. The data collected during the interviews were then applied to the modified PIPESS tool to calculate a preconflict score based on recall and a during conflict score to quantify differences before and during conflict.

RESULTS

We interviewed 12 key informants: 6 patients, 3 doctors, and 3 other staff. The themes extracted from the preconflict period highlight major barriers including rudimentary prehospital care and referral limitations from remote areas, lack of funding and training, and a demand exceeding the supply of care. COVID-19 resulted in an influx of resources into the region and did not disrupt care to the extent of the conflict. Quantitatively, the PIPESS score for preconflict was 110, and the PIPESS score during conflict was 115, showing an increase in resources, specifically in personnel and infrastructure during conflict.

CONCLUSIONS

The conflict increased the burden on existing health centers and strained resources for trauma care. Paradoxically, surgical resources increased during the conflict likely because of increased international support along with local displacement of staff toward the hospital. Further data should be collected during the postconflict setting.