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Beresford M, Casula A, Pippias M, Griffin S, Hilton R, Greenhall G, Savino M, Bailey P, Steenkamp R, Nitsch D, Hole B. A registry-based retrospective study comparing pre-dialysis care and early outcomes in native vs transplant kidney failure. Clin Kidney J 2025; 18:sfaf158. [PMID: 40491780 PMCID: PMC12146846 DOI: 10.1093/ckj/sfaf158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Indexed: 06/11/2025] Open
Abstract
Background Starting dialysis is associated with morbidity and mortality. Outcomes for people with failed transplants can be poorer than for people with native kidney failure. We aimed to determine whether dialysis modality, place of initiation and mortality outcomes differed in the first 90 days between people starting dialysis for transplant and native kidney failure. Methods Retrospective cohort using linked UK Renal Registry data and Hospital Episode Statistics. Modality, place of initiation and outcomes compared with Day 90 for 16 417 adults starting dialysis in England between January 2018 and December 2019. Results Relative to those with native kidney failure (90.6%), those with transplant failure (9.4%) were younger (median 55.2 vs 66.3 years) and commenced more in-centre haemodialysis [86.8% vs 82.2%, adjusted odds ratio (OR) 1.72, 95% confidence interval (CI) 1.47-2.01; P < .0001]. Compared with individuals reported to have native chronic kidney disease, and accounting for age, sex, diabetes and ethnicity, those with transplant failure had increased odds of starting dialysis in hospital (adjusted OR 2.26, 95% CI 1.84-2.76; P < .0001), at higher estimated glomerular filtration rates (eGFRs) (8.9 vs 7.9 mL/min/1.73 m²; P = .0001), and death [adjusted OR 1.95, 95% CI 1.31-2.90; P = .001). Discussion UK patients starting dialysis for transplant failure do so at higher eGFRs than those receiving specialist chronic kidney disease care. Those with transplant failure appear disproportionately likely to start as inpatients, receive haemodialysis or die within 90 days. These findings are likely to reflect differences between both patient groups and care pathways. Deeper understanding may inform improvements in care.
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Affiliation(s)
- Matthew Beresford
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Anna Casula
- UK Kidney Association, UK Renal Registry, Bristol, UK
| | - Maria Pippias
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Sian Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, UK
| | - Rachel Hilton
- Departments of Nephrology and Transplantation, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - George Greenhall
- Department of Nephrology and Transplantation, Barts Health NHS Trust, London, UK
| | - Manuela Savino
- UK Kidney Association, UK Renal Registry, Bristol, UK
- University Hospitals Bristol & Weston, Bristol, UK
| | - Phillippa Bailey
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | | | - Dorothea Nitsch
- UK Kidney Association, UK Renal Registry, Bristol, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Barnaby Hole
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
- UK Kidney Association, UK Renal Registry, Bristol, UK
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Bessa AB, Cristelli MP, Felipe CR, Foresto RD, Fonseca MCM, Pestana JM, Tedesco-Silva H. Real-world cost-effectiveness analysis of thymoglobulin versus no induction therapy in kidney transplant recipients at low risk of graft loss. J Bras Nefrol 2025; 47:e20240060. [PMID: 39776149 PMCID: PMC11772011 DOI: 10.1590/2175-8239-jbn-2024-0060en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 10/07/2024] [Indexed: 01/11/2025] Open
Abstract
BACKGROUND A new induction therapy strategy of a single 3 mg/kg dose of rabbit antithymocyte globulin (r-ATG) showed a lower incidence of acute rejection. METHODS The objective of this study was to use real-world data to determine the incremental cost-effectiveness ratio (ICER) of r-ATG induction for the prevention of acute rejection (AR) in the first year following kidney transplantation and for kidney graft survival over 1, 4, and 10 years of post-transplantation from the perspective of the national public healthcare system. A Markov state transition model was developed utilizing real-world data extracted from medical invoices from a single center. The study population consisted of adults at low immunological risk undergoing their initial transplantation and received kidneys from either living or deceased donors. The intervention of r-ATG induction was compared to no induction. The clinical outcomes considered for this analysis were acute rejection, cytomegalovirus infection/disease, death, graft loss, and retransplantation. RESULTS The cost-effectiveness analysis in the first year revealed that the r-ATG group was more cost-effective, with an ICER of US$ 399.96 per avoided AR episode, an effectiveness gain of 0.01 year in graft survival and a total incremental cost of US$ 147.50. The 4- and 10-year analyses revealed an effectiveness gain of 0.06 and 0.16 years in graft survival in the r-ATG induction group, and a total incremental cost of US$ -321.68 and US$ -2,440.62, respectively. CONCLUSION The single 3 mg/kg dose of r-ATG is cost-effective in preventing acute rejection episodes and dominant in the long term of transplantation, conferring survival gain.
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Affiliation(s)
- Adrieli Barros Bessa
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | | | | | - Renato Demarchi Foresto
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
- Fundação Oswaldo Ramos, Hospital do Rim, São Paulo, SP, Brazil
| | - Marcelo Cunio Machado Fonseca
- Universidade Federal de São Paulo, Departamento de Ginecologia, Núcleo de Avaliação em Tecnologias em Saúde, São Paulo, SP, Brazil
| | - Jose Medina Pestana
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
- Fundação Oswaldo Ramos, Hospital do Rim, São Paulo, SP, Brazil
| | - Helio Tedesco-Silva
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
- Fundação Oswaldo Ramos, Hospital do Rim, São Paulo, SP, Brazil
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Okumi M, Inoue Y, Miyashita M, Ueda T, Fujihara A, Hongo F, Ukimua O. Genitourinary malignancies in kidney transplant recipients. Int J Urol 2024; 31:1321-1329. [PMID: 39316503 DOI: 10.1111/iju.15588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/09/2024] [Indexed: 09/26/2024]
Abstract
Advances in immunosuppressive therapy and postoperative management have greatly improved the graft and patient survival rates after kidney transplantation; however, the incidence of post-transplant malignant tumors is increasing. Post-renal transplantation malignant tumors are associated with renal failure, immunosuppression, and viral infections. Moreover, the risk of developing cancer is higher in kidney transplant recipients than in the general population, and the tendency to develop cancer is affected by the background and environment of each patient. Recently, cancer after kidney transplantation has become the leading cause of death in Japan. Owing to the aggressive nature and poor prognosis of genitourinary malignancies, it is crucial to understand their epidemiology, risk factors, and best practices in kidney transplant recipients. This review has a special emphasis on the epidemiology, risk factors, and treatment protocols of genitourinary malignancies in kidney transplant recipients to enhance our understanding of the appropriate management strategies. Optimal immunosuppressive therapy and cancer management for these patients remain controversial, but adherence to the general guidelines is recommended.
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Affiliation(s)
- Masayoshi Okumi
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuta Inoue
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masatsugu Miyashita
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Ueda
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Atsuko Fujihara
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumiya Hongo
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Ukimua
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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4
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Pan FS, Yang DP, Zhao GD, Huang SQ, Wang Y, Xu M, Qiu J, Zheng YL, Xie XY, Huang G. Prediction of allograft function in pre-transplant kidneys using sound touch elastography (STE): an ex vivo study. Insights Imaging 2024; 15:245. [PMID: 39392520 PMCID: PMC11469982 DOI: 10.1186/s13244-024-01837-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Accepted: 09/29/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND The purpose of the study was to evaluate renal quality and predict posttransplant graft function using ex vivo sound touch elastography (STE). METHODS In this prospective study, 106 donor kidneys underwent ex vivo STE examination and biopsy from March 2022 to August 2023. The mean stiffness of the superficial cortex (STEsc), deep cortex (STEdc), and medulla (STEme) was obtained and synthesized into one index (STE) through the factor analysis method. Additionally, 100 recipients were followed up for 6 months. A random forest algorithm was employed to explore significant predictive factors associated with the Remuzzi score and allograft function. The performance of parameters was evaluated by using the area under the receiver operating characteristic curve (AUC). RESULTS STE had AUC values of 0.803 for diagnosing low Remuzzi and 0.943 for diagnosing high Remuzzi. Meanwhile, STE had an AUC of 0.723 for diagnosing moderate to severe ATI. Random forest algorithm identified STE and Remuzzi score as significant predictors for 6-month renal function. The AUC for STE in predicting postoperative allograft function was 0.717, which was comparable with that of the Remuzzi score (AUC = 0.756). Nevertheless, the specificity of STE was significantly higher than that of Remuzzi (0.913 vs 0.652, p < 0.001). Given these promising results, donor kidneys can be transplanted directly without the need for biopsy when STE ≤ 11.741. CONCLUSIONS The assessment of kidney quality using ex vivo STE demonstrated significant predictive value for the Remuzzi score and allograft function, which could help avoid unnecessary biopsy. CRITICAL RELEVANCE STATEMENT Pre-transplant kidney quality measured with ex vivo STE can be used to assess donor kidney quality and avoid unnecessary biopsy. KEY POINTS STE has significant value for diagnosing low Remuzzi and high Remuzzi scores. STE achieved good performance in predicting posttransplant allograft function. Assessment of kidney quality using ex vivo STE could avoid unnecessary biopsies.
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Affiliation(s)
- Fu-Shun Pan
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dao-Peng Yang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
| | - Guo-Dong Zhao
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Shu-Qi Huang
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ming Xu
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jiang Qiu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yan-Ling Zheng
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Yan Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Gang Huang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China.
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Murakami N, Reich AJ, He K, Gelfand SL, Leiter RE, Sciacca K, Adler JT, Lu E, Ong SC, Concepcion BP, Singh N, Murad H, Anand P, Ramer SJ, Dadhania DM, Lentine KL, Lakin JR, Alhamad T. Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study. Am J Kidney Dis 2024; 83:173-182.e1. [PMID: 37726050 PMCID: PMC11360225 DOI: 10.1053/j.ajkd.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/03/2023] [Accepted: 07/09/2023] [Indexed: 09/21/2023]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population. STUDY DESIGN National explanatory sequential mixed methods study including an online survey and semistructured interviews. SETTING & PARTICIPANTS Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022. ANALYTICAL APPROACH Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data. RESULTS A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care. LIMITATIONS Potential selection bias. CONCLUSIONS Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them. PLAIN-LANGUAGE SUMMARY Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine He
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samantha L Gelfand
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joel T Adler
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Emily Lu
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Song C Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | - Haris Murad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Prince Anand
- Medical University of South Carolina, Greenville, South Carolina
| | | | | | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St Louis, Missouri
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri.
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6
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Perez-Gutierrez A, McGill RL, Juengel B, Bachul PJ, Danz DN, Josephson M, Chung BB, Nguyen A, Fung JJ, Barth RN, Becker YT. The Seattle Heart Failure Model in Kidney Transplant Recipients. J Clin Med 2023; 12:7614. [PMID: 38137683 PMCID: PMC10743453 DOI: 10.3390/jcm12247614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Cardiovascular disease is the leading cause of mortality following kidney transplantation. Heart failure affects 17-21% of patients with chronic kidney disease and increases along with time receiving dialysis. The Seattle Heart Failure Model (SHFM) is a validated mortality risk model for heart failure patients that incorporates clinical, therapeutic, and laboratory parameters but does not include measures of kidney function. We applied the SHFM to patients with end-stage renal disease (ESRD) who were being evaluated for kidney transplantation to determine if the model was associated with post-transplant mortality. This retrospective single-center study analyzed survival among 360 adult deceased-donor kidney transplant recipients. Cox regression was used to model post-transplant patient survival. Our findings indicated that a 1.0-point increase in the adapted SHFM score was significantly associated with post-transplant mortality (HR 1.76, 95% CI = 1.10-2.83, p = 0.02), independently of the Kidney Donor Profile Index and Estimated Post-Transplant Survival. Individual covariates of the SHFM were evaluated in univariate analyses, and age, sodium, cholesterol, and lymphocyte count were significantly related to mortality. This study provides preliminary evidence that an adapted SHFM score could be a useful tool in evaluating mortality risk post-transplant in patients with ESRD.
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Affiliation(s)
| | - Rita L. McGill
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Braden Juengel
- Department of Surgery, Transplant Institute, University of Chicago, Chicago, IL 60637, USA
| | - Piotr J. Bachul
- Department of Surgery, Transplant Institute, University of Chicago, Chicago, IL 60637, USA
| | - David N. Danz
- Department of Economics, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Michelle Josephson
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Ben B. Chung
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Ann Nguyen
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - John J. Fung
- Department of Surgery, Transplant Institute, University of Chicago, Chicago, IL 60637, USA
| | - Rolf N. Barth
- Department of Surgery, Transplant Institute, University of Chicago, Chicago, IL 60637, USA
| | - Yolanda T. Becker
- Department of Surgery, Transplant Institute, University of Chicago, Chicago, IL 60637, USA
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7
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Zhang C, Mathur AK. Breaking Barriers and Bridging Gaps: Advancing Diversity, Equity, and Inclusion in Kidney Transplant Care for Black and Hispanic Patients in the United States. Transpl Int 2023; 36:11455. [PMID: 37829616 PMCID: PMC10565005 DOI: 10.3389/ti.2023.11455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/15/2023] [Indexed: 10/14/2023]
Abstract
Kidney transplantation offers better mortality and quality of life outcomes to patients with end-stage renal failure compared to dialysis. Specifically, living donor kidney transplantation is the best treatment for end-stage renal disease, since it offers the greatest survival benefit compared to deceased donor kidney transplant or dialysis. However, not all patients from all racial/ethnic backgrounds enjoy these benefits. While black and Hispanic patients bear the predominant disease burden within the United States, they represent less than half of all kidney transplants in the country. Other factors such as cultural barriers that proliferate myths about transplant, financial costs that impede altruistic donation, and even biological predispositions create a complex maze and can also perpetuate care inaccessibility. Therefore, blanket efforts to increase the overall donation pool may not extend access to vulnerable populations, who may require more targeted attention and interventions. This review uses US kidney transplantation data to substantiate accessibility differences amongst racial minorities as well as provides examples of successful institutional and national systemic level changes that have improved transplantation outcomes for all.
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Affiliation(s)
- Chi Zhang
- Mayo Clinic Arizona, Phoenix, AZ, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
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8
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Tanriover C, Copur S, Basile C, Ucku D, Kanbay M. Dialysis after kidney transplant failure: how to deal with this daunting task? J Nephrol 2023; 36:1777-1787. [PMID: 37676635 DOI: 10.1007/s40620-023-01758-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 08/06/2023] [Indexed: 09/08/2023]
Abstract
The best treatment for patients with end-stage kidney disease is kidney transplantation, which, if successful provides both a reduction in mortality and a better quality of life compared to dialysis. Although there has been significant improvement in short-term outcomes after kidney transplantation, long-term graft survival still remains insufficient. As a result, there has been an increase in the number of individuals who need dialysis again after kidney transplant failure, and increasingly contribute to kidney transplant waiting lists. Starting dialysis after graft failure is a difficult task not only for the patients, but also for the nephrologists and the care team. Furthermore, recommendations for management of dialysis after kidney graft loss are lacking. Aim of this narrative review is to provide a perspective on the role of dialysis in the management of patients with failed kidney allograft. Although numerous studies have reported higher mortality in patients undergoing dialysis following kidney allograft failure, reports are contrasting. A patient-centered, individualized approach should drive the choices of initiating dialysis, dialysis modality, maintenance of immunosuppressive drugs and vascular access.
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Affiliation(s)
- Cem Tanriover
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Via Battisti 192, 74121, Taranto, Italy.
| | - Duygu Ucku
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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9
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Ogawa L, Beaird OE, Schaenman JM. Risk factors for infection in patients with a failed kidney allograft on immunosuppressive medications. FRONTIERS IN NEPHROLOGY 2023; 3:1149116. [PMID: 37675348 PMCID: PMC10479655 DOI: 10.3389/fneph.2023.1149116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 07/17/2023] [Indexed: 09/08/2023]
Abstract
Patients with a failing kidney allograft are often continued on immunosuppression (IS) to preserve residual kidney function and prevent allosensitization. It has been previously accepted that maintaining patients on immunosuppressive therapy results in an increased risk of infection, hospitalization, and mortality. However, as the management of IS in patients with a failed kidney allograft continues to evolve, it is important to review the data regarding associations between infection and specific immunosuppression regimens. We present a review of the literature of failed kidney allograft management and infection risk, and discuss practices for infection prevention. Fifteen studies, published from 1995 to 2022, which investigated the experience of patients with failed allograft and infection, were identified. Infection was most commonly documented as a general event, but when specified, included infections caused by Candida, Mycobacterium tuberculosis, and Aspergillus. In addition, the definition of reduced "IS" varied from decreased doses of a triple drug regimen to monotherapy, whereas others did not specify which medications patients were receiving. Despite attempts at lowering net immunosuppression, patients with failed allografts remain at risk of acquiring opportunistic and non-opportunistic infections. Although opportunistic infections secondary to IS are expected, somewhat surprisingly, it appears that the greatest risk of infection may be related to complications of dialysis. Therefore, mitigating strategies, such as planning for an arteriovenous (AV) fistula over a hemodialysis catheter placement, may reduce infection risk. Additional studies are needed to provide more information regarding the types and timing of infection in the setting of a failed kidney allograft. In addition, more data are needed regarding specific medications, doses, and timing of taper of IS to guide future patient management and inform strategies for infection surveillance and prophylaxis.
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Affiliation(s)
| | | | - Joanna M. Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine at University of California—Los Angeles, Los Angeles, CA, United States
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10
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Alhamad T, Murad H, Dadhania DM, Pavlakis M, Parajuli S, Concepcion BP, Singh N, Murakami N, Casey MJ, Ji M, Lubetzky M, Tantisattamo E, Alomar O, Faravardeh A, Blosser CD, Basu A, Gupta G, Adler JT, Adey D, Woodside KJ, Ong SC, Parsons RF, Lentine KL. The Perspectives of General Nephrologists Toward Transitions of Care and Management of Failing Kidney Transplants. Transpl Int 2023; 36:11172. [PMID: 37456682 PMCID: PMC10348051 DOI: 10.3389/ti.2023.11172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
The management of failing kidney allograft and transition of care to general nephrologists (GN) remain a complex process. The Kidney Pancreas Community of Practice (KPCOP) Failing Allograft Workgroup designed and distributed a survey to GN between May and September 2021. Participants were invited via mail and email invitations. There were 103 respondents with primarily adult nephrology practices, of whom 41% had an academic affiliation. More than 60% reported listing for a second kidney as the most important concern in caring for patients with a failing allograft, followed by immunosuppression management (46%) and risk of mortality (38%), while resistant anemia was considered less of a concern. For the initial approach to immunosuppression reduction, 60% stop antimetabolites first, and 26% defer to the transplant nephrologist. Communicating with transplant centers about immunosuppression cessation was reported to occur always by 60%, and sometimes by 29%, while 12% reported making the decision independently. Nephrologists with academic appointments communicate with transplant providers more than private nephrologists (74% vs. 49%, p = 0.015). There are heterogeneous approaches to the care of patients with a failing allograft. Efforts to strengthen transitions of care and to develop practical practice guidelines are needed to improve the outcomes of this vulnerable population.
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Affiliation(s)
- Tarek Alhamad
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Haris Murad
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Darshana M. Dadhania
- Department of Transplantation Medicine, Weill Cornel Medicine - New York Presbyterian Hospital, New York, NY, United States
| | - Martha Pavlakis
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard University, Boston, MA, United States
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin - Madison, Madison, WI, United States
| | | | - Neeraj Singh
- John C. McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, LA, United States
| | - Naoka Murakami
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Michael J. Casey
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Mengmeng Ji
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Michelle Lubetzky
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Ekamol Tantisattamo
- Department of Medicine, University of California, Irvine, Orange, CA, United States
| | - Omar Alomar
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, CA, United States
| | - Christopher D. Blosser
- Department of Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Arpita Basu
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Gaurav Gupta
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Joel T. Adler
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Deborah Adey
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | | | - Song C. Ong
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ronald F. Parsons
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University, Saint Louis, MO, United States
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11
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Gniewkiewicz M, Gozdowska J, Deborska‐Materkowska D, Czerwinska K, Perkowska‐Ptasinska A, Burban A, Cieslik A, Kosieradzki M, Durlik M. Potential utility of urinary chemokine CCL2 to creatinine ratio in prognosis of 5-year graft failure and mortality post 1-year protocol biopsy in kidney transplant recipients. Immun Inflamm Dis 2023; 11:e901. [PMID: 37382267 PMCID: PMC10281015 DOI: 10.1002/iid3.901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Chemokines (chemotactic cytokines) are small proteins which are engaged in many pathophysiological processes, including inflammation and homeostasis. In recent years, application of chemokines in transplant medicine was intensively studied. The aim of this study was to determine the utility of urinary chemokines CCL2 (C-C motif ligand 2) and CXCL10 (C-X-C motif chemokine ligand 10) in prognosis of 5-year graft failure and mortality post 1-year protocol biopsy in renal transplant recipients. METHODS Forty patients who had a protocol biopsy 1 year after renal transplantation were included. Concentrations of CCL2 and CXCL10 in urine with reference to urine creatinine were measured. All patients were under the supervision of one transplant center. Long-term outcomes within 5 years after 1-year posttransplant biopsy were analyzed. RESULTS Urinary CCL2:Cr at the time of biopsy was significantly increased in patients who died or had graft failure. CCL2:Cr was proven to be a significant predictor of 5-year graft failure and mortality (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.02-1.19, p = .02; OR: 1.08, 95% CI: 1.02-1.16, p = .04; respectively). CONCLUSION Chemokines are easily detected by current methods. In the era of personalized medicine, urinary CCL2:Cr can be considered as a factor providing complementary information regarding risk of graft failure or increased mortality.
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Affiliation(s)
- Michal Gniewkiewicz
- Department of Transplantation Medicine, Nephrology and Internal MedicineMedical University of WarsawWarsawPoland
| | - Jolanta Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal MedicineMedical University of WarsawWarsawPoland
| | | | - Katarzyna Czerwinska
- Department of Transplantation Medicine, Nephrology and Internal MedicineMedical University of WarsawWarsawPoland
| | | | - Anna Burban
- Department of Transplantation Medicine, Nephrology and Internal MedicineMedical University of WarsawWarsawPoland
| | - Aleksandra Cieslik
- Department of Transplantation Medicine, Nephrology and Internal MedicineMedical University of WarsawWarsawPoland
| | - Maciej Kosieradzki
- Department of General and Transplantation SurgeryMedical University of WarsawWarsawPoland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal MedicineMedical University of WarsawWarsawPoland
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12
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Elgenidy A, Shemies RS, Atef M, Awad AK, El-Leithy HH, Helmy M, Aly MG. Revisiting maintenance immunosuppression in patients with renal transplant failure: early weaning of immunosuppression versus prolonged maintenance-systematic review and meta-analysis. J Nephrol 2023; 36:537-550. [PMID: 36109426 DOI: 10.1007/s40620-022-01458-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/28/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Prolonged immunosuppression after dialysis start has been assumed to reduce sensitization, need for graft nephrectomy, and to favor re-transplantation. In contrast, immunosuppression is considered to increase the risk of mortality, infection, and malignancy. We aimed to assess the evidence regarding superiority of early or late withdrawal of maintenance immunosuppression post renal transplant failure. METHODS A literature search of the PubMed, WOS, Ovid, and Scopus databases was conducted. Combined relative risks, (RRs), mean differences, and 95% confidence intervals (CIs) were calculated by using a random-effect model. RESULTS Ten studies involving 1187 patients with kidney transplant failure were included. No difference could be detected between patients with early withdrawal of immunosuppressive drugs (≤ 3 months) or prolonged immunosuppressive treatment (> 3 months) regarding mortality (95% CI 0.91-2.28), panel reactive antibodies (PRAs) (95% CI - 0.75-30.10), re-transplantation rate (95% CI 0.55-1.35), infectious episodes (95% CI 0.67, 1.17), cancer (95% CI 0.26-1.54), and graft nephrectomy (95% CI 0.82-1.63). Similarly, no difference was found between immunosuppressive drug withdrawal over < 6 or ≥ 6 months regarding mortality (95% CI 0.16, 2.89), re-transplantation rate (95% CI 0.85-1.55), cancer (95% CI 0.37-1.63), and allograft nephrectomy (95% CI 0.87-4.33). CONCLUSION Prolonged maintenance immunosuppression post kidney transplant failure is not associated with increased risk of mortality, infection, or malignancy, or reduced risk of sensitization or allograft nephrectomy compared with early withdrawal.
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Affiliation(s)
| | - Rasha Samir Shemies
- Mansoura and Nephrology Dialysis Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mostafa Atef
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | | | | | - Mostafa G Aly
- Nephrology Unit, Internal Medicine Department, Assiut University, Assiut, Egypt.
- Transplantation Immunology, Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany.
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany.
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13
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Murakami N, Reich AJ, Pavlakis M, Lakin JR. Conservative Kidney Management in Kidney Transplant Populations. Semin Nephrol 2023; 43:151401. [PMID: 37499572 PMCID: PMC10543459 DOI: 10.1016/j.semnephrol.2023.151401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.
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Affiliation(s)
- Naoka Murakami
- Harvard Medical School, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Amanda J Reich
- Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Martha Pavlakis
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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14
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Bunthof K, Saboerali K, Wetering JVD, Nurmohamed A, Bemelman F, Zuilen AV, Brand JVD, Baas M, Hilbrands L. Can We Predict Graft Intolerance Syndrome After Kidney Transplant Failure? External Validation of a Previously Developed Model. Transpl Int 2023; 36:11147. [PMID: 37213489 PMCID: PMC10195885 DOI: 10.3389/ti.2023.11147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/25/2023] [Indexed: 05/23/2023]
Abstract
Previously we established a prediction model for graft intolerance syndrome requiring graft nephrectomy in patients with late kidney graft failure. The aim of this study is to determine generalizability of this model in an independent cohort. The validation cohort included patients with late kidney graft failure between 2008 and 2018. Primary outcome is the prognostic performance of our model, expressed as the area under the receiver operating characteristic curve (ROC-AUC), in the validation cohort. In 63 of 580 patients (10.9%) a graft nephrectomy was performed because of graft intolerance. The original model, which included donor age, graft survival and number of acute rejections, performed poorly in the validation cohort (ROC-AUC 0.61). After retraining of the model using recipient age at graft failure instead of donor age, the model had an average ROC-AUC of 0.70 in the original cohort and of 0.69 in the validation cohort. Our original model did not accurately predict the graft intolerance syndrome in a validation cohort. However, a retrained model including recipient age at graft failure instead of donor age performed moderately well in both the development and validation cohort enabling identification of patients with the highest and lowest risk of graft intolerance syndrome.
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Affiliation(s)
- Kim Bunthof
- Department of Nephrology, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Internal Medicine, Bravis Ziekenhuis, Roosendaal, Netherlands
| | - Khalid Saboerali
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | | | - Azam Nurmohamed
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Frederike Bemelman
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Arjan Van Zuilen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Marije Baas
- Department of Nephrology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Centre, Nijmegen, Netherlands
- *Correspondence: Luuk Hilbrands,
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15
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Effect of Maintaining Immunosuppression After Kidney Allograft Failure on Mortality and Retransplantation. Transplant Direct 2022; 9:e1415. [DOI: 10.1097/txd.0000000000001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022] Open
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16
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Takahashi K, Furuya K, Gosho M, Usui J, Kimura T, Hoshi A, Hashimoto S, Nishiyama H, Oda T, Yuzawa K, Yamagata K. Prediction of early graft function after living donor kidney transplantation by quantifying the "nephron mass" using CT-volumetric software. Front Med (Lausanne) 2022; 9:1007175. [PMID: 36388906 PMCID: PMC9649930 DOI: 10.3389/fmed.2022.1007175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/10/2022] [Indexed: 08/30/2023] Open
Abstract
Early renal function after living-donor kidney transplantation (LDKT) depends on the "nephron mass" in the renal graft. In this study, as a possible donor-recipient size mismatch parameter that directly reflects the "nephron mass," the cortex to recipient weight ratio (CRWR) was calculated by CT-volumetric software, and its ability to predict early graft function was examined. One hundred patients who underwent LDKT were enrolled. Patients were classified into a developmental cohort (n = 79) and a validation cohort (n = 21). Using the developmental cohort, the correlation coefficients between size mismatch parameters, including CRWR, and the posttransplantation estimated glomerular filtration rate (eGFR) were calculated. Multiple regression analysis was conducted to define a formula to predict eGFR 1-month posttransplantation. Using the validation cohort, the validity of the formula was examined. The correlation coefficient was the highest for CRWR (1-month r = 0.66, p < 0.001). By multiple regression analysis, eGFR at 1-month was predicted using the linear model: 0.23 × donor preoperative eGFR + 17.03 × CRWR + 8.96 × preemptive transplantation + 5.10 (adjusted coefficient of determination = 0.54). In most patients in the validation cohort, the observed eGFR was within a 10 ml/min/1.73 m2 margin of the predicted eGFR. CRWR was the strongest parameter to predict early graft function. Predicting renal function using this formula could be useful in clinical application to select proper donors and to avoid unnecessary postoperative medical interventions.
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Affiliation(s)
- Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, Tsukuba, Japan
| | - Kinji Furuya
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, Tsukuba, Japan
| | - Masahiko Gosho
- Department of Biostatistics, University of Tsukuba, Tsukuba, Japan
| | - Joichi Usui
- Department of Nephrology, University of Tsukuba, Tsukuba, Japan
| | - Tomokazu Kimura
- Department of Urology, University of Tsukuba, Tsukuba, Japan
| | - Akio Hoshi
- Department of Urology, University of Tsukuba, Tsukuba, Japan
| | - Shinji Hashimoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, Tsukuba, Japan
| | | | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, University of Tsukuba, Tsukuba, Japan
| | - Kenji Yuzawa
- Department of Transplant Surgery, Mito Medical Center, Mito, Japan
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17
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Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review. J Clin Med 2022; 11:6108. [PMID: 36294429 PMCID: PMC9605319 DOI: 10.3390/jcm11206108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Patients with a failed kidney allograft have steadily increase in recent years and returning to dialysis after graft loss is one of the most difficult transitions for chronic kidney disease patients and their assistant physicians. The management of these patients is complex and encompasses the treatment of chronic kidney disease complications, dialysis restart and access planning, immunosuppression withdrawal, graft nephrectomy, and evaluation for a potential retransplant. In recent years, several groups have focused on the management of the patient with a failing renal graft and expert recommendations are arising. A review of Pubmed, ScienceDirect and the Cochrane Library was performed focusing on the specific care of these patients, from the management of low clearance complications to concerns with a subsequent kidney transplant. Conclusion: There is a growing interest in the failing renal graft and new approaches to improve these patients' outcomes are being defined including specific multidisciplinary programs, individualized immunosuppression withdrawal schemes, and strategies to prevent HLA sensitization and increase retransplant rates.
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Affiliation(s)
- Rita Leal
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Clara Pardinhas
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - António Martinho
- Coimbra Histocompatibility Center, Portuguese Institute of Blood and Transplantation, 3041-861 Coimbra, Portugal
| | - Helena Oliveira Sá
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Urology and Kidney Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
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18
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Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:5753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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Affiliation(s)
- Rita Leal
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Clara Pardinhas
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - António Martinho
- Coimbra Histocompatibility Center, Portuguese Institute of Blood and Transplantation, 3041-861 Coimbra, Portugal
| | - Helena Oliveira Sá
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Urology and Kidney Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
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19
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Sorohan BM, Ismail G, Tacu D, Obrișcă B, Ciolan G, Gîngu C, Sinescu I, Baston C. Mycobacterium Tuberculosis Infection after Kidney Transplantation: A Comprehensive Review. Pathogens 2022; 11:pathogens11091041. [PMID: 36145473 PMCID: PMC9505385 DOI: 10.3390/pathogens11091041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis (TB) in kidney transplant (KT) recipients is an important opportunistic infection with higher incidence and prevalence than in the general population and is associated with important morbidity and mortality. We performed an extensive literature review of articles published between 1 January 2000 and 15 June 2022 to provide an evidence-based review of epidemiology, pathogenesis, diagnosis, treatment and outcomes of TB in KT recipients. We included all studies which reported epidemiological and/or outcome data regarding active TB in KT, and we approached the diagnostic and treatment challenges according to the current guidelines. Prevalence of active TB in KT recipients ranges between 0.3–15.2%. KT recipients with active TB could have a rejection rate up to 55.6%, a rate of graft loss that varies from 2.2% to 66.6% and a mortality rate up to 60%. Understanding the epidemiological risk, risk factors, transmission modalities, diagnosis and treatment challenges is critical for clinicians in providing an appropriate management for KT with TB. Among diagnostic challenges, which are at the same time associated with delay in management, the following should be considered: atypical clinical presentation, association with co-infections, decreased predictive values of screening tests, diverse radiological aspects and particular diagnostic methods. Regarding treatment challenges in KT recipients with TB, drug interactions, drug toxicities and therapeutical adherence must be considered.
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Affiliation(s)
- Bogdan Marian Sorohan
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
- Correspondence: ; Tel.: +40-740156198
| | - Gener Ismail
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Dorina Tacu
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Bogdan Obrișcă
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gina Ciolan
- Department of Pneumology, Marius Nasta National Institute of Pneumology, 050159 Bucharest, Romania
| | - Costin Gîngu
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
| | - Ioanel Sinescu
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
| | - Cătălin Baston
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
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20
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Sharif A. Deceased Donor Characteristics and Kidney Transplant Outcomes. Transpl Int 2022; 35:10482. [PMID: 36090778 PMCID: PMC9452640 DOI: 10.3389/ti.2022.10482] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the therapy of choice for people living with kidney failure who are suitable for surgery. However, the disparity between supply versus demand for organs means many either die or are removed from the waiting-list before receiving a kidney allograft. Reducing unnecessary discard of deceased donor kidneys is important to maximize utilization of a scarce and valuable resource but requires nuanced decision-making. Accepting kidneys from deceased donors with heterogenous characteristics for waitlisted kidney transplant candidates, often in the context of time-pressured decision-making, requires an understanding of the association between donor characteristics and kidney transplant outcomes. Deceased donor clinical factors can impact patient and/or kidney allograft survival but risk-versus-benefit deliberation must be balanced against the morbidity and mortality associated with remaining on the waiting-list. In this article, the association between deceased kidney donor characteristics and post kidney transplant outcomes for the recipient are reviewed. While translating this evidence to individual kidney transplant candidates is a challenge, emerging strategies to improve this process will be discussed. Fundamentally, tools and guidelines to inform decision-making when considering deceased donor kidney offers will be valuable to both professionals and patients.
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Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Adnan Sharif,
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21
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Vanhove T, Elias N, Safa K, Cohen-Bucay A, Schold JD, Riella LV, Gilligan H. Long-term outcome reporting in older kidney transplant recipients and the limitations of conventional survival metrics. Kidney Int Rep 2022; 7:2397-2409. [DOI: 10.1016/j.ekir.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/14/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
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22
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Cooper M, Schnitzler M, Nilubol C, Wang W, Wu Z, Nordyke RJ. Costs in the Year Following Deceased Donor Kidney Transplantation: Relationships With Renal Function and Graft Failure. Transpl Int 2022; 35:10422. [PMID: 35692736 PMCID: PMC9184448 DOI: 10.3389/ti.2022.10422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/28/2022] [Indexed: 11/18/2022]
Abstract
Relationships between renal function and medical costs for deceased donor kidney transplant recipients are not fully quantified post-transplant. We describe these relationships with renal function measured by estimated glomerular filtration rate (eGFR) and graft failure. The United States Renal Data System identified adults receiving single-organ deceased donor kidneys 2012–2015. Inpatient, outpatient, other facility costs and eGFRs at discharge, 6 and 12 months were included. A time-history of costs was constructed for graft failures and monthly costs in the first year post-transplant were compared to those without failure. The cohort of 24,021 deceased donor recipients had a 2.4% graft failure rate in the first year. Total medical costs exhibit strong trends with eGFR. Recipients with 6-month eGFRs of 30–59 ml/min/1.73m2 have total costs 48% lower than those <30 ml/min/1.73m2. For recipients with graft failure monthly costs begin to rise 3–4 months prior to failure, with incremental costs of over $38,000 during the month of failure. Mean annual total incremental costs of graft failure are over $150,000. Total costs post-transplant are strongly correlated with eGFR. Graft failure in the first year is an expensive, months-long process. Further reductions in early graft failures could yield significant human and economic benefits.
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Affiliation(s)
- Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, DC, United States
| | - Mark Schnitzler
- School of Medicine, Saint Louis University, St. Louis, MO, United States
| | - Chanigan Nilubol
- Medstar Georgetown Transplant Institute, Washington, DC, United States
| | | | - Zheng Wu
- Genesis Research, Hoboken, NJ, United States
| | - Robert J. Nordyke
- Beta6 Consulting Group, Los Angeles, CA, United States
- *Correspondence: Robert J. Nordyke, , orcid.org/0000-0003-2424-7852
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23
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Sageshima J, Chandar J, Chen LJ, Shah R, Al Nuss A, Vincenzi P, Morsi M, Figueiro J, Vianna R, Ciancio G, Burke GW. How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond. Transplantation 2022; 106:709-721. [PMID: 34310100 DOI: 10.1097/tp.0000000000003888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.
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Affiliation(s)
- Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rushi Shah
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ammar Al Nuss
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Paolo Vincenzi
- Surgical Transplant Fellow, Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
- Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
| | - George W Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL
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24
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Improving Outcomes after Allograft Nephrectomy through Use of Preoperative Angiographic Kidney Embolization. J Am Coll Surg 2022; 234:493-503. [PMID: 35290268 DOI: 10.1097/xcs.0000000000000079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Allograft nephrectomy (AN) has been associated with considerable perioperative morbidity. We aimed to determine if preoperative angiographic kidney embolization (PAKE) to induce graft thrombosis before AN improves outcomes. STUDY DESIGN We reviewed adult kidney transplant alone patients who underwent AN at a single center from 2002 to 2020 and compared perioperative outcomes for patients with and without PAKE. RESULTS Eighty patients underwent AN, including 54 (67.5%) with PAKE before AN and 26 (32.5%) with AN alone. PAKE was associated with significantly reduced blood loss (PAKE: mean 266 ± 292 mL vs AN alone: 495 ± 689 mL; p = 0.04) and reduced transfusion requirements (PAKE: mean 0.5 ± 0.8 packed red blood cell units vs AN alone: 1.6 ± 2.6 units; p = 0.004) despite similar preoperative hemoglobin levels. Mean operating time (PAKE: 142 ± 43 minutes vs AN alone: 202 ± 111 minutes; p = 0.001) and length of hospital stay (PAKE: 4.3 ± 2.0 days vs AN alone: 9.3 ± 9.4 days; p = 0.0003) also favored PAKE, as did the surgical complication rate (PAKE: 6/54 [11%] vs AN alone: 9/26 [35%], p = 0.02). Long-term patient survival after AN was comparable in both groups. CONCLUSIONS PAKE was associated with lower intraoperative blood loss, fewer transfusions, reduced operating time, shorter length of stay, and fewer surgical complications compared with AN alone at our center.
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25
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Murakami N, Baggett ND, Schwarze ML, Ladin K, Courtwright AM, Goldberg HJ, Nolley EP, Jain N, Landzberg M, Wentlandt K, Lai JC, Shinall MC, Ufere NN, Jones CA, Lakin JR. Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation. J Palliat Med 2022; 25:1136-1142. [PMID: 35275707 PMCID: PMC9467633 DOI: 10.1089/jpm.2022.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nathan D Baggett
- Division of Emergency Medicine, Health Partners Institute/Regions Hospital, St. Paul, Minnesota, USA
| | | | - Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, Massachusetts, USA.,Department of Community Health, Tufts University, Medford, Massachusetts, USA
| | - Andrew M Courtwright
- Department of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eric P Nolley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael Landzberg
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kirsten Wentlandt
- Division of Palliative Care, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, California, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Section of Palliative Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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26
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Pyrża M, Małyszko J, Głogowski T, Wieliczko M, Żebrowski P, Małyszko J. Kidney Transplant Recipients Have Higher Malignancy Prevalence Than Hemodialyzed Patients. Transplant Proc 2022; 54:972-975. [DOI: 10.1016/j.transproceed.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/07/2022] [Indexed: 10/18/2022]
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27
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Alhamad T, Lubetzky M, Lentine KL, Edusei E, Parsons R, Pavlakis M, Woodside KJ, Adey D, Blosser CD, Concepcion BP, Friedewald J, Wiseman A, Singh N, Chang SH, Gupta G, Molnar MZ, Basu A, Kraus E, Ong S, Faravardeh A, Tantisattamo E, Riella L, Rice J, Dadhania DM. Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers. Am J Transplant 2021; 21:3034-3042. [PMID: 33559315 DOI: 10.1111/ajt.16523] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 01/25/2023]
Abstract
Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.
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Affiliation(s)
- Tarek Alhamad
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Michelle Lubetzky
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Emmanuel Edusei
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Deborah Adey
- University of California San Francisco, San Francisco, California, USA
| | | | | | | | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - Su-Hsin Chang
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Gaurav Gupta
- Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | | | - Song Ong
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California, USA
| | | | | | - Jim Rice
- Scripps Heath, San Diego, California, USA
| | - Darshana M Dadhania
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
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28
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Ouahmi H, Moceri P, Zorzi K, Albano L, Durand M, Karimi F, Morelon E, Buron F, Le Quintrec M, Pernin V, Ladriere M, Girerd S, Dantal J, Loupy A, Couzi L, Ferrari E, Esnault V, Merville P, Legendre C, Giral M, Sicard A. Cohort study: "Outcomes of kidney transplantation in patients with prosthetic heart valves". Transpl Int 2021; 34:2297-2304. [PMID: 34425020 DOI: 10.1111/tri.14008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022]
Abstract
The number of kidney transplant candidates with prosthetic heart valves (PHVs) is increasing. Yet, outcomes of kidney transplantation in these patients are still unclear. This is the first report of post-transplant outcomes in patients with PHVs at time of kidney transplantation. We conducted a matched cohort study among recipients from the multicentric and prospective DIVAT cohort to compare the outcomes in patients with left-sided PHVs at time of transplantation and a group of recipients without PHV matched according to age, dialysis time, initial disease, pretransplant DSA, diabetes, and cardiovascular events. Of 23 018 patients, 92 patients with PHVs were included and compared to 276 patients without PHV. Delayed graft function and postoperative bleeding occurred more frequently in patients with PHVs. Kidney graft survival was similar between groups. 5-year overall survival was 68.5% in patients with PHV vs. 87.9% in patients without PHV [HR, 2.72 (1.57-4.70), P = 0.0004]. Deaths from infection, endocarditis, and bleeding were more frequent in patients with PHV. Mechanical valves, but not bioprosthetic valves, were independent risk factors for mortality [HR, 2.89 (1.68-4.97), P = 0.0001]. Patients with PHV have high mortality rates after kidney transplantation. These data suggest that mechanical valves, but not biological valves, increase risks of post-transplant mortality.
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Affiliation(s)
- Hajar Ouahmi
- Nephrology, Dialysis and Transplantation Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France.,Clinical Research Unit of Côte d'Azur University (UR2CA), Nice, France
| | - Pamela Moceri
- Clinical Research Unit of Côte d'Azur University (UR2CA), Nice, France.,Cardiology Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France
| | - Kevin Zorzi
- Nephrology, Dialysis and Transplantation Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France.,Clinical Research Unit of Côte d'Azur University (UR2CA), Nice, France
| | - Laetitia Albano
- Nephrology, Dialysis and Transplantation Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France
| | - Matthieu Durand
- Urology Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France
| | - Fatimaezzahra Karimi
- Nephrology, Dialysis and Transplantation Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France
| | - Emmanuel Morelon
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Fanny Buron
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Moglie Le Quintrec
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, University of Montpellier, Montpellier, France
| | - Vincent Pernin
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, University of Montpellier, Montpellier, France
| | - Marc Ladriere
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Sophie Girerd
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Jacques Dantal
- CRTI UMR 1064, Inserm, ITUN, CHU Nantes, RTRS Centaure, Université de Nantes, Nantes, France.,Centre d'Investigation Clinique en Biothérapie, Nantes, France
| | - Alexandre Loupy
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS «Centaure», Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France.,UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Emile Ferrari
- Cardiology Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France
| | - Vincent Esnault
- Nephrology, Dialysis and Transplantation Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France.,Clinical Research Unit of Côte d'Azur University (UR2CA), Nice, France
| | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France.,UMR CNRS 5164, ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS «Centaure», Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Magali Giral
- CRTI UMR 1064, Inserm, ITUN, CHU Nantes, RTRS Centaure, Université de Nantes, Nantes, France.,Centre d'Investigation Clinique en Biothérapie, Nantes, France
| | - Antoine Sicard
- Nephrology, Dialysis and Transplantation Department, Pasteur 2 Hospital, Nice University Hospital, Nice, France.,Clinical Research Unit of Côte d'Azur University (UR2CA), Nice, France.,CNRS, UMR7370, Laboratory of Molecular PhysioMedicine, LP2M, Nice, France
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29
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Poggio ED, Augustine JJ, Arrigain S, Brennan DC, Schold JD. Long-term kidney transplant graft survival-Making progress when most needed. Am J Transplant 2021; 21:2824-2832. [PMID: 33346917 DOI: 10.1111/ajt.16463] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/23/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Current short-term kidney post-transplant survival rates are excellent, but longer-term outcomes have historically been unchanged. This study used data from the national Scientific Registry of Transplant Recipients (SRTR) and evaluated 1-year and 5-year graft survival and half-lives for kidney transplant recipients in the US. All adult (≥18 years) solitary kidney transplants (n = 331,216) from 1995 to 2017 were included in the analysis. Mean age was 49.4 years (SD +/-13.7), 60% male, and 25% Black. The overall (deceased and living donor) adjusted hazard of graft failure steadily decreased from 0.89 (95%CI: 0.88, 0.91) in era 2000-2004 to 0.46 (95%CI: 0.45, 0.47) for era 2014-2017 (1995-1999 as reference). Improvements in adjusted hazards of graft failure were more favorable for Blacks, diabetics and older recipients. Median survival for deceased donor transplants increased from 8.2 years in era 1995-1999 to an estimated 11.7 years in the most recent era. Living kidney donor transplant median survival increased from 12.1 years in 1995-1999 to an estimated 19.2 years for transplants in 2014-2017. In conclusion, these data show continuous improvement in long-term outcomes with more notable improvement among higher-risk subgroups, suggesting a narrowing in the gap for those disadvantaged after transplantation.
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Affiliation(s)
- Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Joshua J Augustine
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel C Brennan
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Jesse D Schold
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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30
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Martin K, Cantwell L, Barraclough KA, Lian M, Masterson R, Hughes PD, Chow KV. Prolonged immunosuppression does not improve risk of sensitisation or likelihood of re-transplantation after kidney transplant graft failure. Transpl Int 2021; 34:2353-2362. [PMID: 34320262 DOI: 10.1111/tri.13998] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimum approach toward immunosuppression withdrawal following kidney transplant failure is unclear. Prolonged weaning may be associated with reduced sensitisation, less graft nephrectomy and greater likelihood of re-transplantation, but conversely increased risk of infection, malignancy and death. METHODS We conducted a single centre retrospective analysis of patients experiencing graft failure between 2007-2017, comparing rates of sensitisation, re-transplantation, nephrectomy, infection, malignancy and death between patients who had immunosuppression weaned over <90 vs. 90-180 vs. >180 days. RESULTS Patient survival after immunosuppression withdrawal over <90 vs. 90-180 vs. >180 days was 73.3%, 72.1% and 80.4% respectively (p=0.35), with no differences in cPRA (80.06 vs. 81.21 vs. 85.42, p=0.66) or re-transplantation rate (24/31 (77.4%) vs. 21/35 (60.0%) vs. 22/36 (61.1%), p=0.13). There was significantly less nephrectomy after late immunosuppression cessation (10/42 (23.8%) vs. 7/42 (16.7%) vs. 3/43 (7.0%), p=0.01) but no differences in infections or malignancy. On competing risk regression (death as competing risk) controlling for cofactors including age, nephrectomy and rejection, prolonged immunosuppression did not predict likelihood of re-transplantation (SHR 1.000, p=0.88). CONCLUSIONS Prolonged immunosuppression withdrawal does not reduce sensitisation or improve re-transplantation rates but is associated with less nephrectomy. Immunosuppression withdrawal should be tailored to individual circumstances after graft failure.
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Affiliation(s)
- Kylie Martin
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia
| | - Linda Cantwell
- Victorian Transplantation and Immunogenetics Service, Australian Red Cross Life Blood, Victoria, Australia
| | - Katherine A Barraclough
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Michael Lian
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Peter D Hughes
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Kevin V Chow
- Department of Nephrology, Royal Melbourne Hospital, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
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31
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Vrakas G, Weissenbacher A, Ploeg R, Friend P. Effect of Utilizing More Than 20-Year Older Deceased Donor Kidneys for Young Recipients: An Analysis of the UK Registry. EXP CLIN TRANSPLANT 2021; 19:405-410. [PMID: 33877038 DOI: 10.6002/ect.2021.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Despite the wider acceptance of expanded criteria kidneys and the advances in immunosuppression, clinicians remain sceptical when it comes to accepting kidneys from significantly older donors, especially for the young adult recipient population (age ≤40 years). MATERIALS AND METHODS We utilized prospectively maintained data from the United Kingdom Registry and analyzed the deceased donor renal transplant outcomes for 2 cohorts: (1) young recipients who received either a younger kidney or a kidney from a donor who was less than 20 years older (group <20; n = 2072) and (2) young recipients who received a kidney from donors who were 20 or more years older (group ≥20, n = 764). We used life tables for survival and performed Cox regression analysis to identify significant variables. RESULTS Median follow-up was 2918 days. The univariate analysis for graft loss showed the strongest predictors to be donor age, recipient age, recipient ethnicity, and delayed graft function, which retained their significance in the multivariate model. Graft survival rates were 94% versus 90% at 1 year, 86% versus 75% at 5 years, and 75% versus 63% at 10 years for group <20 versus group ≥20, respectively. Respective patient survival rates were comparable for both cohorts: 99% versus 98% at 1 year, 97% versus 96% at 5 years, and 91% versus 91% at 10 years. CONCLUSIONS Our analysis showed that allografts from ≥20-year-older deceased donors are beneficial and should be considered for transplant in younger recipients. Allograft survival may be worse compared with survival with younger allografts; however, young recipients do potentially better and survive longer compared with remaining on dialysis.
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Affiliation(s)
- Georgios Vrakas
- From the Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,From the Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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32
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Moist LM, Gill JS. Patient Management When Returning to Dialysis after a Failed Kidney Transplant. Clin J Am Soc Nephrol 2021; 16:1423-1425. [PMID: 33858829 PMCID: PMC8729589 DOI: 10.2215/cjn.19731220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Louise M Moist
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - John S Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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33
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Imamura R, Nakazawa S, Yamanaka K, Kakuta Y, Tsutahara K, Taniguchi A, Kawamura M, Kato T, Abe T, Uemura M, Takao T, Kishikawa H, Nonomura N. Cumulative cancer incidence and mortality after kidney transplantation in Japan: A long-term multicenter cohort study. Cancer Med 2021; 10:2205-2215. [PMID: 33314709 PMCID: PMC7982608 DOI: 10.1002/cam4.3636] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022] Open
Abstract
Kidney transplantation is the most promising treatment to improve mortality and life quality in end-stage kidney disease; however, cancer remains a leading cause of death. Several factors including immunosuppressants might be associated with a gradual increase in cumulative cancer incidence after kidney transplantation. Risk factors for cancer and overall and cancer-specific survival were analyzed in 1973 kidney transplant recipients from three study institutions in Japan. The 5-, 10-, 20-, and 30-year overall and cancer-specific survival rates were 93.3%, 88.4%, 78.0%, and 63.6% and 99.4%, 98.0%, 95.3%, and 91.7%, respectively. The overall survival rate was significantly higher and the graft survival rate was significantly lower in recipients without cancer than in those with cancer. Older recipient age, longer dialysis duration before kidney transplantation, and history of transfusion were significant predictors of cancer. Dialysis duration before kidney transplantation was a prognostic factor of overall survival rate. Regarding cancer-specific survival rates, older recipient age and dialysis duration before kidney transplantation were prognostic factors of worse cancer-specific survival rates. The type of immunosuppressant was not associated with an increased cancer rate. Aggressiveness of immunosuppressant regimens or potent immunosuppressants might improve graft survival rate while inducing de novo cancer after kidney transplantation. Older age and longer dialysis duration before kidney transplantation were risk factors of cancer-specific survival rate.
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Affiliation(s)
- Ryoichi Imamura
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
| | - Shigeaki Nakazawa
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
| | - Kazuaki Yamanaka
- Department of UrologyHyogo Prefectural Nishinomiya HospitalNishinomiya HyogoJapan
| | - Yoichi Kakuta
- Department of UrologyOsaka General Medical CenterOsakaJapan
| | | | - Ayumu Taniguchi
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
| | - Masataka Kawamura
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
| | - Taigo Kato
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
| | - Toyofumi Abe
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
| | - Motohide Uemura
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
| | - Tetsuya Takao
- Department of UrologyOsaka General Medical CenterOsakaJapan
| | - Hidefumi Kishikawa
- Department of UrologyHyogo Prefectural Nishinomiya HospitalNishinomiya HyogoJapan
| | - Norio Nonomura
- Department of UrologyOsaka University Graduate School of MedicineSuita OsakaJapan
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Munshi VN, Saghafian S, Cook CB, Aradhyula SV, Chakkera HA. Use of Imputation and Decision Modeling to Improve Diagnosis and Management of Patients at Risk for New-Onset Diabetes After Transplantation. Ann Transplant 2021; 26:e928624. [PMID: 33723204 PMCID: PMC7980500 DOI: 10.12659/aot.928624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/06/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is a complication of solid organ transplantation. We sought to determine the extent to which NODAT goes undiagnosed over the course of 1 year following transplantation, analyze missed or later-diagnosed cases of NODAT due to poor hemoglobin A1c (HbA1c) and fasting blood glucose (FBG) collection, and to estimate the impact that improved NODAT screening metrics may have on long-term outcomes. MATERIAL AND METHODS This was a retrospective study utilizing 3 datasets from a single center on kidney, liver, and heart transplantation patients. Retrospective analysis was supplemented with an imputation procedure to account for missing data and project outcomes under perfect information. In addition, the data were used to inform a simulation model used to estimate life expectancy and cost-effectiveness of a hypothetical intervention. RESULTS Estimates of NODAT incidence increased from 27% to 31% in kidney transplantation patients, from 31% to 40% in liver transplantation patients, and from 45% to 67% in heart transplantation patients, when HbA1c and FBG were assumed to be collected perfectly at all points. Perfect screening for kidney transplantation patients was cost-saving, while perfect screening for liver and heart transplantation patients was cost-effective at a willingness-to-pay threshold of $100 000 per life-year. CONCLUSIONS Improved collection of HbA1c and FBG is a cost-effective method for detecting many additional cases of NODAT within the first year alone. Additional research into both improved glucometric monitoring as well as effective strategies for mitigating NODAT risk will become increasingly important to improve health in this population.
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Affiliation(s)
- Vidit N. Munshi
- Department of Health Policy, Harvard University, Cambridge, MA, U.S.A
| | | | - Curtiss B. Cook
- Department of Endocrinology, Mayo Clinic, Scottsdale, AZ, U.S.A
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Muir MA, Szempruch KR, Dupuis R, Toledo AH, Isaak RS, Arora H, Prasad R, Serrano Rodriguez P. Utilizing multimodal analgesia to evaluate postoperative analgesic requirements in kidney transplant recipients. Clin Transplant 2021; 35:e14240. [PMID: 33525058 DOI: 10.1111/ctr.14240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 11/30/2022]
Abstract
The use of non-opioid analgesics following surgery has proven beneficial in managing pain and decreasing adverse outcomes following surgery. Data assessing outcomes related to opioid use is limited in kidney transplant recipients (KTRs). We evaluated the effectiveness of implementing a reduced to no opioid use protocol in KTRs. This retrospective cohort study included adult KTRs between January 2017 and July 2019 with a multimodal analgesic protocol (MAP), focused on limiting opioids, implemented in August 2018. We compared analgesic requirements in morphine milligram equivalents (MME) during transplant admissions between the MAP cohort and traditional cohort. There were 217 KTRs who met the criteria. Inpatient opioid use was significantly reduced in the MAP cohort (16.5 ± 19.2 MME/day vs 24.7 ± 19.7 MME/day; P <.05) with no significant difference in pain scores. No use of opioids within six months of discharge was significantly increased in the MAP cohort (50% vs 7%; P <.001), and there were no reported deaths at six months in either cohort. The use of multimodal analgesia is beneficial in KTRs to provide adequate pain control with limited to no exposure of opioids during admission or at discharge.
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Affiliation(s)
- Michele A Muir
- Department of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Kristen R Szempruch
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Robert Dupuis
- Department of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Alexander H Toledo
- Department of Surgery, Division Abdominal Transplant Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Ravindra Prasad
- Department of Anesthesiology, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Pablo Serrano Rodriguez
- Department of Surgery, Division Abdominal Transplant Surgery, University of North Carolina Medical Center, Chapel Hill, NC, USA
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36
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Naylor KL, Knoll GA, McArthur E, Garg AX, Lam NN, Field B, Getchell LE, Hahn E, Kim SJ. Outcomes of an Inpatient Dialysis Start in Patients With Kidney Graft Failure: A Population-Based Multicentre Cohort Study. Can J Kidney Health Dis 2021; 8:2054358120985376. [PMID: 33552528 PMCID: PMC7841655 DOI: 10.1177/2054358120985376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/28/2020] [Indexed: 11/20/2022] Open
Abstract
Background: The frequency and outcomes of starting maintenance dialysis in the hospital as an inpatient in kidney transplant recipients with graft failure are poorly understood. Objective: To determine the frequency of inpatient dialysis starts in patients with kidney graft failure and examine whether dialysis start status (hospital inpatient vs outpatient setting) is associated with all-cause mortality and kidney re-transplantation. Design: Population-based cohort study. Setting: We used linked administrative healthcare databases from Ontario, Canada. Patients: We included 1164 patients with kidney graft failure from 1994 to 2016. Measurements: All-cause mortality and kidney re-transplantation. Methods: The cumulative incidence function was used to calculate the cumulative incidence of all-cause mortality and kidney re-transplantation, accounting for competing risks. Subdistribution hazard ratios from the Fine and Gray model were used to examine the relationship between inpatient dialysis starts (vs outpatient dialysis start [reference]) and the dependent variables (ie, mortality or re-transplant). Results: We included 1164 patients with kidney graft failure. More than half (55.8%) of patients with kidney graft failure, initiated dialysis as an inpatient. Compared with outpatient dialysis starters, inpatient dialysis starters had a significantly higher cumulative incidence of mortality and a significantly lower incidence of kidney re-transplantation (P < .001). The 10-year cumulative incidence of mortality was 51.9% (95% confidence interval [CI]: 47.4, 56.9%) (inpatient) and 35.3% (95% CI: 31.1, 40.1%) (outpatient). After adjusting for clinical characteristics, we found inpatient dialysis starters had a significantly increased hazard of mortality in the first year after graft failure (hazard ratio: 2.18 [95% CI: 1.43, 3.33]) but at 1+ years there was no significant difference between groups. Limitations: Possibility of residual confounding and unable to determine inpatient dialysis starts that were unavoidable. Conclusions: In this study we identified that most patients with kidney graft failure had inpatient dialysis starts, which was associated with an increased risk of mortality. Further research is needed to better understand the reasons for an inpatient dialysis start in this patient population.
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Affiliation(s)
- Kyla L Naylor
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Gregory A Knoll
- Department of Medicine (Nephrology), University of Ottawa and Ottawa Hospital Research Institute, ON, Canada
| | | | - Amit X Garg
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Nephrology, Western University, London, ON, Canada
| | - Ngan N Lam
- Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Bonnie Field
- Renal Patient and Family Advisory Council, London Health Sciences Centre, ON, Canada
| | - Leah E Getchell
- Division of Nephrology, London Health Sciences Centre, ON, Canada
| | - Emma Hahn
- Division of Nephrology, London Health Sciences Centre, ON, Canada
| | - S Joseph Kim
- Division of Nephrology, Toronto General Hospital, University Health Network and University of Toronto, ON, Canada
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Requião-Moura LR, Albino CRM, Bicalho PR, Ferraz ÉDA, Pires LMDMB, da Silva MFR, Pacheco-Silva A. Long-term outcomes after kidney transplant failure and variables related to risk of death and probability of retransplant: Results from a single-center cohort study in Brazil. PLoS One 2021; 16:e0245628. [PMID: 33471845 PMCID: PMC7816974 DOI: 10.1371/journal.pone.0245628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
Background Returning to dialysis after kidney graft loss (GL) is associated with a high risk of mortality, mainly in the first 3–6 months. The follow-up of patients with GL should be extended to better understand crude patient outcomes, mainly in emerging countries, where the transplantation activity has increased. Methods This is a historical single-center cohort study conducted in an emerging country (Brazil) that included 115 transplant patients with kidney allograft failure who were followed for 44.1 (21.4; 72.6) months after GL. The outcomes were death or retransplantation after GL calculated by Kaplan-Meier and log-rank tests. Proportional hazard ratios for death and retransplantation were assessed by Cox regression. Results The 5-year probability of retransplantation was 38.7% (95% CI: 26.1%-51.2%) and that of death was 37.7% (95% CI: 24.9%-50.5%); OR = 1.03 (95% CI: 0.71–1.70) and P = 0.66. The likelihood of retransplantation was higher in patients who resumed dialysis with higher levels of hemoglobin (HR = 1.22; 95% CI = 1.04–1.43; P = 0.01) and lower in blood type O patients (HR = 0.48; 95% CI = 0.25–0.93; P = 0.03), which was associated with a lower frequency of retransplantation with a subsequent living-donor kidney. On the other hand, the risk of death was significantly associated with Charlson comorbidity index (HR for each point = 1.37; 95% CI 1.19–1.50; P<0.001), and residual eGFR at the time when patients had resumed to dialysis (HR for each mL = 1.14; 95% CI = 1.05–1.25; P = 0.002). The trend toward a lower risk of death when patients had resumed to dialysis using AV fistula access was observed (HR = 0.50; 95% CI 0.25–1.02; P = 0.06), while a higher risk seems to be associated with the number of previous engraftment (HR = 2.01; 95% CI 0.99–4.07; P = 0.05). Conclusions The 5-year probability of retransplantation was not less than that of death. Variables related to the probability of retransplantation were hemoglobin level before resuming dialysis and ABO blood type, while the risk of death was associated with comorbidities and residual eGFR.
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Affiliation(s)
- Lúcio R. Requião-Moura
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
- * E-mail:
| | | | | | | | | | | | - Alvaro Pacheco-Silva
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
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La Porta E, Conversano E, Zugna D, Camilla R, Labbadia R, Paglialonga F, Parolin M, Vidal E, Verrina E, on behalf of the Italian Registry of Paediatric Chronic Dialysis. Returning to dialysis after kidney allograft failure: the experience of the Italian Registry of Paediatric Chronic Dialysis. Pediatr Nephrol 2021; 36:3961-3969. [PMID: 34128094 PMCID: PMC8599402 DOI: 10.1007/s00467-021-05140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/19/2021] [Accepted: 05/14/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The need for dialysis after kidney allograft failure (DAGF) is among the top five reasons for dialysis initiation, making this an important topic in clinical nephrology. However, data are scarce on dialysis choice after transplantation and clinical outcomes for DAGF in children. METHODS Patients receiving chronic dialysis < 18 years were recorded from January 1991 to January 2019 by the Italian Registry of Pediatric Chronic Dialysis (IRPCD). We investigated factors influencing choice of dialysis modality, patient outcome in terms of mortality, switching dialysis modality, and kidney transplantation. RESULTS Among 118 patients receiving DAGF, 41 (35%) were treated with peritoneal dialysis (PD), and 77 (65%) with haemodialysis (HD). Significant predictors for treatment with PD were younger age at dialysis start (OR 0.85 per year increase [95%CI 0.72-1.00]) and PD use before kidney transplantation (OR 8.20 [95%CI 1.82-37.01]). Patients entering DAGF in more recent eras (OR 0.87 per year increase [95%CI 0.80-0.94]) and with more than one dialysis modality before kidney transplantation (OR 0.56 for being treated with PD [0.12-2.59]) were more likely to be initiated on HD. As compared to patients on HD, those treated with PD exhibited increased but non-significant mortality risk (HR 2.15 [95%CI 0.54-8.6]; p = 0.28) and higher prevalence of dialysis-related complications during DAGF (p = 0.002) CONCLUSIONS: Patients entering DAGF in more recent years are more likely to be initiated on HD. In this specific population of children, use of PD seems associated with a more complicated course. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Edoardo La Porta
- Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Genova, Italy
| | - Ester Conversano
- grid.418712.90000 0004 1760 7415Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Daniela Zugna
- grid.7605.40000 0001 2336 6580Department of Medical Sciences, Cancer Epidemiology Unit, University of Torino and CPO-Piemonte, Turin, Italy
| | - Roberta Camilla
- grid.415778.80000 0004 5960 9283Paediatric Nephrology Unit, Regina Margherita Children’s Hospital, CDSS, Turin, Italy
| | - Raffaella Labbadia
- grid.414125.70000 0001 0727 6809Nephrology and Dialysis Unit, Department of Pediatrics, “Bambino Gesù” Children’s Hospital-IRCCS, Rome, Italy
| | - Fabio Paglialonga
- grid.414818.00000 0004 1757 8749Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mattia Parolin
- grid.411474.30000 0004 1760 2630Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman’s and Child’s Health, University Hospital, Padova, Padua, Italy
| | - Enrico Vidal
- Division of Pediatrics, Department of Medicine (DAME), University of Udine, P.le S.M della Misericordia, 15 33100, Udine, Italy.
| | - Enrico Verrina
- Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Genova, Italy
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Freist M, Bertrand D, Bailly E, Lambert C, Rouzaire PO, Lemal R, Aniort J, Büchler M, Heng AE, Garrouste C. Management of Immunosuppression After Kidney Transplant Failure: Effect on Patient Sensitization. Transplant Proc 2020; 53:962-969. [PMID: 33288310 DOI: 10.1016/j.transproceed.2020.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/03/2020] [Accepted: 10/20/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immunosuppressive treatment is often interrupted in the first months following kidney transplant failure (KTF) to limit side effects. The aim of this study was to assess the effect of prolonged treatment (PT) of more than 3 months' duration after KTF on HLA sensitization and treatment tolerance. METHODS We performed a retrospective observational study involving 119 patients with KTF in 3 French kidney transplant centers between June 2007 and June 2017. Sensitization was defined as the development of HLA donor-specific antibodies (DSA). RESULTS In the PT group receiving calcineurin inhibitor (CNI) treatment, 30 of 52 patients (57.7%) were sensitized vs 52 of 67 patients (77.6%) who had early cessation of treatment (P = .02). The results were confirmed by multivariate analysis (odds ratio [OR] = 0.39, 95% confidence interval [CI] [0.16; 0.98], P = .04). The development of de novo DSAs after CNI treatment (n = 63/90 [70.0%]) was significantly more frequent than during CNI treatment, (n = 18/52 [34.6%], P = .01). Panel-reactive antibody ≥85% was lower in the PT group in multivariate analysis (OR = 0.28, 95% CI [0.10; 0.78], P = .02). No differences in the rates of infection, cardiovascular complications, neoplasia, and deaths were observed between the 2 groups. In multivariate analysis, continuation of corticosteroid treatment had no influence on sensitization but was associated with a higher rate of infection (OR = 2.66, 95% CI [1.09; 6.46], P = .03). CONCLUSION Maintenance of CNI treatment after return to dialysis in patients requesting a repeat transplant could avoid the development of anti-HLA sensitization with a good tolerance.
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Affiliation(s)
- Marine Freist
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Dominique Bertrand
- Service de Néphrologie, Centre Hospitalier Régional Universitaire, Rouen, France
| | - Elodie Bailly
- Department of Nephrology and Clinical Immunology, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Céline Lambert
- Biostatistics Unit, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Paul Olivier Rouzaire
- Department of Human Leucocyte Antigen, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Richard Lemal
- Department of Human Leucocyte Antigen, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Julien Aniort
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Matthias Büchler
- Department of Nephrology and Clinical Immunology, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Anne Elisabeth Heng
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Cyril Garrouste
- Department of Nephrology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France.
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Williams N, Korneffel K, Koizumi N, Ortiz J. African American polycystic kidney patients receive higher risk kidneys, but do not face increased risk for graft failure or post-transplant mortality. Am J Surg 2020; 221:1093-1103. [PMID: 33028497 DOI: 10.1016/j.amjsurg.2020.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
African Americans (AA) are disproportionately affected by end-stage renal disease (ESRD) and have worse outcomes following renal transplantation. Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic condition leading to ESRD necessitating transplant. We explored this population with respect to race by conducting a retrospective analysis of the UNOS database between 2005 and 2019. Our study included 10,842 (AA n = 1661; non-AA n = 9181) transplant recipients whose primary diagnosis was ADPKD. We further stratified the AA ADPKD population with respect to blood groups (AA blood type B n = 295 vs AA non-B blood type n = 1366), and also compared this cohort to AAs with a diagnosis of DM (n = 16,706) to identify unique trends in the ADPKD population. We analyzed recipient and donor characteristics, generated survival curves, and conducted multivariate analyses. African American ADPKD patients waited longer for transplants (924 days vs 747 days P < .001), and were more likely to be on dialysis (76% vs 62%; p < .001). This same group was also more likely to have AA donors (21% vs 9%; p < .001) and marginally higher KDPI kidneys (0.48 vs 0.45; p < .001). AA race was a risk factor for delayed graft function (DGF), increasing the chance of DGF by 45% (OR 1.45 95% CI 1.26-1.67; p < .001). AA race was not associated with graft failure (HR 1.10 95% CI 0.95-1.28; p = .21) or patient mortality (HR 0.84 95% CI 0.69-1.03; p = .09). Racial disparities exist in the ADPKD population. They should be continually studied and addressed to improve transplant equity.
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Affiliation(s)
- Nathan Williams
- College of Medicine and Life Science, University of Toledo, Toledo, OH, USA.
| | - Katie Korneffel
- College of Medicine and Life Science, University of Toledo, Toledo, OH, USA
| | | | - Jorge Ortiz
- Department of Surgery, Albany Medical College, Albany, NY, USA
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Subbotin VM. Pattern of organ remodeling in chronic non-communicable diseases is due to endogenous regulations and falls under the category of Kauffman's self-organization: A case of arterial neointimal pathology. Med Hypotheses 2020; 143:110106. [PMID: 32759005 DOI: 10.1016/j.mehy.2020.110106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/07/2020] [Accepted: 07/11/2020] [Indexed: 01/10/2023]
Abstract
Clinical diagnosis is based on analysis of pathologic findings that may result in perceived patterns. The same is true for diagnostic pathology: Pattern analysis is a foundation of the histopathology-based diagnostic system and, in conjunction with clinical and laboratory findings, forms a basis for the classification of diseases. Any histopathology diagnosis is based on the explicit assumption that the same diseased condition should result in formation of the same (or highly similar) morphologic patterns in different individuals; it is a standard approach in microscopic pathology, including that of non-communicable chronic diseases with organ remodeling. During fifty years of examining diseased tissues under microscopy, I keep asking the same question: Why is a similarity of patterns expected for chronic organ remodeling? For infection diseases, xenobiotic toxicity and deficiencies forming an identical pathologic pattern in different individuals is understandable and logical: The same infection, xenobiotic, or deficiency strikes the same target, which results in identical pathology. The same is true for Mendelian diseases: The same mutations lead to the same altered gene expressions and the same pathologic pattern. But why does this regularity hold true for chronic diseases with organ remodeling? Presumable causes (or risk factors) for a particular chronic disease differ in magnitude and duration between individuals, which should result in various series of transformations. Yet, mysteriously enough, pathological remodeling in a particular chronic disease always falls into a main dominating pattern, perpetuating and progressing in a similar fashion in different patients. Furthermore, some chronic diseases of different etiologies and dissimilar causes/risk factors manifest as identical or highly similar patterns of pathologic remodeling. HYPOTHESIS: I hypothesize that regulations governing a particular organ's chronic remodeling were selected in evolution as the safest response to various insults and physiologic stress conditions. This hypothesis implies that regulations directing diseased chronic remodeling always preexist but normally are controlled; this control can be disrupted by a diverse range of non-specific signals, liberating the pathway for identical pathologic remodeling. This hypothesis was tested in an analysis of arterial neointimal formation, the identical pathology occurring in different diseases and pathological conditions: graft vascular disease in organ transplantation, in-stent restenosis, peripheral arterial diseases, idiopathic intimal hyperplasia, Kawasaki disease, coronary atherosclerosis and as reaction to drugs. The hypothesis suggests that arterial intimal cells are poised between only two alternative pathways: the pathway with controlled intimal cell proliferation or the pathway where such control is disrupted, ultimately leading to the progressive neointimal pathology. By this property the arterial neointimal formation constitutes a special case of Kauffman's self-organization. This new hypothesis gives a parsimonious explanation for identical pathological patterns of arterial remodeling (neointimal formation), which occurs in diseases of different etiologies and due to dissimilar causes/risk factors, or without any etiology and causes/risk factors at all. This new hypothesis also suggests that regulation facilitating intimal cell proliferation cannot be overwritten or annulled because this feature is vital for arterial differentiation, cell renewal, and integrity. This hypothesis suggests that studying numerous, and likely interchangeable, non-specific signals that disrupt regulation controlling intimal cell proliferation is unproductive; instead, a study of the controlling regulation(s) itself should be a priority of our research.
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Affiliation(s)
- Vladimir M Subbotin
- University of Pittsburgh, Pittsburgh, PA 15260, USA; University of Wisconsin, Madison, WI 53705, USA; Arrowhead Parmaceuticals, Madison, WI 53719, USA.
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Bisigniano L, Laham G, Giordani MC, Tagliafichi V, Hansen Krogh D, Maceira A, Rosa-Diez GJ. Reduced survival in patients who return to dialysis after kidney allograft failure. Clin Transplant 2020; 34:e14014. [PMID: 32567723 DOI: 10.1111/ctr.14014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The outcome of patients who return to dialysis after Kidney allograft failure (KAF) remains unclear. Our aim was to compare the outcome of KAF patients vs two different types of transplant naive incident dialysis (TNID) patients, those on the waiting list (WL) and those with a kidney transplant contraindication (KTC). METHODS We performed an observational study using data from the Argentinian Dialysis Registry between 2005 and 2016. We compare mortality between KAF, WL, and KTC. RESULTS We included 75 722 patients of which 2734 were KAF. Survival between the three cohorts (KAF vs WL (n = 14 630) vs KTC (n = 58 358) revealed a significant difference (log-rank test: P < .0001) indicating worse survival for KTC patients and best survival for WL. We found that KAF patients had as poor outcome as KTC patients after multivariate adjustment. Cox regression showed that age >65 years: HR: 1.845 (1.79-1.89) P < .0001, transient catheter: HR: 1.303 (1.26-1.34) P < .0001, diabetic: HR: 1.273 (1.22-1.31) P < .0001, hepatitis C: HR: 1.156 (1.09-1.22) P < .0001, and albumin: HR: 1.247 (1.21-1.28) P < .0001 were associated with mortality. CONCLUSION Patients who return to dialysis after KAF have higher mortality than WL patients and similar to KTC patients.
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Affiliation(s)
- Liliana Bisigniano
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Gustavo Laham
- Department of Internal Medicine, Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Maria Cora Giordani
- Nephrology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Viviana Tagliafichi
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Daniela Hansen Krogh
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Alberto Maceira
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
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Fiorentino M, Gallo P, Giliberti M, Colucci V, Schena A, Stallone G, Gesualdo L, Castellano G. Management of patients with a failed kidney transplant: what should we do? Clin Kidney J 2020; 14:98-106. [PMID: 33564409 PMCID: PMC7857798 DOI: 10.1093/ckj/sfaa094] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/10/2020] [Indexed: 12/18/2022] Open
Abstract
The number of kidney transplant recipients returning to dialysis after graft failure is steadily increasing over time. Patients with a failed kidney transplant have been shown to have a significant increase in mortality compared with patients with a functioning graft or patients initiating dialysis for the first time. Moreover, the risk for infectious complications, cardiovascular disease and malignancy is greater than in the dialysis population due to the frequent maintenance of low-dose immunosuppression, which is required to reduce the risk of allosensitization, particularly in patients with the prospect of retransplantation from a living donor. The management of these patients present several controversial opinions and clinical guidelines are lacking. This article aims to review the leading evidence on the main issues in the management of patients with failed transplant, including the ideal timing and modality of dialysis reinitiation, the indications for an allograft nephrectomy or the correct management of immunosuppression during graft failure. In summary, retransplantation is a feasible option that should be considered in patients with graft failure and may help to minimize the morbidity and mortality risk associated with dialysis reinitiation.
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Affiliation(s)
- Marco Fiorentino
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Pasquale Gallo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Marica Giliberti
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Vincenza Colucci
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Antonio Schena
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
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Motta G, Ferraresso M, Lamperti L, Di Paolo D, Raison N, Perego M, Favi E. Treatment options for localised renal cell carcinoma of the transplanted kidney. World J Transplant 2020; 10:147-161. [PMID: 32742948 PMCID: PMC7360528 DOI: 10.5500/wjt.v10.i6.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/07/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023] Open
Abstract
Currently, there is no consensus among the transplant community about the treatment of renal cell carcinoma (RCC) of the transplanted kidney. Until recently, graftectomy was universally considered the golden standard, regardless of the characteristics of the neoplasm. Due to the encouraging results observed in native kidneys, conservative options such as nephron-sparing surgery (NSS) (enucleation and partial nephrectomy) and ablative therapy (radiofrequency ablation, cryoablation, microwave ablation, high-intensity focused ultrasound, and irreversible electroporation) have been progressively used in carefully selected recipients with early-stage allograft RCC. Available reports show excellent patient survival, optimal oncological outcome, and preserved renal function with acceptable complication rates. Nevertheless, the rarity and the heterogeneity of the disease, the number of options available, and the lack of long-term follow-up data do not allow to adequately define treatment-specific advantages and limitations. The role of active surveillance and immunosuppression management remain also debated. In order to offer a better insight into this difficult topic and to help clinicians choose the best therapy for their patients, we performed and extensive review of the literature. We focused on epidemiology, clinical presentation, diagnostic work up, staging strategies, tumour characteristics, treatment modalities, and follow-up protocols. Our research confirms that both NSS and focal ablation represent a valuable alternative to graftectomy for kidney transplant recipients with American Joint Committee on Cancer stage T1aN0M0 RCC. Data on T1bN0M0 lesions are scarce but suggest extra caution. Properly designed multi-centre prospective clinical trials are warranted.
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Affiliation(s)
- Gloria Motta
- Urology, IRCCS Policlinico San Donato, San Donato Milanese 27288, Italy
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Luca Lamperti
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Dhanai Di Paolo
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Nicholas Raison
- MRC Centre for Transplantation, King’s College London, London WC2R 2LS, United Kingdom
| | - Marta Perego
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
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Arshad A, Hodson J, Khalil K, Sharif A. Changes in Body Mass Index and Outcomes After Kidney Transplant: A Single-Center, Retrospective, Observational Study. EXP CLIN TRANSPLANT 2020; 18:292-299. [PMID: 32370695 DOI: 10.6002/ect.2019.0416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We aimed to describe changes in body mass index after kidney transplant and to assess how these changes influence long-term outcomes. MATERIALS AND METHODS Data were collected from kidney transplant recipients seen at our center between January 2007 and July 2016. Changes in body mass index over the posttransplant period were modeled using a generalized estimating equation, with changes calculated for each patient from pretransplant to 6 months posttransplant. Calculations were then categorized into 3 body mass index groups: stable (change of ± 1.5 kg/m² or less), reduced (reduction of > 1.5 kg/m²), and increased (increase of > 1.5 kg/m²). Outcomes among groups were compared. RESULTS Among 1344 total patients, the geometric mean pretransplant body mass index was 27.3 kg/m². This declined significantly (P < .001) to a geometric mean of 25.6 kg/m² at 1 month posttransplant, before increasing and stabilizing to pretransplant levels by 36 months (geometric mean body mass index of 27.2 kg/m² ; P = .522). Of 822 patients with body mass index measurements at 6 months, 303 had reduced, 388 had stable, and 131 had increased levels relative to pretransplant levels. On multivariate analyses, 12-month creatinine levels were significantly higher in the reduced cohort, with adjusted levels of 160.6 versus 135.0 μmol/L for the stable cohort. However, no significant associations were detected between 6-month body mass index changes and patient survival, graft survival, incidences of posttransplant diabetes and cancer, and a range of other clinical and histologic outcomes (all P > .05). CONCLUSIONS Our data demonstrated that body mass index was significantly reduced in the first month after kidney transplant before increasing to pretransplant levels during years 3 to 5. Furthermore, patients who retained decreased levels at 6 months had impaired graft function in long-term follow-up. These observations conflict with the existing literature and warrant further investigations.
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Affiliation(s)
- Adam Arshad
- From the College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Shah S, Chan MR, Lee T. Perspectives in Individualizing Solutions for Dialysis Access. Adv Chronic Kidney Dis 2020; 27:183-190. [PMID: 32891301 DOI: 10.1053/j.ackd.2020.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/15/2020] [Accepted: 03/05/2020] [Indexed: 11/11/2022]
Abstract
The vascular access is the lifeline for the hemodialysis patient. Previous national vascular access guidelines have emphasized placement of arteriovenous fistulas in most hemodialysis patients. However, the new Kidney Disease Outcomes Quality Initiative guidelines for vascular access, soon to be published, will focus on a patient's end-stage kidney disease "life plan" and take a patient "first" approach. One of the major themes of the new Kidney Disease Outcomes Quality Initiative guidelines is selecting the "right access, for the right patient, at the right time, for the right reason". Given the availability of new advances in biomedical technologies, techniques, and devices in the vascular access field, this shift to a more patient-centered vascular access approach presents unique opportunities to individualize the solutions and care for patients requiring a dialysis vascular access. This review article will address 3 potential areas where there is an unmet need to individualize solutions for dialysis vascular access care: (1) biological approaches to improve vascular access selection and selection of therapies, (2) vascular access care for the post-transplant patient, and (3) vascular access disparities in race, gender, and the elderly patient.
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Thongprayoon C, Hansrivijit P, Leeaphorn N, Acharya P, Torres-Ortiz A, Kaewput W, Kovvuru K, Kanduri SR, Bathini T, Cheungpasitporn W. Recent Advances and Clinical Outcomes of Kidney Transplantation. J Clin Med 2020; 9:1193. [PMID: 32331309 PMCID: PMC7230851 DOI: 10.3390/jcm9041193] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023] Open
Abstract
Recent advances in surgical, immunosuppressive and monitoring protocols have led to the significant improvement of overall one-year kidney allograft outcomes. Nonetheless, there has not been a significant change in long-term kidney allograft outcomes. In fact, chronic and acute antibody-mediated rejection (ABMR) and non-immunological complications following kidney transplantation, including multiple incidences of primary kidney disease, as well as complications such as cardiovascular diseases, infections, and malignancy are the major factors that have contributed to the failure of kidney allografts. The use of molecular techniques to enhance histological diagnostics and noninvasive surveillance are what the latest studies in the field of clinical kidney transplant seem to mainly focus upon. Increasingly innovative approaches are being used to discover immunosuppressive methods to overcome critical sensitization, prevent the development of anti-human leukocyte antigen (HLA) antibodies, treat chronic active ABMR, and reduce non-immunological complications following kidney transplantation, such as the recurrence of primary kidney disease and other complications, such as cardiovascular diseases, infections, and malignancy. In the present era of utilizing electronic health records (EHRs), it is strongly believed that big data and artificial intelligence will reshape the research done on kidney transplantation in the near future. In addition, the utilization of telemedicine is increasing, providing benefits such as reaching out to kidney transplant patients in remote areas and helping to make scarce healthcare resources more accessible for kidney transplantation. In this article, we discuss the recent research developments in kidney transplants that may affect long-term allografts, as well as the survival of the patient. The latest developments in living kidney donation are also explored.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Napat Leeaphorn
- Department of Nephrology, Department of Medicine, Saint Luke’s Health System, Kansas City, MO 64111, USA;
| | - Prakrati Acharya
- Division of Nephrology, Department of Medicine, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA;
| | - Aldo Torres-Ortiz
- Department of Medicine, Ochsner Medical Center, New Orleans, LA 70121, USA;
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Karthik Kovvuru
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.)
| | - Swetha R. Kanduri
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.)
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.)
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Fan P, Zhang W, Liu Y. CYC1, SDHA, UQCRC1, UQCRQ, and SDHB might be important biomarkers in kidney transplant rejection. Clin Chim Acta 2020; 507:132-138. [PMID: 32302684 DOI: 10.1016/j.cca.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/08/2020] [Accepted: 04/11/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Kidney transplant rejection is considered as a vital factor of kidney transplant failure. Therefore, it's necessary to search for effective biomarkers for kidney transplant surveillance. METHODS In this study, we conducted time-series gene expression profiles analysis of samples from kidney transplant patients with different post-transplant days through weighted gene co-expression network analysis (WGCNA). Associations between gene co-expression modules and days post-transplant were determined through spearman rank correlation analysis. Potential kidney transplant rejection-related modules were subjected to gene functional enrichment analysis through clusterProfiler and protein-protein interaction analysis via STRING database. RESULTS A total of 11 gene co-expression modules were identified, and the pink module which was mainly involved in "energy derivation by oxidation of organic compounds" and "Huntington disease" showed significant correlation with the phenotypic trait "days post-transplant". CYC1, SDHA, UQCRC1, UQCRQ, and SDHB in the pink module exhibited high scores in the protein-protein interaction network analysis. CONCLUSIONS We reported several potential genes may be associated with the kidney transplant rejection, which should provide novel biomarkers for kidney transplant surveillance.
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Affiliation(s)
- Pengfei Fan
- Organ Transplant Center, Tianjin First Central Hospital, Tianjin 300192, China
| | - Weiye Zhang
- Organ Transplant Center, Tianjin First Central Hospital, Tianjin 300192, China.
| | - Yi Liu
- Department of Critical Care Medicine, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300380, China
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Weaning Immunosuppressant in Patients with Failing Kidney Grafts and The Outcomes: A Single-Center Retrospective Cohort Study. Sci Rep 2020; 10:6425. [PMID: 32286398 PMCID: PMC7156393 DOI: 10.1038/s41598-020-63266-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/19/2020] [Indexed: 11/14/2022] Open
Abstract
An immunosuppressant weaning protocol in failing allografts has not yet been established. Maintaining immunosuppressants would preserve residual renal function (RRF) and prevent graft intolerance syndrome and sensitization but would increase the risks of infection and malignancy. In this study, graft failure cases after kidney transplantation in a single center were reviewed retrospectively. The outcome differences in all-cause mortality, infection-related hospitalization, cancer, graft intolerance syndrome, re-transplantation, and RRF duration between the immunosuppressant maintaining and weaning groups 6 months after graft failure were compared. Among the weaning group, the outcome differences according to low-dose steroid use were also compared at 6 and 12 months. In a total of 131 graft failure cases, 18 mortalities, 42 infection-related hospitalizations, 22 cancer cases, 11 graft intolerance syndrome cases, and 28 re-transplantations occurred during the 94-month follow-up. Immunosuppressant maintenance significantly decreased the patient survival rate 6 months after graft failure compared with weaning (log-rank P = 0.008) and was an independent risk factor for mortality, even after adjustments (hazard ratio, 3.01; P = 0.025). Infection-related hospitalization, graft intolerance syndrome development, and re-transplantation were not affected by the immunosuppressant weaning protocol. Among the immunosuppressant weaning group, low-dose steroid maintenance at 6 and 12 months helped preserved RRF (P = 0.008 and P = 0.003, respectively).
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Gómez-Dos-Santos V, Lorca-Álvaro J, Hevia-Palacios V, Fernández-Rodríguez AM, Diez-Nicolás V, Álvarez-Rodríguez S, Burgos JB, Guerrero CS, Burgos-Revilla FJ. The Failing Kidney Transplant Allograft. Transplant Nephrectomy: Current State-of-the-Art. Curr Urol Rep 2020; 21:4. [PMID: 31960160 DOI: 10.1007/s11934-020-0957-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This review provides a critical literature overview of the risks and benefits of transplantectomy in patients with a failed allograft. Additionally, it offers a summary of related problems, primarily alloantibody sensitization in the event of nephrectomy and immunosuppression weaning. RECENT FINDINGS Transplant nephrectomy has high morbidity and mortality rates. The morbidity of transplant nephrectomy (4.3 to 82%) is mostly due to hemorrhage or infection. Mortality rates range from 1.2 to 39%, and most are due to sepsis. Transvascular graft embolization has been described as a less invasive alternative technique for the management of symptomatic graft rejection, with minimal complications compared with transplantectomy. The number of patients with a failed allograft returning to dialysis is increasing. The role of allograft nephrectomy in the management of asymptomatic transplant failure is still controversial and up today continues to depend on the usual clinical practice of each institution. The less invasive transvascular embolization could have applicability in asymptomatic patients with the obvious lower morbidity and mortality rate.
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Affiliation(s)
- Victoria Gómez-Dos-Santos
- Transplantation and Research Unit, Hospital Ramón y Cajal, Alcalá University, Carretera de Colmenar Km 9.100, 28034, Madrid, Spain.
| | - Javier Lorca-Álvaro
- Urology Department, Hospital Ramón y Cajal, Urology Surgical Research Group and Transplantation, IRYCIS, Alcalá University, Madrid, Spain
| | - Vital Hevia-Palacios
- Urology Department, Urology Surgical Research Group and Transplantation, IRYCIS, Alcalá University, Madrid, Spain
| | | | - Victor Diez-Nicolás
- Urology Department, Urology Surgical Research Group and Transplantation, IRYCIS, Alcalá University, Madrid, Spain
| | - Sara Álvarez-Rodríguez
- Urology Department, Urology Surgical Research Group and Transplantation, IRYCIS, Alcalá University, Madrid, Spain
| | - Jennifer Brasero Burgos
- Urology Department, Hospital Ramón y Cajal, Urology Surgical Research Group and Transplantation, IRYCIS, Alcalá University, Madrid, Spain
| | - Clara Sánchez Guerrero
- Urology Department, Hospital Ramón y Cajal, Urology Surgical Research Group and Transplantation, IRYCIS, Alcalá University, Madrid, Spain
| | - Francisco Javier Burgos-Revilla
- Urology Department, Hospital Ramón y Cajal, Urology Surgical Research Group and Transplantation, IRYCIS, Alcalá University, Madrid, Spain
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