Brian J. Boyarsky

Pregnancy Outcomes in Kidney Transplant Recipients: A Systematic Review and Meta-Analysis

Approximately 50 000 women of reproductive age in the United States are currently living after kidney transplantation (KT), and another 2800 undergo KT each year. Although KT improves reproductive function in women with ESRD, studies of post‐KT pregnancies are limited to a few voluntary registry analyses and numerous single‐center reports. To obtain more generalizable inferences, we performed a systematic review and meta‐analysis of articles published between 2000 and 2010 that reported pregnancy‐related outcomes among KT recipients. Of 1343 unique studies, 50 met inclusion criteria, representing 4706 pregnancies in 3570 KT recipients. The overall post‐KT live birth rate of 73.5% (95%CI 72.1–74.9) was higher than the general US population (66.7%); similarly, the overall post‐KT miscarriage rate of 14.0% (95%CI 12.9–15.1) was lower (17.1%). However, complications of preeclampsia (27.0%, 95%CI 25.2–28.9), gestational diabetes (8.0%, 95%CI 6.7–9.4), Cesarean section (56.9%, 95%CI 54.9–58.9) and preterm delivery (45.6%, 95%CI 43.7–47.5) were higher than the general US population (3.8%, 3.9%, 31.9% and 12.5%, respectively). Pregnancy outcomes were more favorable in studies with lower mean maternal ages; obstetrical complications were higher in studies with shorter mean interval between KT and pregnancy. Although post‐KT pregnancy is feasible, complications are relatively high and should be considered in patient counseling and clinical decision making.

Frailty as a Novel Predictor of Mortality and Hospitalization in Individuals of All Ages Undergoing Hemodialysis

To quantify the prevalence of frailty in adults of all ages undergoing chronic hemodialysis, its relationship to comorbidity and disability, and its association with adverse outcomes of mortality and hospitalization.

Pregnancy outcomes of liver transplant recipients: A systematic review and meta-analysis

Approximately 14,000 women of reproductive age are currently living in the United States after liver transplantation (LT), and another 500 undergo LT each year. Although LT improves reproductive function in women with advanced liver disease, the associated pregnancy outcomes and maternal‐fetal risks have not been quantified in a broad manner. To obtain more generalizable inferences, we performed a systematic review and meta‐analysis of articles that were published between 2000 and 2011 and reported pregnancy‐related outcomes for LT recipients. Eight of 578 unique studies met the inclusion criteria, and these studies represented 450 pregnancies in 306 LT recipients. The post‐LT live birth rate [76.9%, 95% confidence interval (CI) = 72.7%‐80.7%] was higher than the live birth rate for the US general population (66.7%) but was similar to the post–kidney transplantation (KT) live birth rate (73.5%). The post‐LT miscarriage rate (15.6%, 95% CI = 12.3%‐19.2%) was lower than the miscarriage rate for the general population (17.1%) but was similar to the post‐KT miscarriage rate (14.0%). The rates of pre‐eclampsia (21.9%, 95% CI = 17.7%‐26.4%), cesarean section delivery (44.6%, 95% CI = 39.2%‐50.1%), and preterm delivery (39.4%, 95% CI = 33.1%‐46.0%) were higher than the rates for the US general population (3.8%, 31.9%, and 12.5%, respectively) but lower than the post‐KT rates (27.0%, 56.9%, and 45.6%, respectively). Both the mean gestational age and the mean birth weight were significantly greater (P < 0.001) for LT recipients versus KT recipients (36.5 versus 35.6 weeks and 2866 versus 2420 g). Although pregnancy after LT is feasible, the complication rates are relatively high and should be considered during patient counseling and clinical decision making. More case and center reports are necessary so that information on post‐LT pregnancy outcomes and complications can be gathered to improve the clinical management of pregnant LT recipients. Continued reporting to active registries is highly encouraged at the center level. Liver Transpl, 2012.

National Trends Over 25 Years in Pediatric Kidney Transplant Outcomes

OBJECTIVE: To investigate changes in pediatric kidney transplant outcomes over time and potential variations in these changes between the early and late posttransplant periods and across subgroups based on recipient, donor, and transplant characteristics. METHODS: Using multiple logistic regression and multivariable Cox models, graft and patient outcomes were analyzed in 17 446 pediatric kidney-only transplants performed in the United States between 1987 and 2012. RESULTS: Ten-year patient and graft survival rates were 90.5% and 60.2%, respectively, after transplantation in 2001, compared with 77.6% and 46.8% after transplantation in 1987. Primary nonfunction and delayed graft function occurred in 3.3% and 5.3%, respectively, of transplants performed in 2011, compared with 15.4% and 19.7% of those performed in 1987. Adjusted for recipient, donor, and transplant characteristics, these improvements corresponded to a 5% decreased hazard of graft loss, 5% decreased hazard of death, 10% decreased odds of primary nonfunction, and 5% decreased odds of delayed graft function with each more recent year of transplantation. Graft survival improvements were lower in adolescent and female recipients, those receiving pretransplant dialysis, and those with focal segmental glomerulosclerosis. Patient survival improvements were higher in those with elevated peak panel reactive antibody. Both patient and graft survival improvements were most pronounced in the first posttransplant year. CONCLUSIONS: Outcomes after pediatric kidney transplantation have improved dramatically over time for all recipient subgroups, especially for highly sensitized recipients. Most improvement in graft and patient survival has come in the first year after transplantation, highlighting the need for continued progress in long-term outcomes.

Estimating the Potential Pool of HIV‐Infected Deceased Organ Donors in the United States

Human immunodeficiency virus (HIV) is no longer a contraindication to transplantation. For HIV‐infected patients, HIV‐infected deceased donors (HIVDD) could attenuate the organ shortage and waitlist mortality. However, this practice would violate United States federal law. The goal of this study was to estimate the potential impact of legalizing transplantation of HIV‐infected organs by quantifying the potential pool of HIVDD. Using Nationwide Inpatient Sample (NIS) data, HIV‐infected deaths compatible with donation were enumerated. Using HIV Research Network (HIVRN) data, CD4 count, plasma HIV‐1 RNA level, AIDS‐defining illnesses and causes of death were examined in potential HIVDD. Using UNOS data, evaluated donors who later demonstrated unanticipated HIV infections were studied. From NIS, a yearly average of 534 (range: 481–652) potential HIVDD were identified, with 63 (range: 39–90) kidney‐only, 221 (range: 182–255) liver‐only and 250 (range: 182–342) multiorgan donors. From HIVRN, a yearly average of 494 (range: 441–533) potential HIVDD were identified. Additionally, a yearly average of 20 (range: 11–34) donors with unanticipated HIV infection were identified from UNOS. Deceased HIV‐infected patients represent a potential of approximately 500–600 donors per year for HIV‐infected transplant candidates. In the current era of HIV management, a legal ban on the use of these organs seems unwarranted and likely harmful.

Live Donor Champion: Finding Live Kidney Donors by Separating the Advocate from the Patient

Background Lack of education and reluctance to initiate a conversation about live donor kidney transplantation is a common barrier to finding a donor. Although transplant candidates are often hesitant to discuss their illness, friends or family members are often eager to spread awareness and are empowered by advocating for the candidates. We hypothesized that separating the advocate from the patient is important in identifying live donors. Methods We developed an intervention to train a live donor champion (LDC; a friend, family member, or community member willing to advocate for the candidate) for this advocacy role. We compared outcomes of 15 adult kidney transplant candidates who had no prospective donors and underwent the LDC intervention with 15 matched controls from our waiting list. Results Comfort in initiating a conversation about transplantation increased over time for LDCs. Twenty-five potential donors contacted our center on behalf of LDC participants; four participants achieved live donor kidney transplantation and three additional participants have donors in evaluation, compared with zero among matched controls (P < 0.001). Conclusions Transplant candidates are ill equipped to seek live donors; by separating the advocate from the patient, understandable concerns about initiating conversations are reduced.

Potential limitations of presumed consent legislation.

A causal link has been proposed between presumed consent (PC) and increased donation; we hypothesized that too much heterogeneity exists in transplantation systems to support this inference. We explored variations in PC implementation and other potential factors affecting donation rates. In-depth interviews were performed with senior transplant physicians from 13 European PC countries. Donation was always discussed with family and would not proceed against objections. Country-specific, nonconsent factors were identified that could explain differences in donation rates. Because the process of donation in PC countries does not differ dramatically from the process in non-PC countries, it seems unlikely that PC alone increases donation rates.

Challenges and Clinical Decision‐Making in HIV‐to‐HIV Transplantation: Insights From the HIV Literature

Life expectancy among HIV‐infected (HIV+) individuals has improved dramatically with effective antiretroviral therapy. Consequently, chronic diseases such as end‐stage liver and kidney disease are growing causes of morbidity and mortality. HIV+ individuals can have excellent outcomes after solid organ transplantation, and the need for transplantation in this population is increasing. However, there is a significant organ shortage, and HIV+ individuals experience higher mortality rates on transplant waitlists. In South Africa, the use of organs from HIV+ deceased donors (HIVDD) has been successful, but until recently federal law prohibited this practice in the United States. With the recognition that organs from HIVDD could fill a critical need, the HIV Organ Policy Equity (HOPE) Act was passed in November 2013, reversing the federal ban on the use of HIV+ donors for HIV+ recipients. In translating this policy into practice, the biologic risks of using HIV+ donors need to be carefully considered. In this mini‐review, we explore relevant aspects of HIV virology, antiretroviral treatment, drug resistance, opportunistic infections and HIV‐related organ dysfunction that are critical to a transplant team considering HIV‐to‐HIV transplantation.

Experiences Obtaining Insurance After Live Kidney Donation

The impact of kidney donation on the ability to change or initiate health or life insurance following donation is unknown. To quantify this risk, we surveyed 1046 individuals who donated a kidney at our center between 1970 and 2011. Participants were asked whether they changed or initiated health or life insurance after donation, and if they had any difficulty doing so. Among 395 donors who changed or initiated health insurance after donation, 27 (7%) reported difficulty; among those who reported difficulty, 15 were denied altogether, 12 were charged a higher premium and 8 were told they had a preexisting condition because they were kidney donors. Among 186 donors who changed or initiated life insurance after donation, 46 (25%) reported difficulty; among those who reported difficulty, 23 were denied altogether, 27 were charged a higher premium and 17 were told they had a preexisting condition because they were kidney donors. In this single‐center study, a high proportion of kidney donors reported difficulty changing or initiating insurance, particularly life insurance. These practices by insurers create unnecessary burden and stress for those choosing to donate and could negatively impact the likelihood of live kidney donation among those considering donation.

From Bench to Bill: How a Transplant Nuance Became 1 of Only 57 Laws Passed in 2013.

I had long been frustrated by the fact that we could successfully transplant hepatitis C-positive (HCVþ) organs into HCVþ recipients, but federal law prohibited parallel therapy for human immunodeficiency virus-positive (HIVþ) patients. At the height of the acquired immunodeficiency syndrome (AIDS) scare in the 1980s, Congress banned the recovery of organs from HIVþ individuals as a small part of the National Organ Transplant Act (NOTA), and this restriction had never been updated to reflect changes in modern HIV care. Then in May 2010, Brian Boyarsky, fresh out of his Bachelor’s in Public Health at Johns Hopkins University, was sitting in my office trying to figure out how to spend his gap years before medical school. As part of his senior thesis comparing transplant programs in different countries, he met Elmi Muller in South Africa who had been successfully transplanting organs between HIVþ donors and recipients. I asked Brian whether he would be interested in sacrificing several years of his life to battle Congress on this issue. Based on my experience as a Health and Aging Policy Fellow in Washington, DC, I warned him that enacting change on the federal level was nearly impossible: fewer than 5% of bills introduced become law. The challenge only seemed to pique his interest. Over the ensuing 3 years, we conducted robust policy-driven research that led to positive press, Congressional and White House attention to a nuance of transplant surgery practice, and 1 of only 57 bills passed in 2013 by the most unproductive Congress in the history of the US (Fig. 1).