Courtenay M. Holscher

The National Landscape of Living Kidney Donor Follow-up in the United States

In 2013, the Organ Procurement and Transplantation Network (OPTN)/ United Network for Organ Sharing (UNOS) mandated that transplant centers collect data on living kidney donors (LKDs) at 6 months, 1 year, and 2 years postdonation, with policy‐defined thresholds for the proportion of complete living donor follow‐up (LDF) data submitted in a timely manner (60 days before or after the expected visit date). While mandated, it was unclear how centers across the country would perform in meeting thresholds, given potential donor and center‐level challenges of LDF. To better understand the impact of this policy, we studied Scientific Registry of Transplant Recipients data for 31,615 LKDs between January 2010 and June 2015, comparing proportions of complete and timely LDF form submissions before and after policy implementation. We also used multilevel logistic regression to assess donor‐ and center‐level characteristics associated with complete and timely LDF submissions. Complete and timely 2‐year LDF increased from 33% prepolicy (January 2010 through January 2013) to 54% postpolicy (February 2013 through June 2015) (p < 0.001). In an adjusted model, the odds of 2‐year LDF increased by 22% per year prepolicy (p < 0.001) and 23% per year postpolicy (p < 0.001). Despite these annual increases in LDF, only 43% (87/202) of centers met the OPTN/UNOS‐required 6‐month, 1‐year, and 2‐year LDF thresholds for LKDs who donated in 2013. These findings motivate further evaluation of LDF barriers and the optimal approaches to capturing outcomes after living donation.

Turn down for what? Patient outcomes associated with declining increased infectious risk kidneys

Transplant candidates who accept a kidney labeled increased risk for disease transmission (IRD) accept a low risk of window period infection, yet those who decline must wait for another offer that might harbor other risks or never even come. To characterize survival benefit of accepting IRD kidneys, we used 2010‐2014 Scientific Registry of Transplant Recipients data to identify 104 998 adult transplant candidates who were offered IRD kidneys that were eventually accepted by someone; the median (interquartile range) Kidney Donor Profile Index (KDPI) of these kidneys was 30 (16‐49). We followed patients from the offer decision until death or end‐of‐study. After 5 years, only 31.0% of candidates who declined IRDs later received non‐IRD deceased donor kidney transplants; the median KDPI of these non‐IRD kidneys was 52, compared to 21 of the IRDs they had declined. After a brief risk period in the first 30 days following IRD acceptance (adjusted hazard ratio [aHR] accept vs decline: 1.222.063.49, P = .008) (absolute mortality 0.8% vs. 0.4%), those who accepted IRDs were at 33% lower risk of death 1‐6 months postdecision (aHR 0.500.670.90, P = .006), and at 48% lower risk of death beyond 6 months postdecision (aHR 0.460.520.58, P < .001). Accepting an IRD kidney was associated with substantial long‐term survival benefit; providers should consider this benefit when counseling patients on IRD offer acceptance.

Kidney exchange match rates in a large multicenter clearinghouse

Kidney paired donation (KPD) can facilitate living donor transplantation for candidates with an incompatible donor, but requires waiting for a match while experiencing the morbidity of dialysis. The balance between waiting for KPD vs desensitization or deceased donor transplantation relies on the ability to estimate KPD wait times. We studied donor/candidate pairs in the National Kidney Registry (NKR), a large multicenter KPD clearinghouse, between October 2011 and September 2015 using a competing‐risk framework. Among 1894 candidates, 52% were male, median age was 50 years, 66% were white, 59% had blood type O, 42% had panel reactive antibody (PRA)>80, and 50% obtained KPD through NKR. Median times to KPD ranged from 2 months for candidates with ABO‐A and PRA 0, to over a year for candidates with ABO‐O or PRA 98+. Candidates with PRA 80‐97 and 98+ were 23% (95% confidence interval , 6%‐37%) and 83% (78%‐87%) less likely to be matched than PRA 0 candidates. ABO‐O candidates were 67% (61%‐73%) less likely to be matched than ABO‐A candidates. Candidates with ABO‐B or ABO‐O donors were 31% (10%‐56%) and 118% (82%‐162%) more likely to match than those with ABO‐A donors. Providers should counsel candidates about realistic, individualized expectations for KPD, especially in the context of their alternative treatment options.

Persistent regional and racial disparities in nondirected living kidney donation

Nondirected living donors (NDLDs) are an important and growing source of kidneys to help reduce the organ shortage. In its infancy, NDLD transplantation was clustered at a few transplant centers and rarely benefited African American (AA) recipients. However, NDLDs have increased 9.4‐fold since 2000, and now are often used to initiate kidney paired donation chains. Therefore, we hypothesized that the initial geographic clustering and racial disparities may have improved. We used Scientific Registry of Transplant Recipients data to compare NDLDs and their recipients between 2008‐2015 and 2000‐2007. We found that NDLD increased an average of 12% per year, from 20 in 2000 to 188 in 2015 (IRR: 1.12, 95% CI: 1.11‐1.13, P < .001). In 2000‐2007, 18.3% of recipients of NDLD kidneys were AA; this decreased in 2008‐2015 to 15.7%. NDLD transplants initially became more evenly distributed across centers (Gini 0.91 in 2000 to Gini 0.69 in 2011), but then became more clustered at fewer transplant centers (Gini 0.75 in 2015). Despite the increased number of NDLDs, racial disparities have worsened and the center‐level distribution of NDLD transplants has narrowed in recent years.

Factors associated with perceived donation-related financial burden among living kidney donors

The perception of living kidney donation–related financial burden affects willingness to donate and the experience of donation, yet no existing tools identify donors who are at higher risk of perceived financial burden. We sought to identify characteristics that predicted higher risk of perceived financial burden. We surveyed 51 living kidney donors (LKDs) who donated from 01/2015 to 3/2016 about socioeconomic characteristics, predonation cost concerns, and perceived financial burden. We tested associations between both self‐reported and ZIP code–level characteristics and perceived burden using Fishers exact test and bivariate modified Poisson regression. Donors who perceived donation‐related financial burden were less likely to have an income above their ZIP code median (14% vs. 72%, P = .006); however, they were more likely than donors who did not perceive burden to rent their home (57% vs. 16%, P = .03), have an income <

Trends in Transplantation with Older Liver Donors in the United States

60 000 (86% vs. 20%, P = .002), or have had predonation cost concerns (43% vs. 7%, P = .03). Perceived financial burden was 3.6‐fold as likely among those with predonation cost concerns and 10.6‐fold as likely for those with incomes <

Surgical approach, cost, and complications of appendectomy in kidney transplant recipients

60 000. Collecting socioeconomic characteristics and asking about donation‐related cost concerns prior to donation might allow transplant centers to target financial support interventions toward potential donors at higher risk of perceiving donation‐related financial burden.

Temporal changes in the composition of a large multicenter kidney exchange clearinghouse: Do the hard-to-match accumulate?

As the United States population ages, older liver donors (OLDs) represent a potential expansion of the donor pool. Historically, grafts from OLDs have been associated with poor outcomes and higher rates of discard. We sought to evaluate trends in demographics, discard, and outcomes of OLDs. Methods We identified 4127 OLDs (aged≥70) and 3350 liver-only OLD graft recipients using data from the Scientific Registry of Transplant Recipients in the United States (1/1/2003-12/31/2016). We studied temporal changes in OLD graft characteristics, utilization, and recipient characteristics. Modified Poisson regression was used to estimate the annual discard rate. Cuzick test of trend was used to compare changes in OLD transplants performed over the study period. Kaplan-Meier methods were also used to create unadjusted cumulative incidence curves of mortality and all-cause graft loss. Cox proportional hazards models were used to estimate mortality and graft loss for OLD graft recipients. Results From 2003 to 2016, the discard of OLDs increased from 11.6% to 15.4% with the highest discard rate in 2008 at 24.5%. Discarded OLDs were more likely to become younger (74.3 years in 2013-2016 vs. 75.6 years in 2003-2006, p=0.004), have a higher BMI (28.7 vs. 26.7, p=0.008), and less likely to be Caucasian (73.7 vs. 80.8, p=0.03). Since 2003 the percentage of OLD transplants performed out of all adult liver transplants has decreased from 6.0% to 3.2% (p=0.001). The average age of OLD recipients increased from 55.9 years in 2003 to 59.8 years in 2016 (p<0.001). Since 2003, the indication for liver transplant in recipients of OLD grafts has changed. OLD recipients became more likely to have non-alcoholic steatohepatitis (16.9% in 2013-2016 vs 4.1% in 2003-2006) or HCC (22.6% vs 10.6%) as their indication for LT. Also, the average cold ischemia time decreased from 7.7 hours in 2003-2006 to 5.7 hours in 2013-2016 (p<0.001). Graft and patient survival for OLD graft recipients improved since 2003: OLD graft recipients from 2013-2016, mortality was 60% lower (aHR:0.40,95%CI:0.31-0.52,p<0.001) and all-cause graft loss was 55% lower (aHR:0.45,95%CI:0.36-0.57,p<0.001) than between 2003-2006. Conclusion Up to 25% of OLDs are discarded annually across the US, and the number of OLD transplants performed has decreased. However, there is a significant improvement in graft and patient survival for OLD recipients since 2003. Particularly in the setting of an aging population, these trends in improved outcomes can guide OLD use and decrease OLD discard to possibly expand the donor pool. National Institutes of Health. Figure. No caption available. Figure. No caption available. Figure. No caption available. Figure. No caption available.

Living donor postnephrectomy kidney function and recipient graft loss: A dose-response relationship

Kidney transplant recipients (KTRs) have greater morbidity and length of stay (LOS) following certain surgical procedures than non‐KTR. Given that appendectomy is one of the most common surgical procedures, we investigated differences in outcomes between 1336 KTR and 2 640 247 non‐KTR postappendectomy at transplant and nontransplant centers in the United States from 2000 to 2011, using NIS data and adjusting for patient‐level and hospital‐level factors. Postoperative complications were identified using ICD‐9 codes. Among KTR, there were no post‐appendectomy in‐hospital deaths, compared to a 0.2% in non‐KTR (P = .5). Overall complications were similar among KTR and non‐KTR (17.0% vs 11.6%; aOR:0.77 1.121.61). LOS and costs were greater for KTR compared to non‐KTR (LOS ratio 1.191.311.45; cost ratio 1.111.171.26). Only 44.8% of KTR had laparoscopic approach compared to 54.5% of non‐KTR, but had similar complication rates (10.6 vs 8.7%, P = .5). When treated at transplant centers, KTR had similar complications (aOR 0.440.791.43), but longer LOS (ratio 1.211.371.55) and greater hospital‐associated costs (ratio 1.191.291.41) than non‐KTR. Conversely, at nontransplant centers, KTR and non‐KTR had similar complications (aOR 0.751.232.0), LOS (ratio 0.840.961.09), and cost (ratio 0.931.011.10). Contrary to other procedures, KTR did not constitute a high‐risk group for patients undergoing appendectomy.

Better graft outcomes from offspring donor kidneys among living donor kidney transplant recipients in the United States

One criticism of kidney paired donation (KPD) is that easy‐to‐match candidates leave the registry quickly, thus concentrating the pool with hard‐to‐match sensitized and blood type O candidates. We studied candidate/donor pairs who registered with the National Kidney Registry (NKR), the largest US KPD clearinghouse, from January 2012‐June 2016. There were no changes in age, gender, BMI, race, ABO blood type, or panel‐reactive antibody (PRA) of newly registering candidates over time, with consistent registration of hard‐to‐match candidates (59% type O and 38% PRA ≥97%). However, there was no accumulation of type O candidates over time, presumably due to increasing numbers of nondirected type O donors. Although there was an initial accumulation of candidates with PRA ≥97% (from 33% of the pool in 2012% to 43% in 2014, P = .03), the proportion decreased to 17% by June 2016 (P < .001). Some of this is explained by an increase in the proportion of candidates with PRA ≥97% who underwent a deceased donor kidney transplantation (DDKT) after the implementation of the Kidney Allocation System (KAS), from 8% of 2012 registrants to 17% of 2015 registrants (P = .02). In this large KPD clearinghouse, increasing participation of nondirected donors and the KAS have lessened the accumulation of hard‐to‐match candidates, but highly sensitized candidates remain hard‐to‐match.