Dale A. Distant

Determinants of discard of expanded criteria donor kidneys: Impact of biopsy and machine perfusion

We examined factors associated with expanded criteria donor (ECD) kidney discard. Scientific Registry of Transplant Recipients (SRTR)/Organ Procurement and Transplantation Network (OPTN) data were examined for donor factors using logistic regression to determine the adjusted odds ratio (AOR) of discard of kidneys recovered between October 1999 and June 2005. Logistic and Cox regression models were used to determine associations with delayed graft function (DGF) and graft failure. Of the 12 536 recovered ECD kidneys, 5139 (41%) were discarded. Both the performance of a biopsy (AOR = 1.21, p = 0.02) and the degree of glomerulosclerosis (GS) on biopsy were significantly associated with increased odds of discard. GS was not consistently associated with DGF or graft failure. The discard rate of pumped ECD kidneys was 29.7% versus 43.6% for unpumped (AOR = 0.52, p < 0.0001). Among pumped kidneys, those with resistances of 0.26–0.38 and >0.38 mmHg/mL/min were discarded more than those with resistances of 0.18–0.25 mmHg/mL/min (AOR = 2.5 and 7.9, respectively). Among ECD kidneys, pumped kidneys were less likely to have DGF (AOR = 0.59, p < 0.0001) but not graft failure (RR = 0.9, p = 0.27). Biopsy findings and machine perfusion are important correlates of ECD kidney discard; corresponding associations with graft failure require further study.

Kidney and pancreas transplantation

Data from the Scientific Registry of Transplant Recipients offer a unique and comprehensive view of US trends in kidney and pancreas waiting list characteristics and outcomes, transplant recipient and donor characteristics, and patient and allograft survival. Important findings from our review of developments during 2002 and the decades transplantation trends appear below.

Unemployment in inner-city renal transplant recipients: Predictive and sociodemographic factors

Studies of dialysis patients report unemployment rates of 60% to 75%; however, it is generally believed that following transplantation, improvement in well-being and removal of time constraints imposed by the dialytic regimen afford improvement in employment status. We studied 58 stable renal transplant recipient attending an outpatient transplant clinic by questionnaire, administered anonymously. Only 25 (43%) of the patients were currently employed. Employed and unemployed patients did not differ when compared for age, gender, race, cause of renal disease, type of transplant or prior dialysis, time on dialysis or time since transplantation, years of education, or prestige score or classification (blue collar v white collar) of prior job. In the employed group, 24 (96%) patients had worked before developing kidney disease compared with 23 (70%) patients in the unemployed group (P < 0.05). While on dialysis, 19 (79%) of the employed patients continued working compared with 10 (30%) of the unemployed patients (P < 0.005). Major reasons for discontinuing work after starting dialysis for both groups were subjective illness (feeling too sick, 51%), followed by interference of the dialysis regimen with time necessary for work (32%). Only 15% of the previously employed patients did not work after transplantation because of feeling too sick. By multiple logistic regression, the strongest predictors of employment posttransplant were being more than 1 year posttransplant (odds ratio, 2.35; 95% confidence interval, 1.01 to 5.5) and having been employed before transplantation (odds ratio, 3.79; 95% confidence interval, 1.60 to 9.02). Over half of the unemployed patients (20 [61%]) expressed interest in job training. Eighty percent to 90% of patients in both groups were insured by Medicare, with the second greatest number insured by Medicaid. Of the 15 unemployed patients insured by Medicaid, 67% reported that their decision not to work was related to fear of losing Medicaid benefits because they could not afford medications without it. Despite no difference in actual type of insurance carried, 17 (51%) of the unemployed patients believed their health insurance coverage was inadequate compared with four (12%) of the employed patients (P = 0.005, chi-squared test). Unemployment remains a significant problem for our population of inner-city renal transplant recipients. Attention to job retention or retraining during the early renal disease and dialysis therapy period may promote better rehabilitation following transplantation. However, for this population, with limited employment opportunities, removal of disincentives to work, including loss of Insurance and Inability to pay for medications, will be necessary before we can provide optimal rehabilitation for renal transplant recipients from all social strata.

Workgroup on expanded criteria organs for liver transplantation

Organ transplantation has progressed, in a relatively brief period of medical history, from an experimental to a standard treatment for end-stage organ failure. The replacement of a diseased heart, liver, or kidney with a functional transplant has become the preferred approach to restoring the well-being of a patient. However, while the number of patients who are medically suitable to undergo organ transplantation has markedly risen, the supply of deceased organ donors has remained insufficient to provide for the increasing demand. Thus, organ procurement and transplant professionals have considered other ways of addressing this organ shortage, such as the transplantation of organs from living donors or from deceased donors whose medical characteristics are not ideal. The ideal deceased donor of an organ has been identified as a donor younger than 40 years of age who has no characteristics that may predispose his or her organs to graft failure after transplantation. Currently, ideal deceased liver donors provide approximately one-third of all livers transplanted in the United States. All other deceased liver donors present a continuum of increased risk of graft failure compared with the ideal donor. The expanded criteria donor (ECD) designation is meant to describe a deceased donor with substantially increased risk of graft failure compared with the ideal donor. The following deceased donor characteristics have been associated with increased risk of graft failure and have been used to describe the ECD:

Long‐term outcomes of dual kidney transplantation—a single center experience

Abstract:u2002 The shortage of kidney donors has led to broadening of the acceptance criteria for deceased donor organs beyond the traditional use of young donors. We determined long‐term post‐transplant outcomes in recipients of dual expanded criteria donor kidneys (dECD, nu2003=u200344) and compared them to recipients of standard criteria donor kidneys (SCD, nu2003=u2003194) and single expanded criteria donor kidneys (sECD, nu2003=u200362). We retrospectively reviewed these 300 deceased donor kidney transplants without primary non‐function (PNF) or death in the first two wk, at our center from 1996 to 2003. The three groups were similar in baseline characteristics. Kidney allograft survival and patient survival (nine yr) were similar in the three respective donor groups, SCD, sECD and dECD (60% vs. 59% vs. 64% and 82% vs. 73% vs. 73%). Acute rejection in the first three months was 23.2%, 16.1%, and 22.7% in SCD, sECD and dECD, respectively (pu2003=u20030.49) and delayed graft function was 25.2%, 31.9% and 17.1% in the three groups, respectively (pu2003=u20030.28). When PNF and death within the first two wk was included, there was no significant difference in graft survival between the three groups. In our population, recipients of dECD transplants have acceptable patient and graft survival with kidneys that would have usually been discarded.

Long-term kidney transplant outcome in obese patients in a predominantly African American population.

Karabicak I, Aytug S, Lewis S, Shah S, Sumrani N, Hayat A, Distant DA, Salifu MO. Long‐term kidney transplant outcome in obese patients in a predominantly African American population.u2028Clin Transplant 2011: 25: E264–E270.

Poor kidney allograft survival associated with positive B cell - Only flow cytometry cross matches: a ten year single center study.

The presence of donor specific antibody (DSA) to class 1 or class 2 HLA as detected respectively in T cell or B cell - only flow cytometry cross matches (FCXMs) are risk factors for renal allograft survival, though the comparative risk of these XMs has not been definitively established. Allograft survival and FCXM data in 624 microcytotoxicity (CDC) XM negative kidney transplants were evaluated. Short and long term allograft survival was significantly less in recipients with T(-) B(+) FCXMs (1 year, 74%, 10 year, 58%) compared to T(+) B(+) FCXMs (1 year, 84%, 10 year, 68%) and to T(-) B(-) FCXM (1 year, 90%, 10 year, 85%). Risk factors were positive FCXM, deceased donor (DD) transplantation and donor age, but not race, gender, recipient age or previous transplant. Recipients with T(-) B(+) and T(+) B(+) FCXMs were at 4.5 and 2.5 fold greater risk, respectively, of DD allograft failure compared to patients with T(-) B(-) FCXMs. The quantitative value of FCXM did not correlate with the duration of graft survival. We conclude that patients with DSA to class 2 HLA have a greater risk of early and late allograft failure compared to patients with DSA to class 1 HLA.

Impact of Human Leukocyte Antigen-DR Mismatch Status on Kidney Graft Survival in a Predominantly African-American Population Under the Newer Immunosuppressive Era

BACKGROUNDnHuman leukocyte antigen (HLA)-DR has been shown to be immunogenic and associated with poor long-term graft function. However, under potent induction immunosuppression with antithymocyte globulin, the impact of the HLA-DR remains unclear.nnnMETHODnWe reviewed 672 renal transplant recipients who received their transplants between 1998 and 2007. All patients received antithymocyte globulin as induction therapy followed by tacrolimus + prednisone + mycophenolate mofetil for maintenance immunosuppression. We divided the patients into three groups according to HLA-DR mismatch status (zero, one, or two mismatches).nnnRESULTSnThe three groups were different in total number of mismatches, deceased donor transplant, and delayed graft function, respectively. By Kaplan-Meier survival analysis, actuarial graft survival was significantly lower in the HLA-DR two mismatches group (72%) compared to HLA-DR zero mismatches group (78.5%) or HLA-DR one mismatch group (78.5%; P = .05, by log-rank test). Using Cox regression analysis, the risk of graft failure with two HLA-DR mismatches as compared with zero HLA-DR mismatches was 1.6 (95% confidence interval = 1.0-2.44, P = .049). When adjusted for age, wait time, race, type of transplant, retransplant status, T-cell flow crossmatch, delayed graft function, acute rejection, HLA-A and HLA-B, the effect of HLA-DR on survival was not significant (P = .55).nnnCONCLUSIONnThe independent effect of HLA-DR mismatches on adverse graft survival is diminished under potent antibody induction and maintenance immunosuppression in our predominantly African-American population.

Prevalence of Central Vein Stenosis in Patients Referred for Vein Mapping

BACKGROUND AND OBJECTIVESnCentral vein stenosis is considered to be common in patients on hemodialysis but its exact prevalence is not known. In this study, we report the prevalence of central vein stenosis in patients with CKD referred for vein mapping.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnWe conducted a retrospective study of adult patients who had bilateral upper extremity venographic vein mapping from September 1, 2011 to December 31, 2015. Patients with and without stenosis were compared for differences in clinical or demographic characteristics. Multiple logistic regression was used to identify independent associations between patient characteristics and central vein stenosis.nnnRESULTSnThere were 525 patients who underwent venographic vein mapping during the study period, 27% of whom were referred before initiation of hemodialysis. The mean age (±SD) and body mass index were 59 (±15) years and 28 (±7), respectively. Women accounted for 45% of patients; 82% were black. The prevalence of central vein stenosis was 10% (95% confidence interval [95% CI], 8% to 13%) for the whole group, and 13% (95% CI, 10% to 17%) among patients with tunneled central venous dialysis catheters. Current use of tunneled hemodialysis catheters (odds ratio [OR], 14.5; 95% CI, 3.25 to 65.1), presence of cardiac rhythm devices (OR, 5.07; 95% CI, 1.82 to 14.11), previous history of fistula or graft (OR, 3.28; 95% CI, 1.58 to 6.7), and history of previous kidney transplant (OR, 18; 95% CI, 4.7 to 68.8) were independently associated with central vein stenosis.nnnCONCLUSIONSnIn this population, the prevalence of central vein stenosis was 10% and was clustered among those with tunneled hemodialysis catheters, cardiac rhythm device, and previous history of dialysis access or transplant.

Elderly Transplant Recipients

While the total number of organs transplanted in this country has increased over the years, there is still an ever-widening gap between the need for organs and our capacity to meet that need as the overall waiting list continues to grow. This is due in part to significant advances in transplant techniques and outcomes such that Americans with organ failure now seek transplants in greater numbers. Additionally, life-expectancy gains in the United States are creating an aging population who are more likely to suffer organ failure than younger Americans. The national transplant waiting list has continued to shift toward older candidates. The Scientific Registry of Transplant Recipients (SRTR) reported that at the end of 2007, 59.7% of all 97,248 candidates on the waiting list for all organs were 50 years old or older, and 14.9% were 65 years or older. These percentages are substantially higher than they were in 1998 (41.5 and 8.1%, respectively) [1].