James J. Wynn

Expanded criteria donors for kidney transplantation.

TransLife-Florida Hospital Medical Center, Orlando, FL Massachusetts General Hospital, Boston, MA University of California San Francisco, San Francisco, CA Scientific Registry of Transplant Recipients (SRTR)/ University Renal Research and Education Association (URREA), Ann Arbor, MI Medical College of Georgia, Augusta, GA SRTR/University of Michigan, Ann Arbor, MI *Corresponding author: Friedrich K. Port, fport@urrea.org

Report of the Crystal City Meeting to Maximize the Use of Organs Recovered from the Cadaver Donor

A consensus meeting to develop guidelines that would improve the recovery and transplantation of organs from the cadaver donor was held on 28–29 March 2001, in Crystal City, Virginia, sponsored by the American Society of Transplant Surgeons and the American Society of Transplantation. The crisis in organ supply persists and the continuing shortage presents a compelling responsibility for the transplant community to maximize the use of organs procured from cadaver donors.

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.

The Report of a National Conference on the Wait List for Kidney Transplantation

In March, 2002, over 100 members of the transplant community assembled in Philadelphia for a meeting designed to address problems associated with the growing number of patients seeking kidney transplantation and added to the waiting list each year. The meeting included representatives of nine US organizations with interests in these issues. Participants divided into work groups addressing access to the waiting list, assigning priority on the list, list management, and identifying appropriate candidates for expanded criteria donor kidneys. Each work group outlined problems and potential remedies within each area. This report summarized the issues and recommendations regarding the waiting list for kidney transplantation addressed in the Philadelphia meeting.

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.

Renal transplant patient compliance with free immunosuppressive medications.

Background. Noncompliance with immunosuppressive medications after renal transplantation is believed to be a major cause of allograft rejection and graft loss, with the impressive costs of these agents considered a significant reason for noncompliance. Our purpose was to determine the compliance rates of renal transplant patients who received their immunosuppressant therapy free of charge and evaluate their patterns of compliance. Methods. All patients who received a renal transplant and received their immunosuppressant medications at our institution for their first year posttransplant were included in the study. Compliance rate was calculated and serum immunosuppressant concentrations were obtained to validate compliance assessments. Results. Eighteen patients were included in the study. Approximately 48% of noncompliant patients were found to have subtarget drug concentrations, although only 14% of compliant patients had subtarget levels (&khgr;2=12.9, P <0.001). At 5 months posttransplant, 95% of the patients remained compliant; however, by 12 months posttransplant, only 48% of the patients remained compliant. The mean time to the first noncompliant month was 9.8 months (95% confidence intervals=8.60–11.0). Conclusions. Patients who received their immunosuppressants free of charge were generally compliant within their first year of transplantation, however, compliance tended to decrease over time. This suggests that drug cost alone does not explain noncompliant behavior. Intensive efforts to increase medication compliance before month 8 posttransplantation should be implemented.

Early Mortality Rates in Older Kidney Recipients With Comorbid Risk Factors

Background. There are over 60,000 candidates on the deceased donor kidney wait-list and the percentage of candidates over age 50 years continues to grow each year. National data have not previously been used to evaluate the association of comorbidities with mortality in older patients. Methods. A multivariate analysis of 30,262 deceased donor primary kidney recipients aged 18–59 years and 8,895 aged ≥60 years evaluated the association of six recipient comorbidities on 90- and 365-day patient mortality rates. The additional effects of expanded criteria donors (ECD) and development of delayed graft function (DGF) were also evaluated. Results. The 365-day mortality rate for recipients aged ≥60 years (10.5%) was more than twice that of recipients aged 18–59 years (4.4%) and comorbidities significantly increased mortality rates even higher (10.6–21.4%). The 365-day mortality rate for recipients aged ≥60 years who received an ECD kidney was 14.4% and who developed DGF was 15.9% while recipients with comorbidities but no DGF and no ECD ranged from 16.0 to 42.3%. The 365-day transplant mortality rate of recipients aged ≥60 years with comorbidities is higher than the 365-day wait-list mortality for patients with the same comorbidities, suggesting a lack of survival benefit from transplantation. Conclusions. Mortality rates for patients aged ≥60 years with comorbidities are higher than for those without comorbidities, significantly higher than for younger patients, and higher than for wait-listed patients. Thus, utility may be poorly served by allocating kidneys to older patients with comorbidities, and perhaps discussion of exclusionary listing criteria is warranted.

Living kidney donor follow-up: State-of-the-art and future directions, conference summary and recommendations

In light of continued uncertainty regarding postkidney donation medical, psychosocial and socioeconomic outcomes for traditional living donors and especially for donors meeting more relaxed acceptance criteria, a meeting was held in September 2010 to (1) review limitations of existing data on outcomes of living kidney donors; (2) assess and define the need for long‐term follow‐up of living kidney donors; (3) identify the potential system requirements, infrastructure and costs of long‐term follow‐up for living kidney donor outcomes in the United States and (4) explore practical options for future development and funding of United States living kidney donor data collection, metrics and endpoints. Conference participants included prior kidney donors, physicians, surgeons, medical ethicists, social scientists, donor coordinators, social workers, independent donor advocates and representatives of payer organizations and the federal government. The findings and recommendations generated at this meeting are presented.

Increasing organ donation and transplantation: the U.S. experience over the past decade

The growing gap between the need for and supply of transplantable organs in the U.S. led to several initiatives over the past decade. UNOS implemented policies intended to facilitate the use of expanded criteria donor kidneys with mixed success. The U.S. government sponsored several organ donation and transplantation collaboratives, leading to significant increases in organ donation over several years. The use of organs from donors dying from cardiac death has increased steadily over the past decade, with such donors now exceeding 10% of the total. Revisions of state anatomic death acts allowed persons to declare their intention to donate by enrolling in state donor registries, facilitating the identification of willing donors by organ procurement organization. Despite these initiatives, the disparity between organ demand and supply has continued to grow, primarily as a result of marked increase in the number of candidates awaiting kidney transplantation.

Elevated basilic vein arteriovenous fistula

BACKGROUND Many surgeons continue to use prosthetic arteriovenous grafts for dialysis access despite the clear superiority of native arteriovenous fistulas. This study was undertaken to review our experience with elevated brachial-basilic fistulas as an alternative to prosthetic grafts in patients lacking veins suitable for more conventional arteriovenous fistulas. METHODS We retrospectively reviewed the outcomes of 67 patients receiving elevated brachial-basilic arteriovenous fistulas over a 10-year period. Operative complications and causes of failure were identified and actuarial fistula patency determined. RESULTS No patients suffered wound infections, and only 1 developed a steal syndrome in the late postoperative period. Actuarial fistula patency was 84% at 1 year, 73% at 3 and 5 years, and 52% at 10 years. CONCLUSIONS The elevated brachial-basilic arteriovenous fistula is a superb alternative to prosthetic arteriovenous grafts in patients lacking suitable cephalic veins for native arteriovenous fistulas. Operative complications are uncommon, vascular steal is rare, and long-term patency is excellent.