Roland A. Hernandez

The combined risk of donor quality and recipient age: higher-quality kidneys may not always improve patient and graft survival.

Background The Kidney Donor Profile Index (KDPI) is a more precise donor organ quality metric replacing age-based characterization of donor risk. Little prior attention has been paid on the outcomes of lower-quality kidneys transplanted into elderly recipients. Although we have previously shown that immunological risks associated with older organs are attenuated by advanced recipient age, it remains unknown whether risks associated with lower-quality KDPI organs are similarly reduced in older recipients. Methods Donor organ quality as measured by the KDPI was divided into quintiles (very high, high, medium, low, and very low quality), and Cox proportional hazards was used to assess graft and recipient survival in first-time adult deceased donor transplant recipients by recipient age. Results In uncensored graft survival analysis, recipients older than 69 years had demonstrated comparable outcomes if they received low-quality kidneys compared to medium-quality kidneys. Death-censored analysis demonstrated no increased relative risk when low-quality kidneys were transplanted into recipients aged 70 to 79 years (hazard ratio [HR], 1.11; P=0.19) or older than 79 years (HR, 1.08; P=0.59). In overall survival analysis, elderly recipients gained no relative benefit from medium-quality kidneys over low-quality kidneys (70–79 years: HR, 1.03, P=0.51; >79 years: HR, 1.08; P=0.32). Conclusion Our analysis demonstrates that transplanting medium-quality kidneys into elderly recipients does not provide significant advantage over low-quality kidneys.

Disparities in kidney transplantation across the United States: Does residential segregation play a role?

BACKGROUND Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. METHODS Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000-2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. RESULTS Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. CONCLUSION Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. SUMMARY Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.

A Prediction Tool to Assess the Probability of Deceased Donor Kidney Transplant.: Abstract# C1837

C1838 External Validation of the Estimated Post-Transplant Survival (EPTS) Score for Allocation of Deceased Donor Kidneys in the USA. P. Clayton,1 S. McDonald,1 J. Snyder,2 N. Salkowski,2 S. Chadban.1 1Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Royal Adelaide Hospital, Adelaide, SA, Australia; 2Scientifi c Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN. Background: The US kidney allocation system adopted in 2013 will allocate the best 20% of deceased donor kidneys (based on the kidney donor risk index, KDRI) to the 20% of wait-listed patients with the highest estimated post-transplant survival (EPTS). The EPTS has not been externally validated, raising concerns as to its suitability to discriminate between kidney transplant candidates. Methods: We examined EPTS using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. We included 4983 adult kidney-only deceased donor transplants over 2000-2011. We constructed three Cox models for patient survival: (1) EPTS alone; (2) EPTS plus donor age, hypertension and HLADR mismatch; (3) EPTS plus log(KDRI). Results: All models demonstrated moderately good discrimination, with Harrell’s C statistics of 0.67, 0.68 and 0.69 respectively. These results are virtually identical to the internal validation which demonstrated a c-statistic of 0.69. Conclusion: The EPTS is externally valid and is moderately good at discriminating post-transplant survival of adult kidney-only transplant recipients. Abstract# C1839 Kidney Transplantation Using Extended Criteria Donor (ECD) Kidneys From Donors With Acute Kidney Injury (AKI). R. Heilman, C1839 Kidney Transplantation Using Extended Criteria Donor (ECD) Kidneys From Donors With Acute Kidney Injury (AKI). R. Heilman, H. Khamash, J. Huskey, A. Moss, N. Katariya, W. Hewitt, M. Smith, R. Batra, K. Reddy. Mayo Clinic, Phoenix, AZ. Background: Our aim was to study the outcomes following transplant using ECD AKI compared to ECD non AKI kidneys. Methods: We included all ECD kidneys transplanted at our center between July 2004 and October 2013. We defi ned AKI as donor with terminal creatinine > 2.0. In this analysis we focused on the outcome following transplant of ECD kidneys with AKI compared to ECD kidneys without AKI. Criteria for accepting AKI donor kidneys were: no cortical necrosis or signifi cant chronic changes on pre-implantation biopsy and acceptable pump parameters (fl ow>80 and RI<0.40). Results: There were 160 ECD kidneys transplanted during this period: 23 in the AKI group and 137 in the control group (ECD Non AKI group). There was no signifi cant difference in baseline recipient characteristics. The mean recipient age was 64.3±7.5, 42.5% were female, 4% were Black race, BMI was 28.9±4.9, 53% were diabetic, 7.5% were re-transplant, 18% were preemptive, mean HLA mismatch 4.2±1.7 and 18% had PRA > 20%. For the AKI group, the donors were younger (56.6±9.1 vs 61.6±9.2, p=0.02), more likely to be male (74% vs 52%, p=0.04) and had longer CIT (22.2±6.9 vs 16.7±7.2 hrs, p=0.001). Additional data for the AKI ECD group: admitting creatinine was 1.11±0.48, peak creatinine 3.68±1.63, terminal creatinine 3.31±1.04, 39% were oligo-anuric and 13% (n=3) were on renal replacement therapy. Delayed graft function (DGF) was more common in the AKI group, but GFR and biopsy fi ndings at 1 yr and graft survival were all similar between the groups. ECD AKI Group (n=23) ECD Non-AKI Group (n=137) p DGF 74% 27% <.0001 Days of DGF (median, 25-75) 8.5 (2.5-14.25) 6 (2.75-14.5) 0.84 Creatinine 1 week 4.36±2.05 2.69±1.74 <0.0001 Creatinine 1 year 1.33±0.41 (n=10) 1.85±1.65 (n=80) 0.33 eGFR 1 year 55.3±18.5 45.3±17.4 0.09 IFTA > 2 on 1 year biopsy 56% (n=9) 50% (n=56) 0.76 Conclusion: Outcomes after transplant using AKI ECD kidneys is similar to transplant with ECD kidneys without AKI. There may be an opportunity to increase the utilization of kidneys from AKI ECD donors. Abstract# C1840 Infl uence of a Sensitized Patient Program and Clinic On Kidney Transplant Rates and Outcomes in Highly HLA-Sensitized Patients. A. Shields,1 M. Cuffy,1 N. Ejaz,1 M. Barker,1 E. Brown,2 A. Girnita,1 M. Cardi,2 B. Abu Jawdeh,1 G. Mogilishetty,1 E. Woodle.1 1Univ of Cincinnati; 2The Christ Hospital. Background: The infl uence of dedicated programs and clinics for HLA-sensitized patients (pts) on transplantation rates and outcomes has not been clearly defi ned. Methods: Pts were eligible for Sensitized Patient Education and Evaluation Program/ Clinic (SPEEC) if 1) waitlisted with cPRA >25%, or 2) had a living donor (LD) with crossmatch or donor specifi c antibody (DSA) at levels that increased antibody mediated rejection (AMR) risk. SPEEC program included 1) educational sessions, 2) kidney champion program, 3) kidney exchange, and 4) desensitization. Priority for SPEEC program included: Wait listed patients with identifi ed living donors, waiting time, new referrals with identifi ed living donors. Results: Between 2009-2013, 359 HLA-sensitized kidney transplant (txp) candidates were identifi ed who met SPEEC program eligibility. To date 195 (54%) pts have entered SPEEC program; 58 (30%) had 2 or more clinic visits. 54 pts (28%) have been transplanted. This txp rate was higher than in 164 SPEEC-eligible pts who have not yet entered the SPEEC program, of which 27 (16%) were transplanted, p < 0.007. (These 164 patients have not yet entered SPEEC primarily due to staff workload limitations). Notably, cPRA was higher in pts in the SPEEC program. C1840 Infl uence of a Sensitized Patient Program and Clinic On Kidney Transplant Rates and Outcomes in Highly HLA-Sensitized Patients. A. Shields,1 M. Cuffy,1 N. Ejaz,1 M. Barker,1 E. Brown,2 A. Girnita,1 M. Cardi,2 B. Abu Jawdeh,1 G. Mogilishetty,1 E. Woodle.1 1Univ of Cincinnati; 2The Christ Hospital. Background: The infl uence of dedicated programs and clinics for HLA-sensitized patients (pts) on transplantation rates and outcomes has not been clearly defi ned. Methods: Pts were eligible for Sensitized Patient Education and Evaluation Program/ Clinic (SPEEC) if 1) waitlisted with cPRA >25%, or 2) had a living donor (LD) with crossmatch or donor specifi c antibody (DSA) at levels that increased antibody mediated rejection (AMR) risk. SPEEC program included 1) educational sessions, 2) kidney champion program, 3) kidney exchange, and 4) desensitization. Priority for SPEEC program included: Wait listed patients with identifi ed living donors, waiting time, new referrals with identifi ed living donors. Results: Between 2009-2013, 359 HLA-sensitized kidney transplant (txp) candidates were identifi ed who met SPEEC program eligibility. To date 195 (54%) pts have entered SPEEC program; 58 (30%) had 2 or more clinic visits. 54 pts (28%) have been transplanted. This txp rate was higher than in 164 SPEEC-eligible pts who have not yet entered the SPEEC program, of which 27 (16%) were transplanted, p < 0.007. (These 164 patients have not yet entered SPEEC primarily due to staff workload limitations). Notably, cPRA was higher in pts in the SPEEC program.