Vineeta Kumar

The APOL1 Genotype of African American Kidney Transplant Recipients Does Not Impact 5‐Year Allograft Survival

Apolipoprotein L‐1 (APOL1) gene variants are associated with end‐stage renal disease in African Americans (AAs). Here we investigate the impact of recipient APOL1 gene distributions on kidney allograft outcomes. We conducted a retrospective analysis of 119 AA kidney transplant recipients, and found that 58 (48.7%) carried two APOL1 kidney disease risk variants. Contrary to the association seen in native kidney disease, there is no difference in allograft survival at 5‐year posttransplant for recipients with high‐risk APOL1 genotypes. Thus, we were able to conclude that APOL1 genotypes do not increase risk of allograft loss after kidney transplantations, and carrying 2 APOL1 risk alleles should not be an impediment to transplantation.

Solid Organ Transplantation From Hepatitis B Virus–Positive Donors: Consensus Guidelines for Recipient Management

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non‐liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti‐HBc+) donors. Organs from anti‐HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non‐liver recipients but is not recommended in immune non‐liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost‐effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.

Predictors of final specialty choice by internal medicine residents

BACKGROUND: Sociodemographic factors and personality attributes predict career decisions in medical students. Determinants of internal medicine residents’ specialty choices have received little attention.OBJECTIVE: To identify factors that predict the clinical practice of residents following their training.DESIGN: Prospective cohort study.PARTICIPANTS: Two hundred and four categorical residents from 2 university-based residency programs.MEASUREMENTS: Sociodemographic and personality inventories performed during residency, and actual careers 4 to 9 years later.RESULTS: International medical school graduates (IMGs) were less likely to practice general medicine than U.S. graduates (33.3% vs 70.6%,P<.001). Residents with higher loan indebtedness more often became generalists (P=.001). A corresponding trend favoring general internal medicine was observed among those who perceived General Internists to have lower potential incomes (69.0% vs 53.3%,P=.08). There was a trend for generalists to have lower scores on scales measuring authoritarianism, negative orientation to psychological problems, and Machiavellianism (0.05<P<.10). In a logistic regression, graduation from a U.S. medical school (odds ratio [OR] 3.02; 95% confidence interval [CI], 1.00 to 9.10,P=.049] and perception of low future income (OR 1.65; 95% CI, 1.06 to 2.56,P=.03) predicted entry into general medicine, with trends apparent for higher debt (P=.05) and greater comfort caring for patients with psychological problems (P=.07).CONCLUSION: Recruitment of IMGs may not increase the supply of General Internists. Prospects of lower income, even in the face of large debt, may not discourage residents from becoming generalists. If increasing generalist manpower is a goal, residencies should consider weighing applicants’ personal attributes during the selection process.

The contribution of podocytes to chronic allograft nephropathy.

Background: Progressive proteinuria and glomerulosclerosis characterize chronic allograft nephropathy. However, the causes are not fully elucidated. Podocytes function to prevent proteinuria; injury to this glomerular cell leads to glomerulosclerosis. The potential role of podocytes in the failing transplanted kidney is unknown. A rat model of kidney transplantation, characterized by proteinuria and glomerulosclerosis, was utilized to examine the potential role of podocytes. Methods: Archival tissue was examined from allografts (Dark Agouti kidneys transplanted into operationally tolerant Albino Surgery rats), isografts (Dark Agouti) and controls (Dark Agouti: age-matched or after unilateral nephrectomy). The number of podocytes (by WT-1 staining) as well as the podocyte proteins podocin, nephrin and synaptopodin (by immunostaining) were measured at days 0, 2, 6 and at 6 months after transplantation. Changes in these parameters were compared between groups and correlated with urinary protein excretion. Results: At 6 months, podocyte number was reduced in allografted kidneys, accompanied by a decrease in nephrin and synaptopodin, but not podocin staining. Remnant kidneys in the uninephrectomized rats also showed a decreased podocyte number but no change in podocyte protein staining. Podocyte loss in allografts was established on day 6, whereas a decrease in nephrin and synaptopodin was not evident until 6 months. In contrast, podocyte number and protein staining was decreased but not significantly so in remnant and isografted kidneys. Conclusion: A decrease in the slit diaphragm proteins, nephrin and synaptopodin, is a component of chronic allograft pathology.

Reassessing Medical Risk in Living Kidney Donors

The short- and long-term effects of unilateral nephrectomy on living donors have been important considerations for 60 years. Short-term risk is well established (0.03% mortality and <1% risk of major morbidity), but characterization of long-term risk is evolving. Relative to the general population, risk of mortality, ESRD, hypertension, proteinuria, and cardiovascular disease is comparable or lower. However, new studies comparing previous donors with equally healthy controls indicate increased risk of metabolic derangements (particularly involving calcium homeostasis), renal failure, and possibly, mortality. We discuss how these results should be interpreted and their influence on the practice of living donor kidney transplantation.

Secondary Listing for Deceased-Donor Kidney Transplantation Does Not Increase Likelihood of Engraftment at a Large Transplant Center

The supply of donor organs has not increased as fast as has the number of patients awaiting kidney transplantation. Few organs are shared outside the areas of recovery. This trend has caused some ESRD patients to seek listing at multiple centers. We examined UNOS registry data and transplant registry data at the University of Alabama at Birmingham (UAB) for the 576 patients listed at multiple centers over an 8‐year span ending December 31, 2005. We identified 72 multilisted patients who received a deceased‐donor renal allograft at UAB and reviewed their records for demographics, HLA matching and transfer of listing time. The only predictors for transplantation at UAB were initial listing at UAB or transfer of waiting time. Fifty‐one of the 72 patients had listed at UAB first; the other 21 had transferred waiting time. None of the 176 patients who listed elsewhere first and did not transfer waiting time had been transplanted at UAB. Aggregate cost of listing and evaluation for the 176 patients listed elsewhere first who did not transfer waiting time was

Apolipoprotein L1 and Chronic Kidney Disease Risk in Young Potential Living Kidney Donors

1 254 528. Secondary listing at UAB, with a large cohort awaiting transplantation, without transfer of waiting time from another center was an expensive and futile process.

Ocular bartonellosis in transplant recipients: two case reports and review of the literature

Objective:The aim of this study was to develop a novel chronic kidney disease (CKD) risk prediction tool for young potential living kidney donors. Summary of Background Data:Living kidney donor selection practices have evolved from examining individual risk factors to a risk calculator incorporating multiple characteristics. Owing to limited long-term data and lack of genetic information, current risk tools lack precision among young potential living kidney donors, particularly African Americans (AAs). Methods:We identified a cohort of young adults (18–30 years) with no absolute contraindication to kidney donation from the longitudinal cohort study Coronary Artery Risk Development in Young Adults. Risk associations for CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2) were identified and assigned weighted points to calculate risk scores. Results:A total of 3438 healthy adults were identified [mean age 24.8 years; 48.3% AA; median follow-up 24.9 years (interquartile range: 24.5–25.2)]. For 18-year olds, 25-year projected CKD risk varied by ethnicity and sex even without baseline clinical and genetic abnormalities; risk was 0.30% for European American (EA) women, 0.52% for EA men, 0.52% for AA women, 0.90% for AA men. Among 18-year-old AAs with apolipoprotein L1 gene (APOL1) renal-risk variants without baseline abnormalities, 25-year risk significantly increased: 1.46% for women and 2.53% for men; among those with 2 APOL1 renal-risk variants and baseline abnormalities, 25-year risk was higher: 2.53% to 6.23% for women and 4.35% to 10.58% for men. Conclusions:Young AAs were at highest risk for CKD, and APOL1 renal-risk variants drove some of this risk. Understanding the genetic profile of young AA potential living kidney donors in the context of baseline health characteristics may help to inform candidate selection and counseling.

Current status on the evaluation and management of the highly sensitized kidney transplant recipient.

Cat scratch disease is caused by Bartonella henselae and usually manifests as localized lymphadenopathy and fever in immunocompetent patients. Immunocompromised patients are at risk for developing disseminated disease affecting the liver, spleen, eyes, central nervous system, and other organs. Bartonellosis is infrequently reported in solid organ transplant recipients, and published case reports usually discuss disseminated infection. Localized ocular disease with B. henselae, while well documented in immunocompetent hosts, is uncommon in immunocompromised patients. Herein, we present 2 cases of ocular bartonellosis in renal transplant patients, 1 with disseminated infection, and 1 without.

Predialysis Vascular Access Surgery in Patients With Failing Kidney Transplants

Purpose of reviewIn light of the recent changes to the kidney allocation system (KAS) and the observed increase in the rate of transplantation of the highly sensitized kidney transplant candidate, the evaluation and care of this population is a timely topic. Recent findingsIn its first year, the new KAS has already realized one goal of improving the chances of transplanting the most highly sensitized patients in the waiting list. This has brought to the forefront the need for recipient readiness in this special population, as well as the need for histocompatibility labs and kidney transplant programs to align themselves with each other, and also with the requirements of the United Network for Organ Sharing, and increase proficiency in testing and data interpretation. This manuscript is a review of the literature as well as practice patterns as they relate to the changes in KAS and the observed outcome since the activation of the new KAS, with the ultimate goal of aiding in the development of a more unified approach in the care of this specialized population which will allow for interdisciplinary and cross centre dialogue to optimize long term care and outcomes. SummaryHere we will review the changes to the KAS as they affect the highly sensitized kidney transplant recipient, and additional considerations in the evaluation and management of these patients.