William S. Asch

Oncologic Issues and Kidney Transplantation: A Review of Frequency, Mortality, and Screening

Kidney transplant recipients are at increased risk for development of malignancy compared with the general population, and malignancies occur at an earlier age. This increased risk, as expressed by the standard incidence ratio (SIR), varies widely, but it is highest in malignancies triggered by oncogenic viruses. For other cancers, this increased risk is the direct consequence of immunosuppressants promoting tumor growth and lowering immune system tumor surveillance. In this review, we briefly discuss the common malignancies with increased risk after kidney transplantation, explore the pros and cons associated with screening, and summarize current prevention and treatment recommendations.

A One-Day Centralized Work-up for Kidney Transplant Recipient Candidates: A Quality Improvement Report

BACKGROUND Waiting time for a kidney transplant is calculated from the date the patient is placed on the UNOS (United Network for Organ Sharing) waitlist to the date the patient undergoes transplant. Time from transplant evaluation to listing represents unaccounted waiting time, potentially resulting in longer dialysis exposure for some patients with prolonged evaluation times. There are established disparities demonstrating that groups of patients take longer to be placed on the waitlist and thus have less access to kidney transplant. STUDY DESIGN Quality improvement report. SETTING & PARTICIPANTS 905 patients from a university-based hospital were evaluated for kidney transplant candidacy, and analysis was performed from July 1, 2004, to January 31, 2010. QUALITY IMPROVEMENT PLAN A 1-day centralized work-up was implemented on July 1, 2007, whereby the transplant center coordinated the necessary tests needed to fulfill minimal listing criteria. OUTCOME Time from evaluation to UNOS listing was compared between the 2 cohorts. Multivariable Cox proportional hazards models were created to assess the relative hazards of waitlist placement comparing 1-day versus conventional work-up and were adjusted for age, sex, race, and education. RESULTS Of 905 patients analyzed, 378 underwent conventional evaluation and 527 underwent a 1-day center-coordinated evaluation. Median time to listing in the 1-day center-coordinated evaluation compared with conventional was significantly less (46 vs 226 days, P < 0.001). On multivariable analysis controlling for age, sex, and education level, the 1-day in-center group was 3 times more likely to place patients on the wait list (adjusted HR, 3.08; 95% CI, 2.64-3.59). Listing time was significantly decreased across race, sex, education, and ethnicity. LIMITATIONS Single center, retrospective. Variables that may influence transplant practitioners, such as comorbid conditions or functional status, were not assessed. CONCLUSIONS A 1-day center-coordinated pretransplant work-up model significantly decreased time to listing for kidney transplant.

Kidney Transplantation and HIV: Does Recipient Privacy Outweigh the Donor's Right to Information?

BACKGROUND AND OBJECTIVES There exists an inherent conflict between a kidney donors right to know key aspects of a recipients medical history and specific disease, such as HIV, where federal and state statues protect this information. The authors of the live organ donor consensus group expressly stated the principal of a donors right to recipient information. This information includes the risks and benefits of not only the donation procedure, but also the risks, benefits, and alternative treatment options of the recipient. In this paper, a case will be presented highlighting this conflict and the ethical and legal reasoning used to resolve it. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A 22-year-old woman came forward as a directed kidney donor for an HIV-positive individual. The donor and recipient were medically appropriate for kidney donation and transplantation. During the donor advocacy panel review, there was disagreement regarding whether or not the potential donor had the right to know about the HIV status of the potential recipient. RESULTS In living kidney transplantation to HIV-positive individuals, the recipients right to privacy of information outweighs the donors right to know. CONCLUSIONS Although protecting the recipients right to privacy is paramount, the donor is still entitled to consider factors a priori that could alter their decision to donate. This can be accomplished by informing the donor that they are not entitled to protected health information of the recipient and that their decision to donate should be based on knowing the recipient is medically appropriate for kidney transplantation.

Should Living Kidney Donor Candidates with Impaired Fasting Glucose Donate

As the kidney transplant waiting list grows, the willingness of transplant centers to accept complex donors increases. Guidelines for the evaluation of living kidney donors exist but do not provide clear guidance when evaluating the complex donor. Although few transplant centers will approve donor candidates with impaired glucose tolerance and most, if not all, will deny candidates with diabetes, many will approve candidates with impaired fasting glucose (IFG). Furthermore, the demographic of living donors has changed in the past 10 years to increasingly include more nonwhite and Hispanic individuals who are at greater risk for future diabetes and hypertension. IFG may be more of a concern in potential donors whose nonwhite and Hispanic ethnicity already places them at greater risk. We review the definition of diabetes, diabetes prediction tools, and transplant guidelines for donor screening and exclusion as it pertains to impaired glucose metabolism, and additional ethnic and nonethnic factors to consider. We offer an algorithm to aid in evaluation of potential living donors with IFG in which ethnicity, age, and features of the metabolic syndrome play a role in the decision making.

New Organ Allocation System for Combined Liver-Kidney Transplants and the Availability of Kidneys for Transplant to Patients with Stage 4–5 CKD

A new proposal has been created for establishing medical criteria for organ allocation in recipients receiving simultaneous liver-kidney transplants. In this article, we describe the new policy, elaborate on the points of greatest controversy, and offer a perspective on the policy going forward. Although we applaud the fact that simultaneous liver-kidney transplant activity will now be monitored and appreciate the creation of medical criteria for allocation in simultaneous liver-kidney transplants, we argue that some of the criteria proposed, especially those for allocating a kidney to a liver recipient with AKI, are too liberal. We call on the nephrology community to follow the consequences of this new policy and push for a re-examination of the longstanding policy of allocating kidneys to multiorgan transplant recipients before all other candidates. The charge to protect our system of equitable organ allocation is very challenging, but it is a challenge that we must embrace.

Delayed graft function phenotypes and 12-month kidney transplant outcomes

Background Ischemia-reperfusion injury (IRI) leading to delayed graft function (DGF), defined by the United Network for Organ Sharing as dialysis in the first week (UNOS-DGF), associates with poor kidney transplant outcomes. Controversies remain, however, about dialysis initiation thresholds and the utility for other criteria to denote less severe IRI, or slow graft function (SGF). Methods Multicenter, prospective study of deceased-donor kidney recipients to compare UNOS-DGF to a definition that combines impaired creatinine reduction in the first 48 hours or greater than 1 dialysis session for predicting 12-month estimated glomerular filtration rate (eGFR). We also assessed 10 creatinine and urine output-based SGF definitions relative to 12-month eGFR. Results In 560 recipients, 215 (38%) had UNOS-DGF, 330 (59%) met the combined definition, 14 (3%) died, and 23 (4%) had death-censored graft failure by 12 months. Both DGF definitions were associated with lower adjusted 12-month eGFR (95% confidence interval)—by 7.3 (3.6-10.9) and 7.4 (3.8-11.0) mL/min per 1.73 m2, respectively. Adjusted relative risks for 12-month eGFR less than 30 mL/min per 1.73 m2 were 1.9 (1.2-3.1) and 2.1 (1.1-3.7), with unadjusted areas under the curve of 0.618 and 0.627, respectively. For SGF definitions, postoperative day (POD) 7 creatinine had the strongest association with 12-month eGFR, and POD5 creatinine and creatinine reduction between POD1 and POD2 demonstrated modest separations in 12-month eGFR. Conclusions Although UNOS-DGF does not adequately predict 12-month function on its own, our findings do not support changing the definition. Postoperative day 7 creatinine is correlated with 12-month eGFR, but large translational studies are needed to understand the biological link between IRI severity at transplant and longer-term outcomes.

Patient Education to Reduce Disparities in Renal Transplantation

Healthcare disparities can be defined as differences in health outcomes that are unnecessary and avoidable, and in addition, that are considered unfair and unjust ([1][1],[2][2]). The existence of such disparities in kidney transplantation has been recognized for over a decade ([3][3],[4][4]).

Duration of prophylaxis against fungal infection in kidney transplant recipients

Objective— To compare the efficacy of 2 strategies that use nystatin to prevent thrush and Candida esophagitis in kidney transplant recipients. Methods— A retrospective chart review was conducted of adult kidney transplant recipients at our center, where the protocol for prophylaxis against fungal infection was changed in March 2013. Before the protocol change, kidney transplant recipients received nystatin for 1 month (before group) and after the change they received nystatin for the duration of admission (after group). The primary outcome measure was the incidence of thrush and Candida esophagitis within 3 months after transplant. Analyses were conducted on all kidney transplant recipients (intention to treat) and on only those kidney transplant recipients who received at least 1 dose of nystatin (modified intention to treat). Additional data collected included the duration of nystatin and immunosuppression regimens. The Student t test and Fisher exact test were used to calculate P values for continuous and categorical data. Results— A total of 84 kidney transplant recipients, 42 in each cohort, were included in the analysis. The groups did not differ significantly at baseline. Nystatin was administered for a mean of 29 days in the before group and 5.74 days in the after group. Overall, 3 kidney transplant recipients (4%), all from the after group, experienced an episode of thrush and no patients experienced Candida esophagitis. Two recipients who experienced thrush did not receive any nystatin. Conclusions— Limiting the administration of nystatin to the duration of admission after transplant may be sufficient for prophylaxis of fungal infections in kidney transplant recipients.

New England BK consortium: Regional survey of BK screening and management protocols in comparison to published consensus guidelines

BK polyomavirus (BKPyV) continues to impact renal transplant recipients (RTR). The New England BK Consortium aims to jointly optimize screening and management of BKPyV.

Frailty and Perioperative Outcomes

Purpose of ReviewFrailty is associated with serious adverse outcomes, such as disability, health care utilization, and death in the perioperative period. In this review, we discuss surgical outcomes in a frail individual, and risk stratification for a frail individual.Recent FindingsFrailty is associated with increased length of hospital stay and 30- and 90-day mortality. The data on association of frailty on discharge to home and quality of life is scant, but it is likely that they are closely related. Prehabilitation involving a diet and exercise program seems to improve outcomes in the frail surgical candidates.SummaryMaking a surgical decision in frail patients is complex. Frailty is commonly associated with the older age group. The balance between high operative risk and the potential benefits of surgery is not always clear. The challenge lies in effectively identifying patients that will benefit most from operative intervention and then optimize them for surgery.