Publications by authors named "Bertram L Kasiske"

187 Publications

Outcomes of Living Kidney Donor Candidate Evaluations in the Living Donor Collective Pilot Registry.

Transplant Direct 2021 May 22;7(5):e689. Epub 2021 Apr 22.

Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Gaps in our knowledge of long-term outcomes affect decision making for potential living kidney donors.

Methods: The Scientific Registry of Transplant Recipients was asked to determine the feasibility of a candidate registry.

Results: Ten living kidney donor programs evaluated 2107 consecutive kidney donor candidates; 2099 of 2107 (99.6%) completed evaluations, 1578 of 2099 (75.2%) had a decision, and 790 of 1578 (50.1%) were approved to donate as of March 12, 2020. By logistic regression, candidates most likely to be approved were married or had attended college or technical school; those least likely to be approved had ≥1 of the following characteristics: Black race, history of cigarette smoking, and higher blood pressure, higher triglycerides, or higher urine albumin-to-creatinine ratios. Reasons for 617 candidates not being approved included medical issues other than chronic kidney disease risk (25.3%), chronic kidney disease risk (18.5%), candidate withdrawal (15.2%), recipient reason (13.6%), anatomical risk to the recipient (10.3%), noneconomic psychosocial (10.3%), economic (0.5%), and other reasons (6.4%).

Conclusions: These results suggest that a comprehensive living donor registry is both feasible and necessary to assess long-term outcomes that may inform decision making for future living donor candidates. There may be socioeconomic barriers to donation that require more granular identification so that active measures can address inequities. Some candidates who did not donate may be suitable controls for discerning the appropriateness of acceptance decisions and the long-term outcomes attributable to donation. We anticipate that these issues will be better identified with modifications to the data collection and expansion of the registry to all centers over the next several years.
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http://dx.doi.org/10.1097/TXD.0000000000001143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078331PMC
May 2021

Incidence, risk factors, treatment, and consequences of antibody-mediated kidney transplant rejection: A systematic review.

Clin Transplant 2021 Apr 17:e14320. Epub 2021 Apr 17.

Department of Medicine, Hennepin County Medical Center, Hennepin Healthcare, Minneapolis, MN, USA.

Background: Antibody-mediated rejection (AMR) is a leading cause of kidney allograft failure, but its incidence, risk factors, and outcomes are not well understood.

Methods: We searched Ovid MEDLINE, Cochrane, EMBASE, and Scopus from January 2000 to January 2020 to identify published cohorts of ≥500 incident adult or 75 pediatric kidney transplant recipients followed for ≥1 year post-transplant.

Results: At least two reviewers screened 5061 articles and abstracts; 28 met inclusion criteria. Incidence of acute AMR was 1.1%-21.5%; most studies reported 3%-12% incidence, usually within the first year post-transplant. Few studies reported chronic AMR incidence, from 7.5%-20.1% up to 10 years. Almost all patients with acute or chronic AMR received corticosteroids and intravenous immunoglobulin; most received plasmapheresis, and approximately half with rituximab. Most studies examining death-censored graft failure identified AMR as an independent risk factor. Few reported refractory AMR rates or outcomes, and none examined costs. Most studies were single-center and varied greatly in design.

Conclusions: Cohort studies of kidney transplant recipients demonstrate that AMR is common and associated with increased risk of death-censored graft failure, but studies vary widely regarding populations, definitions, and reported incidence. Gaps remain in our understanding of refractory AMR, its costs, and resulting quality of life.
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http://dx.doi.org/10.1111/ctr.14320DOI Listing
April 2021

Incidence, Clinical Correlates, and Outcomes of Pulmonary Hypertension after Kidney Transplantation: Analysis of Linked U.S. Registry and Medicare Billing Claims.

Transplantation 2021 Apr 9. Epub 2021 Apr 9.

Saint Louis University, St. Louis, MO, USA University of Calgary, Calgary, AB, Canada University of Iowa, Iowa City, IA, USA Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA UT Health, San Antonio, TX, USA University of Wisconsin, Madison, WI, USA University of Chicago, Chicago, IL, USA Einstein Medical Center, Philadelphia, PA, USA Weill Cornell Medicine, New York, NY, USA Hennepin County Medical Center, Minneapolis, MN, USA University Virginia, Charlottesville, VA, USA.

Background: The incidence, risks, and outcomes associated with pulmonary hypertension (P-HTN) in the kidney transplant (KTx) population are not well described.

Methods: We linked U.S. transplant registry data with Medicare claims (2006-2016) to investigate P-HTN diagnoses among Medicare-insured KTx recipients (N=35,512) using billing claims. Cox regression was applied to identify independent correlates and outcomes of P-HTN (adjusted hazard ratio, aHR, 95%LCLaHR95%UCL), and to examine P-HTN diagnoses as time-dependent mortality predictors.

Results: Overall, 8.2% of recipients had a diagnostic code for P-HTN within 2 years preceding transplant. By 3 years posttransplant, P-HTN was diagnosed in 10.310.6%11.0 of the study cohort. After adjustment, posttransplant P-HTN was more likely in KTx recipients who were older (aHR for age >60 vs. 18-30 years: 1.912.403.01) or female (aHR, 1.151.241.34), who had pretransplant P-HTN (aHR, 4.384.795.24), coronary artery disease (aHR, 1.051.151.27), valvular heart disease (aHR, 1.221.321.43), peripheral vascular disease (aHR, 1.051.181.33), chronic pulmonary disease (aHR, 1.201.311.43), obstructive sleep apnea (aHR, 1.151.281.43), longer dialysis duration, pretransplant hemodialysis (aHR, 1.171.371.59), or who underwent transplant in the more recent era (2012-2016 vs. 2006-2011: aHR, 1.291.391.51). Posttransplant P-HTN was associated with >2.5-fold increased risk of mortality (aHR, 2.572.843.14) and all-cause graft failure (aHR, 2.422.642.88) within 3 years posttransplant. Outcome associations of newly-diagnosed posttransplant P-HTN were similar.

Conclusions: Posttransplant P-HTN is diagnosed in 1 in 10 KTx recipients and is associated with an increased risk of death and graft failure. Future research is needed to refine diagnostic, classification, and management strategies to improve outcomes in KTx recipients who develop P-HTN.
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http://dx.doi.org/10.1097/TP.0000000000003783DOI Listing
April 2021

Survival implications of prescription opioid and benzodiazepine use in lung transplant recipients: Analysis of linked transplant registry and pharmacy fill records.

J Heart Lung Transplant 2021 Feb 17. Epub 2021 Feb 17.

Saint Louis Transplant Center, St. Louis, Missouri, USA.

Background: Prescription opioid and benzodiazepine use have been associated with morbidity and mortality among some groups of solid organ transplant recipients, but implications for outcomes among lung transplant patients are not well described.

Methods: We conducted a retrospective cohort study using linked national transplant registry and pharmaceutical records to characterize the associations between benzodiazepine and opioid prescription fills in the years before and after lung transplant (2006-2017), with risk-adjusted posttransplant survival (adjusted hazard ratio, aHR).

Results: Among 11,568 recipients, 33.7% filled an opioid prescription, and 25.8% filled a benzodiazepine prescription before transplant. Compared to patients without prescriptions, those who filled both short- and long-acting benzodiazepine prescriptions before transplant had 2-fold higher mortality in the first year posttransplant (aHR, 2.12), after adjustment for baseline factors and opioid fills, while pretransplant opioid fills were not associated with posttransplant mortality after adjustment for benzodiazepine fills. Pretransplant opioid and benzodiazepine use strongly predicted more use after transplant. Fills of both short- and long-acting benzodiazepines in the first year posttransplant were associated with 77% increased mortality >1-to-2 years posttransplant (aHR, 1.77). Compared with no posttransplant opioid fills, there was a dose-dependent association between first-year opioid fills and subsequent adjusted mortality risk (level 2: aHR, 1.50 to level 4: aHR, 2.01). These effects were independent, and interactions were not detected.

Conclusions: Benzodiazepine prescription fills before and after lung transplant, and opioid fills after transplant, are independently associated with posttransplant mortality. Review of benzodiazepine and opioid use history is relevant to risk-stratifying patients before and after lung transplant.
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http://dx.doi.org/10.1016/j.healun.2021.02.004DOI Listing
February 2021

Risk Prediction for Delayed Allograft Function: Analysis of The Deterioration of Kidney Allograft Function (Dekaf) Study Data.

Transplantation 2021 Feb 23. Epub 2021 Feb 23.

University of Minnesota, Department of Surgery, Transplantation Division, Minneapolis, MN; University of Minnesota, School of Public Health, Biostatistics Division, Minneapolis, MN; University of Alabama, Department of Medicine, Birmingham, AL; Hennepin Healthcare, Division of Nephrology, Minneapolis, MN; University of Manitoba, Department of Internal Medicine, Winnipeg, Manitoba. University of Iowa, Department of Internal Medicine, Iowa City, IA; Mayo Clinic, Division of Nephrology & Hypertension, Department of Internal Medicine, Rochester, MN; Mayo Clinic, Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Rochester, MN; University of California, UCLA Immunogenetics Center, Los Angeles, CA Univeristy of Nebraska Medical Center and Nebraska-Western Iowa Veterans Affairs Medical Center, Omaha, NE.

Background: Delayed graft function (DGF) of a kidney transplant results in increased cost and complexity of management. For clinical care or a DGF trial, it would be ideal to accurately predict individual DGF risk and provide preemptive treatment. A calculator developed by Irish et al has been useful for predicting population, but not individual risk.

Methods: We analyzed the Irish calculator (IC) in the DeKAF prospective cohort (incidence of DGF= 20.4%) and investigated potential improvements.

Results: We found that the predictive performance of the calculator in those meeting Irish inclusion criteria was comparable to that reported by Irish et. al. For cohorts excluded by Irish: a) in pump-perfused kidneys the IC over-estimated DGF risk; b) in simultaneous pancreas kidney (SPK) transplants, the DGF risk was exceptionally low. For all 3 cohorts, there was considerable overlap in IC scores between those with and those without DGF. Using a modified definition of DGF - excluding those with a single dialysis in the first 24 hours posttransplant - we found that the calculator had similar performance as with the traditional DGF definition. Studying whether DGF prediction could be improved, we found that recipient cardiovascular disease was strongly associated with DGF even after accounting for IC predicted risk.

Conclusions: The IC can be a useful population guide for predicting DGF in the population for which it was intended, but has limited scope in expanded populations (SPK, pump) and for individual risk prediction. DGF risk prediction can be improved by inclusion of recipient cardiovascular disease.
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http://dx.doi.org/10.1097/TP.0000000000003718DOI Listing
February 2021

Mortality among solid organ waitlist candidates during COVID-19 in the United States.

Am J Transplant 2021 Feb 23. Epub 2021 Feb 23.

Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.

We examined the effects of COVID-19 on solid organ waiting list mortality in the United States and compared effects across patient demographics (e.g., race, age, and sex) and donation service areas. Three separate piecewise exponential survival models estimated for each solid organ the overall, demographic-specific, and donation service area-specific differences in the hazard of waitlist mortality before and after the national emergency declaration on March 13, 2020. Kidney waiting list mortality was higher after than before the national emergency (adjusted hazard ratio [aHR], 1.37; 95% CI, 1.23-1.52). The hazard of waitlist mortality was not significantly different before and after COVID-19 for liver (aHR, 0.94), pancreas (aHR, 1.01), lung (aHR, 1.00), and heart (aHR, 0.94). Kidney candidates had notable variability in differences across donation service areas (aHRs, New York City, 2.52; New Jersey, 1.84; and Michigan, 1.56). The only demographic group with increased waiting list mortality were Blacks versus Whites (aHR, 1.41; 95% CI, 1.07-1.86) for kidney candidates. The first 10 weeks after the declaration of a national emergency had a heterogeneous effect on waitlist mortality rate, varying by geography and ethnicity. This heterogeneity will complicate comparisons of transplant program performance during COVID-19.
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http://dx.doi.org/10.1111/ajt.16550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014331PMC
February 2021

A New Panel-Estimated GFR, Including β-Microglobulin and β-Trace Protein and Not Including Race, Developed in a Diverse Population.

Am J Kidney Dis 2021 05 7;77(5):673-683.e1. Epub 2020 Dec 7.

Division of Nephrology, Tufts Medical Center; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA.

Rationale And Objective: Glomerular filtration rate (GFR) estimation based on creatinine and cystatin C (eGFR) is more accurate than estimated GFR (eGFR) based on creatinine or cystatin C alone (eGFR or eGFR, respectively), but the inclusion of creatinine in eGFR requires specification of a person's race. β-Microglobulin (B2M) and β-trace protein (BTP) are alternative filtration markers that appear to be less influenced by race than creatinine is.

Study Design: Study of diagnostic test accuracy.

Setting And Participants: Development in a pooled population of 7 studies with 5,017 participants with and without chronic kidney disease. External validation in a pooled population of 7 other studies with 2,245 participants.

Tests Compared: Panel eGFR using B2M and BTP in addition to cystatin C (3-marker panel) or creatinine and cystatin C (4-marker panel) with and without age and sex or race.

Outcomes: GFR measured as the urinary clearance of iothalamate, plasma clearance of iohexol, or plasma clearance of [Cr]EDTA.

Results: Mean measured GFRs were 58.1 and 83.2 mL/min/1.73 m, and the proportions of Black participants were 38.6% and 24.0%, in the development and validation populations, respectively. In development, addition of age and sex improved the performance of all equations compared with equations without age and sex, but addition of race did not further improve the performance. In validation, the 4-marker panels were more accurate than the 3-marker panels (P < 0.001). The 3-marker panel without race was more accurate than eGFR (percentage of estimates greater than 30% different from measured GFR [1 - P] of 15.6% vs 17.4%; P = 0.01), and the 4-marker panel without race was as accurate as eGFR (1 - P of 8.6% vs 9.4%; P = 0.2). Results were generally consistent across subgroups.

Limitations: No representation of participants with severe comorbid illness and from geographic areas outside of North America and Europe.

Conclusions: The 4-marker panel eGFR is as accurate as eGFR without requiring specification of race. A more accurate race-free eGFR could be an important advance.
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http://dx.doi.org/10.1053/j.ajkd.2020.11.005DOI Listing
May 2021

Immunosuppression Regimen Use and Outcomes in Older and Younger Adult Kidney Transplant Recipients: A National Registry Analysis.

Transplantation 2020 Nov 18. Epub 2020 Nov 18.

University of Iowa, Iowa City, IA, USA.

Background: Although the population of older transplant recipients has increased dramatically, there are limited data describing the impact of immunosuppression regimen choice on outcomes in this recipient group.

Methods: National data for U.S. Medicare-insured adult kidney recipients (N=67,362; 2005-2016) were examined to determine early immunosuppression regimen and associations with acute rejection, death-censored graft failure and mortality using multivariable regression analysis in younger (18-64 years) and older (>65 years) adults.

Results: The use of anti-thymocyte globulin (TMG) or alemtuzumab (ALEM) induction with triple maintenance immunosuppression (reference) was less common in older compared with younger (36.9% vs 47.0%) recipients, as was TMG/ALEM + steroid avoidance (19.2% vs 20.1%) and mTORi-based (6.7% vs 7.7%) treatments. Conversely, older patients were more likely to receive IL2-receptor antibody (IL2rAb) + triple maintenance (21.1% vs 14.7%), IL2rAb + steroid avoidance (4.1% vs 1.8%), and cyclosporine-based (8.3% vs 6.6%) immunosuppression. Compared to older recipients treated with TMG/ALEM + triple maintenance (reference regimen), those managed with TMG/ALEM + steroid avoidance (adjusted odds ratio (aOR), 0.440.520.61) and IL2rAb + steroid-avoidance (aOR, 0.390.550.79) had lower risk of acute rejection. Older patients experienced more death censored graft failure when managed with Tac+ antimetabolite avoidance (adjusted hazard (aHR), 1.411.782.25), mTORi-based (aHR, 1.702.142.71), and cyclosporine-based (aHR, 1.411.782.25) regimens, versus the reference regimen. mTORi-based and cyclosporine-based regimens were associated with increased mortality in both older and younger patients.

Conclusions: Lower-intensity immunosuppression regimens (e.g. steroid-sparing) appear beneficial for older kidney transplant recipients, while mTORi and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes.
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http://dx.doi.org/10.1097/TP.0000000000003547DOI Listing
November 2020

i-IFTA and chronic active T cell-mediated rejection: A tale of 2 (DeKAF) cohorts.

Am J Transplant 2021 May 8;21(5):1866-1877. Epub 2020 Nov 8.

Department of Surgery, Transplantation Division, University of Minnesota, Minneapolis, Minnesota.

Inflammation in areas of fibrosis (i-IFTA) in posttransplant biopsies is part of the diagnostic criteria for chronic active TCMR (CA TCMR -- i-IFTA ≥ 2, ti ≥ 2, t ≥ 2). We evaluated i-IFTA and CA TCMR in the DeKAF indication biopsy cohorts: prospective (n = 585, mean time to biopsy = 1.7 years); cross-sectional (n = 458, mean time to biopsy = 7.8 years). Grouped by i-IFTA scores, the 3-year postbiopsy DC-GS is similar across cohorts. Although a previous acute rejection episode (AR) was more common in those with i-IFTA on biopsy, the majority of those with i-IFTA had not had previous AR. There was no association between type of previous AR (AMR, TCMR) and presence of i-IFTA. In both cohorts, i-IFTA was associated with markers of both cellular (increased Banff i, t, ti) and humoral (increased g, ptc, C4d, DSA) activity. Biopsies with i-IFTA = 1 and i-IFTA ≥ 2 with concurrent t ≥ 2 and ti ≥ 2 had similar DC-GS. These results suggest that (a) i-IFTA≥1 should be considered a threshold for diagnoses incorporating i-IFTA, ti, and t; (b) given that i-IFTA ≥ 2,t ≥ 2, ti ≥ 2 can occur in the absence of preceding TCMR and that the component histologic scores (i-IFTA,t,ti) each indicate an acute change (albeit i-IFTA on the nonspecific background of IFTA), the diagnostic category "CA TCMR" should be reconsidered.
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http://dx.doi.org/10.1111/ajt.16352DOI Listing
May 2021

Hydroxychloroquine and maintenance immunosuppression use in kidney transplant recipients: Analysis of linked US registry and claims data.

Clin Transplant 2020 12 22;34(12):e14118. Epub 2020 Nov 22.

Johns Hopkins University, Baltimore, MD, USA.

Hydroxychloroquine (HCQ) is an antimalarial drug with immunomodulatory effects used to treat systemic lupus erythematosus (SLE) and scleroderma. The antiviral effects of HCQ have raised attention in the context of the COVID-19 pandemic, although safety is controversial. We examined linkages of national transplant registry data with pharmaceutical claims and Medicare billing claims to study HCQ use among Medicare-insured kidney transplant recipients with SLE or scleroderma (2008-2017; N = 1820). We compared three groups based on immunosuppression regimen 7 months-to-1 year post transplant: (a) tacrolimus (Tac) + mycophenolic acid (MPA) + prednisone (Pred) (referent group, 77.7%); (b) Tac + MPA + Pred + HCQ (16.5%); or (c) other immunosuppression + HCQ (5.7%). Compared to the referent group, recipients treated with other immunosuppression + HCQ had a 2-fold increased risk of abnormal ECG or QT prolongation (18.9% vs. 10.7%; aHR, 1.96 , p = .02) and ventricular arrhythmias (15.2% vs. 11.4%; aHR, 1.81 , p = .05) in the >1-to-3 years post-transplant. Tac + MPA + Pred + HCQ was associated with increased risk of ventricular arrhythmias (13.5% vs. 11.4%; aHR, 1.54 , p = .04) and pancytopenia (35.9% vs. 31.4%; aHR, 1.31 , p = .03) compared to triple immunosuppression without HCQ. However, HCQ-containing regimens were not associated with an increased risk of death or graft failure. HCQ may be used safely in selected kidney transplant recipients in addition to their maintenance immunosuppression, although attention to arrhythmias is warranted.
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http://dx.doi.org/10.1111/ctr.14118DOI Listing
December 2020

Impact of Functional Status on Outcomes of Simultaneous Pancreas-kidney Transplantation: Risks and Opportunities for Patient Benefit.

Transplant Direct 2020 Sep 21;6(9):e599. Epub 2020 Aug 21.

Emory University, Atlanta, GA.

Background: The impact of functional status on survival among simultaneous pancreas-kidney transplant (SPKT) candidates and recipients is not well described.

Methods: We examined national Scientific Registry of Transplant Recipients (SRTR) data for patients listed for SPKT in the United States (2006-2019). Functional status was categorized by center-reported Karnofsky Performance Score (KPS). We used Cox regression to quantify associations of KPS at listing and transplant with subsequent patient survival, adjusted for baseline patient and transplant factors (adjusted hazard ratio, aHR). We also explored time-dependent associations of SPKT with survival risk after listing compared with continued waiting in each functional status group.

Results: KPS distributions among candidates (N = 16 822) and recipients (N = 10 316), respectively, were normal (KPS 80-100), 62.0% and 57.8%; capable of self-care (KPS 70), 23.5% and 24.7%; requires assistance (KPS 50-60), 12.4% and 14.2%; and disabled (KPS 10-40), 2.1% and 3.3%. There was a graded increase in mortality after listing and after transplant with lower functional levels. Compared with normal functioning, mortality after SPKT rose progressively for patients capable of self-care (aHR, 1.18), requiring assistance (aHR, 1.31), and disabled (aHR, 1.55). In time-dependent regression, compared with waiting, SPKT was associated with 2-fold mortality risk within 30 days of transplant. However, beyond 30 days, SPKT was associated with reduced mortality, from 52% for disabled patients (aHR, 0.48) to 70% for patients with normal functioning (aHR, 0.30).

Conclusions: While lower functional status is associated with increased mortality risk among SPKT candidates and recipients, SPKT can provide long-term survival benefit across functional status levels in those selected for transplant.
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http://dx.doi.org/10.1097/TXD.0000000000001043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447442PMC
September 2020

Survey of US Living Kidney Donation and Transplantation Practices in the COVID-19 Era.

Kidney Int Rep 2020 Nov 25;5(11):1894-1905. Epub 2020 Aug 25.

Organ Transplant Center, University of Iowa, Iowa City, Iowa, USA.

Introduction: The scope of the impact of the coronavirus disease 2019 (COVID-19) pandemic on living donor kidney transplantation (LDKT) practices is not well defined.

Methods: We surveyed US transplant programs to assess practices, strategies, and barriers to living LDKT during the COVID-19 pandemic. After institutional review board approval, the survey was distributed from 9 May 2020 to 30 May 2020 by e-mail and postings to professional society list-servs. Responses were stratified based on state COVID-19 cumulative incidence levels.

Results: Staff at 118 unique centers responded, representing 61% of US living donor recovery programs and 75% of LKDT volume in the prepandemic year. Overall, 66% reported that LDKT surgery was on hold (81% in "high" vs. 49% in "low" COVID-19 cumulative incidence states). A total of 36% reported that evaluation of new donor candidates had paused, 27% reported that evaluations were very much decreased (>0% to <25% typical), and 23% reported that evaluations were moderately decreased (25% to <50% typical). Barriers to LDKT surgery included program concerns for donor (85%) and recipient (75%) safety, patient concerns (56%), elective case restrictions (47%), and hospital administrative restrictions (48%). Programs with higher local COVID-19 cumulative incidence reported more barriers related to staff and resource diversion. Most centers continuing donor evaluations used remote strategies (video, 82%; telephone, 43%). As LDKT resumes, all programs will screen for COVID-19, although timeframe and modalities will vary. Recommendations for presurgical self-quarantine are also variable.

Conclusion: The COVID-19 pandemic has had broad impacts on LDKT practice. Ongoing research and consensus building are needed to reduce barriers, to guide optimal practices, and to support safe restoration of LDKT across centers.
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http://dx.doi.org/10.1016/j.ekir.2020.08.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445484PMC
November 2020

Outcome implications of benzodiazepine and opioid co-prescription in kidney transplant recipients.

Clin Transplant 2020 09 3;34(9):e14005. Epub 2020 Aug 3.

Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA.

The outcomes of benzodiazepine and opioid co-prescription are not well-defined in transplant populations. We examined linked national transplant registry and pharmaceutical records to characterize benzodiazepine and opioid use in the years before and after transplant in large US cohort of kidney transplant recipients (2007-2016; N = 98 620), and associations (adjusted hazard ratio, aHR ) with death and graft failure. Among the cohort, 15.6% filled benzodiazepine prescriptions in the year before transplant, and 14.0% filled benzodiazepine prescriptions in the year after transplant (short-acting, 9.5%; long-acting, 3.3%; both 1.1%). Use of short-acting benzodiazepines in the year before transplant was associated with a 22% increased risk of death in the year after transplant (aHR, 1.22 ), while use of all classes in the year after transplant was associated with increased risk of death from >1 to 5 years (aHR: short-acting 1.39 ; long-acting 1.25 ; both 1.74 ). Recipients who used benzodiazepines were also more likely to fill opioid prescriptions. Recipients who filled both classes of benzodiazepine and the highest level of opioids had a 2.9-fold increased risk of death compared to recipients who did not use either. Co-prescription of benzodiazepines and opioids in kidney transplant recipients is associated with increased mortality. Ongoing research is needed to understand mechanisms of risk relationships.
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http://dx.doi.org/10.1111/ctr.14005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722087PMC
September 2020

Prescription patterns of opioids and non-steroidal anti-inflammatory drugs in the first year after living kidney donation: An analysis of U.S. Registry and Pharmacy fill records.

Clin Transplant 2020 08 29;34(8):e14000. Epub 2020 Jun 29.

Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA.

We examined a novel database linking national donor registry identifiers to records from a US pharmaceutical claims warehouse (2007-2015) to describe opioid and NSAID prescription patterns among LKDs during the first year postdonation, divided into three periods: 0-14 days, 15-182 days, and 183-365 days. Associations of opioid and NSAID prescription fills with baseline factors were examined by logistic regression (adjusted odds ratio, aOR ). Among 23,565 donors, opioid prescriptions were highest during days 0-14 (36.6%), but 12.6% of donors filled opioids during days 183-365. NSAID prescriptions rose from 0.5% during days 0-14 to 3.3% during days 183-365. Women filled opioids more commonly than men, and black donors filled both opioids and NSAIDs more commonly than white donors. After covariate adjustment, significant correlates of opioid prescription fills during days 183-365 included obesity (aOR, 1.38 ), less than college education (aOR, 1.31 ), smoking (aOR, 1.45 ), and nephrectomy complications (aOR, 1.29 ). NSAID prescription fills in year 1 were not associated with differences in estimated glomerular filtration rate, incidence of proteinuria or new-onset hypertension at the first and second year postdonation. Prescription fills for opioids and NSAIDs for LKDs varied with demographic and clinic traits. Future work should examine longer-term outcome implications to help inform safe analgesic regimen choices after donation.
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http://dx.doi.org/10.1111/ctr.14000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449599PMC
August 2020

A prospective controlled study of metabolic and physiologic effects of kidney donation suggests that donors retain stable kidney function over the first nine years.

Kidney Int 2020 07 3;98(1):168-175. Epub 2020 Feb 3.

Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland, USA.

While there have been numerous studies of living kidney donors, most have been retrospective without suitable controls and have yielded conflicting results. To clarify this we studied 205 living donor candidates and 203 controls having no medical conditions precluding donation. Before and at six months, one, two, three, six, and nine years after donation we measured iohexol glomerular filtration rate, clinic blood pressure, urine protein excretion and metabolic parameters reported to be affected by kidney function. We measured 24 hour ambulatory blood pressure at three, six, and nine years and at six and nine years blood pressure after treadmill exercise, carotid-femoral pulse wave velocity and arterial elasticity. Between six months and nine years, the mean (95% confidence interval) change in glomerular filtration rate was significantly different among 133 donors 0·02 (-0·16-0·20) mL/min/1·73m/year versus -1·26 (-1·52--1·00) mL/min/1·73m/year in 113 healthy controls. Blood pressure, urine protein, urine albumin, glucose, hemoglobin A1c, insulin, and lipoproteins were not different in controls versus donors; but parathyroid hormone, homocysteine and uric acid remained higher at nine years. At six and nine years carotid-femoral pulse wave velocity was not different, but the mean small artery elasticity was significantly lower in 141 donors 6·1 mL/mmHg x100, versus 113 controls 7·1 mL/mmHg x100, and 6·1 mL/mmHg x100 in 137 donors versus 7·6 mL/mmHg x100 in 112 controls at six and nine years, respectively [significant adjusted difference of 1·1 mL/mmHg x100]. Thus, donors remain healthy with stable kidney function for the first nine years, but differences in metabolic and vascular parameters could be harbingers of adverse outcomes requiring future interventions.
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http://dx.doi.org/10.1016/j.kint.2020.01.017DOI Listing
July 2020

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation.

Transplantation 2020 Apr;104(4S1 Suppl 1):S11-S103

The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada.

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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http://dx.doi.org/10.1097/TP.0000000000003136DOI Listing
April 2020

Posttransplant outcome assessments at listing: Long-term outcomes are more important than short-term outcomes.

Am J Transplant 2020 10 5;20(10):2813-2821. Epub 2020 May 5.

Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.

Posttransplant outcome assessments are publicly reported for patient and regulatory use. However, the currently reported 1-year posttransplant graft survival assessments are commonly criticized for not identifying clinically meaningful differences between programs, and not providing information about longer-term posttransplant outcomes. We investigated the association of different posttransplant outcome assessments available to patients at the time of listing with subsequent posttransplant graft survival. The posttransplant assessments were from period prevalent, rather than incident, cohorts with more timely 1-, 3-, and 5-year follow-up and 6-, 12-, 18-, 24-, and 30-month cohort windows. The association of these assessments at listing with subsequent posttransplant graft survival included candidates listed between July 12, 2011, and December 15, 2015, who subsequently underwent transplant before December 31, 2018. The assessments with 1-year follow-up had uniformly weaker associations than the assessments with 3- and 5-year follow-up. The assessments with 5-year follow-up had the strongest association in kidney and liver transplantation. For kidney, liver, and lung transplantation, assessment windows of at least 18 months typically had the strongest associations with subsequent graft survival. Posttransplant assessments with 5-year follow-up and 18-30-month cohort windows are better than the current posttransplant assessment with 1-year follow-up, particularly at the time of listing.
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http://dx.doi.org/10.1111/ajt.15911DOI Listing
October 2020

Application of the 2017 KDIGO Guideline for the Evaluation and Care of Living Kidney Donors to Clinical Practice.

Clin J Am Soc Nephrol 2020 06 10;15(6):896-905. Epub 2020 Apr 10.

Saint Louis University Transplant Center, St. Louis, Missouri

The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 "Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors" was developed to assist medical professionals who evaluate living kidney donor candidates and provide care before, during, and after donation. This guideline Work Group concluded that a comprehensive approach to donor candidate risk assessment should replace eligibility decisions on the basis of assessments of single risk factors in isolation. To address all issues important to living donors in a pragmatic and comprehensive guideline, many of the guideline recommendations were on the basis of expert consensus opinion even when no direct evidence was available. To advance available evidence, original data analyses were also undertaken to produce a "proof-of-concept" risk projection model for kidney failure. This was done to illustrate how the community can advance a new quantitative framework of risk that considers each candidate's profile of demographic and health characteristics. A public review by stakeholders and subject matter experts as well as industry and professional organizations informed the final formulation of the guideline. This review highlights the guideline framework, key concepts, and recommendations, and uses five patient scenarios and 12 guideline statements to illustrate how the guideline can be applied to support living donor evaluation and care in clinical practice.
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http://dx.doi.org/10.2215/CJN.12141019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274294PMC
June 2020

Association between changes in Membership and Professional Standards Committee review criteria and use of higher-risk kidneys for transplant.

Clin Transplant 2020 07 27;34(7):e13872. Epub 2020 Apr 27.

Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.

The Organ Procurement and Transplantation Network's Membership and Professional Standards Committee implemented an operational rule on March 1, 2017, intended to increase the number of kidneys transplanted from donors with kidney donor profile index (KDPI) ≥ 85% into recipients with poor estimated posttransplant survival (≥ 80%). Using data from the Scientific Registry of Transplant Recipients, ordinal and logistic regressions estimated, respectively, differences in kidney yield (number of transplanted kidneys per recovered donor) and offer acceptance practices before and after implementation. We included donors recovered January 1, 2016-February 28, 2018. The odds of higher kidney yield for donors with KDPI ≥ 85% were 27% higher after implementation (odds ratio, 1.27 ), but odds were also 20% higher for donors with KDPI < 85% ( 1.20 ). Thus, kidney yield was higher for all donors, with a slightly larger difference for donors with KDPI ≥ 85%. Additionally, the difference in offer acceptance before and after implementation was similar regardless of KDPI (KDPI < 85%, 1.02 ; KDPI ≥ 85%, 1.04 ). In the first year after implementation, kidney yield increased for donors with KDPI < and ≥ 85%. Thus, kidney yield from higher KDPI donors may have increased without the operational rule.
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http://dx.doi.org/10.1111/ctr.13872DOI Listing
July 2020

Summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation.

Transplantation 2020 04;104(4):708-714

The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada.

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence. The strengths of recommendations are provided in the full report. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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http://dx.doi.org/10.1097/TP.0000000000003137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147399PMC
April 2020

Inflammation in areas of fibrosis: The DeKAF prospective cohort.

Am J Transplant 2020 09 15;20(9):2509-2521. Epub 2020 Apr 15.

Mayo Clinic, Rochester, Minnesota, USA.

Inflammation in areas of fibrosis (i-IFTA) in posttransplant biopsy specimens has been associated with decreased death-censored graft survival (DC-GS). Additionally, an i-IFTA score ≥ 2 is part of the diagnostic criteria for chronic active TCMR (CA TCMR). We examined the impact of i-IFTA and t-IFTA (tubulitis in areas of atrophy) in the first biopsy for cause after 90 days posttransplant (n = 598); mean (SD) 1.7 ± 1.4 years posttransplant. I-IFTA, present in 196 biopsy specimens, was strongly correlated with t-IFTA, and Banff i. Of the 196, 37 (18.9%) had a previous acute rejection episode; 96 (49%) had concurrent i score = 0. Unlike previous studies, i-IFTA = 1 (vs 0) was associated with worse 3-year DC-GS: (i-IFTA = 0, 81.7%, [95% CI 77.7 to 85.9%]); i-IFTA = 1, 68.1%, [95% CI 59.7 to 77.6%]; i-IFTA = 2, 56.1%, [95% CI 43.2 to 72.8%], i-IFTA = 3, 48.5%, [95% CI 31.8 to 74.0%]). The association of i-IFTA with decreased DC-GS remained significant when adjusted for serum creatinine at the time of the biopsy, Banff i, ci and ct, C4d and DSA. T-IFTA was similarly associated with decreased DC-GS. Of these indication biopsies, those with i-IFTA ≥ 2, without meeting other criteria for CA TCMR had similar postbiopsy DC-GS as those with CA TCMR. Those with i-IFTA = 1 and t ≥ 2, ti ≥ 2 had postbiopsy DC-GS similar to CA TCMR. Biopsies with i-IFTA = 1 had similar survival as CA TCMR when biopsy specimens also met Banff criteria for TCMR and/or AMR. Studies of i-IFTA and t-IFTA in additional cohorts, integrating analyses of Banff scores meeting criteria for other Banff diagnoses, are needed.
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http://dx.doi.org/10.1111/ajt.15862DOI Listing
September 2020

The Centers for Medicare and Medicaid Services' proposed metrics for recertification of organ procurement organizations: Evaluation by the Scientific Registry of Transplant Recipients.

Am J Transplant 2020 09 19;20(9):2466-2480. Epub 2020 Apr 19.

Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.

On December 23, 2019, the US Centers for Medicare and Medicaid Services proposed 2 new standards that organ procurement organizations (OPOs) must meet for recertification. An OPO's organ donation rate (deceased donors/potential donors) and organ transplant rate (organs transplanted/potential donors) must not fall significantly below the 75th percentile for rates among all OPOs. We examined how OPOs would have fared under the proposed performance standards in 2016-2017. Data on donors and transplants were from the Organ Procurement and Transplantation Network; donor potential was estimated from Detailed Multiple Cause of Death data collected by the Centers for Disease Control and Prevention. In 2017, 31 (53%) OPOs failed to meet the proposed donation rate standard, 36 (62%) failed to meet the proposed organ transplant rate standard, and 37 (64%) failed at least 1 standard. We found that adjusting for age, race, and Hispanic ethnicity altered the evaluation: 8 OPOs changed their pass/fail status for the donation rate and 5 for the proposed organ transplant rate standard. We conclude that the proposed new standards may result in over half of OPOs facing decertification, and risk adjustment suggests that underlying characteristics of deaths vary regionally such that decertification decisions may be affected.
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http://dx.doi.org/10.1111/ajt.15842DOI Listing
September 2020

Continuous distribution as an organ allocation framework.

Curr Opin Organ Transplant 2020 04;25(2):115-121

Scientific Registry of Transplant Recipients, Chronic Disease Research Group, Hennepin Healthcare Research Institute.

Purpose Of Review: The Scientific Registry of Transplant Recipients (SRTR) supports the Organ Procurement and Transplantation Network (OPTN) efforts to better align liver allocation with the Final Rule. Here, we review recent literature related to removing place of residence or listing from organ allocation policy and describe how SRTR may help advance the OPTN policy development process.

Recent Findings: In December 2018, the OPTN Board of Directors endorsed the recommendation from OPTN's ad hoc Committee on Geography to develop organ-allocation policies that do not rely on geographic boundaries, called 'continuous distribution.' Many objections to wider organ distribution stem from efforts to address inequities in allocation for populations within geographic regions rather than for individual patients. A continuous distribution system could equitably address the needs of individual patients, merging ethical-medical urgency with geographic feasibility.

Summary: The effort to remove geographic boundaries from organ distribution and allocation has been controversial. An integrated continuous distribution system may help focus the debate on priorities that matter most to patients.
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http://dx.doi.org/10.1097/MOT.0000000000000733DOI Listing
April 2020

Economic impacts of alternative kidney transplant immunosuppression: A national cohort study.

Clin Transplant 2020 04 11;34(4):e13813. Epub 2020 Mar 11.

Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri.

Understanding the economic implications of induction and maintenance immunosuppression (ISx) is important in developing personalized kidney transplant (KTx) care. Using data from a novel integrated data set including financial records from the University Health System Consortium, Medicare, and pharmacy claims (2007-2014), we estimated the differences in the impact of induction and maintenance ISx regimens on transplant hospitalization costs and Medicare payments from KTx to 3 years. Use of thymoglobulin (TMG) significantly increased transplant hospitalization costs ($12 006; P = .02), compared with alemtuzumab and basiliximab. TMG resulted in lower Medicare payments in posttransplant years 1 (-$2058; P = .05) and 2 (-$1784; P = .048). Patients on steroid-sparing ISx incurred relatively lower total Medicare spending (-$10 880; P = .01) compared with patients on triple therapy (tacrolimus, antimetabolite, and steroids). MPA/AZA-sparing, mammalian target of rapamycin inhibitors-based, and cyclosporine-based maintenance ISx regimens were associated with significantly higher payments. Alternative ISx regimens were associated with different KTx hospitalization costs and longer-term payments. Future studies of clinical efficacy should also consider cost impacts to define the economic effectiveness of alternative ISx regimens.
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http://dx.doi.org/10.1111/ctr.13813DOI Listing
April 2020

The economic burden of kidney graft failure in the United States.

Am J Transplant 2020 05 4;20(5):1323-1333. Epub 2020 Feb 4.

Hennepin County Medical Center, Minneapolis, Minnesota.

Despite improvements in outcomes for kidney transplant recipients in the past decade, graft failure continues to impose substantial burden on patients. However, the population-wide economic burden of graft failure has not been quantified. This study aims to fill that gap by comparing outcomes from a simulation model of kidney transplant patients in which patients are at risk for graft failure with an alternative simulation in which the risk of graft failure is assumed to be zero. Transitions through the model were estimated using Scientific Registry of Transplant Recipients data from 1987 to 2017. We estimated lifetime costs, overall survival, and quality-adjusted life-years (QALYs) for both scenarios and calculated the difference between them to obtain the burden of graft failure. We find that for the average patient, graft failure will impose additional medical costs of $78 079 (95% confidence interval [CI] $41 074, $112 409) and a loss of 1.66 QALYs (95% CI 1.15, 2.18). Given 17 644 kidney transplants in 2017, the total incremental lifetime medical costs associated with graft failure is $1.38B (95% CI $725M, $1.98B) and the total QALY loss is 29 289 (95% CI 20 291, 38 464). Efforts to reduce the incidence of graft failure or to mitigate its impact are urgently needed.
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http://dx.doi.org/10.1111/ajt.15750DOI Listing
May 2020

The Cost of Screening Kidney Transplant Candidates for Coronary Artery Disease.

Am J Kidney Dis 2020 05 31;75(5):684-686. Epub 2020 Jan 31.

Hennepin Healthcare, Minneapolis, MN.

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http://dx.doi.org/10.1053/j.ajkd.2019.11.003DOI Listing
May 2020

Impacts of center and clinical factors in antihypertensive medication use after kidney transplantation.

Clin Transplant 2020 03 29;34(3):e13803. Epub 2020 Feb 29.

Division of Nephrology, Department of Medicine, Saint Louis University, St. Louis, MO, USA.

Hypertension guidelines recommend calcium channel blockers (CCBs), thiazide diuretics, and angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs) as first-line agents to treat hypertension. Hypertension is common among kidney transplant (KTx) recipients, but data are limited regarding patterns of antihypertensive medication (AHM) use in this population. We examined a novel database that links national registry data for adult KTx recipients (age > 18 years) with AHM fill records from a pharmaceutical claims warehouse (2007-2016) to describe use and correlates of AHM use during months 7-12 post-transplant. For patients filling AHMs, individual agents used included: dihydropyridine (DHP) CCBs, 55.6%; beta-blockers (BBs), 52.8%; diuretics, 30.0%; ACEi/ARBs, 21.1%; non-DHP CCBs, 3.0%; and others, 20.1%. Both BB and ACEi/ARB use were significantly lower in the time period following the 2014 Eighth Joint National Committee (JNC-8) guidelines (2014-2016), compared with an earlier period (2007-2013). The median odds ratios generated from case-factor adjusted models supported variation in use of ACEi/ARBs (1.51) and BBs (1.55) across transplant centers. Contrary to hypertension guidelines for the general population, KTx recipients are prescribed relatively more BBs and fewer ACEi/ARBs. The clinical impact of this AHM prescribing pattern warrants further study.
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http://dx.doi.org/10.1111/ctr.13803DOI Listing
March 2020

Tool to Aid Patients in Selecting a Liver Transplant Center.

Liver Transpl 2020 03;26(3):337-348

Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN.

Variations in candidate and donor acceptance criteria may influence access and mortality for liver transplantation. We sought to understand how recipient and donor characteristics vary across centers and how patients interpret this information, and we used these data to develop a tool to provide tailored information to candidates seeking a center (www.transplantcentersearch.org). We analyzed liver recipient data from the Scientific Registry of Transplant Recipients to determine how recipient and donor characteristics (eg, age, Medicaid use, and human immunodeficiency virus status) varied across programs. Data included recipients and donors at each US program between January 1, 2015, and December 31, 2017. The variation in characteristics was plotted with centers stratified by total transplant volume and by volume of each characteristic. A subset of characteristics was plotted to show variation over 3 years. We created mockups of potential reports displaying recipient characteristics alongside pretransplant and posttransplant outcomes and solicited feedback at patient and family interviews and focus groups, which included 39 individuals: 10 pilot interviews with candidates seeking liver transplant at the University of Minnesota-Fairview (UMNF) and 5 focus groups with 13 UMNF candidates, 6 UMNF family members, and 10 national recipients. Transcripts were analyzed using a thematic analysis. Several themes emerged: (1) Candidates experience gaps in existing education about center options; (2) patients requested information about how selection criteria might impact access to transplant; and (3) information tailored to a candidate's medical characteristics can inform decisions. Characteristics shown on mockups varied across centers (P < 0.01). Variation was widespread for small and large centers. In conclusion, variation exists in recipient and donor characteristics across centers. Liver transplant patients provide positive feedback upon viewing patient-specific search tools.
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http://dx.doi.org/10.1002/lt.25715DOI Listing
March 2020

The Collaborative Innovation and Improvement Network (COIIN): Effect on donor yield, waitlist mortality, transplant rates, and offer acceptance.

Am J Transplant 2020 04 14;20(4):1076-1086. Epub 2019 Nov 14.

Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.

The Organ Procurement and Transplantation Network implemented the Collaborative Improvement and Innovation Network (COIIN) to improve the use of donors with kidney donor profile index >50%. COIIN recruited 2 separate cohorts of kidney transplant programs. Cohort A included 19 programs of 44 applicants (January 1, 2017, to September 30, 2017), and cohort B included 39 programs of 47 applicants (October 1, 2017, to June 30, 2018). We investigated the effect of COIIN on kidney yield (number of kidneys transplanted from donors from whom any organ was recovered), offer acceptance, deceased donor transplant rates, and waitlist mortality rates for January 1, 2016, to March 31, 2019. COIIN did not notably affect kidney yield or waitlist mortality rates. Cohort A, but not cohort B, had significantly higher deceased donor transplant and offer acceptance rates during its intervention period than programs not in COIIN (adjusted transplant rate ratio: cohort A, 1.17 , cohort B, 1.01 ; adjusted offer acceptance ratio: cohort A, 1.18 , cohort B, 1.00 ). Thus, COIIN improved the use of kidneys at programs in cohort A but not at those in cohort B. Further research is necessary to understand the different effects for cohorts A and B, and further monitoring of posttransplant outcomes is required.
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http://dx.doi.org/10.1111/ajt.15657DOI Listing
April 2020

Postdonation eGFR and New-Onset Antihypertensive Medication Use After Living Kidney Donation.

Transplant Direct 2019 Aug 25;5(8):e474. Epub 2019 Jul 25.

Saint Louis University, St. Louis, MO.

Background: Limited data are available regarding clinical implications of lower renal function after living kidney donation. We examined a novel integrated database to study associations between postdonation estimated glomerular filtration rate (eGFR) and use of antihypertensive medication (AHM) treatment after living kidney donation.

Methods: Study data were assembled by linking national U.S. transplant registry identifiers, serum creatinine (SCr) values from electronic medical records, and pharmacy fill records for 3222 living donors (1989-2016) without predonation hypertension. Estimated GFR (mL/min per 1.73 m) was computed from SCr values by the CKD-EPI equation. Repeated measures multivariable mixed effects modeling examined the associations (adjusted odds ratio, aOR) between AHM use and postdonation eGFR levels (random effect) with fixed effects for baseline donor factors.

Results: The linked database identified an average of 3 postdonation SCr values per donor (range: 1-38). Lower postdonation eGFR (vs ≥75) bore graded associations with higher odds of AHM use (eGFR 30-44: aOR 1.47; <30: aOR 2.52). Other independent correlates of postdonation AHM use included older age at donation (aOR per decade: 1.23), black race (aOR 1.51), body mass index > 30 kg/m (aOR 1.45), first-degree donor-recipient relationship (aOR 1.38), "prehypertension" at donation (systolic blood pressure 120-139: aOR 1.46; diastolic blood pressure 80-89: aOR 1.45).

Conclusions: This novel linkage illustrates the ability to identify postdonation kidney function and associate it with clinically meaningful outcomes; lower eGFR after living kidney donation is a correlate of AHM treatment requirements. Further work should define relationships of postdonation renal function, hypertension, and other morbidity measures.
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http://dx.doi.org/10.1097/TXD.0000000000000913DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708633PMC
August 2019