Publications by authors named "Kenneth J Woodside"

81 Publications

CT Measured Cortical Volume Ratio Is an Accurate Alternative to Nuclear Medicine Split Scan Ratio Among Living Kidney Donors.

Transplantation 2021 Feb 8. Epub 2021 Feb 8.

1 Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI. 2 Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI. 3 Medical School, University of Michigan, Ann Arbor, MI. 4 Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI. 5 Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI. 6 Division of Abdominal Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI. 7 Michigan Radiology Quality Collaborative, University of Michigan, Ann Arbor, MI.

Background: The I-iothalamate clearance and Tc diethylenetriamine-pentaacetic acid (Tc-DTPA) split scan nuclear medicine studies are used among living kidney donor candidates to determine measured glomerular filtration rate (mGFR) and split-scan ratio (SSR). The CT-derived cortical-volume ratio (CVR) is a novel measurement of split-kidney function and can be combined with predonation estimated GFR (eGFR) or mGFR to predict postdonation kidney function. Whether predonation SSR predict postdonation kidney function better than predonation CVR and whether predonation mGFR provides additional information beyond predonation eGFR is unknown.

Methods: We performed a single-center retrospective analysis of 204 patients who underwent kidney donation between 06/2015-03/2019. The primary outcome was 1-year postdonation eGFR. Model bases were created from a measure of predonation kidney function (mGFR or eGFR) multiplied by the proportion that each nondonated kidney contributed to predonation kidney function (SSR or CVR). Multivariable elastic net regression with 1,000 repetitions was used to determine the mean and 95%CI of R, root mean square error (RMSE), and proportion overprediction ≥15 mL/min/1.73m between models.

Results: In validation cohorts, eGFR-CVR models performed best (R 0.547, RMSE 9.2 mL/min/1.73m, proportion overprediction 3.1%) whereas mGFR-SSR models performed worst (R 0.360, RMSE 10.9 mL/min/1.73m, proportion overprediction 7.2%) (P<.001 for all comparisons).

Conclusions: These findings suggest that predonation CVR may serve as an acceptable alternative to SSR during donor evaluation and furthermore that a model based on CVR and predonation eGFR may be superior to other methods.Supplemental Visual Abstract; http://links.lww.com/TP/C140.
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http://dx.doi.org/10.1097/TP.0000000000003676DOI Listing
February 2021

Arteriovenous Vascular Access-Related Procedural Burden Among Incident Hemodialysis Patients in the United States.

Am J Kidney Dis 2021 Apr 12. Epub 2021 Apr 12.

Arbor Research Collaborative for Health, Ann Arbor, Michigan.

Rationale & Objective: As the proportion of arteriovenous fistulae (AVF) compared to arteriovenous grafts (AVG) in the United States has increased, there has been a concurrent increase in interventions. We sought to explore AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis.

Study Design: Observational cohort study.

Setting & Participants: Patients initiating hemodialysis from July 1, 2012, to December 31, 2014 and having a first time AVF or AVG placement between dialysis initiation and 1 year were identified (N=73,027) using the United States Renal Data System (USRDS).

Predictors: Patient characteristics.

Outcomes: Successful AVF/AVG use and intervention procedure burden.

Analytical Approach: For each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modelling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase.

Results: During maturation phase, 13,989 of 57,275 (24.4%) patients in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person (pp). In the AVG group, 2,904 of 15,572 (18.4%) patients required intervention during maturation, with therapeutic interventional requirements of 0.28 pp. During maintenance phase, in the AVF group, 12,732 of 32,115 (39.6%) patients required intervention, with a therapeutic intervention rate of 0.93 per person-year (ppy). During maintenance phase, in the AVG group, 5,928 of 10,271 (57.7%) patients required intervention, with a therapeutic intervention rate of 1.87 ppy. For both phases, intervention rates for AVF tended to be higher on the East Coast, while those for AVG were more uniform geographically.

Limitations: This study relies on administrative data, with monthly recording of access use.

Conclusions: During maturation, interventions for both AVF and AVG were relatively common. Once successfully matured, AVF had lower maintenance interventional requirements. During maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.
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http://dx.doi.org/10.1053/j.ajkd.2021.01.019DOI Listing
April 2021

Postoperative Opioid Prescription and Use After Outpatient Vascular Access Surgery.

J Surg Res 2021 Apr 6;264:173-178. Epub 2021 Apr 6.

Michigan Opioid Prescribing and Engagement Network, Ann Arbor, Michigan; Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.

Background: Larger opioid prescriptions are associated with increased consumption without improvements in pain, and the majority of opioids prescribed go unused. We examined postoperative opioid prescription and use in patients undergoing vascular access surgery, where preoperative opioid exposure is common.

Methods: A retrospective analysis was conducted in adult CKD patients who underwent outpatient vascular access surgery. Patients were surveyed by telephone >2 weeks after surgery to assess pain level and opioid and non-opioid medication use.

Results: Of 117 patients contacted, 76 responded (65% response rate), with a median (interquartile range) age of 56 (42-69) years. Sixty-three patients (83%) were prescribed an opioid postoperatively. Respondents were prescribed 60 (38-75) oral morphine equivalents (OMEs) and consumed 0 (0-15) OMEs over 1 day with a pain score of 5 out of 10. Thirty-nine patients (>50%) used no opioids. There were no differences in postoperative opioid prescribing or use in patients with recent opioid exposure compared to patients without. Patients who underwent arteriovenous fistula (AVF) creation (short surgical incision procedure) were prescribed 60 (38-75) OMEs, compared with 75 (56-111) OMEs for patients who underwent AVF superficialization, AVG, or BVT (long surgical incision procedure; P < 0.01) and consumed 0 (0-15) OMEs compared with 10 (0-43) OMEs, respectively (P = 0.07).

Conclusion: Regardless of preoperative opioid exposure, CKD patients undergoing vascular access surgery consumed fewer opioids than prescribed, with a median of <10% of opioids used. Therefore, we've reduced our institutional prescribing recommendations to 4 and 6 oxycodone 5mg pills for short and long surgical incision procedures, respectively.
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http://dx.doi.org/10.1016/j.jss.2021.02.005DOI Listing
April 2021

COVID-19 test result reporting for deceased donors: Emergent policies, logistical challenges, and future directions.

Clin Transplant 2021 Mar 10:e14280. Epub 2021 Mar 10.

University of Iowa, Iowa City, IA, USA.

The coronavirus disease 2019 (COVID-19) pandemic poses unprecedented challenges to the transplant community, including organ procurement organizations (OPOs), transplant centers, regulatory agencies, and recipient candidates. Access to timely, accurate information on the status of deceased donor viral infection is essential in determining organ acceptance. The Organ Procurement and Transplantation Network expeditiously added fields to collect these data; however, use of the data collection fields was not uniform nationally. Standardized, field-defined data capture and reporting are vital to ensure optimal organ utilization during this pandemic, and to prepare the community for subsequent challenges.
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http://dx.doi.org/10.1111/ctr.14280DOI Listing
March 2021

Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers.

Am J Transplant 2021 Feb 8. Epub 2021 Feb 8.

New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA.

Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.
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http://dx.doi.org/10.1111/ajt.16523DOI Listing
February 2021

Survival Among Incident Peritoneal Dialysis Versus Hemodialysis Patients Who Initiate With an Arteriovenous Fistula.

Kidney Med 2020 Nov-Dec;2(6):732-741.e1. Epub 2020 Oct 22.

Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

Rationale & Objective: Comparisons of outcomes between in-center hemodialysis (HD) and peritoneal dialysis (PD) are confounded by selection bias because PD patients are typically younger and healthier and may have received longer predialysis care. We compared first-year survival between what we hypothesized were clinically equivalent groups; namely, patients who initiate maintenance HD using an arteriovenous fistula (AVF) and those selecting PD as their initial modality.

Study Design: Observational, registry-based, retrospective cohort study.

Setting & Participants: US Renal Data System data for 5 annual cohorts (2010-2014; n = 130,324) of incident HD with an AVF and incident PD patients.

Exposures And Predictors: Exposure was more than 1 day receiving PD or more than 1 day receiving HD with an AVF. Time at risk for both cohorts was determined for 12 consecutive 30-day segments, censoring for transplantation, loss to follow-up, or end of time. Predictors included patient-level characteristics obtained from Centers for Medicare & Medicaid Services 2728 Form and other data sources.

Outcomes: Patient survival.

Analytical Approach: Unadjusted and multivariable risk-adjusted HRs for death of HD versus PD patients, averaged over 2010 to 2014, were calculated.

Results: The HD cohort's average unadjusted mortality rate was consistently higher than for the PD cohort. The HR of HD versus PD was 1.25 (95% CI, 1.20-1.30) in the unadjusted model and 0.84 (95% CI, 0.80-0.87) in the adjusted model. However, multivariable risk-adjusted analyses showed the HR of HD versus PD for the first 90 days was 1.06 (95% CI, 0.98-1.14), decreasing to 0.74 (95% CI, 0.68-0.80) in the 270- to 360-day period.

Limitations: Residual confounding due to selection bias inherent in dialysis modality choice and the observational study design. Form 2728 provides baseline data at dialysis incidence alone, but not over time.

Conclusions: US patients receiving HD with an AVF appear to have a survival advantage over PD patients after 90 days of dialysis initiation after accounting for patient characteristics. These findings have implications in the choice of initial dialysis modality and vascular access for patients.
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http://dx.doi.org/10.1016/j.xkme.2020.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729241PMC
October 2020

International Comparisons of Native Arteriovenous Fistula Patency and Time to Becoming Catheter-Free: Findings From the Dialysis Outcomes and Practice Patterns Study (DOPPS).

Am J Kidney Dis 2021 02 21;77(2):245-254. Epub 2020 Sep 21.

Arbor Research Collaborative for Health, Ann Arbor, MI.

Rationale & Objective: Optimizing vascular access use is crucial for long-term hemodialysis patient care. Because vascular access use varies internationally, we examined international differences in arteriovenous fistula (AVF) patency and time to becoming catheter-free for patients receiving a new AVF.

Study Design: Prospective cohort study.

Setting & Participants: 2,191 AVFs newly created in 2,040 hemodialysis patients in 2009 to 2015 at 466 randomly selected facilities in the Dialysis Outcomes and Practice Patterns Study (DOPPS) from the United States, Japan, and EUR/ANZ (Belgium, France, Germany, Italy, Spain, Sweden, United Kingdom, Australia, and New Zealand).

Predictors: Demographics, comorbid conditions, dialysis vintage, body mass index, AVF location, and country/region.

Outcomes: Primary/cumulative AVF patency (from creation), primary/cumulative functional patency (from first use), catheter dependence duration, and mortality.

Analytical Approach: Outcomes estimated using Cox regression.

Results: Across regions, mean patient age ranged from 61 to 66 years, with male preponderance ranging from 55% to 66%, median dialysis vintage of 0.3 to 3.2 years, with 84%, 54%, and 32% of AVFs created in the forearm in Japan, EUR/ANZ, and United States, respectively. Japan displayed superior primary and cumulative patencies due to higher successful AVF use, whereas cumulative functional patency was similar across regions. AVF patency associations with age and other patient characteristics were weak or varied considerably between regions. Catheter-dependence following AVF creation was much longer in EUR/ANZ and US patients, with nearly 70% remaining catheter dependent 8 months after AVF creation when AVFs were not successfully used. Not using an arteriovenous access within 6 months of AVF creation was related to 53% higher mortality in the subsequent 6 months.

Limitations: Residual confounding.

Conclusions: Our findings highlight the need to reevaluate practices for optimizing long-term access planning and achievable AVF outcomes, especially AVF maturation. New AVFs that are not successfully used are associated with long-term catheter exposure and elevated mortality risk. These findings highlight the importance of selecting the best access type for each patient and developing effective clinical pathways for when AVFs fail to mature successfully.
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http://dx.doi.org/10.1053/j.ajkd.2020.06.020DOI Listing
February 2021

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

An overview of frailty in kidney transplantation: measurement, management and future considerations.

Nephrol Dial Transplant 2020 07;35(7):1099-1112

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

The construct of frailty was first developed in gerontology to help identify older adults with increased vulnerability when confronted with a health stressor. This article is a review of studies in which frailty has been applied to pre- and post-kidney transplantation (KT) populations. Although KT is the optimal treatment for end-stage kidney disease (ESKD), KT candidates often must overcome numerous health challenges associated with ESKD before receiving KT. After KT, the impacts of surgery and immunosuppression represent additional health stressors that disproportionately impact individuals with frailty. Frailty metrics could improve the ability to identify KT candidates and recipients at risk for adverse health outcomes and those who could potentially benefit from interventions to improve their frail status. The Physical Frailty Phenotype (PFP) is the most commonly used frailty metric in ESKD research, and KT recipients who are frail at KT (~20% of recipients) are twice as likely to die as nonfrail recipients. In addition to the PFP, many other metrics are currently used to assess pre- and post-KT vulnerability in research and clinical practice, underscoring the need for a disease-specific frailty metric that can be used to monitor KT candidates and recipients. Although frailty is an independent risk factor for post-transplant adverse outcomes, it is not factored into the current transplant program risk-adjustment equations. Future studies are needed to explore pre- and post-KT interventions to improve or prevent frailty.
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http://dx.doi.org/10.1093/ndt/gfaa016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417002PMC
July 2020

Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic.

Am J Transplant 2020 08 18;20(8):2143-2155. Epub 2020 Feb 18.

Mayo Clinic, Rochester, Minnesota, USA.

The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplant and unique challenges in perioperative and postoperative outcomes. Because of comorbidities associated with obesity, along with the underlying end-stage organ disease leading to transplant candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplant. However, the use of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease and improve perioperative and postoperative outcomes. We review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients and explore potential interventions to address obesity in these populations.
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http://dx.doi.org/10.1111/ajt.15784DOI Listing
August 2020

Variable Benefits of Antibody Induction by Kidney Allograft Type.

J Surg Res 2020 04 19;248:69-81. Epub 2019 Dec 19.

Section of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

Background: Kidneys from acute renal failure (ARF), expanded criteria donors (ECD), and donation after cardiac death (DCD) donors are often discarded due to concerns for delayed graft function (DGF) and graft failure. Induction immunosuppression may be used to minimize these risks, but practices vary widely. Furthermore, little is known regarding national outcomes of transplant recipients receiving induction immunosuppression for receipt of high-risk kidneys.

Materials And Methods: Using a center-level retrospective study, deceased donor transplants (115,485) from the Scientific Registry of Transplant Recipients from January 2003 to June 2016 were evaluated. Patients who received induction immunosuppression, including lymphocyte immune globulin, muromonab CD-3, IL-1 receptor antagonist, anti-thymocyte globulin, daclizumab, basiliximab, alemtuzumab, and rituximab, were included. Associations of center-level induction use with acute rejection in the first post-transplant year, graft failure, and patient mortality were evaluated using multivariable Cox and logistic regression.

Results: Among all kidneys, increasing percentage of center-level induction was associated with lower risk of graft failure, acute rejection, and patient mortality. In recipients of ARF kidneys, the beneficial association of induction on graft failure and acute rejection was greater than in those that received non-ARF kidneys. Marginally greater benefit of induction was seen for acute rejection in ECD compared to standard criteria donor (SCD) recipients and for graft failure in DCD compared to donors after brain death (DBD). No benefit of induction was detected for patient and graft survival in ECD recipients, acute rejection in DCD recipients, and patient survival in DGF recipients. No difference in the benefit of induction was detected in any other comparisons.

Conclusions: While seemingly beneficial for recipients of all kidneys, induction has more robust associations with lower graft failure and acute rejection probability for recipients of ARF kidneys. Given the lack of observed benefit for ECD recipients, induction policies should be carefully considered in these patients.
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http://dx.doi.org/10.1016/j.jss.2019.11.015DOI Listing
April 2020

Surgeon Characteristics and Dialysis Vascular Access Outcomes in the United States: A Retrospective Cohort Study.

Am J Kidney Dis 2020 02 1;75(2):158-166. Epub 2019 Oct 1.

Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI.

Rationale & Objective: An arteriovenous fistula (AVF) is the preferred access for most patients receiving maintenance hemodialysis, but maturation failure remains a challenge. Surgeon characteristics have been proposed as contributors to AVF success. We examined variation in AVF placement and AVF outcomes by surgeon and surgeon characteristics.

Study Design: Retrospective cohort study.

Setting & Participants: National Medicare claims and web-based data submitted by dialysis facilities on maintenance hemodialysis patients from 2009 through 2015.

Exposures: Patient characteristics, including demographics and comorbid conditions; surgeon characteristics, including specialty, prior volume of AVF placements, and years since medical school graduation.

Outcomes: Percent of access placements that were an AVF from 2009 to 2015 (designated AVF placement), and percent of AVFs with successful use within 6 months of placement (maturation) from 2013 to 2014.

Analytical Approach: Multilevel logistic regression models examining the association of surgeon characteristics with the outcomes, adjusted for patient characteristics and dialysis facilities as random effects.

Results: Among 4,959 surgeons placing 467,827 accesses, median AVF placement was 71% (IQR, 59%-84%). More recent year of medical school graduation and general surgery specialty (vs vascular, cardiothoracic, or transplantation surgery) were associated with higher odds of AVF placement. Among 2,770 surgeons placing 49,826 AVFs, the median AVF maturation rate was 59% (IQR, 44%-71%). More recent year of medical school graduation, but not surgical specialty, was associated with higher odds of AVF maturation. Greater prior volume of AVF placement was associated with higher odds of AVF maturation: OR of 1.46 (95% CI, 1.37-1.57) for highest (>84 AVF placements in 2years) versus lowest (<14) volume quintile.

Limitations: The study relied on administrative data, limiting capture of some factors affecting access outcomes.

Conclusions: There is substantial surgeon-level variation in AVF placements and AVF maturation. Surgeons' prior volume of AVF placements is strongly associated with AVF maturation.
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http://dx.doi.org/10.1053/j.ajkd.2019.08.001DOI Listing
February 2020

Transplant Center Volume: Is Bigger Better?

Am J Kidney Dis 2019 10 26;74(4):432-434. Epub 2019 Jul 26.

Department of Surgery, University of Michigan, Ann Arbor, MI. Electronic address:

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http://dx.doi.org/10.1053/j.ajkd.2019.04.030DOI Listing
October 2019

Trends in Bariatric Surgery Procedures among Patients with ESKD in the United States.

Clin J Am Soc Nephrol 2019 08 25;14(8):1193-1199. Epub 2019 Jul 25.

Department of Surgery, Section of Transplantation.

Background And Objectives: Despite the potential for improving health status or increasing access to transplantation, national practice patterns for bariatric surgery in obese patients with ESKD are poorly understood. The purpose of this study was to describe current trends in surgical care for this population.

Design, Setting, Participants, & Measurements: Using 100% Medicare data, we identified all beneficiaries undergoing bariatric surgery in the United States between 2006 and 2016. We evaluated longitudinal practice patterns using linear regression models. We also estimated risk-adjusted complications, readmissions, and length of stay using Poisson regression for patients with and without ESKD.

Results: The number of patients with ESKD undergoing bariatric surgery increased ninefold between 2006 and 2016. The proportional use of sleeve gastrectomy increased from <1% in 2006 to 84% in 2016. For sleeve gastrectomy, complication rates were similar between patients with and without ESKD (3.4% versus 3.6%, respectively; difference, -0.3%; 95% confidence interval, -1.3% to 0.1%; =0.57). However, patients with ESKD had more readmissions (8.6% versus 5.4%, respectively; difference, 3.2%; 95% confidence interval, 1.9% to 4.6%; <0.001) and slightly longer hospitals stays (2.2 versus 1.9 days, respectively; difference, 0.3; 95% confidence interval, 0.1 to 0.4; <0.001).

Conclusions: This study suggests that laparoscopic sleeve gastrectomy has replaced Roux-en-Y gastric bypass as the most common bariatric surgical procedure in patients with ESKD. The data also demonstrate a favorable complication profile in patients with sleeve gastrectomy.
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http://dx.doi.org/10.2215/CJN.01480219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682821PMC
August 2019

Perceptions and Practices Regarding Frailty in Kidney Transplantation: Results of a National Survey.

Transplantation 2020 02;104(2):349-356

Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY.

Background: Given the potential utility of frailty, a clinical phenotype of decreased physiologic reserve and resistance to stressors, to predict postkidney transplant (KT) outcomes, we sought to understand the perceptions and practices regarding frailty measurement in US KT programs.

Methods: Surveys were emailed to American Society of Transplantation Kidney/Pancreas Community of Practice members and 202 US transplant programs (November 2017 to April 2018). Program characteristics were gleaned from Scientific Registry of Transplant Recipients.

Results: The 133 responding programs (response rate = 66%) represented 77% of adult KTs and 79% of adult KT candidates in the United States. Respondents considered frailty to be a useful concept in evaluating candidacy (99%) and endorsed a need to develop a frailty measurement specific to KT (92%). Frailty measurement was more common during candidacy evaluation (69%) than during KT admission (28%). Of the 202 programs, 38% performed frailty assessments in all candidates while 23% performed assessments only for older candidates. There was heterogeneity in the frailty assessment method; 18 different tools were utilized to measure frailty. The most common tool was a timed walk test (19%); 67% reported performing >1 tool. Among programs that measure frailty, 53% reported being less likely to list frail patients for KT.

Conclusions: Among US KT programs, frailty is recognized as a clinically relevant construct and is commonly measured at evaluation. However, there is considerable heterogeneity in the tools used to measure frailty. Efforts to identify optimal measurement of frailty using either an existing or a novel tool and subsequent standardization of its measurement and application across KT programs should be considered.
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http://dx.doi.org/10.1097/TP.0000000000002779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834867PMC
February 2020

The impact of intraoperative fluid management during laparoscopic donor nephrectomy on donor and recipient outcomes.

Clin Transplant 2019 06 29;33(6):e13542. Epub 2019 Apr 29.

Division of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, Michigan.

Background: Intraoperative fluid management during laparoscopic donor nephrectomy (LDN) may have a significant effect on donor and recipient outcomes. We sought to quantify variability in fluid management and investigate its impact on donor and recipient outcomes.

Methods: A retrospective review of patients who underwent LDN from July 2011 to January 2016 with paired kidney recipients at a single center was performed. Patients were divided into tertiles of intraoperative fluid management (standard, high, and aggressive). Donor and recipient demographics, intraoperative data, and postoperative outcomes were analyzed.

Results: Overall, 413 paired kidney donors and recipients were identified. Intraoperative fluid management (mL/h) was highly variable with no correlation to donor weight (kg) (R = 0.017). The aggressive fluid management group had significantly lower recipient creatinine levels on postoperative day 1. However, no significant differences were noted in creatinine levels out to 6 months between groups. No significant differences were noted in recipient postoperative complications, graft loss, and death. There was a significant increase (P < 0.01) in the number of total donor complications in the aggressive fluid management group.

Conclusions: Aggressive fluid management during LDN does not improve recipient outcomes and may worsen donor outcomes compared to standard fluid management.
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http://dx.doi.org/10.1111/ctr.13542DOI Listing
June 2019

Resident perceptions and evaluations of fellow-led and resident-led surgical services.

Am J Surg 2019 02 7;217(2):373-381. Epub 2018 Sep 7.

Department of Surgery, University of Michigan, Ann Arbor, MI, USA.

Background: The impact of fellowship training on general surgery residency has remained challenging to assess. Surgical resident perceptions of fellow-led and resident-led surgical services have not been well described.

Methods: Retrospective cross-sectional data were collected from residents' service evaluations from 7/2014 through 7/2017. Surgical services were categorized as resident-led or fellow-led. 31 variables were evaluated and collapsed into 7 factors including clinical experience, educational experiences, clinical staff, workload, feedback, treatment of residents, and overall rotation.

Results: Among all PGY levels, fellow-led surgical services were rated significantly higher (p < 0.05) regarding clinical experience, clinical staff, treatment of residents, and overall rotation. PGY1-2 residents rated resident-led services significantly higher in the area of educational experiences, while PGY 3 residents rated resident-led services higher in the area of workload. However, PGY4-5 residents rated fellow-led services significantly higher in all 7 categories. Individual fellow-led services were rated significantly higher for various categories at different PGY levels.

Conclusions: Surgical residents appear to value the educational experiences of fellow-led services. Each fellow-led service may ultimately provide unique educational opportunities and resources for different PGY levels.
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http://dx.doi.org/10.1016/j.amjsurg.2018.09.005DOI Listing
February 2019

Racial disparity in kidney transplant survival relates to late rejection and is independent of steroid withdrawal.

Clin Transplant 2018 09 30;32(9):e13381. Epub 2018 Aug 30.

Case Western Reserve University School of Medicine, Cleveland, Ohio.

Black kidney transplant recipients have more acute rejection (AR) and inferior graft survival. We sought to determine whether early steroid withdrawal (ESW) had an impact on AR and death-censored graft loss (DCGL) in blacks. From 2006 to 2012, AR and graft survival were analyzed in 483 kidney recipients (208 black and 275 non-black). Rates of ESW were similar between blacks (65%) and non-blacks (67%). AR was defined as early (≤3 months) or late (>3 months). The impact of black race, early AR, and late AR on death-censored graft failure was analyzed using univariate and multivariate Cox models. Blacks had greater dialysis vintage, more deceased donor transplants, and less HLA matching, yet rates of early AR were comparable between blacks and non-blacks. However, black race was a risk factor for late AR (HR: 3.48 (95% CI: 1.87-6.47)) Blacks had a greater rate of DCGL, partially driven by late AR (HR with late AR: 5.6; 95% CI: 3.3-9.3). ESW had no significant interaction with black race for risk of early AR, late AR, or DCGL. Independent of ESW, black kidney recipients had a higher rate of late AR after kidney transplantation. Late AR was highly predictive of DCGL and contributed to inferior graft survival in blacks.
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http://dx.doi.org/10.1111/ctr.13381DOI Listing
September 2018

Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study.

Am J Kidney Dis 2018 06 9;71(6):793-801. Epub 2018 Feb 9.

Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI. Electronic address:

Background: Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States.

Study Design: Nonconcurrent observational cohort study.

Setting & Participants: Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System.

Predictors: Demographics, geographic location, dialysis vintage, comorbid conditions.

Outcomes: Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data.

Measurements: AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of 2014.

Results: In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation.

Limitations: This study relies on administrative data, with monthly recording of access use.

Conclusions: We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.
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http://dx.doi.org/10.1053/j.ajkd.2017.11.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6551206PMC
June 2018

Risk of peritoneal dialysis catheter-associated peritonitis following kidney transplant.

Clin Transplant 2018 03 6;32(3):e13189. Epub 2018 Mar 6.

Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.

Objective: Peritoneal dialysis (PD) patients have equivalent or slightly better kidney transplant outcomes when compared to hemodialysis (HD) patients. However, given the risk for postoperative infection, we sought to determine the risk factors for PD catheter-associated infections for patients who do not have the PD catheter removed at the time of engraftment.

Methods: Demographic and outcomes data were collected from 313 sequential PD patients who underwent kidney transplant from 2000 to 2015. Risk factors for postoperative peritonitis were analyzed using logistical regression.

Results: Of 329 patients with PD catheters at transplant, 16 PD catheters were removed at engraftment. Of the remaining 313 patients, 8.9% suffered post-transplant peritonitis. On univariate analysis, patients with peritonitis were significantly more likely to have used the PD catheter or HD within 6 weeks after transplant. Multivariate analysis had similar findings, with increased risk for those using the PD catheter after transplant, with a trend for those who underwent HD only within 6 weeks of transplant.

Conclusion: These results suggest that delayed graft function requiring any type of dialysis is associated with increased post-transplant peritonitis risk.
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http://dx.doi.org/10.1111/ctr.13189DOI Listing
March 2018

Risk Factors for Abnormal Cervical Cytology in Women Undergoing Kidney Transplant Evaluation.

Exp Clin Transplant 2019 02 18;17(1):31-36. Epub 2017 Dec 18.

From the Division of Transplant Surgery, Department of Surgery, Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, Ohio, USA.

Objectives: Cervical cytology screening has been successful in reducing deaths from cervical cancer. We sought to determine risk factors for abnormal Pap test results in women undergoing kidney transplant evaluation.

Materilas And Methods: We retrospectively examined women undergoing kidney transplant evaluations from 2008 to 2011. Patients were stratified based on normal cytology and atypical/malignant cytology.

Results: Of 404 patients, 293 patients (72.5%) had normal cytologic findings, whereas 111 (27.5%) had abnormal findings. On univariate logistic regression analyses, patients who had chronic kidney disease with an autoimmune cause (odds ratio = 2.71 [95% confidence interval, 1.41-5.19]; P = .003), previous renal transplants (odds ratio = 2.64 [95% confidence interval, 1.20-5.82], P = .016), or age ≤ 50 years (odds ratio = 1.68 [95% confidence interval, 1.08-2.61], P = .022) were more likely to have abnormal findings. Patients with normal and abnormal findings had similar rates of dialysis use. On multivariate logistic regression, patients who had chronic kidney disease with autoimmune causes (odds ratio = 2.48 [95% confidence interval, 1.26-4.88]; P = .008) and who had previous renal transplants (odds ratio = 2.67 [95% confidence interval, 1.20-5.95]; P = .017) were more likely to have abnormal findings.

Conclusions: Previous kidney transplant, autoimmune disease, and age ≤ 50 years were associated with abnormalities on cervical cancer screening in our female group of patients. Patients with these characteristics may benefit more from routine cervical cancer screening than other patients evaluated for kidney transplant.
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http://dx.doi.org/10.6002/ect.2017.0064DOI Listing
February 2019

Expanding the Donor Pool: Organ Donation After Brain Death for Extracorporeal Membrane Oxygenation Patients.

Crit Care Med 2017 10;45(10):1790-1791

Section of Transplantation Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.

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http://dx.doi.org/10.1097/CCM.0000000000002633DOI Listing
October 2017

Impact of screening for metabolic syndrome on the evaluation of obese living kidney donors.

Am J Surg 2018 Jan 1;215(1):144-150. Epub 2017 Sep 1.

Department of Surgery, University of Michigan, Ann Arbor, MI, USA. Electronic address:

Background: We report our experience with metabolic syndrome screening for obese living kidney donor candidates to mitigate the long-term risk of CKD.

Methods: We retrospectively reviewed 814 obese (BMI≥30) and 993 nonobese living kidney donor evaluations over 12 years. Using logistic regression, we explored interactions between social/clinical variables and candidate acceptance before and after policy implementation.

Results: Obese donor candidate acceptance decreased after metabolic syndrome screening began (56.3%, 46.3%, p < 0.01), while nonobese candidate acceptance remained similar (59.6%, 59.2%, p = 0.59). Adjusting for age, gender, race, BMI, and number of prior evaluations, acceptance of obese candidates decreased significantly more than nonobese (p = 0.025). In candidates without metabolic syndrome, there was no significant change in how age, sex, race, or BMI affected a donor candidate's probability of acceptance.

Conclusion: Metabolic syndrome screening is a simple stratification tool for centers with liberal absolute BMI cut-offs to exclude potentially higher-risk obese candidates.
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http://dx.doi.org/10.1016/j.amjsurg.2017.08.019DOI Listing
January 2018

Morphometric age and survival following kidney transplantation.

Clin Transplant 2017 10 28;31(10). Epub 2017 Aug 28.

Department of Surgery, Morphomics Analysis Group (MAG), University of Michigan, Ann Arbor, MI, USA.

Background: As patients with chronic kidney disease become older, there is greater need to identify who will most benefit from kidney transplantation. Analytic morphomics has emerged as an objective risk assessment tool distinct from chronologic age. We hypothesize that morphometric age is a significant predictor of survival following transplantation.

Methods: A retrospective cohort of 158 kidney transplant patients from 2005 to 2014 with 1-year preoperative imaging was identified. Based on a control population comprising of trauma patients and kidney donors, morphometric age was calculated using the validated characteristics of psoas area, psoas density, and abdominal aortic calcification. The primary outcome was post-transplant survival.

Results: Cox regression showed morphometric age was a significant predictor of survival (hazard ratio, 1.06 per morphometric year [95% confidence interval, 1.03-1.08]; P < .001). Chronological age was not significant (hazard ratio, 1.03 per year [0.98-1.07]; P = .22). Among the chronologically oldest patients, those with younger morphometric age had greater survival rates compared to those with older morphometric age.

Conclusions: Morphometric age predicts survival following kidney transplantation. Particularly for older patients, it offers improved risk stratification compared to chronologic age. Morphomics may improve the transplant selection process and provide a greater assessment of prospective survival benefits.
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http://dx.doi.org/10.1111/ctr.13066DOI Listing
October 2017

Using analytic morphomics to describe body composition associated with post-kidney transplantation diabetes mellitus.

Clin Transplant 2017 Sep 20;31(9). Epub 2017 Jul 20.

Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.

Background: Better risk assessment tools are needed to predict post-transplantation diabetes mellitus (PTDM). Using analytic morphomic measurements from computed tomography (CT) scans, we aimed to identify specific measures of body composition associated with PTDM.

Methods: We retrospectively reviewed 99 non-diabetic kidney transplant recipients who received pre-transplant CT scans at a single institution between 1/2005 and 5/2014. Analytic morphomic techniques were used to measure abdominal adiposity, abdominal size, and psoas muscle area and density, standardized by gender. We measured the associations of these morphomic factors with PTDM.

Results: One-year incidence of PTDM was 18%. The morphomic factors significantly associated with PTDM included visceral fat area (OR=1.84 per standard deviation increase, P=.020), body depth (OR=1.79, P=.035), and total body area (OR=1.67, P=.049). Clinical factors significantly associated with PTDM included African American race (OR=3.01, P=.044), hypertension (OR=2.97, P=.041), and dialysis vintage (OR=1.24 per year on dialysis, P=.048). Body mass index was not associated with PTDM (OR=1.05, P=.188). On multivariate modeling, visceral fat area was an independent predictor of PTDM (OR=1.91, P=.035).

Conclusions: Analytic morphomics can identify pre-transplant measurements of body composition that are predictive of PTDM in kidney transplant recipients. Pre-transplant imaging contains a wealth of underutilized data that may inform PTDM prevention strategies.
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http://dx.doi.org/10.1111/ctr.13040DOI Listing
September 2017

The Utility of Screening Colonoscopy During Kidney Transplant Evaluation.

Exp Clin Transplant 2017 Dec 16;15(6):602-608. Epub 2017 Jun 16.

From the Division of Transplant Surgery, Department of Surgery, Case Western Reserve University and University Hospitals, Case Medical Center, Cleveland, Ohio, USA.

Objectives: Transplant centers often recommend, but not necessarily require, screening colonoscopies for people over 50 years of age in accordance with the US Preventative Services Task Force guidelines for the general population. We sought to identify risk factors affecting colonoscopy results in renal failure patients undergoing kidney transplant evaluation.

Materials And Methods: We retrospectively examined patients undergoing kidney transplant evaluation from 2009 to 2012 (n = 469 patients). Comparisons were made between colonoscopy reports categorized as normal (no finding or hyperplastic polyp) or abnormal (adenomatous polyp or carcinoma).

Results: Of 469 patients who met the study criteria, 303 (64.6%) had normal colonoscopies and 166 (35.4%) had abnormal colonoscopies. Logistic regression analysis showed that male sex (odds ratio = 2.09; 95% confidence interval, 1.37-3.20; P = .001) and increasing age (odds ratio = 1.04; 95% confidence interval, 1.01-1.08; P = .019) were more likely to correspond to abnormal findings. Those with dialysis vintage (length of time on dialysis) up to 3 years (odds ratio = 2.10; 95% confidence interval, 1.09-4.06; P = .027) and hypertension as the cause of renal failure (odds ratio = 1.79; 95% confidence interval, 1.05-2.87; P = .002) had more abnormal findings. No differences in length of evaluation, rate of being listed for transplant, and rate of transplant were shown.

Conclusions: The overall rate of adenomatous findings on colonoscopy was higher among patients with pretransplant end-stage renal disease than in the general population, as shown in other studies. Age, sex, dialysis vintage up to 3 years, and hypertensive renal failure were associated with adenomatous polyps of the colon in this study population. Because adenomatous polyp rates are high in patients with chronic kidney disease who are undergoing transplant evaluation and colonoscopic findings do not appear to delay transplant evaluations or listing rates, screening colonoscopies should be encouraged.
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http://dx.doi.org/10.6002/ect.2016.0214DOI Listing
December 2017