Publications by authors named "Krista L Lentine"

239 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

LIMS1 Risk Genotype and T-Cell Mediated Rejection in Kidney Transplant Recipients.

Nephrol Dial Transplant 2021 Apr 28. Epub 2021 Apr 28.

Division of Nephrology, Saint Louis University, Saint Louis, MO, USA.

Background: This study aims to examine the association of LIM Zinc Finger Domain Containing 1 (LIMS1) genotype with allograft rejection in an independent kidney transplant cohort.

Methods: We genotyped 841 kidney transplant recipients for LIMS1 rs893403 variant by Sanger sequencing followed by PCR confirmation of the deletion. Recipients who were homozygous for LIMS1 rs893403 genotype GG were compared to AA/AG genotypes. The primary outcome was T-cell mediated (TCMR) or antibody mediated rejection (ABMR) and secondary outcome was allograft loss.

Results: After a median follow-up of 11.4 years, the rate of TCMR was higher in recipients with the GG (n = 200) compared to AA/AG (n = 641) genotypes [25 (12.5%) vs 35 (5.5%); p = 0.001] while ABMR did not differ by genotype [18 (9.0%) vs 62 (9.7%)]. Recipients with GG genotype had 2.4-times higher risk of TCMR than those who did not have this genotype (adjusted hazard ratio (aHR), 1.442.434.12, p = 0.001). A total of 189 (22.5%) recipients lost their allografts during follow up. Kaplan-Meier estimates of 5-year (94.3% vs. 94.4%, p = 0.99) and 10-year graft survival rates (86.9% vs. 83.4%, p = 0.31) did not differ significantly in those with GG compared to AA/AG groups.

Conclusions: Our study demonstrates that recipient LIMS1 risk genotype is associated with increased risk of TCMR after kidney transplantation, confirming the role of LIMS1 locus in allograft rejection. These findings may have clinical implications for the prediction and clinical management of kidney transplant rejection by pretransplant genetic testing of recipients and donors for LIMS1 risk genotype.
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http://dx.doi.org/10.1093/ndt/gfab168DOI Listing
April 2021

Opioids and Kidney Transplantation.

Semin Nephrol 2021 Jan;41(1):42-53

Center for Transplantation Sciences, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

The United States has faced an unprecedented opioid crisis in recent years, which has led to an increase in opioid overdose-related deaths and, consequently, an increase in the number of potential deceased donors available for transplantation. This new pool of potential organ donors is composed of younger donors with higher infectious disease transmission risk. The use of organs from these donors requires appropriate patient education, informed consent, and post-transplant monitoring practices. Prescription opioid use is also an important component of the evaluation of transplant and living donor candidates because it may impact outcomes and eligibility for the procedures. In kidney transplant recipients, prescription opioid use predicts a higher risk of mortality, graft loss, and post-transplant complications. These effects seem to be proportional to the levels of opioid use, and to parallel patterns in other transplant populations such as liver, heart and lung recipients. Among living kidney donors, predonation prescription opioid use is associated with an increased risk of re-admission after nephrectomy. Overall, the opioid epidemic creates educational needs for patients awaiting deceased donor transplant, and also impacts the evaluation and care of transplant candidates. Among transplant candidates and recipients, the identification of patients with chronic opioid use should prompt multidisciplinary evaluation and management strategies to minimize risks.
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http://dx.doi.org/10.1016/j.semnephrol.2021.02.005DOI Listing
January 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

Correction to: High-dose opioid utilization and mortality among individuals initiating hemodialysis.

BMC Nephrol 2021 Apr 15;22(1):133. Epub 2021 Apr 15.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA.

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http://dx.doi.org/10.1186/s12882-021-02332-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051104PMC
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

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

High-dose opioid utilization and mortality among individuals initiating hemodialysis.

BMC Nephrol 2021 Feb 23;22(1):65. Epub 2021 Feb 23.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA.

Background: Individuals undergoing hemodialysis in the United States frequently report pain and receive three-fold more opioid prescriptions than the general population. While opioid use is appropriate for select patients, high-dose utilization may contribute to an increased risk of death due to possible accumulation of opioid metabolites.

Methods: We studied high-dose opioid utilization (≥120 morphine milligram equivalents [MME] per day) among adults initiating hemodialysis in the United States between 2007 and 2014 using national registry data. We calculated the cumulative incidence (%) of high-dose utilization and depicted trends in the average percentage of days individuals were exposed to opioids. We used adjusted Cox proportional hazards models to identify which opioid doses were associated with mortality.

Results: Among 327,344 adults undergoing hemodialysis, the cumulative incidence of high-dose utilization was 14.9% at 2 years after initiating hemodialysis. Among patients with ≥1 opioid prescription during follow-up, the average percentage of days exposed to high-dose utilization increased from 13.9% in 2007 to 26.1% in 2014. Compared to 0MME per day, doses < 60MME were not associated with an increased risk of mortality, but high-dose utilization was associated with a 1.63-fold (95% CI, 1.57, 1.69) increased risk of mortality. The risk of mortality associated with opioid dose was highest in the first year after hemodialysis initiation.

Conclusions: The risk of mortality associated with opioid utilization among individuals on hemodialysis increases as doses exceed 60MME per day and is greatest during periods of high-dose utilization. Patients and clinicians should carefully weigh the risks and benefits of opioid doses exceeding 60MME per day.
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http://dx.doi.org/10.1186/s12882-021-02266-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901089PMC
February 2021

Outcomes of Surgical Mitral and Aortic Valve Replacements Among Kidney Transplant Candidates: Implications for Valve Selection.

J Am Heart Assoc 2021 Feb 18;10(5):e018971. Epub 2021 Feb 18.

Transplant Institute University Hospitals Cleveland Medical Center Cleveland OH.

Background Limited literature exists that evaluated outcomes of kidney transplant-eligible patients who are having dialysis and who are undergoing valve replacement. Our main objective in this study was to compare mortality, reoperation, and bleeding episodes between bioprosthetic and mechanical valve procedures among kidney transplant-eligible patients who are having dialysis. Methods and Results We studied 887 and 1925 dialysis patients from the United States Renal Data System, who underwent mitral valve replacement and aortic valve replacement (AVR) after being waitlisted for a kidney transplant (2000-2015), respectively. Time to death, time to reoperation, and time to bleeding requiring hospitalizations were compared separately for AVR and mitral valve replacement. Kaplan-Meier survival curves, Cox proportional hazards model for time to death, accelerated time to event model for time to reoperation, and counting process model for time to recurrent bleeding were used. There were no differences in mortality (hazard ratio [HR], 0.92; 95% CI, 0.77-1.09) or risk of reoperation or risk of significant bleeding events between bioprosthetic and mechanical mitral valve replacement. However, mechanical AVR was associated with a modestly significant less hazard of death (HR, 0.83; 95% CI, 0.74-0.94) compared with bioprosthetic AVR. There were no differences in time to reoperation, or time to significant bleeding events between bioprosthetic and mechanical AVR. Conclusions For kidney transplant waitlisted patients who are on dialysis and who are undergoing surgical valve replacement, bioprosthetic and mechanical valves have comparable survival, reoperation rates, and bleeding episodes requiring hospitalizations at both mitral and aortic locations. These findings emphasize that an individualized informed decision is recommended when choosing the type of valve for this special group of patients having dialysis.
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http://dx.doi.org/10.1161/JAHA.120.018971DOI Listing
February 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

Living Organ Donor Health Care Priorities During the COVID-19 Pandemic.

Kidney Int Rep 2021 Apr 4;6(4):1151-1155. Epub 2021 Feb 4.

Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.

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http://dx.doi.org/10.1016/j.ekir.2021.01.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857996PMC
April 2021

Trends in Discard of Kidneys from Hepatitis C Viremic Donors in the United States.

Clin J Am Soc Nephrol 2021 Feb 15;16(2):251-261. Epub 2021 Jan 15.

Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri

Background And Objectives: Kidneys from hepatitis C virus (HCV) viremic donors have become more commonly accepted for transplant, especially after effective direct-acting antiviral therapy became available in 2014. We examined the contemporary trend of kidney discard from donors with HCV seropositivity and viremia.

Design, Setting, Participants, & Measurements: Data from the Organ Procurement and Transplantation Network were used to identify deceased donor kidneys recovered for transplant. The exposure was donor HCV antibody status in the first analyses, and donor HCV antibody and viremia status in the second analyses. Multilevel, multivariable logistic regression was used to assess the association of these HCV exposure measures with kidney discard, adjusted for donor characteristics. Multilevel analyses were conducted to account for similar kidney discard pattern within clusters of organ procurement organizations and regions.

Results: Among 225,479 kidneys recovered from 2005 to 2019, 5% were from HCV seropositive donors. Compared with HCV seronegative kidneys, the odds of HCV seropositive kidney discard gradually declined, from a multivariable-adjusted odds ratio (aOR) of 7.06 (95% confidence interval [95% CI], 5.65 to 8.81) in 2014, to 1.20 (95% CI, 1.02 to 1.42) in 2019. Among 82,090 kidneys with nucleic acid amplification test results in 2015-2019, 4% were from HCV viremic donors and 2% were from aviremic seropositive donors. Compared with HCV aviremic seronegative kidneys, the odds of HCV viremic kidney discard decreased from an aOR of 4.89 (95% CI, 4.03 to 5.92) in 2018, to 1.48 (95% CI, 1.22 to 1.81) in 2019. By 2018 and 2019, aviremic seropositive status was not associated with higher odds of discard (2018: aOR, 1.13; 95% CI, 0.88 to 1.45; and 2019: aOR, 0.97; 95% CI, 0.76 to 1.23).

Conclusions: Despite the decrease in kidney discard in recent years, kidneys from viremic (compared with aviremic seronegative) donors still had 48% higher odds of discard in 2019. The potential of these discarded organs to provide successful transplantation should be explored.
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http://dx.doi.org/10.2215/CJN.10960720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863640PMC
February 2021

Practicing With Uncertainty: Kidney Transplantation During the COVID-19 Pandemic.

Am J Kidney Dis 2021 05 1;77(5):777-785. Epub 2021 Jan 1.

Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL. Electronic address:

The coronavirus disease 2019 (COVID-19) pandemic required transplant nephrologists, surgeons, and care teams to make decisions about the full spectrum of transplant program operations and clinical practices in the absence of experience or data. Initially, across the country, there was a reduction in kidney transplant procedures and a striking pause in the conduct of living donation and living-donor transplant surgeries. Aspects of candidate evaluation and follow-up rapidly converted to telehealth. Months into the pandemic, much has been learned from experiences worldwide, yet many questions remain. In this Perspective, we reflect on some of the practice decisions made by the transplant community in the initial response to the pandemic and consider lessons learned, including those related to the risks, benefits, and logistical considerations of proceeding with versus delaying deceased-donor transplantation, living donation, and living-donor transplantation during the pandemic. We review the evolution of therapeutic strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their use in transplant recipients, current consensus related to immunosuppression management in infected transplant recipients, and emerging information on vaccination against SARS-CoV-2. We share our thoughts on research priorities, discuss the areas in which we are still practicing with uncertainty, and look ahead to the next phase of the pandemic response.
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http://dx.doi.org/10.1053/j.ajkd.2020.12.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946342PMC
May 2021

Survey of Clinician Opinions on Kidney Transplantation from Hepatitis C Virus Positive Donors: Identifying and Overcoming Barriers.

Kidney360 2020 Nov 25;1(11):1291-1299. Epub 2020 Nov 25.

University of Iowa, Iowa City, IA.

Background: Transplant practices related to use of organs from Hepatitis C virus infected donors (DHCV+) is evolving rapidly.

Methods: We surveyed U.S. kidney transplant programs by email and professional society listserv postings between 7/19-1/20 to assess attitudes, management strategies, and barriers related to use of viremic (nucleic acid testing (NAT)+) donor organs in HCV uninfected recipients.

Results: Staff at 112 unique programs responded, representing 54% of U.S. adult kidney transplant programs and 69% of adult deceased donor kidney transplant volume in 2019. Most survey respondents were transplant nephrologists (46%) or surgeons (43%). Among responding programs, 67% currently transplant DHCV antibody+/NAT- organs under a clinical protocol or as standard of care. By comparison, only 58% offer DHCV NAT+ kidney transplant to HCV- recipients, including 35% under clinical protocols, 14% as standard of care, and 9% under research protocols. Following transplant of DHCV NAT+ organs to uninfected recipients, 53% start direct acting antiviral agent (DAA) therapy after discharge and documented viremia. Viral monitoring protocols after DHCV NAT+ to HCV uninfected recipient kidney transplantation varied substantially. 56% of programs performing these transplants report having an institutional plan to provide DAA treatment if declined by the recipient's insurance. Respondents felt a mean decrease in waiting time of ≥18 months (range 0-60) justifies the practice. Program concerns related to use of DHCV NAT+ kidneys include insurance coverage concerns (72%), cost (60%), and perceived risk of transmitting resistant infection (44%).

Conclusions: Addressing knowledge about safety and logistical/financial barriers related to use of DHCV NAT+ kidney transplantation for HCV uninfected recipients may help reduced discards and expand the organ supply.
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http://dx.doi.org/10.34067/KID.0004592020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695231PMC
November 2020

An International survey on living kidney donation and transplant practices during the COVID-19 pandemic.

Transpl Infect Dis 2021 Apr 19;23(2):e13526. Epub 2020 Dec 19.

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

The scope of the impact of the Coronavirus disease 19 (COVID-19) pandemic on living donor kidney transplantation (LDKT) practices across the world is not well-defined. We received survey responses from 204 transplant centers internationally from May to June 2020 regarding the impact of the COVID-19 pandemic on LDKT practices. Respondents represented 16 countries on five continents. Overall, 75% of responding centers reported that LDKT surgery was on hold (from 67% of North American centers to 91% of European centers). The majority (59%) of centers reported that new donor evaluations were stopped (from 46% of North American centers to 86% of European centers), with additional 23% of centers reporting important decrease in evaluations. Only 10% of centers reported slight variations on their evaluations. For the centers that continued donor evaluations, 40% performed in-person visits, 68% by video, and 42% by telephone. Center concerns for donor (82%) and recipient (76%) safety were the leading barriers to LDKT during the pandemic, followed by patients concerns (48%), and government restrictions (46%). European centers reported more barriers related to staff limitations while North and Latin American centers were more concerned with testing capacity and insufficient resources including protective equipment. As LDKT resumes, 96% of the programs intend to screen donor and recipient pairs for coronavirus infection, most of them with polymerase chain reaction testing of nasopharyngeal swab samples. The COVID-19 pandemic has had broad impact on all aspects of LDKT practice. Ongoing research and consensus-building are needed to guide safe reopening of LDKT programs.
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http://dx.doi.org/10.1111/tid.13526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744917PMC
April 2021

Using race to estimate glomerular filtration and its impact in kidney transplantation.

Clin Transplant 2021 Jan 24;35(1):e14136. Epub 2020 Nov 24.

Department of Surgery, Division of Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Since direct measurement of glomerular filtration rate (GFR) is time-consuming and more expensive, estimated GFR (eGFR) based on measured laboratory values is widely used to determine kidney function. Commonly used formulae to calculate eGFR are dependent on variables, which include filtration markers like serum creatinine and patient characteristics including race. Medical algorithms which utilize race are increasingly being scrutinized, as race is recognized to be a social construct rather than a biologic one. eGFR calculations have important implications for kidney transplantation, both in the listing of candidates as well as in the evaluation of potential kidney donors. This review considers the specific implications of race-based eGFR calculations on recipient evaluation and on decisions related to living kidney donation. We suggest a potential policy solution to ensure that racial and ethnic minority patients are not disadvantaged by eGFR as a result of current calculation methods.
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http://dx.doi.org/10.1111/ctr.14136DOI Listing
January 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

Financial Evaluation of Kidney Transplant With Hepatitis C Viremic Donors to Uninfected Recipients.

Transplant Direct 2020 Dec 10;6(12):e627. Epub 2020 Nov 10.

Department of Medicine, Saint Louis University, St. Louis, MO.

Kidney transplantation with hepatitis C viremic (dHCV+) donors appears safe for recipients without HCV when accompanied by direct acting antiviral (DAA) treatment. However, US programs have been reluctant to embrace this approach due to concern about insurance coverage. While the cost of DAA treatment is currently offset by the reduction in waiting time, increased competition for dHCV+ organs may reduce this advantage. This analysis sought to demonstrate the financial benefit of dHCV+ transplant for third-party health insurers to expand coverage availability.

Methods: An economic analysis was developed using a Markov model for 2 decisions: first, to accept a dHCV+ organ versus wait for a dHCV uninfected organ; or second, accept a high kidney donor profile index (KDPI) (>85) organ versus wait for a better quality dHCV+ organ. The analysis used Medicare payments, historical survival data, cost report data, and an estimated cost of DAA of $29 874.

Results: In the first analysis, using dHCV+ kidneys reduced the cost of end-stage kidney disease care if the wait for a dHCV uninfected organ exceeded 11.5 months. The financial breakeven point differed according to the cost of DAA treatment. In the second analysis, declining a high-KDPI organ in favor of a waiting dHCV+ organ was marginally clinically beneficial if waiting times were <12 months but not cost effective.

Conclusions: dHCV+ transplant appears to be economically and clinically advantageous compared with waiting for dHCV-uninfected transplant but should not replace high-KDPI transplant when appropriate. Despite the high cost of DAA therapy, health insurers benefit financially from dHCV+ transplant within 1 year.
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http://dx.doi.org/10.1097/TXD.0000000000001056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665247PMC
December 2020

Incidence, Risk Factors, and Outcomes of Kidney Transplant Recipients Treated With Both Basiliximab and Antithymocyte Globulin.

Can J Kidney Health Dis 2020 15;7:2054358120964061. Epub 2020 Oct 15.

Cumming School of Medicine, Division of Nephrology, University of Calgary, AB, Canada.

Background: Kidney transplant recipients are given induction therapy to rapidly reduce the immune response and prevent rejection. Guidelines recommend that an interleukin-2 receptor antibody (basiliximab) be the first-line agent and that a lymphocyte-depleting agent (antithymocyte globulin [ATG]) be reserved for those at high immunologic risk.

Objective: To determine the incidence, risk factors, and outcomes for patients who receive both basiliximab and ATG for induction compared to either agent alone.

Design: Retrospective cohort study.

Setting: We used the transplant electronic medical record at the University of Alberta Hospital in Edmonton, Canada.

Patients/samples/participants: We included incident adult kidney transplant recipients from 2013 to 2018.

Measurements: We measured baseline characteristics, type, and dose of induction therapy used, estimated glomerular filtration rate (eGFR) at 1-year posttransplant, and outcomes of all-cause graft failure, death-censored graft failure, all-cause mortality, and death with a functioning graft.

Methods: Differences between induction groups were compared using chi-square test for categorical variables and Kruskal-Wallis tests for continuous variables. We performed multivariable logistic regression modeling with type of induction therapy as the dependent variable and the case-level factors as the predictors (adjusted odds ratio). We estimated the Kaplan-Meier failure functions and used log-rank tests to assess statistical significance of differences in unadjusted incidence across induction therapy types. We compared cumulative incidence functions using a Fine and Gray competing risk regression model.

Results: In all, 430 kidney transplant recipients were followed for a mean of 3.9 years (standard deviation 1.5). Of these, 71% (n = 305) received basiliximab alone, 22% (n = 93) received ATG alone, and 7% (n = 32) received both basiliximab and ATG. After adjusting for age and sex, compared to the basiliximab alone group, patients were more likely to receive dual-induction therapy if they were sensitized (calculated panel reactive antibody ≥80%), had diabetes mellitus or peripheral vascular disease, or experienced delayed graft function. Compared to the ATG alone group, the dual-induction therapy group had worse graft function at 1 year (mean eGFR 42 vs. 59 mL/min/1.73 m, = .0008) and an increased risk of all-cause graft failure (31% vs. 13%, = .02) and death-censored graft failure (16% vs. 4%, = .03).

Limitations: There is a risk of confounding by indication, as patients who received dual-induction therapy likely had worse outcomes due to the indication for dual-induction therapy (such as delayed graft function).

Conclusions: In our study, 1 out of 10 recipients who were treated with basiliximab also received ATG for induction therapy. These patients experienced worse outcomes than those treated with ATG alone.

Trial Registration: Not applicable (cohort study).
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http://dx.doi.org/10.1177/2054358120964061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573718PMC
October 2020

Early Changes in Kidney Transplant Immunosuppression Regimens During the COVID-19 Pandemic.

Transplantation 2021 01;105(1):170-176

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

Background: Kidney transplant recipients have higher risk of infectious diseases due to their reliance on immunosuppression. During the current COVID-19 pandemic, some clinicians might have opted for less potent immunosuppressive agents to counterbalance the novel infectious risk. We conducted a nationwide study to characterize immunosuppression use and subsequent clinical outcomes during the first 5 months of COVID-19 pandemic in the United States.

Methods: Using data from the Scientific Registry of Transplant Recipients, we studied all kidney-only recipients in the United States from January 1, 2017, to March 12, 2020 ("prepandemic" era; n = 64 849) and from March 13, 2020, to July 31, 2020 ("pandemic" era; n = 5035). We compared the use of lymphocyte-depleting agents (versus basiliximab or no induction) and maintenance steroids (versus steroid avoidance/withdrawal) in the pandemic era compared with the prepandemic era. Then, we compared early posttransplant outcomes by immunosuppression regimen during the pandemic era.

Results: Recipients in the pandemic era were substantially less likely to receive lymphocyte-depleting induction agents compared with their prepandemic counterparts (aOR = 0.400.530.69); similar trends were found across subgroups of state-level COVID-19 incidence, donor type, and recipient age. However, lymphocyte-depleting induction agents were associated with decreased rejection during admission (aOR = 0.110.230.47) but not with increased mortality in the pandemic era (aHR = 0.130.471.66). On the other hand, the use of maintenance steroids versus early steroid withdrawal remained similar (aOR = 0.711.071.62).

Conclusions: The use of lymphocyte-depleting induction agents has decreased in favor of basiliximab and no induction during the COVID-19 pandemic. However, this shift might have resulted in increases in rejection with no clear reductions in posttransplant mortality.
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http://dx.doi.org/10.1097/TP.0000000000003502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752821PMC
January 2021

Induction immunosuppression and the risk of incident malignancies among older and younger kidney transplant recipients: A prospective cohort study.

Clin Transplant 2020 12 20;34(12):e14121. Epub 2020 Nov 20.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Older (≥65) KT recipients differ from their younger counterparts in their immune response to immunosuppression (IS) and may have a different risk of malignancy after receiving induction.

Methods: We identified 66 700 adult KT recipients treated with anti-thymocyte globulin (ATG) (n = 40 443) or interleukin-2 receptor antagonist (IL-2RA) (n = 26 327) induction (1/1/1999-12/31/2014) using USRDS/Medicare data. We estimated the risk of first-diagnosed post-KT malignancy associated with induction (ATG vs. IL-2RA) using Cox proportional hazard models. We then tested whether these risks differed between older and younger recipients (Wald test for interaction). Models incorporated inverse probability of treatment weights to adjust for confounders.

Results: The 3-year cumulative incidences of any diagnosed malignancy were 11.5%. ATG was associated with a higher malignancy risk (HR = 1.12, 95%CI:1.06-1.18). This association differed (p  = 0.04) between younger (HR = 1.12, 95%CI:1.06-1.18) and older recipients (HR = 1.03, 95%CI:0.96-1.09). ATG was also associated with higher risk of skin (HR = 1.18, 95%CI:1.08-1.29), lung (HR = 1.24, 95%CI:1.05-1.47), and ovary malignancies (HR = 1.94, 95%CI:1.08-3.48). However, only the association of ATG with post-KT skin malignancy differed (p  = 0.01) between younger (HR = 1.18; 95%CI:1.08-1.29) and older (HR = 1.01; 95%CI:0.93-1.09) recipients.

Conclusions: Compared with IL-2RA induction, ATG was associated with elevated post-KT malignancy risk but only among younger recipients. Transplant centers may need to tailor induction IS for younger recipients to mitigate malignancy risk.
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http://dx.doi.org/10.1111/ctr.14121DOI Listing
December 2020

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

Apolipoprotein L1: role in the evaluation of kidney transplant donors.

Curr Opin Nephrol Hypertens 2020 Nov;29(6):645-655

Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.

Purpose Of Review: To summarize the current state of evidence regarding the role of apolipoprotein L1 (APOL1) genotyping in evaluating donors for kidney transplantation.

Recent Findings: African ancestry is associated with an increased risk of kidney failure following living donation. Moreover, kidney transplants from African ancestry deceased donors have an increased risk of graft failure. Preliminary evidence suggests that APOL1 genotype may mediate at least a portion of this racial variation, with high-risk APOL1 genotypes defined by presence of two renal risk variants (RRVs). A pilot study 136 African ancestry living donors found that those with APOL1 high-risk genotypes had lower baseline kidney function and faster rates of kidney function decline after donation. To date, three retrospective studies identified a two-to-three times greater risk of allograft failure associated with kidneys from donors with high-risk APOL1 genotype. Active research initiatives seek to address unanswered questions, including reproducibility in large national samples, the role of 'second hits' injuries, and impact of recipient genotype, with a goal to build consensus on applications for policy and practice.

Summary: As evidence evolves, APOL1 genotyping may have applications for organ quality scoring in deceased donor kidney allocation, and for the evaluation and selection of living donor candidates.
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http://dx.doi.org/10.1097/MNH.0000000000000653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7741488PMC
November 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

A simple risk-based reimbursement system for kidney transplant.

Clin Transplant 2021 Jan 24;35(1):e14068. Epub 2020 Sep 24.

University of Iowa, Iowa City, IA, USA.

Transplant centers were challenged by the Executive Order on Advancing Kidney health to increase access to kidney transplant (KTx) by accepting higher risk patients and organs. However, Medicare reimbursement for KTx does not include adjustment for major complicating comorbidities (MCCs) like other transplants. The prevalence of MCCs was assessed for KTx performed from 10/15 to 10/19 at a single academic center, using Medicare ICD10 MCC criteria exclusive of end-stage kidney disease. KTx hospital resource utilization and estimated margin, assuming Medicare reimbursement, were determined for cases with and without MCC. Among 260 KTx recipients, 49 (19%) had an MCC. Patients with MCCs had longer wait times (1121 days vs 703 days, P < .001); however, there were no differences in age, gender, race, or diagnosis. Donor characteristics associated with an MCC included greater cold ischemic time (1042 vs 670 minutes, P < .001) and fewer living donor KTx (9% vs 32%, P < .001). KTx cost, exclusive of organ acquisition, was 31% higher (MCC: $38 293 vs No MCC: $29 132) and estimated margin was markedly lower (-$7750 vs -$1001, P = .001). In conclusion, KTx with qualifying MCCs resulted in significant financial losses and modification of KTx payment methodology to align with other organ transplants is needed.
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http://dx.doi.org/10.1111/ctr.14068DOI Listing
January 2021

Care of international living kidney donor candidates in the United States: A survey of contemporary experience, practice, and challenges.

Clin Transplant 2020 11 19;34(11):e14064. Epub 2020 Oct 19.

Cedars-Sinai Comprehensive Transplant Center, Los Angeles, California, USA.

The evaluation and care of non-US citizen, non-US residents who wish to come to the United States to serve as international living kidney donors (ILKDs) can pose unique challenges. We surveyed US transplant programs to better understand practices related to ILKD care. We distributed the survey by email and professional society list-servs (Fall 2018, assessing 2017 experience). Eighty-five programs responded (36.8% program response rate), of which 80 considered ILKD candidates. Only 18 programs had written protocols for ILKD evaluation. Programs had a median of 3 (range: 0,75) ILKD candidates who initiated contact during the year, from origin countries spanning 6 continents. Fewer (median: 1, range: 0,25) were approved for donation. Program-reported reasons for not completing ILKD evaluations included visa barriers (58.6%), inability to complete evaluation (34.3%), concerns regarding follow-up (31.4%) or other healthcare access (28.6%), and financial impacts (21.4%). Programs that did not evaluate ILKDs reported similar concerns. Staff time required to evaluate ILKDs was estimated as 1.5-to-3-times (47.9%) or >3-times (32.9%) that needed for domestic candidates. Among programs accepting ILKDs, on average 55% reported successful completion of 1-year follow-up. ILKD evaluation is a resource-intensive process with variable outcomes. Planning and commitment are necessary to care for this unique candidate group.
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http://dx.doi.org/10.1111/ctr.14064DOI Listing
November 2020

Impact of ABO-Incompatible Living Donor Kidney Transplantation on Patient Survival.

Am J Kidney Dis 2020 11 12;76(5):616-623. Epub 2020 Jul 12.

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD; Scientific Registry for Transplant Recipients, Minneapolis, MN. Electronic address:

Rationale & Objective: Compared with recipients of blood group ABO-compatible (ABOc) living donor kidney transplants (LDKTs), recipients of ABO-incompatible (ABOi) LDKTs have higher risk for graft loss, particularly in the first few weeks after transplantation. However, the decision to proceed with ABOi LDKT should be based on a comparison of the alternative: waiting for future ABOc LDKTs (eg, through kidney paired exchange) or for a deceased donor kidney transplant (DDKT). We sought to evaluate the patient survival difference between ABOi LDKTs and waiting for an ABOc LDKT or an ABOc DDKT.

Study Design: Retrospective cohort study of adults in the Scientific Registry of Transplant Recipients.

Setting & Participants: 808 ABOi LDKT recipients and 2,423 matched controls from among 245,158 adult first-time kidney-only waitlist registrants who did not receive an ABOi LDKT and who remained on the waitlist or received either an ABOc LDKT or an ABOc DDKT, 2002 to 2017.

Exposure: Receipt of ABOi LDKT.

Outcome: Death.

Analytical Approach: We compared mortality among ABOi LDKT recipients versus a weighted matched comparison population using Cox proportional hazards regression and Cox models that accommodated for changing hazard ratios over time.

Results: Compared with matched controls, ABOi LDKT was associated with greater mortality risk in the first 30 days posttransplantation (cumulative survival of 99.0% vs 99.6%) but lower mortality risk beyond 180 days posttransplantation. Patients who received an ABOi LDKT had higher cumulative survival at 5 and 10 years (90.0% and 75.4%, respectively) than similar patients who remained on the waitlist or received an ABOc LDKT or ABOc DDKT (81.9% and 68.4%, respectively).

Limitations: No measurement of ABO antibody titers in recipients; eligibility of participants for kidney paired donation is unknown.

Conclusions: Transplant candidates who receive an ABOi LDKT and survive more than 180 days posttransplantation experience a long-term survival benefit compared to remaining on the waitlist to potentially receive an ABOc kidney transplant.
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http://dx.doi.org/10.1053/j.ajkd.2020.03.029DOI Listing
November 2020

Evaluating multiple living kidney donor candidates simultaneously is more cost-effective than sequentially.

Kidney Int 2020 12 30;98(6):1578-1588. Epub 2020 Jun 30.

Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada; Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada. Electronic address:

When multiple living donor candidates come forward to donate a kidney to the same recipient, some living donor programs evaluate one candidate at a time to avoid unnecessary evaluations. Evaluating multiple candidates concurrently rather than sequentially may be cost-effective from a societal perspective if it reduces the time recipients spend on dialysis. We used a simple decision tree to estimate the cost-effectiveness of evaluating two to four candidates simultaneously rather than sequentially as potential kidney donors for the same intended recipient. Evaluating two donor candidates simultaneously cost $1,266 (CAD) more than if they were evaluated sequentially, but living donation occurred one month earlier. This translated into $6,931 in averted dialysis costs and a total cost-savings of $5,665 per intended recipient. Simultaneous evaluations also resulted in one percent more living donor transplants and overall gains in quality-of-life as recipients spent less time on dialysis. If recipients were free from dialysis at the start of donor candidate evaluations, simultaneous evaluations also reduced the rate of dialysis initiation by two percent. Benefits were also observed in the three- and four-candidate scenarios. Thus, living donor programs should consider evaluating up to four living donor candidates simultaneously when they come forward for the same recipient as health care system costs incurred are more than offset by avoided dialysis costs.
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http://dx.doi.org/10.1016/j.kint.2020.06.015DOI Listing
December 2020