Publications by authors named "Olusegun Famure"

37 Publications

Cumulative Deficits Frailty Index Predicts Outcomes for Solid Organ Transplant Candidates.

Transplant Direct 2021 Mar 22;7(3):e677. Epub 2021 Feb 22.

Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

Despite comprehensive multidisciplinary candidacy assessments to determine appropriateness for solid organ transplantation, limitations persist in identifying candidates at risk of adverse outcomes. Frailty measures may help inform candidacy evaluation. Our main objective was to create a solid organ transplant frailty index (FI), using the cumulative deficits model, from data routinely collected during candidacy assessments. Secondary objectives included creating a social vulnerability index (SVI) from assessment data and evaluating associations between the FI and assessment, waitlist, and posttransplant outcomes.

Methods: In this retrospective cohort study of solid organ transplant candidates from Toronto General Hospital, cumulative deficits FI and SVI were created from data collected during candidacy evaluations for consecutive kidney, heart, liver, and lung transplant candidates. Regression modeling measured associations between the FI and transplant listing, death or removal from the transplant waitlist, and survival after waitlist placement.

Results: For 794 patients, 40 variable FI and 10 variable SVI were created (258 lung, 222 kidney, 201 liver, and 113 heart transplant candidates). The FI correlated with assessment outcomes; patients with medical contraindications (mean FI 0.35 ± 0.10) had higher FI scores than those listed (0.29 ± 0.09), < 0.001. For listed patients, adjusted for age, sex, transplant type, and SVI, higher FI was associated with an increased risk of death (pretransplant or posttransplant) or delisting (hazard ratio 1.03 per 0.01 FI score, 95% confidence interval, 1.01-1.05, = 0.01).

Conclusions: A cumulative deficits FI can be derived from routine organ transplant candidacy evaluations and may identify candidates at higher risk of adverse outcomes.
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http://dx.doi.org/10.1097/TXD.0000000000001094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183975PMC
March 2021

Vitamin D Levels and the Risk of Posttransplant Diabetes Mellitus After Kidney Transplantation.

Prog Transplant 2021 Jun 1;31(2):133-141. Epub 2021 Apr 1.

Division of Nephrology and the Kidney Transplant Program, 7989University Health Network, Toronto, Ontario, Canada.

Introduction: Given the burden of posttransplant diabetes mellitus and the high prevalence of low vitamin D levels in kidney transplant recipients, it is reasonable to consider vitamin D as a novel and potentially modifiable risk factor in this patient population.

Research Question: To determine the association between 25- hydroxyvitamin D (25(OH)D) level and posttransplant diabetes among kidney transplant recipients. Design: In a multi-center cohort study of 442 patients who received a kidney transplant between January 1, 2005 and December 31, 2010, serum samples within one-year before transplant were analyzed for 25(OH)D levels. The association between 25(OH)D and posttransplant diabetes were examined in Cox proportional hazard models.

Results: The median 25(OH)D level was 66 nmol/L. The cumulative probability of diabetes at 12-months by quartiles of 25(OH)D (< 42, 42 to 64.9, 65 to 94.9, and > 95 nmol/L) were 23.4%, 26.9%, 21.4%, and 15.6%, respectively. Compared to the highest 25(OH)D quartile, hazard ratios (95% CI) for the risk were 1.85 (1.03, 3.32), 2.01 (1.12, 3.60), 1.77 (0.96, 3.25) across the first to third quartiles, respectively. The associations were accentuated in a model restricted to patients on tacrolimus. When modeled as a continuous variable, 25(OH)D levels were significantly associated with a higher risk of diabetes (hazard ratio 1.06, 95% CI: 1.01, 1.13 per 10 nmol/L decrease).

Discussion: Serum 25(OH)D was an independent predictor of posttransplant diabetes in kidney transplant recipients. These results may inform the design of trials using vitamin D to reduce the risk in kidney transplant recipients.
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http://dx.doi.org/10.1177/15269248211002796DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182337PMC
June 2021

What Are the Burden, Causes, and Costs of Early Hospital Readmissions After Kidney Transplantation?

Prog Transplant 2021 Jun 24;31(2):160-167. Epub 2021 Mar 24.

Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Introduction: Kidney transplant recipients are at risk for complications resulting in early hospital readmission. This study sought to determine the incidences, risk factors, causes, and financial costs of early readmissions.

Design: This single-centre cohort study included 1461 kidney recipients from 1 Jul 2004 to 31 Dec 2012, with at least 1-year follow-up. Early readmission was defined as hospitalization within 30 or 90-days postdischarge from transplant admission. Associations between various parameters and 30 and 90-days posttransplant were determined using multivariable Cox proportional hazards models. The hospital-associated costs of were assessed.

Results: The rates of early readmission were 19.4% at 30 days and 26.8% at 90 days posttransplant. Mean cost per 30-day readmission was 11 606 CAD. Infectious complications were the most common reasons and resulted in the greatest cost burden. Factors associated with 30 and 90-days in multivariable models were recipient history of chronic lung disease (hazard ratio or HR 1.78 [95%CI: 1.14, 2.76] and HR 1.68 [1.14, 2.48], respectively), median time on dialysis (HR 1.07 [95% CI: 1.01, 1.13]and HR 1.06 [95% CI: 1.01, 1.11], respectively), being transplanted preemptively (HR 1.75 [95% CI: 1.07, 2.88] and HR 1.66 [95% CI: 1.07, 2.57], respectively), and having a transplant hospitalization lasting of and more than 11 days (HR 1.52 [95% CI: 1.01, 2.27] and HR 1.65 [95% CI: 1.16, 2.34], respectively).

Discussion: Early hospital readmission after transplantation was common and costly. Strategies to reduce the burden of early hospital readmissions are needed for all patients.
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http://dx.doi.org/10.1177/15269248211003563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182333PMC
June 2021

Ureteral strictures post-kidney transplantation: Trends, impact on patient outcomes, and clinical management.

Can Urol Assoc J 2021 Mar 18. Epub 2021 Mar 18.

Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada.

Introduction: Ureteral strictures post-kidney transplantation (KT) can be a significant morbidity to the patient, often requiring surgical intervention and impacting graft function. We sought to investigate the incidence, clinical management, and outcomes of ureteral strictures among kidney transplant recipients (KTRs) at a large, multi-organ transplant center.

Methods: We conducted a single-center cohort study looking at KTRs who had transplant surgery from January 1, 2005 to March 31, 2017 with at least one-year followup (n=1742). Any KTRs done outside of our center or simultaneous multiorgan transplants were excluded. The Kaplan-Meier product-limit method was used to determine the incidence of ureteral strictures. Risk factors for ureteric strictures and clinical outcomes among patients with vs. without ureteric strictures were analyzed using Cox proportional hazards models.

Results: The incidence of ureteral strictures was 1.31 (95% confidence interval [CI] 0.85, 2.01) per 100 person-years or a cumulative incidence of 1.2%. We did not find any donor or recipient demographic variables that were independently associated with an increased risk of ureteral stricture development. A large proportion was managed successfully with radiologic intervention alone (47.6%). Ureteral strictures were associated with death-censored graft failure (hazard ratio [HR] 7.17, 95% CI 2.81, 18.30), total graft failure (HR 3.04, 95% CI 1.41, 6.59), and hospital readmission (HR 2.52, 95% CI 1.58, 4.00).

Conclusions: Although uncommon, ureteral strictures can significantly impact patient outcomes after KT. A better understanding of risk factors and clinical management will be important to ensure optimal graft outcomes.
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http://dx.doi.org/10.5489/cuaj.7003DOI Listing
March 2021

Early postoperative acute myocardial infarction in kidney transplant recipients: A nested case-control study.

Clin Transplant 2021 05 23;35(5):e14283. Epub 2021 Mar 23.

Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada.

Introduction: The epidemiology of early acute myocardial infarctions after kidney transplantation has not been well characterized. This study sought to examine the incidence, risk factors, and clinical outcomes of early acute myocardial infarctions or EAMI in kidney transplant recipients.

Methods: A total of 1976 patients who underwent kidney transplantation at our center from Jan 1, 2000, to Sept 30, 2016, were included. A nested case-control design was used to study EAMI risk factors using a conditional logistic regression model. A Cox proportional hazards model was used to assess the association of EAMI with death-censored graft failure, death with graft function, and total graft failure.

Results: Seventy four patients had an EAMI within 3 months post-transplant. Based on univariable analyses, risk factors for EAMI included age and recipient history of diabetes mellitus or coronary artery disease. After adjustment, recipient history of coronary artery disease was the only independent predictor for EAMI (OR 3.76, p < .001). Patients who experienced EAMI were more likely to experience death-censored graft failure, death with graft function, and total graft failure.

Conclusion: While the incidence of EAMI in kidney transplant recipients is relatively low, these data show that EAMI has profound long-term effects on morbidity and mortality.
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http://dx.doi.org/10.1111/ctr.14283DOI Listing
May 2021

Engaging high school students about organ donation and transplantation: an evaluation of the High School Outreach Initiative (HSOI) program.

Pediatr Transplant 2021 Jun 18;25(4):e13981. Epub 2021 Feb 18.

Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.

Adolescents can be influential in changing societal perceptions of organ donation and transplantation (ODT) but current studies on youth are limited. We sought to (1) assess the baseline knowledge in ODT among students in Toronto, Canada, and (2) evaluate the effectiveness of the High School Outreach Initiative (HSOI) program presentations in changing awareness and interest about ODT. Pre- and post-presentation surveys were administered to high school students about their knowledge of ODT, awareness of donor registration, importance of donation, intent to register, and willingness to talk to their families about donation. Descriptive statistics were used to characterize the students' baseline knowledge and interest. Wilcoxon and McNemar tests were used to analyze changes in perceptions before and after the presentation. A total of 449 HSOI presentations were delivered to 33,090 students at 102 high schools in the Greater Toronto Area between 2012 and 2019. Data from 3327 surveys completed by students before a presentation showed 46.5% were not knowledgeable about ODT. For the 2-year period between 2017 and 2019, 1224 matched pre- and post-presentation surveys were collected. The 49.8% of students who stated they were not knowledgeable about ODT prior to the presentation decreased to 3.8% after (p < 0.001). Those who were not willing to register decreased by half after the presentation (p < 0.001). The HSOI is an effective educational program in improving youth's attitudes and perceptions toward ODT. Further directions of the program include the expansion to other cities and the collection of demographic information of students.
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http://dx.doi.org/10.1111/petr.13981DOI Listing
June 2021

Evaluation of a professional development course on research methods for healthcare professionals.

Healthc Manage Forum 2021 May 8;34(3):186-192. Epub 2020 Oct 8.

Kidney Transplant Program, 33540Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

Healthcare is constantly evolving and thus requires lifelong learning. Evidence-based learning has been shown to lead to better patient outcomes, yet many healthcare professionals report gaps in their research abilities. We sought to evaluate the efficacy of a professional development program in addressing identified gaps.
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http://dx.doi.org/10.1177/0840470420960173DOI Listing
May 2021

Extracellular Matrix Injury of Kidney Allografts in Antibody-Mediated Rejection: A Proteomics Study.

J Am Soc Nephrol 2020 11 8;31(11):2705-2724. Epub 2020 Sep 8.

Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada

Background: Antibody-mediated rejection (AMR) accounts for >50% of kidney allograft loss. Donor-specific antibodies (DSA) against HLA and non-HLA antigens in the glomeruli and the tubulointerstitium cause AMR while inflammatory cytokines such as TNF trigger graft injury. The mechanisms governing cell-specific injury in AMR remain unclear.

Methods: Unbiased proteomic analysis of laser-captured and microdissected glomeruli and tubulointerstitium was performed on 30 for-cause kidney biopsy specimens with early AMR, acute cellular rejection (ACR), or acute tubular necrosis (ATN).

Results: A total of 107 of 2026 glomerular and 112 of 2399 tubulointerstitial proteins was significantly differentially expressed in AMR versus ACR; 112 of 2026 glomerular and 181 of 2399 tubulointerstitial proteins were significantly dysregulated in AMR versus ATN (<0.05). Basement membrane and extracellular matrix (ECM) proteins were significantly decreased in both AMR compartments. Glomerular and tubulointerstitial laminin subunit -1 (LAMC1) expression decreased in AMR, as did glomerular nephrin (NPHS1) and receptor-type tyrosine-phosphatase O (PTPRO). The proteomic analysis revealed upregulated galectin-1, which is an immunomodulatory protein linked to the ECM, in AMR glomeruli. Anti-HLA class I antibodies significantly increased cathepsin-V (CTSV) expression and galectin-1 expression and secretion in human glomerular endothelial cells. CTSV had been predicted to cleave ECM proteins in the AMR glomeruli. Glutathione S-transferase -1, an ECM-modifying enzyme, was significantly increased in the AMR tubulointerstitium and in TNF-treated proximal tubular epithelial cells.

Conclusions: Basement membranes are often remodeled in chronic AMR. Proteomic analysis performed on laser-captured and microdissected glomeruli and tubulointerstitium identified early ECM remodeling, which may represent a new therapeutic opportunity.
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http://dx.doi.org/10.1681/ASN.2020030286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608967PMC
November 2020

A Gap Analysis Assessing the Perceptions of Primary Care Physicians in the Management of Kidney Recipients After Transplantation.

Prog Transplant 2019 12 11;29(4):309-315. Epub 2019 Sep 11.

Division of Nephrology and the Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada.

Objectives: To examine the practice patterns and perceptions of primary care physicians in the management of chronic diseases in kidney recipients, assess care provided to recipients, and identify barriers to the optimal delivery of primary care to recipients.

Methods: A self-administered questionnaire on the primary care of kidney recipients was developed and implemented. The survey investigated physician comfort and practice patterns in providing preventive and chronic care to recipients, patient self-management support, and physician perceptions on communication with transplant centers and barriers to ideal care.

Results: A total of 210 physicians completed the survey (response rate of 22%). Among the respondents, 73% indicated they were currently providing care to kidney recipients. The majority of physicians specified that they rarely (57%) or never (20%) communicate with transplant centers. Most physicians felt comfortable providing care to recipients for non-transplant-related issues (92.5%), vaccinations (85%), and periodic health examinations (94%). The majority (75.3%) of physicians felt uncomfortable managing the immunosuppressive medications of recipients. Physicians' most commonly stated barriers to delivering optimal care to recipients were insufficient guidelines provided by the transplant center (68.9%) and lack of knowledge in managing recipients (58.8%). Suggested resources by physicians to improve their comfort level in managing recipients included guidelines and continuing medical educational activities related to transplantation.

Conclusions: Our results suggest that there are barriers to delivering optimal primary care to kidney recipients. The approach to providing resources needed to bridge the knowledge gap for physicians in the management of recipients requires further exploration.
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http://dx.doi.org/10.1177/1526924819873911DOI Listing
December 2019

Ethnic background is associated with no live kidney donor identified at the time of first transplant assessment-an opportunity missed? A single-center retrospective cohort study.

Transpl Int 2019 Oct 12;32(10):1030-1043. Epub 2019 Jul 12.

Division of Nephrology, Multi-Organ Transplant Program, University Health Network and University of Toronto, Toronto, ON, Canada.

Patients from ethnocultural minorities have reduced access to live donor kidney transplant (LDKT). To explore early pretransplant ethnocultural disparities in LDKT readiness, and the impact of the interactions with the transplant program, we assessed if patients had a potential live donor (LD) identified at first pretransplant assessment, and if patients with no LD initially received LDKT subsequently. Single-center, retrospective cohort of adults referred for kidney transplant (KT) assessment. Multivariable logistic regression assessed the association between ethnicity and having a potential LD. Cox proportional hazard analysis assessed the association between no potential LD initially and subsequent LDKT. Of 1617 participants, 66% of Caucasians indicated having a potential LD, compared with 55% of South Asians, 44% of African Canadians, and 41% of East Asians (P < 0.001). In multivariable logistic regression analysis, the odds of having a potential LD identified was significantly lower for African, East and South Asian Canadians. No potential LD at initial KT assessment was associated with lower likelihood of LDKT subsequently (hazard ratio [HR], 0.14; [0.10-0.19]). Compared to Caucasians, African, East and South Asian and African Canadians are less likely to have a potential LD identified at first KT assessment, which predicts a lower likelihood of subsequent LDKT.
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http://dx.doi.org/10.1111/tri.13476DOI Listing
October 2019

Standardization and alignment of data capture practices to clinical processes in the evaluation of living kidney donor candidates.

Healthc Manage Forum 2019 Jul 15;32(4):202-207. Epub 2019 May 15.

1 Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

The Living Kidney Donation Program at the Toronto General Hospital, University Health Network sought to develop a comprehensive, secure, accurate, and up-to-date information system for the purposes of quality improvement, research, and performance evaluation. The Comprehensive Living Kidney Donor Database (CLiKeD) houses comprehensive demographic, medical, psychosocial, and evaluation data on living kidney donor candidates abstracted from multiple health information sources. Data are routinely audited to ensure high data quality. Over 3,500 living kidney donor candidates are currently included in CLiKeD. The development of this data system will allow for regular performance assessments of the program, implementation of quality improvement initiatives, and the completion of high-impact, clinically relevant research. In addition, the conception and development of CLiKeD has been instrumental in improving documentation of personal health information at the point of care.
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http://dx.doi.org/10.1177/0840470419843672DOI Listing
July 2019

Substance use in kidney transplant candidates and its impact on access to kidney transplantation.

Clin Transplant 2019 06 7;33(6):e13565. Epub 2019 May 7.

Division of Nephrology, Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Background: Due to the increasing public acceptance of substance use, it is important to understand the association between substance use and access to kidney transplant and its outcomes. Here, we assess the sociodemographic predictors of substance use and the association between substance use and KT access.

Methods: Predictors of substance use were examined using a multivariable-adjusted multinomial logistic regression. The association between current substance use (tobacco and drug) and time from referral to listing or receipt of a KT was examined using Cox proportional hazards models.

Results: Of 2346 patients, the prevalence of current substance use was 17%. Predictors of current tobacco use were younger age, male sex, Caucasian ethnicity, being unemployed, and unmarried. Predictors of current drug use were younger age, male sex, Caucasian ethnicity, a history of non-adherence, and a history of mental health disorder. Patients with tobacco use had a decreased likelihood of being cleared for KT (hazard ratio [HR]:0.83[0.70, 0.99]) and receiving a KT (HR:0.80 [0.66, 0.96]). No association was seen in this sample for patients with drug use (HR:0.88 [0.69, 1.11] for being cleared for KT and 0.88 [0.69, 1.14] for KT, respectively).

Conclusions: Tobacco use was associated with a decreased likelihood of access to KT whereas there was no statistically significant difference in access to KT between patients with or without drug use.
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http://dx.doi.org/10.1111/ctr.13565DOI Listing
June 2019

Incidence, Risk Factors, Clinical Management, and Outcomes of Posttransplant Lymphoproliferative Disorder in Kidney Transplant Recipients.

Prog Transplant 2019 06 7;29(2):185-193. Epub 2019 Mar 7.

1 Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.

Background: Posttransplant lymphoproliferative disorder (PTLD) is a severe complication after kidney transplantation. This study examined the incidence, risk factors, clinical management, and outcomes of PTLD in a cohort of kidney transplant recipients.

Design: This single-center cohort study included 1642 patients transplanted from January 1, 2000, to December 31, 2012, with follow-up until December 31, 2013. The incidence and risk factors for PTLD were examined using a Cox proportional hazards model. A Cox model was also used to assess the association of PTLD and graft outcomes.

Results: Sixteen recipients developed PTLD over follow-up. The incidence rate was 0.18 (95% confidence interval [CI]: 0.11-0.29) cases per 100 person-years. Four were from Epstein-Barr virus (EBV) mismatched (D+/R-) transplants and 12 from EBV-positive recipients (R+). Recipients with D+/R- matches were at a significantly higher risk of developing PTLD than R+ (hazard ratio [HR]: 7.52 [95% CI: 2.42-23.32]). Fifteen cases had immunosuppression reduced, 11 cases were supplemented with rituximab or ganciclovir, 6 cases required chemotherapy or radiation, and 6 cases had tumors excised. By the end of follow-up, 6 patients went into remission, 5 returned to chronic dialysis, and 5 patients died. Patients with PTLD were significantly more likely to have total graft failure (return to chronic dialysis, preemptive retransplant, or death with graft function) than patients without PTLD (HR: 3.41 [95% CI: 1.72-6.78).

Discussion: Epstein-Barr virus mismatch continues to be a strong risk factor for developing PTLD after kidney transplantation. Recipients with PTLD have a poor prognosis, as the optimal management remains to be elucidated.
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http://dx.doi.org/10.1177/1526924819835834DOI Listing
June 2019

Bacteremia in kidney transplant recipients: Burden, causes, and consequences.

Clin Transplant 2019 03 8;33(3):e13479. Epub 2019 Feb 8.

Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

Bacteremia is an important complication after kidney transplantation. We examined bacteremia and its outcomes in a large cohort of kidney transplant recipients. Kidney transplants from 1-Jul-2004 to 1-Dec-2014 at the Toronto General Hospital were eligible for study inclusion. Bacteremia was defined as two blood culture positives for common skin contaminants or one blood culture positive for other organisms. The cumulative incidence of first bacteremia was estimated using the Kaplan-Meier method, and risk factors were examined in a Cox proportional hazards model. The risk of graft failure or death was assessed in a time-dependent Cox model. Over follow-up, 154 of 1333 patients had at least one bacteremia episode. The cumulative incidence of first bacteremia was 6.8% (6 months) and 11.9% (5 years). Risk factors included recipient diabetes mellitus, time on dialysis, dialysis modality, delayed graft function, donor age, and donor eGFR. Bacteremia increased the risk of total graft failure (hazard ratio 2.11 [95% CI: 1.50, 2.96]), death-censored graft failure (1.73 [0.99, 3.02]), and death with graft function (2.52 [1.63, 3.89]). In conclusion, bacteremia is common after kidney transplantation and impacts both graft and patient survival. Identifying high-risk patients for targeted preventive strategies may reduce the burden and adverse consequences of this important complication.
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http://dx.doi.org/10.1111/ctr.13479DOI Listing
March 2019

Donor kidney volume measured by computed tomography is a strong predictor of recipient eGFR in living donor kidney transplantation.

World J Urol 2019 Sep 6;37(9):1965-1972. Epub 2018 Dec 6.

Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada.

Purpose: The effect of living donor kidney allograft size on recipient outcomes is not well understood. In this study, we sought to investigate the relationship between preoperatively measured donor kidney volume and recipient estimated glomerular filtration rate (eGFR) in living donor kidney transplantation (LDKT).

Methods: We studied computed tomography (CT) donor kidney volumes and recipient outcomes for 438 LDKTs at the Toronto General Hospital between 2007 and 2016. Estimated glomerular filtration rate (eGFR) was calculated at 1, 3, and 6 months and a multivariable linear regression model was fitted to study the effect of donor kidney volume on recipient eGFR.

Results: The mean volume and weight of the donated kidneys were 157.3 (± 32.3) cc and 186.7 (± 48.7) g, respectively. Kidney volume was significantly associated with eGFR on multivariable analysis (P < 0.001). Specifically, for every 10 cc increase in kidney volume, there was a 1.68 mL/min, 1.25 mL/min and 0.97 mL/min rise in recipient eGFR at 1, 3, and 6 months, respectively.

Conclusions: Donor kidney volume is a strong independent predictor of recipient eGFR in LDKT, and therefore, may be a valuable addition to predictive models of eGFR after transplant. Further research may determine if the inclusion of donor kidney volume in matching algorithms can improve recipient outcomes.
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http://dx.doi.org/10.1007/s00345-018-2595-xDOI Listing
September 2019

A Longitudinal Study Examining the Change in Functional Independence Over Time in Elderly Individuals With a Functioning Kidney Transplant.

Can J Kidney Health Dis 2018 1;5:2054358118775099. Epub 2018 Jun 1.

Division of Nephrology, University Health Network, Toronto, Ontario, Canada.

Background: Functional disability is defined as the need for assistance with self-care tasks.

Objective: To document changes in functional status over time among older prevalent renal transplant recipients.

Design: Single center, prospective, follow-up study.

Setting: Single center, tertiary care transplant center.

Patients: Patients, with a functioning kidney transplant, aged 65 years or older who underwent assessment of functional status approximately 12 months previously.

Measurements: Validated tools used included Barthel Index, the Lawton-Brody Scale of Instrumental Activities of Daily Living, the Timed Up and Go test, the Veterans Specific Activity Questionnaire, the Mini-Cog, and dynamometer handgrip strength.

Methods: Outpatient assessment by a trained observer.

Results: Of the 82 patients previously studied, 64 (78%) patients participated in the follow-up study (mean age 70.5 ± 4.4 years, 58% male, 55% diabetic). Among those completing functional status measures, 32 (50%) had functional disability at baseline. Over the 1-year period, 11 (17%) of these patients experienced progressive functional decline, 6 (9%) exhibited no change, and 15 (23%) had functional recovery. Eleven patients (17%) initially independent, developed new-onset disability. One of the strongest predictors of progressive functional decline was having 1 or more falls in the previous year.

Limitations: Assessments were performed only on 2 occasions separated by approximately 1 year.

Conclusions: Fluctuations in disability states are common among older adults living with renal transplants. Episodes of functional disability may place individuals at higher risk of persistent and/or progressive disability.
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http://dx.doi.org/10.1177/2054358118775099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5985553PMC
June 2018

Incidence, Risk Factors, and Outcomes of Clostridium difficile Infections in Kidney Transplant Recipients.

Transplantation 2018 09;102(9):1576-1581

Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

Background: Kidney transplant recipients (KTR) may be at increased risk for Clostridium difficile infections (CDI) but risk factors and outcomes in this population have not been well studied.

Methods: An observational cohort study was conducted to determine the incidence, risk factors, and outcomes of CDI in KTR. A total of 1816 KTR transplanted between 2000 and 2013 at the Toronto General Hospital were included. Sixty-eight patients developed CDI. Controls were selected at a 4:1 ratio using risk-set sampling, and risk factors were explored using conditional logistic regression models. The impact of CDI on graft outcomes was evaluated using Cox proportional hazards models.

Results: The incidence rate of CDI was 0.64 cases/100 person-years. Independent predictors of CDI included antibiotic use (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.35-6.15), increased duration of hospitalization posttransplant (OR, 1.04; 95% CI, 1.02-1.06]), receiving a deceased donor kidney (OR, 2.98; 95% CI, 1.47-6.05), and a history of biopsy-proven acute rejection (OR, 5.82; 95% CI, 2.22-15.26). In the Cox proportional hazards model, CDI was found to be an independent risk factor for the subsequent development of biopsy-proven acute rejection (hazard ratio, 2.18; 95% CI, 1.34-3.55).

Conclusions: Our results confirm that transplant-specific factors place KTR at a higher risk for CDI. Clostridium difficile infections may increase the risk of adverse outcomes, such as biopsy-proven acute rejection. These findings emphasize the importance of preventive strategies to reduce the morbidity associated with CDI in KTR.
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http://dx.doi.org/10.1097/TP.0000000000002199DOI Listing
September 2018

Incidence and Risk Factors for Leukopenia in Kidney Transplant Recipients Receiving Valganciclovir for Cytomegalovirus Prophylaxis.

Prog Transplant 2018 06 20;28(2):124-133. Epub 2018 Mar 20.

1 Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

Context: Valganciclovir is used not only for cytomegalovirus prophylaxis after kidney transplantation but can also induce leukopenia, thereby making patients more susceptible to other infections. The epidemiology of leukopenia in patients on valganciclovir remains poorly understood.

Objective: To determine the incidence and risk factors for leukopenia in patients receiving valganciclovir for cytomegalovirus prophylaxis after kidney transplantation.

Methods: In this single-center, retrospective, cohort study, we included kidney recipients transplanted from January 1, 2003, to December 31, 2010, to determine the incidence and risk factors for leukopenia in patients who received valganciclovir for cytomegalovirus prophylaxis. The Kaplan-Meier product limit method was used to graphically assess time to leukopenia, and risk factors were assessed using Cox proportional hazards models.

Results: A total of 542 kidney transplant recipients were included in the study cohort. The cumulative incidence of leukopenia at 6 months posttransplant was 39.3% (11.0% for neutropenia). Low baseline white blood cell count (hazard ratio [HR] 2.34 [95% confidence interval [CI], 1.37-4.00]) and high baseline body mass index (HR 1.05 [95% CI, 1.02-1.09]) were independently associated with an increased risk of leukopenia, while higher Cockcroft-Gault creatinine clearance (HR 0.87 [95% CI, 0.78-0.97]) was significantly associated with a decreased risk of leukopenia.

Conclusions: These data suggest that recipient baseline white blood cell count, baseline body mass index, and kidney function are clinical predictors of new-onset leukopenia after kidney transplantation. Our results may inform the approach to cytomegalovirus prophylaxis to reduce the risk of valganciclovir-induced leukopenia in kidney transplant recipients.
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http://dx.doi.org/10.1177/1526924818765798DOI Listing
June 2018

Pre-transplant history of mental health concerns, non-adherence, and post-transplant outcomes in kidney transplant recipients.

J Psychosom Res 2018 02 28;105:115-124. Epub 2017 Dec 28.

Division of Nephrology, Multi-Organ Transplant Program, University Health Network and University of Toronto, Toronto, Canada. Electronic address:

Objective: The association between pre-transplant mental health concerns and non-adherence and post-transplant outcomes after kidney transplantation is not fully established. We examined the relationship between a pre-transplant history of mental health concerns and non-adherence and post-transplant outcomes among kidney transplant recipients.

Methods: In this retrospective single center cohort study of adult kidney transplant recipients (n=955) the associations between the history of mental health concerns or non-adherence and the time from kidney transplant to biopsy proven acute rejection; death-censored graft failure and total graft failure were examined using Cox proportional hazards models.

Results: Mean (SD) age was 51 (13) years, 61% were male and 27% had a history of diabetes. Twenty-two and 11% of patients had mental health concerns and non-adherence, respectively. Fifteen percent of the patients had acute rejection, 5.6% had death-censored graft failure and 13.0% had total graft failure. The history of mental health concerns was not associated with acute rejection, death-censored graft failure or total graft failure. Patients with versus without a history of non-adherence tended to have higher cumulative incidence of acute rejection (23.3% [95% CI: 16.1, 33.2] vs. 13.6% [95% CI: 11.4, 16.2]) and death-censored graft failure (15.0% [95% CI: 6.9, 30.8] vs. 6.4% [95% CI: 4.7, 8.7]) (log rank p=0.052 and p=0.086, respectively). These trends were not significant after multivariable adjustment.

Conclusion: In summary, a history of pre-transplant mental health concerns or non-adherence is not associated with adverse outcomes in patients who completed transplant workup and received a kidney transplant.
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http://dx.doi.org/10.1016/j.jpsychores.2017.12.013DOI Listing
February 2018

Ethnic Background Is a Potential Barrier to Living Donor Kidney Transplantation in Canada: A Single-Center Retrospective Cohort Study.

Transplantation 2017 04;101(4):e142-e151

1 Division of Nephrology, Multi-Organ Transplant Program, University Health Network and University of Toronto, Toronto, Canada. 2 Division of Nephrology, David Geffen School of Medicine at the University of California, Los Angeles, CA. 3 Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto Toronto, Ontario, Canada. 4 Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary. 5 Institute of Health Policy, Management and Evaluation, University of Toronto Toronto, Ontario, Canada.

Background: We examined if African or Asian ethnicity was associated with lower access to kidney transplantation (KT) in a Canadian setting.

Methods: Patients referred for KT to the Toronto General Hospital from January 1, 2003, to December 31, 2012, who completed social work assessment, were included (n = 1769). The association between ethnicity and the time from referral to completion of KT evaluation or receipt of a KT were examined using Cox proportional hazards models.

Results: About 54% of the sample was white, 13% African, 11% East Asian, and 11% South Asian; 7% had "other" (n = 121) ethnic background. African Canadians (hazard ratio [HR], 0.75; 95% CI: 0.62-0.92]) and patients with "other" ethnicity (HR, 0.71; 95% CI, 0.55-0.92) were less likely to complete the KT evaluation compared with white Canadians, and this association remained statistically significant in multivariable adjusted models. Access to KT was significantly reduced for all ethnic groups assessed compared with white Canadians, and this was primarily driven by differences in access to living donor KT. The adjusted HRs for living donor KT were 0.35 (95% CI, 0.24-0.51), 0.27 (95% CI, 0.17-0.41), 0.43 (95% CI, 0.30-0.61), and 0.34 (95% CI, 0.20-0.56) for African, East or South Asian Canadians and for patients with "other" ethnic background, respectively.

Conclusions: Similar to other jurisdictions, nonwhite patients face barriers to accessing KT in Canada. This inequity is very substantial for living donor KT. Further research is needed to identify if these inequities are due to potentially modifiable barriers.
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http://dx.doi.org/10.1097/TP.0000000000001658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228577PMC
April 2017

Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes.

Transpl Int 2017 May 2;30(5):474-483. Epub 2017 Mar 2.

Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada.

Studies investigating the incidence, risk factors, and outcomes of surgical-site hemorrhage after kidney transplantation are limited. Patients who underwent a kidney transplant from 1 January 2000 to 30 September 2012 (followed until 31 December 2012) at Toronto General Hospital were included in this study. Postoperative surgical-site hemorrhage was defined as a drop in hemoglobin ≥20 g/l over a 24-hour period within 3 days of transplantation, followed by an ultrasound indicating a significant hematoma/collection. A total of 59 of 1203 (4.9%) kidney transplant recipients had postoperative surgical-site hemorrhage. Most cases (89.8%) occurred within 1 day after transplantation. Living donor transplants [OR 0.30 (95% CI: 0.16, 0.55)] and higher recipient BMI [OR 0.54 per 10 kg/m increase in BMI (95% CI: 0.30, 0.99)] were associated with a significantly lower risk of bleeding. Chronic preoperative anticoagulant usage led to an increased risk of bleeding but was not statistically significant [OR 1.75 (95% CI: 0.52, 5.88)]. Postoperative hemorrhage was associated with a higher risk of graft loss or death [HR 1.62 (95% CI: 1.01, 2.60)]. While the incidence of postoperative surgical-site hemorrhage in kidney transplantation is relatively low, it may be associated with an increased risk of graft loss or death.
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http://dx.doi.org/10.1111/tri.12926DOI Listing
May 2017

Mental Health and Behavioral Barriers in Access to Kidney Transplantation: A Canadian Cohort Study.

Transplantation 2017 06;101(6):1182-1190

1 Division of Nephrology, Multi-Organ Transplant Program, University Health Network and University of Toronto, Toronto, Canada. 2 Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Canada. 3 Institute of Behavioural Sciences, Semmelweis University Budapest, Hungary. 4 Institute of Health Policy, Management and Evaluation, University of Toronto.

Background: A history of mental health (MH) disorders or nonadherence (NA) may be barriers to completing the work-up (WU) and/or undergoing kidney transplantation (KT) but this has not been well documented. In this work, we analyzed the relationship between a history of MH disorders or NA and the likelihood of completing the WU or undergoing KT.

Methods: Patients referred for KT to the Toronto General Hospital from January 1, 2003, to December 31, 2012, and who completed a social work assessment, were included (n = 1769). The association between the history of MH disorders or NA and the time from referral to WU completion or KT were examined using Cox proportional hazards models.

Results: A history of MH disorders or NA was present in 24% and 18%, respectively. Patients with MH disorders had a 17% lower adjusted hazard of completing the WU within 2 years of referral (HR 0.83; 95% confidence interval [95% CI], 0.71-0.97). Similarly, patients with a history of NA had a 21% lower hazard of completing the WU (hazard ratio [HR], 0.79; 95% CI, 0.66-0.94). The adjusted HR for KT was 0.88 (95% CI, 0.74-1.05) and 0.79 (95% CI, 0.64-0.97) for MH disorders and NA, respectively.

Conclusions: These findings suggest that a history of MH disorders or NA is a potential barrier to KT. Whether targeted psychosocial support can improve access to KT for these patients requires further study.
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http://dx.doi.org/10.1097/TP.0000000000001362DOI Listing
June 2017

CT volumetry is superior to nuclear renography for prediction of residual kidney function in living donors.

Clin Transplant 2016 09 11;30(9):1028-35. Epub 2016 Jul 11.

Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, Canada.

Living kidney donor evaluation commonly includes nuclear renography to assess split kidney function and computed tomography (CT) scan to evaluate anatomy. To streamline donor workup and minimize exposure to radioisotopes, we sought to assess the feasibility of using proportional kidney volume from CT volumetry in lieu of nuclear renography. We examined the correlation between techniques and assessed their ability to predict residual postoperative kidney function following live donor nephrectomy. In a cohort of 224 live kidney donors, we compared proportional kidney volume derived by CT volumetry with split kidney function derived from nuclear renography and found only modest correlation (left kidney R(2) =26.2%, right kidney R(2) =26.7%). In a subset of 88 live kidney donors with serum creatinine measured 6 months postoperatively, we compared observed estimated glomerular filtration rate (eGFR) at 6 months with predicted eGFR from preoperative imaging. Compared to nuclear renography, CT volumetry more closely approximated actual observed postoperative eGFR for Chronic Kidney Disease Epidemiology Collaboration (J-test: P=.02, Cox-Pesaran test: P=.01) and Mayo formulas (J-test: P=.004, Cox-Pesaran test: P<.001). These observations support the use of CT volumetry for estimation of split kidney function in healthy individuals with normal kidney function and morphology.
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http://dx.doi.org/10.1111/ctr.12784DOI Listing
September 2016

Engaging health care providers to improve the referral and evaluation processes for potential transplant candidates--The Toronto General Hospital Experience.

CANNT J 2016 Jan-Mar;26(1):12-6

The Kidney Transplant Program (KTP) at the Toronto General Hospital has taken great strides in preparing to meet the needs of patients and health care providers, as the number of end-stage renal disease patients in Ontario increases. The KTP has begun the process of increasing engagement and collaboration with various stakeholders from the pre- to the post-transplant phase through (1) the development of innovative programs to increase the number of live kidney donations, (2) the development and maintenance of information technology solutions that work simultaneously to provide data to manage and treat patients, and conduct research, and (3) the development, implementation, and delivery of educational presentations and tools to various stakeholders both at the referring centres and the transplant program. Future steps for the KTP include evaluating the impact of these programmatic tools and activities on the number of referrals received and the subsequent effect on the number of transplants performed.
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June 2016

Outcomes of Kidney Transplantation Abroad: A Single-Center Canadian Cohort Study.

Prog Transplant 2016 Mar;26(1):5-12

Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Context: An increasing demand for kidney transplantation has enticed some patients with end-stage renal disease (ESRD) to venture outside their country of residence, but their posttransplant outcomes may be suboptimal.

Objective: We compared the risks and clinical outcomes among tourists, or patients who pursue a kidney transplant abroad, versus patients who received a transplant at the Toronto General Hospital (TGH).

Methods: A single-center, 1:3 matched (based on age at transplant, time on dialysis, and year of transplant) cohort study was conducted. Forty-five tourists were matched with 135 domestic transplant recipients between January 1, 2000, and December 31, 2011. Multivariable Cox proportional hazards models were fitted to assess graft and patient outcomes.

Results: Among the 45 tourists, the majority (38 of 45) traveled to the Middle East or Far East Asia, and most received living donor kidney transplants (35 of 45). Multivariable Cox proportional hazards models showed that tourists had a higher risk for the composite outcome of acute rejection, death-censored graft failure, or death with graft function (DWGF; hazard ratio [HR] 2.08, 95% confidence interval [CI]: 1.06-4.07). Tourists also showed a higher risk for the individual end points of acute rejection, DWGF, and posttransplant hospitalizations.

Conclusion: Patients going abroad for kidney transplantation may have inferior outcomes compared to domestic patients receiving kidney transplants. Patients who are contemplating an overseas transplant need to be aware of the increased risk of adverse posttransplant outcomes and should be appropriately counseled by transplant professionals during the pretransplant evaluation process.
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http://dx.doi.org/10.1177/1526924816632133DOI Listing
March 2016

Psychosocial needs assessment post kidney transplant: Feasibility of a post-transplant specific support group.

CANNT J 2015 Jul-Sep;25(3):14-21

This project assessed unmet psychosocial needs of kidney transplant recipients and the feasibility of a support group located at an urban Canadian hospital to meet those needs. A survey assessed transplant recipient concerns about psychosocial issues related to transplantation, interest in a support group, desired group composition, facilitation, leadership, barriers and alternative forms of support. Most respondents were more than two years since transplant and were more concerned about medical complications, returning to normalcy, and had a greater desire to talk to other transplant recipients. Forty per cent of respondents indicated they would be interested in a support group. However, 60% indicated that a support group hosted in the hospital setting would be a deterrent to attending, citing time and transportation as the greatest barriers. More research is needed to assess the feasibility of post-kidney transplant support groups closer to recipients' homes and the feasibility of alternative forms of support.
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April 2016

Hypomagnesemia and the Risk of New-Onset Diabetes Mellitus after Kidney Transplantation.

J Am Soc Nephrol 2016 06 8;27(6):1793-800. Epub 2015 Oct 8.

Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology and the Renal Transplant Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Several studies suggest a link between post-transplant hypomagnesemia and new-onset diabetes after transplantation (NODAT), but this relationship remains controversial. We conducted a retrospective cohort study of 948 nondiabetic kidney transplant recipients from January 1, 2000, to December 31, 2011, to examine the association between serum magnesium level and NODAT. Multivariable Cox proportional hazards models were fitted to evaluate the risk of NODAT as a function of baseline (at 1 month), time-varying (every 3 months), and rolling-average (i.e., mean for 3 months moving at 3-month intervals) serum magnesium levels while adjusting for potential confounders. A total of 182 NODAT events were observed over 2951.2 person-years of follow-up. Multivariable models showed an inverse relationship between baseline serum magnesium level and NODAT (hazard ratio [HR], 1.24 per 0.1 mmol/L decrease; 95% confidence interval [95% CI], 1.05 to 1.46; P=0.01). The association with the risk of NODAT persisted in conventional time-varying (HR, 1.32; 95% CI, 1.14 to 1.52; P<0.001) and rolling-average models (HR, 1.34; 95% CI, 1.13 to 1.57; P=0.001). Hypomagnesemia (serum magnesium <0.74 mmol/L) also significantly associated with increased risk of NODAT in baseline (HR, 1.58; 95% CI, 1.07 to 2.34; P=0.02), time-varying (HR, 1.78; 95% CI, 1.29 to 2.45; P<0.001), and rolling-average models (HR, 1.83; 95% CI, 1.30 to 2.57; P=0.001). Our results suggest that lower post-transplant serum magnesium level is an independent risk factor for NODAT in kidney transplant recipients. Interventions targeting serum magnesium to reduce the risk of NODAT should be evaluated.
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http://dx.doi.org/10.1681/ASN.2015040391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884111PMC
June 2016

Delayed graft function and the risk of acute rejection in the modern era of kidney transplantation.

Kidney Int 2015 Oct 24;88(4):851-8. Epub 2015 Jun 24.

Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Delayed graft function (DGF) is commonly considered a risk factor for acute rejection, although this finding has not been uniformly observed across all studies. The link between DGF and acute rejection may have changed over time due to advances in immunosuppression and medical management. Here we conducted a cohort study of 645 patients over 12 years to evaluate the association of DGF and biopsy-proven acute rejection (BPAR) in a modern cohort of kidney transplant recipients. DGF was defined as the need for at least one dialysis session in the first week after kidney transplantation. The 1-, 3-, and 5-year cumulative probabilities of BPAR were 16.0, 21.8, and 22.6% in the DGF group, significantly different from the 10.1, 12.4, and 15.7% in the non-DGF group. In multivariable Cox proportional hazards model, the adjusted relative hazard for BPAR in DGF (vs. no DGF) was 1.55 (95% confidence interval (CI): 1.03, 2.32). This association was generally robust to different definitions of DGF. The relative hazard was also similarly elevated for T-cell- or antibody-mediated BPAR (1.52 (0.92, 2.51) and 1.54 (0.85, 2.77), respectively). Finally, the association was consistent across clinically relevant subgroups. Thus DGF remains an important risk factor for BPAR in a contemporary cohort of kidney transplant recipients. Interventions to reduce the risk of DGF and/or its aftereffects remain of paramount importance to improve kidney transplant outcomes.
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http://dx.doi.org/10.1038/ki.2015.190DOI Listing
October 2015

A cross-sectional study examining the functional independence of elderly individuals with a functioning kidney transplant.

Transplantation 2014 Oct;98(8):864-70

1 Division of Nephrology, University Health Network, Toronto, Canada. 2 Address correspondence to: Sarbjit V. Jassal, M.D., Geriatric Dialysis Rehabilitation Program, 200 Elizabeth St, 8N 857, Toronto, ON, Canada M5G 2C4.

Background: Cross-sectional studies of patients dependent on dialysis show that they have a high need for help with routine daily activities. In many cases, individuals who undergo kidney transplantation have previously been treated with dialysis for a significant period of time, thus many of the characteristics may be similar. The purpose of this study was to estimate the rate of functional disability in a cross-sectional population of older patients with a functioning kidney transplant.

Methods: Kidney transplant patients, aged 65 years or more, were approached to participate. Patients were interviewed to ascertain current living situation, employment status, and 1-year fall history. Functional assessments included the Barthel Index, the Lawton-Brody Scale, the Timed Up and Go (TUG) test, and dynamometer handgrip strength.

Results: Eighty-two patients (71%) agreed to participate. Over half (54%) reported being disabled or requiring assistance for at least one daily-living activity, with housekeeping, grocery shopping, and laundry being the activities most commonly affected. Most patients had markedly impaired TUG and handgrip tests, and 21% recalled having fallen more than once in the past year.

Limitations: We used a single-center, cross-sectional study design.

Conclusions: These results demonstrate a high prevalence of functional dependence, unintentional falls, and significant morbidity associated with decreased muscle strength in the older kidney transplant population.
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http://dx.doi.org/10.1097/TP.0000000000000126DOI Listing
October 2014

Health information management for research and quality assurance: the Comprehensive Renal Transplant Research Information System.

Healthc Manage Forum 2014 ;27(1):30-6

The Kidney Transplant Program at the Toronto General Hospital uses numerous electronic health record platforms housing patient health information that is often not coded in a systematic manner to facilitate quality assurance and research. To address this, the comprehensive renal transplant research information system was conceived by a multidisciplinary healthcare team. Data analysis from comprehensive renal transplant research information system presented at programmatic retreats, scientific meetings, and peer-reviewed manuscripts contributes to quality improvement and knowledge in kidney transplantation.
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http://dx.doi.org/10.1016/j.hcmf.2013.11.002DOI Listing
October 2014
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