Publications by authors named "Peter P Reese"

179 Publications

Race Adjustment in eGFR Equations Does Not Improve Estimation of Acute Kidney Injury Events in Patients with Cirrhosis.

Dig Dis Sci 2021 Mar 24. Epub 2021 Mar 24.

Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.

Background: Accuracy of glomerular filtration rate estimating (eGFR) equations has significant implications in cirrhosis, potentially guiding simultaneous liver kidney allocation and drug dosing. Most equations adjust for Black race, partially accounted for by reported differences in muscle mass by race. Patients with cirrhosis, however, are prone to sarcopenia which may mitigate such differences. We evaluated the association between baseline eGFR and incident acute kidney injury (AKI) in patients with cirrhosis with and without race adjustment.

Methods: We conducted a retrospective national cohort study of veterans with cirrhosis. Baseline eGFR was calculated using multiple eGFR equations including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), both with and without race adjustment. Poisson regression was used to investigate the association between baseline eGFR and incident AKI events per International Club of Ascites criteria.

Results: We identified 72,267 patients with cirrhosis, who were 97.3% male, 57.8% white, and 19.7% Black. Over median follow-up 2.78 years (interquartile range 1.22-5.16), lower baseline eGFR by CKD-EPI was significantly associated with higher rates of AKI in adjusted models. For all equations this association was minimally impacted when race adjustment was removed. For example, removal of race adjustment from CKD-EPI resulted in a 0.1% increase in the association between lower eGFR and higher rate of AKI events per 15 mL/min/1.73 m change (p < 0.001).

Conclusions: Race adjustment in eGFR equations did not enhance AKI risk estimation in patients with cirrhosis. Further study is warranted to assess the impacts of removing race from eGFR equations on clinical outcomes and policy.
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http://dx.doi.org/10.1007/s10620-021-06943-1DOI Listing
March 2021

Incorporating kidney-related multi-organ transplants into the kidney allocation sequence.

Am J Transplant 2021 Feb 16. Epub 2021 Feb 16.

Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1111/ajt.16542DOI 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

Development and Validation of a Model to Predict Long-Term Survival after Liver Transplantation.

Liver Transpl 2021 Feb 4. Epub 2021 Feb 4.

Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.

Background: Patients are prioritized for liver transplant under an 'urgency-based' system using the Model for End Stage Liver Disease score. This system focuses solely on waitlist mortality, without considerations of post-transplant morbidity, mortality, and healthcare utilization. We sought to develop and internally validate a continuous post-transplant risk score over 5- and 10-year time horizons.

Methods: This retrospective cohort study used national registry data of adult deceased-donor liver transplant (DDLT) recipients with ≥90 days of pre-transplant waiting time from 2/27/02-12/31/18. We fit Cox regression models at 5 and 10 years to estimate beta coefficients for a risk score using manual variable selection and calculated absolute predicted survival time.

Results: Among 21,103 adult DDLT recipients, 11 variables were selected for the final model. The AUC's at 5- and 10-years were: 0.63, 95% CI: 0.60-0.66 and 0.67, 95% CI: 0.64-0.70, respectively. The group with the highest ('best') scores had 5- and 10-year survivals of 89.4% and 85.4%, respectively, compared to 45.9% and 22.2% for those with the lowest ('worst') scores. Our score was significantly better at predicting long-term survival compared to existing scores.

Conclusion: We developed and validated a risk score using nearly 17 years of data to prioritize patients with end-stage liver disease based on projected post-transplant survival. This score can serve as the building block by which the transplant field can change the entire approach to prioritizing patients to one that is based on considerations of maximizing benefits (i.e., survival benefit-based allocation) rather than simply waitlist mortality.
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http://dx.doi.org/10.1002/lt.26002DOI Listing
February 2021

The first-order Markov conditional linear expectation approach for analysis of longitudinal data.

Stat Med 2021 Apr 2;40(8):1972-1988. Epub 2021 Feb 2.

Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

We consider longitudinal discrete data that may be unequally spaced in time and may exhibit overdispersion, so that the variance of the outcome variable is inflated relative to its assumed distribution. We implement an approach that extends generalized linear models for analysis of longitudinal data and is likelihood based, in contrast to generalized estimating equations (GEE) that are semiparametric. The method assumes independence between subjects; first-order antedependence within subjects; exponential family distributions for the first outcome on each subject and for the subsequent conditional distributions; and linearity of the expectations of the conditional distributions. We demonstrate application of the method in an analysis of seizure counts and in a study to evaluate the performance of transplant centers. Simulations for both studies demonstrate the benefits of the proposed likelihood based approach; however, they also demonstrate better than anticipated performance for GEE.
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http://dx.doi.org/10.1002/sim.8883DOI Listing
April 2021

Transplant regimen adherence for kidney recipients by engaging information technologies (TAKE IT): Rationale and methods for a randomized controlled trial of a strategy to promote medication adherence among transplant recipients.

Contemp Clin Trials 2021 Jan 27;103:106294. Epub 2021 Jan 27.

Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States of America.

Background: Several studies report a high prevalence of non-adherence to prescribed immunosuppressive (IS) medications among kidney transplant recipients (KTRs), yet few interventions have been effective for helping patients sustain appropriate post-transplant adherence. We describe a multifaceted, evidence-based, medication adherence monitoring strategy ('TAKE IT') that leverages available transplant center resources to identify potential medication non-adherence and other concerns earlier to prevent complications that could result from inadequate IS adherence.

Methods: The TAKE IT strategy includes: 1) medication adherence mobile application; 2) routine, online patient self-reported adherence assessments; 3) care alert notifications via the electronic health record (EHR) directed to transplant coordinators; 4) quarterly adherence reports to monitor IS values and summarize adherence trends; 5) deployment of adherence support tools tailored to specific adherence concerns. To test the TAKE IT intervention, we will conduct a two-arm, patient-randomized controlled trial at two large, diverse transplant centers (Northwestern University, Mayo Clinic, AZ) with planned recruitment of 450 KTRs (n = 225 per site) within 2 years of transplantation and 2 years of follow-up. Study assessments will take place at baseline, 6 weeks, 6, 12, 18 and 24 months. The primary effectiveness outcome is medication adherence via pill count, secondary outcomes include self-reported adherence and clinical outcomes. Process outcomes and cost-effectiveness will also be examined.

Conclusion: The TAKE IT trial presents an innovative approach to monitoring and optimizing medication adherence among a population taking complex medication regimens. This trial seeks to evaluate the effectiveness and feasibility of this strategy compared to usual care.
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http://dx.doi.org/10.1016/j.cct.2021.106294DOI Listing
January 2021

Quantifying Risk Tolerance Among Potential Living Kidney Donors With the Donation-Specific Risk Questionnaire.

Am J Kidney Dis 2021 Jan 25. Epub 2021 Jan 25.

Department of Surgery, Yale University, New Haven, CT. Electronic address:

Rationale & Objective: Enhanced informed consent tools improve patient engagement. A novel visual aid measured potential donors' risk tolerance to post-donation kidney failure and assessed if the closeness of the relationship to the intended recipient altered willingness to accept risk.

Study Design: Cross-sectional analysis of donor evaluations at the time of enrollment into a longitudinal mixed-methods study between November 2014 and February 2016.

Setting & Population: Three United States kidney transplant centers. English-speaking adults presenting for in-person living kidney donor evaluation.

Exposure: Closeness of the relationship between the potential living donor and intended recipient.

Outcome: Willingness to accept post-donation kidney failure.

Analytical Approach: The Donation-Specific Risk Questionnaire, a dot matrix visual diagram, was used to measure willingness to accept kidney failure risk. Multivariable logistic regression assessed associations between risk acceptance and data from social science instruments, which measured donors' perceived closeness with the recipient. Qualitative data were analyzed thematically per grounded theory.

Results: 307 participants (response rate: 86%) completed testing. 96% indicated a willingness to accept a risk of kidney failure of 0.9% or greater. Those who were older (OR 0.98, 95% CI [0.96,0.99]), women (OR 0.54, 95% CI [0.31,0.93]), and Black (OR 0.25; 95% CI [0.08,0.76]) were less likely to be in the medium versus low willingness to accept risk group. Closeness of the relationship to the recipient was independently associated with greater risk acceptance (for every 1-point greater closeness score, ORs for being in the medium and high willingness to accept risk groups were 1.21 [95% CI, 1.03-1.41] and 2.42, 95% CI, [1.53-3.82] compared to being in the low willingness to accept risk group). With the exception of parental relationships, biological linkages were not associated with accepting higher kidney failure risk.

Limitations: First demonstration of visual aid that used one risk estimate of kidney failure provided to all participants. Risk estimates were not customized to different demographic groups.

Conclusions: Relationship closeness was independently associated with a greater willingness to accept post-donation kidney failure. Visual aids can provide transplant teams individualized donor perspectives on risk thresholds and can potentially facilitate greater patient-centered care for living donors.
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http://dx.doi.org/10.1053/j.ajkd.2020.11.028DOI Listing
January 2021

Predicting survival after liver transplantation in patients with hepatocellular carcinoma using the LiTES-HCC score.

J Hepatol 2021 Jan 13. Epub 2021 Jan 13.

Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Renal-Electrolye and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.

Background & Aims: Liver transplant priority in the US and Europe follows the 'sickest-first' principle. However, for patients with hepatocellular carcinoma (HCC), priority is based on binary tumor criteria to expedite transplant for patients with 'acceptable' post-transplant outcomes. Newer risk scores developed to overcome limitations of these binary criteria are insufficient to be used for waitlist priority as they focus solely on HCC-related pre-transplant variables. We sought to develop a risk score to predict post-transplant survival for patients using HCC- and non-HCC-related variables.

Methods: We performed a retrospective cohort study using national registry data on adult deceased-donor liver transplant (DDLT) recipients with HCC from 2/27/02-12/31/18. We fit Cox regression models focused on 5- and 10-year survival to estimate beta coefficients for a risk score using manual variable selection. We then calculated absolute predicted survival time and compared it to available risk scores.

Results: Among 6,502 adult DDLT recipients with HCC, 11 variables were selected in the final model. The AUCs at 5- and 10-years were: 0.62, 95% CI 0.57-0.67 and 0.65, 95% CI 0.58-0.72, which was not statistically significantly different to the Metroticket and HALT-HCC scores. The LiTES-HCC score was able to discriminate patients based on post-transplant survival among those meeting Milan and UCSF criteria.

Conclusion: We developed and validated a risk score to predict post-transplant survival for patients with HCC. By including HCC- and non-HCC-related variables (e.g., age, chronic kidney disease), this score could allow transplant professionals to prioritize patients with HCC in terms of predicted survival. In the future, this score could be integrated into survival benefit-based models to lead to meaningful improvements in life-years at the population level.

Lay Summary: We created a risk score to predict how long patients with liver cancer will live if they get a liver transplant. In the future, this could be used to decide which waitlisted patients should get the next transplant.
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http://dx.doi.org/10.1016/j.jhep.2020.12.021DOI Listing
January 2021

Contemporary incidence and risk factors of post transplant Erythrocytosis in deceased donor kidney transplantation.

BMC Nephrol 2021 Jan 12;22(1):26. Epub 2021 Jan 12.

Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Post-Transplant erythrocytosis (PTE) has not been studied in large recent cohorts. In this study, we evaluated the incidence, risk factors, and outcome of PTE with current transplant practices using the present World Health Organization criteria to define erythrocytosis. We also tested the hypothesis that the risk of PTE is greater with higher-quality kidneys.

Methods: We utilized the Deceased Donor Study which is an ongoing, multicenter, observational study of deceased donors and their kidney recipients that were transplanted between 2010 and 2013 across 13 centers. Eryrthocytosis is defined by hemoglobin> 16.5 g/dL in men and> 16 g/dL in women. Kidney quality is measured by Kidney Donor Profile Index (KDPI).

Results: Of the 1123 recipients qualified to be in this study, PTE was observed at a median of 18 months in 75 (6.6%) recipients. Compared to recipients without PTE, those with PTE were younger [mean 48±11 vs 54±13 years, p < 0.001], more likely to have polycystic kidney disease [17% vs 6%, p < 0.001], have received kidneys from younger donors [36 ±13 vs 41±15 years], and be on RAAS inhibitors [35% vs 22%, p < 0.001]. Recipients with PTE were less likely to have received kidneys from donors with hypertension [16% vs 32%, p = 0.004], diabetes [1% vs 11%, p = 0.008], and cerebrovascular event (24% vs 36%, p = 0.036). Higher KDPI was associated with decreased PTE risk [HR 0.98 (95% CI: 0.97-0.99)]. Over 60 months of follow-up, only 17 (36%) recipients had sustained PTE. There was no association between PTE and graft failure or mortality, CONCLUSIONS: The incidence of PTE was low in our study and PTE resolved in majority of patients. Lower KDPI increases risk of PTE. The underutilization of RAAS inhibitors in PTE patients raises the possibility of under-recognition of this phenomenon and should be explored in future studies.
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http://dx.doi.org/10.1186/s12882-021-02231-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802150PMC
January 2021

Assessment of the Utility of Kidney Histology as a Basis for Discarding Organs in the United States: A Comparison of International Transplant Practices and Outcomes.

J Am Soc Nephrol 2021 Feb 15;32(2):397-409. Epub 2020 Dec 15.

Université de Paris, Institut National de la Santé et de la Recherche Médicale U970, Paris Translational Research Centre for Organ Transplantation, Paris, France

Background: Many kidneys donated for transplant in the United States are discarded because of abnormal histology. Whether histology adds incremental value beyond usual donor attributes in assessing allograft quality is unknown.

Methods: This population-based study included patients who received a deceased donor kidney that had been biopsied before implantation according to a prespecified protocol in France and Belgium, where preimplantation biopsy findings are generally not used for decision making in the allocation process. We also studied kidneys that had been acquired from deceased United States donors for transplantation that were biopsied during allocation and discarded because of low organ quality. Using donor and recipient characteristics, we fit multivariable Cox models for death-censored graft failure and examined whether predictive accuracy (C index) improved after adding donor histology. We matched the discarded United States kidneys to similar kidneys transplanted in Europe and calculated predicted allograft survival.

Results: In the development cohort of 1629 kidney recipients at two French centers, adding donor histology to the model did not significantly improve prediction of long-term allograft failure. Analyses using an external validation cohort from two Belgian centers confirmed the lack of improved accuracy from adding histology. About 45% of 1103 United States kidneys discarded because of histologic findings could be accurately matched to very similar kidneys that had been transplanted in France; these discarded kidneys would be expected to have allograft survival of 93.1% at 1 year, 80.7% at 5 years, and 68.9% at 10 years.

Conclusions: In this multicenter study, donor kidney histology assessment during allocation did not provide substantial incremental value in ascertaining organ quality. Many kidneys discarded on the basis of biopsy findings would likely benefit United States patients who are wait listed.
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http://dx.doi.org/10.1681/ASN.2020040464DOI Listing
February 2021

A Randomized Trial of Theory-Informed Appeals for Organ Donor Registration Using Internet Advertisements.

Kidney Int Rep 2020 Dec 12;5(12):2238-2245. Epub 2020 Sep 12.

The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Introduction: Many people do not register as organ donors. We developed 5 different brief appeals for organ donation that were disseminated online. The content was informed by theories of behavior change and studies of the specific cognitive barriers to organ donor registration.

Methods: One message was a persuasive narrative about a transplant recipient. Another message promoted the idea that organ donor registration is a social norm. The knowledge-based message communicated that 1 donor could improve the lives of 50 people. The message on reciprocity offered a free organ donation wristband, whether or not the participant registered as a donor. The message on control simply encouraged organ donation. Using Google AdWords, the messages were deployed randomly as banners of different sizes on diverse online sites and carried a link to an organ donor registration site. We measured clicks, page visits, and organ donor registrations.

Results: There were 5,156,048 impressions and 25,001 total clicks, a click-through rate of 0.49%. The messages on control and reciprocity both had the highest click-through rates of 0.51%. A total of 152 unique individuals requested wristbands and there were 52 total organ donor registration events. The message on reciprocity had the highest number of organ donor registrations (n = 18).

Conclusion: Online organ donation messages rapidly generated substantial attention through clicks, but no message led to a meaningful number of organ donor registrations. Future research may focus on effectively capturing the attention of viewers through social networks or other convenient online venues with less competition for attention than Internet banners.
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http://dx.doi.org/10.1016/j.ekir.2020.09.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710840PMC
December 2020

Using Clinical Trial Data to Estimate the Costs of Behavioral Interventions for Potential Adopters: A Guide for Trialists.

Med Decis Making 2021 01 20;41(1):9-20. Epub 2020 Nov 20.

Department of Medical Ethics and Health Policy, Perelman School of Medicine, and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA.

Behavioral interventions involving electronic devices, financial incentives, gamification, and specially trained staff to encourage healthy behaviors are becoming increasingly prevalent and important in health innovation and improvement efforts. Although considerations of cost are key to their wider adoption, cost information is lacking because the resources required cannot be costed using standard administrative billing data. Pragmatic clinical trials that test behavioral interventions are potentially the best and often only source of cost information but rarely incorporate costing studies. This article provides a guide for researchers to help them collect and analyze, during the trial and with little additional effort, the information needed to inform potential adopters of the costs of adopting a behavioral intervention. A key challenge in using trial data is the separation of implementation costs, the costs an adopter would incur, from research costs. Based on experience with 3 randomized clinical trials of behavioral interventions, this article explains how to frame the costing problem, including how to think about costs associated with the control group, and describes methods for collecting data on individual costs: specifications for costing a technology platform that supports the specialized functions required, how to set up a time log to collect data on the time staff spend on implementation, and issues in getting data on device, overhead, and financial incentive costs.
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http://dx.doi.org/10.1177/0272989X20973160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772275PMC
January 2021

Does Sex, Race, and the Size of a Kidney Transplant Candidate's Social Network Affect the Number of Living Donor Requests? A Multicenter Social Network Analysis of Patients on the Kidney Transplant Waitlist.

Transplantation 2020 12;104(12):2632-2641

Center for Data Analytics and Biomedical Informatics, Temple University, Philadelphia, PA.

Background: A kidney transplant candidate's social network serves as a pool of potential living donors. Sex and racial differences in network size, network strength, and living donor requests may contribute to disparities in living donor kidney transplantation.

Methods: In this multicenter cross-sectional study, we performed an egocentric network analysis via a telephone survey of 132 waitlisted candidates (53% female and 69% Black) to identify demographic and network factors associated with requesting living kidney donations.

Results: Female participants made requests to more network members than male participants: incidence rate ratio (IRR) 1.95, 95% confidence interval (CI) [1.24-3.06], P < 0.01. Black participants tended to make more requests than whites (IRR 1.65, 95% CI [0.99-2.73], P = 0.05). The number of requests increased with the size of the network (IRR 1.09, 95% CI [1.02-1.16], P = 0.01); however, network size did not differ by sex or race. Network members who provided greater instrumental support to the candidates were most likely to receive a request: odds ratio 1.39, 95% CI [1.08-1.78], P = 0.01.

Conclusions: Transplant candidates' networks vary in size and in the number of requests made to the members. Previously observed racial and sex disparities in living donor kidney transplantation do not appear to be related to network size or to living donation requests, but rather to the network members themselves. Future living donor interventions should focus on the network members and be tailored to their relationship with the candidate.
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http://dx.doi.org/10.1097/TP.0000000000003167DOI Listing
December 2020

Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial.

Am J Kidney Dis 2020 Nov 16. Epub 2020 Nov 16.

Department of Urology, University of Washington School of Medicine, Seattle, WA.

Rationale & Objective: Although maintaining high fluid intake is an effective low-risk intervention for the secondary prevention of urinary stone disease, many patients with stones do not increase their fluid intake.

Study Design: We describe the rationale and design of the Prevention of Urinary Stones With Hydration (PUSH) Study, a randomized trial of a multicomponent behavioral intervention program to increase and maintain high fluid intake. Participants are randomly assigned (1:1 ratio) to the intervention or control arm. The target sample size is 1,642 participants.

Setting & Participants: Adults and adolescents 12 years and older with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of urinary stone disease and comorbid conditions precluding increased fluid intake.

Interventions: All participants receive usual care and a smart water bottle with smartphone application. Participants in the intervention arm receive a fluid intake prescription and an adaptive program of behavioral interventions, including financial incentives, structured problem solving, and other automated adherence interventions. Control arm participants receive guideline-based fluid instructions.

Outcomes: The primary end point is recurrence of a symptomatic stone during 24 months of follow-up. Secondary end points include changes in radiographic stone burden, 24-hour urine output, and urinary symptoms.

Limitations: Periodic 24-hour urine volumes may not fully reflect daily behavior.

Conclusions: With its highly novel features, the PUSH Study will address an important health care problem.

Funding: National Institute of Diabetes and Digestive and Kidney Diseases.

Trial Registration: Registered at ClinicalTrials.gov with study number NCT03244189.
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http://dx.doi.org/10.1053/j.ajkd.2020.09.016DOI Listing
November 2020

Acute Kidney Injury in Deceased Organ Donors and Kidney Transplant Outcomes: A National Cohort Study using a Novel Data Source.

Ann Surg 2020 Nov 13. Epub 2020 Nov 13.

Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

Objective: To determine graft function and survival for kidney transplants from deceased donors with acute kidney injury (AKI) that persists at the time of organ procurement.

Background: Kidneys from donors with AKI are often discarded and may provide an opportunity to selectively expand the donor pool.

Methods: Using OPTN and DonorNet data, we studied adult kidney-only recipients between 5/1/2007-12/31/2016. DonorNet was used to characterize longitudinal creatinine trends and urine output. Donor AKI was defined using KDIGO guidelines and terminal creatinine ≥ 1.5 mg/dL. We compared outcomes between AKI kidneys versus "ideal comparator" kidneys from donors with no or resolved AKI stage 1 plus terminal creatinine < 1.5 mg/dL. We fit proportional hazards models and hierarchical linear regression models for the primary outcomes of all-cause graft failure (ACGF) and 12-month estimated glomerular filtration rate (eGFR), respectively.

Results: We identified 7,660 donors with persistent AKI (33.2% with AKI stage 3) from whom ≥1 kidney was transplanted. Observed rates of ACGF within 3 years were similar between recipient groups (15.5% in AKI vs 15.1% ideal comparator allografts, p = 0.2). After risk adjustment, ACGF was slightly higher among recipients of AKI kidneys (aHR 1.05, 95%CI:1.01-1.09). The mean 12-month eGFR for AKI kidney recipients was lower, but differences were not clinically important (56.6 vs. 57.5 mL/min/1.73m for ideal comparator kidneys; p < 0.001). There were 2,888 kidneys discarded from donors with AKI, age ≤ 65, without hypertension or diabetes, and terminal creatinine ≤ 4 mg/dL.

Conclusions: Kidney allografts from donors with persistent AKI are often discarded, yet those that were transplanted did not have clinically meaningful differences in graft survival and function.
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http://dx.doi.org/10.1097/SLA.0000000000004597DOI Listing
November 2020

Racial disparities in preemptive waitlisting and deceased donor kidney transplantation: Ethics and solutions.

Am J Transplant 2021 03 3;21(3):958-967. Epub 2020 Dec 3.

Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Kidney transplantation prior to dialysis, known as "preemptive transplant," enables patients to live longer and avoid the substantial quality of life burdens due to chronic dialysis. Deceased donor kidneys are a public resource that ought to provide health benefits equitably. Unfortunately, White, better educated, and privately insured patients enjoy disproportionate access to preemptive transplantation using deceased donor kidneys. This problem has persisted for decades and is exacerbated by the first-come, first-served approach to kidney allocation for predialysis patients. In this Personal Viewpoint, we describe the diverse barriers to preemptive waitlisting and kidney transplant. The analysis focuses on healthcare system features that particularly disadvantage Black patients, such as the waitlisting eligibility criterion of a single glomerular filtration rate or creatinine clearance ≤20 ml/min, and neglect of wide variation in the rate of progression to end-stage kidney disease (ESKD) in allocating preemptive transplants. We propose initiatives to improve equity including: (1) standardization of waitlisting eligibility criteria related to kidney function; (2) aggressive education for clinicians about early transplant referral; (3) innovations in electronic medical record capabilities; and (4) rapid status 7 listing by centers. If those initiatives fail, the transplant field should consider eliminating preemptive waitlisting and transplantation with deceased donor kidneys.
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http://dx.doi.org/10.1111/ajt.16392DOI Listing
March 2021

Health-Related Quality of Life, Depressive Symptoms, and Kidney Transplant Access in Advanced CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study.

Kidney Med 2020 Sep-Oct;2(5):600-609.e1. Epub 2020 Aug 11.

Department of Medicine, Loyola University Medical Center, Maywood, IL.

Rationale & Objective: Among individuals with chronic kidney disease (CKD), poor self-reported health is associated with adverse outcomes including hospitalization and death. We sought to examine the association between health-related quality-of-life (HRQoL) and depressive symptoms in advanced CKD and subsequent access to the kidney transplant waiting list.

Study Design: Prospective cohort study.

Setting & Population: 1,676 Chronic Renal Insufficiency Cohort (CRIC) study participants with estimated glomerular filtration rates ≤ 30 mL/min/1.73 m at study entry or during follow-up.

Exposures: HRQoL ascertained by 5 scales of the Kidney Disease Quality of Life-36 Survey (Physical Component Summary [PCS], Mental Component Summary, Symptoms, Burdens, and Effects), with higher scores indicating better HRQoL, and depressive symptoms ascertained using the Beck Depression Inventory.

Outcomes: Time to kidney transplant wait-listing and time to pre-emptive wait-listing.

Analytic Approach: Time-to-event analysis using Cox proportional hazards regression.

Results: During a median follow-up of 5.1 years, 652 (39%) participants were wait-listed, of whom 304 were preemptively wait-listed. Adjusted for demographics, comorbid conditions, estimated glomerular filtration rate slope, and cognitive function, participants with the highest scores on the Burden and Effects scales, respectively, had lower rates of wait-listing than those with the lowest scores on the Burden (wait-listing adjusted hazard ratio [aHR], 0.70; 95% CI, 0.57-0.85;  < 0.001) and Effects scales (wait-listing aHR, 0.74; 95% CI, 0.59-0.92;  = 0.007). Participants with fewer depressive symptoms (ie, Beck Depression Inventory score < 14) had lower wait-listing rates than those with more depressive symptoms (aHR, 0.81; 95% CI, 0.66-0.99;  = 0.04). Participants with lower Burden and Effects scale scores and those with higher Symptoms and PCS scores had higher pre-emptive wait-listing rates (aHR in highest tertile of PCS relative to lowest tertile, 1.58; 95% CI, 1.12-2.23;  = 0.01).

Limitations: Unmeasured confounders.

Conclusions: Self-reported health in late-stage CKD may influence the timing of kidney transplantation.
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http://dx.doi.org/10.1016/j.xkme.2020.06.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568061PMC
August 2020

Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design.

J Endourol 2020 Nov 16. Epub 2020 Nov 16.

Department of Urology, University of Washington School of Medicine, Seattle, Washington, USA.

Ureteral stents are commonly employed after ureteroscopy to treat urinary stone disease, but the devices impose a substantial burden of stent-associated symptoms (SAS), including pain and urinary side effects. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) Urinary Stone Disease Research Network sought to develop greater understanding of SAS causes and severity among individuals treated ureteroscopically for ureteral or renal stones. We designed a prospective, observational cohort study comprising adolescents and adults undergoing ureteroscopic intervention for ureteral or renal stones. Participants will undergo detailed symptom assessment using validated questionnaires, a psychosocial assessment, and detailed collection of clinical and operative data. Quantitative sensory testing will be utilized to assess pain sensitization. In addition, a small cohort (∼40 individuals) will participate in semi-structured interviews to develop more granular information regarding their stent symptoms and experience. Biospecimens (blood and urine) will be collected for future research. The Study to Enhance Understanding of sTent-associated Symptoms (STENTS) enrolled its first participant in March 2019 and completed nested qualitative cohort follow-up in August 2019. After a planned pause, enrollment for the main study cohort resumed in September 2019 and is expected to be completed in 2021. STENTS is expected to provide important insights into the mechanisms and risk factors for severe ureteral SAS after ureteroscopy. These insights will generate future investigations to mitigate the burden of SAS among individuals with urinary stone disease.
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http://dx.doi.org/10.1089/end.2020.0776DOI Listing
November 2020

Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes.

J Gen Intern Med 2021 Feb 15;36(2):464-471. Epub 2020 Oct 15.

Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Advancing health equity entails reducing disparities in care. African-American patients with chronic kidney disease (CKD) have poorer outcomes, including dialysis access placement and transplantation. Estimated glomerular filtration rate (eGFR) equations, which assign higher eGFR values to African-American patients, may be a mechanism for inequitable outcomes. Electronic health record-based registries enable population-based examination of care across racial groups.

Objective: To examine the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and care delivery.

Design: Cross-sectional study SETTING: Two large academic medical centers and affiliated community primary care and specialty practices.

Participants: A total of 56,845 patients in the Partners HealthCare System CKD registry in June 2019, among whom 2225 (3.9%) were African-American.

Measurements: Exposures included race, age, sex, comorbidities, and eGFR. Outcomes were transplant referral and dialysis access placement.

Results: Of 2225 African-American patients, 743 (33.4%) would hypothetically be reclassified to a more severe CKD stage if the race multiplier were removed from the CKD-EPI equation. Similarly, 167 of 687 (24.3%) would be reclassified from stage 3B to stage 4. Finally, 64 of 2069 patients (3.1%) would be reassigned from eGFR > 20 ml/min/1.73 m to eGFR ≤ 20 ml/min/1.73 m, meeting the criterion for accumulating kidney transplant priority. Zero of 64 African-American patients with an eGFR ≤ 20 ml/min/1.73 m after the race multiplier was removed were referred, evaluated, or waitlisted for kidney transplant, compared to 19.2% of African-American patients with eGFR ≤ 20 ml/min/1.73 m with the default CKD-EPI equation.

Limitations: Single healthcare system in the Northeastern United States and relatively small African-American patient cohort may limit generalizability.

Conclusions: Our study reveals a meaningful impact of race-adjusted eGFR on the care provided to the African-American CKD patient population.
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http://dx.doi.org/10.1007/s11606-020-06280-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878608PMC
February 2021

Major Variation across Local Transplant Centers in Probability of Kidney Transplant for Wait-Listed Patients.

J Am Soc Nephrol 2020 12 9;31(12):2900-2911. Epub 2020 Oct 9.

Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York

Background: Geographic disparities in access to deceased donor kidney transplantation persist in the United States under the Kidney Allocation System (KAS) introduced in 2014, and the effect of transplant center practices on the probability of transplantation for wait-listed patients remains unclear.

Methods: To compare probability of transplantation across centers nationally and within donation service areas (DSAs), we conducted a registry study that included all United States incident adult kidney transplant candidates wait listed in 2011 and 2015 (pre-KAS and post-KAS cohorts comprising 32,745 and 34,728 individuals, respectively). For each center, we calculated the probability of deceased donor kidney transplantation within 3 years of wait listing using competing risk regression, with living donor transplantation, death, and waiting list removal as competing events. We examined associations between center-level and DSA-level characteristics and the adjusted probability of transplant.

Results: Candidates received deceased donor kidney transplants within 3 years of wait listing more frequently post-KAS (22%) than pre-KAS (19%). Nationally, the probability of transplant varied 16-fold between centers, ranging from 4.0% to 64.2% in the post-KAS era. Within DSAs, we observed a median 2.3-fold variation between centers, with up to ten-fold and 57.4 percentage point differences. Probability of transplantation was correlated in the post-KAS cohort with center willingness to accept hard-to-place kidneys (=0.55, <0.001) and local organ supply (=0.44, <0.001).

Conclusions: Large differences in the adjusted probability of deceased donor kidney transplantation persist under KAS, even between centers working with the same local organ supply. Probability of transplantation is significantly associated with organ offer acceptance patterns at transplant centers, underscoring the need for greater understanding of how centers make decisions about organs offered to wait-listed patients and how they relate to disparities in access to transplantation.
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http://dx.doi.org/10.1681/ASN.2020030335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790218PMC
December 2020

Effect of Patient Financial Incentives on Statin Adherence and Lipid Control: A Randomized Clinical Trial.

JAMA Netw Open 2020 10 1;3(10):e2019429. Epub 2020 Oct 1.

Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Importance: Financial incentives can improve medication adherence and cardiovascular disease risk, but the optimal design to promote sustained adherence after incentives are discontinued is unknown.

Objective: To determine whether 6-month interventions involving different financial incentives to encourage statin adherence reduce low-density lipoprotein cholesterol (LDL-C) levels from baseline to 12 months.

Design, Setting, And Participants: This 4-group, randomized clinical trial was conducted from August 2013 to July 2018 among several large US insurer or employer populations and the University of Pennsylvania Health System. The study population included adults with elevated risk of cardiovascular disease, suboptimal LDL-C control, and evidence of imperfect adherence to statin medication. Data analysis was performed from July 2017 to June 2019.

Interventions: The interventions lasted 6 months during which all participants received daily medication reminders and an electronic pill bottle. Statin adherence was measured by opening the bottle. For participants randomized to the 3 intervention groups, adherence was rewarded with financial incentives. The sweepstakes group involved incentives for daily adherence. In the deadline sweepstakes group, incentives were reduced if participants were adherent only after a reminder. The sweepstakes plus deposit contract group split incentives between daily adherence and a monthly deposit reduced for each day of nonadherence.

Main Outcomes And Measures: The primary outcome was change in LDL-C level from baseline to 12 months.

Results: Among 805 participants randomized (199 in the simple daily sweepstakes group, 204 in the deadline sweepstakes group, 201 in the sweepstakes plus deposit contract group, and 201 in the control group), the mean (SD) age was 58.5 (10.3) years; 519 participants (64.5%) were women, 514 (63.9%) had diabetes, and 273 (33.9%) had cardiovascular disease. The mean (SD) baseline LDL-C level was 143.2 (42.5) mg/dL. Measured adherence at 6 months (defined as the proportion of 180 days with electronic pill bottle opening) in the control group (0.69; 95% CI, 0.66-0.72) was lower than that in the simple sweepstakes group (0.84; 95% CI, 0.81-0.87), the deadline sweepstakes group (0.86; 95% CI, 0.83-0.89), and the sweepstakes plus deposit contract group (0.87; 95% CI, 0.84-0.90) (P < .001 for each incentive group vs control). LDL-C levels were measured for 636 participants at 12 months. Mean LDL-C level reductions from baseline to 12 months were 33.6 mg/dL (95% CI, 28.4-38.8 mg/dL) in the control group, 32.4 mg/dL (95% CI, 27.3-37.6 mg/dL) in the sweepstakes group, 33.2 mg/dL (95% CI, 28.1-38.3 mg/dL) in the deadline sweepstakes group, and 36.5 mg/dL (95% CI, 31.3-41.7 mg/dL) in the sweepstakes plus deposit contract group (adjusted P > .99 for each incentive group vs control).

Conclusions And Relevance: Compared with the control group, different financial incentives improved measured statin adherence but not LDL-C levels. This result points to the importance of directly measuring health outcomes, rather than simply adherence, in trials aimed at improving health behaviors.

Trial Registration: ClinicalTrials.gov Identifier: NCT01798784.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.19429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547367PMC
October 2020

Effect of Neighborhood Food Environment and Socioeconomic Status on Serum Phosphorus Level for Patients on Chronic Dialysis.

J Am Soc Nephrol 2020 11 11;31(11):2622-2630. Epub 2020 Sep 11.

Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Background: Elevated blood phosphorus levels are common and associated with a greater risk of death for patients receiving chronic dialysis. Phosphorus-rich foods are prevalent in the American diet, and low-phosphorus foods, including fruits and vegetables, are often less available in areas with more poverty. The relative contributions of neighborhood food availability and socioeconomic status to phosphorus control in patients receiving dialysis are unknown.

Methods: Using longitudinal data from a national dialysis provider, we constructed hierarchical, linear mixed-effects models to evaluate the relationships between neighborhood food environment or socioeconomic status and serum phosphorus level among patients receiving incident dialysis.

Results: Our cohort included 258,510 patients receiving chronic hemodialysis in 2005-2013. Median age at dialysis initiation was 64 years, 45% were female, 32% were Black, and 15% were Hispanic. Within their residential zip code, patients had a median of 25 "less-healthy" food outlets (interquartile range, 11-40) available to them compared with a median of four "healthy" food outlets (interquartile range, 2-6). Living in a neighborhood with better availability of healthy food was not associated with a lower phosphorus level. Neighborhood income also was not associated with differences in phosphorus. Patient age, race, cause of ESKD, and mean monthly dialysis duration were most closely associated with phosphorus level.

Conclusions: Neither neighborhood availability of healthy food options nor neighborhood income was associated with phosphorus levels in patients receiving chronic dialysis. Modifying factors, such as nutrition literacy, individual-level financial resources, and adherence to diet restrictions and medications, may be more powerful contributors than food environment to elevated phosphorus.
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http://dx.doi.org/10.1681/ASN.2020030290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608959PMC
November 2020

End-of-Life Care among US Adults with ESKD Who Were Waitlisted or Received a Kidney Transplant, 2005-2014.

J Am Soc Nephrol 2020 10 9;31(10):2424-2433. Epub 2020 Sep 9.

Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, Seattle, Washington.

Background: The care of patients in the United States who have ESKD is often shaped by their hopes and prognostic expectations related to kidney transplant. Little is known about how patients' engagement in the transplant process might relate to patterns of end-of-life care.

Methods: We compared six measures of intensity of end-of-life care among adults in the United States with ESKD who died between 2005 and 2014 after experiencing differing exposure to the kidney transplant process.

Results: Of 567,832 decedents with ESKD, 27,633 (5%) had a functioning kidney transplant at the time of death, 14,653 (3%) had a failed transplant, 16,490 (3%) had been removed from the deceased donor waitlist, 17,010 (3%) were inactive on the waitlist, 11,529 (2%) were active on the waitlist, and 480,517 (85%) had never been waitlisted for or received a transplant (reference group). In adjusted analyses, compared with the reference group, patients exposed to the transplant process were significantly more likely to have been admitted to an intensive care unit and to have received an intensive procedure in the last 30 days of life; they were also significantly more likely to have died in the hospital. Those who died on the transplant waitlist were also less likely than those in the reference group to have been enrolled in hospice and to have discontinued dialysis before death.

Conclusions: Patients who had engaged in the kidney transplant process received more intensive patterns of end-of-life care than other patients with ESKD. These findings support the relevance of advance care planning, even for this relatively healthy segment of the ESKD population.
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http://dx.doi.org/10.1681/ASN.2020030342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608994PMC
October 2020

In Reply to 'Response to the KDOQI US Commentary on the 2018 KDIGO Hepatitis C Guideline'.

Am J Kidney Dis 2021 01 3;77(1):152-153. Epub 2020 Sep 3.

Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine and the Miami Transplant Institute, Miami, FL.

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http://dx.doi.org/10.1053/j.ajkd.2020.08.001DOI Listing
January 2021

Multicenter Study to Transplant Hepatitis C-Infected Kidneys (MYTHIC): An Open-Label Study of Combined Glecaprevir and Pibrentasvir to Treat Recipients of Transplanted Kidneys from Deceased Donors with Hepatitis C Virus Infection.

J Am Soc Nephrol 2020 11 25;31(11):2678-2687. Epub 2020 Aug 25.

Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Single-center trials and retrospective case series have reported promising outcomes using kidneys from donors with hepatitis C virus (HCV) infection. However, multicenter trials are needed to determine if those findings are generalizable.

Methods: We conducted a prospective trial at seven centers to transplant 30 kidneys from deceased donors with HCV viremia into HCV-uninfected recipients, followed by 8 weeks of once-daily coformulated glecaprevir and pibrentasvir, targeted to start 3 days posttransplant. Key outcomes included sustained virologic response (undetectable HCV RNA 12 weeks after completing treatment with glecaprevir and pibrentasvir), adverse events, and allograft function.

Results: We screened 76 patients and enrolled 63 patients, of whom 30 underwent kidney transplantation from an HCV-viremic deceased donor (median kidney donor profile index, 53%) in May 2019 through October 2019. The median time between consent and transplantation of a kidney from an HCV-viremic donor was 6.3 weeks. All 30 recipients achieved a sustained virologic response. One recipient died of complications of sepsis 4 months after achieving a sustained virologic response. No severe adverse events in any patient were deemed likely related to HCV infection or treatment with glecaprevir and pibrentasvir. Three recipients developed acute cellular rejection, which was borderline in one case. Three recipients developed polyomavirus (BK) viremia near or >10,000 copies/ml that resolved after reduction of immunosuppression. All recipients had good allograft function, with a median creatinine of 1.2 mg/dl and median eGFR of 57 ml/min per 1.73 m at 6 months.

Conclusions: Our multicenter trial demonstrated safety and efficacy of transplantation of 30 HCV-viremic kidneys into HCV-negative recipients, followed by early initiation of an 8-week regimen of glecaprevir and pibrentasvir.
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http://dx.doi.org/10.1681/ASN.2020050686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608971PMC
November 2020

Trajectories of glomerular filtration rate and progression to end stage kidney disease after kidney transplantation.

Kidney Int 2021 01 8;99(1):186-197. Epub 2020 Aug 8.

Université de Paris, INSERM, PARCC, Paris Translational Research Centre for Organ Transplantation, Paris, France; Kidney Transplant Department, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France. Electronic address:

Although the gold standard of monitoring kidney transplant function relies on glomerular filtration rate (GFR), little is known about GFR trajectories after transplantation, their determinants, and their association with outcomes. To evaluate these parameters we examined kidney transplant recipients receiving care at 15 academic centers. Patients underwent prospective monitoring of estimated GFR (eGFR) measurements, with assessment of clinical, functional, histological and immunological parameters. Additional validation took place in seven randomized controlled trials that included a total of 14,132 patients with 403,497 eGFR measurements. After a median follow-up of 6.5 years, 1,688 patients developed end-stage kidney disease. Using unsupervised latent class mixed models, we identified eight distinct eGFR trajectories. Multinomial regression models identified seven significant determinants of eGFR trajectories including donor age, eGFR, proteinuria, and several significant histological features: graft scarring, graft interstitial inflammation and tubulitis, microcirculation inflammation, and circulating anti-HLA donor specific antibodies. The eGFR trajectories were associated with progression to end stage kidney disease. These trajectories, their determinants and respective associations with end stage kidney disease were similar across cohorts, as well as in diverse clinical scenarios, therapeutic eras and in the seven randomized control trials. Thus, our results provide the basis for a trajectory-based assessment of kidney transplant patients for risk stratification and monitoring.
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http://dx.doi.org/10.1016/j.kint.2020.07.025DOI Listing
January 2021

Uromodulin to Osteopontin Ratio in Deceased Donor Urine Is Associated With Kidney Graft Outcomes.

Transplantation 2021 Apr;105(4):876-885

Division of Nephrology, School of Medicine, Johns Hopkins University, Baltimore, MD.

Background: Deceased-donor kidneys experience extensive injury, activating adaptive and maladaptive pathways therefore impacting graft function. We evaluated urinary donor uromodulin (UMOD) and osteopontin (OPN) in recipient graft outcomes.

Methods: Primary outcomes: all-cause graft failure (GF) and death-censored GF (dcGF). Secondary outcomes: delayed graft function (DGF) and 6-month estimated glomerular filtration rate (eGFR). We randomly divided our cohort of deceased donors and recipients into training and test datasets. We internally validated associations between donor urine UMOD and OPN at time of procurement, with our primary outcomes. The direction of association between biomarkers and GF contrasted. Subsequently, we evaluated UMOD:OPN ratio with all outcomes. To understand these mechanisms, we examined the effect of UMOD on expression of major histocompatibility complex II in mouse macrophages.

Results: Doubling of UMOD increased dcGF risk (adjusted hazard ratio [aHR], 1.1; 95% confidence interval [CI], 1.02-1.2), whereas OPN decreased dcGF risk (aHR, 0.94; 95% CI, 0.88-1). UMOD:OPN ratio ≤3 strengthened the association, with reduced dcGF risk (aHR, 0.57; 0.41-0.80) with similar associations for GF, and in the test dataset. A ratio ≤3 was also associated with lower DGF (aOR, 0.73; 95% CI, 0.60-0.89) and higher 6-month eGFR (adjusted β coefficient, 3.19; 95% CI, 1.28-5.11). UMOD increased major histocompatibility complex II expression elucidating a possible mechanism behind UMOD's association with GF.

Conclusions: UMOD:OPN ratio ≤3 was protective, with lower risk of DGF, higher 6-month eGFR, and improved graft survival. This ratio may supplement existing strategies for evaluating kidney quality and allocation decisions regarding deceased-donor kidney transplantation.
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http://dx.doi.org/10.1097/TP.0000000000003299DOI Listing
April 2021

Wide Variation in the Percentage of Donation After Circulatory Death Donors Across Donor Service Areas: A Potential Target for Improvement.

Transplantation 2020 08;104(8):1668-1674

Department of Surgery, University of Pennsylvania, Philadelphia, PA.

Background: Substantial differences exist in the clinical characteristics of donors across the 58 donor service areas (DSAs). Organ procurement organization (OPO) performance metrics incorporate organs donated after circulatory determination of death (DCDD) donors but do not measure potential DCDD donors.

Methods: Using 2011-2016 United Network for Organ Sharing data, we examined the variability in DCDD donors/all deceased donors (%DCDD) across DSAs. We supplemented United Network for Organ Sharing data with CDC death records and OPO statistics to characterize underlying process and system factors that may correlate with donors and utilization.

Results: Among 52 184 deceased donors, the %DCDD varied widely across DSAs, with a median of 15.1% (interquartile range [9.3%, 20.9%]; range 0.0%-32.0%). The %DCDD had a modest positive correlation with 4 DSA factors: median match model for end-stage liver disease, proportion of white deaths out of total deaths, kidney center competition, and %DCDD livers by a local transplant center (all Spearman coefficients 0.289-0.464), and negative correlation with 1 factor: mean kidney waiting time (Spearman coefficient -0.388). Adjusting for correlated variables in linear regression explained 46.3% of the variability in %DCDD.

Conclusions: Donor pool demographics, waitlist metrics, center competition, and DCDD utilization explain only a portion of the variability of DCDD donors. This requires further studies and policy changes to encourage consideration of all possible organ donors.
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http://dx.doi.org/10.1097/TP.0000000000003019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170761PMC
August 2020

Thematic analysis of the medical records of patients evaluated for kidney transplant who did not receive a kidney.

BMC Nephrol 2020 07 25;21(1):300. Epub 2020 Jul 25.

Division of Nephrology, Department of Medicine and the Kidney Research Institute, University of Washington, 1959 NE Pacific St, Campus Box 356521, Seattle, WA, 98195, USA.

Background: A potential pitfall of policies intended to promote referral for kidney transplant is that greater numbers of patients may be evaluated for transplant without experiencing the intended benefit of receiving a kidney. Little is known about the potential implications of this experience for patients.

Methods: We performed a thematic analysis of clinician documentation in the electronic medical records of all adults at a single medical center with advanced kidney disease who were referred to the local transplant coordinator for evaluation between 2008 and 2018 but did not receive a kidney.

Results: 148 of 209 patients referred to the local kidney transplant coordinator at our center (71%) had not received a kidney by the end of follow-up. Three dominant themes emerged from qualitative analysis of documentation in the medical records of these patients: 1) Forward momentum: patients found themselves engaged in an iterative process of testing and treatment that tended to move forward unless an absolute contraindication to transplant was identified or patients disengaged; 2) Potential for transplant shapes other medical decisions: engagement in the transplant evaluation process could impact many other aspects of patients' care; and 3) Personal responsibility and psychological burden for patients and families: clinician documentation suggested that patients felt personally responsible for the course of their evaluation and that the process could take an emotional toll on them and their family members.

Conclusions: Engagement in the kidney transplant evaluation process can be a significant undertaking for patients and families and may impact many other aspects of their care. Policies to promote referral for kidney transplant should be coupled with efforts to strengthen shared decision-making to ensure that the decision to undergo transplant evaluation is framed as an explicit choice with benefits, risks, and alternatives and patients have an opportunity to shape their involvement in this process.
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http://dx.doi.org/10.1186/s12882-020-01951-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382039PMC
July 2020