Malignancy-related mortality following kidney transplantation is common.

There is a paucity of studies describing malignancy-related mortality after kidney transplantation. To help quantify this, we extracted data for all kidney-alone transplant procedures performed in England between April 2001 and March 2012. Data linkage analysis was performed between Hospital Episode Statistics and the Office for National Statistics to identify all deaths occurring in this cohort. Among 19,103 kidney transplant procedures analyzed (median follow-up 4.4 years), 2085 deaths occurred, of which 376 (18.0%) were due to malignancy (crude mortality rate 361 malignancy-related deaths per 100,000 person-years). Common sites of malignancy-related death were lymphoma (18.4%), followed by lung (17.6%) and renal (9.8%), with 14.1% unspecified. The risk of malignancy-related death increased with age: under 50 (0.8%), 50-59 (2.5%), 60-69 (4.8%), 70-79 (6.5%) and over 80 years (9.1%). Age- and gender-stratified malignancy-related mortality risk difference was higher in the transplant compared with the general population. Cox proportional hazard models identified increased age, pretransplant history of malignancy and deceased-donor kidney transplantation to be independently associated with risk for post-transplant death from malignancy. Thus, malignancy as a cause of post-kidney transplantation death is common and requires heightened surveillance.

Mortality after pediatric kidney transplantation in England--a population-based cohort study.

The aim of this study was to explore mortality after pediatric kidney transplantation in England over the last decade. We used data from HES to select all kidney transplant procedures performed in England between April 2001 and March 2012. Data linkage analysis was performed with the ONS to identify all deaths occurring among this study cohort. Data for 1189 pediatric recipients were compared to 17 914 adult recipients (number of deaths, 33 vs. 2052, respectively, p < 0.001), with median follow-up 4.4 yr (interquartile range 2.2-7.3 yr). There was no difference in mortality within the pediatric cohort; age 0-1 (n = 25, patient survival 100.0%), age 2-5 (n = 198, patient survival 96.0%), age 6-12 (n = 359, patient survival 97.5%), and age 13-18 (n = 607, patient survival 97.4%), respectively (p = 0.567). The most common causes of death were renal (n = 8, 24.2%), infection (n = 6, 18.2%), and malignancy (n = 5, 15.2%). All deaths from malignancy were secondary to PTLD. In a fully adjusted Cox regression model, only white ethnicity was significantly associated with risk of pediatric mortality post-kidney transplantation (hazard ratio 2.7, 95% confidence interval [1.0-7.3], p = 0.047). To conclude, this population-based cohort study confirms low mortality after pediatric kidney transplantation with short follow-up.

Preserved Quality of Life in Octogenarians at Early, Mid, and Late Follow-Up Intervals Irrespective of Cardiac Procedure.

Cardiac surgery has become established in octogenarians over the past decade. This study assessed the quality of life (QOL) and survival in patients undergoing various cardiac procedures at various time intervals postoperative. Patients older than 80 years at the time of their cardiac procedure were initially included (n = 427). Patients were grouped according to the time interval from their operations namely as within 3 years postoperative (Group A), 3-5 years postoperative (Group B), and older than 5 years postoperative (Group C). Patients who were at least 2 years postoperative and who were still alive were sent the Medical Outcomes Study Short Form 12 Health Survey version 2 QOL questionnaire (n = 308). In results, there were no significant differences in the preoperative characteristics among the groups including type of surgery and logistic Euroscore. There were also no significant differences in the immediate postoperative phase in the complication rates except for renal replacement therapy (P < 0.01). At follow-up, a further 20 patients had died, and for those still alive 87% (61 of 70), 86% (86 of 100), and 74% (87 of 118) of patients returned questionnaire for each group, respectively. There were no significant differences in mental scores (P = 0.3) and physical scores (P = 0.07) among the groups at the various time intervals. This was irrespective of the type of surgery performed on multivariate analysis. Moreover, most octogenarians who underwent cardiac surgery had equivalent or better QOL than expected when compared with the general population of the same age and sex. In conclusion, the QOL in octogenarians undergoing cardiac surgery is preserved, irrespective of the interval from and the type of procedure. Octogenarians enjoy a good QOL, both physical and mental performance, irrespective of the time interval after surgery and the type of cardiac surgery that they have undergone. Based on these data, any type of cardiac surgery should still be an option in this age group including complex cardiac procedures.

How does the 'Heart Team' decision get enacted for patients with coronary artery disease?

OBJECTIVES: A heart team approach has been recommended for managing patients with coronary artery disease. Although this seems to be a new concept, we have been developing such a practice for over 8 years. In this report, the enactment of the heart team decision is reviewed and possible improvement is discussed. DESIGN: Review of 1000 heart team decisions over a 1-year period for patients with coronary artery disease. These decisions were recorded contemporaneously at the time of the team discussion. Thereafter, patient's notes were reviewed 6 months following the heart team meeting to assess whether the decision was enacted and, if not, what were the reasons for aberration. RESULTS: The heart team decision was enacted in 95.5% of patients. The reasons for aberration in the remaining 45 patients included patient's choice (refusal), unrecognised comorbidities at the time of the heart team discussion, change in patient's clinical condition requiring urgent intervention and death while awaiting procedure, among others. CONCLUSIONS: The decision of a well set-up heartteam meeting is carried out for most patients. Aberration is uncommon and usually due to unknown factors at the time of the discussion. The heart team approach ensures that patients receive best available care (most likely evidence-based), and demonstrates transparency.

Recipient age and risk for mortality after kidney transplantation in England.

BACKGROUND: The aim of this study was to explore age-related mortality post-kidney transplantation in England over the last decade. METHODS: This study used data from Hospital Episode Statistics to select all kidney transplant procedures performed in England between April 2001 and March 2012. Demographics and medical comorbidities (based upon ICD-10 codes) were extracted at baseline. Data linkage analysis was performed with the Office for National Statistics to identify all deaths occurring among this study cohort. RESULTS: Data for 19,103 kidney transplant procedures was analyzed, with a median follow-up of 4.4 years (interquartile range 2.2-7.3 years). Categorization of age cohorts at time of transplantation were age below 50 (n=11,421, 59.8%), 50 to 59 (n=4,195, 22.0%), 60 to 69 (n=2,887, 15.1%), 70 to 79 (n=589, 3.1%), and 80 and above (n=11, 0.1%). There were 2,085 deaths that occurred among the study cohort during follow-up and mortality risk increased with age: below 50 (5.8%), 50 to 59 (14.2%), 60 to 69 (22.0%), 70 to 79 (31.9%), and 80 and above (45.5%). The three most common causes of deaths for recipients 70 and over were cardiac (21.2%), infection (21.2%), and malignancy (20.2%), respectively. Lower mortality was observed with the receipt of a living-donor kidney for recipients aged 70 and above. On Cox regression analysis, risk for death increased with each additional decade of recipient age over 50. CONCLUSION: Increasing age is a strong, independent risk factor for death after kidney transplantation. Although lower mortality was observed with living kidney transplantation among elderly recipients, living-donor rates decrease with increasing recipient age. Pretransplant counseling and posttransplant tailored immunosuppression should be explored, the latter requiring targeted clinical trials.