A single-center analysis of early readmission after renal transplantation.

BACKGROUND: Thirty-day readmission rates (early hospital readmission, EHR) are an important benchmark for quality improvement. Nationally, patients undergoing renal transplantation incur a 31% EHR rate. While national databases provide useful data, the impact of EHR on individual centers has received little attention. We proposed that an institutional review of EHR after renal transplantation may provide a benchmark for individual transplant programs and identify modifiable program-specific issues to reduce EHR. METHODS: We reviewed 269 consecutive kidney transplant recipients over a five-year period (2012-2016). Early hospital readmission was modeled using generalized linear modeling assuming a binary distribution. RESULTS: About 21% of patients were readmitted within 30 days. Deceased kidney donation (DD), delayed graft functioning (DGF), anti-thymocyte globulin (ATG) induction, diabetes, public insurance, weekend discharge, and low glomerular filtration rate (eGFR) at discharge were all identified as risk factors for readmission. Early hospital readmission was not correlated with risk of death (5.4% at 44 months: HR 2.2 (95% CI [0.7, 6.6]; P = 0.1473) or graft loss. CONCLUSIONS: EHR after renal transplantation is common. Certain factors may predict an increased risk for EHR. A multi-disciplinary approach to discharge planning may limit some EHR, but most complications and adverse events are unpredictable and require hospital-level of care.

Organ donation and imminent death: pro position.

PURPOSE OF REVIEW: Donation after cardiac death is associated with many problems including ischemic injury, high rates of delayed allograft function, prolonged time to asystole, and frequent organ discard. Imminent death donation (IDD) has been proposed as a separate category of organ donation: distinct from living donation and donation after cardiac death. RECENT FINDINGS: A protocol for IDD was developed at Rhode Island Hospital and published in the ethics literature. The United Network for Organ Sharing (UNOS) Ethics Committee reviewed the protocol and stated that IDD was ethically appropriate in some cases. A wider review by a working group within UNOS concluded similarly, but felt that a myriad of policy revisions would be required and were concerned about a possible negative impact on public trust in organ donation. Nonetheless, IDD and other nontraditional strategies continue to be proposed, implemented in other countries and discussed by patients and donor families. SUMMARY: This review, on the 'Pro' side of IDD, proposes that the medical community continue to work toward implementing IDD. Donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for their loved one. In some cases, IDD is the best strategy to meet these goals.

Immunosuppression in the failing and failed transplant kidney: optimizing outcomes.

There is little data to guide clinicians on the optimal management of immunosuppression in patients whose kidney transplant has failed and who have returned to dialysis. Nor is there robust data on whether to perform a transplant nephrectomy. Finally, management of late stage chronic kidney disease, including deciding on dialysis initiation, modality and access planning, must occur simultaneously with efforts aimed at preserving the failing kidney and residual renal function for as long as possible. In this article, we will review the evidence on these topics and suggest areas for improvement.

Immunosuppression after renal allograft failure: a survey of US practices.

BACKGROUND: Little data exist to guide the management of immunosuppression after renal graft failure. More aggressive tapering of immunosuppressive medications may reduce the risk of infection, but may increase the risk of rejection and sensitization. METHODS: To document current practices in the US, we emailed a questionnaire to medical and surgical transplant directors as identified by the United Network for Organ Sharing (UNOS). RESULTS: Emails were sent to 221 programs, of which 93 (42.1%) responded. About 24.7% of respondents reported adjusting immunosuppression according to a standard protocol; 75.3% said practices are physician dependent. The majority said that 80 or 100% of patients are off all immunosuppression one yr after returning to dialysis. The most important factors cited in deciding whether to stop immunosuppression were plans to retransplant (40.2%) and signs and symptoms of rejection (37.0%). When asked which immunosuppressive medications are continued indefinitely, 21.5% responded prednisone and 71.0% said none. Respondents most commonly said they performed graft nephrectomy only if there are signs and symptoms of rejection (47.3%) or if signs and symptoms of rejection fail to respond to steroids (34.4%). CONCLUSIONS: In the absence of good data to guide decisions on immunosuppression in patients with failed allografts, practices in the US vary greatly. More data are needed to determine which policies lead to the best outcomes.

The case for kidney donation before end-of-life care.

Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor's death, this approach satisfies the dead donor rule. The donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives.

Online Patient Portal Use and Time to Renal Transplantation in Patients on Hemodialysis.

BACKGROUND: Online portals have been shown to be a valuable tool for patients to improve compliance with medical treatment in numerous studies across medical specialties. Our aim was to study the effects of the use of web-based applications that allow patients to track their appointments, labs, and provider visit notes on achievement of renal transplantation. STUDY DESIGN: This is a retrospective chart review of patients in 2 outpatient dialysis centers associated with a 719-bed tertiary care academic medical center. RESULTS: Nine percent of portal users at 3 years after initiation of hemodialysis were the recipients of kidney transplants vs 9% of nonusers. At 4 years, 23% of users were transplant recipients vs 13% of nonusers. At 5 years, 40% of users were transplant recipients vs 14% of nonusers. There was statistically significant divergence of the curves, with the greatest difference observed at 5 years (p = 0.047). In addition, increased number of logins per month was associated with shortened time to renal transplantation (p = 0.0067). CONCLUSIONS: Online portal use is associated with a higher likelihood of being approved as a transplantation candidate and increased number of logins is associated with shortened time to renal transplantation.

Online patient resources for deceased donor and live donor kidney recipients: a comparative analysis of readability.

BACKGROUND: The Internet has extensive resources for kidney transplantation recipients. Half of the population reads below a seventh-grade level. Previous studies showed that living donor recipients have higher health literacy rates compared with deceased donor recipients. There has been no study comparing the readability of online living donor recipient materials versus deceased donor recipient materials. METHODS: Analysis was performed using eight readability scales on the top 10 websites for live donor and deceased donor kidney transplantation. Analysis was performed through the Readability Studio Software. USA reading grade level was determined for each site. RESULTS: Overall, the mean reading level for the living donor materials was 12.54 (range 9.2-17) and for the deceased donor materials, 12.87 (range 8.7-17, P = 0.73), corresponding to a university level. None of the sites met the seventh-grade level recommended by the National Institute of Health. CONCLUSIONS: The readability of online materials remains too high for the corresponding health literacy rates among patients requiring kidney transplantation. Specifically, the lower health literacy rates among deceased donor recipients does not mirror the readability of online materials provided at a university level. This may affect decision-making, contributing to a smaller proportion of patients of a lower socioeconomic status and those with poor English language skills pursuing live donor organs.

Medication noncompliance and its implications in transplant recipients.

The transplant patient's therapeutic regimen consists of a lifelong drug therapy, including immunosuppressive drugs, prophylactic antimicrobials and often medications for the treatment of hypertension, diabetes mellitus and other comorbid diseases. Regular clinic appointments are required to monitor for signs and symptoms of immunological injury, recurrent disease and adverse drug effects. Patients are instructed to avoid risk factors for cardiovascular disease and cancer (e.g. diet, exercise, sun protection and not smoking). Noncompliance with all aspects of this regimen is substantial. Medication noncompliance leads to an increased incidence of acute rejection, chronic rejection and graft loss. Undoubtedly, many practitioners fail to appreciate the extent of noncompliance as the signs are often subtle and most patients are unwilling to disclose deliberate or widespread disregard for medication use. Newer immunosuppressive agents, particularly once-daily medications and long-acting antibody preparations offer convenience and monitoring that may improve compliance. This review focuses on the prevalence, correlates and consequences of medication nonadherence after organ transplantation. Current recommendations to enhance adherence are discussed.

Utility of a mathematical nomogram to predict delayed graft function: a single-center experience.

BACKGROUND: In 2003, Irish and colleagues published a weighted nomogram designed to predict the risk of delayed graft function (DGF) in a given transplant. It was anticipated that the predictive nomogram would permit preemptive therapies or allocation decisions based on the risk of DGF. The potential for reducing unfavorable outcomes and expenses appeared significant. This nomogram, however, was developed using population data found in the United States Renal Data System and has not been prospectively validated. METHODS: We evaluated the accuracy and utility of this nomogram in all cadaver renal transplants performed at a single transplant center. In addition, we correlated DGF with a variety of independent donor and recipient variables outside the established nomogram. RESULTS: The average nomogram DGF risk was 0.41 (a 41% chance of DGF) among the 169 cases in our population. The mean was 0.45+/-0.14 (confidence interval: 0.40-0.49) for the 42 DGF-positive subjects, and 0.40+/-0.14 (confidence interval: 0.38-0.43) for the 127 DGF-negatives (t=1.80; P=0.07). CONCLUSIONS: Although there was a trend showing the predictive value of the nomogram the overlap was tremendous, limiting the accuracy of the calculation for any single recipient. Prospective application of a nomogram on a case-by-case basis did not contribute meaningful information that could guide clinical decision-making regarding use, allocation or immunosuppressive regimen aimed at minimizing DGF.

Living kidney donation: evolution and technical aspects of donor nephrectomy.

For more than 40 years, living donor nephrectomy was performed through a flank incision drawn on the urologic experience with nephrectomy for cancer. Since its introduction one decade ago, laparoscopic donor nephrectomy has gained widespread acceptance and popularity; currently over one-half of donor nephrectomies in the United States are performed with this technique. The changing practice of donor nephrectomy resembles in many ways the evolution of minimally invasive in other subspecialties. The lessons learned from these technical developments are valuable and can be adapted by general surgeons and urologists when called upon to perform nephrectomy for organ donation or kidney disease.

Renal transplantation: older recipients and donors.

The majority of patients receiving a renal allograft, including a kidney from an older donor, do well. Renal transplantation from a living donor is associated with distinct advantages, including prolonged allograft survival. When live donors are not available, however, deceased donor kidneys provide suitable renal function that frequently lasts the lifetime of elderly recipients. Elderly patients who receive a kidney transplant enjoy improved survival, better quality of life, and lower medical costs than those who remain on dialysis.

Renal transplant survival from older donors: a single center experience.

HYPOTHESIS: Despite the observation that kidney transplantations from older donors have an increased risk of failure, the percentage of kidney donors 55 years and older has increased. We explored the risk of allograft failure in a single transplantation center with older (55-79 years) vs younger (18-54 years) donors. DESIGN: Retrospective cohort review with a mean follow-up of 32 months. SETTING: Academic transplant center. PATIENTS: Consecutive recipients (n = 324) of renal transplants from adult donors. INTERVENTIONS: Patients were divided into 4 groups based on donor status (living or deceased) and donor age (< or =54 or > or =55 years). MAIN OUTCOME MEASURES: Allograft survival and function, incidence of acute rejection. RESULTS: Recipients of older donor kidneys were significantly older (53.6 vs 43.6 years, P<.001). Seven allografts (12.7%) failed from 55 transplants from donors 55 years and older, compared with 41 allografts (15.2%) from 269 younger donors (P =.63). Renal function was superior following renal transplantation using younger donors (P =.004). However, renal function was acceptable in all groups, with a mean +/- SD serum creatinine level of 1.7 +/- 0.4 mg/dL (150 +/- 35 micro mol/L) among recipients of older donor kidneys. Allograft survival at 1, 2, and 3 years, censored for death with allograft function, did not differ when comparing older vs younger donors. CONCLUSIONS: Most patients receiving allografts from older donors do well. Older donor kidneys provide suitable renal function for many patients on dialysis awaiting transplantation.

Donation after circulatory death: current practices, ongoing challenges, and potential improvements.

Organ donation after circulatory death (DCD) has been endorsed by the World Health Organization and is practiced worldwide. This overview examines current DCD practices, identifies problems and challenges, and suggests clinical strategies for possible improvement. Although there is uniform agreement on DCD donor candidacy (ventilator-dependent individuals with nonrecoverable or irreversible neurologic injury not meeting brain death criteria), there are variations in all aspects of DCD practice. Utilization of DCD organs is limited by hypoxia, hypotension, reduced--then absent--organ perfusion, and ischemia/reperfusion syndrome. Nevertheless, DCD kidneys exhibit comparable function and survival to donors with brain death kidneys, although they have higher rates of primary graft nonfunction, delayed graft function, discard, and retrieval associated injury. Concern over ischemic organ injury underscores the reluctance to recover extrarenal DCD organs since lack of medical therapy to support inadequate allograft function limits their acceptability. Nevertheless, limited results with DCD pancreas, liver, and lung allografts (but not heart) are now approaching that of donors with brain death organs. Pretransplant machine perfusion of DCD kidneys (vs. static storage) may reduce delayed graft function but has no effect on long-term organ function and survival. Normothermic regional perfusion used during DCD abdominal organ retrieval may reduce ischemic organ injury and increase the number of usable organs, although critical confirmative studies have yet to be done. Minor increases in usable DCD kidneys could accrue from increased use of pediatric DCD kidneys and from selective use of DCD/ECD kidneys, whereas a modest increase could result through utilization of donors declared dead beyond 1 hr from withdrawal of life support therapy. A significant increase in transplantable kidneys could be achieved by extension of the concept of living kidney donation in relation to imminent death of potential DCD donors. Progress in research to identify, prevent, and repair DCD-associated organ retrieval injury should improve utilization of DCD organs. Recent results using ex situ pretransplant organ perfusion of DCD organs has been encouraging in this regard.

Efficacy and safety of phenylephrine in the management of low systolic blood pressure after renal transplantation.

BACKGROUND: Phenylephrine can be used to treat postoperative hypotension after renal transplantation. However, its effect on the renal allograft is unknown. We evaluated the safety and efficacy of this approach. STUDY DESIGN: A retrospective cohort study of 307 renal transplant recipients between November 2005 and October 2011 was conducted, including 75 who required phenylephrine, 46 of whom were deceased donors renal transplant (DDRT) recipients and 29 who were living donor transplant (LDRT) recipients. These were compared with 75 controls matched by sex, age, type of transplant, and etiology of renal failure. The primary outcome was rate of delayed graft function (DGF). The following statistical tools were used: paired t-test for continuous data, McNemar's test for categorical data, and a nonlinear mixed decay model for change in serum creatinine (Cr). RESULTS: Of 46 DDRT recipients who required phenylephrine, 17 developed DGF compared with 10 matched controls (relative risk [RR] 2.9, CI 1.4 to 6.0, p = 0.0040). Only one LDRT recipient required hemodialysis (DGF). No differences were noted in the number of hemodialysis treatments required (mean 2.7 in treatment group vs 3.4 in control). No significant differences were observed between phenylephrine and control groups in renal function on postoperative days 30, 90, and 365 Cr or graft survival. The immediate postoperative normalization of Cr was slower in the DDRT phenylephrine group compared with DDRT controls (p < 0.0001), but no difference in Cr was noted before discharge (p = 0.49). CONCLUSIONS: Although there is a brief association between phenylephrine administration and a slower rate of transplanted kidney recovery, there is no clinically or statistically significant impaired outcome in the phenylephrine group at time of discharge. Administration of phenylephrine to support low blood pressure after renal transplant appears safe.

Use of an immune function assay to monitor immunosuppression for treatment of post-transplant lymphoproliferative disorder.

The first-line treatment for PTLD is reduction in immunosuppression, allowing partial reconstitution of cell-mediated immunity. However, there is a risk of inducing acute allograft rejection during clinical resolution of PTLD. A recently available assay, Immuknow, measures the cell-mediated immune response and could be used to monitor reduction of immunosuppression. We report a case of PTLD occurring in a pediatric kidney transplant recipient where the reduction in immunosuppression was serially followed using this assay and quantitative EBV-PCR. A rapid reduction to minimal immunosuppression was followed by resolution of PTLD. Later, when the cell-mediated immune response increased, with negative viral load, immunosuppression was gradually increased utilizing the assay to adjust dosing. Presently, there are no signs of PTLD and renal function remains normal.

Management of thrombophilia in renal transplant patients.

Renal allograft recipients with thrombophilia (a hypercoagulable state) are at higher risk for early allograft loss. Following an episode of allograft renal vein thrombosis in a patient subsequently diagnosed with protein C deficiency, we adopted universal screening for hypercoagulable risk factors. Patients with a history of a thromboembolic event underwent laboratory screening for thrombophilia. Eight patients with a defined hypercoagulable disorder or a strong clinical history of thrombosis even in the absence of hematologic abnormalities were treated with anticoagulation following renal transplantation. We reviewed the outcomes of these eight patients and all renal transplant recipients at our center who developed thrombotic complications after renal transplantation. Since the introduction of universal screening for hypercoagulable risk factors, 235 consecutive transplants were performed without allograft thrombosis. Eight patients with evidence of thrombophilia, recognized before renal transplantation, received perioperative heparin and postoperative oral anticoagulation. Two of these eight patients developed perinephric hematomas requiring evacuation, blood transfusion, and temporary withholding of anticoagulation. Of interest, two of the remaining 227 patients, not identified with thrombophilia before surgery, developed thrombotic complications after renal transplantation. A hypercoagulable disorder was subsequently documented in each. Identifying patients with thrombophilia before transplantation and defining their management presents many challenges. The risk of allograft thrombosis must be weighed against the risk of perioperative bleeding and the need for long-term anticoagulation. Recommendations for managing thrombophilia in renal transplant recipients are suggested based on our experience and review of the literature.