KDPI score is a strong predictor of future graft function: Moderate KDPI (35 - 85) and high KDPI (> 85) grafts yield similar graft function and survival
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BACKGROUND: Efforts have been made to maximize the utility of each organ transplanted. Policy changes to capture unrealized graft years have been implemented utilizing the kidney donor profile index (KDPI). Understanding the impact of KDPI on long-term graft function is critical to an informed organ acceptance decision. METHODS: We reviewed the records of 309 consecutive deceased adult donor kidney recipients who underwent kidney transplantation at our center. We obtained KDPI of the allografts directly from United Network for Organ Sharing (UNOS) and patients were divided into four categories: KDPI ≤ 20, KDPI 21 - 35, KDPI 36 - 85, and KDPI > 85. RESULTS: Of the 309 recipients, 48 (15.5%) received kidneys from donors with KDPI ≤ 20, 57 (18.4%) from donors with KDPI 21 - 35, 161 (52.1%) from donors with KDPI 36 - 85, and 43 (13.9%) from donors with KDPI > 85. Older recipients were more likely to receive high KDPI kidneys (p = 0.025). Kaplan-Meier analysis demonstrated the KDPI > 35 group had worse survival than the KDPI ≤ 20 group, but KDPI 36 - 85 was not different from KDPI > 85. The rate of poor graft function differed at 1 year: 14.6% of KDPI ≤ 20 recipients, 14.3% of KDPI 21 - 35 recipients, 30.6% of KDPI 35 - 85 recipients, and 40.5% of KDPI > 85 recipients had serum creatinine greater than 2.0 mg/dL at 1 year. KDPI > 35 had statistically significantly greater incidence of poor graft function than KDPI ≤ 35 (p < 0.05). CONCLUSIONS: Our study demonstrates that high KDPI grafts behave more like moderate KDPI grafts (KDPI 35 - 85). Creatinine (Cr) greater than 2.0 mg/dL portends poorer long-term graft survival, and this outcome is similar amongst all recipients of KDPI > 35 allografts.
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Peritransplant kidney biopsies: comparison of pathologic interpretations and practice patterns of organ procurement organizations.

The preimplantation kidney biopsy affects utilization by diagnosing glomerulosclerosis, interstitial fibrosis (IF), arteriosclerosis, and arteriolar hyalinosis. Organ procurement organizations (OPOs) determine whether a donor warrants this biopsy and the donor hospital pathologists (DHPs) report on an OPO-specific pathology interpretation form. Biopsy slides from 40 deceased donor kidneys transplanted at our institution were used to compare interpretations between our transplant pathologist and the DHPs. Thirty-three of these kidneys also had post-perfusion biopsies (PPB). All 58 OPOs were queried for criteria used to request a preimplantation biopsy, and their pathology interpretation forms were also analyzed. The transplant and DHPs had substantial agreement for percent glomerulosclerosis with 75% of biopsies being interpreted within five percentage points. Concordance for IF was poor. The DHP rarely reported arterial pathology. Seventy percent of preimplantation and PPB were read similarly for glomerulosclerosis; concordance for other lesions was weaker. There were no cues for arterial disease on our OPO's pathology interpretation form. Criteria for obtaining a preimplantation biopsy lacked uniformity for the 21 OPOs with a self-generated policy. The pathology interpretation forms varied widely among the OPOs. Current OPO practices with regard to the preimplantation biopsy should be improved.

Metoprolol succinate, a selective beta-adrenergic blocker, has no effect on insulin sensitivity.

Insulin resistance is a risk factor for cardiovascular disease. Therapies to lower blood pressure should not decrease insulin sensitivity. Some b-adrenergic blocking agents can have an adverse effect on insulin sensitivity. This study examined the effect of extended-release metoprolol succinate on insulin sensitivity. Nondiabetics with hypertension (N=30) were started on (or changed to) hydrochlorothiazide (HCTZ) 12.5 mg daily for 14 days. Patients with blood pressure>140/90 mm Hg while taking HCTZ alone underwent an insulin clamp procedure to quantify insulin sensitivity. Metoprolol succinate treatment was begun at 50 mg daily and titrated to a dose that lowered blood pressure to <140/90 mm Hg. Following 12 weeks of metoprolol succinate plus HCTZ therapy, the insulin clamp procedure was repeated. On metoprolol succinate plus HCTZ treatment, there were no significant changes in insulin clamp measures of insulin sensitivity. Plasma cholesterol and low-density lipoprotein cholesterol decreased significantly on metoprolol succinate plus HCTZ. When b-blocker therapy is considered, metoprolol succinate can be used to treat hypertension without adverse metabolic effects.

Hypertension. Contemporary challenges in geriatric care.

Hypertension has been unequivocally linked to morbid complications such as heart attack, congestive heart failure, renal failure, and stroke. Despite the availability of myriad effective antihypertensive agents, blood pressure remains either untreated or inadequately controlled to even conservative goals in many patients. Only 68.4% of hypertensive individuals are aware of their condition, only 53.6% are under treatment, and nearly 75% fail to reach the recommended target pressure of 140/90 mm Hg. Significantly, only 40 to 50% of hypertensives will be controlled on a single agent, while most patients with more severe hypertension will require 3 or even 4 agents. This article reviews the overall approach to the hypertensive patient, with special emphasis on target blood pressures in special populations and problems frequently encountered in the older patient.

Patterns of volunteerism, testing, and exclusion among potential living kidney donors.

We found that in kidney transplantation, more females donate. We analyzed transplant recipients for patterns of potential donor exclusion and found that equal proportions of male and female potential donors existed among first-degree biological relatives. More male recipients were married and therefore had more spousal potential donors. Among friends and non-first-degree relatives, significantly fewer males offered to donate to females. Equal proportions of female and male potential donors were excluded from donating for medical comorbidities, blood type incompatibility, recipient refusal, and potential donor reluctance. We concluded that female transplant candidates had fewer potential donors among spouses and opposite sex volunteers from friends and non-first-degree relatives.

Successful living donor renal transplantation despite ABO incompatibility and a positive crossmatch.

Potential live kidney donors have been rejected when the prospective recipients are blood type or crossmatch incompatible. By utilizing plasmapheresis combined with intravenous immune globulin (PP/IVIg) prior to surgery, donor-specific antibodies against blood group or human leukocyte antigens (HLA) have been removed, thereby allowing successful renal transplantation. A 26-yr-old male with a panel reactive antibody level of 100% and repeated positive crossmatches against deceased donor kidney offers, including zero HLA mismatched donors, successfully underwent ABO-incompatible kidney transplantation from his HLA-identical but nevertheless crossmatch-incompatible sister. The initial anti-A blood group isoagglutinin titers were 128, 256, and 1024 at room temperature, 37 degrees C, and 37 degrees C anti-IgG enhanced, respectively. With an individualized PP/IVIg regimen based on donor-specific antibody titer, however, the relevant antibodies were adequately reduced and hyperacute rejection avoided. Subsequent antibody-mediated rejection, likely directed against a minor histocompatibility antigen, was diagnosed on postoperative day 7 and successfully treated. Neither ABO, or crossmatch incompatibility, or both in combination prohibit kidney transplantation.