RESUMO
Race-inclusive estimated glomerular filtration rate (eGFR) could contribute to racial disparity in access to kidney transplantation. The Organ Procurement and Transplantation Network (OPTN) issued a policy allowing waiting time modification for candidates affected by race-inclusive eGFR calculations. Implementation of the new OPTN policy at the kidney transplant program of the Mount Sinai Hospital involved review of 921 African American candidates, of whom 240 (26%) candidates gained a median of 1 year and 10 months. The duration of time candidates gained varied from a minimum of 5 days to a maximum of 12 years and 3 months; 45.4% gained at least 2 years, and 12% gained at least 4 years of wait time. Among those who gained wait time, 20 (8.3%) candidates received deceased donor kidney transplants. Candidates who gained wait time had similar sociodemographic characteristics as those who did not, except that the median age for the former was higher by 3 years (59 vs. 56). Our early data suggest that the current policy on waiting time modification for candidates affected by race-inclusive estimation of GFR has the potential to improve racial disparity in access to kidney transplantation. However, the generalizability of our findings to other centers requires further study.
Assuntos
Transplante de Rim , Obtenção de Tecidos e Órgãos , Listas de Espera , Humanos , Negro ou Afro-Americano , Taxa de Filtração Glomerular , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVES: (1) Determine inter-observer reproducibility and test-retest repeatability of 4D flow parameters in renal allograft vessels; (2) determine if 4D flow measurements in the renal artery (RA) and renal vein (RV) can distinguish between functional and dysfunctional allografts; (3) correlate haemodynamic parameters with estimated glomerular filtration rate (eGFR), perfusion measured with dynamic contrast-enhanced MRI (DCE-MRI) and histopathology. METHODS: Twenty-five prospectively recruited renal transplant patients (stable function/chronic renal allograft dysfunction, 12/13) underwent 4D flow MRI at 1.5 T. 4D flow coronal oblique acquisitions were performed in the transplant renal artery (RA) (velocity encoding parameter, VENC = 120 cm/s) and renal vein (RV) (VENC = 45 cm/s). Test-retest repeatability (n = 3) and inter-observer reproducibility (n = 10) were assessed by Cohen's kappa, coefficient of variation (CoV) and Bland-Altman statistics. Haemodynamic parameters were compared between patients and correlated to the estimated glomerular filtration rate, DCE-MRI parameters (n = 10) and histopathology from allograft biopsies (n = 15). RESULTS: For inter-observer reproducibility, kappa was > 0.99 and 0.62 and CoV of flow was 12.6% and 7.8% for RA and RV, respectively. For test-retest repeatability, kappa was > 0.99 and 0.5 and CoV of flow was 27.3% and 59.4%, for RA and RV, respectively. RA (p = 0.039) and RV (p = 0.019) flow were both significantly reduced in dysfunctional allografts. Both identified chronic allograft dysfunction with good diagnostic performance (RA: AUC = 0.76, p = 0.036; RV: AUC = 0.8, p = 0.018). RA flow correlated negatively with histopathologic interstitial fibrosis score ci (ρ = - 0.6, p = 0.03). CONCLUSIONS: 4D flow parameters had better repeatability in the RA than in the RV. RA and RV flow can identify chronic renal allograft dysfunction, with RA flow correlating with histopathologic interstitial fibrosis score. KEY POINTS: ⢠Inter-observer reproducibility of 4D flow measurements was acceptable in both the transplant renal artery and vein, but test-retest repeatability was better in the renal artery than in the renal vein. ⢠Blood flow measurements obtained with 4D flow MRI in the renal artery and renal vein are significantly reduced in dysfunctional renal transplants. ⢠Renal transplant artery flow correlated negatively with histopathologic interstitial fibrosis score.
Assuntos
Nefropatias/diagnóstico por imagem , Transplante de Rim , Adulto , Idoso , Biópsia , Velocidade do Fluxo Sanguíneo/fisiologia , Feminino , Taxa de Filtração Glomerular , Hemodinâmica , Humanos , Nefropatias/cirurgia , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos TestesRESUMO
The influence of patient characteristics and immunosuppression management on COVID-19 outcomes in kidney transplant recipients (KTRs) remains uncertain. We performed a single-center, retrospective review of all adult KTRs admitted to the hospital with confirmed COVID-19 between 03/15/2020 and 05/15/2020. Patients were followed from the date of admission up to 1 month following hospital discharge or study conclusion (06/15/2020). Baseline characteristics, laboratory parameters, and immunosuppression were compared between survivors and patients who died to identify predictors of mortality. 38 KTRs with a mean baseline eGFR of 52.5 ml/min/1.73 m2 were hospitalized during the review period. Maintenance immunosuppression included tacrolimus (84.2%), mycophenolate (89.5%), and corticosteroids (81.6%) in the majority of patients. Eleven patients (28.9%) died during the hospitalization. Older age (OR = 2.05; 1.04-4.04), peak D-dimer (OR = 1.20; 1.04-1.39), and peak white blood cell count (OR = 1.11; 1.02-1.21) were all associated with mortality among KTRs hospitalized for COVID-19. Increased mortality was also observed among KTRs with concomitant HIV infection (87.5% vs. 36.1%; p < .01). Conversely, immunosuppression intensity and degree of reduction following COVID-19 diagnosis were not associated with either survival or acute allograft rejection. Our findings potentially support a strategy of individualization of immunosuppression targets based on patient-specific risk factors, rather than universal immunosuppression reduction for KTRs at risk from COVID-19.
Assuntos
COVID-19/mortalidade , Imunossupressores/uso terapêutico , Transplante de Rim/mortalidade , Corticosteroides/uso terapêutico , Adulto , Idoso , Feminino , Rejeição de Enxerto/epidemiologia , Infecções por HIV , Humanos , Terapia de Imunossupressão , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Tacrolimo/uso terapêutico , TransplantadosRESUMO
Here we assessed the diagnostic value of a quantitative multiparametric magnetic resonance imaging (mpMRI) protocol for evaluation of renal allograft dysfunction with fibrosis. Twenty-seven renal transplant patients, including 15 with stable functional allografts (eGFR mean 71.5 ml/min/1.73m2), and 12 with chronic dysfunction/established fibrosis (eGFR mean 30.1 ml/min/1.73m2), were enrolled in this prospective single-center study. Sixteen of the patients had renal biopsy (mean 150 days) before the MRI. All patients underwent mpMRI at 1.5T including intravoxel-incoherent motion diffusion-weighted imaging, diffusion tensor imaging, blood oxygen level dependent (BOLD R2*) and T1 quantification. True diffusion D, pseudodiffusion D*, perfusion fraction PF, apparent diffusion coefficient (ADC), fractional anisotropy (FA), R2* and T1 were calculated for cortex and medulla. ΔT1 was calculated as (100x(T1 Cortex-T1 Medulla)/T1 Cortex). Test-retest repeatability and inter-observer reproducibility were assessed in four and ten patients, respectively. mpMRI parameters had substantial test-retest and interobserver repeatability (coefficient of variation under 15%), except for medullary PF and D* (coefficient of variation over 25%). Cortical ADC, D, medullary ADC and ΔT1 were all significantly decreased, while cortical T1 was significantly elevated in fibrotic allografts. Cortical T1 showed positive correlation to the Banff fibrosis and tubular atrophy scores. The combination of ΔT1 and cortical ADC had excellent cross-validated diagnostic performance for detection of chronic dysfunction with fibrosis. Cortical ADC and T1 had good performance for predicting eGFR decline at 18 months (4 or more ml/min/1.73m2/year). Thus, the combination of cortical ADC and T1 measurements shows promising results for the non-invasive assessment of renal allograft histology and outcomes.
Assuntos
Transplante de Rim , Imageamento por Ressonância Magnética Multiparamétrica , Imagem de Tensor de Difusão , Fibrose , Humanos , Transplante de Rim/efeitos adversos , Imageamento por Ressonância Magnética , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
Transplantation of organs from hepatitis C virus (HCV)-antibody (Ab) and -nucleic acid test (NAT) positive donors into HCV-negative recipients has been proposed to expand the donor pool and shorten waiting times. Data on early single-center outcomes are lacking. Nineteen liver (LT, including seven simultaneous liver-kidney [SLKT]) and 17 kidney transplant (KT) recipients received organs from HCV (+) donors; of these, 13 were HCV NAT (+) in each group. All patients who received organs from HCV NAT (+) donors developed HCV viremia post-transplant except for 2 KT recipients. Patients were treated with a variety of direct-acting antiviral regimens, with high rates of sustained virologic response among those with at least 12 weeks of follow-up past the end of treatment: 12/13 (92%) and 8/8 (100%) among LT/SLKT, and KT recipients. Median time to treatment start was 42 days (interquartile range [IQR] 35-118 days) and 40 days (IQR 26-73) post-LT/SLKT and KT, respectively. One death occurred in a SLKT recipient unrelated to HCV or its treatment. There was no significant increase in rejection, proteinuria, or changes in immunosuppression in any group. Organs from HCV-viremic donors can be utilized for HCV-uninfected recipients with good short-term outcomes.
Assuntos
Hepatite C Crônica , Hepatite C , Transplante de Rim , Transplante de Fígado , Antivirais/uso terapêutico , Hepacivirus , Hepatite C/tratamento farmacológico , Hepatite C Crônica/tratamento farmacológico , Humanos , Rim , Doadores de TecidosRESUMO
BACKGROUND: There is an unmet need for noninvasive methods to diagnose and stage renal allograft fibrosis. PURPOSE: To investigate the utility of T1ρ measured with MRI for the assessment of fibrosis in renal allografts. STUDY TYPE: Institutional Review Board (IRB)-approved prospective. SUBJECTS: Fifteen patients with stable functional allograft (M/F 9/6, mean age 56 years) and 12 patients with allograft dysfunction and established fibrosis (M/F 6/6, mean age 51 years). FIELD STRENGTH/SEQUENCE: T1ρ imaging at 1.5T using a custom-developed sequence. ASSESSMENT: Average T1ρ in the cortex and medulla was quantified and T1ρ repeatability (expressed by the coefficient of variation [CV]) was measured in four patients. STATISTICAL TESTS: Differences in T1ρ values between the 2 groups were assessed using Mann-Whitney U-tests. Diagnostic performance of T1ρ for differentiation between functional and fibrotic allografts was evaluated using receiver operating characteristic (ROC) analysis. Spearman correlations of T1ρ with Masson's trichrome-stained fractions and serum estimated glomerular filtration rate (eGFR) were assessed. RESULTS: Higher T1ρ repeatability was found for cortex compared with medulla (mean CV T1ρ cortex 7.4%, medulla 13.3%). T1ρ values were significantly higher in the cortex of fibrotic vs. functional allografts (111.8 ± 17.2 msec vs. 99.0 ± 11.0 msec, P = 0.027), while there was no difference in medullary T1ρ values (122.6 ± 20.8 msec vs. 124.3 ± 20.8 msec, P = 0.789). Cortical T1ρ significantly correlated with Masson's trichrome-stained fractions (r = 0.515, P = 0.044) and eGFR (r = -0.546, P = 0.004), and demonstrated an area under the curve (AUC) of 0.77 for differentiating between functional and fibrotic allografts (sensitivity and specificity of 75.0% and 86.7%, using threshold of 106.9 msec). DATA CONCLUSION: Our preliminary results suggest that T1ρ is a potential imaging biomarker of renal allograft fibrosis. These results should be verified in a larger study. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;50:1085-1091.
Assuntos
Interpretação de Imagem Assistida por Computador/métodos , Nefropatias/diagnóstico por imagem , Nefropatias/patologia , Transplante de Rim , Imageamento por Ressonância Magnética/métodos , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/patologia , Adulto , Idoso , Feminino , Fibrose , Humanos , Rim/diagnóstico por imagem , Rim/patologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
Candidates for living donor kidney transplantation (LDKT) find it difficult to discuss living donation with people in their social network, and there is a lack of useful interventions to train them. The Kidney Coach Program (KCP) was developed to equip individuals (advocates for candidates and candidate themselves) with the tools needed to find potential donors. The purpose of this pilot study is to evaluate the effects of the KCP on increasing the number of people considering living donation. METHODS: Candidates for the KCP were recruited. Data were collected on the number of live donor inquiries in the coach group compared to listed patients (historical controls). RESULTS: Over a 12-month period, 20 transplant candidates enrolled in the KCP were compared to 50 controls. Eighty percent of the participants in the KCP had at least one donor inquiry compared to 38% of controls (P = 0.001). Significantly, more Caucasian candidates participated in the KCP compared to other racial groups. CONCLUSIONS: The KCP can be an effective method to increase awareness of a patient's need for LDKT. Existing clinical staff successfully implemented the program. Transplant programs should provide training to candidates and their supports on effective ways to find a living donor.
Assuntos
Educação em Saúde/métodos , Implementação de Plano de Saúde , Transplante de Rim , Doadores Vivos/educação , Doadores Vivos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Inquéritos e Questionários , Adulto JovemRESUMO
Belatacept is a non-nephrotoxic immunosuppressive agent, which may make it the ideal agent for patients with delayed or slow graft function on calcineurin inhibitors. There are limited data on conversion of patients to belatacept within 6 months of transplantation. Between January 2012 and December 2015, 16 patients were converted to belatacept for delayed or poor graft function (eGFR<30 mL/min/1.73 m2 , MDRD); three were HIV positive. Conversion protocols were analyzed in patients ≤4 months and 4-6 months post-transplantation. Mean serum creatinine levels after belatacept conversion were compared with preconversion levels. Patient survival was 100%, and graft survival was 88%. The mean creatinine fell from 3.9±1.82 mg/dL prebelatacept conversion to 2.1±1.1 mg/dL at 6 months and 1.9±0.47 mg/dL (median 1.8 mg/dL) at 12 months postconversion. There was no significant increased risk of rejection, infection, or malignancy. HIV parameters remained largely stable. Early conversion to belatacept in patients with DGF or slow graft function is safe and efficacious, in a single-center nonrandomized retrospective analysis.
Assuntos
Abatacepte/uso terapêutico , Inibidores de Calcineurina/farmacologia , Rejeição de Enxerto/tratamento farmacológico , Sobrevivência de Enxerto/efeitos dos fármacos , Imunossupressores/uso terapêutico , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/etiologia , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de RiscoRESUMO
Limited data exist on the effect of intravenous immunoglobulin (IVIg) on anti-HLA antibodies as determined by solid-phase assays. We reviewed our experience treating sensitized wait-listed kidney transplant recipients with IVIg as a method for desensitization and report our results utilizing Luminex single antigen (LSA) bead assay to quantify antibody reactivity (MFI). Fifteen patients with a cPRA > 40% received 2 g/kg IVIg per month for four months or until transplanted. LSA testing was performed before and after IVIg. Median MFI for anti-class I antibodies fell in 11 (73%) and increased in 4 (27%) patients after IVIg. Similar significant changes in MFI for anti-class II antibodies were observed in 10 patients (66%). Administration of IVIg was associated with a modest decrease in reactivity to both class I and II HLA antigens (median MFI change 493 and 1110, respectively; p < 0.0001) but did not significantly alter mean cPRA (85% before IVIg vs. 80% after IVIg; p = 0.1). Our data suggest a smaller effect of IVIg on HLA antibody reactivity than previously described, leading us to question how best to measure the efficacy of a desensitization protocol in current practice.
Assuntos
Antígenos HLA/imunologia , Hipersensibilidade/tratamento farmacológico , Imunoglobulinas Intravenosas/administração & dosagem , Fatores Imunológicos/administração & dosagem , Isoanticorpos/imunologia , Transplante de Rim/imunologia , Adolescente , Adulto , Idoso , Criança , Dessensibilização Imunológica , Feminino , Seguimentos , Rejeição de Enxerto/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Condicionamento Pré-Transplante , Listas de EsperaRESUMO
Introduction: Insulin is commonly prescribed to manage early post-kidney transplant hyperglycemia due to its flexibility. Studies comparing the effectiveness of oral therapies on glycemic outcomes remain limited. Project aims: The purpose of this program evaluation was to analyze our experience using oral antiglycemic agents immediately post-kidney transplant, compared to patients managed with insulin monotherapy. Design: This was a single-center, retrospective review of adult kidney transplant recipients with new or worsening hyperglycemia between 01/2014-05/2020. Patients were excluded if they had a prior or combined organ transplant, type 1 diabetes, or were previously on intensive insulin. Patients discharged on oral medications were 1:1 matched to patients receiving intensive insulin based on pre-specified clinical parameters. The primary endpoint was the number of diabetes-related readmissions within 6-months of transplant. Key secondary endpoints included mean serum glucose and hemoglobin A1c levels. Results: Thirty patients prescribed oral therapies were successfully matched to patients receiving intensive insulin. Baseline characteristics were similar between groups, except for more whites in the insulin group. There were no differences in diabetes-related (6.7% vs 3.3%; P = 1.00) or all-cause readmissions within 6-months. Mean serum glucose (P = .99) and hemoglobin A1c (P = .49) levels were also similar between patients receiving oral agents and insulin. However, 7 patients in the oral group were eventually converted to standing insulin. Conclusion: Our experience suggested that the early use of oral antiglycemics post-kidney transplant in select patients can result in similar outcomes relative to insulin. Meticulous follow-up is necessary as one-quarter of patients may require conversion to insulin within 1-month.
Assuntos
Diabetes Mellitus Tipo 2 , Hiperglicemia , Transplante de Rim , Adulto , Humanos , Insulina/uso terapêutico , Insulina/efeitos adversos , Hemoglobinas Glicadas/análise , Hemoglobinas Glicadas/uso terapêutico , Hipoglicemiantes/uso terapêutico , Hipoglicemiantes/efeitos adversos , Transplante de Rim/efeitos adversos , Controle Glicêmico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/etiologia , Glicemia , Hiperglicemia/tratamento farmacológico , Hiperglicemia/induzido quimicamenteRESUMO
Mount Sinai Hospital in New York has a long history in the field of organ transplantation. The first kidney transplant at Mount Sinai was performed in 1967 by the late Dr. Lewis Burrows and the first laparoscopic donor nephrectomy in New York was performed at Mount Sinai in 1996. Over 3000 kidney transplantations have been performed at Mount Sinai. In the early 1990s, the first hepatitis C virus (HCV) positive patient at Mount Sinai underwent a kidney transplant and the first kidney transplant in a patient with human immunodeficiency virus (HIV) in New York was performed at Mount Sinai in 2001. In general, these patients have done well after renal transplantation, with outcomes similar to those seen in non-infected patients. This chapter will describe the evolution of immunosuppressive regimens in HCV positive and HIV positive patients, and will describe the outcomes of kidney transplantation in these patients. Given the favorable outcomes, it is reasonable to continue to offer renal transplantation as a treatment for end stage renal disease patients with HCV and/or HIV.