Outcomes of kidney transplant from deceased donors with acute kidney injury and prolonged cold ischemia time - a retrospective cohort study.

While deceased donor renal transplants (DDRT) from donors with either acute kidney injury (AKI) or long cold ischemia time (CIT) are associated with increased risk of delayed graft function (DGF), recipients of these kidneys have good patient and allograft survival. There are limited data on whether kidneys with both AKI and long CIT have outcomes similar to kidneys with only one of these insults. Using data from the Scientific Registry of Transplant Recipients, we analyzed transplant outcomes in patients (2005-2015) receiving kidneys with AKI (terminal creatinine ≥2.0 mg/dl) and CIT 24-30 h (n = 1289), 30-36 h (n = 734), and >36 h (n = 614), using kidneys with AKI and CIT <24 h (n = 5434) as a reference. DGF was more common with increasing CIT up to 36 h, then decreased slightly (41.2% vs. 46.8% vs. 52.5% vs. 50.2%, P < 0.001). Death-censored graft survival (DCGS) at 3 years was better with CIT <24 h compared with other groups (92.5% vs. 90.8% vs. 92% vs. 89.2%, P = 0.018). On multivariable analysis, donor creatinine was predictive of DCGS, whereas only CIT >36 h was predictive of DCGS (aHR 1.27, P = 0.03). Recipients transplanted with kidneys with both AKI and long CIT have excellent intermediate-term outcomes.

Factors leading to the discard of deceased donor kidneys in the United States.

The proportion of deceased donor kidneys procured for transplant but subsequently discarded has been growing steadily in the United States, but factors contributing to the rising discard rate remain unclear. To assess the reasons for and probability of organ discard we assembled a cohort of 212,305 deceased donor kidneys recovered for transplant from 2000-2015 in the SRTR registry that included 36,700 kidneys that were discarded. 'Biopsy Findings' (38.2%) was the most commonly reported reason for discard. The median Kidney Donor Risk Index of discarded kidneys was significantly higher than transplanted organs (1.78 vs 1.12), but a large overlap in the quality of discarded and transplanted kidneys was observed. Kidneys of donors who were older, female, Black, obese, diabetic, hypertensive or HCV-positive experienced a significantly increased odds of discard. Kidneys from donors with multiple unfavorable characteristics were more likely to be discarded, whereas unilaterally discarded kidneys had the most desirable donor characteristics and the recipients of their partner kidneys experienced a one-year death-censored graft survival rate over 90%. There was considerable geographic variation in the odds of discard across the United States, which further supports the notion that factors beyond organ quality contributed to kidney discard. Thus, while the discard of a small fraction of organs procured from donors may be inevitable, the discard of potentially transplantable kidneys needs to be avoided. This will require a better understanding of the factors contributing to organ discard in order to remove the disincentives to utilize less-than-ideal organs for transplantation.

Effect of the iChoose Kidney decision aid in improving knowledge about treatment options among transplant candidates: A randomized controlled trial.

We previously developed a mobile- and web-based decision aid (iChoose Kidney) that displays individualized risk estimates of survival and mortality, for the treatment modalities of dialysis versus kidney transplantation. We examined the effect of iChoose Kidney on change in transplant knowledge and access to transplant in a randomized controlled trial among patients presenting for evaluation in three transplant centers. A total of 470 patients were randomized to standard transplantation education (control) or standard education plus iChoose Kidney (intervention). Change in transplant knowledge (primary outcome) among intervention versus control patients was assessed using nine items in pre- and postevaluation surveys. Access to transplant (secondary outcome) was defined as a composite of waitlisting, living donor inquiries, or transplantation. Among 443 patients (n = 226 intervention; n = 216 control), the mean knowledge scores were 5.1 ± 2.1 pre- and 5.8 ± 1.9 postevaluation. Change in knowledge was greater among intervention (1.1 ± 2.0) versus control (0.4 ± 1.8) patients (P < .0001). Access to transplantation was similar among intervention (n = 168; 74.3%) versus control patients (n = 153; 70.5%; P = .37). The iChoose Kidney decision aid improved patient knowledge at evaluation, but did not impact transplant access. Future studies should examine whether combining iChoose Kidney with other interventions can increase transplantation. (Clinicaltrials.gov NCT02235571).

Association between the "Timed Up and Go Test" at transplant evaluation and outcomes after kidney transplantation.

BACKGROUND: Studies have demonstrated the Timed Up and Go Test's (TUGT) ability to forecast postoperative outcomes for several surgical specialties. Evaluations of the TUGT for waitlist and posttransplant outcomes have yet to be examined in kidney transplantation. OBJECTIVE: To assess the prognostic utility of the TUGT and its associations with waitlist and posttransplant outcomes for kidney transplant candidates. DESIGN AND METHODS: Single-center, prospective study of 518 patients who performed TUGT during their transplant evaluation between 9/1/2013-11/30/2014. TUGT times were evaluated as a continuous variable or 3-level discrete categorical variable with TUGT times categorized as long (>9 seconds), average (8-9 seconds), or short (5-8 seconds). RESULTS: Transplanted individuals had shorter TUGT times than those who remained on the waitlist (8.99 vs 9.79 seconds, P < 0.001). Bivariable and multivariable logistic regression showed that after adjusting for age, there was no association between TUGT times and probability of waitlist removal (OR 0.997 [0.814-1.221]), prolonged length of stay posttransplant (OR 1.113 [0.958-1.306] for deceased donor, OR 0.983 [0.757-1.277] for living donor), and 30-day readmissions (OR 0.984 [0.845-1.146] for deceased donor, OR 1.254 [0.976-1.613] for living donor). CONCLUSIONS: The TUGT was not associated with waitlist removal or prolonged hospitalization for kidney transplant candidates. Alternative assessments of global health, such as functional status or frailty, should be considered for evaluation of potential kidney transplant candidates.

Outcomes for potential kidney transplant recipients offered public health service increased risk kidneys: A single-center experience.

BACKGROUND: Discard rate of Public Health Service Increased Risk (PHS-IR) organs is high despite the absence of worse kidney transplant outcomes. METHODS: We conducted a retrospective, single-center study of PHS-IR kidney offers made to kidney transplant-only potential recipients from 6/2004 to 5/2015. Overall mortality and transplant outcomes between potential recipients were stratified by response to PHS-IR kidney offers. Cox regression and Kaplan-Meier analyses of mortality and allograft failure were performed. RESULTS: A total of 2423 potential recipients were offered a PHS-IR kidney, with 1502 transplanted, with or without a PHS-IR kidney. Predictors of accepting a PHS-IR kidney included higher Estimated Post Transplant Survival (EPTS) score, prior kidney transplant, and lower educational achievement on multivariable analysis (P = 0.025, P = 0.004, P = 0.023). A positive response to a PHS-IR kidney was associated with lower risk of mortality (3.63% vs 11.6%; aHR 0.467, P = 0.0008). PHS-IR kidney recipients had decreased risk of allograft loss compared to non-PHS-IR recipients (P = 0.007), though mortality outcomes were not significantly different based on PHS-IR status (P = 0.38). No transmission of HIV, HBV, or HCV occurred from PHS-IR kidney donors in this cohort. CONCLUSIONS: Efforts must be made to increase awareness of the beneficial outcomes of PHS-IR organs to maximize appropriate donor allocation.

Association between Reperfusion Renal Allograft Biopsy Findings and Transplant Outcomes.

Biopsy findings at the time of procurement of deceased donor kidneys remain the most common reason cited for kidney discard. To determine the value of renal allograft histology in predicting outcomes, we evaluated the significance of histologic findings, read by experienced renal pathologists, in 975 postreperfusion biopsy specimens collected from 2005 to 2009 after living donor (n=427) or deceased donor (n=548) renal transplant. We evaluated specimens for the degree of glomerulosclerosis, interstitial fibrosis and tubular atrophy, and vascular disease; specimens with a score of 0 or 1 (scale, 0-3) for each parameter were considered optimal. Overall, 66.3% of living donor kidneys and 50.7% of deceased donor kidneys received an optimal histology score (P<0.001). Irrespective of donor status, suboptimal kidneys came from older donors with a higher incidence of diabetes mellitus, hypertension, and obesity and a higher mean kidney donor risk index (all P<0.001). Death-censored outcomes after transplant differed significantly between optimal and suboptimal kidneys only in the deceased donor transplants (P=0.02). Regardless of histologic classification, outcomes with deceased donor kidneys were inferior to outcomes with living donor kidneys. However, 73.2% of deceased donor kidneys with suboptimal histology remained functional at 5 years. Our findings suggest that histologic findings on postreperfusion biopsy associate with outcomes after deceased donor but not living donor renal transplants, thus donor death and organ preservation-related factors may be of greater prognostic importance. Discarding donated kidneys on the basis of histologic factors may be inappropriate and merits further study.

Decisional conflict between treatment options among end-stage renal disease patients evaluated for kidney transplantation.

Although kidney transplantation provides a significant benefit over dialysis, many patients with end-stage renal disease (ESRD) are conflicted about their decision to undergo kidney transplant. We aimed to identify the prevalence and characteristics associated with decisional conflict between treatment options in ESRD patients presenting for transplant evaluation. Among a cross-sectional sample of patients with ESRD (n=464) surveyed in 2014 and 2015, we assessed decisional conflict through a validated 10-item questionnaire. Decisional conflict was dichotomized into no decisional conflict (score=0) and any decisional conflict (score>0). We investigated potential characteristics of patients with decisional conflict using bivariate and multivariable logistic regression. The overall mean age was 50.6 years, with 62% male patients and 48% African American patients. Nearly half (48.5%) of patients had decisional conflict regarding treatment options. Characteristics significantly associated with decisional conflict in multivariable analysis included male sex, lower educational attainment, and less transplant knowledge. Understanding characteristics associated with decisional conflict in patients with ESRD could help identify patients who may benefit from targeted interventions to help patients make informed, value-based, and supported decisions when deciding how to best treat their kidney disease.

The weekend effect alters the procurement and discard rates of deceased donor kidneys in the United States.

Factors contributing to the high rate of discard among deceased donor kidneys remain poorly understood and the influence of resource limitations of weekends on kidney transplantation is unknown. To quantify this we used data from the Scientific Registry of Transplant Recipients and assembled a retrospective cohort of 181,799 deceased donor kidneys recovered for transplantation from 2000-2013. We identified the impact of the day of the week on the procurement and subsequent utilization or discard of deceased donor kidneys in the United States, as well as report the geographic variation of the impact of weekends on transplantation. Compared with weekday kidneys, organs procured on weekends were significantly more likely to be discarded than transplanted (odds ratio: 1.16; 95% confidence interval: 1.13-1.19), even after adjusting for organ quality (adjusted odds ratio: 1.13; 95% confidence interval: 1.10-1.17). Weekend discards were of a significantly higher quality than weekday discards (Kidney Donor Profile Index: 76.5% vs. 77.3%). Considerable geographic variation was noted in the proportion of transplants that occurred over the weekend. Kidneys available for transplant over the weekend were significantly more likely to be used at larger transplant centers, be shared without payback, and experienced shorter cold ischemia times. Thus, factors other than kidney quality are contributing to the discard of deceased donor kidneys, particularly during weekends. Policy prescriptions, administrative or organizational solutions within transplant programs may potentially mitigate against the recent increase in kidney discards.

Cigarette smoking and 9/11-related posttraumatic stress disorder among World Trade Center Health Registry enrollees, 2003-12.

OBJECTIVE: Numerous studies have observed higher rates of smoking among adults with mental health conditions. We examined posttraumatic stress disorder (PTSD) and smoking over a 7-9year period among adults with firsthand exposure to the 9/11 attacks enrolled in the World Trade Center Health Registry. METHOD: Data were collected at three waves: W1 (2003-04), W2 (2006-07), and W3 (2011-12). Enrollees aged ≥25 at W1 and who completed all three waves (n=34,458) were categorized by smoker-type: non-smoker, non-daily (smoked some days in last 30days), light (1-10 cigarettes per day (CPD)), or heavy (11+ CPD). Enrollees who smoked at W1 but not W3 were considered to have quit. PTSD was defined as a score of ≥44 on the PTSD Checklist-Civilian Version. RESULTS: Smoking declined significantly from W1 (12.6%) to W3 (9.2%). Smoking prevalence was higher among enrollees with PTSD. In multivariable models, odds of quitting were 25-39% lower among heavy, light, and non-daily smokers with PTSD compared to those without. CONCLUSION: PTSD was associated with reduced odds of quitting regardless of smoker-type. Disaster-exposed smokers with PTSD are likely in need of more supportive services in order to abstain from smoking.

Deceased Brain Dead Donor Liver Transplantation and Utilization in the United States: Nighttime and Weekend Effects.

BACKGROUND: Understanding factors that contribute to liver discards and nonusage is urgently needed to improve organ utilization. METHODS: Using Scientific Registry of Transplant Recipient data, we studied a national cohort of all US adult, deceased brain dead donor, isolated livers available for transplantation from 2003 to 2016, including organ-specific and system-wide factors that may affect organ procurement and discard rates. RESULTS: Of 73 686 available livers, 65 316 (88.64%) were recovered for transplant, of which 6454 (9.88%) were ultimately discarded. Livers that were not procured or, on recovery, discarded were more frequently from older, heavier, hepatitis B virus (HCV)+, and more comorbid donors (P < 0.001). However, even after adjustment for organ quality, the odds of liver nonusage were 11% higher on the weekend (defined as donor procurements with cross-clamping occurring from 5:00 PM Friday until 11:59 AM Sunday) compared with weekdays (P < 0.001). Nonuse rates were also higher at night (P < 0.001), defined as donor procurements with cross-clamping occurring from 5:00 PM to 5:00 AM; however, weekend nights had significantly higher nonuse rates compared with weekday nights (P = 0.005). After Share 35, weekend nonusage rates decreased from 21.77% to 19.51% but were still higher than weekday nonusage rates (P = 0.065). Weekend liver nonusage was higher in all 11 United Network of Organ Sharing regions, with an absolute average of 2.00% fewer available livers being used on the weekend compared with weekdays. CONCLUSIONS: Although unused livers frequently have unfavorable donor characteristics, there are also systemic and operational factors, including time of day and day of the week a liver becomes available, that impact the chance of liver nonprocurement and discard.

Characteristics and Performance of Unilateral Kidney Transplants from Deceased Donors.

BACKGROUND AND OBJECTIVES: The fraction of kidneys procured for transplant that are discarded is rising in the United States. Identifying donors from whom only one kidney was discarded allows us to control for donor traits and better assess reasons for organ discard. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective cohort study using United Network for Organ Sharing Standard Transplant Analysis and Research file data to identify deceased donors from whom two kidneys were procured and at least one was transplanted. Unilateral pairs were defined as kidney pairs from a single donor from whom one kidney was discarded ("unilateral discard") but the other was transplanted ("unilateral transplant"). Organ quality was estimated using the Kidney Donor Risk Index and Kidney Donor Profile Index (KDPI). We compared all-cause graft failure rates for unilateral transplants to those for bilateral transplant Kaplan-Meier methods, and life table methodology was used to evaluate 1-, 2-, 3-, and 5-year survival rates of transplants from bilateral and unilateral donors. RESULTS: Compared with bilateral donors (i.e., both kidneys transplanted) (n=80,584), unilateral donors (i.e., only one kidney transplanted) (n=7625) had higher mean terminal creatinine (1.3±2.1 mg/dl versus 1.1±0.9 mg/dl) and KDPI (67%±25% versus 42%±27%), were older, and were more likely to have hypertension, diabetes, hepatitis C, terminal stroke, or meet Centers for Disease Control and Prevention high-risk donor criteria. Unilateral discards were primarily attributed to factors expected to be similar in both kidneys from a donor: biopsy findings (22%), no interested recipient (13%), and donor history (7%). Anatomic abnormalities (14%), organ damage (11%), and extended ischemia (6%) accounted for about 30% of discards, but were the commonest reasons among low KDPI kidneys. Among kidneys with KDPI≥60%, there was an incremental difference in allograft survival over time (for unilateral versus bilateral transplants, 1-year survival: 83% versus 87%; 3-year survival: 69% versus 73%; 5-year survival: 51% versus 58%). CONCLUSIONS: A large number of discarded kidneys were procured from donors whose contralateral kidneys were transplanted with good post-transplant outcomes.

Relation of Coronary Flow Reserve to Other Findings on Positron Emission Tomography Myocardial Perfusion Imaging and Left Heart Catheterization in Patients With End-stage Renal Disease Being Evaluated for Kidney Transplant.

Cardiovascular disease is the leading cause of death in patients with end-stage renal disease (ESRD) and often goes undetected. Abnormal coronary flow reserve (CFR), which predicts increased risk of cardiac death, may be present in patients with ESRD without other evidence of coronary artery disease (CAD). We prospectively studied 131 patients who had rest and dipyridamole pharmacologic stress N13-ammonia positron emission tomography myocardial perfusion imaging (PET MPI) for kidney transplant evaluation. Thirty-four patients also had left heart catheterization. Abnormal PET MPI was defined as qualitative ischemia or infarct, stress electrocardiogram ischemia, or transient ischemic dilation. CFR was calculated as the ratio of stress to rest coronary blood flow. Global CFR < 2 was defined as abnormal. Of 131 patients who had PET MPI (66% male, 55.6 ± 12.1 years), 30% (39 of 131) had abnormal PET MPI and 59% (77 of 131) had abnormal CFR. In a subset of 34 patients who had left heart catheterization (66% male, 61.0 ± 12.1 years), 68% (23 of 34) had abnormal CFR on PET MPI, and 68% (23 of 34) had ≥70% obstruction on left heart catheterization. Abnormal CFR was not significantly associated with abnormal PET MPI (p = 0.13) or obstructive CAD on left heart catheterization (p = 0.26). In conclusion, in the first prospective study of PET MPI in patients with ESRD, abnormal CFR is highly prevalent and is independent of abnormal findings on PET MPI or obstructive CAD on left heart catheterization.

Incidence of Hyponatremia with High-Dose Trimethoprim-Sulfamethoxazole Exposure.

BACKGROUND: Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly prescribed antibiotic used at high doses for treatment of pneumocystis pneumonia and other infections. Trimethoprim is structurally related to the potassium-sparing diuretic amiloride and has been associated with hyperkalemia and hyponatremia through blocking of epithelial sodium channels in the distal nephron. The incidence of hyponatremia in hospitalized patients treated with high-dose TMP-SMX is unknown. METHODS: We performed a single-center retrospective chart review of all hospitalized patients who received high-dose TMP-SMX (n = 235) from January 2012 to July 2014. Patients with congestive heart failure, cirrhosis, estimated glomerular filtration rate <30 mL/min/1.73 m2, baseline hyponatremia, and those on other medications associated with hyponatremia were excluded. Hyponatremia was defined as a serum sodium level <136 mEq/L. RESULTS: Analysis was restricted to 76 unique patients who received more than 8 mg/kg/d of TMP for ≥3 days. Mean starting serum sodium at time of TMP-SMX initiation was 138.4 ± 2.1 mEq/L. Fifty-five patients (72.3%) developed hyponatremia while on therapy, of which 43.6% (n = 24) were cases of serum sodium <130 mEq/L. Mean sodium at the time of nadir was 131.6 ± 5.1 mEq/L. Hyponatremia was noted, on average, 5.5 days after initiation of therapy, with more severe hyponatremia development among African American patients. Urine sodium concentrations were available for 40.0% (22/55) of incident hyponatremia cases, with mean urinary sodium of 104.8 ± 55.9 mEq/L. Hyponatremia often resolved within 3 weeks of drug discontinuation. CONCLUSIONS: There is a high incidence (72.3%) of hyponatremia associated with the use of high-dose TMP-SMX among hospitalized patients. This is an overlooked and potentially reversible cause of hyponatremia.

A Randomized Controlled Trial of a Mobile Clinical Decision Aid to Improve Access to Kidney Transplantation: iChoose Kidney.

Kidney transplantation is the preferred treatment for patients with end-stage renal disease, as it substantially increases a patient's survival and is cost saving compared to a lifetime of dialysis. However, transplantation is not universally chosen by patients with renal failure, and limited knowledge about the survival benefit of transplantation vs. dialysis may play a role. We created a mobile application clinical decision aid called iChoose Kidney to improve access to individualized prognosis information comparing dialysis and transplantation outcomes. We describe the iChoose Kidney study, a randomized controlled trial designed to test the clinical efficacy of a mobile health decision aid among end-stage renal disease patients referred for kidney transplantation at three large, diverse transplant centers across the U.S. Approximately 450 patients will be randomized to receive either: (1) standard of care or "usual" transplantation education, or (2) standard of care plus iChoose Kidney. The primary outcome is change in knowledge about the survival benefit of kidney transplantation vs. dialysis from baseline to immediate follow-up; secondary outcomes include change in treatment preferences, improved decisional conflict, and increased access to kidney transplantation. Analyses are also planned to examine effectiveness across subgroups of race, socioeconomic status, health literacy and health numeracy. Engaging patients in health care choices can increase patient empowerment and improve knowledge and understanding of treatment choices. If the effectiveness of iChoose Kidney has a greater impact on patients with low health literacy, lower socioeconomic status, and minority race, this decision aid could help reduce disparities in access to kidney transplantation.