Kidney transplant outcomes in minority populations: can we close the gap?

PURPOSE OF REVIEW: Health disparity in minority populations has been increasingly recognized over the last decade. The COVID-19 pandemic sheds a bright light on this very issue impressing upon the need for more research regarding healthcare in disparate populations. Although kidney transplantation remains the treatment of choice for end-stage renal disease management and longevity of life, access to transplantation remains a critical barrier in minority populations. The literature on disparity in access abounds but remains limited with regards to posttransplantation outcomes. The purpose of this review is to draw attention to existing research and literature in posttransplant outcomes and highlight the overall knowledge gap that persists in postkidney transplant care among disparate populations. RECENT FINDINGS: The current review focuses on important paradigm shifts in the determinants of outcomes in posttransplantation care in minority populations. It emphasizes a departure from immune mediated causes to more salient health inequities and socioeconomic factors contributing to patient and graft survival which require further investigation. SUMMARY: Despite increased awareness of health disparity in minority populations, outcomes data postkidney transplantation remains sparse. Critical to the future of kidney transplantation and improved healthcare coordination in minority populations will be a deeper understanding of contributing socio-economic variables in disparate outcomes.

Adherence to thromboprophylaxis guidelines in elderly patients with hospital acquired venous thromboembolism: a case control study.

Venous thromboembolism (VTE) remains the number one preventable cause of hospital acquired mortality and morbidity. Each year, more than 12 million patients are at risk for VTE. The delivery of appropriate and timely VTE prophylaxis is still suboptimal in many healthcare institutions and can lead to increased readmissions, morbidity, as well as costs. To clarify this issue further, we performed a retrospective case control study at our institution to determine if poor adherence to the VTE prophylaxis guidelines could lead to an increase in VTE events. This was a retrospective case control study conducted at Winthrop-University Hospital from January 2007 to December 2011. Exclusion criteria were age < 18 and concurrent use of anticoagulant agents. Out of 322 cases of hospital acquired VTE or readmission with VTE within 30 days of discharge, 289 cases were selected for final analysis and paired with age and sex matched controls. Patients with a hospital acquired VTE or a readmission for VTE within 30 days of discharge had a significantly reduced rate of VTE prophylaxis when compared to the control group (54.0 vs. 79.2 %, p < 0.0001). The VTE risk assessment rate was also lower in the VTE group (77.2 vs. 85.5 %, p = 0.035). No difference was noted in the time to prophylaxis administration between the two groups (34.8 vs. 33.1 h, p = 0.34). Lastly, sequential compression device (SCD) documentation rate was not different: 68/116 (58.6 %) vs. 44/87 (50.6 %), p = 0.32, between the two arms. Low adherence to the American College of Chest Physician (ACCP) guidelines for VTE prophylaxis correlated with an increase in hospital acquired VTE. The decreased adherence may be linked to a lower VTE risk assessment rate, and other barriers including incorrect identification of contraindications to pharmacologic prophylaxis, and poor documentation of mechanical prophylaxis. There was no difference in SCD documentation rate and timeliness to administration of initial thromboprophylaxis between the two groups. Future studies are needed to reassess adherence and documentation rates after system-wide improvements.

Comparing Length of Stay Between Patients Taking Rivaroxaban and Conventional Anticoagulants for Treatment of Venous Thromboembolism.

BACKGROUND: Recent studies have demonstrated non-inferiority of rivaroxaban when compared to warfarin for the treatment of pulmonary embolism and deep venous thrombosis. Analysis of data from the EINSTEIN trials has demonstrated that patients who received rivaroxaban had a shorter length of stay (LOS) compared to those who received warfarin. However, these trials had strict inclusion and exclusion criteria, and were designed for a different primary outcome. Also, data from these closely monitored clinical trials may not reflect the daily practice of medicine. OBJECTIVES: To clarify this issue further, we performed a retrospective analysis at our institution, comparing the LOS between patients discharged on rivaroxaban and other conventional anticoagulants (warfarin, enoxaparin, and enoxaparin with warfarin). METHODS: This was a retrospective study of consecutive patients admitted to our institution from January 2011 to July 2014 with newly diagnosed venous thromboembolism (VTE). Inclusion criteria were age > 18 years and objective confirmation of VTE. Exclusion criteria included diagnosis of VTE 24 h after admission, contraindication to anticoagulation, treatment with fibrinolytic agents, patients already on anticoagulation, and pregnancy. Out of 1553 consecutive patients diagnosed with VTE, a total of 414 patients met the eligibility criteria. These patients were further subdivided into four groups based on their discharge anticoagulant: rivaroxaban, warfarin, enoxaparin, and warfarin with enoxaparin. RESULTS: Patients discharged on rivaroxaban had a significantly shorter LOS compared with patients discharged on warfarin (3.5 vs. 7.0 days; p < 0.001), but not when compared to those discharged on enoxaparin alone (3.0 days) or enoxaparin with warfarin (4.0 days) (p > 0.05). The hospital incidence of bleeding and the 6-month readmission rates were not different among the different anticoagulants. CONCLUSIONS: In patients admitted with newly diagnosed VTE, those discharged on rivaroxaban had a significantly shorter LOS compared to those discharged on warfarin. In the appropriate subset of patients with VTE, treatment with rivaroxaban may result in significant cost savings for the hospital.

A Case of Pneumonia Caused by Pneumocystis Jirovecii and Cryptococcus Neoformans in a Patient with HTLV-1 Associated Adult T- Cell Leukemia/Lymphoma: Occam's Razor Blunted.

Adult T-cell leukemia/lymphoma (ATLL) is usually preceded by infection with human T-cell lymphotropic virus I (HTLV-I). Patients with ATLL frequently get opportunistic infections of the lungs, intestines, and central nervous system. Pneumocystis pneumonia is commonly known as an AIDS defining illness. Grocott's methenamine silver stain of bronchoalveolar lavage (BAL) samples obtained via bronchoscopy remain the gold standard for diagnosis. Pulmonary cryptococcosis is seen in patients with T-cell deficiencies and a diagnosis is made by culture of sputum, BAL, or occasionally of pleural fluid. We present the second case of coinfection with these two organisms in a patient with ATLL who was successfully treated with trimethoprim-sulfamethoxazole, corticosteroids, and fluconazole. We illustrate the need for high clinical vigilance for seeking out an additional diagnosis, especially in immunocompromised patients if they are not improving despite receiving appropriate treatment.

Central venous catheters: incidence and predictive factors of venous thrombosis.

AIMS: Central venous catheter access in an acute setting can be a challenge given underlying disease and risk for venous thrombosis. Peripherally inserted central venous catheters (PICCs) are commonly placed but limit sites for fistula creation in patients with chronic renal failure (CKD). The aim of this study is to determine the incidence of venous thrombosis from small bore internal jugular (SBIJ) and PICC line placement. This investigation identifies populations of patients who may not be ideal candidates for a PICC and highlights the importance of peripheral vein preservation in patients with renal failure. MATERIALS AND METHODS: A venous Doppler ultrasound was performed at the time of SBIJ insertion and removal to evaluate for thrombosis in the internal jugular vein. Data was collected pre- and post-intervention to ascertain if increased vein preservation knowledge amongst the healthcare team led to less use of PICCs. Demographic factors were collected in the SBIJ and PICC groups and risk factor analysis was completed. RESULTS: 1,122 subjects had PICC placement and 23 had SBIJ placement. The incidence of thrombosis in the PICC group was 10%. One patient with an SBIJ had evidence of central vein thrombosis when the catheter was removed. Univariate and multivariate analysis demonstrated a history of transplant, and the indication of total parenteral nutrition was associated with thrombosis (p<0.001). The decrease in PICCs placed in patients with CKD 6 months before and after intervention was significant (p<0.05). CONCLUSIONS: There are subsets of patients ith high risk for thrombosis who may not be ideal candidates for a PICC.

Association Between Total Cell Free DNA and SARS-CoV-2 In Kidney Transplant Patients: A Preliminary Study.

BACKGROUND: Kidney transplant (KT) recipients are at high risk for developing severe COVID-19. Lowering immunosuppression levels in KT recipients with COVID-19 encourages native immune responses but can raise the risk of rejection. Donor-derived cell-free DNA (dd-cfDNA), reported as a fraction of total cfDNA, is a proven biomarker for KT rejection. Total cfDNA levels are elevated in patients with COVID-19, which may depress dd-cfDNA fractions, potentially leading to missed rejections. METHODS: A retrospective analysis of 29 KT recipients hospitalized with COVID-19 between April and November 2020 examined total and dd-cfDNA levels. Blood samples were collected after onset of COVID-19, with follow-up samples collected from a subset of patients, when infection had likely subsided. RESULTS: After COVID-19 diagnosis, the median total cfDNA level was elevated (7.9 multiples of median [MoM]). A significant decrease in total cfDNA levels was observed between the first and second time points (6.2 MoM, 1.0 MoM; P <001). A significant positive association was identified between total cfDNA levels and COVID-19 severity (P = .02; R2 = .19). Two patients with biopsy-proven acute cellular rejection had dd-cfDNA fractions below the 1% cutoff for rejection (0.20% and 0.78%), with elevated total cfDNA levels of 7.9 MoM and 41.8 MoM, respectively. CONCLUSIONS: In this preliminary study, total cfDNA levels were elevated in KT patients with COVID-19, subsiding after resolution of infection. High total cfDNA levels may confound dd-cfDNA results, leading to failure to identify rejection. Considering total cfDNA levels is important in interpretation of dd-cfDNA tests for assessment of rejection in KT patients with COVID-19 or other infection.

Kidney Transplantation for Erdheim-Chester Disease.

Erdheim-Chester disease is a rare inflammatory disease that infiltrates skeletal and extra-skeletal tissue. Chronic kidney disease (CKD) in Erdheim-Chester disease is usually attributed to retroperitoneal lesions that lead to urologic obstruction and hydronephrosis. In this report, we describe a patient diagnosed with Erdheim-Chester disease who eventually developed end-stage kidney disease (ESKD). After complete remission of Erdheim-Chester disease by vemurafenib therapy and 2 years of hemodialysis, the patient underwent a deceased donor kidney transplantation with basiliximab induction and tacrolimus/mycophenolic acid maintenance. After conversion of mycophenolic acid to azathioprine due to cost, acute cellular rejection had occurred, and he was treated with steroid therapy. The patient remained in complete remission from Erdheim-Chester disease and dialysis-free 16 months after transplant. Kidney transplantation is another treatment option for those patients with Erdheim-Chester disease who suffer from renal failure in the setting of complete remission.

A Randomized Controlled Trial of a Mobile Medical App for Kidney Transplant Recipients: Effect on Use of Sun Protection.

BACKGROUND: Perception of skin cancer risk, belief that sun protection prevents skin cancer, and having sun protection choices enhance sun protection behaviors by kidney transplant recipients, who are at greater risk of developing skin cancer than the general population. METHODS: A randomized controlled trial used stratified recruitment of non-Hispanic White, non-Hispanic Black, and Hispanic/Latino kidney transplant recipients, who received a transplant 2-24 months prior to the study. The same culturally sensitive SunProtect™ program was delivered to all recipients with tablet personal computers in two urban ambulatory offices. Text messages reminders were provided at two week intervals. Self-reported surveys and skin pigmentation measured prior to the intervention and six weeks later were analyzed. RESULTS: Among 552 eligible participants, 170 participated (62 non-Hispanic Whites, 60Blacks, and 48 Hispanics). Among participants receiving the intervention with skin that burns after sun exposure and becomes tan or becomes irritated and gets darker, there was a statistically significant increase in self-reported knowledge, recognition of personal skin cancer risk, confidence in sun protection preventing skin cancer, and sun protection behaviors in participants compared to those receiving usual education (p<0.05). At the six week follow-up, participants in the intervention group with skin that burns or becomes irritated, had significantly less darkening of the sun-exposed forearm than control participants (p<0.05). CONCLUSIONS: Providing sun protection education with SunProtect™ in the springwith reminders during the summer facilitated adoption of sun protection behaviors among kidney transplant recipients with skin that burns or becomes irritated.

Impact of Maintenance Steroids versus Rapid Steroid Withdrawal in African-American Kidney Transplant Recipients: Comparison of Two Urban Centers.

BACKGROUND: Rapid steroid withdrawal (RSW) is used increasingly in kidney transplantation but long-term outcomes in African-American (AA) recipients are not well known. We compared 1 and 5 year transplant outcomes in a large cohort of AA patients who were maintained on continued steroid therapy (CST) to those who underwent RSW. METHODS: Post-transplant courses of A as receiving kidney allografts from 2003-2011 at two urban transplant centers in Chicago were followed. Prior to outcome analysis, we used Inverse Probability of Treatment Weights (IPTW) to match the two groups on a set of baseline risk factors. Graft and patient survival, GFR at 1 and 5 years, incidence and type of rejection, incidence of post-transplant diabetes mellitus (PTDM), delayed graft function, CMV and BK viremia were compared. RESULTS: There were 150 AA recipients in the CST analytic group and 157 in the RSW analytic group. Graft and patient survival was similar between the two groups. Rates of CMV viremia were higher in the RSW compared to the CST analytic group at 1 year. Biopsy-proven acute rejection and PTDM were similar between the RSW and CST groups. CONCLUSIONS: In AA recipients, RSW has similar long-term outcomes to CST.

Response Across the Health-Literacy Spectrum of Kidney Transplant Recipients to a Sun-Protection Education Program Delivered on Tablet Computers: Randomized Controlled Trial.

BACKGROUND: Sun protection can reduce skin cancer development in kidney transplant recipients, who have a greater risk of developing squamous cell carcinoma than the general population. OBJECTIVE: A culturally sensitive sun-protection program (SunProtect) was created in English and Spanish with the option of choosing audio narration provided by the tablet computer (Samsung Galaxy Tab 2 10.1). The intervention, which showed skin cancer on patients with various skin tones, explained the following scenarios: skin cancer risk, the ability of sun protection to reduce this risk, as well as offered sun-protection choices. The length of the intervention was limited to the time usually spent waiting during a visit to the nephrologist. METHODS: The development of this culturally sensitive, electronic, interactive sun-protection educational program, SunProtect, was guided by the "transtheoretical model," which focuses on decision making influenced by perceptions of personal risk or vulnerability to a health threat, importance (severity) of the disease, and benefit of sun-protection behavior. Transportation theory, which holds that narratives can have uniquely persuasive effects in overcoming preconceived beliefs and cognitive biases because people transported into a narrative world will alter their beliefs based on information, claims, or events depicted, guided the use of testimonials. Participant tablet use was self-directed. Self-reported responses to surveys were entered into the database through the tablet. Usability was tested through interviews. A randomized controlled pilot trial with 170 kidney transplant recipients was conducted, where the educational program (SunProtect) was delivered through a touch-screen tablet to 84 participants. RESULTS: The study involved 62 non-Hispanic white, 60 non-Hispanic black, and 48 Hispanic/Latino kidney transplant recipients. The demographic survey data showed no significant mean differences between the intervention and control groups in age, sex, income, or time since transplantation. The mean duration of program use varied by the ethnic/racial group, with non-Hispanic whites having the shortest use (23 minutes) and Hispanic/Latinos having the longest use (42 minutes). Knowledge, awareness of skin cancer risk, willingness to change sun protection, and use of sun protection increased from baseline to 2 weeks after the program in participants from all ethnic/racial groups in comparison with controls (P<.05). Kidney transplant recipients with inadequate (47/170, 28%) and marginal functional health literacy (59/170, 35%) listened to either Spanish or English audio narration accompanying the text and graphics. After completion of the program, Hispanic/Latino patients with initially inadequate health literacy increased their knowledge more than non-Hispanic white and black patients with adequate health literacy (P<.05). Sun protection implemented 2 weeks after education varied by the ethnic/racial group. Outdoor activities were reduced by Hispanics/Latinos, non-Hispanic blacks sought shade, Hispanic/Latinos and non-Hispanic blacks wore clothing, and non-Hispanic whites wore sunscreen (P<.05). CONCLUSION: Educational program with a tablet computer during the kidney transplant recipients' 6- or 12-month follow-up visits to the transplant nephrologist improved sun protection in all racial/ethnic groups. Tablets may be used to provide patient education and reduce the physician's burden of educating and training patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT01646099; https://clinicaltrials.gov/ct2/show/NCT01646099.

A Retrospective Review of CyberKnife Stereotactic Body Radiotherapy for Adrenal Tumors (Primary and Metastatic): Winthrop University Hospital Experience.

The adrenal gland is a common site of cancer metastasis. Surgery remains a mainstay of treatment for solitary adrenal metastasis. For patients who cannot undergo surgery, radiation is an alternative option. Stereotactic body radiotherapy (SBRT) is an ablative treatment option allowing larger doses to be delivered over a shorter period of time. In this study, we report on our experience with the use of SBRT to treat adrenal metastases using CyberKnife technology. We retrospectively reviewed the Winthrop University radiation oncology data base to identify 14 patients for whom SBRT was administered to treat malignant adrenal disease. Of the factors examined, the biological equivalent dose (BED) of radiation delivered was found to be the most important predictor of local adrenal tumor control. We conclude that CyberKnife-based SBRT is a safe, non-invasive modality that has broadened the therapeutic options for the treatment of isolated adrenal metastases.

Impact of immunosuppression on recall immune responses to influenza vaccination in stable renal transplant recipients.

BACKGROUND: The recommendation by the American Society of Transplantation for annual trivalent inactivated influenza vaccination greater than 3 to 6 months post-kidney transplantation provides a unique opportunity to test the in vivo impact of immunosuppression on recall T- and B-cell responses to influenza vaccination. METHODS: This study took advantage of recent breakthroughs in the single-cell quantification of human peripheral blood B-cell responses to prospectively evaluate both B- and T-cell responses to the seasonal (2010 and 2011) influenza vaccine in 23 stable renal transplant recipients and 22 healthy controls. RESULTS AND CONCLUSION: The results demonstrate that the early B-cell response to influenza vaccination, quantified by the frequency of influenza-specific antibody-secreting cells (ASC) in peripheral blood, was significantly reduced in stable transplant recipients compared to healthy controls. The magnitude of the seroresponse and the rate of seroconversion were also blunted. The influenza-specific interferon-gamma (IFNγ) T-cell response was significantly reduced in transplant recipients; however, there was no correlation between the magnitude of the influenza-specific IgG ASC and IFNγ responses. The induction of memory T- and B-cell responses to influenza vaccination supports the recommendation to vaccinate while the blunted responses demonstrate the efficacy of immunosuppression in controlling memory responses individual transplant recipients.

Reuse of a previously transplanted kidney: does success come with a price?

Longer wait times for deceased donor kidney transplant have prompted newer initiatives to expedite the process. Reuse of a previously transplanted kidney might be appropriate in certain circumstances. However, one must also consider the unique issues that may arise after such transplants. We describe our experience in one such case where the donor kidney had lesions of focal and segmental glomerulosclerosis and signs of alloreactivity (positive C4d staining) prior to transplantation and the recipient developed ganciclovir-resistant cytomegalovirus (CMV) infection, which was perhaps transmitted from the donor. Despite the challenges, the allograft function remained stable 5 years after reuse.