Electronic Patient Portal Use After Kidney Transplant: A Single-Center Retrospective Study.

INTRODUCTION: Online patient portals have become a core component of patient-centered care. Limited research exists on such portal use in patients after kidney transplantation. The aim of this study was to examine preoperative, perioperative, and postoperative factors associated with post-transplantation portal use. METHODS: This cross-sectional study included all patients who underwent kidney transplantation from April 2016 to May 2019 at the University of Toledo Medical Center. Exclusion criteria included international travel for transplantation and those without available postoperative lab or follow-up records. Data were collected for 2 y post-transplantation. Univariable and multivariable linear regression was performed to determine associations with portal use. RESULTS: Two hundred and forty-seven kidney transplant recipients were included in the study; 35.6% (n = 88) used the portal versus 64.4% (n = 159) did not. Preoperative factors associated with increased use included income >$40,000 (odds ratio [OR], 2.95; P = 0.006) and cancer history (OR, 2.46; P = 0.007), whereas diabetes history had reduced use (OR, 0.51; P = 0.021). The Black race had the least use. Perioperatively, reduced use was associated with dialysis before transplant (OR, 0.25; P < 0.001) and hospital stay ≥4 d (OR, 0.49; P = 0.009). Postoperatively, associations with increased use included average eGFR >30 (P = 0.04) and hospital readmissions (n = 102), whereas those with ER (n = 138) visits had decreased use. Multivariable analysis revealed increased use with income >$40,000 (OR, 2.51; P = 0.033). CONCLUSIONS: There was no observed difference in clinical outcomes for portal users and nonusers undergoing kidney transplantation, although portal use may decrease the likelihood of ER visits. Socioeconomic status and ethnicity may play a role on who utilizes the patient portals.

Demographic inequities exist and influence transplant outcomes in liver transplantation for acute alcohol-associated hepatitis.

BACKGROUND: Liver transplantation has inherent disparities but data is scarce in liver transplant (LT) candidates with acute alcohol-associated hepatitis (AAH). We aimed to investigate demographic inequities and its impact on survival outcomes among AAH LT candidates. METHODS: A retrospective analysis using the United Network of Organ Sharing database was conducted between 2000 and 2021. 25 981 LT recipients with alcohol-associated liver cirrhosis and 662 recipients with AAH were included. Waitlisted candidates were also evaluated. RESULTS: In comparison with alcohol-associated liver cirrhosis, AAH LT recipients were more likely Asian or "other" race and younger. Hispanics demonstrated better graft and patient survival (p < 0.05) but were less likely to be waitlisted and transplanted for AAH than for liver cirrhosis. Women with AAH were more likely to be waitlisted and transplanted. Pre-existing diabetes and male sex were associated with higher graft failure (25% and 8% respectively). Increasing recipient age were 2% more likely to experience negative outcomes. Chronicity of liver disease did not impact graft (p = 0.137) or patient survival (p = 0.145). CONCLUSION: Our results revealed demographic factors have a significant impact on transplant listing, organ allocation and survival outcomes. Further investigations are imperative to minimize disparities in LT evaluation and provide equity in healthcare.

Endovascular control during partial nephrectomy in a renal allograft.

Partial nephrectomy of renal allografts is technically challenging. We report a case of robotic-assisted laparoscopic partial nephrectomy performed with selective cannulation and endovascular balloon occlusion of vascular inflow to transplanted kidney. Endovascular control during partial nephrectomy in a renal allograft and review of literature.

Underrepresented minority representation trends in gynecologic oncology fellowships in the United States.

OBJECTIVE: To evaluate representation trends of historically underrepresented minority (URM) groups in gynecologic oncology fellowships in the United States using a nationwide database collected by the Accreditation Council for Graduate Medical Education (ACGME). METHODS: Data on self-reported ethnicity/race of filled residency positions was collected from ACGME Database Books across three academic years from 2016 to 2019. Primary chi-square analysis compared URM representation in gynecologic oncology to obstetrics and gynecology, other surgical specialties, and other medical specialties. Secondary analysis examined representation of two URM subgroups: 1) Asian/Pacific Islander, and 2) Hispanic, Black, Native American, Other (HBNO), across specialty groups. RESULTS: A total of 528 gynecologic oncology positions, 12,559 obstetrics and gynecology positions, 52,733 other surgical positions, and 240,690 other medical positions from ACGME accredited medical specialties were included in analysis. Primary comparative analysis showed a statistically significant lower proportion (P < 0.05) of URM trainees in gynecologic oncology in comparison to each of obstetrics and gynecology, other surgical fields, and other medical fields. Secondary analysis also demonstrated a significantly lower proportion (P < 0.05) of HBNO physicians in gynecologic oncology in comparison to obstetrics and gynecology, as well as all other medical and surgical specialties. CONCLUSIONS: This study illustrates the disparities in URM representation, especially those who identify as HBNO, in gynecologic oncology fellowship training in comparison to obstetrics and gynecology as well as other medical and surgical fields. Improvements to the current recruitment and selection practices in gynecologic oncology fellowships in the United States are necessary in order to ensure a diverse and representative workforce.

Robotic-assisted Donor Nephrectomy: As Safe as Laparoscopic Donor Nephrectomy.

OBJECTIVES: Robotic-assisted donor nephrectomy has become increasingly popular in recent years. We sought to compare robotic-assisted outcomes to operative outcomes in a historical cohort of laparoscopic donor nephrectomies. MATERIALS AND METHODS: A retrospective review of 58 consecutive donor nephrectomies at a single center by two surgeons from 2015 to 2019 was performed. RESULTS: Robotic-assisted (n = 32) and laparoscopic (n =26) donors were comparable in terms of estimated blood loss (66.4 vs. 62.5 mL; p=0.81) and length of stay (1.6 vs. 1.5 days; p=0.37). The post-operative change in creatinine was not significantly different between the groups (-0.45 vs. -0.45; p=0.97). Warm ischemia time was longer in the robotic group (7.36 vs. 5.15 minutes; p < 0.01). Case duration was significantly longer for robotic-assisted cases (306 vs. 247 minutes; p < 0.01). However, robotic cases were more likely to be right-sided (6/32 (18.8%) vs. 1/26 (3.8%)) and have vascular multiplicity (7/32 (21.9%) vs. 0/26 (0%)). There was one Clavien II or greater complication in the robotic group, and none in the laparoscopic group. CONCLUSIONS: Our data agree with previous reports that robotic-assisted donor nephrectomy is safe and has similar outcomes to a laparoscopic approach. Moreover, cases with multiple renal arteries or veins and right-sided cases were completed safely using the robotic approach. The longer case duration in the robotic group was attributed to the learning curve associated with implementing a new technique, and later robotic operative times approached laparoscopic operative times.

Pediatric liver transplantation: predictors of survival and resource utilization.

PURPOSE: We sought to identify factors associated with increased resource utilization and in-hospital mortality for pediatric liver transplantation (LT). METHODS: Kids' Inpatient Database (1997-2009) was used to identify cases of LT in patients <20 years old. RESULTS: Overall, 2905 cases were identified, with an in-hospital survival of 91 %. LT was performed most frequently in < 5 year olds (61 %), females (51 %), and Caucasians (56 %). LT was performed at urban teaching hospitals (97 %) and facilities with children's units (51 %). Indications included pathologic conditions of the biliary tract (44 %) and inborn errors of metabolism (34 %), though unspecified end stage liver disease was the most common (75 %). Logistic regression found higher mortality in children undergoing LT for malignant conditions (odds ratio: 4.8) and acute hepatic failure (OR 3.4). Cases complicated by renal failure (OR 7.7) and complications of LT (OR 2.7) had higher mortality rates. Resource utilization increased for children with renal failure and those with hemorrhage as a complication of LT, p < 0.05. CONCLUSION: Hospital survival is predicted by indication and complications associated with LT. Resource utilization increased with renal failure and complications related to LT. Admission length was sensitive to payer status, hospital characteristics, and UNOS region, whereas total costs were unaffected by payer status or hospital type.

Everolimus with low-dose tacrolimus in simultaneous pancreas and kidney transplantation.

The efficacy and safety of everolimus (EVR) in simultaneous pancreas and kidney transplantation (SPKT) is unclear. We retrospectively evaluated 25 consecutive SPKT recipients at our center from November 2011 to March 2013. All patients received dual induction (Thymoglobulin/basiliximab) and low-dose tacrolimus plus corticosteroids. Nine patients who received EVR were compared with 14 patients who received enteric-coated mycophenolate sodium (EC-MPS); two patients who received sirolimus were excluded from the analysis. With a median follow-up of 14 months, the pancreas graft survival rate was 100% in both groups, and the kidney graft survival rate was 100% and 93% in EVR and EC-MPS patients, respectively. One EC-MPS patient lost her kidney graft from proteinuric kidney disease. Another EC-MPS patient received treatment for clinically diagnosed pancreas and kidney graft rejection. No rejection was observed in EVR patients. Serum creatinine and HbA1c levels were similar between the groups. There was no significant difference of surgical or medical complications. In conclusion, EVR seems to provide comparable short-term outcome to EC-MPS when combined with low-dose tacrolimus/steroids and dual induction therapy. A larger study with a longer follow-up is required to further assess this combination.

Cerebrovascular Disease Hospitalization Rates in End-Stage Kidney Disease Patients with Kidney Transplant and Peripheral Vascular Disease: Analysis Using the National Inpatient Sample (2005-2019).

Individuals with end-stage kidney disease (ESKD) face higher cerebrovascular risk. Yet, the impact of peripheral vascular disease (PVD) and kidney transplantation (KTx) on hospitalization rates for cerebral infarction and hemorrhage remains underexplored. Analyzing 2,713,194 ESKD hospitalizations (2005-2019) using the National Inpatient Sample, we investigated hospitalization rates for ischemic and hemorrhagic cerebrovascular diseases concerning ESKD, PVD, KTx, or their combinations. Patients hospitalized with cerebral infarction due to thrombosis/embolism/occlusion (CITO) or artery occlusion resulting in cerebral ischemia (AOSI) had higher rates of comorbid ESKD and PVD (4.17% and 7.29%, respectively) versus non-CITO or AOSI hospitalizations (2.34%, p < 0.001; 2.29%, p < 0.001). Conversely, patients hospitalized with nontraumatic intracranial hemorrhage (NIH) had significantly lower rates of ESKD and PVD (1.64%) compared to non-NIH hospitalizations (2.34%, p < 0.001). Furthermore, hospitalizations for CITO or AOSI exhibited higher rates of KTx and PVD (0.17%, 0.09%, respectively) compared to non-CITO or AOSI hospitalizations (0.05%, p = 0.033; 0.05%, p = 0.002). Patients hospitalized with NIH showed similar rates of KTx and PVD (0.04%) versus non-NIH hospitalizations (0.05%, p = 0.34). This nationwide analysis reveals that PVD in ESKD patients is associated with increased hospitalization rates with cerebral ischemic events and reduced NIH events. Among KTx recipients, PVD correlated with increased hospitalizations for ischemic events, without affecting NIH. This highlights management concerns for patients with KTx and PVD.

A Comprehensive Analysis of Litigation in Organ Transplantation for Allegations of Insufficient Policy Coverage, Discrimination and Malpractice.

Introduction: Transplantation is a field with unique medical and administrative challenges that involve an equally diverse array of stakeholders. Expectantly, the litigation stemming from this field should be similarly nuanced. There is a paucity of comprehensive reviews characterizing this medicolegal landscape. Design: The Caselaw Access Project Database was used to collect official court briefs of 2053 lawsuits related to kidney, liver, heart, lung, and pancreas transplantation. A thematic analysis was undertaken to characterize grounds for litigation, defendant type, and outcomes. Cases were grouped into policy, discrimination, poor or unsuccessful outcome, or other categories. Results: One hundred sixty-four court cases were included for analysis. Cases involving disputes over policy coverage were the most common across all organ types (N = 55, 33.5%). This was followed by poor outcomes (N = 51, 31.1%), allegations of discrimination against prison systems and employers (N = 37, 22.6%) and other (N = 21, 12.8%). Defendants involved in discrimination trials won with the greatest frequency (N = 29, 90.62%). Defendants implicated in policy suits won 65.3% (N = 32), poor outcomes 62.2% (N = 28), and other 70% (N = 14). Of the 51 cases involving poor outcomes, plaintiffs indicated lack of informed consent in 23 (45.1%). Conclusion: Reconsidering the informed consent process may be a viable means of mitigating future legal action. Most discrimination suits favoring defendants suggested previous concerns of structural injustices in transplantation may not be founded. The prevalence of policy-related cases could be an indication of financial burden on patients. Future work and advocacy will need to substantiate these concerns and address change where legal recourse falls short.

C-X-C chemokine receptor 7: a functionally associated molecular marker for bladder cancer.

BACKGROUND: C-X-C chemokine receptor 4 (CXCR4) and CXCR7 are 7-transmembrane chemokine receptors of the stroma-derived factor (SDF-1). CXCR4, but not CXCR7, has been examined in bladder cancer (BCa). This study examined the functional and clinical significance of CXCR7 in BCa. METHODS: CXCR4 and CXCR7 levels were measured in BCa cell lines, tissues (normal = 25; BCa = 44), and urine specimens (n = 186) by quantitative polymerase chain reaction and/or immunohistochemistry. CXCR7 function in BCa cells were examined by transient transfections using a CXCR7 expression vector or small interfering RNA. RESULTS: In BCa cell lines, CXCR7 messenger RNA levels were 5- to 37-fold higher than those for CXCR4. Transient overexpression of CXCR7 in BCa cell lines promoted growth and chemotactic motility. CXCR7 colocalized and formed a functional complex with epidermal growth factor receptor, phosphoinositide 3-kinase/Akt, Erk, and src and induced their phosphorylation. CXCR7 also induced up-regulation of cyclin-D1 and bcl-2. Suppression of CXCR7 expression reversed these effects and induced apoptosis. CXCR7 messenger RNA levels and CXCR7 staining scores were significantly (5- to 10-fold) higher in BCa tissues than in normal tissues (P < .001). CXCR7 expression independently associated with metastasis (P = .019) and disease-specific mortality (P = .03). CXCR7 was highly expressed in endothelial cells in high-grade BCa tissues when compared to low-grade BCa and normal bladder. CXCR7 levels were elevated in exfoliated urothelial cells from high-grade BCa patients (P = .0001; 90% sensitivity; 75% specificity); CXCR4 levels were unaltered. CONCLUSIONS: CXCR7 promotes BCa cell proliferation and motility plausibly through epidermal growth factor receptor receptor and Akt signaling. CXCR7 expression is elevated in BCa tissues and exfoliated cells and is associated with high-grade and metastasis.

Quantifying mortality burden in patients with cancer due to COVID-19 in the US: A national cross-sectional analysis.

INTRODUCTION: There is limited information on the impact of certain social factors on mortality outcomes in patients with cancer and COVID-19 on a national scale. This study aims to characterize excess mortality and analyze a subset of sociodemographic trends in COVID-19 and cancer mortality. METHODS: Patients with cancer listed on their death certificates from 2018 to 2021 and patients with COVID-19 and cancer listed on multiple cause of death certificates from the CDC Wide-Ranging Online Data for Epidemiologic Research database from March 2020 to December 2021 were included. Age-adjusted mortality rates (AAMR) per 1,000,000 population were compared across race/ethnicity groups, sex, and census regions. Crude mortality rates were compared across different age groups and regions based on urbanization status. RESULTS: Average AAMR in patients with COVID-19 and cancer was 41.7 in 2020 and 56.7 in 2021. CONCLUSIONS: Mortality rates in patients with cancer and COVID-19 were significantly higher in certain populations. Targeted interventions are necessary to improve outcomes.

Patient-reported disruptions to cancer care during the COVID-19 pandemic: A national cross-sectional study.

BACKGROUND: The aim of this study is to evaluate the extent and associations with patient-reported disruptions to cancer treatment and cancer-related care during the COVID-19 pandemic utilizing nationally representative data. METHODS: This analysis uses data from the 2020 National Health Interview Survey (NHIS), an annual, cross-sectional survey of US adults. Adults (age >18) who reported requiring current cancer treatment or other cancer-related medical care in the second half of 2020 were included. Estimated proportions of patients with self-reported changes, delays, or cancelations to cancer treatment or other cancer care due to the COVID-19 pandemic were calculated using sampling weights and associations with sociodemographic and other health-related variables were analyzed. RESULTS: In total, 574 (sample-weighted estimate of 2,867,326) adults reported requiring cancer treatment and/or other cancer care since the start of the COVID-19 pandemic. An estimated 32.1% reported any change, delay, or cancelation. On sample-weighted univariable analysis, patients who were younger, female, had one or fewer comorbidities, and uninsured were significantly more likely to report disruptions. On sample-weighted, multivariable analysis, patients who were younger and female remained significant predictors. Nearly 90% of patients included in the study reported virtual appointment use. Patients reporting disruptions were also significantly more likely to report feelings of anxiety. CONCLUSIONS: An estimated 1/3 of patients experienced disruptions to cancer care due to the COVID-19 pandemic. Patients experiencing disruptions in care were more likely to be female or younger which may reflect risk stratification strategies in the early stages of the pandemic, and also had higher rates of anxiety. The longitudinal impact of these disruptions on outcomes merits further study.

The Impact of the COVID-19 Pandemic on Kidney Transplant Candidate Waitlist Status across Demographic and Geographic Groups: A National Analysis of UNOS STAR Data.

The primary goal of this retrospective study is to understand how the COVID-19 pandemic differentially impacted transplant status across race, sex, age, primary insurance, and geographic regions by examining which candidates: (i) remained on the waitlist, (ii) received transplants, or (iii) were removed from the waitlist due to severe sickness or death on a national level. Methods: The trend analysis aggregated by monthly transplant data from 1 December 2019 to 31 May 2021 (18 months) at the transplant center level. Ten variables about every transplant candidate were extracted from UNOS standard transplant analysis and research (STAR) data and analyzed. Characteristics of demographical groups were analyzed bivariately using t-test or Mann-Whitney U test for continuous variables and using Chi-sq/Fishers exact tests for categorical variables. Results: The trend analysis with the study period of 18 months included 31,336 transplants across 327 transplant centers. Patients experienced a longer waiting time when their registration centers in a county where high numbers of COVID-19 deaths were observed (SHR < 0.9999, p < 0.01). White candidates had a more significant transplant rate reduction than minority candidates (-32.19% vs. -20.15%) while minority candidates were found to have a higher waitlist removal rate than White candidates (9.23% vs. 9.45%). Compared to minority patients, White candidates' sub-distribution hazard ratio of the transplant waiting time was reduced by 55% during the pandemic period. Candidates in the Northwest United States had a more significant reduction in the transplant rate and a greater increase in the removal rate during the pandemic period. Conclusions: Based on this study, waitlist status and disposition varied significantly based on patient sociodemographic factors. During the pandemic period, minority patients, those with public insurance, older patients, and those in counties with high numbers of COVID-19 deaths experienced longer wait times. In contrast, older, White, male, Medicare, and high CPRA patients had a statistically significant higher risk of waitlist removal due to severe sickness or death. The results of this study should be considered carefully as we approach a reopening world post-COVID-19, and further studies should be conducted to elucidate the relationship between transplant candidate sociodemographic status and medical outcomes during this era.

A Quality Analysis of Donor Nephrectomy-Related Information on YouTube; Education or Misinformation?

INTRODUCTION: There currently remains an urgent need to increase living kidney donation to help mitigate the high demand for waitlisted kidney failure patients. Potential kidney donors can readily access social media, particularly YouTube, to gain basic knowledge about live donor nephrectomy surgical procedures. YouTube is an open-source platform where anyone can upload videos about any topic without peer review or quality control and is frequently used for disseminating health education. This study aims to assess the quality and accuracy of information regarding live donor nephrectomy on YouTube. METHODS: A YouTube search was performed using the keywords "donor nephrectomy" and "kidney transplant." A total of 57 videos were assessed for eligibility criteria. Two validated tools for evaluating health information, the DISCERN and The Patient Education Materials Assessment Tool for Audiovisual Materials tools, were used to assess YouTube video information quality, understandability, and actionability. RESULTS: A total of 53 of 57 screened videos were included in this study, with 4 videos being excluded for not being primarily in the English language. The mean (SD) DISCERN score was 23.3 (±8.3), and the mean (SD) The Patient Education Materials Assessment Tool for Audiovisual Materials Understandability and Actionability scores of 41.7% (±17.5) and 8.2% (±22.9%), respectively. Although videos were generally relevant in content to donor nephrectomy, videos lacked quality information and actionable items. CONCLUSIONS: Information on living donor nephrectomies is prevalent on YouTube. Our assessment using quality measures of selected videos illustrates substantial misinformation on living donor nephrectomies. YouTube has the potential to be a source of reliable and accurate information on living donor nephrectomies and donations.

Concomitant Polyoma BK Virus and West Nile Virus in Renal Allografts.

Surveillance of the renal allograft recipient is essential when monitoring renal function to detect the early onset of rejection and alter therapeutic treatments to treat acute rejection or other causes and improve long-term graft function. If renal function begins to deteriorate, a renal biopsy is often indicated to assess the Banff grade of potential rejection or other causes, especially in the setting of polyoma BK viral load elevation. Although BK infection in the allograft is asymptomatic, reactivation of the virus is known to be associated with the acceleration of pathologic change and a poor outcome in the allograft. BK reactivation in a transplant kidney is not uncommon, and determining inflammation related to the virus versus acute rejection is paramount for appropriate immunosuppressive therapy management. We identified a concomitant polyoma BK virus and West Nile Virus (WNV) infection in two renal transplant patients which, to our knowledge, has not previously been reported. However, other concomitant infections have been reported in renal allografts including BK virus and cytomegalovirus (CMV), CMV and hepatitis C (HCV), and HCV and human immunodeficiency virus (HIV). As WNV has become endemic in many regions of the United States, and since the transmission of the virus via transplanted organs is associated with significant morbidity and mortality, it may be prudent to consider serologic screening for WNV in living donors prior to organ procurement. Regardless, the observation we made and report here should underscore the potential for concomitant viral infections that may be masked when a renal allograft has a significant inflammatory response to BK virus.

Molecular characterization of kidney cancer: association of hyaluronic acid family with histological subtypes and metastasis.

BACKGROUND: Molecular profiling of renal cell carcinomas (RCCs) may improve the distinction between oncocytoma and malignant RCC subtypes and aid in early detection of metastasis. The hyaluronic acid (HA) family includes HA synthases (HAS1, HAS2, HAS3), hyaluronidases (HYAL-1, HYAL-2, HYAL-3, HYAL-4, PH20, HYAL-P1), and HA receptors (CD44s, CD44v, RHAMM). HA family members promote tumor growth and metastasis. The authors evaluated the expression of HA family members in kidney specimens. METHODS: By using quantitative polymerase chain reaction, mRNA levels of 12 HA family members were measured in tumor specimens obtained from 86 consecutive patients undergoing nephrectomy; 80 of them also provided normal specimens. Mean and median follow-up were 15.2 ± 8.8 and 13.8 months. RCC specimens included clear cell RCC: 65; papillary: 10; chromophobe: 5; oncocytoma: 6; metastasis positive: 17. RESULTS: Median HAS1, CD44s, and RHAMM transcript levels were elevated 3- to 25-fold in clear cell RCC and papillary and chromophobe tumors when compared with normal tissues. HYAL-4, CD44s, and RHAMM levels were elevated 4- to 12-fold in clear cell RCC and papillary tumors when compared with oncocytomas; only HYAL-4 levels distinguished between chromophobe and oncocytoma (P = .009). CD44s and RHAMM levels were significantly higher in tumors <4 cm (510 ± 611 and 19.6 ± 20.8, respectively) when compared with oncocytoma (46.4 ± 20 and 3.8 ± 2.5; P ≤ .006). In univariate and multivariate analyses, CD44s (P < .0001), RHAMM (P < .0001), stage, tumor size, and/or renal vein involvement were significantly associated with metastasis. The combined CD44s + RHAMM marker had 82% sensitivity and 86% specificity to predict metastasis. CONCLUSIONS: CD44s and RHAMM levels distinguish between oncocytoma and RCC subtypes regardless of tumor size and are potential predictors of RCC metastasis.