Reduced survival in patients who return to dialysis after kidney allograft failure.

BACKGROUND: The outcome of patients who return to dialysis after Kidney allograft failure (KAF) remains unclear. Our aim was to compare the outcome of KAF patients vs two different types of transplant naive incident dialysis (TNID) patients, those on the waiting list (WL) and those with a kidney transplant contraindication (KTC). METHODS: We performed an observational study using data from the Argentinian Dialysis Registry between 2005 and 2016. We compare mortality between KAF, WL, and KTC. RESULTS: We included 75 722 patients of which 2734 were KAF. Survival between the three cohorts (KAF vs WL (n = 14 630) vs KTC (n = 58 358) revealed a significant difference (log-rank test: P < .0001) indicating worse survival for KTC patients and best survival for WL. We found that KAF patients had as poor outcome as KTC patients after multivariate adjustment. Cox regression showed that age >65 years: HR: 1.845 (1.79-1.89) P < .0001, transient catheter: HR: 1.303 (1.26-1.34) P < .0001, diabetic: HR: 1.273 (1.22-1.31) P < .0001, hepatitis C: HR: 1.156 (1.09-1.22) P < .0001, and albumin: HR: 1.247 (1.21-1.28) P < .0001 were associated with mortality. CONCLUSION: Patients who return to dialysis after KAF have higher mortality than WL patients and similar to KTC patients.

Donor selection criteria for liver transplantation in Argentina: are current standards too rigorous?

Organ shortage is the major limitation for the growth of deceased donor liver transplant worldwide. One strategy to ameliorate this problem is to maximize the liver utilization rate. To assess predictors of liver utilization in Argentina. The national database was used to analyze transplant activity in 2010. Donor, recipient, and transplant variables were evaluated as predictors of graft utilization of number of rejected donor offers before grafting and with the occurrence of primary nonfunction (PNF) or early post-transplant mortality (EM). Of the 582 deceased donors, 293 (50.3%) were recovered for liver transplant. Variables associated with the nonrecovery of the liver were age ≥46 years, umbilical perimeter ≥92 cm, organ procurement outside Gran Buenos Aires, AST ≥42 U/l and ALT ≥29 U/l. The median number of rejected offers before grafting was 4, and in 71 patients (25%), there were ≥13. The only independent predictor for the occurrence of PNF (3.4%) or EM (5.2%) was the recipient's emergency status. During 2010 in Argentina, the liver was recovered in only half of donors. The low incidence of PNF and EM and the characteristics of the nonrecovered liver donors suggest that organ acceptance criteria should be less rigorous.

Results after the adoption of a MELD/PELD-based liver allocation policy in Argentina.

In July 2005, Argentina switched from a categorical liver allocation system to a MELD/PELD-based policy for patients with CLD. To analyze WL outcomes and survival after LT in children. From January 2000 to December 2010, 923 children were registered. Two consecutive five-yr periods were analyzed and compared: Era I (January 2000-July 2005) (n = 379) and Era II (July 2005-December 31, 2010) (n = 544). All data were prospectively collected and analyzed using the Kaplan-Meier method. After adopting the MELD/PELD system, WL registrations increased by 44% (from 379 to 544) and the number of LT increased by only 24% (from 278 to 365). However, three-month WL mortality rate (32% to 18%, p < 0.0001, HR 2.002 CI 95% 1.5-2.8) decreased significantly. No significant differences were observed between Era 1 and II in one-yr post-LT survival (77.5% vs. 84.1%, p = 0.3053) and in acute re-LT rate (9% vs. 5%, p = 0.1746). Under the MELD/PELD-based allocation system in Argentina, mortality on the WL significantly decreased in children with CLD without affecting post-LT survival, although reduced access to LT was observed.

Temporal trends in hematopoietic stem cell transplantation in Argentina between 2009 and 2018: A collaborative study by GATMO-TC and INCUCAI.

INTRODUCTION: Hematopoietic stem cell transplantation is the only curative treatment for many disorders and international data shows a growing trend. METHOD: We aimed to evaluate the temporal trends in HSCT transplant rates in Argentina. A time-series analysis was performed for the period 2009 to 2018 using the national database from the National Central Coordinating Institute for Ablations and Implants. Crude and standardized transplant rates were calculated. A permutation joinpoint regression model analysis was used to identify significant changes over time. RESULTS: Altogether, 8,474 transplants were reported to INCUCAI by 28 centers (autologous 67.5%); the main indication was multiple myeloma (30%). The WHO age-sex standardized HSCT rates for the entire country were 153.3 HSCT/10 million inhabitants (95% CI 141.7-165.8) in 2009 and 260.1 HSCT/10 million inhabitants (95% CI 245.5-275.5) in 2018. There was a large gap in HSCT rates among the states and regions. The transplant rate was higher for autologous transplants throughout the years. Within the allogeneic group, the related donor transplant rate was higher than the unrelated donor transplant rate. The joinpoint regression analysis of HSCT rates for the whole country over time showed an observed annual percentage change of 6.3% (95% CI 5.4-7.3; p < 0.01). No changes were observed for unrelated donors during the study period. CONCLUSIONS: Age-sex standardized HSCT rates in Argentina are increasing, mainly due to autologous and family donor allogeneic transplants. A wide variation across the country was found, demonstrating differences in the access to transplantation among Argentine regions.

[COVID-19 infection in chronic dialysis patients in Argentina]. / Infección por COVID-19 en pacientes en diálisis crónica en Argentina.

The report of the preliminary data of the Argentine Registry of COVID in chronic dialysis is presented, from April 10, 2020 to April 9, 2021 and includes all dialysis centers in the country. In the study period, 36 918 prevalent patients on chronic dialysis were registered. COVID-19 infection was confirmed in 3709 patients (10% of prevalent patients), of which 1675 patients (45.2%) required hospitalization, and of these, 39% (550 patients) required ICU admission. 62% of those admitted to the ICU (339 patients) required mechanical ventilation (MV). 1307 patients died (35.24%). Multivariate analysis showed as factors associated with mortality from COVID in dialysis patients, age greater than 60 years (OR 2.6; 95% CI 2.2-3.1); diabetes (OR 1.5; 95% CI 1.3-1.8); time on dialysis greater than 55 months (OR 1.5; 95% CI 1.2-1.7); cerebrovascular disease (OR 1.6; 95% CI 1.1-2.3); neoplasia (OR 1.7; 95% CI 1.1-2.6); hospitalization requirement (OR 3.4; 95% CI 2.8-3.9); ICU admission (OR 1.8; 95% CI 1.3-2.5); need of MV (OR 11.8; 95% CI 6.9-20.2). The population on chronic dialysis in Argentina, as shown in the rest of the world, is highly vulnerable to COVID infection, showing a lethality 12 times higher than the general population. The measures implemented in dialysis units, patient care and their family environment, and above all priority vaccination are essential in this vulnerable population of patients.

Se presentan los datos preliminares del Registro Argentino de COVID en diálisis crónica, desde el 10 de abril de 2020 al 9 de abril 2021 que incluye todos los centros de diálisis crónica del país. En el período de estudio se registraron 36 918 pacientes prevalentes en diálisis crónica. La infección por COVID-19 fue confirmada en 3709 pacientes (10% prevalentes), de los cuales 1675 (45.2%) requirieron internación, y de éstos el 39% (550) internación en UTI. El 62% de los ingresados a UTI (339) requirió asistencia respiratoria mecánica (ARM). Fallecieron 1307 pacientes (35.24 %). El análisis multivariado, mostró como factores asociados a mortalidad por COVID en diálisis crónica, la edad mayor a 60 años (OR 2.6; IC 95% 2.2-3.1); la diabetes (OR 1.5; IC 95% 1.3-1.8); tiempo en diálisis mayor a 55 meses (OR 1.5; IC 95% 1.2-1.7); enfermedad cerebrovascular OR 1.6; IC 95% 1.1-2.3); neoplasia (OR 1.7; IC 95% 1.1-2.6); requerimiento de internación (OR 3.4; IC 95% 2.8-3.9); internación en UTI (OR 1.8; IC 95% 1.3-2.5); necesidad de ARM (OR 11.8; IC 95% 6.9-20.2). La población en diálisis crónica en Argentina, como se muestra en el resto del mundo, es altamente vulnerable a la infección COVID, mostrando una letalidad 12 veces mayor que la población general. Las medidas implementadas en las unidades de diálisis, los cuidados de los pacientes y su entorno familiar, y por sobre todo la vacunación prioritaria, son fundamentales en esta población vulnerable de pacientes.

COVID-19 pandemic and worldwide organ transplantation: a population-based study.

BACKGROUND: Preliminary data suggest that COVID-19 has reduced access to solid organ transplantation. However, the global consequences of the COVID-19 pandemic on transplantation rates and the effect on waitlisted patients have not been reported. We aimed to assess the effect of the COVID-19 pandemic on transplantation and investigate if the pandemic was associated with heterogeneous adaptation in terms of organ transplantation, with ensuing consequences for waitlisted patients. METHODS: In this population-based, observational, before-and-after study, we collected and validated nationwide cohorts of consecutive kidney, liver, lung, and heart transplants from 22 countries. Data were collected from Jan 1 to Dec 31, 2020, along with data from the same period in 2019. The analysis was done from the onset of the 100th cumulative COVID-19 case through to Dec 31, 2020. We assessed the effect of the pandemic on the worldwide organ transplantation rate and the disparity in transplant numbers within each country. We estimated the number of waitlisted patient life-years lost due to the negative effects of the pandemic. The study is registered with ClinicalTrials.gov, NCT04416256. FINDINGS: Transplant activity in all countries studied showed an overall decrease during the pandemic. Kidney transplantation was the most affected, followed by lung, liver, and heart. We identified three organ transplant rate patterns, as follows: countries with a sharp decrease in transplantation rate with a low COVID-19-related death rate; countries with a moderate decrease in transplantation rate with a moderate COVID-19-related death rate; and countries with a slight decrease in transplantation rate despite a high COVID-19-related death rate. Temporal trends revealed a marked worldwide reduction in transplant activity during the first 3 months of the pandemic, with losses stabilising after June, 2020, but decreasing again from October to December, 2020. The overall reduction in transplants during the observation time period translated to 48 239 waitlisted patient life-years lost. INTERPRETATION: We quantified the impact of the COVID-19 pandemic on worldwide organ transplantation activity and revealed heterogeneous adaptation in terms of organ transplantation, both at national levels and within countries, with detrimental consequences for waitlisted patients. Understanding how different countries and health-care systems responded to COVID-19-related challenges could facilitate improved pandemic preparedness, notably, how to safely maintain transplant programmes, both with immediate and non-immediate life-saving potential, to prevent loss of patient life-years. FUNDING: French national research agency (INSERM) ATIP Avenir and Fondation Bettencourt Schueller.

Infección por COVID-19 en pacientes en diálisis crónica en Argentina / COVID-19 infection in chronic dialysis patients in Argentina

Resumen Se presentan los datos preliminares del Registro Argentino de COVID en diálisis crónica, desde el 10 de abril de 2020 al 9 de abril 2021 que incluye todos los centros de diálisis crónica del país. En el período de estudio se registraron 36 918 pacientes prevalentes en diálisis crónica. La infección por COVID-19 fue confirmada en 3709 pacientes (10% prevalentes), de los cuales 1675 (45.2%) requirieron internación, y de éstos el 39% (550) internación en UTI. El 62% de los ingresados a UTI (339) requirió asistencia respiratoria me cánica (ARM). Fallecieron 1307 pacientes (35.24 %). El análisis multivariado, mostró como factores asociados a mortalidad por COVID en diálisis crónica, la edad mayor a 60 años (OR 2.6; IC 95% 2.2-3.1); la diabetes (OR 1.5; IC 95% 1.3-1.8); tiempo en diálisis mayor a 55 meses (OR 1.5; IC 95% 1.2-1.7); enfermedad cerebrovascular OR 1.6; IC 95% 1.1-2.3); neoplasia (OR 1.7; IC 95% 1.1-2.6); requerimiento de internación (OR 3.4; IC 95% 2.8-3.9); internación en UTI (OR 1.8; IC 95% 1.3-2.5); necesidad de ARM (OR 11.8; IC 95% 6.9-20.2). La población en diálisis crónica en Argentina, como se muestra en el resto del mundo, es altamente vulnerable a la infección COVID, mostrando una letalidad 12 veces mayor que la población general. Las medidas implementadas en las unidades de diálisis, los cuidados de los pacientes y su entorno familiar, y por sobre todo la vacunación prioritaria, son fundamentales en esta población vulnerable de pacientes.

Abstract The report of the preliminary data of the Argentine Registry of COVID in chronic dialysis is presented, from April 10, 2020 to April 9, 2021 and includes all dialysis centers in the country. In the study period, 36 918 prevalent patients on chronic dialysis were registered. COVID-19 infection was confirmed in 3709 patients (10% of prevalent patients), of which 1675 patients (45.2%) required hospitalization, and of these, 39% (550 patients) required ICU admission. 62% of those admitted to the ICU (339 patients) required mechanical ventilation (MV). 1307 patients died (35.24%). Multivariate analysis showed as factors associated with mortality from COVID in dialysis patients, age greater than 60 years (OR 2.6; 95% CI 2.2-3.1); diabetes (OR 1.5; 95% CI 1.3-1.8); time on dialysis greater than 55 months (OR 1.5; 95% CI 1.2-1.7); cerebrovascular disease (OR 1.6; 95% CI 1.1-2.3); neoplasia (OR 1.7; 95% CI 1.1-2.6); hospitalization requirement (OR 3.4; 95% CI 2.8-3.9); ICU admission (OR 1.8; 95% CI 1.3-2.5); need of MV (OR 11.8; 95% CI 6.9-20.2). The population on chronic dialysis in Argentina, as shown in the rest of the world, is highly vulnerable to COVID infection, showing a lethality 12 times higher than the general population. The measures implemented in dialysis units, patient care and their family environment, and above all priority vaccination are essential in this vulnerable population of patients.

Initial glomerular filtration rate and survival in hemodialysis. The role of permanent vascular access.

BACKGROUND: A significant increase in the number of patients starting chronic hemodialysis (HD) with an estimated glomerular filtration rate (eGFR)≥10 mL/min/1.73 m(2) was observed in Argentina between 2004 and 2009. METHODS: In order to study this topic, we calculated the mortality hazard ratios (HR) in a cohort of incident HD individuals from the Argentine Registry of Chronic Dialysis [Registro Argentino de Diálisis Crónica] (2004-2009), grouped according to the initial eGFR (0-4.9, 5-9.9, 10-14.9 and ≥15 mL/min/1.73 m(2) ; reference group 0-4.9) estimated by CKD-EPI; in three cohorts: "total population", "healthy" (<65 years, without diabetes or comorbidities) and "planned entry" (with permanent vascular access). RESULTS: After adjusting the population (n=16,931) for age, gender, coexisting conditions, serum albumin, income, and temporary vascular access a HR of 1.19 (95%CI:1.07-1.33) was observed in the group with eGFR≥15 mL/min/1.73 m(2). In the cohort of 3,897 "healthy" after adjusting for the same co-variates, HRs of 1.44 (95%CI: 1.08-1.65) and 1.65 (95%CI: 1.06-2.55) were obtained for the groups with baseline eGFR values of 10-14.9 and ≥15 mL/min/1.73 m(2), respectively. In "planned entry" patients (n=6,280), after adjusting for age, gender, co-morbidities, serum albumin and income, HRs in all groups were not significantly different as compared to the control group. CONCLUSIONS: HD initiation with eGFR>10 mL/min/1.73 m(2) shows no survival advantage. The higher mortality in the group with >eGFR starting dialysis looks like an "artifact" related to higher age, more co-morbidities, low albuminemia and the use of temporary vascular access.

The lack of income is associated with reduced survival in chronic haemodialysis.

INTRODUCTION: Poor socioeconomic status in the patient population is one of the causes of the lack of primary and secondary prevention of chronic kidney disease and negatively affects the survival of patients on chronic haemodialysis (HD). OBJECTIVE: To confirm whether the low or absent income of the incident population on HD is a factor of poor prognosis. METHODS: We used the incident HD population of the Argentine Registry of Chronic Dialysis. Follow-up lasted 12 months, performing an intention to treat analysis. We applied the Cox model to assess the association between income and survival of patients after adjusting for age, sex, diabetes, comorbidities, initial laboratory results, and first vascular access. RESULTS: We analysed 13466 adult patients (age at onset: 60.4 ± 15.6 years; 57.2% were male, and 39.2% diabetic) who were assigned to 2 groups: 1) "no income" group, 5661 patients (age at onset: 60.3 ± 15.4 years; 53.1% were male and 41.4% diabetic), 2) "with income" group, 7805 patients (age at onset, 60.5 ± 15-8] years; 60.1% were male and 37.5% diabetic). The "no income" group had a hazard ratio of 1.19 (95% confidence interval [CI]: 1.11-1.28) in the univariate analysis, 1.23 (95% CI: 1.14-1.32 ) considering age and gender, 1.22 (95% CI: 1.13-1.31) by adding diabetes mellitus, 1.26 (95% CI: 1.18-1.36) by adding comorbidities, 1.25 (95% CI: 1.16- 1.35) by adding the initial laboratory results, and 1.24 (95% CI: 1.15- 1.33) if temporary vascular access is included. All models resulted in a significance of P=.000. CONCLUSIONS: Low or no income of patients at the time of entry into HD is an independent risk factor for immediate lower survival.

A new prognostic index for one-year survival in incident hemodialysis patients.

PURPOSE: Although scoring comorbidities for patients beginning chronic hemodialysis has proved significant and has led researchers to develop several indexes, none of them has been extensively accepted. The aim of this study was to: 1) develop a prognostic index for patients entering renal replacement therapy; and 2) identify which one of the available scores better predicts one-year survival. METHODS: Records from 5,360 incident dialysis-requiring ESRD individuals were studied and a novel comorbidity index (NI) was developed. The agreement of this NI with the Charlson age-comorbidity, Kahn-Wright, ACPI, and Hemmelgarn indexes was assessed to identify which one better predicts one-year survival. The Cox proportional hazard regression with time-dependent covariates was used to analyze survival and the area under the receiver operating characteristic (ROC) curve was calculated to assess the ability of this score to discriminate between prognoses and to compare this NI with indexes already in use. RESULTS: 16 of the original 19 predictor variables displayed hazard ratios =1.2. Although the area under the ROC curves for all the indexes compared were significantly different from 0.5, the NI showed better performance characteristics (0.74 vs. 0.70 for Charlson's, 0.68 for ACPI, 0.67 for Khan-Wright's and 0.63 for Hemmelgarn's). Compared with the Charlson score, the z statistic was 7.78 (p<0.001). One-year survival estimate for the high-risk group was 43% with the NI and ranged from 66% to 72% when assessed through other indexes. CONCLUSIONS: We recommend the use of this NI because it better predicts the one-year survival probability of incident hemodialysis-requiring ESRD individuals.

Características de la población incidente en diálisis crónica en Argentina / Characteristics of the incident hemodialysis population in chronic hemodialysis in Argentina

Evaluamos las características de la población incidente en Diálisis Crónica (DC) en Argentina desde 2004 hasta 2008. La tasa de incidencia del total del país fue en 2008 de 143.1 pacientes por millón de habitantes-año (ppm), con cambios significativos entre los años 2006, 2007 y 2008. Existe una gran dispersión de tasas entre provincias de Argentina con un rango de 71-201 ppm. La edad de la población fue envejeciendo significativamente llegando en 2008 a 59.8 años de promedio y aumentando significativamente la población mayor a 64 años, especialmente en varones, cuyas tasas duplican a la de las mujeres a partir de los 70 años. La Nefropatía Diabética es la primer causa de Incidencia a DC representando el 35,5% del total en 2008, en aumento permanente desde 2004. Las comorbilidades cardiovasculares disminuyeron en el tiempo, no obstante se continúa con altos porcentajes. El 67% de los pacientes presentan Hematocrito menor al 30%. El 52% de los pacientes inician DC con Albuminemia menor a 3.5 gramos / decilitros. El 1.4-2.0% de la población ingresa con presencia del anticuerpo de la Hepatitis C. Llegan sin vacunarse contra la Hepatitis B el 61% de los pacientes, con aumento significativo en los años transcurridos. Aumentó la población que comienza Hemodiálisis Crónica (HD) con catéter transitorio, llegando a 2008 a representar el 66% del total. La población que declara no poseer ingresos económicos disminuyó al 22% en 2008. Concluimos que es de importancia fundamental el seguimiento o monitoreo anual de estas variables iniciales en pacientes incidentes en DC porque muchas de ellas demostraron estar directamente relacionadas con peor pronóstico vital.

Sobrevida en diálisis crónica en Argentina: período 2004-2008 / Survival in chronic dialysis in Argentina: period 2004-2008

Se presenta la sobrevida según método de Kaplan-Meier(KM) de pacientes incidentes (01/04/2004 al 31/12/2008) al Registro Argentino de Diálisis Crónica (DC). El seguimiento (N=27.224) tuvo un máximo de 2101 días o 69.07 meses, en ese período fallecieron 9747 pacientes y al 31/12/2009 estaban con vida 10319 pacientes. La mediana de sobrevida fue de 47,9 meses. Se recurrió al Modelo del riesgo proporcional de Cox multivariado para determinar riesgo relativo o Hazard Ratio (HR) entre cada variable independiente al ingreso a DC. Del total de variables tomamos 29 (siempre que no entren en conflicto entre ellas y con casos perdidos <25%). 19 variables se muestran como predictoras significativas : Edad al ingreso (4,1% de mayor riesgo de muerte por cada año), presencia de: Insuficiencia Cardíaca, Angina Persistente o Infartos de Miocardio previos, Enfermedad Cerebrovascular, Insuficiencia Vascular Periférica, Virus C de la Hepatitis+, Arritmia Cardíaca, haber recibido Transfusiones en los últimos 6 meses, Enfermedad Pulmonar Crónica, Neoplasia al ingreso y ser portador de SIDA.