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1.
Am J Kidney Dis ; 83(3): 360-369, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-37844725

RESUMO

Delayed graft function (DGF) is a common complication after kidney transplant. Despite extensive literature on the topic, the extant definition of DGF has not been conducive to advancing the scientific understanding of the influences and mechanisms contributing to its onset, duration, resolution, or long-term prognostic implications. In 2022, the National Kidney Foundation sponsored a multidisciplinary scientific workshop to comprehensively review the current state of knowledge about the diagnosis, therapy, and management of DGF and conducted a survey of relevant stakeholders on topics of clinical and regulatory interest. In this Special Report, we propose and defend a novel taxonomy for the clinical and research definitions of DGF, address key regulatory and clinical practice issues surrounding DGF, review the current state of therapies to reduce and/or attenuate DGF, offer considerations for clinical practice related to the outpatient management of DGF, and outline a prospective research and policy agenda.


Assuntos
Função Retardada do Enxerto , Transplante de Rim , Humanos , Função Retardada do Enxerto/terapia , Estudos Prospectivos , Rim , Transplante de Rim/efeitos adversos , Prognóstico , Fatores de Risco , Sobrevivência de Enxerto , Rejeição de Enxerto/etiologia
2.
Am J Transplant ; 22(2): 381-385, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34780109

RESUMO

The question of whether transplant clinicians should mandate COVID-19 vaccination as a condition of transplant candidacy is complex. A vaccine mandate may be defensible on the grounds that transplant clinicians are obligated to ensure transplantation is conducted safely, and in a manner that entails the best use of a scarce public good. However, mandate proponents will inexorably predicate their arguments on contingent clinical judgments that meliorate rather than resolve core value disagreements. Vaccine mandates are conceivably defensible on narrow grounds, but may prove to be purchased at the expense of an attenuation of shared decision-making, proffering claims of risk reduction from a vaccine mandate beyond what the current evidence base supports, and unintentionally exacerbating durable inequities in access to transplantation.


Assuntos
COVID-19 , Transplante de Rim , Vacinas contra COVID-19 , Humanos , SARS-CoV-2 , Estados Unidos , Vacinação
3.
Am J Transplant ; 22(6): 1705-1713, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35143100

RESUMO

An electronic survey canvassing current policies of transplant centers regarding a COVID-19 vaccine mandate for transplant candidates and living donors was distributed to clinicians at US solid organ transplant centers performing transplants from October 14, 2021-November 15, 2021. Responses were received from staff at 141 unique transplant centers. These respondents represented 56.4% of US transplant centers, and responding centers performed 78.5% of kidney transplants and 82.4% of liver transplants in the year prior to survey administration. Only 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported that vaccination was not required. A minority (42%) of responding centers with a vaccine mandate for transplant candidates also mandated vaccination for living organ donors. Centers with a vaccine mandate most frequently cited clinical evidence supporting the efficacy of pre-transplant vaccination (82%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64%). Centers without a vaccine mandate cited a variety of reasons including administrative, equity, and legal considerations for their decision. Transplant centers in the United States exhibit significant heterogeneity in COVID-19 vaccination mandate policies for transplant candidates. While all centers encourage vaccination, most centers have not mandated COVID-19 vaccination for candidates and living donors, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants.


Assuntos
Vacinas contra COVID-19 , COVID-19 , COVID-19/epidemiologia , COVID-19/prevenção & controle , Vacinas contra COVID-19/uso terapêutico , Humanos , Doadores Vivos , SARS-CoV-2 , Inquéritos e Questionários , Transplantados , Estados Unidos/epidemiologia
4.
Am J Transplant ; 20(5): 1244-1250, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31561276

RESUMO

The announcement of the Advancing American Kidney Health (AAKH) Initiative on July 10, 2019 was met with a mix of excitement and trepidation, befitting a proposed radical reconfiguration of the delivery of kidney disease care. Aspiring to reduce the incidence of end-stage renal disease, increase the prevalence of home dialysis, and double the number of organs available for transplant, the AAKH payment models primarily focus on incenting behaviors of general nephrologists, though actualizing positive incentives will require the active cooperation of dialysis providers and transplant centers. Here, we review the AAKH initiatives' potential impact on all stakeholders and opine on financial and regulatory pressures on kidney transplant programs, outlining areas of uncertainty and concern, and suggest key points of reflection for clinical and administrative leaders of kidney transplant centers weighing participation in any of the voluntary payment models.


Assuntos
Falência Renal Crônica , Transplante de Rim , Humanos , Rim , Falência Renal Crônica/cirurgia , Motivação , Diálise Renal , Estados Unidos
6.
Am J Transplant ; 18(1): 43-52, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28898574

RESUMO

Healthcare reimbursement is increasingly tied to value instead of volume, with special attention paid to resource-intensive populations such as patients with renal disease. To this end, Medicare has sponsored pilot projects to encourage providers to develop care coordination and population health management strategies to provide quality care while reducing resource utilization. In this Personal Viewpoint essay, we argue in favor of expanding one such pilot project-the Comprehensive ESRD Care (CEC) initiative-to include patients with advanced chronic kidney disease and kidney transplant recipients. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) offers a time-sensitive incentive for transplant centers in particular to align with extant CECs. An "expanded" CEC model proffers opportunity for robust cooperation between general nephrology practices, dialysis providers, and transplant centers to develop care coordination strategies for all patients with renal disease, realign incentives for all clinical stakeholders to increase kidney transplantation rates, and reduce total costs of care.


Assuntos
Prestação Integrada de Cuidados de Saúde/tendências , Medicare/tendências , Nefrologia/tendências , Qualidade da Assistência à Saúde , Insuficiência Renal Crônica/prevenção & controle , Redução de Custos , Prestação Integrada de Cuidados de Saúde/economia , Humanos , Medicare/economia , Nefrologia/economia , Prognóstico , Diálise Renal , Transplantados , Estados Unidos
7.
Kidney Int Rep ; 9(6): 1590-1600, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38899170

RESUMO

In the United States, kidney care payment models are migrating toward value-based care (VBC) models incentivizing quality of care at lower cost. Current kidney VBC models will continue through 2026. We propose a future transplant-inclusive VBC (TIVBC) model designed to supplement current models focusing on patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The proposed TIVBC is structured as an episode-of-care model with risk-based reimbursement for "referral/evaluation/waitlisting" (REW, referencing kidney transplantation), "primary hospitalization to 180 days posttransplant," and "long-term graft survival." Challenges around organ acquisition costs, adjustments to quality metrics, and potential criticisms of the proposed model are discussed. We propose next steps in risk-adjustment and cost-prediction to develop as an end-to-end, TIVBC model.

9.
Transplantation ; 107(12): e348-e354, 2023 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-37726879

RESUMO

BACKGROUND: The Organ Procurement Transplant Network (OPTN)/United Network for Organ Sharing (UNOS) registry is an important national registry in the field of solid organ transplantation. Data collected are mission critical, given its role in organ allocation prioritization, program performance monitoring by both the OPTN and the Centers for Medicare & Medicaid Services, and countless observational analyses that helped to move the field forward. Despite the multifaceted importance of the OPTN/UNOS database, there are clear indications that investments in the database to ensure the quality and reliability of the data have been lacking. METHODS: This analysis outlines 2 examples: (1) primary diagnosis for patients who are receiving a second transplant and (2) reporting peripheral vascular disease in kidney transplantation to illustrate the extensive challenges facing the veracity and integrity of the OPTN/UNOS database today. RESULTS: Despite guidance that repeat kidney transplant patients should be coded as "retransplant/graft failure" rather than their native kidney disease, only 59% of new incident patients are coded in this manner. Peripheral vascular disease prevalence more than doubled in a 20-y span when the variable became associated with risk adjustment. CONCLUSIONS: This article summarizes critical gaps in the OPTN/UNOS database, and we bring forward ideas and proposals for consideration as a path toward improvement.


Assuntos
Transplante de Órgãos , Doenças Vasculares Periféricas , Obtenção de Tecidos e Órgãos , Idoso , Humanos , Estados Unidos/epidemiologia , Reprodutibilidade dos Testes , Medicare , Transplante de Órgãos/efeitos adversos , Sistema de Registros
10.
Kidney360 ; 3(10): 1754-1762, 2022 10 27.
Artigo em Inglês | MEDLINE | ID: mdl-36514724

RESUMO

Background: The coronavirus disease 2019 (COVID-19) pandemic created unprecedented challenges for solid organ transplant centers worldwide. We sought to assess an international perspective on COVID-19 vaccine mandates and rationales for or against mandate policies. Methods: We administered an electronic survey to staff at transplant centers outside the United States (October 14, 2021-January 28, 2022) assessing the reasons cited by transplant centers for or against implementing a COVID-19 vaccine mandate. Each responding center was represented once in the analysis. Results: Respondents (N=90) represented 27 countries on five continents. Half (51%) of responding transplant center representatives reported implementing a COVID-19 vaccine mandate, 38% did not, and 12% were unsure. Staff at centers implementing a vaccine mandate cited efficacy of pretransplant vaccination versus post-transplant vaccination, importance for public health, and minimizing exposure of other patients as rationale for the mandate. Of centers with a mandate, the majority (81%) of the centers mandate vaccination regardless of prior SARS-CoV-2 infection status and regardless of prevaccination spike-protein antibody titer or other markers of prior infection. Only 27% of centers with a vaccine mandate for transplant candidates also extended a vaccine requirement to living donor candidates. Centers not implementing a vaccine mandate cited concerns for undue pressure on transplant candidates, insufficient evidence to support vaccine mandates, equity, and legal considerations. Conclusions: The approach to pretransplant COVID-19 vaccination mandate policies at international transplant centers is heterogeneous. International transplant centers with a vaccine mandate were more willing to extend vaccine requirements to candidates' support persons, cohabitants, and living donors. Broader stakeholder engagement to overcome vaccine hesitancy across the world is needed to increase the acceptance of pretransplant COVID-19 vaccination to protect the health of transplant patients.


Assuntos
COVID-19 , Transplantes , Humanos , Vacinas contra COVID-19/uso terapêutico , COVID-19/epidemiologia , SARS-CoV-2 , Vacinação
11.
Kidney360 ; 3(6): 1089-1094, 2022 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-35845323

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic profoundly impacted transplant services, with a particularly strong impact on living donor kidney transplantation.The COVID-19 pandemic appears to have disproportionately impacted Black patients' access to living donor kidney transplantation.As the pandemic evolves through surges and vaccine acceptance disparities persist, ongoing attention to transplant disparities is needed.


Assuntos
COVID-19 , Transplante de Rim , Disparidades em Assistência à Saúde , Humanos , Doadores Vivos , Pandemias
12.
Clin J Am Soc Nephrol ; 16(10): 1552-1559, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34620650

RESUMO

BACKGROUND AND OBJECTIVES: Current race-based eGFR calculators assign a higher eGFR value to Black patients, which could affect the care of kidney transplant candidates and potential living donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a survey of staff at adult kidney transplant centers in the United States (December 17, 2020 to February 28, 2021) to assess opinions on use of race-based eGFR equations for waitlisting and living donor candidate evaluation, availability of serum cystatin C testing and measured GFR, and related practices. RESULTS: Respondents represented 57% (124 of 218) of adult kidney transplant programs, and the responding centers conducted 70% of recent kidney transplant volume. Most (93%) programs use serum creatinine-based eGFR for listing candidates. However, only 6% of respondents felt that current race-based eGFR calculators are appropriate, with desire for change grounded in concerns for promotion of health care disparities by current equations and inaccuracies in reporting of race. Most respondents (70%) believed that elimination of race would allow more preemptive waitlisting for Black patients, but a majority (79%) also raised concerns that such an approach could incur harms. More than one third of the responding programs lacked or were unsure of availability of testing for cystatin C or measured GFR. At this time, 40% of represented centers did not plan to remove race from eGFR calculators, 46% were planning to remove, and 15% had already done so. There was substantial variability in eGFR reporting and listing of multiracial patients with some Black ancestry. There was no difference in GFR acceptance thresholds for Black versus non-Black living donors. CONCLUSIONS: This national survey highlights a broad consensus that extant approaches to GFR estimation are unsatisfactory, but it also identified a range of current opinions.


Assuntos
Negro ou Afro-Americano , Técnicas de Apoio para a Decisão , Taxa de Filtração Glomerular , Nefropatias/diagnóstico , Transplante de Rim , Rim/fisiopatologia , Modelos Biológicos , Atitude do Pessoal de Saúde , Seleção do Doador , Pesquisas sobre Atenção à Saúde , Humanos , Nefropatias/etnologia , Nefropatias/fisiopatologia , Doadores Vivos , Valor Preditivo dos Testes , Fatores Raciais , Medição de Risco , Fatores de Risco , Estados Unidos/epidemiologia , Listas de Espera
16.
J Med Philos ; 30(6): 593-626, 2005 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-16396787

RESUMO

The current system of organ procurement which relies on donation is inadequate to the current and future need for transplantable kidneys. The growing disparity between demand and supply is accompanied by a steep human cost. I argue that a regulated market in organs from living vendors is the only plausible solution, and that objections common to opponents of organ markets are de-feasible. I argue that a morally defensible market in kidneys from living vendors includes four characteristics: (1) the priority of safety for both vendors and recipients, (2) transparency regarding the risks to vendors and recipients, (3) institutional integrity regarding guidelines for cooperating with kidney vendors, and (4) operation under a rule of law. I conclude with some remarks on remaining problems with this account, and offer some suggestions as to how these problems might be addressed.


Assuntos
Comércio , Transplante de Rim/economia , Doadores Vivos/ética , Obtenção de Tecidos e Órgãos/economia , Altruísmo , Humanos , Transplante de Rim/ética , Transplante de Rim/legislação & jurisprudência , Doadores Vivos/legislação & jurisprudência , Motivação , Obtenção de Tecidos e Órgãos/ética , Obtenção de Tecidos e Órgãos/legislação & jurisprudência
17.
Am J Transplant ; 5(9): 2248-52, 2005 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16095505

RESUMO

We undertook a study to ascertain the relationship between the presence of CD20-positive B-lymphocytes in renal allografts undergoing acute cellular rejection and graft survival. We identified 27 patients transplanted between January 1, 1998 and December 31, 2001, with biopsy-proven Banff 1-A or Banff 1-B rejection in the first year after transplantation, and stained the specimens for CD20 and C4d. At least 4 years of follow-up data were available for each patient studied. Six patients had CD20-positive B-cell clusters in the interstitium, and 21 patients were negative for CD20 infiltrates. The CD20-positive group was significantly more likely to have steroid-resistant rejection and reduced graft survival compared to CD20-negative controls. This study supports prospective identification of CD20-positive B-cell clusters in biopsy-proven rejection and offers a therapeutic rationale for a trial of monoclonal anti-CD20 antibody in such patients.


Assuntos
Antígenos CD20/biossíntese , Rejeição de Enxerto , Transplante de Rim/métodos , Adulto , Idoso , Anticorpos Monoclonais/química , Linfócitos B/metabolismo , Biópsia , Complemento C4b/biossíntese , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Imuno-Histoquímica , Imunossupressores/uso terapêutico , Rim/metabolismo , Rim/patologia , Masculino , Pessoa de Meia-Idade , Fragmentos de Peptídeos/biossíntese , Estudos Retrospectivos , Fatores de Tempo , Transplante Homólogo , Resultado do Tratamento
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