Chronic Active Antibody-mediated Rejection in Kidney Transplant Recipients: Treatment Response Rates and Value of Early Surveillance Biopsies.

There is limited information on the value of short-term invasive and noninvasive monitoring in kidney transplant recipients (KTR) undergoing therapy for chronic active antibody-mediated rejection (cAMR). Methods: We describe response rates in patients with cAMR receiving pulse steroids/IVIG ± rituximab 3-mo after index biopsy. Results: The study included 82 consecutive KTR. Mean time from transplant to cAMR was 10 y. Mean peritubular capillaritis (ptc), glomerulitis (g), microvascular inflammation (MVI), C4d, and cg Banff scores were 1.1, 2.1, 3.2, 0.2, and 2, respectively. Mean estimated glomerular filtration rate (eGFR) and urine protein creatinine (UPC) ratio were 38 mL/min and 1.6 g/g, respectively. Thirty (37%) patients lost their allograft during the mean follow-up of 2.4 y. In patients treated with pulse steroids/IVIG (n = 41), response rates for eGFR, UPC, donor-specific antibodies (DSAs), and MVI were 27%, 49%, 7%, and 19%, respectively. In the pulse steroids/IVIG/rituximab group, response rates were 66%, 61%, 20%, and 69%, respectively. Univariate analysis identified response in eGFR (HR = 0.03; P = 0.001; 95% CI, 0.004-0.26), UPC (HR = 0.38; P = 0.01; 95% CI, 0.18-0.82), and DSA (HR = 0.11; P = 0.004; 95% CI, 0.02-0.49) as predictors of graft survival. Multivariate analysis only retained eGFR response (HR = 0.12; P = 0.01; 95% CI, 0.02-0.64). Conclusions: In cAMR, short-term response to treatment for kidney function and DSA was associated with graft survival, but the role of early surveillance biopsies needs further evaluation.

In kidney recipients from the same deceased donor, discordance in delayed graft function is associated with the worst outcomes.

INTRODUCTION: Delayed graft function (DGF) is a common complication among deceased donor kidney transplant recipients (DDKTs) and is associated with worse outcomes. The effect on outcomes of concordance versus discordance in DGF between two different recipients of kidneys from the same donor is largely unknown. METHODS: We reviewed all adult DDKTs for which both kidneys were transplanted to two different recipients at our center between 2014-2019. DDKTs were divided into four groups based on the DGF status: concordance no DGF (cc-no-DGF); discordance no DGF(dd-no-DGF); discordance DGF (dd-DGF) and concordance in DGF (cc-DGF). Acute rejection (AR) and death censored graft failure (DCGF) were outcomes of interest. RESULTS: A total of 578 DDKTs fulfilled our selection criteria, 280were in cc-no-DGF, 83 in dd-no-DGF, 83 in dd-DGF, and 132 in cc-DGF. Compared to cc-no-DGF, in univariate analysis, dd-DGF was associated with an increased risk of AR (HR: 1.60; 95% CI: 1.0-2.56) but cc-DGF was not (HR: 1.01; 95% CI: 0.63-1.62). dd-DGF was not associated with an increased risk of AR in multivariate analysis. In multivariate analysis, dd-DGF was associated with an increased risk of DCGF (HR: 2.70; 95% CI: 1.05-6.93) but cc-DGFwas not (HR: 2.36; 95% CI: 0.97-5.70). CONCLUSION: Discordance in DGF is associated with worse outcomes and may need closefollow-up and monitoring to improve the outcomes.

Predictors of a Top-Box Patient Experience: A Retrospective Observational Study of HCAHPS Data at a Safety Net Institution.

Hospitals commonly seek to improve patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, yet there are limited data to guide improvement efforts. The HCAHPS survey was developed for interhospital comparisons, whereas its use in intrahospital comparisons has not been validated. We sought to better understand the validity of utilizing intrahospital score comparisons and to identify the factors that may predict top-box HCAHPS scores. We performed a retrospective observational cohort study at an academic urban safety-net hospital examining 4898 HCAHPS surveys completed by hospitalized patients. We found that while most Patient-Mix Adjustment factors for which HCAHPS scores are adjusted were associated with top-box scores on intrahospital comparisons, few additional variables were associated with top-box scores. Further, HCAHPS questions pertaining to nurse and doctor communication were highly correlated with overall hospital rating, suggesting that communication-related factors may influence a patient's hospital experience more strongly than do administrative factors.

Retropharyngeal Hematoma as an Unusual Presentation of Myelodysplastic Syndrome: A Case Report.

BACKGROUND Retropharyngeal hematoma is a relatively rare diagnosis that requires a high clinical suspicion and stabilization of the airway to prevent rapid deterioration. We report a case of a spontaneous retropharyngeal hematoma in an elderly patient with myelodysplastic syndrome and associated thrombocytopenia. CASE REPORT A 90-year-old man with myelodysplastic syndrome was brought to the Emergency Department with complaints of difficulty swallowing and muffled voice for 24 hours. Upon arrival, his vital signs and physical exam were unremarkable, except that when he was asked to take a sip of water, he could not swallow it. Complete blood count was remarkable for leukocytosis of 14.3×10³/mcL, hemoglobin of 9.0 gm/dL, and platelet count of 26×10³/mcL. Chest X-ray and lateral soft-tissue neck X-rays were grossly unremarkable. The patient was admitted for further evaluation and was scheduled for esophagogastroduodenoscopy. During intubation for esophagogastroduodenoscopy, the patient was noted to have significant airway narrowing. A subsequent CT scan revealed a 3×2×2 cm supraglottic hypodensity, thought to represent a retropharyngeal hematoma. The patient was transferred to the Intensive Care Unit (ICU) and received platelet transfusions. The ICU course was complicated by anemia, which necessitated transfusion of packed red blood cells. On hospital day 7, the patient reported resolution of his symptoms and was discharged home. CONCLUSIONS This case adds to the growing body of literature on spontaneous retropharyngeal hematomas. High clinical suspicion is warranted in patients who present with acute dysphagia, odynophagia, and dysphonia. Prompt imaging and airway management are vital in managing patients with this condition.