Risk of End-Stage Renal Disease in HIV-Positive Potential Live Kidney Donors.

New federal regulations allow HIV-positive individuals to be live kidney donors; however, potential candidacy for donation is poorly understood given the increased risk of end-stage renal disease (ESRD) associated with HIV infection. To better understand this risk, we compared the incidence of ESRD among 41 968 HIV-positive participants of North America AIDS Cohort Collaboration on Research and Design followed for a median of 5 years with the incidence of ESRD among comparable HIV-negative participants of National Health and Nutrition Examination III followed for a median of 14 years. We used risk associations from multivariable Cox proportional hazards regression to derive cumulative incidence estimates for selected HIV-positive scenarios (no history of diabetes, hypertension, AIDS, or hepatitis C virus coinfection) and compared these estimates with those from similarly selected HIV-negative scenarios. For 40-year-old HIV-positive individuals with health characteristics that were similar to those of age-matched kidney donors, viral load <400 copies/mL, and CD4+ count ≥500 cells/µL, the 9-year cumulative incidence of ESRD was higher than that of their HIV-negative peers, yet still low: 2.5 versus 1.1 per 10 000 among white women, 3.0 versus 1.3 per 10 000 among white men, 13.2 versus 3.6 per 10 000 among black women, and 15.8 versus 4.4 per 10 000 among black men. HIV-positive individuals with no comorbidities and well-controlled disease may be considered low-risk kidney donor candidates.

Recipient Outcomes Following Transplantation of Allografts From Live Kidney Donors Who Subsequently Developed End-Stage Renal Disease.

Live kidney donors have an increased risk of end-stage renal disease (ESRD) compared with nondonors; however, it is unknown whether undetected, subclinical kidney disease exists at donation that subsequently contributes to this risk. To indirectly test this hypothesis, the authors followed the donated kidneys, by comparing the outcomes of 257 recipients whose donors subsequently developed ESRD with a matched cohort whose donors remained ESRD free. The compared recipients were matched on donor (age, sex, race/ethnicity, donor-recipient relationship), transplant (HLA mismatch, peak panel-reactive antibody, previous transplantation, year of transplantation), and recipient (age, sex, race/ethnicity, body mass index, cause of ESRD, and time on dialysis) risk factors. Median recipient follow-up was 12.5 years (interquartile range 7.4-17.9, maximum 20 years). Recipients of allografts from donors who developed ESRD had increased death-censored graft loss (74% versus 56% at 20 years; adjusted hazard ratio [aHR] 1.7; 95% confidence interval [CI] 1.5-2.0; p < 0.001) and mortality (61% versus 46% at 20 years; aHR 1.5; 95% CI 1.2-1.8; p < 0.001) compared with matched recipients of allografts from donors who did not develop ESRD. This association was similar among related, spousal, and unrelated nonspousal donors. These findings support a novel view of the mechanisms underlying donor ESRD: that of pre-donation kidney disease. However, biopsy data may be required to confirm this hypothesis.

A Smartphone App for Increasing Live Organ Donation.

The incidence of live donor transplantation has declined over the past decade, and waitlisted candidates report substantial barriers to identifying a live donor. Since asking someone to donate feels awkward and unfamiliar, candidates are hesitant to ask directly and may be more comfortable with a passive approach. In collaboration with Facebook leadership (Facebook Inc., Menlo Park, CA), we developed a mobile application-an app-that enables waitlisted candidates to create a Facebook post about their experience with organ failure and their need for a live donor. We conducted a single-center prospective cohort study of 54 adult kidney-only and liver-only waitlisted candidates using the Facebook app. Cox proportional hazards models were used to describe donor referral on behalf of candidates using the app compared with matched controls. The majority of candidates who used the app reported it to be "good" or "excellent" with regard to the installation process (82.9%), readability (88.6%), simplicity (70.6%), clarity (87.5%) and the information provided (85.3%). Compared with controls, candidates using the Facebook app were 2.43 6.6117.98 times more likely to have a donor come forward on their behalf (p < 0.001). The Facebook app is an easy-to-use instrument that enables waitlisted candidates to passively communicate with their social network about their need for a live donor.

Patterns of End-Stage Renal Disease Caused by Diabetes, Hypertension, and Glomerulonephritis in Live Kidney Donors.

Inferences about late risk of end-stage renal disease (ESRD) in live kidney donors have been extrapolated from studies averaging <10 years of follow-up. Because early (<10 years) and late (≥10 years) postdonation ESRD may differ by causal mechanism, it is possible that extrapolations are misleading. To better understand postdonation ESRD, we studied patterns of common etiologies including diabetes, hypertension and glomerulonephritis (GN; as reported by providers) using donor registry data linked to ESRD registry data. Overall, 125 427 donors were observed for a median of 11.0 years (interquartile range 5.3-15.7 years; maximum 25 years). The cumulative incidence of ESRD increased from 10 events per 10 000 at 10 years after donation to 85 events per 10 000 at 25 years after donation (late vs. early ESRD, adjusted for age, race and sex: incidence rate ratio [IRR] 1.3 1.72.3 [subscripts are 95% confidence intervals]). Early postdonation ESRD was predominantly reported as GN-ESRD; however, late postdonation ESRD was more frequently reported as diabetic ESRD and hypertensive ESRD (IRR 2.3 7.725.2 and 1.4 2.64.6 , respectively). These time-dependent patterns were not seen with GN-ESRD (IRR 0.4 0.71.2 ). Because ESRD in live kidney donors has traditionally been reported in studies averaging <10 years of follow-up, our findings suggest caution in extrapolating such results over much longer intervals.

Experiences obtaining insurance after live kidney donation.

The impact of kidney donation on the ability to change or initiate health or life insurance following donation is unknown. To quantify this risk, we surveyed 1046 individuals who donated a kidney at our center between 1970 and 2011. Participants were asked whether they changed or initiated health or life insurance after donation, and if they had any difficulty doing so. Among 395 donors who changed or initiated health insurance after donation, 27 (7%) reported difficulty; among those who reported difficulty, 15 were denied altogether, 12 were charged a higher premium and 8 were told they had a preexisting condition because they were kidney donors. Among 186 donors who changed or initiated life insurance after donation, 46 (25%) reported difficulty; among those who reported difficulty, 23 were denied altogether, 27 were charged a higher premium and 17 were told they had a preexisting condition because they were kidney donors. In this single-center study, a high proportion of kidney donors reported difficulty changing or initiating insurance, particularly life insurance. These practices by insurers create unnecessary burden and stress for those choosing to donate and could negatively impact the likelihood of live kidney donation among those considering donation.

Identifying appropriate recipients for CDC infectious risk donor kidneys.

Over 10% of deceased donors in 2011 met PHS/CDC criteria for infectious risk donor (IRD), and discard rates are significantly higher for kidneys from these donors. We hypothesized that patient phenotypes exist for whom the survival benefit outweighs the infectious risk associated with IRDs. A patient-oriented Markov decision process model was developed and validated, based on SRTR data and meta-analyses of window period risks among persons with IRD behaviors. The Markov model allows patients to see, for their phenotype, their estimated survival after accepting versus declining an IRD offer, graphed over a 5-year horizon. Estimated 5-year survival differences associated with accepting IRDs ranged from -6.4% to +67.3% for a variety of patient phenotypes. Factors most predictive of the survival difference with IRD transplantation were age, PRA, previous transplant, and the expected time until the next non-IRD deceased donor offer. This study suggests that survival benefit derived from IRD kidneys varies widely by patient phenotype. Furthermore, within the inherent limitations of model-based prediction, this study demonstrates that it is possible to identify those predicted to benefit from IRD kidneys, and illustrates how estimated survival curves based on a clinical decision can be presented to better inform patient and provider decision-making.