Significantly Lower Rates of Kidney Transplantation among Candidates Listed with the Veterans Administration: A National and Local Comparison.

BACKGROUND: The process for evaluating kidney transplant candidates and applicable centers is distinct for patients with Veterans Administration (VA) coverage. We compared transplant rates between candidates on the kidney waiting list with VA coverage and those with other primary insurance. METHODS: Using the Scientific Registry of Transplant Recipients database, we obtained data for all adult patients in the United States listed for a primary solitary kidney transplant between January 2004 and August 2016. Of 302,457 patients analyzed, 3663 had VA primary insurance coverage. RESULTS: VA patients had a much greater median distance to their transplant center than those with other insurance had (282 versus 22 miles). In an adjusted Cox model, compared with private pay and Medicare patients, VA patients had a hazard ratio (95% confidence interval) for time to transplant of 0.72 (0.68 to 0.76) and 0.85 (0.81 to 0.90), respectively, and lower rates for living and deceased donor transplants. In a model comparing VA transplant rates with rates from four local non-VA competing centers in the same donor service areas, lower transplant rates for VA patients than for privately insured patients persisted (hazard ratio, 0.72; 95% confidence interval, 0.65 to 0.79) despite similar adjusted mortality rates. Transplant rates for VA patients were similar to those of Medicare patients locally, although Medicare patients were more likely to die or be delisted after waitlist placement. CONCLUSIONS: After successful listing, VA kidney transplant candidates appear to have persistent barriers to transplant. Further contemporary analyses are needed to account for variables that contribute to such differential transplant rates.

Downhill varices secondary to HeRO graft-related SVC syndrome.

Tunneled hemodialysis catheters are well-documented causes of benign central vein stenosis, which can be associated with proximal or downhill esophageal varices due to shunting of blood flow from the upper portion of the body through the esophageal venous plexuses. A majority of these cases remain asymptomatic. As a result, studies are largely limited to symptomatic patients, with incidence rates ranging from 16% to 29%. Recently, Hemodialysis Reliable Outflow (HeRO) graft has been introduced as an effective alternate hemodialysis access in catheter-dependent patients, especially in the presence of significant central venous occlusion. It differs from a conventional arteriovenous graft (AVG) by the fact that its venous outflow end is in the right atrium via one of the central veins, bypassing any significant occlusion upstream. Lower intervention rates and reduced incidence of bacteremia make it comparable to conventional tunneled catheters. However, the incidence of central vein occlusion and associated complications with HeRO grafts is unknown. We present the first case of gastrointestinal bleeding from downhill esophageal varices secondary to HeRO-graft-related SVC occlusion.