Gender disparities in kidney replacement therapies and transplantation in Colombia.

BACKGROUND: In chronic kidney disease (CKD), there are historical inequities in multiple stages of the pathway for organ transplantation. Women have been recognized as disadvantaged within this process even after several efforts. Therefore, we aimed to analyze the prevalence and incidence of CKD by gender and their access to Kidney replacement therapy (KRT) in Colombia. METHODS: A cross-sectional study based on secondary analysis of national information on CKD, hypertension, diabetes, waiting list, deceased, and living donor transplantation between 2015 and 2020. RESULTS: In Colombia, 4.934.914 patients were diagnosed with hypertension, diabetes, or CKD. 60,64% were female, with a mean age of 63.84 years (SD 14,36). Crude incidence for hypertension (10.85 vs. 7.21 /1000 inhabitants), diabetes mellitus (3.77 vs. 2.98 /1000 inhabitants), and CKD (4 vs. 2 /1000 inhabitants) was higher for females. Crude incidence for KRT was 86.45 cases /100.0000 inhabitants. In 2020, 2978 patients were on the waiting list, 44% female. There were 251 deaths on the waiting list, 38% female. This year, 517 kidney transplants were performed, and only 40% were female. CONCLUSION: In Colombia, there are proportionally more females with CKD and precursor comorbidities. Nevertheless, there are fewer females on the waiting list and transplanted annually.

Understanding the dynamics of deceased organ donation and utilization in Colombia.

Objective: To obtain a comprehensive overview of organ donation, organ utilization, and discard in the entire donation process in Colombia. Methods: A retrospective study of 1 451 possible donors, distributed in three regions of Colombia, evaluated in 2022. The general characteristics, diagnosis, and causes of contraindication for potential donors were described. Results: Among the 1 451 possible donors, 441 (30.4%) fulfilled brain death criteria, constituting the potential donor pool. Families consented to organ donation in 141 medically suitable cases, while 60 instances utilized legal presumption, leading to 201 eligible donors (13.9%). Of those, 160 (11.0%) were actual donors (in whom operative incision was made with the intent of organ recovery or who had at least one organ recovered). Finally, we identified 147 utilized donors (10.1%) (from whom at least one organ was transplanted). Statistically significant differences were found between age, sex, diagnosis of brain death, and donor critical pathway between regions. A total of 411 organs were transplanted from 147 utilized donors, with kidneys being the most frequently procured and transplanted organs, accounting for 280 (68.1%) of the total. This was followed by 85 livers (20.7%), 31 hearts (7.5%), 14 lungs (3.4%), and 1 pancreas (0.2%). The discard rate of procured deceased donors was 8.1%. Conclusions: About one-tenth of donors are effectively used for transplantation purposes. Our findings highlight areas of success and challenges, providing a basis for future improvements in Colombia.

Understanding the relevance of surgical specialties in undergraduate medical education: Insights of graduates.

BACKGROUND: The relevance of training medical students in surgical specialty services has been a matter of debate in contexts where the health care system focuses on primary health care. Some educators argue that medical students should be trained in primary care settings. Other educators assert that rotating in highly complex hospitals strengthens the competencies of future general practitioners. Nonetheless, little attention has been paid to the added value that rotations in surgical specialties have brought to newly graduated doctors' lives. In this study, we explored the perceptions of a group of graduates by focusing on the relevant experiences they had during their surgical specialty rotations in undergraduate medical training and how this training influenced their personal and professional life. METHODS: We conducted a qualitative study using a convenience sampling strategy to recruit a total of seven junior doctors. Data were collected through semi-structured interviews in 2022. Thematic analysis was used to analyse the data until code saturation was reached. RESULTS: The recurring themes were (1) perception of rotations, (2) valuable learning for medical practice and (3) defining their professional future. Participants felt that their experiences in surgical specialty rotations were beneficial, as they gained confidence to perform professionally and decide on future employment and strengthened their research and primary healthcare competencies. CONCLUSION: Although training in primary healthcare centres is crucial in undergraduate medical education, these results suggest that including rotations in surgical specialties may be valuable in enhancing the future careers of junior doctors.

Incidence and Outcomes of BK Virus Nephropathy in Kidney Transplant Recipients With Steroid-Free Maintenance Immunosuppression.

BACKGROUND: BK virus nephropathy (BKVN) is a significant complication in kidney transplant recipients, resulting in graft dysfunction and potentially leading to graft loss. This study aims to investigate the incidence and outcomes of BKVN in kidney transplant recipients receiving steroid-free maintenance immunosuppression in a Latin -American cohort. METHODS: Case series study of BKVN among kidney transplant recipients who underwent transplantation between 2008 and 2023. The primary outcome was graft loss caused by BKVN, excluding death with function. Secondary outcomes included graft function and acute rejection episodes. The statistical analysis involved descriptive statistics and the Kaplan-Meier (K-M) method to plot the overall probabilities of not initiating dialysis. RESULTS: During the 15-year period, 2236 kidney transplants were performed, BKVN was histologically diagnosed in 38 kidney recipients and 33 cases were analyzed. Median age was 50 years and men were 48.5% of patients. A total of 45.4% of BKVN occurred within the first 12 months of transplant. The incidence of BKVN was 1.6% but it varied by era. The rate of graft loss was 75.7% (25 cases). The K-M graft survival probability at 6 months and 12 months after diagnosis of BKVN was 38.3% (95% CI 24.7-59.4) and 22.3% (95% CI 11.7-42.8), respectively. CONCLUSION: BKVN affected 1.6% of transplant recipients and it was associated with high-rate of graft loss. We observed that significant graft disfunction at the time of diagnosis resulted in worse outcomes with a reduced probability of graft survival.

The Value of Protocol Biopsy in Kidney Transplantation on Monitoring Transplant Outcomes: A Systematic Review and Meta-Analysis.

BACKGROUND: There is a great debate about the role of biopsies per protocol in kidney transplant recipients, and the published studies show contradictory results. We aimed to assess the safety and effectiveness of protocol biopsies in kidney transplant recipients in improving short- and long-term outcomes. METHODS: We conducted searches until July of 2023 to identify all randomized clinical trials (RCT). Studies were identified through search strategies for CENTRAL, MEDLINE, EMBASE, and LILACS. Titles and abstracts were screened independently by 2 authors; 2 authors independently assessed retrieved abstracts and the full text. Assessment of risk of bias was carried out using the Cochrane risk of bias tool. The outcomes of interest were: Acute rejection, graft loss, mortality, glomerular filtration rate, and safety outcomes. Meta-analysis was performed for variables of interest when appropriate. Quality of evidence was assessed using GRADE methodology. RESULTS: We screened 5,695 records. Four trials met all eligibility criteria. No benefit of protocol biopsy was found in detecting acute rejection (3 studies RR: 2.0, 95% CI: 0.68-5.85, p = .2) or preventing graft loss at 12 months (2 studies, RR 0.33, 95% CI 0.06-1.72, p = .19). No differences were found between the groups in the glomerular filtration rate at 6 months post-transplantation (2 studies, MD 2.97, 95% CI 1.4-7.3, p = .18). A total of 23 safety events were present in the biopsy group compared to six in the control group. CONCLUSION: No benefit was found in performing protocol biopsy following kidney transplantation.

Clinical Outcomes in Living Donor Kidney Transplantation: A Single Center Experience in Latin America.

BACKGROUND: In Latin America, few reports are available about the clinical outcomes of living donor kidney transplants (LDKT). We aim to evaluate the main clinical outcomes for LDKT patients in a single center's experience. METHODS: We retrospectively evaluated 530 LDKT patients who underwent transplantation from August 2008 to December 2020 at Colombiana de Trasplantes. Graft survival censored for death and patient survival were determined up to 5 years post-transplantation by the Kaplan-Meier method. Vascular and urinary complications, readmission, and reintervention rates were documented. RESULTS: A total of 530 LDKT patients were analyzed. Most of the recipients were men (56%). There were 123 patients (23.2%) with a preemptive transplant. Panel reactive antibody type I and II had higher immunologic risk (>20%) in 15.9% of the patients. The donor mean age was 37.8 ± 11.5 years. Most of the donors were women (52.6%) and related to the recipient (69.1%). Multivariate analysis identified panel reactive antibody type II (P = 0.003), female donor (P = 0.001), surgical reintervention at 30 days post-transplantation (P < .01), and delayed graft function (P < .01) as risk factors for graft loss. The graft survival death-censored rates were 93.7% and 89% at 1 and 5 years, respectively. Patient survival rates were 97.0% and 94.1% at 1 and 5 years after transplantation, respectively. CONCLUSIONS: The long-term graft and patient survival rates in our center are comparable to previous reports from other leading centers. The clinical outcomes from a medium-sized center can be noteworthy, although not entirely new.

Comparison of Three Glomerular Filtration Rate Estimating Equations with 24-Hour Urine Creatinine Clearance Measurement in Potential Living Kidney Donors.

Background: The accuracy of the measurement of renal function in potential living kidney donors (PLKD) is essential. The direct measurement of glomerular filtration rate (mGFR) has been considered the "gold standard." The estimated GFR (eGFR) with 24-hour urinary creatinine clearance (CrCl) is frequently used because of its availability. We aim to evaluate the correlation and agreement of eGFR using serum-based creatinine formulas (Cockcroft-Gault, MDRD, and CKD-EPI) and the eGFR based on 24-hour urinary CrCl to evaluate kidney function in PLKD. Methods: We evaluated the kidney function in 799 PLKD using 24-hour urinary CrCl method and compared the correlation and agreement with the eGFR based on creatinine formulas (Cockcroft-Gault, MDRD, and CKD-EPI). We calculated the mean bias (difference), precision (SD of this difference), accuracy, and performed Bland-Altman plots. Results: A total of 799 PLKD were analyzed. The age of the PLKD ranged from 18 to 73 years. Weak to mild correlation was observed between 24-hour urinary CrCl and all formulas (ranged from 0.31 to 0.49). The three equations underestimated the GFR. Using the Bland-Altman graphic, we observed that the CKD-EPI was the least scattered and most precise; however, mean bias and the interval range (limits of agreement) of all formulas were too big to assume equivalence between 24-hour urinary CrCl method and eGFR based on creatinine. Results of mean bias were similar when comparing the three equations in patients with CrCl GFR <60. However, the accuracy of all formulas was better for the female group and the youngest individuals (≤40 years old). Conclusion: In this PLKD cohort, of all the three equations, the CKD-EPI was the least scattered and most precise. However, the correlation and the level of agreement between the three equations and 24-hour urinary CrCl were too low to assume the equivalence.

Predicting 5-year survival after kidney transplantation in Colombia using the survival benefit estimator tool.

INTRODUCTION: A complex relationship between donor and recipient characteristics influences kidney transplant (KT) success. A tool developed by Bae S. et al. (Survival Benefit Estimator, SBE) helps estimate post-KT survival. We aim to evaluate the predictive performance of the SBE tool in terms of 5-year patient survival after a kidney transplant. METHODS: A retrospective cohort study of all deceased-donor KT recipients between January 2009 to December 2021. A descriptive analysis of clinical and sociodemographic characteristics was performed. The SBE online tool was used to calculate the predicted patient survival (PPS) and the survival benefit at five years post-KT. Comparisons between predictive vs. actual patient survival were made using quintile subgroups. Three Cox regression models were built using PPS, EPTS, and KDPI. RESULTS: A total of 1145 recipients were evaluated. Mortality occurred in 157 patients. Patient survival was 86.2%. Predictive survival for patients if they remained on the waiting list was 70.6%. The PPS was 89.3%, which results in a survival benefit (SB) of 18.7% for our population. Actual survival rates were lower than the predicted ones across all the quintiles. In unadjusted analysis, PPS was a significant protective factor for mortality (HR 0.66), whereas EPTS (HR 8.9) and KDPI (HR 3.25) scores were significant risk factors. The discrimination of KDPI, PPS, and EPTS scores models were 0.59, 0.65, and 0.66, respectively. CONCLUSION: SBE score overestimated actual survival rates in our sample. The discrimination power of the score was moderate, although the utility of this tool may be limited in this specific population.

Prevalence and Modifiable Factors for Holistic Non-Adherence in Renal Transplant Patients: A Cross-Sectional Study.

Introduction: In renal transplant recipients, compliance with medical therapy is vital. Non-adherence is considered a risk factor for worst outcomes in kidney recipients, with attributed outcomes of 64% for graft loss and 80% for late acute rejection. Most literature defines adherence as self-based immunosuppression compliance but does not consider other relevant factors such as consult and procedure compliance. Therefore, this study aims to describe adherence prevalence in kidney transplant recipients and the factors related to non-adherence. Methods: This cross-sectional study included 1030 renal transplant patients followed by Colombiana de Trasplantes between January 2019 and July 2021. Sociodemographic and clinical variables were obtained based on clinical records. The mental-health group diagnosed holistic adherence in a semi-structured interview. The diagnosis considered medication intake failure, frequency and number of failures to medical controls or other procedures, suspicious non-adherence behaviors, and serum levels of immunosuppressants. A bivariate followed a descriptive analysis, and a forward logistic regression was performed for non-adherence. Results: Patients had a median of 47 years, and 58.1% were male. Non-adherence was presented in 30.7% of patients. The non-adherence patients were younger, with a higher prevalence of males, single, divided transplant care, had a longer time after transplantation, psychopathological diagnosis, and more reinforcement education by only nursing. Older age and multidisciplinary reinforcement education were protective factors. On the other hand, poor social support, psychopathology diagnosis, and longer time after transplant presented as non-adherence risk factors. Conclusion: Holistic non-adherence was diagnosed in approximately one-third of renal transplant recipients. Its definition included more than just medication non-compliance and could identify more non-adherent patients. Notably, there is a need to consider the related factors in the health follow-up and encourage future research in modifiable factor interventions aiming to increase adherence and achieve better outcomes for renal transplant patients.

Is Non-Adherence Associated with Adverse Outcomes in Kidney Transplant Recipients? The Role of Non-Adherence as a Risk and Predictor Factor for Graft Loss and Death.

Introduction:  Non-adherence in kidney transplants is diversely defined. Immunosuppression non-adherence (INA) is the most used definition and has been associated with graft loss and acute rejection. But INA assesses only one fraction of adherence. Therefore, we analyzed the association of a holistic non-adherence definition with transplant outcomes and compared its prediction performance with other definitions. Methods:  We retrospectively included 739 kidney recipients between 2019 and 2021. We evaluated holistic non-adherence (HNA), suboptimal-immunosuppressor levels (SIL), appointment non-adherence (ANA), procedure non-adherence (PNA) and INA. The main outcomes were graft loss, graft rejection, and mortality. A backward logistic regression was performed estimating adjusted and un-adjusted odds ratio (OR) for each outcome. Finally, we compared the non-adherence definitions' prediction for the main outcomes using the area under the curve. Results: HNA was present in 28.7% of patients. Non-adherent patients had an adjusted OR of 2.66 (1.37-5.15) for mortality, 6.44 for graft loss (2.71-16.6), and 2.28 (1.15-4.47) for graft rejection. INA and PNA presented a moderate discrimination for graft loss and HNA and ANA mild-to-moderate discrimination for graft loss and death. Conclusion: Holistic non-adherence was associated with worst outcomes in kidney recipients and had a significant prediction performance for graft loss and mortality.

Risk Factors for Urologic Complications After Kidney Transplantation and Impact in Graft Survival.

Background and Purpose: Kidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients. Patients and Methods: A retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method. Results: A total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs. Conclusion: MUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.

Safety and Intraoperative Results in Live Kidney Donors with Vascular Multiplicity After Hand-Assisted Laparoscopy Living Donor Nephrectomy.

BACKGROUND AND PURPOSE: Vascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN). PATIENTS AND METHODS: Data from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations. RESULTS: MRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively. CONCLUSION: HALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.

Risk factors for graft loss and death among kidney transplant recipients: A competing risk analysis.

INTRODUCTION: Kidney transplantation is the best therapeutical option for CKD patients. Graft loss risk factors are usually estimated with the cox method. Competing risk analysis could be useful to determine the impact of different events affecting graft survival, the occurrence of an outcome of interest can be precluded by another. We aimed to determine the risk factors for graft loss in the presence of mortality as a competing event. METHODS: A retrospective cohort of 1454 kidney transplant recipients who were transplanted between July 1, 2008, to May 31, 2019, in Colombiana de Trasplantes, were analyzed to determine risk factors of graft loss and mortality at 5 years post-transplantation. Kidney and patient survival probabilities were estimated by the competing risk analysis. The Fine and Gray method was used to fit a multivariable model for each outcome. Three variable selection methods were compared, and the bootstrapping technique was used for internal validation as split method for resample. The performance of the final model was assessed calculating the prediction error, brier score, c-index and calibration plot. RESULTS: Graft loss occurred in 169 patients (11.6%) and death in 137 (9.4%). Cumulative incidence for graft loss and death was 15.8% and 13.8% respectively. In a multivariable analysis, we found that BKV nephropathy, serum creatinine and increased number of renal biopsies were significant risk factors for graft loss. On the other hand, recipient age, acute cellular rejection, CMV disease were risk factors for death, and recipients with living donor had better survival compared to deceased-donor transplant and coronary stent. The c-index were 0.6 and 0.72 for graft loss and death model respectively. CONCLUSION: We developed two prediction models for graft loss and death 5 years post-transplantation by a unique transplant program in Colombia. Using a competing risk multivariable analysis, we were able to identify 3 significant risk factors for graft loss and 5 significant risk factors for death. This contributes to have a better understanding of risk factors for graft loss in a Latin-American population. The predictive performance of the models was mild.

Retrospective Analysis of the Kidney Donor Profile Index to Predict Patient and Graft Survival at 5 Years Posttransplantation in a Colombian Cohort.

BACKGROUND: The Kidney Donor Profile Index (KDPI) has been used to predict patient and graft outcomes in deceased donor kidney transplantation. We aimed to evaluate the impact of KDPI on transplantation major outcomes applied to a Colombian cohort. METHODS: We retrospectively assessed 260 adult patients who underwent kidney transplantation (KT) from January 2011 to June 2014 at our center and compared their KDPIs with graft and patient outcomes at 5 years posttransplantation. Kaplan-Meier survival method and Cox analysis were fitted to analyze the impact of the 3 KDPI categories on graft and patient outcomes. RESULTS: A total of 18.4% of transplants were from donors with a KDPI ≥75%. There was a significant decrement in renal function with increasing KDPI at 5 years posttransplantation (P < .05). The final model indicates that donor diabetes was associated with elevated risk for graft loss (hazard ratio [HR], 6.5; 95% confidence interval [CI] 1.35-31.8; P = .019) at 5 years posttransplantation. Recipient age (HR, 2.3; 95% CI, 1.1-4.5; P = .001), diabetes status (HR, 2.17; CI, 1.04-5.5; P = .003), dialysis duration (HR, 1.08; 95% CI, 1.00-1.16; P = .003), and operating room time (HR, 1.47; 95% CI, 1.02-2.12; P = .003) were associated with elevated risk for death at 5 years posttransplantation. KDPI categories were not significantly associated with graft loss or death. CONCLUSIONS: We found limited KDPI power to predict graft and patient survival when applied to a Latin American population in Colombia. Our findings highlight the importance of analyzing the application of KDPI in different populations. Therefore, our findings may not be generalizable to other regions outside of Colombia.

Acute Kidney Injury in Hospitalized Kidney Transplant Recipients.

BACKGROUND: Acute kidney injury (AKI) is a main cause of morbidity, hospitalization, and hospital readmission in kidney transplant recipients. We aimed to determine AKI incidence and risk factors following kidney transplant to assess outcomes such as renal function and graft loss after AKI. METHODS: We conducted a retrospective cohort study with hospitalized kidney transplant recipients during 2016 to 2017. Clinical data of 179 patients were reviewed. The primary outcome was AKI incidence and risk factors. To determine AKI occurrence, we based it on creatinine criteria from Acute Kidney Injury Network classification. RESULTS: We documented a total of 179 hospital admissions; AKI was diagnosed in 104 patients (58.1%). Recipients with higher baseline serum creatinine (odds ratio, 2.6; confidence interval [CI], 1.5-4.5; P < .001) and hospital admission because of infections (odds ratio, 2.4; CI, 1.1-5.2; P = .020) were more likely to experience AKI. A total of 19 recipients (10.6%) had graft loss with a significant AKI association (P = .003) at 12 months after admission. Intensive care unit length of stay (P = .63) and hospital stay (P = .55) were not different in patients with AKI compared with the control group. CONCLUSIONS: As a main clinical finding, we concluded that infections and higher serum creatinine baseline level were associated with the development of AKI.

Hand-assisted Laparoscopic Nephrectomy: Evaluation of the Learning Curve.

BACKGROUND: Hand-assisted laparoscopic donor nephrectomy (HALDN) has rapidly become the best alternative to open nephrectomy for living kidney donation. As more centers continue to adopt the laparoscopic technique, the safety of the initial transplants must be ensured while ascending the learning curve (LC). This study looks to determine the safety of HALDN and to describe the results of the LC in our center. METHODS: We conducted a retrospective review of 500 HALDNs performed in our center from July 2003 to July 2017. We analyzed demographic and perioperative characteristics and complications during the first postoperative month. We divided HALDNs into 2 groups: before and after completing the LC (50 nephrectomies). For each group, we assessed operating room time, estimated blood loss, length of stay, and complication and conversion rates. RESULTS: A total of 500 HALDNs were performed in the study period. Of those, 454 were analyzed in the 2 groups. The median operating room time was 2 hours, length of stay was 2 days, and blood loss was 50 cc. The overall rate of complication was 6.8%. There were significant differences between the 2 groups in operating time, blood loss, and length of stay (P < .05). No differences were found in terms of complication (P = .42) and conversion (P = .28) rates. CONCLUSION: There was a significant decrease in operating time, blood loss, and length of stay in patients who underwent laparoscopic donor nephrectomy by an experienced laparoscopist. However, no differences were found in complication and conversion rates, which suggests that improvement in surgical training can be accomplished without altering the donor safety.

Relación entre la compatibilidad del HLA y la pérdida del injerto en trasplante renal de donante cadavérico: Un análisis por propensity score matching en Colombia / Relationship between HLA compatibility and graft loss in renal transplant from a deceased donor: An analysis by propensity score matching in Colombia

Introducción. En Colombia, solo un 24 % de los pacientes en lista recibieron un trasplante renal, la mayoría de donante cadavérico. Para la asignación de órganos se considera el HLA A-B-DR, pero la evidencia reciente sugiere que el HLA A-B no está asociado con los desenlaces del trasplante. El objetivo de este estudio fue evaluar la relevancia del HLA A-B-DR en la sobrevida del injerto de los receptores de trasplante renal. Métodos. Estudio de cohorte retrospectivo que incluyó pacientes trasplantados renales con donante cadavérico en Colombiana de Trasplantes, desde 2008 a 2023. Se aplicó un propensity score matching (PSM) para ajustar las covariables en grupos de comparación por compatibilidad y se evaluó la relación del HLA A-B-DR con la sobrevida del injerto renal por medio de la prueba de log rank y la regresión de Cox. Resultados. Se identificaron 1337 pacientes transplantados renales, de los cuales fueron mujeres un 38,7 %, con mediana de edad de 47 años y de índice de masa corporal de 23,8 kg/m2. Tras ajustar por PSM las covariables para los grupos de comparación, la compatibilidad del HLA A-B no se relacionó significativamente con la pérdida del injerto, con HR de 0,99 (IC95% 0,71-1,37) para HLA A y 0,75 (IC95% 0,55-1,02) para HLA B. Solo la compatibilidad por HLA DR fue significativa para pérdida del injerto con un HR de 0,67 (IC95% 0,46-0,98). Conclusión. Este estudio sugiere que la compatibilidad del HLA A-B no influye significativamente en la pérdida del injerto, mientras que la compatibilidad del HLA DR sí mejora la sobrevida del injerto en trasplante renal con donante cadavérico

Introduction. In Colombia, only 24% of patients on the waiting list received a renal transplant, most of them from cadaveric donors. HLA A-B-DR is considered for organ allocation, but recent evidence suggests that HLA A-B is not associated with transplant outcomes. The objective of this study was to evaluate the relevance of HLA A-B-DR on graft survival in kidney transplant recipients. Methods. Retrospective cohort study that included kidney transplant recipients with a cadaveric donor in Colombiana de Trasplantes from 2008 to 2023. A propensity score matching (PSM) was applied to adjust the covariates in comparison groups for compatibility, and the relationship of HLA A-B-DR with kidney graft survival was evaluated using the log rank test and Cox regression. Results. A total of 1337 kidney transplant patients were identified; of those, 38.7% were female, with median age of 47 years, and BMI 23.8 kg/m2. After adjusting the covariates with PSM for the comparison groups, HLA A-B matching was not significantly related to graft loss, with HR of 0.99 (95% CI 0.71-1.37) and 0.75 (95% CI 0.55-1.02), respectively. Only HLA DR matching was significant for graft loss with an HR of 0.67 (95% CI 0.46-0.98). Conclusions. This study suggests that HLA A-B matching does not significantly influence graft loss, whereas HLA DR matching does improve graft survival in renal transplantation with a cadaveric donor.

Acute Rejection in Kidney Transplantation and Early Beginning of Tacrolimus.

BACKGROUND: Although tacrolimus is an effective immunosuppressive drug used for preventing biopsy proven acute rejection (BPAR) in kidney transplanted patients, its nephrotoxicity may compromise renal function and lead to delayed initiation because of its side effects. This study aimed to evaluate the safety of early initiation of tacrolimus in the occurrence of BPAR during the first 90 days post transplant. METHODS: We conducted a retrospective cohort study involving 315 patients who underwent kidney transplantation from 2015 to 2017. Comparisons were performed between 2 groups according to whether the start time of tacrolimus therapy was delayed or not delayed. Cox proportional hazards models were used to examine the association between variables and the occurrence of BPAR. RESULTS: The incidence of BPAR was 14.9% (n = 47) and it was significantly higher in the delayed group (19.4% vs 6.4%; P = .002). Delayed initiation tacrolimus group was significantly associated with the risk of BPAR (hazard ratio: 2.95; P < .036). The overall mortality rate was 2.5% (n = 8) and there was no association between delayed initiation therapy and death (P = .56). CONCLUSION: Our study confirmed that delayed initiation of tacrolimus in patients with delayed graft function is associated with a high risk of BPAR.

Understanding the dynamics of deceased organ donation and utilization in Colombia / Examen de la dinámica de la donación y utilización de órganos de personas fallecidas en Colombia / Entendendo a dinâmica da doação e do aproveitamento de órgãos de pessoas falecidas na Colômbia

ABSTRACT Objective. To obtain a comprehensive overview of organ donation, organ utilization, and discard in the entire donation process in Colombia. Methods. A retrospective study of 1 451 possible donors, distributed in three regions of Colombia, evaluated in 2022. The general characteristics, diagnosis, and causes of contraindication for potential donors were described. Results. Among the 1 451 possible donors, 441 (30.4%) fulfilled brain death criteria, constituting the potential donor pool. Families consented to organ donation in 141 medically suitable cases, while 60 instances utilized legal presumption, leading to 201 eligible donors (13.9%). Of those, 160 (11.0%) were actual donors (in whom operative incision was made with the intent of organ recovery or who had at least one organ recovered). Finally, we identified 147 utilized donors (10.1%) (from whom at least one organ was transplanted). Statistically significant differences were found between age, sex, diagnosis of brain death, and donor critical pathway between regions. A total of 411 organs were transplanted from 147 utilized donors, with kidneys being the most frequently procured and transplanted organs, accounting for 280 (68.1%) of the total. This was followed by 85 livers (20.7%), 31 hearts (7.5%), 14 lungs (3.4%), and 1 pancreas (0.2%). The discard rate of procured deceased donors was 8.1%. Conclusions. About one-tenth of donors are effectively used for transplantation purposes. Our findings highlight areas of success and challenges, providing a basis for future improvements in Colombia.

RESUMEN Objetivo. Presentar una descripción integral de la donación, utilización y descarte de órganos en todo el proceso de donación en Colombia. Métodos. Estudio retrospectivo de 1 451 donantes posibles, distribuidos en tres regiones de Colombia, que fueron evaluados en el 2022. Se describen las características generales, el diagnóstico y las causas de contraindicación de los donantes potenciales. Resultados. De los 1 451 donantes posibles, 441 (30,4%) cumplían con los criterios de muerte encefálica y constituyeron el conjunto de donantes potenciales. Las familias consintieron la donación de órganos en 141 casos aptos desde el punto de vista médico, mientras que en 60 casos se recurrió a la presunción legal, con lo que se llegó a 201 donantes aptos (13,9%). De estos, 160 (11,0%) fueron donantes reales (en los que se les practicó una incisión quirúrgica para la extracción de órganos o se obtuvo al menos un órgano). En última instancia, hubo 147 donantes utilizados (10,1%) (de los que se trasplantó al menos un órgano). Se observaron diferencias estadísticamente significativas entre las regiones en cuanto a edad, sexo, diagnóstico de muerte encefálica y vía crítica del donante. Se trasplantaron un total de 411 órganos procedentes de 147 donantes utilizados; los riñones fueron los órganos obtenidos y trasplantados con mayor frecuencia, ya que supusieron 280 (68,1%) del total de órganos, seguidos del hígado (85, 20,7%), el corazón (31 , 7,5%), los pulmones (14, 3,4%) y el páncreas (1, 0,2%). La tasa de descarte de los donantes fallecidos disponibles fue del 8,1%. Conclusiones. Aproximadamente una décima parte de los donantes son utilizados, de hecho, para realizar trasplantes. Estos datos destacan las áreas en las que se han obtenido buenos resultados y aquellas en las que se presentan desafíos, lo cual proporciona una base para futuras mejoras en Colombia.

RESUMO Objetivo. Obter uma visão geral e abrangente da doação, do aproveitamento e do descarte de órgãos em todo o processo de doação na Colômbia. Métodos. Estudo retrospectivo de 1 451 possíveis doadores em três regiões da Colômbia que foram avaliados em 2022. Foram descritas as características gerais, o diagnóstico e os motivos para a contraindicação de potenciais doadores. Resultados. Dentre os 1 451 possíveis doadores, 441 (30,4%) preencheram os critérios de morte encefálica, formando o grupo de potenciais doadores. Em 141 casos considerados clinicamente aptos, as famílias consentiram com a doação de órgãos, e em 60 casos utilizou-se o princípio da presunção legal, resultando em 201 doadores elegíveis (13,9%). Desses, 160 (11,0%) foram doadores efetivos (ou seja, doadores nos quais foi feita uma incisão cirúrgica com a intenção de remover um órgão ou pessoas com pelo menos um órgão removido). Por fim, foram identificados 147 doadores utilizados (10,1%) (ou seja, que doaram pelo menos um órgão que foi transplantado). Foram encontradas diferenças estatisticamente significantes entre idade, sexo, diagnóstico de morte encefálica e itinerário crítico de doação entre as regiões. Um total de 411 órgãos foram transplantados de 147 doadores utilizados. Os rins foram os órgãos mais frequentemente removidos e transplantados, representando 280 (68,1%) do total, seguido de 85 fígados (20,7%), 31 corações (7,5%), 14 pulmões (3,4%) e 1 pâncreas (0,2%). A taxa de descarte de doadores falecidos com órgãos removidos foi de 8,1%. Conclusões. Cerca de um décimo dos doadores são efetivamente usados para fins de transplante. Nossos achados destacam áreas de sucesso e desafios, oferecendo uma base para futuras melhorias na Colômbia.

Critical pathway for deceased donors: An analysis in three regions of Colombia / Ruta crítica de donantes fallecidos: un análisis de tres regiones en Colombia

Introduction. The critical pathway for deceased donation offers a methodical framework for guiding the donation process. It not only serves to assess performance but also to identify areas of potential improvement. Therefore, the identification and selection of potential organ donors (POD) is a key process. This study aims to describe the critical pathway for deceased donation in a cohort of POD in three regions (CRT1, CRT2, and CRT5) of Colombia. Methods. We retrospectively reviewed data of POD assessed from January 2022 to December 2022. General characteristics of POD, diagnosis, contraindication causes, and organ procurement were described. Analysis was conducted using the Chi-squared test for categorical variables and the Mann-Whitney test for quantitative variables. Results. Within the cohort of 1451 assessed POD, 441 (30.3%) were diagnosed with brain death. Among potential donors after brain death, 198 (44.9%) were eligible donors (medically suitable). Of these, 157 donors (79.3%) became actual donors (undergoing operative incision for organ recovery), with 147 (93,6 %) having at least one organ recovered (actual donors with organ recovery). Ultimately, 411 utilized organs were utilized. Additionally, there were observed differences in the characteristics of donors from different regions. Conclusion. This study reports the critical pathway for deceased donation in a cohort of POD in three regions of Colombia. This provides useful information and helps to gain insight and understanding into the process of organ donation and organ procurement in order to take actions that could improve the donation rates.

Introducción. La ruta crítica de donantes fallecidos permite un enfoque sistemático para la donación de riñón, y, proporciona una herramienta para evaluar el rendimiento de áreas de mejora potencial. La selección de posibles donantes de órganos (PDO) es un proceso clave. El objetivo de este estudio fue describir la ruta crítica para la donación de fallecidos en una cohorte de PDO en tres regiones de Colombia. Métodos. Estudio retrospectivo de PDO evaluados durante 2022. Se describieron las características generales de los PDO, el diagnóstico y las causas de contraindicación. El análisis se llevó a cabo utilizando la prueba de Chi-cuadrado para las variables categóricas y la prueba de Mann-Whitney para las variables cuantitativas. Resultados. Entre los 1451 POD evaluados, 441 (30,3 %) fueron diagnosticados con muerte cerebral. De los posibles donantes después de la muerte cerebral, 198 (44,9 %) fueron donantes elegibles (adecuados desde el punto de vista médico). Entre ellos, 157 donantes (79,3 %) fueron donantes reales (en quienes se realizó una incisión operatoria con la intención de recuperar órganos) y 147 (93,6 %) tuvieron al menos un órgano recuperado (donantes reales con recuperación de órganos). Finalmente, se identificaron 411 órganos utilizados. Conclusión. Este estudio reporta la ruta crítica para la donación de fallecidos en una cohorte de POD en tres regiones de Colombia. Esto proporciona información útil, ayuda a obtener conocimientos y comprender el proceso de donación y obtención de órganos, para tomar medidas que puedan mejorar las tasas de donación.