Thirty-Day Morbidity after Simultaneous Resection of Colorectal Cancer and Colorectal Liver Metastasis: American College of Surgeons NSQIP Analysis.

BACKGROUND: Approximately 20% of patients with colorectal cancer (CRC) present with synchronous liver metastases (CRLM). The decision to resect simultaneously or sequentially remains controversial. The primary aim of this study was to determine whether simultaneous resection of CRC and CRLM is associated with increased complications compared to isolated resection. STUDY DESIGN: Prospective data from the American College of Surgeons (ACS) NSQIP, including the ACS NSQIP procedure-specific colectomy and hepatectomy modules from 2014 to 2017, were reviewed in a retrospective cohort study. Primary study outcome was combined 30-day complication rates; secondary outcomes included colectomy and hepatectomy-specific complication. Multivariable logistic regression was performed to control for confounding factors associated with postoperative complication. RESULTS: A total of 23,643 patients underwent colectomy, 7,462 hepatectomy, and 592 simultaneous resection for CRC and CLRM. Overall morbidity was higher among patients treated with simultaneous resection (29.9%) compared with either isolated colorectal (22.2%) or hepatic resection (17.1%; p < 0.001). Additionally, postoperative ileus (36.4% vs 19.1%) and anastomotic failure (7.9% vs 3.8%) were more common after simultaneous resection compared with colorectal resection (p < 0.05). Similarly, rates of bile leak (8.3% vs 6.2%, p = 0.195) and post-hepatectomy liver failure (8.7% vs 3.8%, p < 0.001) were higher after simultaneous resection compared with isolated hepatectomy. By multivariable logistic regression, simultaneous resection was associated with increased overall complication compared with isolated colon (odds ratio 1.64 [95% CI 1.36 to 1.96]) or liver resection (odds ratio 2.11 [95% CI 1.75 to 2.55]), as well as increased procedure-specific complication. CONCLUSIONS: Although simultaneous resection offers definitive resection for patients with synchronous CRC and CRLM, it is associated with significantly increased 30-day overall and procedure-specific postoperative morbidity.

Race, Relationship and Renal Diagnoses After Living Kidney Donation.

BACKGROUND: In response to recent studies, a better understanding of the risks of renal complications among African American and biologically related living kidney donors is needed. METHODS: We examined a database linking U.S. registry identifiers for living kidney donors (1987-2007) to billing claims from a private health insurer (2000-2007 claims) to identify renal condition diagnoses categorized by International Classification of Diseases 9th Revision coding. Cox regression with left and right censoring was used to estimate cumulative incidence of diagnoses after donation and associations (adjusted hazards ratios, aHR) with donor traits. RESULTS: Among 4650 living donors, 13.1% were African American and 76.3% were white; 76.1% were first-degree relatives of their recipient. By 7 years post-donation, after adjustment for age and sex, greater proportions of African American compared with white donors had renal condition diagnoses: chronic kidney disease (12.6% vs 5.6%; aHR, 2.32; 95% confidence interval [95% CI], 1.48-3.62), proteinuria (5.7% vs 2.6%; aHR, 2.27; 95% CI, 1.32-3.89), nephrotic syndrome (1.3% vs 0.1%; aHR, 15.7; 95% CI, 2.97-83.0), and any renal condition (14.9% vs 9.0%; aHR, 1.72; 95% CI, 1.23-2.41). Although first-degree biological relationship to the recipient was not associated with renal risk, associations of African American race persisted for these conditions and included unspecified renal failure and reported disorders of kidney dysfunction after adjustment for biological donor-recipient relationship. CONCLUSIONS: African Americans more commonly develop renal conditions after living kidney donation, independent of donor-recipient relationship. Continued research is needed to improve risk stratification for renal outcomes among African American living donors.

Associations of pre-transplant prescription narcotic use with clinical complications after kidney transplantation.

BACKGROUND: The impact of narcotic use before kidney transplantation on post-transplant clinical outcomes is not well described. METHODS: We examined integrated national transplant registry, pharmacy records, and Medicare billing claims to follow 16,322 kidney transplant recipients, of whom 28.3% filled a narcotic prescription in the year before transplantation. Opioid analgesic fills were normalized to morphine equivalents (ME) and expressed as mg/kg exposures (approximate quartiles: 0.1-1.7, 1.8-5.4, 5.5-23.7, and ≥ 23.8 mg/kg, respectively). Post-transplant cardiovascular, respiratory, neurological, accidents, substance abuse, and noncompliance events were identified using diagnosis codes on Medicare billing claims. Adjusted associations of ME level with post-transplant complications were quantified by multivariate Cox regression. RESULTS: The incidence of complications at 3 years post-transplant among those with the highest pre-transplant ME exposure compared to no use included: ventricular arrhythmias, 1.1 vs. 0.2% (p < 0.001); cardiac arrest, 4.7 vs. 2.7% (p < 0.05); hypotension, 14 vs. 8% (p < 0.0001); hypercapnia, 1.6 vs. 0.9% (p < 0.05); mental status changes, 5.3 vs. 2.7% (p < 0.001); drug abuse/dependence, 7.0 vs. 1.7% (p < 0.0001); alcohol abuse, 1.8 vs. 0.6% (p = 0.0001); accidents, 0.9 vs. 0.3% (p < 0.05); and noncompliance, 3.5 vs. 2.3% (p < 0.05). In multivariate analyses, transplant recipients with the highest level of pre-transplant narcotic use had approximately 2 to 4 times the risks of post-transplant ventricular arrhythmias, mental status changes, drug abuse, alcohol abuse, and accidents compared with non-users, and 35-45% higher risks of cardiac arrest and hypotension. CONCLUSION: Although associations may reflect underlying conditions or behaviors, high-level prescription narcotic use before kidney transplantation predicts increased risk of clinical complications after transplantation.

Gout after living kidney donation: correlations with demographic traits and renal complications.

BACKGROUND: The demographic and clinical correlates of gout after living kidney donation are not well described. METHODS: Using a unique database that integrates national registry identifiers of U.S. living kidney donors (1987-2007) with billing claims from a private health insurer (2000-2007), we identified post-donation gout based on medical diagnosis codes or pharmacy fills for gout therapies. The frequencies and demographic correlates of gout after donation were estimated by Cox regression with left- and right-censoring. We also compared the rates of renal diagnoses among donors with and without gout, matched in the ratio 1:3 by age, sex, and race. RESULTS: The study sample of 4,650 donors included 13.1% African Americans. By seven years, African Americans were almost twice as likely to develop gout as Caucasian donors (4.4 vs. 2.4%; adjusted hazard ratio, aHR, 1.8; 95% confidence interval (CI) 1.0-3.2). Post-donation gout risk also increased with older age at donation (aHR per year 1.05) and was higher in men (aHR 2.80). Gout rates were similar in donors and age- and sex-matched general non-donors (rate ratio 0.86; 95% CI 0.66-1.13). Compared to matched donors without gout, donors with gout had more frequent renal diagnoses, reaching significance for acute kidney failure (rate ratio 12.5; 95% CI 1.5-107.0), chronic kidney disease (rate ratio 5.0; 95% CI 2.1-11.7), and other disorders of the kidney (rate ratio 2.2; 95% CI 1.2-4.2). CONCLUSION: Donor subgroups at increased risk of gout include African Americans, older donors, and men. Donors with gout have a higher burden of renal complications after demographic adjustment.

Quantifying prognostic impact of prescription opioid use before kidney transplantation through linked registry and pharmaceutical claims data.

BACKGROUND: Limited data are available on the outcome implications of prescription narcotic use before kidney transplantation. METHODS: We examined a novel database wherein national transplant registry identifiers for kidney transplant recipients were linked to records from a large U.S. pharmaceutical claims clearinghouse (2005-2010). We selected recipients with 1 year of captured pretransplant pharmaceutical fill records (N=31,197). Opioid analgesic fills in the year before transplantation were normalized to morphine equivalents (ME) and expressed as mg/kg exposures. Adjusted associations of ME level with posttransplant graft and patient survival (adjusted hazards ratio, aHR) were quantified by multivariate Cox regression. RESULTS: Among the 29% of the sample who filled opioid prescriptions in the year before transplantation, the 25th, 50th, and 75th percentiles of annual ME were 1.8, 5.5, and 23.7 mg/kg, respectively. Three-year graft survival was 88.0% and 84.4% in live donor recipients with upper quartiles of ME use, compared with 92.0% among those who did not receive prescription narcotics (P<0.0001). Adjusted risks of posttransplant death and all-cause graft loss in live donor recipients with the highest quartile of narcotic use were 2.3 times (aHR, 2.27; 95% confidence interval, 1.66-3.10) and 1.8 times (aHR, 1.75; 95% confidence interval, 1.37-2.26), respectively, that of narcotic nonusers. Graded associations of pretransplant opioid exposure level with death and graft loss after deceased donor transplantation were also observed. CONCLUSIONS: Although associations may in part reflect underlying conditions or behaviors, high levels of prescription opioid use before kidney transplantation predict increased risk of posttransplant death and graft loss.

Clopidogrel use as a risk factor for poor outcomes after kidney transplantation.

BACKGROUND: Limited data are available on outcome implications of clopidogrel use before kidney transplantation. METHODS: A novel dataset linking national transplant registry data with records from a large pharmacy claims clearinghouse (2005 to 2010) was examined to estimate risks of post-transplant death and graft failure associated with clopidogrel fills within 90 or more than 90 days before transplant. RESULTS: Clopidogrel fills within 90 days of transplant were associated with 61% of increased relative mortality risk and 23% of increased graft failure risk. Risks were higher in those whose last clopidogrel fill was more than 90 days before transplantation (111% for death, 59% for graft loss). Adverse prognostic associations persisted among recipients of live and deceased donor allografts, older recipients, and those with diabetes or reported cardiovascular disease. CONCLUSIONS: Clopidogrel use before kidney transplantation portends increased risks of post-transplant death and graft loss. Pharmacy claims may identify novel prognostic markers not currently captured in the transplant registry.

Understanding antihypertensive medication use after living kidney donation through linked national registry and pharmacy claims data.

BACKGROUND: Use of antihypertensive medications (AHM) after living kidney donation is not well described. METHODS: We examined a database wherein national transplant registry data for 4,650 living kidney donors in 1987-2007 were linked to pharmacy claims from a US private health insurer (2000-2007 claims) to identify post-donation AHM fills. Cox regression with left- and right-censoring was used to estimate the frequencies and relative likelihood (adjusted hazards ratios, aHR) of post-donation AHM fills according to donor demographic traits. Medication possession ratio (MPRs), defined as (days of AHM dispensed)/(days observed), were also compared among donors and non-donor general beneficiaries. RESULTS: Overall, 17.8% of the sample filled at least one AHM by 5 years post-donation. As compared with White living donors, African-Americans had 37% higher relative likelihood of any AHM use after donation (aHR 1.37, p < 0.0007), including significantly higher likelihoods of filling diuretics (aHR 2.25, p < 0.0001), ACEi/ARBs (aHR 1.46, p < 0.01), calcium channel blockers (aHR 1.56, p = 0.03), and vasodilators/other agents (aHR 2.17, p = 0.03). MPRs for any AHM and subcategories were lower among donors compared with age- and sex-matched non-donors. However, AHM MPRs rose in donors with multiple hypertension diagnoses, and prescription fill exposure for all AHM classes except diuretics was similar among donors and general non-donors with ≥ 3 hypertension diagnoses. CONCLUSIONS: While AHM requirements are lower after kidney donation than among unscreened general persons, racial variation in AHM use occurs in privately insured donors. Demonstration of pharmaceutical care needs of insured donors supports the need for long-term follow-up and healthcare access for all donors.

National assessment of early biliary complications after liver transplantation: economic implications.

BACKGROUND: Despite improvement in surgical technique and medical management of liver transplant recipients, biliary complications remain a frequent cause of posttransplant morbidity and graft loss. Biliary complications require potentially expensive interventions including radiologic procedures and surgical revisions. METHODS: A national data set linking transplant registry and Medicare claims data for 12,803 liver transplant recipients was developed to capture information on complications, treatments, and associated direct medical costs up to 3 years after transplantation. RESULTS: Biliary complications were more common in recipients of donation after cardiac death compared to donation after brain death allografts (23% vs. 19% P<0.001). Among donation after brain death recipients, biliary complications were associated with $54,699 (95% confidence interval [CI], $49,102 to $60,295) of incremental spending in the first year after transplantation and $7,327 in years 2 and 3 (95% CI, $4,419-$10,236). Biliary complications in donation after cardiac death recipients independently increased spending by $94,093 (95% CI, $64,643-$124,542) in the first year and $12,012 (95% CI, $-1,991 to $26,016) in years 2 and 3. CONCLUSION: This national study of biliary complications demonstrates the significant economic impact of this common perioperative complication and suggests a potential target for quality of care improvements.

Prognostic impact of mechanical ventilation after liver transplantation: a national database study.

BACKGROUND: The impact of mechanical ventilatory support (MCVS) on mortality and graft loss after liver transplantation (LT) is not well described. METHODS: Multivariate analysis of a novel database linking national transplant registry and Medicare claims data was used to assess the impact of early MCVS on mortality and graft survival following LTs performed between 2002 and 2008. RESULTS: Among 10,517 LT recipients, 6.9% (n = 726) required postoperative MCVS, 25.6% of whom required less than 96 hours, 24.2% required 96 hours or longer, and 50.1% received an unspecified duration. Significant predictors of prolonged MCVS included older age, female sex, pretransplant dialysis requirement, and ascites. After multivariate adjustment, MCVS of 96 hours or longer was associated with nearly 3 times the adjusted hazard ratio of mortality (2.95, P < .001), while MCVS less than 96 hours was not significantly associated with mortality (adjusted hazard ratio .88, P = .55). CONCLUSIONS: Recognition of LT patients at risk for prolonged MCVS may help to reduce the incidence and consequences of this complication.

Early clinical complications after ABO-incompatible live-donor kidney transplantation: a national study of Medicare-insured recipients.

BACKGROUND: Descriptions of the sequelae of ABO-incompatible (ABOi) kidney transplantation are limited to single-center reports, which may lack power to detect important effects. METHODS: We examined U.S. Renal Data System registry data to study associations of ABOi live-donor kidney transplantation with clinical complications in a national cohort. Among 14,041 Medicare-insured transplants in 2000 to 2007, 119 non-donor-A2 ABOi transplants were identified. A2-incompatible (n=35) transplants were categorized separately. Infection and hemorrhage events were identified by diagnosis codes on billing claims. Associations of ABO incompatibility with complications were assessed by multivariate Cox regression. RESULTS: Recipients of ABOi transplants experienced significantly (P<0.05) higher incidence of wound infections (12.7% vs. 7.3%), pneumonia (7.6% vs. 3.8%), and urinary tract infections (UTIs) or pyelonephritis (24.5% vs. 15.3%) in the first 90 days compared with ABO-compatible recipients. In adjusted models, ABO incompatibility was associated with twice the risk of pneumonia (adjusted hazard ratio [aHR], 2.22; 95% confidence interval [CI], 1.14-4.33) and 56% higher risk of UTIs or pyelonephritis (aHR, 1.56; 95% CI, 1.05-2.30) in the first 90 posttransplantation days, and 3.5 times the relative risk of wound infections in days 91 to 365 (aHR, 3.55; 95% CI, 1.92-6.57). ABOi recipients, 19% of whom underwent pre- or peritransplant splenectomy, experienced twice the adjusted risk of early hemorrhage (aHR, 1.96; 95% CI, 1.19-3.24). A2-incompatible transplantation was associated only with early risk of UTIs or pyelonephritis. CONCLUSION: ABOi transplantation offers patients with potential live donors an additional transplant option but with higher risks of infectious and hemorrhagic complications. Awareness of these complications may help improve protocols for the management of ABOi transplantation.

Accountability for end-stage organ care: implications of geographic variation in access to kidney transplantation.

BACKGROUND: The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by "accountable" providers of transplant services. METHODS: Novel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to "accountable" transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients <60 years old diagnosed between 2000 and 2008. RESULTS: In total, 113 TRRs were defined, 51% of which included >1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P < .0001) and transplantation (0.90; P < .0001). CONCLUSION: Residence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve.

National assessment of early biliary complications following liver transplantation: incidence and outcomes.

Despite improved overall liver transplant outcomes, biliary complications remain a significant cause of morbidity. A national data set linking transplant registry and Medicare claims data for 17,012 liver transplant recipients was used to identify all recipients with a posttransplant biliary diagnosis code within the first 6 months after transplantation. Patients were further categorized as follows: a diagnosis without a procedure, a diagnosis and an associated radiological or endoscopic procedure, or a diagnosis treated with surgery. Overall, 15.0% had a biliary diagnosis, 11.2% required a procedure, and 2.2% had a surgical revision. Factors independently associated with biliary complications included donation after cardiac death (DCD), donor age, recipient age, split grafts, and long cold ischemia times. Graft loss was significantly more common for patients with biliary diagnoses [adjusted hazard ratio (aHR) = 1.89, confidence interval (CI) = 1.63-2.19], interventions (aHR = 2.08, CI = 1.77-2.44), and surgical procedures (aHR = 1.80, CI = 1.31-2.49). Mortality after transplantation was also markedly increased for patients with biliary diagnoses (aHR = 2.18, CI = 1.97-2.40), procedures (aHR = 2.21, CI = 1.99-2.46), and surgeries (aHR = 1.77, CI = 1.41-2.23). In stratified analyses, the impact of early biliary complications was greater for DCD liver recipients, but they remained highly significant for recipients of allografts from brain-dead donors as well. Reducing biliary complications should improve posttransplant survival and reduce graft loss.

Consistency of racial variation in medical outcomes among publicly and privately insured living kidney donors.

BACKGROUND: Racial disparities in health outcomes after living donation have been reported, but generalizability is not known. METHODS: We linked Organ Procurement and Transplantation Network (OPTN) registry data for 4,007 living kidney donors in 1987 to 2008 with Medicare billing claims (2000-2008). Cox regression with left and right censoring was used to estimate the frequencies and relative risks of postdonation medical diagnoses according to race. Patterns were compared with findings from a previous linkage of OPTN donor records and private insurance claims. RESULTS: Among the Medicare-insured donors, 8% were African American and 5.7% were Hispanic. Diagnosis frequencies at 5 years after donation in the Medicare- versus privately insured donors included the following: malignant hypertension, 5.0% versus 0.9%; diabetes, 18.5% versus 4.1%; and chronic kidney disease, 21.8% versus 4.9%. After age and sex adjustment in the Medicare sample, African Americans, as compared with white donors, experienced higher risks of any hypertension diagnosis, including 2.4 times the likelihood of malignant hypertension (adjusted hazard ratio [aHR], 2.35; 95% confidence interval [CI], 1.40-3.93), and more common diabetes (aHR, 1.50; 95% CI, 1.12-2.04), chronic kidney disease (aHR, 1.84; 95% CI, 1.37-2.47), and proteinuria (aHR, 2.44; 95% CI, 1.45-4.11) diagnoses. Relative patterns for privately insured African American versus white donors were similar, including approximately three times the risk of malignant hypertension (aHR, 3.27; 95% CI, 1.82-5.88) and twice the relative risks of chronic kidney disease and proteinuria. CONCLUSIONS: Consistent demonstration of racial variation in postdonation medical conditions regardless of sample/payer source supports the need for continued study of mediators and consequences of outcomes in non-white donors.

Understanding medical care of transplant recipients through integrated registry and pharmacy claims data.

BACKGROUND: Limited data exist on medication use aside from immunosuppression among large samples of kidney transplant recipients. METHODS: We examined a novel database wherein Organ Procurement and Transplantation Network (OPTN) registry data were linked to records from a US pharmaceutical claims clearinghouse (2005-2010 claims) to examine pharmaceutical care at the first transplant anniversary (n = 16,157). We quantified the use of the following medication types within ±60 days of the first-year OPTN report according to estimated glomerular filtration rate (eGFR): antihypertensives, lipid-lowering, bone and mineral, and anemia treatments. Adjusted associations of medication use with eGFR and other clinical factors were quantified by multivariate logistic regression. RESULTS: Requirements for multiple antihypertensive agents rose with lower eGFR, with ß-blockers comprising the most commonly used antihypertensive agent. The adjusted likelihood of vitamin D (adjusted odds ratio (aOR) 2.07, 95% CI 1.19-3.59) and especially erythrocyte-stimulating agents (aOR 19.94, 95% CI 7.01-56.00) rose in a graded manner to peak with eGFR <15 versus >90, whereas statin use was most common with eGFR 30-59 ml/min/1.73 m(2). Black race was independently associated with increased use of all classes of antihypertensives and vitamin D, but lower adjusted statin use. Rapamycin-based immunosuppression was associated with increased use of statins and erythrocyte-stimulating agents. CONCLUSIONS: Integrated registry and pharmacy fill data provide a novel tool for pharmacoepidemiologic investigations of delivered post-transplant care. Transplant recipients with reduced renal function have increased requirements for pharmaceutical care of comorbidities. Causes of racial variation in medication fills warrant further investigation.

Clinical correlates, outcomes and healthcare costs associated with early mechanical ventilation after kidney transplantation.

BACKGROUND: Information is lacking on the frequency, clinical implications, and costs of respiratory failure requiring mechanical ventilation after kidney transplantation. METHODS: U.S. Renal Data System records for Medicare-insured kidney transplant recipients (1995 to 2007; n = 88,392) were examined to identify post-transplantation mechanical ventilation from billing claims within 30 days after transplantation. RESULTS: Post-transplantation mechanical ventilation was required among 2.1% of the cohort. Independent correlates of early mechanical ventilation included recipient age, low body mass index, coronary artery disease, and cerebrovascular disease. Post-transplantation mechanical ventilation was twice as likely with delayed graft function (adjusted odds ratio, 2.13; P < .001) and 35% lower among recipients of living versus deceased donor allografts. Patients needing early mechanical ventilation experienced 5-fold higher 1-year mortality, as well as significantly higher Medicare costs during the transplant hospitalization and first post-transplantation year. CONCLUSIONS: Recognition of patients at risk for post-transplantation respiratory failure may help direct protocols for reducing the incidence and consequences of this complication.

Transplant certification and quality assessment: time to take the front line?

In the beginning of the past decade, a series of highly publicized events led the general public to question the ability of the transplant community to effectively police itself. Common to the events was the perception that insufficient regulation of the transplant community allowed both unintentional errors and, rarely, purposeful violations of policy, to affect the safety and justice of organ allocation and transplant practice. The goal of this article is to discuss the resulting regulatory responses to these events and to highlight one transplant center's experience with the current external review process. The potential benefits of using process control charts to prospectively monitoring a center's outcomes, as well as the benefits of implementing procedures that ensure the quality of publically reported data, are described. Specifically, the critical need for each center to understand the components, limitations, and implications of public outcome reporting and to define processes that promote real time self-evaluation and quality improvement are demonstrated.

Obesity and kidney transplant candidates: how big is too big for transplantation?.

Obesity impacts many inter-related, and sometimes conflicting, considerations for transplant practice. In this article, we describe an approach for applying available data on the importance of body composition to the kidney transplant population that separates implications for candidate selection, risk stratification among selected candidates, and interventions to optimize health of the individual. Transplant recipients with obesity defined by elevated body mass index (BMI) have been shown in many (but not all) studies to experience an array of adverse outcomes more commonly than normal-weight transplant recipients, including wound infections, delayed graft function, graft failure, cardiac disease, and increased costs. However, current studies have not defined limits of body composition that preclude clinical benefit from transplantation compared with long-term dialysis in patients who have passed a transplant evaluation. Formal cost-effectiveness studies are needed to determine if payers and society should be compensating centers for clinical and financial risks of transplanting obese end-stage renal disease patients. Recent studies also demonstrate the limitations of BMI alone as a measure of adiposity, and further research should be pursued to define practical measures of body composition that refine accuracy for outcomes prediction. Regarding individual management, observational registry studies have not found beneficial associations of pretransplant weight loss with patient or graft survival. However, association studies cannot distinguish purposeful from unintentional weight loss as a result of illness and comorbidity. Prospective evaluations of the impact of targeted risk modification efforts in this population including dietary changes, monitored exercise programs, and bariatric surgery are urgently needed.