Kidney Transplantation in Patients With AA Amyloidosis: Outcomes in a French Multicenter Cohort.

RATIONALE & OBJECTIVE: Outcomes of kidney transplantation for patients with renal AA amyloidosis are uncertain, with reports of poor survival and high rates of disease recurrence. However, the data are inconclusive and mostly based on studies from the early 2000s and earlier. STUDY DESIGN: Retrospective multicenter cohort study. SETTING & PARTICIPANTS: We searched the French national transplant database to identify all patients with renal AA amyloidosis who underwent kidney transplantation between 2008 and 2018. EXPOSURES: Age, cause of amyloidosis, use of biotherapies, and C-reactive protein levels. OUTCOMES: Outcomes were all-cause mortality and allograft loss. We also reported amyloidosis allograft recurrence, occurrence of acute rejection episodes, as well as infectious, cardiovascular, and neoplastic disease events. ANALYTICAL APPROACH: Kaplan-Meier estimator for mortality and cumulative incidence function method for allograft loss. Factors associated with patient and allograft survival were investigated using a Cox proportional hazards model and a cause-specific hazards model, respectively. RESULTS: 86 patients who received kidney transplants for AA amyloidosis at 26 French centers were included. The median age was 49.4 years (IQR, 39.7-61.1). The main cause of amyloidosis was familial Mediterranean fever (37 cases; 43%). 16 (18.6%) patients received biotherapy after transplantation. Patient survival rates were 94.0% (95% CI, 89.1-99.2) at 1 year and 85.5% (77.8-94.0) at 5 years after transplantation. Cumulative incidences of allograft loss were 10.5% (4.0-17.0) at 1 year and 13.0% (5.8-20.1) at 5 years after transplantation. Histologically proven AA amyloidosis recurrence occurred in 5 transplants (5.8%). An infection requiring hospitalization developed in 55.8% of cases, and there was a 27.9% incidence of acute allograft rejection. Multivariable analysis showed that C-reactive protein concentration at the time of transplantation was associated with patient survival (HR, 1.01; 95% CI, 1.00-1.02; P=0.01) and allograft survival (HR, 1.68; 95% CI, 1.10-2.57; P=0.02). LIMITATIONS: The study lacked a control group, and the effect of biotherapies on transplantation outcomes could not be explored. CONCLUSIONS: This relatively contemporary cohort of patients who received a kidney transplant for AA amyloidosis experienced favorable rates of survival and lower recurrence rates than previously reported. These data support the practice of treating these patients with kidney transplantation for end-stage kidney disease. PLAIN-LANGUAGE SUMMARY: AA amyloidosis is a severe and rare disease. Kidney involvement is frequent and leads to end-stage kidney disease. Because of the involvement of other organs, these patients are often frail, which has raised concerns about their suitability for kidney transplantation. We reviewed all patients with AA amyloidosis nephropathy who underwent kidney transplantation in France in the recent era (2008-2018) and found that the outcomes after kidney transplantation were favorable, with 85.5% of patients still alive 5 years after transplantation, a survival rate that is comparable to the outcomes of patients receiving a transplant for other forms of kidney diseases. Recurrence of amyloidosis in the transplanted kidney was infrequent (5.8%). These data support the practice of kidney transplantation for patients with AA amyloidosis who experience kidney failure.

Hospital-Level COVID-19 Preparedness and Crisis Management in Czechia.

Objectives: The COVID-19 pandemic exposed the inadequacy of pandemic preparedness mechanisms worldwide. This study gathered comprehensive data from Czech hospitals, identified possible weaknesses in important areas of crisis preparedness, and quantified changes performed to enhance crisis resilience of healthcare facilities. Methods: Drawing on literature review on pandemic preparedness and hospital crisis management and detailed interviews with hospital representatives, a questionnaire was designed and distributed by email among quality managers of all Czech hospitals. Statistical analysis of their responses was conducted using EZR software. Fisher's exact test and Kruskal-Wallis test, with post hoc testing, were used to assess statistical significance. Results: Achieving response rate of 31.9%, responses from 65 hospitals were analysed. New crisis management policies were necessary in 72.3% of responding hospitals. Furthermore, a majority of the respondents changes indicated the need for changes in policies on general pandemic, human resources and infrastructure and material preparedness. Conclusion: The COVID-19 crisis required significant alterations to previously established hospital crisis management protocols and establishment of new ones. The absence of a unified system for crisis preparedness was noted at hospital and national levels.

Comparison of prevalence of depression symptoms and history of suicidality in students of medical schools and other study programmes of Charles University.

OBJECTIVES: Medical students represent a group of undergraduate students who are exposed to specific risk factors that may lead to the onset of depression and the occurrence of suicidal ideation. The aim of the article is to present information about the prevalence of symptoms of depression in medical students of different faculties at Charles University, Prague, compared to other students of this university. METHODS: We used a standardized Beck's Inventory scale II (BDI-II) with added specific questions electronically distributed to undergraduate students of the full-time forms of study of all faculties of Charles University. The data collection was anonymous and took place in December 2020. The data were statistically assessed in relation to the occurrence of moderate and severe depression using univariate and multivariable analysis. RESULTS: Moderate and severe depression rate (MSDR) was recorded in 19.6% of medical school students, who returned the questionnaire, compared to 23.4% of students of other faculties (p = 0.001) of Charles University in Prague. Differences in MSDR among students of different faculties of medicine of Charles University were not statistically significant. The total number of previous suicide attempts among respondents was 542, of which 115 were medical students, with the lifetime prevalence of suicide attempts among all students participating in the study 6.96% and in medical students of Charles University 5.73%. CONCLUSIONS: The findings of our study highlight the need for systematic, accessible and timely assistance to university students, both in terms of prevention and early intervention, which can take place at the university level and within the mental healthcare system.

Urinary collagen peptides: Source of markers for bone metabolic processes in kidney transplant recipients.

INTRODUCTION: Kidney transplant recipients (KTRs) are at an increased risk of fractures. Total urinary hydroxyproline excretion served as marker for bone resorption (BR) but was replaced by ß-CrossLaps (CTX), a C-terminal collagen α-1(I) chain (COL1A1) telopeptide. We investigated the low-molecular-weight urinary proteome for peptides associated with changes in bone metabolism after kidney transplantation. METHODS: Clinical and laboratory data including serum levels of CTX in 96 KTR from two nephrology centers were correlated with signal intensities of urinary peptides identified by capillary electrophoresis mass spectrometry. RESULTS: Eighty-two urinary peptides were significantly correlated with serum CTX levels. COL1A1 was the predominant peptide source. Oral bisphosphonates were administered for decreased bone density in an independent group of 11 KTR and their effect was evaluated on the aforementioned peptides. Study of the peptides cleavage sites revealed a signature of Cathepsin K and MMP9. Seventeen of these peptides were significantly associated with bisphosphonate treatment, all showing a marked reduction in their excretion levels compared to baseline. DISCUSSION: This study provides strong evidence for the presence of collagen peptides in the urine of KTR that are associated with BR and that are sensitive to bisphosphonate treatment. Their assessment might become a valuable tool to monitor bone status in KTR.

18F-Fluorocholine PET/CT Compared with Current Imaging Procedures for Preoperative Localization of Hyperfunctioning Parathyroids in Patients with Chronic Kidney Disease.

Hyperparathyroidism (HPT) in patients with chronic kidney disease (CKD) includes secondary (sHPT) and tertiary hyperparathyroidism (tHPT). Considering that the role of preoperative imaging in the clinical setting is controversial, in the present study we have retrospectively compared pre-surgical diagnostic performances of 18F-Fluorocholine (18F-FCH) PET/CT, cervical ultrasonography (US), parathyroid scintigraphy, and 4D-CT in a group of 30 patients with CKD and HPT (18/12 sHPT/tHPT), 21 CKD G5 including 18 in dialysis, and 9 kidney transplant recipients. All patients underwent 18F-FCH, and 22 had cervical US, 12 had parathyroid scintigraphy, and 11 had 4D-CT. Histopathology was the gold standard. Seventy-four parathyroids were removed: 65 hyperplasia, 6 adenomas, and 3 normal glands. In the whole population, in a per gland analysis, 18F-FCH PET/CT was significantly more sensitive and accurate (72%, 71%) than neck US (25%, 43%), parathyroid scintigraphy (35%, 47%), and 4D-CT (40%, 47%). The specificity of 18F-FCH PET/CT (69%) was lower than that of neck US (95%) and parathyroid scintigraphy (90%), without, however, achieving significance. 18F-FCH PET/CT was more accurate than all other diagnostic techniques when sHPT and tHPT patients were considered separately. 18F-FCH PET/CT sensitivity was significantly higher in tHPT (88%) than in sHPT (66%). Three ectopic hyperfunctioning glands (in three different patients) were all detected by 18F-FCH PET/CT, two by parathyroid scintigraphy, and none by cervical US and 4D-CT. Our study confirms that 18F-FCH PET/CT is an effective preoperative imaging option in patients with CKD and HPT. These findings may be of greater importance in patients with tHPT (who could benefit from minimally invasive parathyroidectomy) than in patients with sHPT, who often undergo bilateral cervicotomy. In these cases, preoperative 18F-FCH PET/CT may be helpful in locating ectopic glands and may guide the surgical choice for gland preservation.

Viscoelastic Properties of Human Facial Skin and Comparisons with Facial Prosthetic Elastomers.

Prosthesis discomfort and a lack of skin-like quality is a source of patient dissatisfaction with facial prostheses. To engineer skin-like replacements, knowledge of the differences between facial skin properties and those for prosthetic materials is essential. This project measured six viscoelastic properties (percent laxity, stiffness, elastic deformation, creep, absorbed energy, and percent elasticity) at six facial locations with a suction device in a human adult population equally stratified for age, sex, and race. The same properties were measured for eight facial prosthetic elastomers currently available for clinical usage. The results showed that the prosthetic materials were 1.8 to 6.4 times higher in stiffness, 2 to 4 times lower in absorbed energy, and 2.75 to 9 times lower in viscous creep than facial skin (p < 0.001). Clustering analyses determined that facial skin properties fell into three groups-those associated with body of ear, cheek, and remaining locations. This provides baseline information for designing future replacements for missing facial tissues.

Cryptococcal Meningitis in Kidney Transplant Recipients: A Two-Decade Cohort Study in France.

Cryptococcosis is the third most common cause of invasive fungal infection in solid organ transplant recipients and cryptococcal meningitis (CM) its main clinical presentation. CM outcomes, as well as its clinical features and radiological characteristics, have not yet been considered on a large scale in the context of kidney transplantation (KT). We performed a nationwide retrospective study of adult patients diagnosed with cryptococcosis after KT between 2002 and 2020 across 30 clinical centers in France. We sought to describe overall and graft survival based on whether KT patients with cryptococcosis developed CM or not. Clinical indicators of CNS involvement and brain radiological characteristics were assessed. Eighty-eight cases of cryptococcosis were diagnosed during the study period, with 61 (69.3%) cases of CM. Mortality was high (32.8%) at 12 months (M12) but not significantly different whether or not patients presented with CM. Baseline hyponatremia and at least one neurological symptom were independently associated with CM (p < 0.001). Positive serum cryptococcal antigen at diagnosis was also significantly associated with CM (p < 0.001). On magnetic resonance imaging (MRI), three patterns of brain injury were identified: parenchymal, meningeal, and vascular lesions. Although CM does not affect graft function directly, it entails a grim prognosis.

A gain-of-function variant in the Wiskott-Aldrich syndrome gene is associated with a MYH9-related disease-like syndrome.

While loss-of-function variants in the WAS gene are associated with Wiskott-Aldrich syndrome and lead to microthrombocytopenia, gain-of-function variants of WAS are associated with X-linked neutropenia (XLN) and the absence of microthrombocytopenia. Only a few XLN families have been reported so far, and their platelet phenotype was not described in detail. To date, no renal involvement was described in XLN. In the present study, we report exome sequencing of individuals from 3 generations of a family with a dominant disease combining neutropenia, macrothrombocytopenia, and renal failure. We identified a heterozygous missense gain-of-function variant in the WAS gene (c.881T>C, p.I294T) that segregates with the disease and is already known to cause XLN. There was no pathogenic variant in MYH9, TUBB1, or ACTN1. This is the first report of a WAS gain-of-function variant associated with both the hematological phenotype of XLN (neutropenia, macrothrombocytopenia) and renal disease (proteinuria, renal failure) with glomerular tip lesion hyalinosis and actin condensations in effaced podocytes foot processes.

Analysis of Obligatory Involvement of Medical Students in Pandemic Response in the Czech Republic: Competencies, Experiences, and Legal Implications.

Objectives: Medical students in the Czech Republic were mandated by the law to take part in the COVID-19 pandemic response in order to expand healthcare capacity. Our study aimed to analyze student's competencies defined in the legislation and compare them with competencies assigned to them in clinical settings during their deployment. Methods: Online survey with statistical analysis of collected data. Results: The survey was completed by 997 respondents. A major convergence between the system of credentials defined in the legal framework and the competencies that students performed were identified. Conclusion: Medical students represented a valuable resource for addressing shortages of qualified healthcare staff in critical situation. However, the system of competencies and credentials must be aligned with the educational framework to clearly define acquisition of competencies during the course of medical studies and the legal framework regulating students' deployment must ensure consistency of actual and formal competencies in order to guarantee high standards of care and safety of the patients.

Safe environment management in acute psychiatric wards in the Czech Republic, foundation for recommendations for preventive practice.

OBJECTIVES: Suicides of hospitalized patients present rare but very serious adverse events in healthcare settings. The aim of this article is to describe and analyse the facilities and material equipment of acute psychiatric settings in the Czech Republic and contrast these with recommendations for effective prevention of suicidal behaviour. Since there are currently no universally accepted protocols for risk assessment and prevention of suicides in hospital settings in the Czech Republic, these recommendations draw on international guidelines. Based on the outcomes of our study we provide recommendations for risk management and effective prevention of suicidal behaviour of patients hospitalized in acute care settings. METHODS: In order to describe and analyse the environment of acute psychiatric wards in the Czech Republic we have developed a questionnaire based on international recommendations for risk management and prevention of suicidal behaviour. We also collected data on the prevalence of attempted and completed suicides and their respective methods in these hospitals. RESULTS: We have established that acute psychiatric wards in the Czech Republic operate within insufficient safety regimes, especially with respect to the prevention of suicide by hanging and the accessibility of objects for cutting. Our findings demonstrate that only 75% of the wards are equipped with safety glass, and only 50% of the wards with safety mirrors. Only just over 40% of hospitals have safety door handles and shower heads. CONCLUSION: While it is impossible to entirely eliminate the risk of suicidal behaviour it is possible to manage it. The risk reduction is attainable by providing a safe-proofed environment and minimizing opportunities of suicide attempts by hanging and cutting. In order to effectively prevent suicides, it is essential to increase the awareness of the possibilities of safe proofing of the environment as well as standardization of risk assessment of potential suicidal behaviour of patients.

Atypical focal segmental glomerulosclerosis associated with a new PODXL nonsense variant.

BACKGROUND: Podocalyxin (PODXL) is a highly sialylated adhesion glycoprotein that plays an important role in podocyte's physiology. Recently, missense and nonsense dominant variants in the PODXL gene have been associated with focal segmental glomerulosclerosis (FSGS), a leading cause of nephrotic syndrome and kidney failure. Their histologic description, however, was superficial or absent. METHODS: We performed exome sequencing on a three-generation family affected by an atypical glomerular nephropathy and characterized the disease by light and electron microscopy. RESULTS: The disease was characterized by FSGS features and glomerular basement membrane duplication. Six family members displayed chronic proteinuria, ranging from mild manifestations without renal failure, to severe forms with end-stage renal disease. Exome sequencing of affected twin sisters, their affected mother, healthy father, and healthy maternal uncle revealed a new nonsense variant cosegregating with the disease (c.1453C>T, NM_001018111) in the PODXL gene, which is known to be expressed in the kidney and to cause nephropathy when mutated. The variant is predicted to lead to a premature stop codon (p.Q485*) that results in the loss of the intracytoplasmic tail of the protein. CONCLUSION: This is the first description of a peculiar association combining a PODXL stop-gain variant and both FSGS and membranoproliferative glomerulonephritis features, described by light and electron microscopy.

SARS-Cov-2 Seroprevalence in a French Kidney Transplant Center Located Within a "High-risk" Zone.

BACKGROUND: Data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence in kidney transplant recipients (KTRs) remain rare. We sought to shed further light on this issue by conducting a single-center study in a kidney transplant center located in one of the France's highest risk zone (Grand Est) for coronavirus disease 2019 (Covid-19) during the initial disease outbreak. METHODS: To this aim, we used a survey approach coupled with systematic investigation of SARS-CoV-2 serology in a cohort of 1390 KTRs. RESULTS: SARS-CoV-2 serologies were available for 780 survey respondents, among whom 48 had anti-SARS-CoV-2 antibodies (total seroprevalence: 6.2%). Thirty-five of the 48 seropositive KTRs had previously received a diagnosis of Covid-19, whereas the remaining 13 patients were not known to be infected (8 asymptomatic cases). Specifically, 18.7% of seropositive KTRs and 1.1% of the entire cohort were asymptomatic. Household exposure was found to markedly increase the risk of SARS-CoV-2 transmission. CONCLUSIONS: Our findings demonstrate that the overall SARS-CoV-2 seroprevalence in KTRs living in one of the France's highest risk zone for Covid-19 during the first French lockdown was as low as 6.3%. Rapid and strict implementation of protective measures could have significantly mitigated virus spread even in an area of high virus circulation.

Intravenous immunoglobulin as a preventive strategy against BK virus viremia and BKV-associated nephropathy in kidney transplant recipients-Results from a proof-of-concept study.

BK virus (BKV) replication occurs frequently in kidney transplant recipients (KTR), potentially leading to BKV-associated nephropathy (BKVAN) and graft loss. Patients with high titers of BKV-neutralizing antibodies (NAbs) are protected against BKV replication, and intravenous immunoglobulin (IVIg) infusion can increase NAb titers. We investigated whether early IVIg administration prevents BKV replication in patients with low NAb titers (<4 log10 against the BKV-specific genotype). Based on NAb titers on the day of transplantation, KTR followed in the Strasbourg University Hospital (n = 174) were retrospectively divided into the following 3 risk categories for BKV replication: (1) patients with low NAb titers ("high-risk") who received IVIg for the first 3 posttransplant months (n = 44), (2) patients with low NAb titers ("high-risk") who did not undergo IVIg treatment (n = 41), and (3) patients with high NAb titers ("low-risk") who did not receive IVIg (n = 89). At 12 posttransplant months, the incidence of BKV viremia in the high-risk group treated with IVIg (6.8%) was similar to that observed in the low-risk group (10.1%) and markedly lower than that of the untreated high-risk group (36.6%; P < .001). Similar results were observed with regard to BKVAN. We conclude that IVIg may be a valuable strategy for preventing BKV replication.

Biomarkers of Cytokine Release Syndrome Predict Disease Severity and Mortality From COVID-19 in Kidney Transplant Recipients.

BACKGROUND: Data on coronavirus disease 2019 (COVID-19) in immunocompromised kidney transplant recipients (KTR) remain scanty. Although markers of inflammation, cardiac injury, and coagulopathy have been previously associated with mortality in the general population of patients with COVID-19, their prognostic impact amongst KTR with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection has not been specifically investigated. METHODS: We conducted a cohort study of 49 KTR who presented with COVID-19. Clinical and laboratory risk factors for severe disease and mortality were prospectively collected and analyzed with respect to outcomes. The study participants were divided into 3 groups: (1) mild disease manageable in an outpatient setting (n = 8), (2) nonsevere disease requiring hospitalization (n = 21), and (3) severe disease (n = 20). RESULTS: Gastrointestinal manifestations were common at diagnosis. The 30-day mortality rate in hospitalized patients was 19.5%. Early elevations of C-reactive protein (>100 mg/L) and interleukin-6 (>65 ng/L) followed by increases in high-sensitivity troponin I (>30 ng/L) and D-dimer (>960 ng/mL) were significantly associated with severe disease and mortality. Viral load did not have prognostic significance in our sample, suggesting that outcomes were chiefly driven by a cytokine release syndrome (CRS). CONCLUSIONS: Regular monitoring of CRS biomarkers in KTR with COVID-19 is paramount to improve clinical outcomes.

POISSON COKRIGING AS A GENERALIZED LINEAR MIXED MODEL.

It is often of interest to predict spatially correlated count outcomes that follow a Poisson distribution. For example, in the environmental sciences we may want to predict pollen counts using temperature or precipitation data as auxiliary variables. To predict a Poisson outcome variable in the presence of an auxiliary variable, Poisson cokriging as a Generalized Linear Mixed Model (GLMM) is proposed. This model has a bivariate structure with a Poisson outcome variable and an auxiliary variable. A covariance matrix similar to that used in cokriging is assumed. A simulation study and a real data example using the number of microplastics in the digestive tracts of fish are presented. The results showed that Poisson cokriging methodology can be applied successfully in practice with small average errors and coverage close to 95%. The Poisson cokriging model can be a useful tool for spatial prediction.

In-depth virological assessment of kidney transplant recipients with COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread widely, causing coronavirus disease 2019 (COVID-19) and significant mortality. However, data on viral loads and antibody kinetics in immunocompromised populations are lacking. We aimed to determine nasopharyngeal and plasma viral loads via reverse transcription-polymerase chain reaction and SARS-CoV-2 serology via enzyme-linked immunosorbent assay and study their association with severe forms of COVID-19 and death in kidney transplant recipients. In this study, we examined hospitalized kidney transplant recipients with nonsevere (n = 21) and severe (n = 19) COVID-19. SARS-CoV-2 nasopharyngeal and plasma viral load and serological response were evaluated based on outcomes and disease severity. Ten recipients (25%) displayed persistent viral shedding 30 days after symptom onset. The SARS-CoV-2 viral load of the upper respiratory tract was not associated with severe COVID-19, whereas the plasma viral load was associated with COVID-19 severity (P = .010) and mortality (P = .010). All patients harbored antibodies during the second week after symptom onset that persisted for 2 months. We conclude that plasma viral load is associated with COVID-19 morbidity and mortality, whereas nasopharyngeal viral load is not. SARS-CoV-2 shedding is prolonged in kidney transplant recipients and the humoral response to SARS-CoV-2 does not show significant impairment in this series of transplant recipients.

Recruiting Medical Students for a First Responder Project in the Social Age: Direct Contact Still Outperforms Social Media.

INTRODUCTION: Efficient recruitment of first responders (FRs) is crucial for long-term success of any FR project. FRs are laypersons who are trained in cardiopulmonary resuscitation (CPR), medical professionals, and firemen, police officers, and other professions with a duty of help. As social media are widely used for rapid communication, we carried out a prospective observational study to test the hypothesis that recruitment of FRs via social media is more efficient than recruitment via direct face-to-face contact. METHODS: Following ethics committee agreement, we informed 600 medical students about becoming FRs when they attended a didactic lecture about the FR project or during their mandatory CPR-course. Furthermore, recruitment was opened to medical students through Facebook, which accessed ∼1,000 medical students to see if they expressed interest in becoming FRs. All of the recruited students successfully completed the FR training. We then used an online questionnaire to ask these students how they had been recruited. RESULTS: Out of 63 registered student FRs, 59 responded to the online questionnaire. Overall, 15.3% of these FR students were recruited via social media. The majority (78.0%) were recruited through direct contact. CONCLUSIONS: Despite widespread use of social media, over three-quarters of these medical students were recruited to the FR project via direct personal contact. This suggests that the advantage of a larger reachable population using social media does not outweigh the impact of personal contact with experts.

Development and validation of an optimized integrative model using urinary chemokines for noninvasive diagnosis of acute allograft rejection.

The urinary chemokines CXCL9 and CXCL10 are promising noninvasive diagnostic markers of acute rejection (AR) in kidney recipients, but their levels might be confounded by urinary tract infection (UTI) and BK virus (BKV) reactivation. Multiparametric model development and validation addressed these confounding factors in a training set of 391 samples, optimizing the diagnostic performance of urinary chemokines. CXCL9/creatinine increased in UTI and BKV viremia with or without nephropathy (BKVN) (no UTI/leukocyturia/UTI: -0.10/1.61/2.09, P = .0001 and no BKV/viremia/BKVN: -0.10/1.90/2.29, P < .001) as well as CXCL10/creatinine (1.17/2.09/1.98, P < .0001 and 1.13/2.21/2.51, P < .001, respectively). An optimized 8-parameter model (recipient age, sex, estimated glomerular filtration rate, donor specific antibodies, UTI, BKV blood viral load, CXCL9, and CXCL10) diagnosed AR with high accuracy (area under the curve [AUC]: 0.85, 95% confidence interval [CI]: 0.80-0.89) and remained highly accurate at the time of screening (AUC: 0.81, 95% CI: 0.48-1) or indication biopsies (AUC: 0.85, 95% CI: 0.81-0.90) and within the first year (AUC: 0.86, 95% CI: 0.80-0.91) or later (AUC: 0.90, 95% CI: 0.84-0.96), achieving AR diagnosis with an AUC of 0.85 and 0.92 (P < .0001) in 2 external validation cohorts. Decision curve analyses demonstrated the clinical utility of the model. Considering confounding factors rather than excluding them, we optimized a noninvasive multiparametric diagnostic model for AR of kidney allografts with unprecedented accuracy.

Patient Safety and the Just Culture.

Within health care, the Just Culture is model of workplace justice intended to create fairness for providers and create better outcome for patients. It is about creating a common language to evaluate provider conduct. A Just Culture helps create an open reporting culture. To create better patient safety outcomes, a Just Culture shifts the focus from errors and outcomes to system design and the facilitation of good behavioral choices.