Impact of prolonged ischemic time on pediatric heart transplantation outcomes: Improved outcomes in the most recent era.

BACKGROUND: Impacts of ischemic time (IT) on pediatric heart transplant outcomes are multifactorial. We aimed to analyze the effect of prolonged IT on graft loss after pediatric heart transplantation. We hypothesized that graft survival with prolonged IT has improved across eras. METHODS: Patients <18 years old in the Pediatric Heart Transplant Society database were included (N=6,765) and stratified by diagnosis and era (1993-2004, 2005-2009, and 2010-2019). Severe graft failure (SGF) was defined as death, retransplant, or need for mechanical circulatory support in the first 7 days post-transplant. Descriptive statistical methods were used to compare differences between patient characteristics and IT. Kaplan-Meier survival analysis compared freedom from graft loss, rejection, and infection. Multivariable analysis was performed for graft loss and SGF (hazard and logistic regression modeling, respectively). RESULTS: Diagnoses were cardiomyopathy (N = 3,246) and congenital heart disease (CHD; N = 3,305). CHD were younger, more likely to have an IT ≥4.5 hours, and more likely to require extracorporeal membrane oxygenation or mechanical ventilation at transplant (all p < 0.001). Median IT was 3.6 hours (interquartile range 2.98-4.31; range 0-10.5). IT was associated with early graft loss (HR 1.012, 95% CI 1.005-1.019), but not when analyzed only in the most recent era. IT was associated with SGF (OR 1.016 95%CI 1.003-1.030). CONCLUSIONS: Donor IT was independently associated with an increased risk of graft loss, albeit with a small effect relative to other risk factors. Graft survival with prolonged IT has improved in the most recent era but the risk of SGF persists.

Population-based screening methods in biliary atresia: a systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to investigate tested methods of population-based biliary atresia (BA) screening. DESIGN: We searched 11 databases between 1 January 1975 and 12 September 2022. Data extraction was independently done by two investigators. MAIN OUTCOME MEASURES: Our primary outcomes were: sensitivity and specificity of screening method in BA detection, age at Kasai, BA associated morbidity and mortality, cost-effectiveness of screening. RESULTS: Six methods of BA screening were evaluated: stool colour charts (SCCs), conjugated bilirubin measurements, stool colour saturations (SCSs), measurements of urinary sulfated bile acids (USBAs), assessments of blood spot bile acids and blood carnitine measurements.In a meta-analysis, USBA was the most sensitive and specific, with a pooled sensitivity and specificity of 100.0% (95% CI 2.5% to 100.0%) and 99.5% (95% CI 98.9% to 99.8%) (based on one study). This was followed by conjugated bilirubin measurements: 100.0% (95% CI 0.0% to 100.0%) and 99.3% (95% CI 91.9% to 99.9%), SCS: 100.0% (95% CI 0.00% to 100.0%) and 92.4% (95% CI 83.4% to 96.7%), and SCC: 87.9% (95% CI 80.4% to 92.8%) and 99.9% (95% CI 99.9% to 99.9%).SCC reduced the age of Kasai to ~60 days, compared with 36 days for conjugated bilirubin. Both SCC and conjugated bilirubin improved overall and transplant-free survival. The use of SCC was considerably more cost-effective than conjugated bilirubin measurements. CONCLUSION: Conjugated bilirubin measurements and SCC are the most researched and demonstrate improved sensitivity and specificity in detecting BA. However, their use is expensive. Further research into conjugated bilirubin measurements, as well as alternative methods of population-based BA screening, is required. PROSPERO REGISTRATION NUMBER: CRD42021235133.

Reduced Presentation of Biliary Atresia During the COVID-19 Lockdown: A Population Based Observational Study.

OBJECTIVE: The aim of this study was to assess whether there has been a change in presentations of biliary atresia (BA) in England and Wales during the first and second coronavirus disease 2019 (COVID-19) lockdowns (January-June 2020 and 2021). DESIGN: This population study assessed all confirmed cases of BA, from January 2020 to December 2021 across the 3 UK pediatric liver centers originating from England and Wales. Data was then compared to the incidence of confirmed BA cases from January to December 2017, 2018, and 2019. RESULTS: During January-June 2020 and 2021, there were only 8 and 12 presenting cases of BA in England and Wales, compared to 16, 13, and 18 for the same time periods in 2017, 2018, and 2019, respectively. This difference was significant in a two-sided t test for 2020 ( P = 0.035) but not for 2021 ( P = 0.385). There was no difference in the mean days to Kasai procedure in January-June 2020 and 2021 compared to 2017-2019; however average time to Kasai after the lockdown periods was significantly higher. CONCLUSIONS: There was a significant reduction in the presenting cases of BA during the first COVID-19 lockdown, with an increased time for BA referrals after the pandemic lockdowns were lifted in England and Wales.

Long-term Follow-up of a Randomized Trial of Tacrolimus or Cyclosporine A Microemulsion in Children Post Liver Transplantation.

The aim of this study was to determine the long-term efficacy and safety of tacrolimus (Tac) and cyclosporine immunosuppression in pediatric liver transplantation (LTx). METHODS: One hundred fifty-six patients who had taken part in a multicenter, randomized, open, parallel study of Tac and corticosteroids versus cyclosporine A microemulsion (CyA-ME), corticosteroids, and azathioprine. Patients were assessed at regular intervals up to 14 y after LTx. Analysis was conducted descriptively. RESULTS: In a long-term follow-up, there was a similar incidence of acute rejection (Tac versus CyA-ME, 5 versus 8) and graft loss (5 versus 10). There were 11 deaths in the cohort, which were from infectious complications/malignancy in the Tac group (n = 2/5) and from chronic rejection/liver failure in the CyA-ME group (n = 3/6). A similar incidence of Epstein-Barr virus and posttransplant lymphoproliferative disease was observed (8 versus 8, 3 versus 3). However, there was a greater incidence of cosmetic adverse events in the CyA-ME cohort, with higher incidences of hypertrichosis (8 versus 27) and gum hyperplasia (20 versus 6). Growth improved equally in both groups. Overall, 81% of patients randomized to Tac remained on Tac therapy at study end, compared with 31% of patients randomized to CyA-ME. Common reasons for switching from CyA-ME included steroid-resistant/acute rejection (n = 12/8) and cosmetic changes (n = 8). CONCLUSIONS: This study is the first prospective, observational follow-up study of pediatric patients randomized to Tac and CyA-ME to evaluate long-term outcomes. Our analysis was limited by the degree of switchover between the cohorts; however, there were fewer deaths from chronic rejection/liver failure and reduced adverse events with Tac. Long-term use of Tac and Tac combination therapy appears to be safe and effective immunosuppression for pediatric LTx recipients.

Systematic Review of Cardiovascular Outcome Trials Using New Antidiabetic Agents in CKD Stratified by Estimated GFR.

INTRODUCTION: Cardiovascular benefits observed with new antidiabetic agents may not extend to chronic kidney disease (CKD) patients. This study performed a systematic review and meta-analysis of cardiovascular outcome trials (CVOTs) using new antidiabetic agents stratified by kidney function. METHODS: MEDLINE (via PubMed) and the Cochrane Central Register of Controlled Trials were searched for eligible studies up to November 16, 2020. Data were stratified by the trial entry estimated glomerular filtration rate (eGFR) and albuminuria. Primary major cardiovascular event (MACE) outcomes were extracted, and a meta-analysis with a random effects model was performed to estimate overall risk ratios (RRs). RESULTS: Our search identified 16 studies for inclusion (glucagon-like peptide-1 [GLP-1] analogues, n = 6; dipeptidyl-peptidase 4 [DPP-4] inhibitors, n = 4; and sodium-glucose cotransporter-2 [SGLT-2] inhibitors, n = 6) with a combined total of 150,816 participants (28.2% with eGFR <60 ml/min per 1.73 m2, n = 42,534). The RR for MACE with GLP-1 analogues with an eGFR ≥60 ml/min per 1.73 m2 was 0.87 (95% confidence interval [CI], 0.77-0.98; P = 0.02) and 0.90 (95% CI, 0.78-1.04; P = 0.14) with an eGFR <60 ml/min per 1.73 m2. The RR for MACE with DPP-4 inhibitors with eGFR ≥60 ml/min per 1.73 m2 was 0.99 (95% CI, 0.92-1.07; P = 0.86) and 0.99 (95% CI, 0.91-1.08; P = 0.86) with an eGFR <60 ml/min per 1.73 m2. The RR for MACE with SGLT-2 inhibitors with an eGFR ≥60 ml/min per 1.73 m2 was 1.01 (95% CI, 0.92-1.10; P = 0.87) and 0.85 (95% CI, 0.75-0.95; P = 0.005) with an eGFR <60 ml/min per 1.73 m2. Most analyses had significant heterogeneity. Sufficient albuminuria data were unavailable to analyze empirically. CONCLUSION: Clear evidence for MACE prevention in diabetes patients with an eGFR <60 ml/min per 1.73 m2 currently exists for SGLT-2 inhibitors only. However, similar GLP-1 analogue effect sizes suggest a lack of sufficient power rather than a lack of effect.

Case Report: Dilated Cardiomyopathy in a Newborn, a Potential Association With SARS-COV-2.

Objective: The objective of this study was to describe the clinical course of a newborn who developed dilated cardiomyopathy (DCM) after COVID-19 infection. Methods: We retrospectively assessed the clinical notes of a pediatric patient with decompensated heart failure and who was previously positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Results: A 23-day-old newborn presented with diarrhea, hypoactivity, tachypnea, and lethargy. The infant progressed to develop respiratory failure and required orotracheal intubation due to apnea. A nasopharyngeal swab tested positive for SARS-COV-2. An echocardiogram (ECHO) demonstrated severe left ventricular dysfunction. The patient was discharged after 18 days with furosemide and angiotensin-converting enzyme inhibitors. During the follow-up period, the infant had two episodes of decompensated heart failure, with evidence of DCM. Investigations for known causes of secondary DCM were negative. The infant was promptly referred for heart transplantation. Conclusion: Although rare, we have observed a case of DCM in a newborn following COVID-19 disease. DCM may be a complication following COVID-19 disease in newborns.

Kidney transplantation outcomes for adult recipients of pediatric donor kidneys.

Despite a paucity of data assessing transplantation of deceased-donor pediatric donor kidneys into adult recipients, utilization of pediatric organs is declining in the UK, likely due to concerns that such organs may have inferior outcomes. However, we hypothesized that these concerns may be unfounded. As such, the aim of the study was to compare kidney transplant outcomes between adult recipients of pediatric and adult deceased-donor organs. Data were collected from the UK Transplant Registry for all adult (18+ years) deceased-donor single-kidney transplant recipients between January 2000 and January 2016. Univariable and multivariable analyses were undertaken, to compare a range of outcomes between recipients of kidneys from pediatric and adult donors. Transplants were stratified by the donor age (years) as follows: 0-16 (n = 666), 17-18 (n = 465), and 19-44 (n = 7378). Recipients of pediatric donor kidneys were observed to have improved long-term graft function, with a median creatinine at 1 year of 109 vs. 117 µmol/L for recipients of donors aged 0-16 vs. 19-44 years (P < .001). However, on multivariable analysis, this was not found to correspond to a significant difference in patient (P = .914) or graft survival (P = .190) between the donor age groups. Subgroup analysis within the younger donors found no significant differences in recipient outcomes between donors aged 0-6, 7-12, and 13-16 years. In this population cohort study, we identified excellent outcomes among adult recipients of pediatric donor kidneys. Pediatric donors are a valuable source of organs for adult recipients in an era where organ demand is rising.

Reducing orthopaedic theatre exposure during the COVID-19 lockdown: does a shift towards virtual reality-based training offer a solution?

PerspectiveOrthopaedic training in the United Kingdom has changed little from the Halstedian apprenticeship model of graduated responsibility, with the mantra "see one, do one, teach one". Whilst still relevant in surgical teaching, the current and ongoing disruption to surgical training secondary to the coronavirus disease 2019 (COVID-19) outbreak highlights the need for alternative methods of experiential surgical learning, which allow for the development of the knowledge, skills, and attitudes of orthopaedic surgeons, to be sought.

Changes in Body Mass Index and Outcomes After Kidney Transplant: A Single-Center, Retrospective, Observational Study.

OBJECTIVES: We aimed to describe changes in body mass index after kidney transplant and to assess how these changes influence long-term outcomes. MATERIALS AND METHODS: Data were collected from kidney transplant recipients seen at our center between January 2007 and July 2016. Changes in body mass index over the posttransplant period were modeled using a generalized estimating equation, with changes calculated for each patient from pretransplant to 6 months posttransplant. Calculations were then categorized into 3 body mass index groups: stable (change of ± 1.5 kg/m² or less), reduced (reduction of > 1.5 kg/m²), and increased (increase of > 1.5 kg/m²). Outcomes among groups were compared. RESULTS: Among 1344 total patients, the geometric mean pretransplant body mass index was 27.3 kg/m². This declined significantly (P < .001) to a geometric mean of 25.6 kg/m² at 1 month posttransplant, before increasing and stabilizing to pretransplant levels by 36 months (geometric mean body mass index of 27.2 kg/m² ; P = .522). Of 822 patients with body mass index measurements at 6 months, 303 had reduced, 388 had stable, and 131 had increased levels relative to pretransplant levels. On multivariate analyses, 12-month creatinine levels were significantly higher in the reduced cohort, with adjusted levels of 160.6 versus 135.0 µmol/L for the stable cohort. However, no significant associations were detected between 6-month body mass index changes and patient survival, graft survival, incidences of posttransplant diabetes and cancer, and a range of other clinical and histologic outcomes (all P > .05). CONCLUSIONS: Our data demonstrated that body mass index was significantly reduced in the first month after kidney transplant before increasing to pretransplant levels during years 3 to 5. Furthermore, patients who retained decreased levels at 6 months had impaired graft function in long-term follow-up. These observations conflict with the existing literature and warrant further investigations.

Long-Term Evaluation of Post-transplant Lymphoproliferative Disorders in Paediatric Heart Transplantation in Sao Paulo, Brazil.

We sought to better define the demographics and characteristics of post-transplant lymphoproliferative disorders (PTLD) in a cohort of paediatric OHT patients from a developing country. Data were collected from the Heart Institute, Sao Paulo, for all paediatric OHT recipients from October 1992 to October 2018. Group differences between the PTLD and non-PTLD cohorts were assessed by Fisher exact and Mann-Whitney U tests. Kaplan-Meier curves analysed the survival in each group. Data were reviewed for 202 paediatric OHT recipients. Overall 1-, 5- and 10-year survival for the entire cohort was 76.5%, 68.3% and 62.9%; 24 patients (11.9%) developed PTLD at a median 3.1 years (IQR 0.8-9.0) after OHT. Cases were evenly spread over the follow-up period, with PTLD diagnosed in 9.8% (n = 137) of patients who were alive at 3 years, 15.3% (n = 78) of patients who were alive at 5 years and 29.3% (n = 41) of patients who were alive at 10 years. The commonest form of PTLD was diffuse large B cell lymphoma (n = 9), and most patients received rituximab with immunosuppression and chemotherapy as treatment (n = 15). We identified no increased risk in mortality amongst the PTLD vs. non-PTLD cohorts in multivariate analysis (P = 0.365). PTLD after paediatric OHT had acceptable outcomes. However, risk factors for PTLD were not identified and warrant further investigation.

Correction to: Age-related Behavioural Change in Cornelia de Lange and Cri du Chat Syndromes: A Seven Year Follow-up Study.

The original version of this article unfortunately published with the incorrect text "details removed for blind review" instead of "Cerebra Centre for Neurodevelopmental Disorders, University of Birmingham, UK".

Knowledge, attitudes, and perceptions towards waterpipe tobacco smoking amongst college or university students: a systematic review.

BACKGROUND: Despite evidence for the harms of waterpipe tobacco smoking (WTS), its use is increasing amongst college and university students worldwide. This systematic review aims to assess the knowledge of, attitudes towards and perceptions of WTS among college or university students. METHODS: We electronically searched MEDLINE, EMBASE, CINAHL, PSYCHINFO and ISI the Web of Science in October 2018, restricting our search to studies published since January 1990. We included studies among university or college students that used qualitative or quantitative methods, and addressed either knowledge, attitudes, or perceptions towards WTS. We excluded studies where WTS could not be distinguished from other forms of tobacco use and studies reported as abstracts where the full text could not be identified. Data were synthesised qualitatively and analysed data by region (global north/ south), and by reasons for use, knowledge of health hazards, how knowledge influences use, perceptions towards dependence, and policy knowledge. RESULTS: Eighty-six studies were included; 45 from the global north and 41 from the global south. Socio-cultural and peer influences were major contributing factors that encouraged students to initiate WTS. Furthermore, WTS dependence had two components: psychological and social. This was compounded by the general perception that WTS is a less harmful, less addictive and more sociable alternative to cigarette smoking. Knowledge of WTS harms failed to correlate with a reduced risk of WTS use, and some students reported symptoms of WTS addiction. A large proportion of students believed that quitting WTS was easy, yet few were able to do so successfully. Finally, students believed current public health campaigns to educate on WTS harms were inadequate and, particularly in the global north, were not required. CONCLUSION: Reasons for WTS amongst university students are multi-faceted. Overall, interventions at both the individual and community level, but also policy measures to portray a message of increased harm amongst students, are required. Additional studies are necessitated to understand temporal changes in students' beliefs, thus allowing for better targeted interventions.

Comparison of organ donation and transplantation rates between opt-out and opt-in systems.

Studies comparing opt-out and opt-in approaches to organ donation have generally suggested higher donation and transplantation rates in countries with an opt-out strategy. We compared organ donation and transplantation rates between countries with opt-out versus opt-in systems to investigate possible differences in the contemporary era. Data were analysed for 35 countries registered with the Organisation for Economic Co-operation and Development (17 countries classified as opt-out, 18 classified as opt-in) and obtained organ donation and transplantation rates for 2016 from the Global Observatory for Donation and Transplantation. Compared to opt-in countries, opt-out countries had fewer living donors per million population (4.8 versus 15.7, respectively) with no significant difference in deceased donors (20.3 versus 15.4, respectively). Overall, no significant difference was observed in rates of kidney (35.2 versus 42.3 respectively), non-renal (28.7 versus 20.9, respectively), or total solid organ transplantation (63.6 versus 61.7, respectively). In a multivariate linear regression model, an opt-out system was independently predictive of fewer living donors but was not associated with the number of deceased donors or with transplantation rates. Apart from the observed difference in the rates of living donation, our data demonstrate no significant difference in deceased donation or solid organ transplantation activity between opt-out versus opt-in countries. This suggests that other barriers to organ donation must be addressed, even in settings where consent for donation is presumed.

Age-related Behavioural Change in Cornelia de Lange and Cri du Chat Syndromes: A Seven Year Follow-up Study.

Age-related behavioural change in Cornelia de Lange syndrome is poorly understood. We report a 7 year follow-up study of adaptive behaviour, autism spectrum disorder symptomatology, language skills and behavioural characteristics in 30 individuals with Cornelia de Lange syndrome, compared with 18 individuals with Cri du Chat syndrome. The proportion of individuals with Cornelia de Lange syndrome meeting criteria for autism spectrum disorder on the Autism Diagnostic Observation Schedule increased, although patterns of change were complex. For both syndrome groups, absolute levels of adaptive ability were stable and receptive language improved, suggesting that changes over time do not result from an overall decline in ability. Reliable change index scores indicate heterogeneity within both groups in the occurrence of improvement or decline.

Development and evaluation of dedicated low clearance transplant clinics for patients with failing kidney transplants.

BACKGROUND: Recipients with failing kidney transplants (RFKTs) may receive sub-optimal care compared with patients with native kidney disease. The aim of this study is to compare the outcomes of RFKTs managed in a dedicated low clearance transplant clinic (LCTC) compared with those attending a general transplant clinic. METHODS: We undertook a retrospective analysis of patients with failing kidney transplants comparing two clinics-a LCTC versus a general transplant clinic. Kidney transplant recipients with an eGFR < 20 ml/min were included. A cross-sectional analysis was undertaken of all patients with two consecutive follow-up visits between the dates of January and July 2016 in either clinic, with follow-up to event or December 2017. RESULTS: Data were analysed for 141 kidney transplant recipients; 60 in the LCTC and 81 in the general transplant clinic. More patients in the LCTC cohort were non-white and early transplant recipients. A significantly greater proportion of LCTC versus general transplant patients had received documented discussions regarding their hepatitis vaccine status (63.3% vs. 17.3%, p < 0.001), counselled regarding dialysis modality (98.3% vs. 55.6%, p < 0.001) and had documented decision regarding re-transplantation (80.0% vs. 58.0%, p = 0.006). No difference was noted in the comparison of any clinical or biochemical parameters. More patients seen in the LCTC lost their kidney allograft (HR: 2.09, 95%CI: 1.17-3.72, p = 0.013) but patient survival was equivalent (p = 0.343). CONCLUSION: Our data suggest the management of RFKTs within LCTCs can focus attention on renal replacement therapy planning and counselling, but further work is warranted to investigate for any benefit in hard outcomes such as survival.

Epidemiology and natural history of hepatitis C virus infection among children and young people.

BACKGROUND & AIMS: Chronic hepatitis C virus (HCV) infection is a global health burden. Although HCV infection rarely contributes to morbidity during childhood, most HCV-infected children develop chronic HCV with a lifetime risk of liver disease. Little is known about the development of long-term liver disease and the effect of treatment in patients infected with HCV in childhood. METHOD: This study was a retrospective review of patients infected with HCV in childhood enrolled in HCV Research UK. A total of 1,049 patients were identified and included. RESULTS: The main routes of infection were intravenous drug use (53%), blood product exposure (24%) and perinatal infection (11%). Liver disease developed in 32% of patients, a median of 33 years after infection, irrespective of the mode of infection. Therefore, patients with perinatal exposure developed cirrhosis at an earlier age than the rest of the risk groups. The incidence of hepatocellular carcinoma (HCC) was 5%, liver transplant 4% and death occurred in 3%. Overall, 663 patients were treated (55% with interferon/pegylated interferon and 40% with direct-acting antivirals). Sustained virological response (SVR) was achieved in 406 (75%). There was a higher mortality rate among patients without SVR vs. those with SVR (5% vs. 1%, p = 0.003). Treatment was more effective in patients without cirrhosis and disease progression was less frequent (13%) than in patients with cirrhosis at the time of therapy (28%) p < 0.001. Patients with cirrhosis were more likely to develop HCC, require liver transplantation, or die. CONCLUSION: HCV infection in young people causes significant liver disease, which can now be prevented with antiviral therapy. Early treatment, especially before development of cirrhosis is essential. Detection of HCV should be aimed at relevant risk groups and antiviral therapy should be made available in childhood to prevent long-term liver disease and spread of HCV. LAY SUMMARY: Chronic hepatitis C virus (HCV) infection is a global health problem, which can now be treated with potent direct-acting antiviral drugs. This study demonstrates that HCV infection in childhood causes serious liver disease in 32% of patients, a median of 33 years after infection, irrespective of age, mode and route of infection. Disease outcomes were better in patients treated before the development of advanced liver disease. Antiviral therapy should be made available in childhood to prevent long-term liver disease and the spread of HCV.

Pyrolysis of blend (oil palm biomass and sawdust) biomass using TG-MS.

The aim of this study was to pyrolyze individual (oil palm shell, empty fruit bunch and sawdust) as well as blend biomass in a thermogravimetric mass spectrometry (TG-MS) from room temperature to 800 °C at constant heating rate of 15 °C/min. The results showed that the onset TG temperature for blend biomass shifted slightly to lower values. Activation energy values were also found to decrease slightly after blending the biomass. Interestingly, the MS spectra of selected gases (H2O CH4, H2O, C2H2, C2H4 or CO, CH2O, CH3OH, HCl, C3H6, CO2, HCOOH, and C6H12) evolved from blend biomass showed decreased in the intensity as compared to their individual biomass. Overall, the blend biomass showed synergy which provides ways to expand the possibility of utilizing multiple feedstocks in one thermo-chemical system.

The Influence of Donor to Recipient Size Matching on Kidney Transplant Outcomes.

BACKGROUND: Nephron endowment in renal transplantation is infrequently considered, but may have important implications for post kidney transplantation outcomes. In this population-cohort study, we analyzed the deceased-donor kidney transplant outcomes stratified by donor-to-recipient size ratios. METHODS: Data for all deceased-donor adult kidney transplantation recipients between 2003 and 2015 were extracted from the UK Transplant Registry. We used weight as a surrogate marker for kidney size and defined the following mismatch categories (donor weight/recipient weight × 100): less than 75% (small donor kidney), 75% to 125% (weight matched kidney), and greater than 125% (large donor kidney). Univariable and multivariable analyses were undertaken to assess the relationship between this marker and patient outcomes. RESULTS: Outcomes for 11 720 transplants were analyzed with weight mismatch stratified as follows; small donor kidney (n = 1608, 13.7%), weight matched kidney (n = 7247, 61.8%) and large donor kidney (n = 2865, 24.4%). On multivariable analysis, no significant differences were detected in overall (P = 0.876) or death-censored (P = 0.173) graft survival, or in rates of delayed graft function (P = 0.396) between these 3 groups. However, 12-month creatinine levels were found to decline progressively across the groups (P < 0.001), with adjusted averages of 144.2 µmol/L for recipients of small donor kidneys, 134.7 µmol/L in weight matched kidneys, and 124.9 µmol/L in recipients of large donor kidneys. In addition, patient survival was found to be significantly shorter in recipients of larger kidneys than those with weight matched kidneys (hazard ratio, 1.21; 95% confidence interval, 1.05-1.40; P = 0.009), which is inconsistent with the existing literature. CONCLUSIONS: Our data demonstrate that 12-month creatinine is influenced by donor-to-recipient difference in body weight, but that no such difference is observed for either delayed graft function or death-censored graft survival. However, we observed increased mortality in recipients receiving larger kidneys; an observation which conflicts with the existing literature and warrants further investigation.