The Severity of Pectus Excavatum Defect Is Associated With Impaired Cardiopulmonary Function.

BACKGROUND: Repair of pectus excavatum has cosmetic benefits, but the physiologic impact remains controversial. The aim of this study was to characterize the relationship between the degree of pectus excavatum and cardiopulmonary dysfunction seen on cardiac magnetic resonance (CMR) imaging, cardiopulmonary exercise testing (CPET), and pulmonary function testing (PFT). METHODS: A single-center analysis of CMR, CPET, and PFT was conducted. Regression models evaluated relationships between pectus indices and the clinical end points of cardiopulmonary function. RESULTS: Data from 345 CMRs, 261 CPETs, and 281 PFTs were analyzed. Patients were a mean age of 15.2 ± 4 years, and 81% were aged <18 years. The right ventricular ejection fraction (RVEF) was <0.50 in 16% of patients, left ventricular ejection fraction (LVEF) was <0.55 in 22%, RVEF Z-score was < -2 in 32%, and the LVEF Z-score was < -2 in 18%. CPET revealed 33% of patients had reduced aerobic fitness. PFT results were abnormal in 23.1% of patients. Adjusted analyses revealed the Haller index had significant (P < .05) inverse associations with RVEF and LVEF. CONCLUSIONS: The severity of pectus excavatum is associated with ventricular systolic dysfunction. Pectus excavatum impacts right and left ventricular systolic function and can also impact exercise tolerance. The Haller index and correction index may be the most useful predictors of impairment.

Targeted donor complement blockade after brain death prevents delayed graft function in a nonhuman primate model of kidney transplantation.

Delayed graft function (DGF) in renal transplant is associated with reduced graft survival and increased immunogenicity. The complement-driven inflammatory response after brain death (BD) and posttransplant reperfusion injury play significant roles in the pathogenesis of DGF. In a nonhuman primate model, we tested complement-blockade in BD donors to prevent DGF and improve graft survival. BD donors were maintained for 20 hours; kidneys were procured and stored at 4°C for 43-48 hours prior to implantation into ABO-compatible, nonsensitized, MHC-mismatched recipients. Animals were divided into 3 donor-treatment groups: G1 - vehicle, G2 - rhC1INH+heparin, and G3 - heparin. G2 donors showed significant reduction in classical complement pathway activation and decreased levels of tumor necrosis factor α and monocyte chemoattractant protein 1. DGF was diagnosed in 4/6 (67%) G1 recipients, 3/3 (100%) G3 recipients, and 0/6 (0%) G2 recipients (P = .008). In addition, G2 recipients showed superior renal function, reduced sC5b-9, and reduced urinary neutrophil gelatinase-associated lipocalin in the first week posttransplant. We observed no differences in incidence or severity of graft rejection between groups. Collectively, the data indicate that donor-management targeting complement activation prevents the development of DGF. Our results suggest a pivotal role for complement activation in BD-induced renal injury and postulate complement blockade as a promising strategy for the prevention of DGF after transplantation.

Surgery Hurts: Characterizing the Experience of Pain in Surgical Patients as Witnessed by Medical Students.

BACKGROUND: The patient experience around surgical care is poorly characterized. Medical students have a unique position on the surgical team, which allows them to observe patient experiences that may otherwise be overlooked. The objective of this study was to characterize surgical patients' experience with pain as witnessed by medical students. STUDY DESIGN: At the end of an 8-week surgical clerkship, we asked all third-year medical students to write a reflective essay describing one surgical patient in pain. We collected 341 essays over a 4-year period and used qualitative content analysis to explore the students' reports of pain experienced by surgical patients. RESULTS: When asked to tell a story about a surgical patient in pain, medical students report vivid descriptions of physical agony, emotional distress, and patient regret. For example, "Throughout the procedure our patient cried out and writhed in agony from the searing pain in his chest," and "The patient was practically shedding tears, complaining of pain, as [we] changed her dressing." The students' accounts reveal wide-ranging physical and emotional suffering among surgical patients, including alterations in self-image and feelings of vulnerability. Pain and suffering were intensified when patients felt they had lost control, in settings of uncertain prognosis and with unexpected outcomes. CONCLUSIONS: Students' descriptions of the surgical patient's experience are disturbingly graphic. They expose suffering ranging from generalized discomfort to anguish and excruciating pain. These data suggest that surgical patients have substantial unmet needs with respect to symptom management and emotional support that, if better addressed, could improve the patient experience.

Brain Death Enhances Activation of the Innate Immune System and Leads to Reduced Renal Metabolic Gene Expression.

BACKGROUND: Brain death (BD)-associated inflammation has been implicated in decreased kidney allograft function and survival, but the underlying mechanisms have not been well distinguished from the conditions of critical care itself. We have developed a clinically translatable model to separate and investigate strategies to improve donor management and critical care. METHODS: Brain-dead (n = 12) and sham (n = 5) rhesus macaques were maintained for 20 hours under intensive care unit-level conditions. Samples were collected for immunophenotyping, analysis of plasma proteins, coagulation studies, and gene analysis for changes in immune and metabolic profile with comparison to naive samples (n = 10). RESULTS: We observed an increase in circulating leukocytes and cytokines, activation of complement and coagulation pathways, and upregulation of genes associated with inflammation in both brain-dead and sham subjects relative to naïve controls. Sham demonstrated an intermediate phenotype of inflammation compared to BD. Analysis of gene expression in kidneys from BD kidneys revealed a similar upregulation of inflammatory profile in both BD and sham subjects, but BD presented a distinct reduction in metabolic and respiratory processes compared to sham and naïve kidneys. CONCLUSION: BD is associated with activation of specific pathways of the innate immune system and changes to metabolic gene expression in renal tissue itself; however, sham donors presented an intermediate inflammatory response attributable to the critical care environment. The early onset and penetrating impact of this inflammatory response underscores the need for early intervention to prevent perioperative tissue injury to transplantable organs.

Age-dependent outcomes in asymptomatic umbilical hernia repair.

PURPOSE: Umbilical hernias are common in young children. Many resolve spontaneously by age four with very low risk of symptoms or incarceration. Complications associated with surgical repair of asymptomatic umbilical hernias have not been well elucidated. We analyzed data from one hospital to test the hypothesis that repair at younger ages is associated with increased complication rates. METHODS: A retrospective chart review of all umbilical hernia repairs performed during 2007-2015 was conducted at a tertiary care children's hospital. Patients undergoing repairs as a single procedure for asymptomatic hernia were evaluated for post-operative complications by age, demographics, and co-morbidities. RESULTS: Of 308 umbilical hernia repairs performed, 204 were isolated and asymptomatic. Postoperative complications were more frequent in children < 4 years (12.3%) compared to > 4 years (3.1%, p = 0.034). All respiratory complications (N = 4) and readmissions (N = 1) were in children < 4 years. CONCLUSIONS: Age of umbilical hernia repair in children varied widely even within a single institution, demonstrating that timing of repair may be a surgeon-dependent decision. Patients < 4 years were more likely to experience post-operative complications. Umbilical hernias often resolve over time and can safely be monitored with watchful waiting. Formal guidelines are needed to support delayed repair and prevent unnecessary, potentially harmful operations.

Practice Variation in Umbilical Hernia Repair Demonstrates a Need for Best Practice Guidelines.

OBJECTIVE: To evaluate and better understand variations in practice patterns, we analyzed ambulatory surgery claims data from 3 demographically diverse states to assess the relationship between age at umbilical hernia repair and patient, hospital, and geographic characteristics. STUDY DESIGN: We performed a cross-sectional descriptive study of uncomplicated hernia repairs performed as a single procedure in 2012-2014, using the State Ambulatory Surgery and Services Database for Wisconsin, New York, and Florida. Age and demographic characteristics of umbilical hernia repair patients are described. RESULTS: The State Ambulatory Surgery and Services Database analysis included 6551 patients. Across 3 states, 8.2% of hernia repairs were performed in children <2 years, 18.7% in children age 2-3 years, and 73.0% in children age ≥4 years, but there was significant variability (P < .001) in practice patterns by state. In regression analysis, race, Medicaid insurance and rural residence were predictive of early repair, with African American patients less likely to have a repair before age 2 (OR 0.62, P = .046) and rural children (OR 1.53, P = .009) and Medicaid patients (OR 2.01, P < .001) more likely to do so. State of residence predicted early repair even when holding these variables constant. CONCLUSIONS: The age of pediatric umbilical hernia repair varies widely. As hernias may resolve over time and can be safely monitored with watchful waiting, formal guidelines are needed to support delayed repair and prevent unnecessary operations.

Third-Year Medical Students' Reactions to Surgical Patients in Pain: Doubt, Distress, and Depersonalization.

CONTEXT: Medical students have limited instruction about how to manage the interpersonal relationships required to care for patients in pain. OBJECTIVES: The objective of this study was to characterize the experiences of medical students as they encounter pain, suffering, and the emotional experiences of doctoring. METHODS: We used qualitative analysis to explore the content of 341 essays written by third-year medical students who described their experiences with surgical patients in pain. We used an inductive process to develop a coding taxonomy and then characterized the content of these essays related to empathy, patient-clinician interaction, and descriptions of clinical norms. RESULTS: Students found it difficult to reconcile patient suffering with the therapeutic objective of treatment. They feared an empathic response to pain might compromise the fortitude and efficiency required to be a doctor and they pursued strategies to distance themselves from these feelings. Students described tension around prescription of pain medications and worried about the side effects of medications used to treat pain. Students felt disillusioned when operations caused suffering without therapeutic benefit or were associated with unexpected complications. Although patients had expressed a desire for intervention, students worried that the burdens of treatment and long-term consequences were beyond patient imagination. CONCLUSION: These observations about patient-doctor relationships suggest that there is a larger problem among clinicians relating to patient distress and personal processing of the emotional nature of patient care. Efforts to address this problem will require explicit instruction in skills to develop a personal strategy for managing the emotionally challenging aspects of clinical work.

The cost effectiveness and utility of a "quick MRI" for the evaluation of intra-abdominal abscess after acute appendicitis in the pediatric patient population.

INTRODUCTION: Contrast-enhanced CT remains the first-line imaging for evaluating postoperative abscess (POA) after appendicitis. Given concerns of ionizing radiation use in children, we began utilizing quick MRI to evaluate POA and summarize our findings in this study. MATERIALS AND METHODS: Children imaged with quick MRI from 2015 to 2017 were compared to children evaluated with CT from 2012 to 2014 using an age and weight matched case-control model. Radiation exposure, size and number of abscesses, length of exam, drain placement, and patient outcomes were compared. RESULTS: There was no difference in age or weight (p>0.60) between children evaluated with quick MRI (n=16) and CT (n=16). Mean imaging time was longer (18.2±8.5min) for MRI (p<0.001), but there was no difference in time from imaging order to drain placement (p=0.969). No children required sedation or had non-diagnostic imaging. There were no differences in abscess volume (p=0.346) or drain placement (p=0.332). Thirty-day follow-up showed no difference in readmissions (p=0.551) and no missed abscesses. Quick MRI reduced imaging charges to $1871 from $5650 with CT. CONCLUSION: Quick MRI demonstrated equivalent outcomes to CT in terms of POA detection, drain placement, and 30-day complications suggesting that MRI provides an equally effective, less expensive, and non-radiation modality for the identification of POA. TYPE OF STUDY: Retrospective Case-Control Study. LEVEL OF EVIDENCE: Level III.

The impact of kidney donor profile index on delayed graft function and transplant outcomes: A single-center analysis.

INTRODUCTION: Renal transplant outcomes result from a combination of factors. Traditionally, donor factors were summarized by classifying kidneys as extended criteria or standard criteria. In 2014, the nomenclature changed to describe donor factors with the kidney donor profile index (KDPI). We aim to evaluate the relationship between KDPI and delayed graft function (DGF), and the impact KDPI on transplant outcomes for both donor after cardiac death (DCD) and donor after brain death (DBD). METHODS: An IRB-approved single-center retrospective chart review was performed from January 1999 to July 2013. The patients were divided into six groups: DBD KDPI ≤60, DBD KPDI 61-84, DBD KDPI ≥85, DCD KDPI ≤60, DCD KPDI 61-84, and DCD KDPI ≥85. Rates of DGF, patient survival, and graft survival were examined among groups. RESULTS: A total of 2161 kidney transplants were included. DGF rates increased, and graft and patient survival decreased with increasing KDPI (P < .001). DCD kidneys had higher DGF rates than their DBD counterparts (P < .001). In DCD kidneys, a higher KDPI score did not significantly affect the DGF rates (P > .302). There was no significant difference in graft or patient survival in all-comers when comparing DCD and DBD kidneys with equivalent KDPIs (P > .317). Patients with DGF across all categories demonstrated worse graft half-lives. CONCLUSION: The KDPI system is an accurate predictor of donor contributions to transplant outcomes. Recipients of DBD kidneys experience an increase in the rate of DGF as their KDPI increases. DCD kidneys have higher DGF rates than their DBD counterparts with similar KDPIs. Patients with documented post-transplant DGF had between 3- and 5-year shorter graft half-lives when compared to recipients that did not experience DGF. Initiatives to reduce the rate of DGF could provide a significant impact on graft survival and result in a reduction in the number of patients requiring retransplant.

Race, insurance status, and traumatic brain injury outcomes before and after enactment of the Affordable Care Act.

BACKGROUND: The Affordable Care Act aims to improve patient outcomes. Race/ethnicity and insurance status impact outcomes after traumatic brain injury. We sought to gauge the Affordable Care Act's effect on outcomes after traumatic brain injury, as graded by race/ethnicity and insurance status. METHODS: The National Trauma Data Bank was utilized to identify traumatic brain injury patients before and after the Affordable Care Act. Patient outcomes comprised of hospital duration of stay, in-hospital mortality, discharge to rehabilitation, and surgical procedures. Using regression analysis, we evaluated the impact of race/ethnicity and insurance status on traumatic brain injury outcomes, then compared them before and after the Affordable Care Act. RESULTS: Mortality decreased for blacks (odds ratio = 0.96 [confidence interval 0.83-1.10] to odds ratio = 0.79 [confidence interval = 0.70-0.89], and Hispanics (odds ratio = 1.03 [confidence interval = 0.90-1.17] to odds ratio = 0.79 [confidence interval = 0.70-0.89]). Mortality increased for the uninsured (odds ratio = 1.28 [confidence interval = 1.11-1.47] to odds ratio = 1.40 [confidence interval = 1.24-1.58]). Medicaid patients underwent decreased duration of stay, (coefficient = 2.75 [confidence interval = 2.49-3.02] to coefficient = 2.17, [confidence interval = 1.98-2.37]), discharge to rehabilitation (odds ratio = 1.15, [confidence interval = 1.04-1.26] to odds ratio = 0.95 [confidence interval = 0.87-1.03]), and surgical procedures (odds ratio = 1.28 [confidence interval = 1.13-1.45] to odds ratio = 1.18, [confidence interval = 1.07-1.30]), while mortality remained unchanged. CONCLUSION: After the Affordable Care Act traumatic brain injury mortality decreased for blacks and Hispanics, but increased for the uninsured. Decreasing trends in resource consumption were also evident, especially for Medicaid patients. These results may illustrate altered delivery of care.

Guidelines for the management of a brain death donor in the rhesus macaque: A translational transplant model.

INTRODUCTION: The development of a translatable brain death animal model has significant potential to advance not only transplant research, but also the understanding of the pathophysiologic changes that occur in brain death and severe traumatic brain injury. The aim of this paper is to describe a rhesus macaque model of brain death designed to simulate the average time and medical management described in the human literature. METHODS: Following approval by the Institutional Animal Care and Use Committee, a brain death model was developed. Non-human primates were monitored and maintained for 20 hours after brain death induction. Vasoactive agents and fluid boluses were administered to maintain hemodynamic stability. Endocrine derangements, particularly diabetes insipidus, were aggressively managed. RESULTS: A total of 9 rhesus macaque animals were included in the study. The expected hemodynamic instability of brain death in a rostral to caudal fashion was documented in terms of blood pressure and heart rate changes. During the maintenance phase of brain death, the animal's temperature and hemodynamics were maintained with goals of mean arterial pressure greater than 60mmHg and heart rate within 20 beats per minute of baseline. Resuscitation protocols are described so that future investigators may reproduce this model. CONCLUSION: We have developed a reproducible large animal primate model of brain death which simulates clinical scenarios and treatment. Our model offers the opportunity for researchers to have translational model to test the efficacy of therapeutic strategies prior to human clinical trials.

Number of rib fractures thresholds independently predict worse outcomes in older patients with blunt trauma.

BACKGROUND: There have been conflicting reports regarding whether the number of rib fractures sustained in blunt trauma is associated independently with worse patient outcomes. We sought to investigate this risk-adjusted relationship among the lesser-studied population of older adults. METHODS: A retrospective review of the National Trauma Data Bank was performed for patients with blunt trauma who were ≥65 years old and had rib fractures between 2009 and 2012 (N = 67,695). Control data were collected for age, sex, injury severity score, injury mechanism, 24 comorbidities, and number of rib fractures. Outcome data included hospital mortality, hospital and intensive care unit durations of stay, duration of mechanical ventilation, and the occurrence of pneumonia. Multiple logistic and linear regression analyses were performed. RESULTS: Sustaining ≥5 rib fractures was associated with increased intensive care unit admission (odds ratio: 1.14, P < .001) and hospital duration of stay (relative duration: 105%, P < .001). Sustaining ≥7 rib fractures was associated with an increased incidence of pneumonia (odds ratio: 1.32, P < .001) and intensive care unit duration of stay (relative duration: 122%, P < .001). Sustaining ≥8 rib fractures was associated with increased mortality (odds ratio: 1.51, P < .001) and duration of mechanical ventilation (relative duration: 117%, P < .001). CONCLUSION: In older patients with trauma, sustaining at least 5 rib fractures is a significant predictor of worse outcomes independent of patient characteristics, comorbidities, and trauma burden.

A call for a standardized definition of perforated appendicitis.

BACKGROUND: Abscess rates have been reported to be as low as 1% and as high as 50% following perforated appendicitis (PA). This range may be because of lack of universal definition for PA. An evidence-based definition (EBD) is crucial for accurate wound classification, risk-stratification, and subsequent process optimization. ACS NSQIP-Pediatric guidelines do not specify a definition of PA. We hypothesize that reported postoperative abscess rates underrepresent true incidence, as they may include low-risk cases in final calculations. METHODS: Local institutional records of PA patients were reviewed to calculate the postoperative abscess rate. The ACS NSQIP-Pediatric participant use file (PUF) was used to determine cross-institutional postoperative abscess rates. A PubMed literature review was performed to identify trials reporting PA abscess rates, and definitions and rates were recorded. RESULTS: 20.9% of our patients with PA developed a postoperative abscess. The ACS NSQIP-Pediatric abscess rate was significantly lower (7.61%, p<0.001). In the eighteen published studies analyzed, average abscess rate (14.49%) was significantly higher than ACS NSQIP-Pediatric (p<0.001). There was significantly more variation in trials that do not employ an EBD of perforation (Levene's test F-value =6.980, p=0.018). CONCLUSIONS: A standard EBD of perforation leads to lower variability in reported postoperative abscess rates following PA. Nonstandard definitions may be significantly altering the aggregate rate of postoperative abscess formation. We advocate for adoption of a standard definition by all institutions participating in ACS NSQIP-Pediatric data submission. LEVEL OF EVIDENCE: III.

A Single Institution Review of Initial Application of a 5-mm Stapler.

BACKGROUND: Operating in small spaces presents physical constraints that can be even more challenging in minimally invasive operations. Recently, a 5-mm stapler was approved for use in general surgery and pediatric surgery. Here, we present our initial experience using the 5-mm stapler in pediatric general surgery. MATERIALS AND METHODS: A retrospective chart review was conducted to identify cases using the 5-mm stapler at our institution. Demographic data included age (in months) and weight (in kilograms). Operative data included indication for use, number of loads used, complications related to 5-mm stapler use, and interventions to address complications. A second review focused on patients undergoing the same operations, but using a 10-mm stapler. RESULTS: A total of 60 staple loads were deployed in 32 procedures. There were four adverse outcomes, all recognized intraoperatively. One bleed resulted from application on irradiated tissue and another bleed from application to a small noninflamed mesoappendix. A bronchial staple line leak resulted from improper stapler loading, and a bowel anastomosis leak was oversewn with a single stitch. When compared with 32 matched cases using a 10-mm stapler, there was no difference in age (5-mm = 39.11 months, 10-mm = 50.21 months, P = .49) or weight (5-mm = 16.34 kg, 10-mm = 19.93 kg, P = .51). A total of 60 staple applications were used, with one bleed noted. There was no significant difference in overall complication rate (5-mm rate = 4/60, 10-mm rate = 1/60; P = .36). CONCLUSION: Our initial experience suggests that although there were more complications with the 5-mm stapler, there is no statistically significant difference in complication rates when compared with the 10-mm stapler. Furthermore, the 5-mm stapler complications can be corrected with device training and proper patient selection. In appropriately selected pediatric surgery cases with size limitations, the 5-mm stapler can be used to minimize the invasiveness of the operation.

The mode of sensitization and its influence on allograft outcomes in highly sensitized kidney transplant recipients.

BACKGROUND: We sought to determine whether the mode of sensitization in highly sensitized patients contributed to kidney allograft survival. METHODS: An analysis of the United Network for Organ Sharing dataset involving all kidney transplants between 1997 and 2014 was undertaken. Highly sensitized adult kidney transplant recipients [panel reactive antibody (PRA) ≥98%] were compared with adult, primary non-sensitized and re-transplant recipients. Kaplan-Meier survival analyses were used to determine allograft survival rates. Cox proportional hazards regression analyses were conducted to determine the association of graft loss with key predictors. RESULTS: Fifty-three percent of highly sensitized patients transplanted were re-transplants. Pregnancy and transfusion were the only sensitizing event in 20 and 5%, respectively. The 10-year actuarial graft survival for highly sensitized recipients was 43.9% compared with 52.4% for non-sensitized patients, P < 0.001. The combination of being highly sensitized by either pregnancy or blood transfusion increased the risk of graft loss by 23% [hazard ratio (HR) 1.230, confidence interval (CI) 1.150-1.315, P < 0.001], and the combination of being highly sensitized from a prior transplant increased the risk of graft loss by 58.1% (HR 1.581, CI 1.473-1.698, P < 0.001). CONCLUSIONS: The mode of sensitization predicts graft survival in highly sensitized kidney transplant recipients (PRA ≥98%). Patients who are highly sensitized from re-transplants have inferior graft survival compared with patients who are highly sensitized from other modes of sensitization.

Pediatric surgeon-directed wound classification improves accuracy.

BACKGROUND: Surgical wound classification (SWC) communicates the degree of contamination in the surgical field and is used to stratify risk of surgical site infection and compare outcomes among centers. We hypothesized that by changing from nurse-directed to surgeon-directed SWC during a structured operative debrief, we will improve accuracy of documentation. METHODS: An institutional review board-approved retrospective chart review was performed. Two time periods were defined: initially, SWC was determined and recorded by the circulating nurse (before debrief, June 2012-May 2013) and allowing 6 mo for adoption and education, we implemented a structured operative debriefing including surgeon-directed SWC (after debrief, January 2014-August 2014). Accuracy of SWC was determined for four commonly performed pediatric general surgery operations: inguinal hernia repair (clean), gastrostomy ± Nissen fundoplication (clean contaminated), appendectomy without perforation (contaminated), and appendectomy with perforation (dirty). RESULTS: One hundred eighty-three cases before debrief and 142 cases after debrief met inclusion criteria. No differences between time periods were noted in regard to patient demographics, ASA class, or case mix. Accuracy of wound classification improved before debrief (42% versus 58.5%, P = 0.003). Before debrief, 26.8% of cases were overestimated or underestimated by more than one wound class, versus 3.5% of cases after debrief (P < 0.001). Interestingly, most after debrief contaminated cases were incorrectly classified as clean contaminated. CONCLUSIONS: Implementation of a structured operative debrief including surgeon-directed SWC improves the percentage of correctly classified wounds and decreases the degree of inaccuracy in incorrectly classified cases. However, after implementation of the debriefing, we still observed a 41.5% rate of incorrect documentation, most notably in contaminated cases, indicating further education and process improvement is needed.

Current outcomes of chronic active antibody mediated rejection - A large single center retrospective review using the updated BANFF 2013 criteria.

BACKGROUND: The updated BANFF 2013 criteria has enabled a more standardized and complete serologic and histopathologic diagnosis of chronic active antibody mediated rejection (cAMR). Little data exists on the outcomes of cAMR since the initiation of this updated criteria. METHODS: 123 consecutive patients with biopsy proven cAMR (BANFF 2013) between 2006 and 2012 were identified. RESULTS: Patients identified with cAMR were followed for a median of 9.5 (2.7-20.3) years after transplant and 4.3 (0-8.8) years after cAMR. Ninety-four (76%) recipients lost their grafts with a median survival of 1.9 years after diagnosis with cAMR. Mean C4d and allograft glomerulopathy scores were 2.6 ± 0.7 and 2.2 ± 0.8, respectively. 53.2% had class II DSA, 32.2% had both class I and II, and 14.5% had class I DSA only. Chronicity score >8 (HR 2.9, 95% CI 1-8.4, p=0.05), DSA >2500 MFI (HR 2.8, 95% CI 1.1-6.8, p=0.03), Scr >3mg/dL (HR 3.2, 95% CI 1.6-6.3, p=0.001) and UPC >1g/g (HR 2.5, 95% CI 1.4-4.5, p=0.003) were associated with a higher risk of graft loss. CONCLUSIONS: cAMR was associated with poor graft survival after diagnosis. Improved therapies and earlier detection strategies are likely needed to improve outcomes of cAMR in kidney transplant recipients.

Predictors and outcomes of delayed graft function after living-donor kidney transplantation.

Delayed graft function (DGF) following deceased donor kidney transplantation is associated with inferior outcomes. Delayed graft function following living-donor kidney transplantation is less common, but its impact on graft survival unknown. We therefore sought to determine risk factors for DGF following living-donor kidney transplantation and DGF's effect on living-donor kidney graft survival. We analyzed living-donor kidney transplants performed between 2000 and 2014 in the UNOS dataset. A total of 64 024 living-donor kidney transplant recipients were identified, 3.6% developed DGF. Cold ischemic time, human leukocyte antigen mismatch, donor age, panel reactive antibody, recipient diabetes, donor and recipient body mass index, recipient race and gender, right nephrectomy, open nephrectomy, dialysis status, ABO incompatibility, and previous transplants were independent predictors of DGF in living-donor kidney transplants. Five-year graft survival among living-donor kidney transplant recipients with DGF was significantly lower compared with graft survival in those without DGF (65% and 85%, respectively, P < 0.001). DGF more than doubled the risk of subsequent graft failure (hazard ratio = 2.3, 95% confidence interval: 2.1-2.6; P < 0.001). DGF after living-donor kidney transplantation is associated with inferior allograft outcomes. Minimizing modifiable risk factors may improve outcomes in living-donor kidney transplantation.