Preoperative Treatment of Hepatitis C Is Associated With Lower Prosthetic Joint Infection Rates in US Veterans.

BACKGROUND: Hepatitis C virus (HCV) is associated with poorer outcomes in total joint arthroplasty (TJA). Recently, oral direct-acting antivirals (DAAs) have become available for HCV curative treatment. The goal of this study is to determine if HCV may be a modifiable risk factor in TJA by comparing postoperative complications among patients with and without preoperative treatment for HCV. METHODS: US Department of Veterans Affairs dataset of all consecutive primary TJAs performed between 2014 and 2018, when DAAs were available, was retrospectively reviewed. HCV-infected patients were identified using International Classification of Diseases, Ninth and Tenth Revision codes and laboratory values. HCV-infected patients treated prior to TJA with DAA were included in the "treated" group. HCV-infected patients untreated preoperatively were assigned to the "untreated" group. Medical and surgical complications up to 1 year postoperatively were identified using International Classification of Diseases, Ninth and Tenth Revision inpatient and outpatient codes. RESULTS: In total, 42,268 patients underwent TJA at Veterans Affairs Hospitals between 2014 and 2018. About 6.0% (n = 2557) of TJA patients had HCV, 17.3% of whom received HCV treatment preoperatively. When evaluating inpatient and outpatient codes, implant infection rates were statistically lower at 90 days and 1 year postoperatively among HCV-treated patients than among those untreated. Odds ratios (ORs) favor lower infection rates in HCV-treated patients (90-day OR: 3.30, P = .045; 1-year OR: 2.16, P = .07). CONCLUSION: Preoperative HCV treatment was associated with lower periprosthetic infection rates among US veterans undergoing TJA. Further investigation is necessary for definitive conclusions.

Freedom From Opioids After Total Knee Arthroplasty.

BACKGROUND: In the United States, opioids are commonly prescribed to treat knee pain after total knee arthroplasty (TKA). While surgery leads to decreased pain in most patients, a sizable minority continue to experience severe pain and consume opioids chronically after TKA. We sought to determine the population-level effect of TKA on opioid consumption by detailing the pattern of opioid prescriptions before and after surgery. METHODS: We retrospectively identified US Veterans Health Administration TKA patients from 2010 to 2015. Outpatient opioid prescriptions were identified from 18 months before to 18 months after surgery, and mean daily opioid doses were calculated. Our primary end point was the achievement of opioid-freedom, defined as a period of at least 6 months without opioids. We compared the percentage of patients who were opioid-free preoperatively to the percentage who were opioid-free 18 months after surgery (no prescriptions after postoperative month 12). We identified factors associated with opioid-freedom. RESULTS: In a cohort of 33,927 patients, 41% were opioid-free in the month before surgery compared to 54% 18 months after surgery (P < .001). Preoperative freedom from opioids (odds ratio, 4.59; 95% confidence interval, 4.34 to 4.85; P < .001) was more strongly associated with postoperative freedom from opioids than patient medical and social factors. CONCLUSION: TKA was associated with an increase in postoperative freedom from opioids. Low preoperative dose of opioids was more strongly associated with postoperative opioid-freedom than patient characteristics, suggesting that opioid prescription patterns are a chief driver of opioid use after surgery. LEVEL OF EVIDENCE III: Retrospective cohort study.

Association between Withholding Angiotensin Receptor Blockers in the Early Postoperative Period and 30-day Mortality: A Cohort Study of the Veterans Affairs Healthcare System.

BACKGROUND: Despite widespread use, there is limited information to guide perioperative management of angiotensin receptor blockers (ARBs). METHODS: In this retrospective cohort study, the authors evaluated the patterns of postoperative ARB use in veterans regularly prescribed ARBs admitted for noncardiac surgery at the Veterans Affairs Healthcare system between 1999 and 2011. Multivariable and propensity score-matched Cox proportional hazards models were used to determine the independent effect of failure to resume ARB by postoperative day 2 on the primary outcome of all-cause 30-day mortality. RESULTS: Out of 1,167,482 surgical admissions, 30,173 inpatient surgical admissions met inclusion criteria. Approximately 10,205 patients (33.8%) in the cohort did not resume ARB by day 2. Those that resumed ARB had a 30-day mortality rate of 1.3% (260 of 19,968), whereas 3.2% (323 of 10,205) died in the group that withheld ARB. The unadjusted hazard ratio (HR) for 30-day mortality was 2.45 (95% CI, 2.08 to 2.89; P < 0.001) for those that withheld ARB compared with those that resumed, whereas the multivariable adjusted HR was 1.74 (95% CI, 1.47 to 2.06; P < 0.001). When restricted to a propensity score-matched subset of 19,490, the HR was similar (1.47; 95% CI, 1.22 to 1.78; P < 0.001). Withholding ARB in younger patients increased mortality risk (HR = 2.52; 95% CI, 1.69 to 3.76; P < 0.001 for age <60 yr) compared with older patients (HR = 1.42; 95% CI, 1.09 to 1.85; P = 0.01 for age >75 yr). CONCLUSIONS: Postoperative delay in resuming ARB is common, particularly in patients who are frail after surgery. Withholding ARB is strongly associated with increased 30-day mortality, especially in younger patients, although residual confounding may be present.

What defines a high-volume hip or knee surgeon in the United States?

The literature suggests that high-volume hip and knee surgeons have better patient outcomes. Therefore, clearly defining a high-volume or a low-volume surgeon is important. The definition of high-volume has been quite arbitrary, and numbers such as 50 surgeries per year have been used to define high-volume. The objective of this study was to show that, on the basis of data contained in the National Inpatient Sample database, using the quartile approach will quantify the increasing number of surgeries required per year to remain a high-volume joint surgeon. Using quartiles may provide a more consistent way to define what is meant by a low- or high-volume surgeon in the United States, and a clear definition of quartiles will aid future studies seeking to determine whether outcomes can be correlated with quartiles.

Mid-term outcomes in HIV-positive patients after primary total hip or knee arthroplasty.

We hypothesized that infection rates following total joint arthroplasty (TJA) in those with the human immunodeficiency virus (HIV) without hemophilia or drug use would be similar to rates in HIV-negative patients. Records at an urban HIV referral hospital were searched for patients who underwent primary total hip and knee arthroplasty from 2003 to 2010. The primary outcome was revision for infection. 372 HIV-negative and 22 HIV-positive TJA patients met inclusion criteria. The HIV-positive group had more deep infections than the HIV-negative group (9.1% v 2.2%, P=0.102). There were no infections in those with AIDS-defining CD4 counts. Those with HIV may have a higher risk of developing a deep infection. A low CD4 count is not an absolute contraindication to TJA in HIV positive patients.

Where do knee revisions for infection, fracture, and other revisions get treated?

Complicated knee revision procedures require specific expertise that may not be available across the healthcare network. Teaching hospitals appear to perform more knee revisions overall than urban or rural hospitals. We examined the location of care and payer status for all knee revisions including complex revisions (infection, periprosthetic fracture). Although only 39.7% of all primary total knee cases were performed in teaching hospitals, over half of all knee revisions were performed in teaching hospitals. Knee revision procedures, including treatment of periprosthetic infections and fractures are performed more often in teaching hospitals than in urban and rural settings combined. Reimbursement that does not match the cost of care for complex revision and infection cases may have a disproportionate impact on teaching hospitals.

Barriers to completion of Patient Reported Outcome Measures.

Patient Reported Outcomes Measures (PROMs) are commonly used in total joint arthroplasty (TJA) to assess surgical outcomes. However certain patient populations may be underrepresented due to lower survey completion rates. The purpose of this study is to evaluate factors that influence PROM completion rates for 1997 TJA patients between 7/1/2007 and 12/31/2010. Completion rates were lower among patients who were over 75, Hispanic or Black, had Medicare or Medicaid, TKA patients and revision TJA patients (P<0.05 for all comparisons). Having multiple risk factors further reduced completion rates (P<0.001). Overall participation increased significantly during the study period, after electronic data capture methods were introduced. Awareness of these factors may help physicians and researchers improve participation of all patient populations so they are well represented in TJA outcomes research.

Is an algorithmic approach to the treatment of recurrent dislocation after THA effective?

BACKGROUND: The indications for surgical techniques for treatment of recurrent hip dislocation after THA differ, and their rates of achievement of stability may not be similar. QUESTIONS/PURPOSES: We (1) describe our indications for different approaches for recurrent dislocation, (2) outline an algorithmic approach to the management of recurrently dislocating hips after THA, and (3) determine the overall rate of restoration of stability via this algorithmic approach and for each of four procedures with our indications. PATIENTS AND METHODS: We retrospectively reviewed 66 patients (69 hips) with revision THA for symptomatic recurrent dislocation from 1993 to 2008. We determined the rate of achievement of stability for the overall patient population and with each revision technique. Minimum followup was 2.8 years (mean, 7.8 years; range, 2.8-12.7 years). RESULTS: Fifty-one of the 69 hips (74%) had no further dislocations while nine (13%) required two revisions and nine (13%) required three or more revisions. Ultimately, all of the 69 hips (100%) were stable at followup. Use of a large (36-mm-diameter) head, constrained cup, trochanteric advancement, correction of malposition, and a combination of techniques was effective in achieving stability in 67%, 68%, 86%, 91%, and 90% of cases, respectively. CONCLUSIONS: Separating the treatment of patients based primarily on the presence or absence of (1) component malposition, (2) an intact abductor mechanism, and (3) implants accommodating a large-diameter femoral head, we were able to achieve hip stability with one operation in 74% of cases. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Value-based care in the management of spinal disorders: a systematic review of cost-utility analysis.

BACKGROUND: Spinal disorders are a major cause of disability and compromise in health-related quality of life. The direct and indirect costs of treating spinal disorders are estimated at more than $100 billion per year. With limited resources, the cost-utility of interventions is important for allocating resources. QUESTIONS/PURPOSES: We therefore performed a systematic review of the literature on cost-utility for nonoperative and operative interventions for treating spinal disorders. METHODS: We searched four databases for cost-utility analysis studies on low back pain management and identified 1004 items. The titles and abstracts of 752 were screened before selecting 27 studies for inclusion; full texts of these 27 studies were individually evaluated by five individuals. RESULTS: Studies of nonoperative treatments demonstrated greater value for graded activity over physical therapy and pain management; spinal manipulation over exercise; behavioral therapy and physiotherapy over advice; and acupuncture and exercise over usual general practitioner care. Circumferential fusion and femoral ring allograft had greater value than posterolateral fusion and titanium cage, respectively. The relative cost-utility of operative versus nonoperative interventions was variable with the most consistent evidence indicating superior value of operative care for treating spinal disorders involving nerve compression and instability. CONCLUSION: The literature on cost-utility for treating spinal disorders is limited. Studies addressing cost-utility of nonoperative and operative management of low back pain encompass a broad spectrum of diagnoses and direct comparison of treatments based on cost-utility thresholds for comparative effectiveness is limited by diversity among disorders and methods to assess cost-utility. Future research will benefit from uniform methods and comparison of treatments in cohorts with well-defined pathology.

Cost and effectiveness of postoperative fever diagnostic evaluation in total joint arthroplasty patients.

The purpose of this study is to examine the characteristics and costs of postoperative fever diagnostic evaluations after total joint arthroplasty. All patients who underwent hip and knee arthroplasty (n = 1100) at a single institution for a 2-year period were included. Fever (temperature > or = 38.5 degrees C) occurred in 15% of patients. The rate of positive tests was as follows: chest radiograph (2%), blood culture (6%), urine culture (22%), and urinalysis (23.7%). Fever occurring after postoperative day 3 (odds ratio [OR] 23.3; P < .001) and multiple days febrile (OR, 8.6; P = .003) are independent predictors of a positive workup, and patients with a maximum temperature of 39.0 degrees C or higher (25.4% vs 6.9%; P = .001) had a significantly higher rate of positive fever evaluations. The total direct cost associated with fever evaluations was $73 878, and cost per change in clinical management was $8209. Fever is a common occurrence after hip and knee arthroplasty, and many elements of an infectious evaluation are costly and clinically unnecessary.

The validity of using administrative claims data in total joint arthroplasty outcomes research.

The purpose of this study was to evaluate concordance between administrative and clinical diagnosis and procedure codes for revision total joint arthroplasty (TJA). Concordance between administrative and clinical records was determined for 764 consecutive revision TJA procedures from 4 hospitals. For revision total hip arthroplasty, concordance between clinical diagnoses and administrative claims was very good for dislocation, mechanical loosening, and periprosthetic joint infection (all kappa > 0.6), but considerably lower for prosthetic implant failure/breakage and other mechanical complication (both kappa < 0.25). Similarly, for revision total knee arthroplasty diagnoses, concordance was very good for periprosthetic fracture, periprosthetic joint infection, mechanical loosening, and osteolysis (all kappa > 0.60), but much lower for implant failure/breakage and other mechanical complication (both kappa < 0.24). Concordance for TJA-specific procedure codes was very good only for revision total knee arthroplasty patellar component revisions and tibial insert exchange procedures. Total (all-component) revisions were overcoded for hips (00.70) and undercoded for knees (00.80). Improved clinical documentation and continued education are needed to enhance the value of these codes.

Does Implant Choice Affect the Episode Cost of Pertrochanteric Hip Fracture for US Veterans?

OBJECTIVE: To investigate an association between a surgeon's choice of a cephalomedullary nail (CMN) or sliding hip screw (SHS) with the cost of treating a pertrochanteric hip fracture. DESIGN: Multicenter retrospective cohort study. SETTING: US Veterans Health Administration Sierra Pacific Network. PATIENTS/PARTICIPANTS: Two hundred ninety-four consecutive US veterans admitted for a principal diagnosis of an OTA/AO 31A-type pertrochanteric hip fracture of a native hip from 2000 to 2015. INTERVENTION: Internal fixation using a CMN or an SHS. MAIN OUTCOME MEASUREMENTS: Veterans Administration Health Economic Resource Center average national cost estimate of combined acute and postacute care episode cost, excluding implant cost, normalized to 2015 US dollars by the Consumer Price Index. RESULTS: Median episode cost was $8223 lower with a CMN than an SHS (95% confidence interval, $5700-$10,746, P < 0.001) after matching on a propensity score for treatment with a CMN based on age, sex, body mass index, Charlson Comorbidity Index, fracture characteristics, study site, and admission year. A subgroup propensity-matched analysis excluding reverse obliquity pertrochanteric fractures was not sufficiently powered to detect a difference in episode cost (ß = 0.76, P = 0.311). CONCLUSIONS: Implant choice significantly affected the episode cost of care of hip fracture at Veterans Health Administration facilities. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Increased risk of graft failure in kidney transplant recipients after a diagnosis of dyspepsia or gastroesophageal reflux disease.

BACKGROUND: Gastrointestinal complications are common in patients who undergo kidney transplantation and may affect posttransplant outcomes. We examined the incidence and predictors of gastroesophageal reflux disease (GERD) and dyspepsia and their associations with graft survival and mortality after transplant. METHODS: We examined United States Renal Data System data and Medicare billing claims to identify diagnoses of dyspepsia and GERD among Medicare beneficiaries transplanted in 1995-2002 (n=42,257). Among GERD cases, we identified patients with reflux esophagitis (RE). We determined independent predictors of upper gastrointestinal complications and modeled these conditions as time-dependent outcomes predictors with Cox regression. RESULTS: The 3-year cumulative incidences of GERD, RE, and dyspepsia were 20%, 5%, and 6%, respectively. Overall, 23% of transplant recipients received a diagnosis of at least one of these complications by 3 years after transplant. Female gender and a pretransplant upper gastrointestinal disease diagnosis predicted posttransplant gastrointestinal complications. Older age, obesity, Caucasian, and African-American race were associated to increased risk of developing GERD. Patients diagnosed with any of the examined upper gastrointestinal complications experienced an increased risk of graft-failure (hazard ratio 1.58; 95% confidence interval 1.48-1.69) and death (hazard ratio 1.61; 95% confidence interval 1.46-1.77). CONCLUSIONS: Upper gastrointestinal complications are relatively common after kidney transplantation and are associated with a significantly increased risk of graft loss and death. Further research is needed to elucidate mechanisms underlying the observed adverse prognoses conferred by diagnosis of upper gastrointestinal complications after kidney transplant.

Expanding the evidence base in transplantation: the complementary roles of randomized controlled trials and outcomes research.

Transplantation offers a unique opportunity to demonstrate the complementary roles of randomized controlled trials and outcome research. The surgery and collaboration necessary for the transplant procedure makes randomization and blinding difficult. Because essentially every recipient is included in a transplant registry, sampling bias is minimized. Regulatory agencies generally do not consider outcomes research when assessing efficacy of new drugs or medical interventions. This workgroup summary examines the suitability of outcomes research to complement results of randomized controlled trials and related issues: efficacy versus effectiveness, internal versus external validity, data types, limitations, and analysis methodologies. Many advances in outcomes research have been pioneered in transplantation. A case is made for regulatory and reimbursement authorities to use outcomes research when making efficacy, effectiveness, and coverage decisions in transplantation.

Incidence and risk factors for diarrhea following kidney transplantation and association with graft loss and mortality.

BACKGROUND: Gastrointestinal complications after kidney transplantation are associated with inferior graft outcomes. We examined the incidence, risk factors, and outcomes of posttransplantation diarrhea. STUDY DESIGN: Historic cohort study. SETTING & PARTICIPANTS: We examined first kidney transplant recipients in the United States from 1995 to 2002, with follow-up through December 2002. Recipients of multiple organs were excluded. We limited our study population to Medicare beneficiaries. PREDICTORS: Recipient, donor, and transplant characteristics were ascertained by means of US Renal Data System database inquiry. OUTCOMES: Incidence of diarrhea, graft loss, and death after transplantation. First episodes of diarrhea after transplantation were ascertained by using International Classification of Disease, Ninth Revision, Clinical Modification codes using Medicare billing data. Cause of diarrhea was classified as infectious or not and according to specific cause. Graft loss and death were ascertained from the date of the first diarrhea episode. RESULTS: We enrolled 41,442 patients. Mean follow-up was 758 +/- 399 days. We observed 7,103 diarrhea cases and 8,104 graft losses (4,201 deaths). The 3-year cumulative incidence of diarrhea was 22%, with 18% diagnosed as noninfectious diarrhea with an unspecified cause. Using multivariate Cox proportional hazards analysis, factors associated with increased risk of unspecified noninfectious diarrhea were female sex (hazard ratio [HR], 1.40; 95% confidence interval, 1.33 to 1.48), type 1 diabetes (HR, 1.20; 95% confidence interval, 1.06 to 1.37), and regimens containing tacrolimus and mycophenolate mofetil (HR, 1.37; 95% confidence interval, 1.28 to 1.46). Unspecified noninfectious diarrhea was associated with increased risk of graft failure (HR, 2.13; 95% confidence interval, 1.98 to 2.28) and patient death (HR, 2.04; 95% confidence interval, 1.85 to 2.24). LIMITATIONS: Use of claims data to ascertain patient characteristics and events; inability to make causal inference based on retrospective designs. CONCLUSIONS: Regimens containing tacrolimus and mycophenolate mofetil were associated with increased risk of noninfectious diarrhea. Episodes of noninfectious diarrhea doubled the hazard of graft loss and patient death.

The evolving notion of "senior" kidney transplant recipients.

The maximum age of recipients expected to benefit with a kidney transplant has increased in the past three decades. In 1980, patients older than age 50 were not listed for a transplant. In 2004, almost 90% aged 50-60 yr with end-stage renal disease were listed, and some were even older than age 80. We summarize previous articles to illustrate how the notion of "senior" has evolved for kidney transplantation, and using data reported to the Organ Procurement Transplant Network, describe characteristics, treatments and outcomes in recipients older than 50 yr. Fractions of male, white, non-obese, unsensitized recipients and use of expanded criteria donors increased in cohorts with increasing recipient age. The percentage of recipients with hypertension or diabetes decreased, but the percentage with cancer increased. The fraction spared steroids increased with increasing age, but other aspects of immunosuppression were not remarkably different. No differences in early outcomes were notable, and elderly recipients likely did not return to dialysis. However, both graft and patient survival rates decreased with increasing age. Although a small fraction was selected, and survival rates were lower, patients older than 80 yr received kidney transplants.

Acute Pain Is Associated With Chronic Opioid Use After Total Knee Arthroplasty.

BACKGROUND AND OBJECTIVES: Pain scores are routinely reported in clinical practice, and we wanted to examine whether this routinely measured, patient-reported variable provides prognostic information, especially with regard to chronic opioid use, after taking preoperative and perioperative variables into account in a preoperative opioid user population. METHODS: In 32,874 preoperative opioid users undergoing primary total knee arthroplasty at Veterans Affairs hospitals between 2010 and 2015, we compared preoperative and perioperative characteristics in patients reporting lower versus higher acute pain (scores ≤4/10 vs >4/10 averaged over days 1-3). We calculated the propensity for lower acute pain based on all available data. After 1:1 propensity score matching, to identify similar patients differing only in acute pain, we contrasted rates of chronic significant opioid use (mean >30 mg/d in morphine equivalents) beyond postoperative month 3, discharge prescriptions, and changes in postoperative versus preoperative dose categories. Sensitivity analysis examined associations with dose escalation. RESULTS: Rates of chronic significant opioid use (21% overall) differed in patients with lower versus higher acute pain (36% vs 64% of the overall cohort). After propensity matching (total n = 20,926 patients) and adjusting for all significant factors, lower acute pain was associated with less chronic significant opioid use (rates 12% vs 16%), smaller discharge prescriptions (ie, supply <30 days and daily oral morphine equivalent <30 mg/d), and more reduction in dose, all P < 0.001. In sensitivity analysis, dose escalation was 15% less likely with lower acute pain (odds ratio, 0.85; 95% confidence interval, 0.80-0.91). CONCLUSIONS: Acute pain predicts chronic opioid use. Prospective studies of efforts to reduce acute pain, in terms of long-term effects, are needed.

Diabetic complications associated with new-onset diabetes mellitus in renal transplant recipients.

BACKGROUND: Data are scarce regarding the incidence and risk factors for complications of new-onset diabetes mellitus (NODM) in renal transplant patients. METHODS: United States Renal Data System (USRDS) data from primary renal transplant recipients during 1995-2001 who developed NODM was used to examine diabetic complications over the first three years posttransplant. Prognostic models were used to evaluate patient characteristics and treatment choices associated with risk of each class of complications. Propensity scores for choice of calcineurin inhibitor were included in multivariate analyses. RESULTS: The analysis included 21,489 patients, of whom 4,105 developed NODM by 3 years posttransplant. One or more NODM complications developed in 2,393 patients (58.3% of all patients with NODM), comprising ketoacidosis (334, 8.1%), hyperosmolarity (131, 3.2%), renal complications (1,286, 31.3%), ophthalmic complications (340, 8.3%), neurological complications (665, 16.2%), peripheral circulatory disorders (170, 4.1%) and hypoglycemia/shock (301, 7.3%). Complications developed within a mean of 500 to 600 days from diagnosis of NODM. Multivariate analysis showed that increased recipient age, higher body mass index, African-American race, hepatitis C infection, hypertension as cause of end-stage renal disease, cold ischemia >or=30 hours, and use of tacrolimus each increased risk of complications. CONCLUSION: NODM is associated with similar complications to those seen in the general population, but these appear to develop at an accelerated rate. Obesity and use of tacrolimus are the only modifiable factors that appear to affect risk of NODM or its complications.

The impact of human leukocyte antigen matching on transplant complications and immunosuppression dosage.

Administrative claims data facilitate ascertainment of outcomes not collected by the transplant registry and provide the opportunity to examine prescribed doses of immunosuppressive medications. Here, we examine the impact of human leukocyte antigen (HLA) matching on traditional outcomes, rejection and survival, and use novel methods to examine immunosuppresion doses and complication rates. The central hypothesis tested in this analysis is that HLA-matched recipients receive lower doses of immunosuppression and have fewer posttransplant complications. We break from tradition by examining HLA matching in both living and deceased donor kidney transplants. As secondary aims, we compare the relative impact of class I and II mismatches and describe outcomes achieved with older donors. Medicare claims linked to the United States Renal Data System database for 23,443 kidney transplants were included in the study. A total of 15,793 transplants were DR mismatched (DRMM), 5,340 manifested no DR mismatches (NODRMM), and 2,310 manifested no ABDR mismatches (NOABDRMM). Patients with NOABDRMM experienced lower adjusted risk of rejection (0.66, 95% confidence interval 0.59-0.74, P < 0.001) and lower hazard of graft loss (0.69, 0.61-0.77, P < 0.001) and death (0.76, 0.63-0.92, P < 0.001) compared with those with DRMM. The hazard of cardiac and diabetic complications was similar between recipients of NOADRMM and DRMM transplants, but the hazard of diarrhea was significantly lower (0.82, 0.73-0.92, P < 0.001) in patients with NOABDRMM. The 6-month dose of mycophenolate mofetil was lower in patients with NOABDRMM. This study validates previous studies that indicated significantly lower risks of rejection, graft loss, and death among patients with 0 HLA-A,B,DR mismatches. Use of administrative claims revealed similar rates of cardiovascular complications. However, HLA-matched deceased donor recipients received lower dosages of mycophenolate mofetil and manifested a lower risk of developing posttransplant diarrhea.