Contemporary incidence and risk factors of post transplant Erythrocytosis in deceased donor kidney transplantation.

BACKGROUND: Post-Transplant erythrocytosis (PTE) has not been studied in large recent cohorts. In this study, we evaluated the incidence, risk factors, and outcome of PTE with current transplant practices using the present World Health Organization criteria to define erythrocytosis. We also tested the hypothesis that the risk of PTE is greater with higher-quality kidneys. METHODS: We utilized the Deceased Donor Study which is an ongoing, multicenter, observational study of deceased donors and their kidney recipients that were transplanted between 2010 and 2013 across 13 centers. Eryrthocytosis is defined by hemoglobin> 16.5 g/dL in men and> 16 g/dL in women. Kidney quality is measured by Kidney Donor Profile Index (KDPI). RESULTS: Of the 1123 recipients qualified to be in this study, PTE was observed at a median of 18 months in 75 (6.6%) recipients. Compared to recipients without PTE, those with PTE were younger [mean 48±11 vs 54±13 years, p < 0.001], more likely to have polycystic kidney disease [17% vs 6%, p < 0.001], have received kidneys from younger donors [36 ±13 vs 41±15 years], and be on RAAS inhibitors [35% vs 22%, p < 0.001]. Recipients with PTE were less likely to have received kidneys from donors with hypertension [16% vs 32%, p = 0.004], diabetes [1% vs 11%, p = 0.008], and cerebrovascular event (24% vs 36%, p = 0.036). Higher KDPI was associated with decreased PTE risk [HR 0.98 (95% CI: 0.97-0.99)]. Over 60 months of follow-up, only 17 (36%) recipients had sustained PTE. There was no association between PTE and graft failure or mortality, CONCLUSIONS: The incidence of PTE was low in our study and PTE resolved in majority of patients. Lower KDPI increases risk of PTE. The underutilization of RAAS inhibitors in PTE patients raises the possibility of under-recognition of this phenomenon and should be explored in future studies.

Opportunistic Screening for Coronary Artery Disease: An Untapped Population Health Resource.

BACKGROUND: Coronary artery disease is the leading cause of death in the United States. At-risk asymptomatic adults are eligible for screening with electrocardiogram-gated coronary artery calcium (CAC) CT, which aids in risk stratification and management decision-making. Incidental CAC (iCAC) is easily quantified on chest CT in patients imaged for noncardiac indications; however, radiologists do not routinely report the finding. OBJECTIVE: To determine the clinical significance of CAC identified incidentally on routine chest CT performed for noncardiac indications. DESIGN: An informationist developed search strategies in MEDLINE, Embase, and SCOPUS, and two reviewers independently screened results at both the abstract and full text levels. Data extracted from eligible articles included age, rate of iCAC identification, radiologist reporting frequency, impact on downstream medical management, and association of iCAC with patient outcomes. RESULTS: From 359 unique citations, 83 research publications met inclusion criteria. The percentage of patients with iCAC ranged from 9% to 100%. Thirty-one investigations measured association(s) between iCAC and cardiovascular morbidity and mortality, and 29 identified significant correlations, including nonfatal myocardial infarction, fatal myocardial infarction, major adverse cardiovascular event, cardiovascular death, and all-cause death. iCAC was present in 20% to 100% of the patients in these cohorts, but when present, iCAC was reported by radiologists in only 31% to 44% of cases. Between 18% and 77% of patients with iCAC were not on preventive medications in studies that reported these data. Seven studies measured the effect of reporting on guideline directed medical therapy, and 5 (71%) reported an increase in medication prescriptions after diagnosis of iCAC, with one confirming reductions in low-density lipoprotein levels. Twelve investigations reported good concordance between CAC grade on noncardiac CT and Agatston score on electrocardiogram-gated cardiac CT, and 10 demonstrated that artificial intelligence tools can reliably calculate an Agatston score on noncardiac CT. CONCLUSION: A body of evidence demonstrates that patients with iCAC on routine chest CT are at risk for cardiovascular disease events and death, but they are often undiagnosed. Uniform reporting of iCAC in the chest CT impression represents an opportunity for radiology to contribute to early identification of high-risk individuals and potentially reduce morbidity and mortality. AI tools have been validated to calculate Agatston score on routine chest CT and hold the best potential for facilitating broad adoption.

Systematic Evaluation of Imaging Features of Early Bladder Cancer Using Computed Tomography Performed before Pathologic Diagnosis.

BACKGROUND: Bladder cancer is the sixth most common malignancy in the United States (US). Despite its high prevalence and the significant potential benefits of early detection, no reliable, cost-effective screening algorithm exists for asymptomatic patients at risk. Nonetheless, reports of incidentally identified early bladder cancer on CT/MRI scans performed for other indications are emerging in the literature. This represents a new opportunity for early detection, with over 80 million CT scans performed in the US yearly, 40% of which are abdominopelvic CTs. This investigation aims to define the imaging features of early bladder cancer, with the mission of facilitating early diagnosis. METHODS: Following IRB approval with a waiver of informed consent, a retrospective review was performed, identifying 624 patients with non-muscle-invasive bladder cancer diagnosed at Johns Hopkins Hospital between 2000 and 2019. Of these patients, 99 patients underwent pelvic CT within the 5 years preceding pathologic diagnosis. These imaging studies were reviewed retrospectively to evaluate for the presence and features of any focal bladder wall abnormality. RESULTS: Median age at the time of pathologic diagnosis was 70 years (range: 51-88 years), and 82% (81/99) of patients were male. A total of 226 CT studies were reviewed. The number of studies per patient ranged from 1 to 33. Median time interval between all available imaging and pathologic diagnosis was 14 months. A total of 62% (141/226) of the scans reviewed were performed for indications other than suspected urinary tract cancer (UTC). A bladder wall mass was visualized in 67% (66/99) of patients and on 35% (78/226) of scans performed before diagnosis. The majority (84%, 67/80) of masses were intraluminal. Mean transverse long- and short-axis measurements were 24 mm and 17 mm, respectively, with long dimension measurements ranging between 5 and 59 mm. CONCLUSIONS: Early bladder cancer was visualized on CT preceding pathologic diagnosis in more than 2/3 of patients, and the majority of scans were performed for indications other than suspected urinary tract cancer/UTC symptoms. These results suggest that cross-sectional imaging performed for other indications can serve as a resource for opportunistic bladder cancer screening, particularly in high-risk patients.

Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning.

PURPOSE: With the rise in popularity of structured reports in radiology, we sought to evaluate whether free-text CT reports on pancreatic ductal adenocarcinoma (PDAC) staging at our institute met published guidelines and assess feedback of pancreatic surgeons comparing free-text and structured report styles with the same information content. METHODS: We retrospectively evaluated 298 free-text preoperative CT reports from 2015 to 2017 for the inclusion of key tumor descriptors. Two surgeons independently evaluated 50 free-text reports followed by evaluation of the same reports in a structured format using a 7-question survey to assess the usefulness and ease of information extraction. Fisher's exact test and Chi-square test for independence were utilized for categorical responses and an independent samples t test for comparing mean ratings of report quality as rated on a 5-point Likert scale. RESULTS: The most commonly included descriptors in free-text reports were tumor location (99%), liver lesions (97%), and suspicious lymph nodes (97%). The most commonly excluded descriptors were variant arterial anatomy and peritoneal/omental nodularity, which were present in only 23% and 42% of the reports, respectively. For vascular involvement, a mention of the presence or absence of perivascular disease with the main portal vein was most commonly included (87%). Both surgeons' rating of overall report quality was significantly higher for structured reports (p < 0.001). CONCLUSION: Our results indicate that free-text reports may not include key descriptors for staging PDAC. Surgeons rated structured reports that presented the same information as free-text reports but in a template format superior for guiding clinical management, convenience of use, and overall report quality.

Post-transplant Diabetes Mellitus in Kidney Transplant Recipients: A Multicenter Study.

Background: De novo post-transplant diabetes mellitus (PTDM) is a common complication after kidney transplant (KT). Most recent studies are single center with various approaches to outcome ascertainment. Methods: In a multicenter longitudinal cohort of 632 nondiabetic adult kidney recipients transplanted in 2010-2013, we ascertained outcomes through detailed chart review at 13 centers. We hypothesized that donor characteristics, such as sex, HCV infection, and kidney donor profile index (KDPI), and recipient characteristics, such as age, race, BMI, and increased HLA mismatches, would affect the development of PTDM among KT recipients. We defined PTDM as hemoglobin A1c ≥6.5%, pharmacological treatment for diabetes, or documentation of diabetes in electronic medical records. We assessed PTDM risk factors and evaluated for an independent time-updated association between PTDM and graft failure using regression. Results: Mean recipient age was 52±14 years, 59% were male, 49% were Black. Cumulative PTDM incidence 5 years post-KT was 29% (186). Independent baseline PTDM risk factors included older recipient age (P<0.001) and higher BMI (P=0.006). PTDM was not associated with all-cause graft failure (adjusted hazard ratio (aHR), 1.10; 95% CI, 0.78 to 1.55), death-censored graft failure (aHR, 0.85; 95% CI, 0.53 to 1.37), or death (aHR, 1.31; 95% CI, 0.84 to 2.05) at median follow-up of 6 (interquartile range, 4.0-6.9) years post-KT. Induction and maintenance immunosuppression were not different between patients who did and did not develop PTDM. Conclusions: PTDM occurred commonly, and higher baseline BMI was associated with PTDM. PTDM was not associated with graft failure or mortality during the 6-year follow-up, perhaps due to the short follow-up time.