Access to the Kidney Transplant Wait List

The study examines selection for kidney transplantation and determines who are referred, how many had contraindications and whether comorbidity indices predict transplant status. Of 113 consecutive adult incident end-stage renal disease (ESRD) patients at this single center 47 (41.6%) were referred. Using published guidelines, 48 (42.5%) had a specific contraindication. However 26 (23%) were neither referred nor had contraindications. An ESRD mortality score, acute renal failure status and albumin were independent predictors of referral but only the mortality score was predictive of contraindication status. The Charlson and ESRD comorbidity indices were less predictive of contraindication or referral status. In a comparison of patients who were Candidates (referred and no contraindication, n = 39) compared to those who were Neither (not referred and no contraindications, n = 26), age was the most discriminating factor (c = 0.99, 95% CI 0.97-1.00). Comorbidity and mortality indices were inferior. Neither patients were older (75 +/- 7 years) and had comorbidity scores that were higher than Candidates but similar to those with contraindications (ESRD index; Neither 3.3 +/- 2.5, Candidate 1.4 +/- 1.8, and contraindication 4.1 +/- 3.4). Comorbitity indices do not help explain selection practices whereas age is an important discriminator. How many Neither patients would benefit from transplantation is not known.     

Individual and Regional Factors of Access to the Renal Transplant Waiting List in France in a Cohort of Dialyzed Patients

Several studies have investigated geographical variations in access to renal transplant waiting lists, but none has assessed the impact on these variations of factors at both the patient and geographic levels. The objective of our study was to identify medical and non‐medical factors at both these levels associated with these geographical variations in waiting‐list placement in France. We included all incident patients aged 18–80 years in 11 French regions who started dialysis between January 1, 2006, and December 31, 2008. Both a multilevel Cox model with shared frailty and a competing risks model were used for the analyses. At the patient level, old age, comorbidities, diabetic nephropathy, non‐autonomous first dialysis, and female gender were the major determinants of a lower probability of being waitlisted. At the regional level, the only factor associated with this probability was an increase in the number of patients on the waiting list from 2005 to 2009. This finding supports a slight but significant impact of a regional organ shortage on waitlisting practices. Our findings demonstrate that patients' age has a major impact on waitlisting practices, even for patients with no comorbidity or disability, whose survival would likely be improved by transplantation compared with dialysis.     

High Cardiovascular Risk Profile in Young Patients on the Kidney Transplant Waiting List

BackgroundCardiovascular complications are the leading causes of morbidity and mortality in patients with end-stage renal disease. The risk profile very often contributes to their death while on the waiting list. Most studies have been carried out in older patients with end-stage renal disease, reflecting the general dialysis population. The aim of this study was to analyze the risk profile in young patients with advanced chronic kidney disease on the kidney transplant waiting list.MethodsThis was a retrospective, single-center study of 748 patients on the kidney transplant waiting list at the University Hospital Essen, Germany. Clinical and laboratory parameters were collected between 2015 and 2016.ResultsOf 748 patients (62% male), the median age was 48 years. Hypertension, coronary heart disease, and diabetes mellitus were the leading comorbidities, and their frequency rose significantly with age. Their median laboratory values did not differ significantly depending on age except for albumin. Hyperuricemia was quite common in our population with a prevalence of about 75% in women and 50% in men throughout all age groups. A total of 26.6% of the patients between 18 and 35 years of age had advanced anemia (hemoglobin < 10 g/dL), and thus they were affected most frequently. Elevated C-reactive protein serum levels were observed in 37.2% of the patients. Regarding the lipid profile, we observed that HDL cholesterol was within the normal range in only among 51.9% of men and 44.3% of women.ConclusionsCardiovascular risk factors are quite common in our cohort and affect young patients similarly.     

Factors Associated with Failure to List HIV-Positive Kidney Transplant Candidates

With improved survival in the antiretroviral era, data from ongoing studies suggest that HIV patients can be safely transplanted. The disproportionate burden of HIV-related end-stage renal disease in minority populations may impose additional obstacles to successful completion of the transplant evaluation. We retrospectively reviewed 309 potentially eligible HIV patients evaluated for kidney transplant at our institution since 2000. Only 20% of HIV patients have been listed, compared to 73% of HIV-negative patients evaluated over the same period (p < 0.00001). Failure to provide documentation of CD4 and viral load (36% of candidates) was the most common reason for failure to progress beyond initial evaluation. Other factors independently associated with failure to complete the evaluation included CD4 < 200 at initial evaluation (OR 15.17; 95% CI 1.94–118.83), black race (OR 2.33; 95% CI 1.07–5.06), and history of drug use (OR 2.56; 95% CI 1.22–5.37). More efficient medical record sharing and an awareness of factors associated with failure to list HIV-positive transplant candidates may enable transplant centers to more effectively advocate for these patients.     

Factors Associated With Waiting Time to Deceased Donor Kidney Transplantation in Transplant Candidates

Although a nationwide activation system has been developed to increase deceased donor kidney transplantation (DDKT), there is still enormous discrepancy between transplant need and deceased donor supply in Korea, and therefore waiting time to DDKT is still long. We need to determine the current status of waiting time and the risk factors for long waiting time. We retrospectively analyzed the medical records of the patients on the wait list for DDKT at the Seoul National University Hospital from 2000 to 2017. Among 2,211 wait-listed patients, 606 (27.5%) received DDKT and mean waiting time to DDKT was 45 months. Among them, blood type A was most prevalent (35.6%) and type AB was the least (14.0%). Panel-reactive assay (PRA) was positive in 59 (11.0%) in the first transplant group and 25 (35.0%) in retransplant group. Waiting time in PRA-positive recipients was 63 and 66 months in the first transplant group and retransplant group, respectively. However, waiting time for patients with negative PRA was 42.8 months. Waiting time was shorter in blood type AB (39 months) than other types (46 months). Waiting time was the shortest in children and adolescents. Among patients who were still on the wait list, retransplantation candidates, especially with PRA higher than 50%, had longer waiting time than first transplant candidates. In conclusion, non-AB blood type, positive PRA, and adult age were significantly associated with long waiting time. Therefore, it is necessary to establish a management strategy such as tailored desensitization for highly sensitized patients on the wait list to reduce their waiting time.     

Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight

Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low‐performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007–2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow‐up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow‐up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow‐up years, p < 0.001), a decrease in transplant rates (?11.9/1000 follow‐up years, p < 0.001) and a decrease in mortality after removal (?67.5 deaths/1000 follow‐up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes.

     

Outcome of Hepatitis C Virus-Infected Kidney Transplant Candidates Who Remain on the Waiting List

The management of patients awaiting transplantation is a growing concern. This retrospective cohort study examined outcomes of hepatitis C virus (HCV)-infected kidney candidates who remain waitlisted. Records from 315 HCV+ kidney candidates evaluated between 1992 and 2002, were reviewed. A total of 300 (95.1%) patients were receiving renal replacement therapy at evaluation, median duration 48.2 + 4.3 months. The diabetes prevalence was 42.9% in HCV+ candidates, compared to 35.9% among 602 currently listed HCV- patients (p = 0.023). Liver disease, defined by abnormal hepatic biochemistry or histology, was observed in 59% patients. Median post-evaluation follow-up was 1440 +/- 75 days; 138 candidates were transplanted. Kaplan-Meier survival was higher among transplanted than non-transplanted patients (p = 0.003). Of 177 patients not transplanted, 76 were delisted, mostly due to death (45%) and non-compliance (28%), infrequently because of liver disease (8.8%). A Cox regression model was fit to examine risk factors for waitlist death; only diabetes was associated (HR: 2.17, 95% CI: 1.1-4.1, p = 0.02), while liver disease was not. This study demonstrates that, in waitlisted HCV+ kidney patients, diabetes occurs with increased prevalence and is a major mortality determinant. Diabetic HCV+ kidney candidates are therefore a patient subgroup that requires frequent and careful reevaluation to ensure ongoing transplantability.     

Influence of Test Technique on Sensitization Status of Patients on the Kidney Transplant Waiting List

The exquisitely sensitive single antigen bead (SAB) technique was shown to detect human leukocyte antigen (HLA) antibodies in sera of healthy male blood donors. Such false reactions can have an impact on critical decisions, especially with respect to the determination of unacceptable HLA‐antigen mismatches in patients awaiting a kidney transplant. We tested pretransplant sera of 534 patients on the kidney waiting list using complement‐dependent cytotoxicity (CDC), enzyme‐linked immunosorbent assay (ELISA) and SAB in parallel. Evidence of HLA antibodies was obtained in 5% of patients using CDC, 14% using ELISA, and 81% using SAB. Among patients without history of an immunizing event, 77% showed evidence of HLA antibodies in SAB. In contrast 98% of these patients were negative in ELISA and CDC. In patients without an immunizing event, SAB‐detected antibodies reacted not always weakly but with mean fluorescence intensity (MFI) values as high as 14 440. High‐MFI‐value antibodies were found in some of these patients with HLA specificities that are rather common in general population, consideration of which would lead to unjustified exclusion of potential kidney donors. False SAB reactions can be unveiled by testing with additional antibody assays. Denial of donor kidneys to recipients based on HLA‐antibody specificities detected exclusively in the SAB assay is not advisable.     

Reasons for Noninclusion on the Kidney Transplant Waiting List: Analysis in a Set of Hemodialysis Centers

Introduction

End-stage renal disease patients' access to the renal transplant (RT) waiting list (WL) depends on general criteria and their specific application in the different treatment units.

Exclusions and Deaths on the Liver Transplant Waiting List

Objective

To analyze the characteristiscs, evolution and survival of patients included on the waiting list (WL) for liver transplantation (OLT).

Patients and Methods

Between February 2002 and April 2009, 254 patients were included on WL to receive a first graft. Two hundred twenty-two patients (87.4%) were transplanted (group T); 7 (2.8%) died on the WL and 25 (9.8%) were excluded, namely, 13 (52%) due to improvement (group IE) and 12, for other reasons (group OE). Data collected prospectively were analyzed retrospectively.

Results

Indications for transplant were cirrhosis (58%), hepatocellular carcinoma (HCC; 29%) and other etiologies (13%.) Average time on the WL was 60.3 ± 62.9 days. Significant differences were not observed among the groups with respect to age, gender, or indication for OLT. The probability for exclusion due to progression and/or death was not significantly greater among patients included for HCC than for other reasons (P = .6). Survivals at 1, 3, and 5 years after WL inclusion were 81.2%, 73.3%, and 68.6%, respectively, in the whole series; and 85,4%, 76,9%, and 71.7% in group T. All group OE patients died before the first year, while group IE showed a survival of 100%, 91.7% and 91.7% at 1, 3, and 5 years, respectively. Survival was not different between groups T and IE (P = .03), but was lower in group OE than in groups T or IE (P < .001).

Conclusion

The list mortality rate in our series was low, probably in relation to the short waiting time. The rate of exclusion from WL was 10%. Patient with hepatocellular carcinoma were not at an increased risk of WL exclusion. Patients excluded due to improvement displayed excellent survivals during the 5 years following exclusion.     

Analysis of the Liver Transplant Waiting List in Our Center

BackgroundLiver transplantation (LT) is an important treatment for acute liver failure and end-stage liver disease. Due to the limited supply of livers, there are still thousands of candidates waiting for transplantation in Turkey. We aimed to analyze LT waiting list access by demographics and etiology, particularly the diagnosis of hepatocellular carcinoma (HCC), which has been prioritized for LT in recent years.Materials and MethodsBetween 2011 and 2018, all patients listed for LT in our center were retrospectively reviewed. Demographic features, etiology of liver disease, waiting time, Model for End-Stage Liver Disease (MELD) score, and survival data were recorded. Differences between the LT group and deceased patients on the waiting list were evaluated.ResultsDuring this period, 266 patients were included in the LT waiting list. Only 119 patients (44.7%) underwent LT (men, 94; women, 25; mean age, 53 years), whereas 103 (38%) died (men, 60; women, 43; mean age, 53 years) in the waiting period. Seventeen patients were status 1A or 1B and of these, 7 patients died from fulminant hepatic failure. MELD score was significantly higher in deceased group (28 ± 7 vs 25 ± 6; P = .014). The frequency of HCC was significantly higher in LT group (29% vs 11%; P = .002). Overall survival of the patients in the waiting list with and without liver transplantation were 63% and 41%, respectively.ConclusionsHCC is one of the leading etiologies that is considered for cadaveric LT from the waiting list in our center. These patients had slightly lower MELD scores compared to deceased patients with shorter waiting times. We recommend early referral and close monitoring of the patients who are LT candidates.     

Preventable Death: Children on the Transplant Waiting List

Children, especially those under 5 years of age, have the highest death rate on the transplant waiting list compared to any other age range. This article discusses the concept, supported by OPTN data, that there is an age range of small pediatric donors, which are almost exclusively transplanted into small pediatric transplant candidates. Allocation policies that allow broader sharing of small pediatric donors into small pediatric candidates are likely to decrease death rates of children on the waiting list. As well, although the number of pediatric deceased donors continues to decline, improving consent rates for eligible pediatric donors, and judicious use of pediatric donors after cardiac death, can enhance the pediatric deceased donor supply.     

Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities

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Factors Related to Osteosarcopenia in Kidney Transplant Recipients

Introduction

Sarcopenia and osteopenia are highly prevalent in older patients, and are associated with a high risk for falls, fractures, and further functional decline. However, related factors in kidney transplant recipients suffering from osteosarcopenia, the combination of sarcopenia and osteopenia, remain unknown.

Significance of PPD Test for the Relationship Between BCG Vaccine and COVID-19 in Patients on Kidney Transplant Waiting List

BackgroundThe aim of this study was to determine the relationship between purified protein derivative of tuberculin (PPD) values, an indicator of BCG protection, and COVID-19 disease in patients with end-stage renal disease (ESRD) on the kidney transplant waiting list.MethodsAge, sex, dialysis type, ERSD etiologies, and PPD values of patients on the renal transplant waiting list were recorded. SARS-CoV-2 PCR data, whether the patients were previously infected with the virus, and, if infected, the severity of the disease were noted. Data were statistically compared.ResultsPCR of 87 (47.02%) of 185 patients were studied; 107 of the patients were male and 78 were female, with a mean age of 52.8 years. The test result was positive for 28 patients. Of the patients for whom PCR was studied, 41 had a negative PPD result, while 46 had a positive PPD result. There was no correlation with SARS-CoV-2 PCR positivity in patients with a PPD ≤ 5 mm and > 5 mm. However, patients with pneumonic infiltration who required hospitalization had a significantly higher PPD value.ConclusionsThe PPD measurement, which is an indicator of BCG protection, might be a significant parameter for predicting the course of the disease in SARS-CoV-2 pneumonia.     

Use of High-Dose Human Immune Globulin in Highly Sensitized Patients on the Kidney Transplant Waiting List: One Center's Experience

Introduction

Transplant rates are low among highly sensitized patients with preformed anti-HLA antibodies, because of the additional immunologic barrier, the increased risk of rejection, and the greater chance of early graft loss. Intravenous infusion of pooled human immune globulin (IVIG) is immunomodulatory, neutralizing circulating antibodies and reducing rejection rates, two factors that may improve long-term transplantation outcomes.

Methods

We selected for high-dose IVIG treatment (1 g/kg monthly for 4 months) 10 adult, stage V, highly HLA-sensitized (PRA, historical >80% and current 56%-100%) chronic kidney disease patients listed for kidney transplantation with a mean waiting time of 7.5 years. They spanned age of 29-52 years. Anti-HLA titers were monitored monthly before each treatment and 1 month after the last IVIG dose; afterwards, patients were placed on an urgent list and followed for their transplant renal function and rejection episodes.

Results

Although 1 subject was transplanted after the first dose of IVIG, 9 patients completed the study, but their PRA decreased only insubstantially, namely, 14.4% (range, 8%-28%). During 6-12 months follow-up, 6 patients were considered for transplantation (negative crossmatch); 5 received kidneys and 1 was disqualified due to infection. The recipients were treated with antithymocyte globulin (n = 3) or basiliximab (n = 2) as well as tacrolimus/mycophenolate/steroids for baseline immunosuppression. Protocol biopsies (months 1, 3, and 6) in 4 patients (1 denied consent) revealed subclinical acute rejection and C4d positivity in most cases, either repeatedly or in the final biopsy. However at 6-12 months the mean serum creatinine concentration averaged 1.5 ± 0.4 mg/dL.

Conclusion

High-dose human IVIG reduced PRA poorly, but short-term transplantation outcomes were encouraging. Surveillance biopsies are advised for sensitized kidney recipients due to the frequent appearance of rejection, particularly of the antibody mediated type.     

Local Variation in Inclusion on Kidney Transplant Waiting Lists: Analysis in the Reference Area of a Kidney Transplant Center

Background

Access for end-stage renal disease (ESRD) patients to the renal transplant (RT) waiting list can vary depending on the criteria used and how they are applied in each dialysis unit.