Single institution series have demonstrated that obese patients have higher rates of wound infection and delayed graft function (DGF), but similar rates of graft survival. We used UNOS data to ...determine whether obesity affects outcome following renal transplantation.
From the UNOS database, we identified patients who underwent primary kidney‐only transplantation between 1997 and 1999. Recipient and donor body mass index (BMI) was categorized as underweight (BMI < 18.5), normal (BMI 18.5–24.9), overweight (BMI 25–29.9), obese (BMI 30–34.9) or morbidly obese (BMI ≥ 35). We correlated BMI with intermediate measures of graft outcome and overall graft survival, and created multivariate models to evaluate the independent effect of BMI on graft outcome, adjusting for factors known to affect graft success.
The study sample comprised 27 377 recipients. Older age, female sex, African American race and increased comorbidity were associated with obesity (p < 0.001). Compared with normal weight patients, morbid obesity was independently associated with an increased risk of DGF (p < 0.001), prolonged hospitalization (p < 0.001), acute rejection (p = 0.006) and decreased overall graft survival (p = 0.001). Donor BMI did not affect overall graft survival (p ≥ 0.07).
Recipient obesity is associated with an increased risk of DGF and decreased graft survival following renal transplantation.
A body mass index (BMI) below morbid obesity range is often a requirement for kidney transplant wait‐listing, but data linking BMI changes to mortality during the waitlist period are lacking. By ...linking the 6‐year (7/2001–6/2007) national databases of a large dialysis organization and the Scientific Registry of Transplant Recipients, we identified 14 632 waitlisted hemodialysis patients without kidney transplantation. Time‐dependent survival models examined the mortality predictability of 13‐week‐averaged BMI, pretransplant serum creatinine as a muscle mass surrogate and their changes over time. The patients were on average 52 ± 13 years old, 40% women and had a BMI of 26.9 ± 6.3 kg/m2. Each kg/m2 increase of BMI was associated with a death hazard ratio (HR) of 0.96 (95%CI: 0.95–0.97). Compared to the lowest creatinine quintile, the 4th and 5th quintiles had death HRs of 0.75 (0.66–0.86) and 0.57 (0.49–0.66), respectively. Compared to minimal (< ± 1 kg) weight change over 6 months, those with 3 kg–<5 kg and ≥5 kg weight loss had death HRs of 1.31 (1.14–1.52) and 1.51 (1.30–1.75), respectively. Similar associations were observed with creatinine changes over time. Transplant‐waitlisted hemodialysis patients with lower BMI or muscle mass and/or unintentional weight or muscle loss have higher mortality in this observational study. Impact of intentional weight change remains unclear.
The authors examined the association of changes in pretransplant BMI or muscle mass with mortality in 14,632 hemodialysis patients over 6 years of kidney transplant waitlisting period (2001–2007) and found that lower BMI or muscle mass and/or unintentional weight or muscle loss were associated with higher mortality. See editorial by Segev et al on page 652.
Live donor kidney transplantation is the best treatment option for most patients with late‐stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. ...A consensus conference was held June 5–6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation.
This article summarizes the proceedings of the June 2014 Consensus Conference on Best Practices in Live Kidney Donation, which include recommendations for educating transplant candidates and potential living donors, improving efficiencies in the living donor evaluation process, reducing disparities in living kidney donation, and steering future research and policy priorities to remove barriers to donation.
The use of living donors for kidney transplantation in the United States is common, and long‐term studies have demonstrated the safety of donation by young, healthy individuals. However, transplant ...programs have little data to guide them in deciding which donors are unacceptable, and which characteristics are associated with kidney disease or poor psychosocial outcomes after donation. To document current practices in evaluating potential donors, we surveyed all US kidney transplant programs. Compared to a survey 12 years ago, medical criteria for donation are more inclusive in several areas. All responding programs now accept living unrelated donors. Most programs no longer have an upper age limit to be eligible. Programs are now more likely to accept donors with treated hypertension, or a history of kidney stones, provided that certain additional criteria are met. In contrast, medical criteria for donation are more restrictive in other areas, such as younger donor age and low creatinine clearance. Overall, significant variability remains among transplant programs in the criteria used to evaluate donors. These findings highlight the need for more data on long‐term outcomes in various types of donors with potential morbidities related to donation.
This survey of US transplant centers documents current practices in the medical evaluation of living kidney donors, and highlights areas of significant variability between programs. Also see editorial by Davis in this issue on page 2219.
Although previous consensus recommendations have helped define patients who would benefit from simultaneous liver–kidney transplantation (SLK), there is a current need to reassess published ...guidelines for SLK because of continuing increase in proportion of liver transplant candidates with renal dysfunction and ongoing donor organ shortage. The purpose of this consensus meeting was to critically evaluate published and registry data regarding patient and renal outcomes following liver transplantation alone or SLK in liver transplant recipients with renal dysfunction. Modifications to the current guidelines for SLK and a research agenda were proposed.
The authors report the findings of a summit meeting on simultaneous liver–kidney transplantation, present modifications to the current guidelines and propose directions for future research. See editorial by Feng and Trotter on page 2869.
Despite universal payer coverage with Medicare, sociodemographic disparities confound the care of patients with renal failure. We sought to determine whether adults who realize access to kidney ...transplantation suffer inequities in the utilization of live donor renal transplantation (LDRT). We identified adults undergoing primary renal transplantation in 2004–2006 from the United Network for Organ Sharing (UNOS). We modeled receipt of live versus deceased donor renal transplant on multilevel multivariate models that examined recipient, center and UNOS region‐specific covariates. Among 41 090 adult recipients identified, 39% underwent LDRT. On multivariate analysis, older recipients (OR 0.62, 95% CI 0.56–0.68 for 50–59 year‐olds vs. 18–39 year‐old recipients), those of African American ethnicity (OR 0.54, 95% CI 0.50–0.59 vs. whites) and of lower socioeconomic status (OR 0.72, 95% CI 0.67–0.79 for high school‐educated vs. college‐educated recipients; OR 0.78, 95% CI 0.71–0.87 for lowest vs. highest income quartile) had lower odds of LDRT. These characteristics accounted for 14.2% of the variation in LDRT, more than recipient clinical variables, transplant center characteristics and UNOS region level variation. We identified significant racial and socioeconomic disparities in the utilization of LDRT. Educational initiatives and dissemination of processes that enable increased utilization of LDRT may address these disparities.
Analysis of US transplant data revealed pronounced disparities in receipt of live donor renal transplantation by race/ethnicity and socioeconomic status, with lower rates in patients who were older, African‐American, or of lower socioeconomic status.
A policy proposal relating to transplantation of deceased donor organs into nonresidents of the United States was jointly sponsored by the Organ Procurement and Transplantation Network (OPTN)/United ...Network for Organ Sharing (UNOS) International Relations and Ethics Committees and approved by the OPTN/UNOS Board in June 2012. The proposal followed prior acceptance by the Board of the definitions of “travel for transplantation” and “transplant tourism” and the introduction in March 2012 of revised data collection categories for transplant candidates who are neither citizens nor residents. The most important aspect of the new policy concerns replacement of the previous so‐called “5% rule” with the review of all residency and citizenship data and the preparation of a public annual report. The new policy does not prohibit organ transplantation in nonresidents. However, the policy and public data report will ensure transparency and support transplant center responsibility to account for their practices. Since the adoption of the policy, the first 19 months of data show that less than 1% of new deceased donor waitlist additions and less than 1% of transplantation recipients were non‐US citizen/nonresidents candidates who traveled to the United States for purposes of transplantation. By adopting this policy, the US transplant community promotes public trust and serves as an example to the international transplant community.
This viewpoint supports increased transparency of national practices by reviewing the first 22 months of data collected regarding noncitizens and nonresidents who traveled to the United States for purposes of transplantation.
The supply of organs—particularly kidneys—donated by living and deceased donors falls short of the number of patients added annually to transplant waiting lists in the United States. To remedy this ...problem, a number of prominent physicians, ethicists, economists and others have mounted a campaign to suspend the prohibitions in the National Organ Transplant Act of 1984 (NOTA) on the buying and selling of organs. The argument that providing financial benefits would incentivize enough people to part with a kidney (or a portion of a liver) to clear the waiting lists is flawed. This commentary marshals arguments against the claim that the shortage of donor organs would best be overcome by providing financial incentives for donation. We can increase the number of organs available for transplantation by removing all financial disincentives that deter unpaid living or deceased kidney donation. These disincentives include a range of burdens, such as the costs of travel and lodging for medical evaluation and surgery, lost wages, and the expense of dependent care during the period of organ removal and recuperation. Organ donation should remain an act that is financially neutral for donors, neither imposing financial burdens nor enriching them monetarily.
In order to increase organ donation while preserving its core ethical values, organ donation should remain an act that is financially neutral for donors, neither imposing financial burdens nor enriching them monetarily. Also see viewpoint by Fisher et al (page 1180) and meeting report by Salomon et al (page 1173).
We conducted a survey of 132 US kidney transplant programs to examine how they evaluate and select potential living kidney donors, focusing on donor‐recipient relationships, psychosocial criteria, ...and consent processes. There is heterogeneity in donor‐recipient relationships that are considered acceptable, although most programs (70%) will not consider publicly solicited donors. Most programs (75%) require a psychosocial evaluation for all potential living donors. Most programs agree that knowledge of financial reward (90%), active substance abuse (86%), and active mental health problems (76%) are absolute contraindications to donation. However, there is greater variability in how other psychosocial issues are considered in the selection process. Consent processes are highly variable across programs: donor and recipient consent for the donor evaluation is presumed in 57% and 76% of programs, respectively. The use of 13 different informed consent elements varied from 65% (alternative donation procedures) to 86% (description of evaluation, surgery and recuperative period) of programs. Forty‐three percent use a ‘cooling off’ period. Findings demonstrate high variability in current practice regarding acceptable donor‐recipient relationships, psychosocial criteria, and consent processes. Whether greater consensus should be reached on these donor evaluation practices, especially in the context of more expansive use of living donor kidney transplantation, is discussed.
This survey of living donor evaluation and selection processes at 132 U.S. kidney transplant programs found considerable variability in current practices regarding acceptable donor‐recipient relationships, psychosocial criteria, and consent processes. Also see editorial by Davis in this issue on page 2219.
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