Cardiovascular Disease Assessment Prior to Kidney Transplantation.

Cardiovascular disease is highly prevalent and the leading cause of mortality in patients with chronic kidney disease, end-stage kidney disease, and kidney transplantation. However, kidney transplantation offers improved survival and quality of life, with an overall reduction in cardiovascular disease events; therefore, it remains the optimal treatment choice for those with advanced kidney disease. Pretransplantation cardiovascular assessment is performed prior to wait-listing and at routine intervals with the principal goal of screening for asymptomatic cardiac disease, intervening when necessary to improve long-term patient and allograft survival. Current clinical practice guidelines are based on expert opinion, with a lack of high-quality evidence to guide standardized screening practices. Recent studies support de-escalation in screening with avoidance of preemptive revascularization in asymptomatic patients, but they fail to provide clear guidance on how best to assess the cardiovascular fitness of this high-risk group. Herein we summarize current practice guidelines, discuss key study findings, highlight the role of optimal medical therapy, and evaluate future directions for cardiovascular disease assessment in this population.

Outcomes of kidney donors with sickle cell trait: A preliminary analysis.

Most transplant centers do not screen kidney donor candidates for sickle cell trait (SCT) and many decline candidates with SCT since it may associate with kidney disease. We compared 17 kidney donors with SCT to propensity score matched donor controls on mortality, reduced eGFR, proteinuria and kidney failure. The prevalence of SCT in African American (AA) donors was 11 per 1000 compared to 73 per 1000 in non-donor AA. Donors with SCT were younger; 33 versus 35 years in controls, nine were AA, six were White, and two were listed as other or unknown ethnicities. After a follow-up period of 18.2 ± 10.5 years, the proportions of donors with SCT and controls who were alive, developed hypertension or cardiovascular disease were similar. No donor with SCT developed an eGFR <30 mL/min/1.73 m2 or kidney failure. SCT was, however, associated with increased risk of proteinuria; RR 5.71 (95% CI 5.7 - 22.7), P = .01. This small and preliminary case series suggest that donors with SCT should perhaps be considered more often provided they were aware of the lack of evidence to support liberal acceptance and that these outcomes reported here likely represent a healthy cohort of donors with SCT.

Seroprevalence of Strongyloides stercoralis and Evaluation of Universal Screening in Kidney Transplant Candidates: A Single-Center Experience in Houston (2012-2017).

BACKGROUND: Disseminated strongyloidiasis in solid organ transplant recipients is a rare but devastating infection. In our center, we implemented a universal screening of all candidates for kidney transplantation. We assessed the seroprevalence and utility of universal screening for strongyloidiasis in our center. METHODS: Patients were identified from our transplant referral list (from July 2012 to June 2017). Demographics, pretransplant laboratory, and serological screenings were retrospectively collected. For Strongyloides-seropositive (SSp) patients, data on travel history, symptoms, treatment, and stool ova and parasite examinations were extracted. Logistic regression and multiple imputation for missing data were performed. RESULTS: A total of 1689 patients underwent serological screening, of whom 168 (9.9%) were SSp. Univariate analysis revealed that SSp patients had higher rates of eosinophilia, diabetes mellitus, latent tuberculosis and were likely to be either Hispanic or Asian (P < .05). In multivariate analysis, eosinophilia (P = .01), diabetes mellitus (P = .02), and Asian race (P = .03) were associated with being SSp, but 45 (27%) of the SSp patients did not have any of these 3 factors, and 18 SSp patients (11%) had no epidemiological risk factors. All patients received ivermectin, and none developed disseminated strongyloidiasis. Of patients who underwent serological screening on multiple occasions, 6.8% seroconverted while waiting for kidney transplantation. CONCLUSIONS: We found a high rate of Strongyloides seropositivity among our kidney transplantation candidates. No epidemiological risk factors effectively predicted SSp status in our population, and universal screening identified a large number of patients without such factors. Serial screening should be considered when a long wait time is expected before transplantation.

Positive Impact of a Pilot Pharmacist-Run Diabetes Pharmacotherapy Clinic in Solid-Organ Transplant Recipients.

PURPOSE: Post-transplant diabetes mellitus (PTDM) can lead to significant morbidity and cardiovascular death with a functioning graft. A paucity of literature exists regarding glycemic control in solid-organ transplant (SOT) recipients, including pharmacist management of PTDM. This study aimed to assess the impact of pharmacist interventions on diabetes management in a pharmacist-run PTDM clinic. METHODS: This was a single-center, prospective, observational study of 24 adult SOT recipients enrolled in a pilot pharmacist-managed PTDM clinic from 1 January to 30 June 2015. RESULTS: Improvements were realized in markers of glycemic control, including changes in A1C, average daily self-monitoring of blood glucose (SMBG) results, fasting SMBG results, and pre-lunch SMBG results from enrollment through at least 3 months of follow-up. Median A1C decreased significantly from 8.05% (interquartile range [IQR] 6.33-11.75) at baseline to 6.45% (IQR 6.05-7.3) at the last follow-up encounter (P = 0.0010). Average daily SMBG results decreased significantly from a median of 191 mg/dL (IQR 138-232 mg/dL) at baseline to 125 mg/dL (IQR 111-167 mg/dL) at the final encounter (P = 0.0023). Median fasting and pre-lunch SMBG results decreased significantly from 153 mg/dL (IQR 117-208 mg/dL) at baseline to 120 mg/dL (IQR 102-134 mg/dL) (P = 0.0064) and from 212 mg/dL (IQR 159-258 mg/dL) to 122 mg/dL (IQR 110-169 mg/dL) (P = 0.0161), respectively. Changes from baseline in other SMBG values, lipid levels, and BMI were not statistically significant. CONCLUSION: The results of our study demonstrate that a pharmacist-managed PTDM clinic can significantly affect glycemic control in SOT recipients.

The New Kidney Donor Allocation System and Implications for Anesthesiologists.

Given potential disparity and limited allocation of deceased donor kidneys for transplantation, a new federal kidney allocation system was implemented in 2014. Donor organ function and estimated recipient survival in this system has implications for perioperative management of kidney transplant recipients. Early analysis suggests that many of the anticipated goals are being attained. For anesthesiologists, implications of increased dialysis duration and burdens of end-stage renal disease include increased cardiopulmonary disease, challenging fluid, hemodynamic management, and central vein access. With no recent evidence to guide anesthesia care within this new system, we describe the kidney allocation system, summarize initial data, and briefly review organ systems of interest to anesthesiologists. As additional invasive and echocardiographic monitoring may be indicated, one consideration may be development of a dedicated anesthesiology team experienced in management and monitoring of complex patients, in a similar manner as has been done for liver transplant recipients.