Virtual microscopy improves sharing of deceased donor kidneys.

BACKGROUND: Donor kidney biopsies used for offer evaluation may lengthen cold ischemia time. Our organ procurement organization began processing wedge biopsies and having them read using virtual microscopy (VM), as opposed to its prior routine of processing/reading at local hospitals. We hypothesized that VM would decrease time to biopsy results and kidney acceptance. METHODS: All donor kidneys biopsied over 1 year were compared with those biopsied during the previous year (n = 43, 40). RESULTS: Time to biopsy result was shortened using VM (5:04 vs 6:30, P = .04), and especially for those cases with cross-clamp between 5 pm and 5 am (4:49 vs 8:12, P < .01). Time to local acceptance was also significantly improved using VM for both the entire group (7:01 vs 9:52, P < .01) and the overnight subset (7:25 vs 11:10, P < .01). CONCLUSIONS: Use of VM decreased time to biopsy result, with the most prominent effects seen during the overnight hours, resulting in shortened time to local acceptance of organs.

Role of Coronary Angiography in the Assessment of Cardiovascular Risk in Kidney Transplant Candidates.

Cardiovascular disease is the leading cause of death among those with renal insufficiency, those requiring dialysis, and in recipients of kidney transplants reflecting the greatly increased cardiovascular burden that these patients carry. The best method by which to assess cardiovascular risk in such patients is not well established. In the present study, 1,225 patients seeking a kidney transplant, over a 30-month period, underwent cardiovascular evaluation. Two hundred twenty-five patients, who met selected criteria, underwent coronary angiography that revealed significant coronary artery disease (CAD) in 47%. Those found to have significant disease underwent revascularization. Among the patients found to have significant CAD, 74% had undergone a nuclear stress test before angiography and 65% of these stress tests were negative for ischemia. The positive predictive value of a nuclear stress test in this patient population was 0.43 and the negative predictive value was 0.47. During a 30-month period, 28 patients who underwent coronary angiography received an allograft. None of these patients died, experienced a myocardial infarction, or lost their allograft. The annual mortality rate of those who remained on the waiting list was well below the national average. In conclusion, our results indicate that, in renal failure patients, noninvasive testing fails to detect the majority of significant CAD, that selected criteria may identify patients with a high likelihood of CAD, and that revascularization reduces mortality both for those on the waiting list and for those who receive an allograft.

The Kidney Transplant Morbidity Index (KTMI): a simple prognostic tool to help determine outcome risk in kidney transplant candidates.

BACKGROUND: The Kidney Transplant Morbidity Index (KTMI) is a novel prognostic morbidity index to help determine the impact that pretransplant comorbid conditions have on transplant outcome. OBJECTIVE: To use national data to validate the KTMI. DESIGN: Retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SETTING AND PARTICIPANTS: The study sample consisted of 100 261 adult patients who received a kidney transplant between 2000 and 2008. MAIN OUTCOME MEASURE: Kaplan-Meier survival curves were used to demonstrate 3-year graft and patient survival for each KTMI score. Cox proportional hazards regression models were created to determine hazards for 3-year graft failure and patient mortality for each KTMI score. RESULTS: A sequential decrease in graft survival (0 = 91.2%, 1 = 88.2%, 2 = 85.4%, 3 = 81.7%, 4 = 77.8%, 5 = 74.0%, 6 = 69.8%, and ≥ 7 = 68.7) and patient survival (0 = 98.2%, 1 = 96.6%, 2 = 93.7%, 3 = 89.7%, 4 = 84.8%, 5 = 80.8%, 6 = 76.0%, and ≥ 7 = 74.7%) is seen as KTMI scores increase. The differences in graft and patient survival between KTMI scores are all significant (P< .001) except between 6 and ≥ 7. Multivariate regression analysis reveals that KTMI is an independent predictor of higher graft failure and patient mortality rates and that risk increases as KTMI scores increase. CONCLUSION: The KTMI strongly predicts graft and patient survival by using pretransplant comorbid conditions; therefore, this easy-to-use tool can aid in determining outcome risk and transplant candidacy before listing, particularly in candidates with multiple comorbid conditions.

Surgical resident perspective on deceased donor organ procurement.

BACKGROUND: Deceased donor organ procurement provides unparalleled opportunity for surgical residents with extensive surgical exposure. We hypothesize that surgical residents regard organ donation positively and organ procurement enhances their education. METHODS: We conducted an institutional review board approved anonymous national survey to evaluate organ procurement experiences and attitudes of general surgical residents. RESULTS: Three hundred ninety-seven residents representing all postgraduate years responded, with 97% completion rate. Organ procurement increased with training level (92% seniors vs. 53% interns). Over 85% agree organ procurement is a good educational and operative experience, and 73% believe that it will benefit their future surgical career. About 68% agree that organ procurement provided knowledge of anatomy and exposures; under 10% felt organ procurement could be duplicated with simulation. Presence of transplant program did not affect attitudes or experience. Eighty-eight percent women versus77% men plan to donate their own organs. CONCLUSION: Results indicate that surgical residents value organ procurement, and it remains an essential encounter that applies to general surgery.

The impact of morbid obesity on hospital length of stay in kidney transplant recipients.

OBJECTIVES: Obesity is often associated with higher hospital costs because of longer length of stay (LOS) but this has not been well studied in the kidney transplant population. Therefore, we used national data to compare LOS in select groups of morbidly obese and normal weight recipients after kidney transplant. DESIGN: This study was a retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SUBJECTS: The study sample consisted of 42,787 morbidly obese (body mass index 35-40 kg/m(2)) and normal weight (body mass index 18.5-24.9 kg/m(2)) who underwent primary kidney-only transplantation between 2000 and 2008. MAIN OUTCOME MEASURES: Morbidly obese and normal-weight subgroups were crudely evaluated for prolonged LOS (>7 days). Logistic regression modeling compared LOS in morbidly obese and normal-weight subgroups with varying characteristics and determined predictors of prolonged LOS. RESULTS: All morbidly obese subgroups had significantly higher crude rates of prolonged LOS (P < .05). However, no significant differences in prolonged LOS were seen between any of the morbidly obese or normal-weight subgroups in multivariate analysis. Morbid obesity was an independent predictor of prolonged LOS (P < .001) but not a stronger predictor than that of being African American, having coronary artery disease, diabetes mellitus, or peripheral vascular disease, being 50 to 80 years of age, having a previous transplant or poor functional status. Receiving a deceased-donor transplant and being dialysis dependent >4 years were significantly better predictors of prolonged LOS compared with morbid obesity (P < .05). CONCLUSIONS: Some morbidly obese populations have LOS rates that are not significantly different than many commonly transplanted normal weight populations, and the impact morbid obesity has on LOS is not different than many other factors often seen in kidney transplant recipients; therefore, morbid obesity alone should not be a financial consideration in kidney transplant.

Morbid obesity is not an independent predictor of graft failure or patient mortality after kidney transplantation.

OBJECTIVE: Obesity is often an absolute contraindication to kidney transplant, but an internal analysis of our center's recipients suggests that not all obese populations exhibit poor outcomes. We used national data to compare outcomes in select groups of morbidly obese and normal-weight recipients after kidney transplant. DESIGN: This study was a retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SUBJECTS: The study sample consisted of 30,132 morbidly obese (body mass index [BMI] 35-40 kg/m(2)) and normal-weight (BMI 18.5-24.9 kg/m(2)) patients who underwent primary kidney-only transplantation between 2001 and 2006. MAIN OUTCOME MEASURE: Crude 3-year graft and patient survival rates of morbidly obese and normal-weight subgroups were evaluated. Logistic regression modeling compared 3-year graft failure and patient mortality in morbidly obese and normal-weight subgroups with opposite characteristics. Kaplan-Meier survival curves were created for 3-year graft and patient survival. Cox proportional hazard regression modeling was used to determine hazards for patient and graft mortality. RESULTS: No differences in crude graft and patient survival rates were seen between normal weight and morbidly obese recipients who were African American, diabetic, and 50 to 80 years of age. Morbidly obese recipients who were nondialysis dependent, nondiabetic, had good functional status, and received living-donor transplants had significantly lower 3-year graft failure and patient mortality risk compared with normal-weight recipients who were dialysis dependent, diabetic, had poor functional status, and received a deceased-donor transplant, respectively (P < .01). Morbidly obese recipients have significantly lower graft and patient survival curves compared with normal-weight recipients; however, multivariate regression analysis reveals that morbid obesity is not an independent predictor of graft failure or patient mortality. CONCLUSIONS: Morbid obesity is not independently associated with graft failure or patient mortality; therefore, it should not be used as a contraindication to kidney transplantation.

Sirolimus lowers myeloperoxidase and p-ANCA titers in a pediatric patient before kidney transplantation.

We report the case of a child with microscopic polyangiitis (myeloperoxidase-antineutrophil cytoplasmic antibody [p-ANCA]-positive vasculitis) whose disease progressed to end-stage renal failure, in whom sirolimus contributed to normalization of myeloperoxidase and ANCA titers. The disease course, various therapies, and outcome are discussed, as is the rationale for using sirolimus.

Dialysis access failure: an indication for immediate kidney transplantation.

In the United States, presently there are more than 50,000 patients with end-stage renal disease (ESRD) awaiting a cadaveric kidney and each year less than a quarter receive kidney transplantation. Although the real incidence in unknown, a significant number of these patients die due to lack of dialysis access. While various medical necessities are indications for emergent transplantation of other organs, the current kidney allocation system of the United Network for Organ Sharing (UNOS) makes no room for those ESRD patients whose death is imminent due to lack of vascular access. Local organ procurement organizations (OPOs) are allowed to make decisions based on arbitrary policies (or no policies at all) which often falter and fail to deal appropriately with a largely ignored issue. The growing wait for cadaveric kidneys makes the problem of ESRD patients dying due to lack of dialysis access increasingly important and one that must be addressed through a revision of the UNOS kidney allocation system.