Unexpected Medical Conditions Discovered During Live Donor Kidney Evaluation: Single Center Study.

OBJECTIVES: Living donor kidney transplantation (LDKT) is the preferred method of treatment for patients with end-stage kidney disease. Potential living kidney donors (PLKD) are evaluated through a thorough medical, psychological and surgical work-up to ensure successful transplantation with minimal risks to all parties involved. The transplant center at Rhode Island Hospital has noticed an increasing number of PLKDs excluded from donation due to conditions newly diagnosed during the screening process. Our objective is to understand the local trends underlying the high PLKD exclusion rates in the context of newly diagnosed conditions, age, race, and sex of the excluded donors. STUDY DESIGN AND METHODS: Our study is a retrospective electronic medical record review of the 429 PLKDs screened at Rhode Island Hospital Kidney Transplant Center between December 2012 and April 2023. Age, race, gender, relationship to recipient, and reasons for exclusion were collected from the medical record for each PLKD. CONCLUSION: 115 of the 429 total PLKDs screened were excluded for newly diagnosed conditions, the most common of which were renal issues (49%), diabetes mellitus (33%), and hypertension (13%), with many comorbid diagnoses. While these donors were able to receive proper treatment after their diagnosis, the earliest intervention possible yields the best prognosis. The high prevalence of treatable yet undiagnosed conditions raise many public health concerns, such as primary care gaps or discontinuous healthcare, and increases awareness about the importance of follow-up care for the excluded PLKDs.

An Easily Implemented, Inexpensive, Useful Novel Surgical Intern Wellness Initiative.

OBJECTIVE: Determine whether use of reflective questions asked on a twice monthly basis is a useful addition to our intern wellness curriculum, with a goal of longitudinal development. Prior studies have demonstrated the use of reflection in processing educational experiences toward professional growth at both the medical student and resident level. DESIGN: During the first year, every 2 weeks, the 13 interns were asked and answered 2 reflective prompts by email. Their responses went to a single faculty member and were then blinded for analysis. The second year of the program, prompts were discussed by participants in a closed group setting. Participation was voluntary. The questions fell into 6 major categories: role expectations, role assessment, role affirmation, role reflection, emotional self-assessment, work-life integration, and boundaries. Thematic analysis of the responses was performed using an inductive approach by 2 independent expert reviewers. SETTING: Brown General Surgery Residency Program, academic years 2021 to 2022 and 2022 to 2023. CONCLUSIONS: Use of reflective questions is a valuable tool as part of an intern wellness curriculum and can be easily implemented. It is inexpensive, does not require a huge time commitment, and is easily adaptable to a program's specific needs. It encourages developing surgeons to recognize and share in their emotions as they encounter the new and stressful experiences inherent in residency and may help to prevent burnout. Sustained participation through the year and robust responses suggest good resident engagement and acceptance of the program.

Appendicocecal Loop Urinary Diversion in a Transplant Kidney: Case Report, Literature Review.

Urinary diversion in renal transplant patients can take a variety of forms - bladder augmentation, continent cutaneous pouch, or intestinal conduits, to name a few. Herein, we present a unique case of an appendicocecal urinary diversion in a patient with history of end stage renal disease, pelvic radiation, and complex surgical history who underwent deceased-donor renal transplantation. During the renal transplant, the transplant ureterovesical anastomosis could not be performed due to inherent anatomical hindrances. A temporary modified cutaneous ureterostomy using a single-J stent was therefore used for drainage of the transplant kidney. Given that the cutaneous ureterostomy was not a durable, long-term option, we sought to develop a creative surgical solution. This report presents a unique case of urinary diversion post renal transplant and reviews the literature of renal transplantation in patients with anatomical abnormalities.

Obstructive Uropathy due to Bilateral Sliding Hernia in a Renal Transplant Patient with Incidental RCC in Native Kidney.

BACKGROUND: Ureteral obstruction is a common complication after kidney transplantation. Ureteral obstruction caused by inguinal hernia, however, is a rare complication of transplantation and requires urgent surgical repair to prevent allograft loss.  Case presentation: A 58-year-old man presented with allograft dysfunction 18-years after renal transplant. He was compliant with medications and given the long duration of allograft survival, a primary renal etiology was suspected. Thus, the initial work-up included allograft biopsy that was unremarkable. Three months later, worsening allograft function prompted further evaluation. At this time, allograft ultrasound and computed tomography led to the diagnosis of ureteral obstruction due to uretero-inguinal herniation of left kidney transplant secondary to bilateral sliding inguinal hernias. The patient was also found to have incidental renal cell carcinoma of the left native kidney. A percutaneous nephrostomy tube was placed and then followed by surgical repair with ureteral reimplantation, herniorrhaphy with mesh, and left native nephrectomy. CONCLUSIONS: Mechanical obstruction can occur years after kidney transplantation. Even though it is uncommon, ureteral obstruction due to inguinal herniation is critical. Early detection of this complication and surgery can salvage the allograft and prolong function. ABBREVIATIONS: RCC: renal cell carcinoma; PCN: Percutaneous Nephrostomy; ACKD: Acquired Cystic Kidney Disease.

Elevated Tacrolimus Levels at Time of Diagnosis of COVID-19 Compared to Baseline Among Hospitalized Organ Transplant Recipients.

BACKGROUND: The effect of COVID-19 on immunosuppressant drug levels in organ transplant recipients (OTRs) has not been adequately studied. OBJECTIVE: To study the effect of COVID-19 on tacrolimus trough levels (primary outcome) in OTRs and the association of the later with acute kidney injury, bacterial infection, and oxygen requirements. METHODS: We studied adult (>18-year-old) hospitalized OTRs with COVID-19, who were receiving tacrolimus between 3/1 and 12/16/2020. RESULTS: Among 30 OTRs, 67% were men, 90% had a kidney transplant. Median age was 60.5 (interquartile range [IQR]: 45-68) years, median time from transplant 36 (IQR: 20-84) months. Tacrolimus troughs were higher on admission for COVID-19 than baseline (average over 6 months prior) (P = .001). Eighteen patients (60%) had admission tacrolimus trough >10, 5 (17%) >20 ng/mL. Patients with diarrhea had borderline higher tacrolimus troughs, compared to those without diarrhea (P = .09). Organ transplant recipients with a tacrolimus trough >10 ng/mL were more likely to have elevated aspartate aminotransferase on admission (P = .01) and require supplemental oxygen. (P = .026). CONCLUSION AND RELEVANCE: Tacrolimus trough levels were elevated in most OTRs with COVID-19 at the time of hospital admission, compared to baseline. Potential mechanisms are diarrhea and hepatic involvement in COVID-19. In OTRs with COVID-19, including outpatients, immunosuppressant drug levels should be closely followed; management of immunosuppression should be individualized.

Low-Dose Valganciclovir Prophylaxis Is Safe and Cost-Saving in CMV-Seropositive Kidney Transplant Recipients.

Introduction: Observational studies suggest that low-dose valganciclovir prophylaxis (450 mg daily for normal renal function) is as effective as and perhaps safer than standard-dose valganciclovir (900 mg daily) in preventing CMV infection among kidney transplant recipients. However, this practice is not supported by current guidelines due to concerns for breakthrough infection from resistant CMV, mainly in high-risk CMV donor-seropositive/recipient-seronegative kidney transplant recipients. Standard-dose valganciclovir is costly and possibly associated with higher incidence of neutropenia and BKV DNAemia. Our institution adopted low-dose valganciclovir prophylaxis for intermediate-risk (seropositive) kidney transplant recipients in January 2018. Research Question: To analyze the efficacy (CMV DNAemia), safety (BK virus DNAemia, neutropenia, graft loss, and death), and cost savings associated with this change. Design: We retrospectively compared the above outcomes between CMV-seropositive kidney transplant recipients who received low-dose and standard-dose valganciclovir, transplanted within our institution, between 1/19/2014 and 7/15/2019, using propensity score-adjusted competing risk analyses. We also compared cost estimates between the two dosing regimens, for 3 months of prophylaxis, and for different percentage of patient-weeks with normal renal function, using the current average wholesale price of valganciclovir. Results: We studied 179 CMV-seropositive kidney transplant recipients, of whom 55 received low-dose and 124 standard-dose valganciclovir. The majority received nonlymphocyte depleting induction (basiliximab). Low-dose valganciclovir was at least as effective and safe as, and more cost-saving than standard-dose valganciclovir. Conclusion: This single-center study contributes to mounting evidence for future guidelines to be adjusted in favor of low-dose valganciclovir prophylaxis in CMV-seropositive kidney transplant recipients.

Coronavirus Disease 2019 in Kidney Transplant Recipients: Single-Center Experience and Case-Control Study.

BACKGROUND: Kidney transplant recipients (KTR) are considered high-risk for morbidity and mortality from coronavirus disease 2019 (COVID-19). However, some studies did not show worse outcomes compared to non-transplant patients and there is little data about immunosuppressant drug levels and secondary infections in KTR with COVID-19. Herein, we describe our single-center experience with COVID-19 in KTR. METHODS: We captured KTR diagnosed with COVID-19 between March 1, 2020 and May 18, 2020. After exclusion of KTR on hemodialysis and off immunosuppression, we compared the clinical course of COVID-19 between hospitalized KTR and non-transplant patients, matched by age and sex (controls). RESULTS: Eleven KTR were hospitalized and matched with 44 controls. One KTR and 4 controls died (case fatality rate: 9.1%). There were no significant differences in length of stay or clinical outcomes between KTR and controls. Tacrolimus or sirolimus levels were >10 ng/mL in 6 out of 9 KTR (67%). Bacterial infections were more frequent in KTR (36.3%), compared with controls (6.8%, P = .02). CONCLUSIONS: In our small case series, unlike earlier reports from the pandemic epicenters, the clinical outcomes of KTR with COVID-19 were comparable to those of non-transplant patients. Calcineurin or mammalian target of rapamycin inhibitor (mTOR) levels were high. Bacterial infections were more common in KTR, compared with controls.

Successful recovery from COVID-19 in three kidney transplant recipients who received convalescent plasma therapy.

Novel coronavirus disease 2019 (COVID-19) is a highly infectious, rapidly spreading viral disease that typically presents with greater severity in patients with underlying medical conditions or those who are immunosuppressed. We present a novel case series of three kidney transplant recipients with COVID-19 who recovered after receiving COVID-19 convalescent plasma (CCP) therapy. Physicians should be aware of this potentially useful treatment option. Larger clinical registries and randomized clinical trials should be conducted to further explore the clinical and allograft outcomes associated with CCP use in this population.

Hyperammonemia syndrome due to Ureaplasma urealyticum in a kidney transplant recipient: A case of disseminated disease from a fluoroquinolone-resistant isolate.

Ureaplasma species (spp.) are common colonizers of the urogenital tract but may cause systemic infection in immunocompromised patients. They release significant amounts of ammonia via urea hydrolysis and have been recently implicated in the pathogenesis of hyperammonemia syndrome after organ transplantation. We describe a unique case of hyperammonemia syndrome after kidney transplant caused by U urealyticum infection, and the first, to our knowledge, case of a fluoroquinolone-resistant Ureaplasma strain causing hyperammonemia syndrome. A 17-year-old female developed intermittent fevers, rising creatinine, sterile pyuria and debilitating polyarthritis approximately 1 year after kidney transplant. Serum ammonia level was elevated, and urine PCR was positive for U urealyticum. Near the end of treatment with levofloxacin, she had rebound hyperammonemia, which preceded clinical relapse of polyarthritis and encephalopathy. Blood and urine PCR and synovial fluid culture were positive for U urealyticum. Susceptibility testing showed fluoroquinolone resistance, but she responded well to azithromycin and doxycycline. The frequency of Ureaplasma spp. infection in immunocompromised patients is probably underestimated due to diagnostic challenges. Ammonia levels were helpful biomarkers of response to antimicrobial therapy in our case. Susceptibility testing of clinical isolates should be pursued. In serious Ureaplasma spp. infections, particularly in immunocompromised patients, two empiric antibiotics may be indicated given the potential for antimicrobial resistance.

Online Patient Portal Use and Time to Renal Transplantation in Patients on Hemodialysis.

BACKGROUND: Online portals have been shown to be a valuable tool for patients to improve compliance with medical treatment in numerous studies across medical specialties. Our aim was to study the effects of the use of web-based applications that allow patients to track their appointments, labs, and provider visit notes on achievement of renal transplantation. STUDY DESIGN: This is a retrospective chart review of patients in 2 outpatient dialysis centers associated with a 719-bed tertiary care academic medical center. RESULTS: Nine percent of portal users at 3 years after initiation of hemodialysis were the recipients of kidney transplants vs 9% of nonusers. At 4 years, 23% of users were transplant recipients vs 13% of nonusers. At 5 years, 40% of users were transplant recipients vs 14% of nonusers. There was statistically significant divergence of the curves, with the greatest difference observed at 5 years (p = 0.047). In addition, increased number of logins per month was associated with shortened time to renal transplantation (p = 0.0067). CONCLUSIONS: Online portal use is associated with a higher likelihood of being approved as a transplantation candidate and increased number of logins is associated with shortened time to renal transplantation.

A single-center analysis of early readmission after renal transplantation.

BACKGROUND: Thirty-day readmission rates (early hospital readmission, EHR) are an important benchmark for quality improvement. Nationally, patients undergoing renal transplantation incur a 31% EHR rate. While national databases provide useful data, the impact of EHR on individual centers has received little attention. We proposed that an institutional review of EHR after renal transplantation may provide a benchmark for individual transplant programs and identify modifiable program-specific issues to reduce EHR. METHODS: We reviewed 269 consecutive kidney transplant recipients over a five-year period (2012-2016). Early hospital readmission was modeled using generalized linear modeling assuming a binary distribution. RESULTS: About 21% of patients were readmitted within 30 days. Deceased kidney donation (DD), delayed graft functioning (DGF), anti-thymocyte globulin (ATG) induction, diabetes, public insurance, weekend discharge, and low glomerular filtration rate (eGFR) at discharge were all identified as risk factors for readmission. Early hospital readmission was not correlated with risk of death (5.4% at 44 months: HR 2.2 (95% CI [0.7, 6.6]; P = 0.1473) or graft loss. CONCLUSIONS: EHR after renal transplantation is common. Certain factors may predict an increased risk for EHR. A multi-disciplinary approach to discharge planning may limit some EHR, but most complications and adverse events are unpredictable and require hospital-level of care.

Cholecystectomy-related malpractice litigation: predictive factors of case outcome.

Complications following cholecystectomy may lead to malpractice litigation. Little research exists regarding cholecystectomy-related malpractice, the complications that lead to litigation, and the outcomes of such cases. This study is a retrospective analysis utilizing the legal database Verdictsearch (ALM Media Properties, LLC, New York, NY). Medical malpractice cases between July 2004 and November 2017 were identified using the search term "gallbladder." Case information was recorded, including patient information, medical details, trial outcome, and resulting payments. Of 46 cases examined, 39 went to trial with a favorable plaintiff (patient) verdict in 43% (20/46) and a favorable physician verdict in 41% (19/46) of the cases. Only 7% (3/46) of the cases resulted in a settlement, with 4% (2/26) concluding in mixed verdicts or arbitration. The mean plaintiff victory payment was $723,844 ± $1,119,457, while the mean settlement payment was $1,350,000 ± $563,471. Intraoperative care was the most frequently litigated phase of care (67%, 31/46 cases). Problematic visualization of the surgical field was the most frequent intraoperative allegation (67.7%, 21/46 cases). Cases of problematic visualization often resulted in favorable plaintiff trial victory (66.7% vs. 19% in defendant victory). Only 9.5% of the problematic visualization cases settled. Bile duct injuries accounted for 43.5% of the injuries (plaintiff victory rate 60.0%; mean payment $736,434 ± $1,365,424). In cholecystectomy litigation, allegations of problematic intraoperative visualization are both the most common allegation and the most likely to end in physician loss. Bile duct injuries remain the most frequent patient injury leading to cholecystectomy litigation.

Medical crowdfunding for organ transplantation.

An increasing number of patients and families are utilizing online crowdfunding to support their medical expenses related to organ transplantation. The factors influencing the success of crowdfunding campaigns are poorly understood. Crowdfunding campaigns were abstracted from a popular crowdfunding web site. Campaigns were included if they were actively accepting donations to fund medical expenses related to transplantation of selected organs. The primary outcome measure was total amount raised among successful campaigns receiving at least one donation. Bivariate and multivariate analyses were performed on various campaign characteristics. A total of 850 campaigns were analyzed. Kidney transplant campaigns were most common (40.5%), followed by liver (33.3%), lung (12.2%), heart (11.3%), and multiorgan (2.7%). 69.1% of campaigns received any donation, and among these, the mean amount raised was $3664 (median $1175). The following factors were significantly associated with amount raised: more positive emotional sentiment in the campaign description (+2.6% per AFINN unit, P < .001), longer campaign description length (+2.4% per 100 characters, P = .001), higher goal amount (+0.6% per $1000 of goal amount, P = .004), and third-person description perspective (+131% vs first person, P < .001). Physicians will likely encounter medical crowdfunding with increasing frequency as it continues to grow in popularity among their patients.

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.