Long-standing diabetes mellitus and pancreas transplantation: An avenue to increase utilization of an ideal treatment modality.

BACKGROUND: Diabetes mellitus (DM) is associated with increased post-operative complications in various surgeries. Little data exist regarding the impact of long-standing DM (>25 years) on outcomes in pancreas transplantation (PTX). The objectives of our study were to determine if long-standing pre-transplant DM (>25 years) was associated with inferior outcomes following PTX. METHODS: Using a 13-year (April, 2000-May, 2012) retrospective analysis, we examined demographic and transplant factors, complications, and outcomes in patients without (Group A) and with (Group B) long-standing (>25 years) pre-PTX DM. RESULTS: Mean follow-up was 4.2 years. Of 214 consecutive PTX performed, 137 (105 simultaneous PTX (SPK), 25 PTX after kidney (PAK), 7 PTX alone (PTA)) had pre-PTX duration of DM recorded, including 65 in Group A and 72 in Group B. There were no differences between cohorts with respect to demographics. There were no differences in post-PTX surgical/medical complications. There were no differences in outcomes between cohorts (ie, rejection, graft loss or death). CONCLUSIONS: This large-scale analysis demonstrated that PTX can be performed in patients with long-standing DM with excellent patient and graft outcomes. Long-standing DM did not lead to an increased post-PTX infections or complications. Our study suggests that duration of DM should not impact PTX candidacy.

Valganciclovir (VGCV) followed by cytomegalovirus (CMV) hyperimmune globulin compared to VGCV for 200 days in abdominal organ transplant recipients at high risk for CMV infection: A prospective, randomized pilot study.

BACKGROUND: With the advent of effective antivirals against cytomegalovirus (CMV), use of CMV hyperimmune globulin (HIG) has decreased. Although antiviral prophylaxis in patients at high risk for CMV is effective, many patients still have late infection, never developing antibodies sufficient to achieve immunity. Utilizing a combination of antiviral and CMV HIG may allow patients to achieve immunity and decrease late CMV infections. METHODS: This was a prospective randomized, open-label, pilot study comparing valganciclovir (VGCV) prophylaxis for 200 days vs VGCV for 100 days followed by CMV HIG in abdominal transplant recipients at high risk for CMV. The primary outcome was a comparison of late CMV disease. RESULTS: Forty patients were randomized to VGCV for 200 days (n = 20) or VGCV for 100 days followed by 3 doses of monthly CMV HIG (n = 20). Numerically, more overall CMV infections occurred in the CMV HIG group (45 vs 20%, P = .09). No differences in overall CMV infections or late CMV disease were seen between groups (20% vs 15%, P = 1.00 and 0 vs 0, P = 1.00). All CMV disease occurred within 200 days, with 63% occurring while patients were on VGCV. No differences were found in toxicities, graft function, or rejection between groups. Patients with CMV infection at any time had a higher body weight than those who did not have an infection (82 vs 95 kg, P = .049). CONCLUSION: Use of CMV HIG sequentially with prophylaxis may be an effective and affordable prophylactic regimen in abdominal transplant recipients at high risk for CMV, and warrants larger prospective study. Increased monitoring for patients with obesity may be warranted.

Cytolytic Induction Therapy Improves Clinical Outcomes in African-American Kidney Transplant Recipients.

OBJECTIVE: Determine the impact of cytolytic versus IL-2 receptor antibody (IL-2RA) induction on acute rejection, graft loss and death in African-American (AA) kidney transplant (KTX) recipients. BACKGROUND: AAs are underrepresented in clinical trials in transplantation; thus, there is controversy regarding the optimal choice of perioperative antibody induction in KTX to improve outcomes. METHODS: National cohort study using US transplant registry data from January 1, 2000 to December 31, 2009 in adult solitary AA KTX recipients, with at least 5 years of follow-up. Multivariable logistic and Cox regression were utilized to assess the outcomes of acute rejection, graft loss, and mortality, with interaction terms to assess effect modification. RESULTS: Twenty-five thousand eighty-four adult AAs receiving solitary KTX were included, 16,927 (67.5%) received cytolytic induction and 8157 (32.5%) received IL-2RA induction. After adjustment for recipient sociodemographics, donor, and transplant characteristics, the use of cytolytic induction therapy reduced the risk of acute rejection by 32% (OR 0.68, 0.62-0.75), graft loss by 9% (HR 0.91, 0.86-0.97), and death by 12% (HR 0.88, 0.83-0.94). There were a number of significant effect modifiers, including public insurance, panel reactive antibody, delayed graft function, and steroid withdrawal; in these groups, cytolytic induction substantially improved clinical outcomes. CONCLUSIONS: These data demonstrate that cytolytic induction therapy, as compared with IL-2RA, reduces the risk of rejection, graft loss, and death in adult AA KTX recipients, particularly in those who are sensitized, receive public insurance, develop delayed graft function, or undergo steroid withdrawal.

Impact of the New Kidney Allocation System on Perioperative Outcomes and Costs in Kidney Transplantation.

BACKGROUND: In December 2014, a new kidney allocation system (KAS) was implemented nationwide with the goal of improving longevity matching, increasing access to sensitized patients, and improving racial/ethnic disparities. STUDY DESIGN: National cohort study of US kidney transplantation programs, analyzing hospital-level outcomes (October 2012 to June 2016) using University HealthSystem Consortium data. In-hospital outcomes and costs were analyzed for trends over time using interrupted time series analysis with segmented regression. RESULTS: There were 38,016 kidney transplantation procedures analyzed during the 3.8-year period. Over time, there was a mean increase of 2.7 cases/month (95% CI -0.02 to 5.4; p = 0.059), unaffected by KAS (18.9 case increase; p = 0.5601). Implementation of KAS led to significant changes in patient demographics, including a decrease in age (-2.8 years; p < 0.001), increase in number of African Americans (3.8%; p < 0.001), decrease in number of Caucasians (6.0%; p < 0.001), increase in number of Hispanics (2.9%; p < 0.001), increase in congestive heart failure (1.3%; p < 0.001), and decrease in diabetes with complications (4.0%; p < 0.001). The KAS had no impact on length of stay (0.12 days; 95% CI -0.11 to 0.35), length of stay index (0.01; 95% CI -0.03 to 0.05), ICU cases, ICU length of stay, patient safety indicators, or in-hospital mortality. The KAS led to a significant increase in delayed graft function rates (5.4%; 95% CI 23.3% to 7.4%); total in-hospital costs ($2,429; 95% CI $594 to $4.263); and 7-day (2.2%), 14-day (2.6%), and 30-day (2.7%) readmission rates. CONCLUSIONS: Policy changes in organ allocation can have a significant impact on perioperative costs and outcomes, which can have a downstream influence on transplantation center perisurgical care processes.

Transplanting Sensitized Kidney Transplant Patients With Equivalent Outcomes Utilizing Stringent HLA Crossmatching.

OBJECIVES: Elevated panel reactive antibody levels have been traditionally associated with increased acute rejection rate and decreased long-term graft survival after kidney transplant. In this study, our objective was to determine patient and allograft outcomes in sensitized kidney transplant recipients with advanced HLA antibody detection and stringent protein sequence epitope analyses. MATERIALS AND METHODS: This was a subanalysis of a prospective, risk-stratified randomized controlled trial that compared interleukin 2 receptor antagonist to rabbit antithymocyte globulin induction in 200 kidney transplant recipients, examining outcomes based on panel reactive antibody levels of < 20% (low) versus ≥ 20% (high, sensitized). The study was conducted between February 2009 and July 2011. All patients underwent solid-phase single antigen bead assays to detect HLA antibodies and stringent HLA epitope analyses with protein sequence alignment for virtual crossmatching. Delayed graft function, acute rejection rates, and graft loss were the main outcomes measured. RESULTS: Both the low (134 patients) and high (66 patients) panel reactive antibody level cohorts had equivalent induction and maintenance immunosuppression. Patients in the high-level group were more likely to be female (P < .001), African American (P < .001), and received a kidney from a deceased donor (P = .004). Acute rejection rates were similar between the low (rate of 8%) and high (rate of 9%) panel reactive antibody groups (P = .783). Delayed graft function, borderline rejection, graft loss, and death were not different between groups. Multivariate analyses demonstrated delayed graft function to be the strongest predictor of acute rejection (odds ratio, 5.7; P = .005); panel reactive antibody level, as a continuous variable, had no significant correlation with acute rejection (C statistic, 0.48; P = .771). CONCLUSIONS: Appropriate biologic matching with single antigen bead assays and stringent epitope analyses provided excellent outcomes in sensitized patients regardless of the induction therapy choice.

Depression, Resource Utilization, and Outcomes Following Liver Transplant.

CONTEXT: There is evidence that depression after liver transplant (LTX) is associated with increased morbidity and mortality; however, the effect of depression treatment on LTX outcomes has not been well established. OBJECTIVE/SETTING/DESIGN: This single-center, longitudinal cohort study aimed to determine whether depression treatment influences outcomes after LTX. Depression diagnosis was based on medical history and documentation from psychosocial providers. PATIENTS/INTERVENTION/MAIN OUTCOME MEASURES: Patients were studied from October 2010 to June 2013 and separated into 3 groups for analysis: no depression, adequately treated depression, and inadequately treated depression. Adequacy of depression treatment was determined using the Antidepressant Treatment History Form. RESULTS: Of the 161 patients included in the analysis, 103 did not have depression, 24 had adequately treated depression, and 34 had inadequately treated depression. Baseline demographics were similar between the groups. Patients with inadequately treated depression had significantly more encounters with a health-care provider (P = .03). Graft loss tended to be higher in these patients (27% in the inadequately treated group, 17% in the adequately treated, and 14% in the no depression group, P = .25). The adequately treated group was more likely than the inadequately treated group to be on antidepressants at 30 days post-LTX (P = .001). The inadequately treated group was more likely to be on a sleep aid 30 days post-LTX (P = .01). CONCLUSION: Inadequately treated depression led to increased health-care resource utilization. Patients with adequately treated depression had similar outcomes as those with no depression. Use of sleep aids early post-LTX may be a surrogate indicator of inadequately treated depression.

Predicting and preventing readmissions in kidney transplant recipients.

A lack of research exploring post-transplant process optimization to reduce readmissions and increasing readmission rates at our center from 2009 to 2013 led to this study, aimed at assessing the effect of patient and process factors on 30-d readmission rates after kidney transplantation. This was a retrospective case-control study in adult kidney transplant recipients. Univariate and multivariate analyses were utilized to assess patient and process determinants of 30-d readmissions. 384 patients were included; 30-d readmissions were significantly associated with graft loss and death (p = 0.001). Diabetes (p = 0.049), pharmacist identification of poor understanding or adherence, and prolonged time on hemodialysis prior to transplant were associated with an increased risk of 30-d readmissions. After controlling for risk factors, readmission rates were only independently predicted by pharmacist identification of patient lack of understanding or adherence regarding post-transplant medications and dialysis exposure for more than three yr (OR 2.3, 95% CI 1.10-4.71, p = 0.026 and OR 2.1, 95% CI 1.22, 3.70, respectively), both of which were significantly modified by history of diabetes. Thirty-d readmissions are attributable to both patient and process-level factors. These data suggest that a lack of post-transplant medication knowledge in high-risk patients drives early hospital readmission.

A randomized, prospective comparison of transition to sirolimus-based CNI-minimization or withdrawal in African American kidney transplant recipients.

BACKGROUND: There is a lack of conclusive evidence to suggest if calcineurin inhibitor (CNI) withdrawal or minimization with sirolimus is the best strategy for African Americans. METHODS: This was a randomized, prospective, open-label, pilot study comparing the two mammalian target of rapamycin (mTOR) transition strategies in adult African Americans between six and 24 wk post-transplant. The primary outcome was a comparison of the eGFR at one yr after conversion. RESULTS: Forty patients were randomized and analyzed in an intent-to-treat fashion. Median day of transition was day 96 (withdrawal) and 68 (minimization). Patients in the CNI-withdrawal group (n = 23) had significantly higher eGFR at one yr compared to the CNI-minimization group (n = 17, 73 vs. 56 mL/min, p = 0.03), as well as a significantly larger increase in eGFR from baseline (12 vs. 5 mL/min, p = 0.03). There were no differences in infections, acute rejection, death, or graft loss. Both regimens were constrained by disproportionately high discontinuation rates despite modest toxicity profiles. CONCLUSION: In spite of considerable withdrawal rate across both study arms, African American kidney transplant recipients who underwent early transition to a sirolimus-based CNI-withdrawal regimen had significantly better graft function at one yr compared to those transitioned to a sirolimus-based CNI-minimization regimen. Clinicaltrials.gov identifier: NCT01005706.

Incidence, risk factors, and outcomes of opportunistic infections in pediatric renal transplant recipients.

OIs present significant risks to patients following solid organ transplantation. The purpose of this study was to identify risk factors for the development of OIs after kidney transplantation in pediatric patients and to evaluate the impact of OIs on outcomes in this patient population. A single-center retrospective longitudinal cohort analysis including pediatric patients 21 yr of age or younger transplanted from July 1999 to June 2013 at an academic medical center was conducted. Patients were excluded if they received multi-organ transplant. A total of 175 patients were included in the study. Patients who developed OIs were more likely to be female and younger at the time of transplant. A six-factor risk model for OI development was developed. Death, disease recurrence, and PTLD development were similar between groups but trended toward increased incidence in the OI group. Incidence of rejection was significantly higher in the OI group (p = 0.04). Patients who developed OIs had several important risk factors, including younger age, EBV-negative serostatus, CMV donor (+)/recipient (-), biopsy-proven acute rejection, ANC <1000, MMF dose >500 mg/m(2), and any infection. Incidence of rejection was higher in the OI group, but rate of graft loss was not statistically different.

Racial disparity outcomes in patients undergoing hepatectomy: is baseline kidney function a potential explanation?

Background-Reasons underlying disparities in outcomes in liver resections between patients who are African American and patients who are not are poorly understood. Methods-An observational longitudinal cohort study was performed. Clinical data were collected from medical records of 166 patients (59 African American, 107 not) undergoing partial hepatectomy between 2004 and 2012. Univariate and multivariate analyses were performed. Results-African Americans patients undergoing partial hepatectomy were more likely to be female, heavier, have hemangiomas or adenomas, and have hepatic steatosis on explant. Intraoperatively, African Americans had longer surgical times, higher estimated blood loss, and greater use of blood products. Major postoperative complications were significantly more common in African Americans. Multivariable modeling demonstrated that race, history of hepatitis C, and estimated blood loss were the only variables that were independently associated with a major complication; however, baseline serum creatinine level was the only variable that significantly modified the effect of race on complications. Conclusions-African Americans with normal serum creatinine levels had a similar rate of complication to patients who were not African American, but as the baseline serum level of creatinine increased, the odds ratio for a complication developing increased dramatically in the African American patients, suggesting that the disparities seen are predominantly driven by a subset of African American patients who have preexisting renal insufficiency.

Significant racial differences in the key factors associated with early graft loss in kidney transplant recipients.

BACKGROUND: There is continued and significant debate regarding the salient etiologies associated with graft loss and racial disparities in kidney transplant recipients. METHODS: This was a longitudinal cohort study of all adult kidney transplant recipients, comparing patients with early graft loss (<5 years) to those with graft longevity (surviving graft with at least 5 years of follow-up) across racial cohorts [African-American (AA) and non-AA] to discern risk factors. RESULTS: 524 patients were included, 55% AA, 151 with early graft loss (29%) and 373 with graft longevity (71%). Consistent within both races, early graft loss was significantly associated with disability income [adjusted odds ratio (AOR) 2.2, 95% CI 1.1-4.5], Kidney Donor Risk Index (AOR 3.2, 1.4-7.5), rehospitalization (AOR 2.1, 1.0-4.4) and acute rejection (AOR 4.4, 1.7-11.6). Unique risk factors in AAs included Medicare-only insurance (AOR 8.0, 2.3-28) and BK infection (AOR 5.6, 1.3-25). Unique protective factors in AAs included cardiovascular risk factor control: AAs with a mean systolic blood pressure <150 mm Hg had 80% lower risk of early graft loss (AOR 0.2, 0.1-0.7), while low-density lipoprotein <100 mg/dl (AOR 0.4, 0.2-0.8), triglycerides <150 mg/dl (AOR 0.4, 0.2-1.0) and hemoglobin A1C <7% (AOR 0.2, 0.1-0.6) were also protective against early graft loss in AA, but not in non-AA recipients. CONCLUSIONS: AA recipients have a number of unique risk factors for early graft loss, suggesting that controlling cardiovascular comorbidities may be an important mechanism to reduce racial disparities in kidney transplantation.

The impact of diabetes mellitus and glycemic control on clinical outcomes following liver transplant for hepatitis C.

Hepatitis C is the leading indication for liver transplantation in the USA and recurrence is universal. The impact of preexisting diabetes, new-onset diabetes after transplant (NODAT), and glycemic control on fibrosis progression has not been studied. This retrospective longitudinal cohort study included adult liver recipients with hepatitis C transplanted between 2000 and 2011. Patients were divided into three groups: preexisting diabetes (n = 41), NODAT (n = 59), and no diabetes (n = 103). Patients with preexisting diabetes (70%) or NODAT (59%) were more likely to develop hepatitis C recurrence (≥stage 1 fibrosis), as compared to non-diabetics (36%, p = 0.006). There was also a trend toward a higher incidence of at least Stage 2 fibrosis (36% and 48% vs. 23%, respectively; p = 0.063). Patients with tight glycemic control had a lower rate of Stage 2 fibrosis development (78% vs. 60%, p = 0.027), while those with good control (<150 mg/dL) also had lower rates of Stage 2 fibrosis (84% vs. 62%, p = 0.004). Multivariable analysis verified a decreased rate of recurrence for patients with blood glucose <138 mg/dL (p = 0.021), after controlling for confounders. These results demonstrate that diabetes is strongly associated with an increased risk of hepatitis C virus-related fibrosis development and glycemic control may reduce the risk and severity of recurrence.

Clinical and economic outcomes associated with medication errors in kidney transplantation.

BACKGROUND AND OBJECTIVES: Modern immunosuppressant regimens have significantly decreased acute rejection rates, but may have increased the risk of graft loss driven by adverse drug reactions (ADRs) and medication errors (MEs). The objectives of this study were to determine the incidence and risk factors for MEs and ADRs and determine the association between transplant outcomes and these events. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a post hoc analysis of a prospective, randomized trial that included patients aged>18 years that received a solitary renal transplant at an academic medical center recruited between March 2009 and July 2011. Patients were divided into groups based on developing a clinical significant ME (CSME), defined as a significant ME that contributed to a hospital admission. RESULTS: The mean study follow-up was 2.5 ± 0.7 years. There were a total of 233 MEs and 327 ADRs in the 200 patients included in the analysis, with 64% of the cohort experiencing at least one ME and 87% experiencing an ADR; 23 patients (12%) experienced a CSME. Patients that experienced CSMEs had a trend toward more post-transplant readmissions (median 1 [interquartile range (IQR), 0-5] versus 0 [0-2]; P=0.06), higher costs for readmissions (median $18,091 [IQR, $3023-$56,268] versus $0 [$0-$15,991]; P<0.01), and overall length of stay (median 5.0 days [IQR, 2.0-14.0] versus 0.0 days [IQR, 0.0-5.5]; P<0.01) after the CSME event. CSME patients were also more likely to experience graft failure (22% versus 10%; P=0.05). CONCLUSIONS: Significant MEs commonly occur in renal transplant recipients and are associated with an increased risk of deleterious clinical outcomes, including subsequent hospital days, costs, and graft loss.

The concept of a composite perioperative quality index in kidney transplantation.

BACKGROUND: Public reporting of patient and graft outcomes in a national registry and close Centers for Medicare and Medicaid Services oversight has resulted in transplantation being a highly regulated surgical discipline. Despite this, transplantation surgery lacks comprehensive tracking and reporting of perioperative quality measures. Therefore, the aim of this study was to determine the association between a kidney transplantation centers' perioperative quality benchmarking and graft and patient outcomes. STUDY DESIGN: This was an analysis of 2011 aggregate data compiled from 2 national datasets that track outcomes from member hospitals and transplantation centers. The transplantation centers included in this study were composed of accredited US kidney transplantation centers that report data through the national registry and are associate members of the University HealthSystem Consortium. RESULTS: A total of 16,811 kidney transplantations were performed at 236 centers in the United States in 2011, of which 10,241 (61%) from 93 centers were included in the analysis. Of the 6 perioperative quality indicators, 3 benchmarked metrics were significantly associated with a kidney transplantation center's underperformance: mean ICU length of stay (C-statistic 0.731; p = 0.002), 30-day readmissions (C-statistic 0.697; p = 0.012) and in-hospital complications (C-statistic 0.785; p = 0.001). The composite quality index strongly correlated with inadequate center performance (C-statistic 0.854; p < 0.001, R(2) = 0.349). The centers in the lowest quartile of the quality index performed 2,400 kidney transplantations in 2011, which led to 2,640 more hospital days, 4,560 more ICU days, 120 more postoperative complications, and 144 more patients with 30-day readmissions, when compared with centers in the 3 higher-quality quartiles. CONCLUSIONS: An objective index of a transplantation center's quality of perioperative care is significantly associated with patient and graft survival.

Clinical outcomes associated with the early postoperative use of heparin in pancreas transplantation.

BACKGROUND: Graft thrombosis following pancreas transplantation is the leading non-immunologic cause of graft loss. Routine systemic anticoagulation is controversial because of an increased bleeding risk. METHODS: This was a retrospective, single-center analysis including all pancreas transplants performed over 9 years evaluating the use of low-dose heparin in the early postoperative period. Clinical outcomes were partial and complete graft thrombosis within 30 days, bleeding events, relaparotomy rates, and 30-day graft and patient survival. Multivariate regression analysis was performed to identify risk factors for early graft loss resulting from thrombosis. RESULTS: One hundred fifty-two patients were included, 52 in the heparin group. The overall complete thrombosis rate was 13.1%, 10% in those who received heparin, and 15% in those who did not. Partial thrombosis was higher in the heparin group (10% vs. 3%). Higher relaparotomy rates were seen in the heparin group (29% vs. 22%); however, bleeding events were similar between groups. Graft and patient survival at 30 days were similar between groups; however, there was a trend toward higher graft survival in the heparin group. Heparin showed a trend toward a protective benefit for early graft loss resulting from thrombosis in all multivariate regression models. CONCLUSION: These data suggest low-dose heparin early in the postoperative period may provide a protective benefit in the prevention of early graft loss resulting from thrombosis, without an increased risk of bleeding.

Safe use of highly steatotic livers by utilizing a donor/recipient clinical algorithm.

The aim of this study was to assess the long-term safety and clinical outcomes associated with the utilization of highly steatotic donor livers utilizing a specific donor/recipient matching algorithm. This was a prospective, observational, single-center, 10-yr follow-up study. Highly steatotic livers were utilized according to a donor/recipient algorithm that guided the surgeon to use highly steatotic donor organs judiciously in low-risk recipients. This study initially compared fat assessment based on frozen-section Ehrlich's hematoxylin and eosin (H&E) to reperfusion biopsy fat assessment and demonstrated that H&E is an insensitive analysis to determine degree of steatosis. Patients were divided into three groups based on donor steatosis (group 1: <30% steatosis, group 2: 30-60% steatosis, group 3: >60% steatosis), and clinical outcomes were assessed. One hundred and sixteen patients were included in the analysis. Patients that received severely steatotic livers (>60% fat) showed increased reperfusion liver injury and delayed return of liver function in the early postoperative period, demonstrated by biochemical markers. However, there were no differences in primary non-function, postoperative complications, length of stay, and patient and graft survival. Using rigorous donor/recipient matching through a detailed algorithm, these data demonstrate that normal liver allograft outcomes are not superior to those in highly steatotic grafts.

Are thiazide diuretics safe and effective antihypertensive therapy in kidney transplant recipients?

BACKGROUND/AIMS: There are no published studies assessing the safety and efficacy of thiazides as antihypertensives in kidney transplantation (KTX). METHODS: This was a longitudinal retrospective cohort study conducted in adult KTX recipients. Patients were grouped based on receiving thiazides following KTX. Safety and efficacy comparisons were made between thiazide recipients and unexposed patients, as well as change in blood pressure (BP) within thiazide patients. RESULTS: 1,093 patients were included (thiazide group: 108, unexposed group: 985). Mean follow-up was 7.3 ± 4.5 years. Thiazide recipients were older (53 ± 11 vs. 48 ± 13 years, p < 0.001) and more likely to be female (52 vs. 41%, p = 0.023) and have pre-KTX hypertension (97 vs. 88%, p = 0.004) or diabetes (36 vs. 27%, p = 0.035). After controlling for baseline differences, safety analysis revealed thiazide recipients were not more likely to be readmitted to the hospital, but were at higher risk to develop hyperkalemia (56 vs. 38%, p < 0.001) or hypokalemia (28 vs. 18%, p = 0.010), with similar rates of hypotension, decreased estimated glomerular filtration rate, graft loss and death. Efficacy analysis demonstrated systolic (147 ± 17 to 139 ± 18 mm Hg, p < 0.001) and diastolic (79 ± 9 to 77 ± 11 mm Hg, p < 0.001) BPs were significantly reduced after thiazide initiation. Compared to unexposed patients, thiazide recipients had higher mean BPs during the entire follow-up (142/78 vs. 136/77, p < 0.001), with similar BPs while on thiazides and comparable rates of goal BPs (<130/80 mm Hg, 32 vs. 36%, p = 0.219). CONCLUSIONS: In KTX, based on long-term outcomes, thiazides appear to be safe and effective antihypertensives; in the short-term, thiazides may increase the risk of developing potassium disturbances.

Clinical and economic analysis of delayed administration of antithymocyte globulin for induction therapy in kidney transplantation.

CONTEXT: The increasing number of marginal deceased kidney donors and an aging recipient population, prolonged hospitalization, and increased costs have destabilized the economic viability of kidney transplants. OBJECTIVE: To determine if a delay in the administration of the day-of-discharge dose of rabbit antithymocyte globulin would result in equivalent clinical outcomes with cost savings. DESIGN: Single-center, prospective, observational before-and-after study of adult kidney transplant recipients who received induction with rabbit antithymocyte globulin.Intervention-Patients who received a transplant between June 2006 and February 2009 and received rabbit antithymocyte globulin served as the control group. Patients who received a transplant between March 2009 and August 2010 and received rabbit antithymocyte globulin had the day-of-discharge dose delayed to the following day and administered in the clinic. A total of 231 patients (146 in the control group, 85 in the study group) were included. Baseline demographic and clinical characteristics were similar in the 2 groups. RESULTS: Patients who had delayed administration of rabbit antithymocyte globulin had shorter stays (3.9 vs 3.1 days, P< .001) and reduced inpatient costs for rabbit antithymocyte globulin (mean $860/patient); these changes were achieved without affecting acute rejection rates (5% vs 5%, P> .99) or readmission rates. In conclusion, delayed inpatient administration of rabbit antithymocyte globulin provided identical clinical outcomes while helping to reduce inpatient costs and increase timely discharges.

Improving the perioperative value of care for vulnerable kidney transplant recipients.

BACKGROUND: The increased use of marginal donors, an aging recipient population, and Diagnosis-Related Group (DRG) cost restraints place significant pressures on kidney transplant centers to maintain financial viability while sustaining high quality outcomes. We engaged in a quality initiative in delayed graft function (DGF) kidney transplant recipients aimed at improving safe and efficient discharge. STUDY DESIGN: This was a retrospective analysis of national databases comparing the perioperative outcomes and costs for our transplant center and national benchmark values for kidney recipients undergoing transplantation between October 2008 and March 2012. During this time, we developed and implemented quality initiatives aimed at improving health care value for kidney transplant recipients, and focused efforts particularly in patients who developed DGF. Pediatric patients and multiorgan transplant recipients were excluded. RESULTS: There were 583 kidney transplants performed at our institution; these were compared with 37,712 transplants available from national data. Rates of DGF increased at our institution from 6% to 25% but were steady at 27% nationally. The quality initiatives improved hospital length of stay (LOS) in DGF patients from an average of 8 days initially to 4 days at study end, which reduced overall LOS from 3.6 ± 1.5 days to 3.3 ± 0.8 days (p = 0.021); national LOS was consistent at a mean of 10 days; hospital costs decreased by 42% at our institution, while national rates rose by 12%. Our institutional 30-day readmission rates in all patients and those with DGF were significantly lower than national rates across the entire study period (9% vs 15% and 12% vs 18%, respectively). CONCLUSIONS: These results demonstrate that health care value can be significantly improved in kidney transplant recipients, particularly in DGF patients, by implementing a multidisciplinary initiative aimed at safely and efficiently discharging patients.

The impact of cardiovascular disease and risk factor treatment on ethnic disparities in kidney transplant.

There is limited data on the use of cardiovascular disease (CVD) risk factor medications following renal transplant, especially when comparing use across ethnicities. The aim of this study was to compare the incidence, treatment, and impact of CVD between ethnicities in kidney transplant recipients. This was a retrospective cohort study of adults who underwent transplant between 2000 and 2008 within our academic medical transplant center. Pediatrics, multiorgan transplants, and those lost to follow-up were excluded. Data collection included all transplant and sociodemographic characteristics, medication use, CVD risk factor management, and follow-up events, including acute rejection, graft loss, and death. A total of 987 patients were included and followed for a mean of 6.7 ± 3.0 years. The baseline demographics revealed black patients were equally likely to have preexisting CVD (24% vs 25%, P = .651), but more likely to have preexisting diabetes (35% vs 23%, P < .001) or hypertension (97% vs 94%, P = .029). Black patients had poorer treatment of CVD risk factors, with lower rates of control of diabetes (35% vs 51%, P < .05) and dyslipidemia (37% vs 42%, P < .05). Black renal transplant recipients who had preexisting CVD had reduced graft survival rates compared to white patients (10-year rate 50% vs 60%, P = .033), but similar rates of graft survival were found in those without CVD (10-year rate 70% vs 71% in white patients, P = .483). CVD is common in transplant recipients, with black patients having higher rates and poorer control of diabetes and dyslipidemia.