Economic costs of expanded criteria donors in renal transplantation.

BACKGROUND: The organ shortage has increased interest in the use of "expanded criteria" donors (ECDs). Although much has been written concerning the clinical outcomes associated with the use of such donors, little has been published concerning the financial results associated with their use. METHODS: A retrospective cost identification study of recipients of kidneys from expanded criteria cadaveric donors was used. RESULTS: Of a total of 78 cadaveric renal transplants in fiscal year 1995, there were 38 kidneys (49%) transplanted from ECDs. Graft survival at 1 year was not statistically different between patients who received kidneys from ECDs and those who received non-ECD kidneys (84% vs. 85%, respectively). Length of stay (P < 0.05), serum creatinine at 1 year after transplantation (P < 0.01), and the percentage of patients requiring hemodialysis (P < 0.05) were all higher among patients who received kidneys from ECDs. Cold ischemic time was significantly longer in patients who received kidneys from ECDs (31.4+/-12 hr vs. 24.0+/-9 hr; P < 0.05). The total average and median costs were $12,190 and $10,911 higher in recipients of kidneys from ECDs as compared with non-ECD controls (P < 0.01). Stepwise linear regression demonstrated that length of stay was the major clinical determinant of total costs; only the use of antilymphocyte induction was otherwise significantly associated. When kidneys from ECDs were transplanted into "high-risk" recipients (age > 60 or retransplant patient), the average total costs were $15,311 more than when kidneys from ECDs were transplanted into non-high-risk patients (n=16 and 21, respectively; P < 0.05) and $20,680 more than when a non-ECD, non-high-risk pairing was undertaken (n=26; P < 0.05). CONCLUSIONS: Kidney transplantation with organs from ECDs is significantly more expensive than with organs from non-ECDs, even in the face of similar graft survival rates. Further study is needed to determine the cost-effectiveness of renal transplantation utilizing kidneys from ECDs vis-a-vis hemodialysis.

Clinical and economic outcomes of expanded criteria donors in renal transplantation.

Although graft and patient survival rates were similar between recipients of kidneys from ECDs and non-ECDs, transplantation with organs from ECDs was significantly more expensive. Multivariate analysis using stepwise linear regression demonstrated length of stay to be a strong proxy for total hospital costs. Inherent tensions between the overall good clinical outcomes associated with the use of ECDs in terms of graft survival and the markedly increased costs seen with these organs are evident.

1,25-dihydroxyvitamin D-mediated hypercalcemia in a renal transplant recipient.

Hypercalcemia occurs in 10 to 30% of renal transplant recipients and is most often due to persistent hyperparathyroidism. Herein we describe a patient with a history of hyperparathyroidism who sought medical assessment because of recurrence of hypercalcemia 7 years after a successful renal transplantation. The hypercalcemia was associated with a normal serum phosphate level, a low to normal parathyroid hormone level, virtually undetectable levels of parathyroid hormone-related protein, and increased 1,25-dihydroxyvitamin D levels. Further assessment led to the diagnosis of an underlying lymphoma. To our knowledge, this is the first report of 1,25-dihydroxyvitamin D-mediated hypercalcemia in a renal transplant recipient with lymphoma. The possibility of an underlying lymphoproliferative disorder should be considered in the differential diagnosis of hypercalcemia in a renal transplant recipient.

Evidence suggesting that iron and calcium are interrelated in oxidant-induced DNA damage.

The effect of iron chelators and agents that buffer cytosolic-free calcium ([Ca2+]i) on hydrogen peroxide-induced DNA strand breaks in LLC-PK1 cells has not been previously examined. In addition, the interrelationship between iron and calcium in the pathogenesis of DNA damage has not been studied in any model of tissue injury. Exposure of LLC-PK1 cells to 1 mM hydrogen peroxide resulted in marked DNA damage, as measured by the alkaline unwinding assay (residual intact double stranded DNA at 10 min, control: 88 +/- 1%; hydrogen peroxide-treated cells: 17 +/- 3%, N = 8). The iron chelators, 1,10-phenanthroline and deferoxamine, and agents which buffer [Ca2+]i, BAPTA and quin-2, provided highly significant protection against hydrogen peroxide-induced DNA strand breaks. We then examined the effect of iron chelators on hydrogen peroxide-induced rise in [Ca2+]i in LLC-PK1 cells. Both 1,10-phenanthroline and deferoxamine prevented the marked and sustained rise in [Ca2+]i induced by exposure of LLC-PK1 cells to 1 mM hydrogen peroxide ([Ca2+]i at 15 min, control 100 +/- 3 nM; hydrogen peroxide 195 +/- 14 nM; 1,10-phenanthroline + hydrogen peroxide 100 +/- 4 nM; deferoxamine + hydrogen peroxide 106 +/- 4 nM; N = 4). We excluded the possibility that the iron chelators were directly chelating calcium by performing experiments using a cell free system. We also confirmed that BAPTA and quin-2, in concentrations used in our study, chelate calcium but not iron or copper.(ABSTRACT TRUNCATED AT 250 WORDS)