Alemtuzumab Induction Is Associated With an Equalization of Outcomes Between White and African American Kidney Transplant Recipients.

OBJECTIVES: Our aim was to assess outcomes in White and African American kidney transplant recipients after induction with alemtuzumab. MATERIALS AND METHODS: We performed a retrospective study of 464 patients who received deceased-donor kidney transplants and were induced with alem-tuzumab between March 2006 and May 2015. We evaluated ethnic influences on patient and graft survival, delayed graft function, allograft failure, and rejection. RESULTS: There were 337 White (67.3%) and 127 African American (25.3%) patients. We observed no significant differences in 1-, 3-, 5-, and 7- year death-censored graft survival. We also observed no significant differences in 1-, 3-, and 5-year patient survival rates. Having African American ethnicity was not a significant predictor of rejection, graft survival, or patient survival. CONCLUSIONS: Our results indicate that recipient ethnicity is not a predictor of rejection, graft survival, or patient survival. White and African American kidney transplant recipients induced with alemtuzumab experienced an equalization of outcomes.

Black Ethnicity is Not a Risk Factor for Mortality or Graft Loss After Kidney Transplant in the United Kingdom.

OBJECTIVES: There are conflicting reports in the literature regarding outcomes after kidney transplant for patients of black ethnicity. To investigate further, we compared outcomes for black versus white kidney transplant recipients in a single UK transplant center. MATERIALS AND METHODS: We analyzed 1066 kidney transplant recipients (80 black patients, 986 white patients) within a single-center cohort (2007-2017) in the United Kingdom, with cumulative 4446 patient-year follow-up. Data were electronically extracted from the Department of Health Informatics database for every study recruit, with manual data linkage to the UK Transplant Registry (for graft survival, delayed graft function, and rejection data) and Office for National Statistics (for mortality data). Primary outcomes of interest were graft/patient survival. RESULTS: Black recipients have increased baseline risk profiles with longer wait times, difficulty in matching, worse HLA matching, more socioeconomic deprivation, and lower rates of living kidney donors. Postoperatively, black versus white recipients had increased risk for delayed graft function (34.3% vs 10.2%; P < .001), increased 1-year rejection (16.7% vs 7.3%; P = .012), higher 1-year creatinine levels (166 vs 138 mmol/L; P = .003), and longer posttransplant length of stay (14.5 vs 9.5 days; P = .020). Although black recipients did not have increased risk of death versus white recipients (10.0% vs 11.0%, respectively; P = .486), they did have increased risk for death-censored graft loss (23.8% vs 11.1%; P = .002). However, in an adjusted Cox regression model, black ethnicity was not associated with increased risk for death-censored graft loss (hazard ratio of 1.209, 95% confidence interval, 0.660-2.216; P = .539). CONCLUSIONS: Black kidney transplant recipients in the United Kingdom have increased risk of adverse graft-related outcomes due to high-risk baseline variables rather than their black ethnicity per se.

Evolving Trends in Racial Disparities for Peri-Operative Outcomes with the New Kidney Allocation System (KAS) Implementation.

INTRODUCTION: To improve kidney transplant allocation equitability, a new Kidney Allocation System (KAS) was implemented December 4, 2014. The purpose of this study was to determine if the impact of KAS on peri-operative outcomes differed by recipient race/ethnicity. METHODS: This was a time series analysis using data aggregated in monthly intervals from October 2012 through September 2015 using the University HealthSystem Consortium (UHC). This includes national data aggregated at the center level of all US kidney transplant centers that participate in the UHC (416 centers). Segmented regression with interaction terms was used to determine the impact of KAS on outcomes and differences by race/ethnicity. RESULTS: A total of 28,809 deceased donor kidney transplants were included with 25 months of pre-KAS data and 10 months of post-KAS data. After KAS implementation, the estimated transplant rate per month decreased significantly for Caucasians by 17.6 cases per month (p = 0.0001), and increased significantly for AAs by 37.8 (p = 0.0001), Hispanics by 16.3 (p = 0.0001), and other races by 8.2 cases per month (p = 0.0001). Delayed graft function, 7- and 14-day readmissions significantly increased after KAS, which did not differ by race. Hispanics saw a 7.7% decrease in ICU admissions after KAS, which differed as compared to other racial/ethnic cohorts (p = 0.0026). Costs of kidney transplantation increased significantly after KAS in all groups except Hispanics. Mortality, length of stay, in-hospital complications, and 30-day readmissions were not significantly impacted by KAS, also not differing by race/ethnicity. CONCLUSION: KAS had substantial impact on transplant rates by race/ethnicity. KAS also led to increased costs, readmissions, and delayed graft function (DGF) across all racial/ethnic groups. The impact of KAS on ICU cases solely within Hispanics requires further investigation into potential etiologies.

Donor and Recipient Ethnicity Impacts Renal Graft Adverse Outcomes.

Renal transplant outcomes have been shown to be impacted by ethnicity. Prior studies have evaluated the disparate transplant outcomes of Black recipients and recipients of Black donors. However, it has remained unclear whether other donor ethnicities independent of medical comorbidities can influence transplant outcomes. Utilizing the Scientific Registry of Transplant Recipients (SRTR) (with greater than 100,000 patients), we evaluated the effect of each ethnicity, Black, American Indian, Hispanic, Native Hawaiian or other Pacific Islander, and Asian as compared to White recipients on adverse kidney transplant outcomes, assessing for delayed graft function, positive urine protein, acute rejection, and graft failure. Additionally, we assessed the interplay of donor ethnicity on recipient transplant outcomes, which has not previously been comprehensively examined. Logistic regression analysis that took into consideration gender, age, comorbidities, graft type, donor ethnicity, body mass index (BMI), HLA mismatch, ever been on hemodialysis, and time on dialysis indicates that Black recipients have worse outcomes compared to Whites in all outcomes assessed. A logistic regression analysis showed that recipient ethnicity was an independent risk factor for adverse outcomes. Notably, we found that donor ethnicity also independently affects graft outcomes. Hispanic donors lead to better outcomes in Whites and Blacks, while Asian donors have the best outcomes amongst Asian recipients. Recipients of Black donors fared the worst of all ethnicity donors. These data suggest the potential importance of risk stratification for the donor allograft and developing risk calculators that include both donor and recipient ethnicity may be useful, which the current Kidney Donor Profile Index (KDPI) does not currently take into account as they give black donors a different weight, but the same score is assigned to Whites, Asians, and Hispanics.

Outcome disparities between African Americans and Caucasians in contemporary kidney transplant recipients.

BACKGROUND: Racial disparities in African-American (AA) kidney transplant have persisted for nearly 40 years, with limited data available on the scope of this issue in the contemporary era of transplantation. METHODS: Descriptive retrospective cohort study of US registry data including adult solitary kidney transplants between Jan 1, 2005 to Dec 31, 2009. RESULTS: 60,695 recipients were included; 41,426 Caucasians (68%) and 19,269 AAs (32%). At baseline, AAs were younger, had lower college graduation rates, were more likely to be receiving public health insurance and have diabetes. At one-year post-transplant, AAs had 62% higher risk of graft loss (RR 1.62, 95% CI 1.50-1.75) which increased to 93% at five years (RR 1.93, 95% CI 1.85-2.01). Adjusted risk of graft loss, accounting for baseline characteristics, was 60% higher in AAs (HR 1.61 [1.52-1.69]). AAs had significantly higher risk of acute rejection and delayed graft function. CONCLUSION: AAs continue to experience disproportionately high rates of graft loss within the contemporary era of transplant, which are related to a convergence of an array of socioeconomic and biologic risk factors.

Twenty years of evolving trends in racial disparities for adult kidney transplant recipients.

Disparities in outcomes for African American (AA) kidney transplant recipients have persisted for 40 years without a comprehensive analysis of evolving trends in the risks associated with this disparity. Here we analyzed U.S. transplant registry data, which included adult Caucasian or AA solitary kidney recipients undergoing transplantation between 1990 and 2009 comprising 202,085 transplantations. During this 20-year period, the estimated rate of 5-year graft loss decreased from 27.6% to 12.8%. Notable trends in baseline characteristics that significantly differed by race over time included the following: increased prevalence of diabetes from 2001 to 2009 in AAs (5-year slope difference: 3.4%), longer time on the waiting list (76.5 more days per 5 years in AAs), fewer living donors in AAs from 2003 to 2009 (5-year slope difference: -3.36%), more circulatory death donors in AAs from 2000-09 (5-year slope difference: 1.78%), and a slower decline in delayed graft function in AAs (5-year slope difference: 0.85%). The absolute risk difference between AAs and Caucasians for 5-year graft loss significantly declined over time (-0.92% decrease per 5 years), whereas the relative risk difference actually significantly increased (3.4% increase per 5 years). These results provide a mixed picture of both promising and concerning trends in disparities for AA kidney transplant recipients. Thus, although the disparity for graft loss has significantly improved, equity is still far off, and other disparities, including living donation rates and delayed graft function rates, have widened during this time.

Role of race in kidney transplant outcomes in children with focal segmental glomerulosclerosis.

It is well established that racial differences exist in kidney transplant outcomes; however, there are no studies which focus on the role of race in transplant outcomes specifically in children diagnosed with FSGS. Associations between race and transplant outcomes in FSGS children were evaluated using the Organ Procurement and Transplantation Network database from 2000 to 2012. Recipients aged 2-21 years who received a kidney-only transplant were included. Multivariate regression models were used to evaluate transplant outcomes by race. Five hundred and thirty-six recipients (59.7% male, 15.6±3.9 years) were black and 1134 (55.7% male, 14.3±5.0 years) were non-black. Graft survival was significantly shorter in the black group (4.2±3.1 vs 4.6±3.3 years, P=.005). Black race was associated with significantly higher risk of graft failure (HR 1.34, 95% CI=1.21-1.49, P<.0001), acute rejection (OR 1.66 95% CI=1.39-1.97, P<.0001), and delayed graft function (OR 1.51, 95% CI=1.33-1.72, P<.001) compared to non-black race. There were no significant differences in mortality, prolonged hospitalization, or FSGS recurrence between groups. Race is a significant predictor for worse transplant outcomes in children with FSGS.

Delayed Graft Function in Living-Donor Kidney Transplant: A Middle Eastern Perspective.

With an increased incidence of living-donor kidney transplants, in response to increasing unmet needs for renal transplant, a clear understanding of determinants of posttransplant outcomes is essential. The importance of delayed graft function in deceased-donor kidney transplant is now part of conventional medical wisdom, due to the large amount of evidence focused on this aspect. However, the same is not true for living-donor kidney transplant, partly due to lack of evidence on this crucial clinical question and partly due to lack of awareness about this issue. The current review aims to highlight the importance of delayed graft function as a crucial determinant of outcomes in living-donor kidney transplant. An exhaustive search of online medical databases was performed with appropriate search criteria to collect evidence about delayed graft function after living-donor kidney transplant, with a special focus on studies from the Middle East. Data on incidence, impact, risk factors, and possible prevention modalities of delayed graft function in patients undergoing living-donor kidney transplant are presented. A key finding of this review is that contemporary incidence rates reported from the Middle East are comparatively higher than those reported from outside the region. Although in absolute terms the incidence is lower than deceased donor kidney transplant, the effects of delayed graft function on graft rejection and graft and patient survival are sufficiently large to warrant the formulation of specific treatment protocols. Key to formulating prevention and treatment strategies is identifying discrete risk factors for delayed graft function. Although this evidence is scant, an overview has been provided. Further studies examining different aspects of delayed graft function incidence after living-donor kidney transplant are urgently needed to address a so far little known clinical question.

Evolution of graft survival in kidney transplantation: an analysis of the OPTN/UNOS Renal Transplant Registry.

In summary, the analysis of more than 270,000 kidney transplants recipients who were transplanted between January 1988 and August 2010 showed the following important points: Despite enormous progress in short-term graft survival in the last decades, long-term graft survival remained largely unchanged over the period from 1988 to 2010. The marked decline in acute rejection episodes in the early transplantation period mainly contributed to the improvement of shortterm graft survival. The immunosuppressive agents that were introduced in the past 3 decades have not improved long-term graft survival. Therefore, new treatment approaches are strongly required to prevent and treat chronic allograft injury especially caused by immunologic factors. Avoiding and controlling risk factors that are responsible for cardiovascular diseases are the sine qua non for increased long-term graft survival.

Transplant tourism in the United States: a single-center experience.

BACKGROUND AND OBJECTIVES: Transplant "tourism" typically refers to the practice of traveling outside the country of residence to obtain organ transplantation. This study describes the characteristics and outcomes of 33 kidney transplant recipients who traveled abroad for transplant and returned to University of California, Los Angeles (UCLA) for follow-up. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: Posttransplantation outcomes were compared between tourists and a matched cohort of patients who underwent transplantation at UCLA (matched for age, race, transplant year, dialysis time, previous transplantation, and donor type). Median follow-up time was 487 d (range 68 to 3056). RESULTS: Compared with all patients who underwent transplantation at UCLA, tourists included more Asians and had shorter dialysis times. Most patients traveled to their region of ethnicity with the majority undergoing transplantation in China (44%), Iran (16%), and the Philippines (13%). Living unrelated transplants were most common. Tourists presented to UCLA a median of 35 d after transplantation. Four patients required urgent hospitalization, three of whom lost their grafts. Seventeen (52%) patients had infections, with nine requiring hospitalization. One patient lost her graft and subsequently died from complications related to donor-contracted hepatitis B. One-year graft survival was 89% for tourists and 98% for the matched UCLA cohort (P = 0.75). The rate of acute rejection at 1 yr was 30% in tourists and 12% in the matched cohort. CONCLUSIONS: Tourists had a more complex posttransplantation course with a higher incidence of acute rejection and severe infectious complications.

Kidney transplantation in the United States.

This chapter summarizes data on 159,119 deceased donor (DD) and 83,471 living donor (LD) kidney transplants reported to the OPTN/ UNOS registry during the 20-year period between 1988 and 2007. The 15-year graft survival rates for transplants performed during 1991-1995 were 25% for 32,327 DD and 40% for 13,992 LD recipients. Graft survival rates improved modestly (4% for DD and 2% for LD) transplants performed during 1996-2005. Graft half-lives rose from 8 to 10 years for DD and from 12 to 18 years for LD transplant recipients during the study period. The number of DD kidney recipients over age 50 increased from 1,620 in 1988 to 4,492 in 2007 with no corresponding increase in the number of younger transplants. Annual LD kidney transplants increased from 1,816 in 1988 to 6,273 in 2004, but the rapid growth in LD transplants leveled off in 2001-2002 and may be falling in more recent years. The growth and slowdown of LD transplants occurred at different times for different groups of LD according to their relationship to the patient. Parent donor transplants have not increased substantially, whereas offspring-to-parent graft, spouse and sibling transplants increased rapidly in the early to mid-1990's donors and leveled off in 2001-2002. Other unrelated LD transplants began to rise in 1995 and continued to increase until 2005. Parent-to-child transplants have declined 33% since the new UNOS prioritization of pediatric recipients for young adult DD kidneys in 2005. The difference in 10-year DD kidney survival between the best and worst HLA-matched combinations was 10%, with halflives ranging from 11.6 years to 8.6 years. Nearly one-third of DD transplants performed during 1996-2005 were completely HLA mismatched (5-6 HLA-A,B,DR mismatches) compared with 15% of transplants with no HLA antigens mismatched. About 11% of LD transplants were HLA-matched (most HLA-identical siblings) and 10-year graft survival was 74% compared with 58% for HLA mismatched transplants. There was no survival difference associated with increasing HLA mismatches among LD kidney recipients. The graft half-lives were 27 years for HLA-matched and 15 years for HLA-mismatched LD transplants The increasing use of newer solid-phase tests for HLA-antibodies appears to have inflated recent PRA estimates for sensitized patients as suggested by the increasing percentage of highly sensitized (80+% PRA) patients transplanted since 2003 (from 25 to 40% of retransplanted patients). Three-year graft survival rates for broadly sensitized recipients during 2004-2007 was 77% (vs 79% for less sensitized) compared with 74% (vs 80% for less sensitized) during 1999-2003, which was more similar to the less sensitized patients in either period. There was considerable variability among centers in the percentage of broadly sensitized patients that were transplanted during each period, but most centers reported transplanting more sensitized patients between 2004-2007. Cold ischemia times (CIT) for DD kidney transplants have been reduced over the past 20 years from an average of 24 hours during 1988-1992 to 18 hours in 2003-2007. Despite this reduction in CIT, the incidence of delayed graft function has remained at 25% each year since 1990. The effect of prolonged CIT (> 30 hours) on graft survival was a 1% reduction over 10 years for DD kidneys under age 35 and a 4% reduction for DD kidneys over age 55 compared with the graft survival results for DD kidneys in either age group transplanted within 18 hours.

Renal transplantation in Indo-Asian patients in the UK.

Membership of some ethnic groups has an effect on renal transplant outcome but little is known about the impact of Indo-Asian ethnicity, despite this group's high incidence of renal disease. We compared outcomes in Indo-Asians and Caucasians at the Hammersmith Hospital (Indo-Asians, N = 46; Caucasians, N = 90), in the Long-Term Efficacy and Safety Surveillance (LOTESS) database of cyclosporin-treated renal transplant recipients (Indo-Asians, N = 254; Caucasians, N = 4262) and the National Transplant Database held by UK Transplant (Indo-Asians, N = 459; Caucasians, N = 4831). The baseline demographic and co-morbid characteristics of the two ethnic groups were comparable, save for more diabetes in the Indo-Asian community. Following transplantation, the incidence of delayed graft function and steroid-resistant acute rejection were also comparable, as were graft and patient survival (out to 5 years) and graft function. In addition, post-transplant blood pressure, levels of cholesterol and triglycerides and exposure to corticosteroids and cyclosporin were comparable. However, when patients who were not diabetic before transplantation were studied separately, there was an increased incidence of diabetes in the Indo-Asian community (Hammersmith data: Indo-Asians 10.9% vs. Caucasians 3.3%, p = 0.02; LOTESS data Indo-Asians 5.5% vs. Caucasians 1.6%, p < 0.0001). Subsequent management of this group should pursue immunosuppressive regimens less likely to impair post-transplant glucose tolerance.