Faculty Bibliography

BACKGROUND AND OBJECTIVES:Long wait times for deceased donor kidneys and low rates of preemptive wait-listing have limited preemptive transplantation in the United States. We aimed to assess trends in preemptive deceased donor transplantation with the introduction of the new Kidney Allocation System (KAS) in 2014 and identify whether key disparities in preemptive transplantation have changed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:We identified adult deceased donor kidney transplant recipients in the United States from 2000 to 2018 using the Scientific Registry of Transplant Recipients. Preemptive transplantation was defined as no dialysis before transplant. Associations between recipient, donor, transplant, and policy era characteristics and preemptive transplantation were calculated using logistic regression. To test for modification by KAS policy era, an interaction term between policy era and each characteristic of interest was introduced in bivariate and adjusted models. RESULTS:<0.05). Medicare patients had a significantly lower odds of preemptive transplantation relative to private insurance holders (pre-KAS adjusted OR, [aOR] 0.26; [95% CI, 0.25 to 0.27], to 0.20 [95% CI, 0.18 to 0.22] post-KAS). Black and Hispanic patients experienced a similar phenomenon (aOR 0.48 [95% CI, 0.45 to 0.51] to 0.41 [95% CI, 0.37 to 0.45] and 0.43 [95% CI, 0.40 to 0.47] to 0.40 [95% CI, 0.36 to 0.46] respectively) compared with white patients. CONCLUSIONS:Although the proportion of deceased donor kidney transplants performed preemptively increased slightly after KAS, disparities in preemptive kidney transplantation persisted after the 2014 KAS policy changes and were exacerbated for racial minorities and Medicare patients.

Asian Americans have the lowest organ donation registration rates in the United States, and the reason for this is incompletely understood. Aiming to understand the reasons for low organ donation registration rate among Asian Americans, more specifically Chinese and Korean Americans, we conducted a systematic search of databases, websites, and gray literature. Altogether, 34 papers were retained after the assessment of relevance and quality. Commonly reported barriers to organ donation registration among Chinese and Koreans in the literature included lack of knowledge about organ donation, distrust of health-care and allocation system, cultural avoidance of discussion of death-related topics, and desire for intact body mainly stemming from the Confucian concept of filial piety. Strong family values coupled with a cultural reluctance to discuss death-related topics among family members appear to underscore the reluctance to organ donation among Chinese and Koreans. Notably, improved knowledge negatively impacted organ donation intent and religion seemed to play a more important role when making decision about organ donation among Koreans, and the distrust of the allocation system is more prominent among Chinese. This information should be used to inform the development of culturally competent organ donation educational materials.

BACKGROUND:Nonadherence to study protocols reduces the generalizability, validity, and statistical power of longitudinal studies. PURPOSE/OBJECTIVE:To determine whether an automated electronically-delivered regret lottery would improve adherence to an intensive mHealth self-monitoring protocol as part of a longitudinal observational study. METHODS:We enrolled 77 adults into a 52-week study requiring five daily ecologic momentary assessments (EMA) of stress and daily accelerometer use. We performed a pre/post single-arm study to evaluate the efficacy of a lottery intervention in improving adherence to this protocol. Midway through the study, participants were invited to enter a weekly regret lottery ($50 prize, expected value <$1) in which prize collection was contingent upon meeting adherence thresholds for the prior week. Study protocol adherence before and after lottery initiation were compared using mixed models repeated measures analysis of variance. RESULTS:62 participants consented to lottery participation. In the 12 weeks prior to lottery initiation, weekly adherence was declining (slope -1.4%/week). The weekly per-participant probability of adherence was higher after lottery initiation when comparing the 4-week (32% pre-lottery vs 50% post-lottery, p < 0.001), 8-week (37% vs 49%, p < 0.001), and 12-week periods (39% vs 45%, p = 0.001) before and after lottery initiation. However, the rate of decline in adherence over time was unchanged. CONCLUSION/CONCLUSIONS:The implementation of an automated, electronically-delivered weekly regret lottery improved adherence with an intensive self-monitoring study protocol. Regret lotteries may represent a cost-effective tool to improve adherence and reduce bias caused by dropout or nonadherence.

IMPORTANCE:In the United States, substantial disparities in access to kidney transplant exist for wait-listed candidates with end-stage renal disease. The implications of transplant centers' willingness to accept kidney offers for access to transplant and mortality outcomes are unknown. OBJECTIVE:To determine the outcomes for wait-listed kidney transplant candidates after the transplant center's refusal of a deceased donor kidney offer. DESIGN, SETTING, AND PARTICIPANTS:This cohort study obtained data from the United Network for Organ Sharing Potential Transplant Recipient data set on all deceased donor kidney offers in the United States made between January 1, 2008, and December 31, 2015. The final study cohort included adult patients who were wait-listed for kidney transplant and received at least 1 allograft offer during the study period (N = 280 041). Data analysis was conducted from June 1, 2018, to March 30, 2019. EXPOSURE:Candidate state of residence. MAIN OUTCOMES AND MEASURES:Waiting list outcome event groups included received deceased donor allograft, received living donor allograft, died while on the waiting list, removed from the waiting list without a transplant, or still on the waiting list at the end of follow-up. RESULTS:Among the 280 041 kidney transplant candidates included in the study, the mean (SD) age at wait-listing was 51.1 (13.1) years, and male patients were predominant (171 517 [61.2%]). In this cohort, 81 750 candidates (29.2%) received a deceased donor kidney allograft, 30 870 (11.0%) received a living donor allograft, 25 967 (9.3%) died while on the waiting list, and 59 359 (21.2%) were removed from the waiting list. Overall, 10 candidates with at least 1 previous allograft offer died each day during the study period. Time to first offer was similar for candidates who received deceased donor kidney allograft compared with those who died while waiting (median [interquartile range {IQR}] time, 79 [16-426] days vs 78 [17-401] days, respectively). Deceased donor allograft recipients had a median of 17 offers (IQR, 6-44) over 422 days (IQR, 106-909 days), whereas candidates who died while waiting received a median of 16 offers (IQR, 6-41) over 651 days (IQR, 304-1117 days). Most kidneys (84%) were declined on behalf of at least 1 candidate before being accepted for transplant. As reported by centers, organ or donor quality concerns accounted for 8 416 474 (92.6%) of all declined offers, whereas offers were infrequently refused because of patient-related factors (232 193 [2.6%]), logistical limitations (49 492 [0.5%]), or other concerns. The odds of death after an offer and the median number of offers received prior to death varied considerably by state. CONCLUSIONS AND RELEVANCE:This study found that transplant candidates appeared to receive a large number of viable deceased donor kidney offers that were refused on their behalf by transplant centers, potentially exacerbating the detrimental consequences of the organ shortage; increased transparency in organ allocation process and decisions may improve patient-centered care and access to kidney transplant.

While deceased donor renal transplants (DDRT) from donors with either acute kidney injury (AKI) or long cold ischemia time (CIT) are associated with increased risk of delayed graft function (DGF), recipients of these kidneys have good patient and allograft survival. There are limited data on whether kidneys with both AKI and long CIT have outcomes similar to kidneys with only one of these insults. Using data from the Scientific Registry of Transplant Recipients, we analyzed transplant outcomes in patients (2005-2015) receiving kidneys with AKI (terminal creatinine ≥2.0 mg/dl) and CIT 24-30 h (n = 1289), 30-36 h (n = 734), and >36 h (n = 614), using kidneys with AKI and CIT <24 h (n = 5434) as a reference. DGF was more common with increasing CIT up to 36 h, then decreased slightly (41.2% vs. 46.8% vs. 52.5% vs. 50.2%, P < 0.001). Death-censored graft survival (DCGS) at 3 years was better with CIT <24 h compared with other groups (92.5% vs. 90.8% vs. 92% vs. 89.2%, P = 0.018). On multivariable analysis, donor creatinine was predictive of DCGS, whereas only CIT >36 h was predictive of DCGS (aHR 1.27, P = 0.03). Recipients transplanted with kidneys with both AKI and long CIT have excellent intermediate-term outcomes.

The presence of 2 APOL1 risk variants (G1/G1, G1/G2, or G2/G2) is an important predictor of focal segmental glomerulosclerosis (FSGS) and chronic kidney disease in individuals of African descent. Although recipient APOL1 genotype is not associated with allograft survival, kidneys from deceased African American donors with 2 APOL1 risk variants demonstrate shorter graft survival. We present a series of cases of presumed de novo collapsing FSGS in 5 transplanted kidneys from 3 deceased donors later identified as carrying 2 APOL1 risk alleles, including 2 recipients from the same donor whose kidneys were transplanted in 2 different institutions. Four of these recipients had viremia in the period preceding the diagnosis of collapsing FSGS. Cytomegalovirus and BK virus infection were present in 3 and 1 of our 5 cases, respectively, around the time that collapsing FSGS occurred. We discuss viral infections, including active cytomegalovirus infection, as possible "second hits" that may lead to glomerular injury and allograft failure in these recipients. Further studies to identify additional second hits are necessary to better understand the pathologic mechanisms of donor APOL1-associated kidney disease in the recipient.