Faculty Bibliography

Racial disparities in living donor kidney transplantation (LDKT) persist but the most effective target to eliminate these disparities remains unknown. One potential target could be delays during completion of the live donor evaluation process. We studied racial differences in progression through the evaluation process for 247 African American (AA) and 664 non-AA living donor candidates at our center between January 2011 and March 2015. AA candidates were more likely to be obese (38% vs 22%: P < .001), biologically related (66% vs 44%: P < .001), and live ≤50 miles from the center (64% vs 37%: P < .001) than non-AAs. Even after adjusting for these differences, AAs were less likely to progress from referral to donation (aHR for AA vs non-AA: _0.26 0.47 _0.83; P = .01). We then assessed racial differences in completion of each step of the evaluation process and found disparities in progression from medical screening to in-person evaluation (aHR: _0.41 0.62_0.94; P = .02) and from clearance to donation (aHR: _0.28 0.51_0.91; P = .02), compared with from referral to medical screening (aHR: _0.78 1.02_1.33; P = .95) and from in-person evaluation to clearance (aHR: _0.59 0.93_1.44; P = .54). Delays may be a manifestation of the transplant candidate's social network, thus, targeted efforts to optimize networks for identification of donor candidates may help address LDKT disparities.

BACKGROUND:Efforts are underway to improve living kidney donor (LKD) education, but current LKD concerns and information-gathering preferences have not been ascertained to inform evidence-based resource development. As a result, prior studies have found that donors desire information that is not included in current informed consent and/or educational materials. METHODS:We conducted semi-structured interviews with 50 LKDs who donated at our center to assess (1) concerns about donation that they either had personally before or after donation or heard from family members or friends, (2) information that they had desired before donation, and (3) where they sought information about donation. We used thematic analysis of verbatim interview transcriptions to identify donation-related concerns. We compared the demographic characteristics of participants reporting specific concerns using Fisher's exact test. RESULTS:We identified 19 unique concerns that participants had or heard about living kidney donation. 20% of participants reported having had no pre-donation concerns; 38% reported no post-donation concerns. The most common concern pre-donation was future kidney failure (22%), post-donation was the recovery process (24%), and from family was endangering their family unit (16%). 44% of participants reported being less concerned than family. 26% of participants wished they had had additional information prior to donating, including practical advice for recovery (10%) and information about specific complications (14%). Caucasian participants were more likely to hear at least one concern from family (76% vs. 33%, p = 0.02). The most commonly consulted educational resources were health care providers (100%) and websites (79% of donors since 2000). 26% of participants had had contact with other donors; an additional 20% desired contact with other LKDs. CONCLUSIONS:Potential donors not only have personal donation-related concerns but frequently hear donation-related concerns from family members and friends. Current gaps in donor education include an absence of practical, peer-to-peer advice about donation from other prior donors and materials directed and potential donors' family members and friends. These findings can inform the development of new educational practices and resources targeted not only at LKDs but at their social networks.

BACKGROUND:The availability of direct-acting antiviral (DAA) therapy might have impacted use of hepatitis C virus (HCV)-infected (HCV+) deceased donor kidneys for transplantation. METHODS:We used 2005 to 2018 Scientific Registry of Transplant Recipients data to identify 18 936 candidates willing to accept HCV+ kidneys and 3348 HCV+ recipients of HCV+ kidneys. We compared willingness to accept, utilization, discard, and posttransplant outcomes associated with HCV+ kidneys between 2 treatment eras (interferon [IFN] era, January 1, 2005 to December 5, 2013 vs DAA era, December 6, 2013 to August 2, 2018). Models were adjusted for candidate, recipient, and donor factors where appropriate. RESULTS:In the DAA era, candidates were 2.2 times more likely to list as willing to accept HCV+ kidneys (adjusted odds ratio, 2.072.232.41; P < 0.001), and HCV+ recipients were 1.95 times more likely to have received an HCV+ kidney (adjusted odds ratio, 1.761.952.16; P < 0.001). Median Kidney Donor Profile Index of HCV+ kidneys decreased from 77 (interquartile range [IQR], 59-90) in 2005 to 53 (IQR, 40-67) in 2017. Kidney Donor Profile Index of HCV- kidneys remained unchanged from 45 (IQR, 21-74) to 47 (IQR, 24-73). After adjustment, HCV+ kidneys were 3.7 times more likely to be discarded than HCV- kidneys in the DAA era (adjusted relative rate, 3.363.674.02; P < 0.001); an increase from the IFN era (adjusted relative rate, 2.783.023.27; P < 0.001). HCV+ kidney use was concentrated within a subset of centers; 22.5% of centers performed 75% of all HCV+ kidney transplants in the DAA era. Mortality risk associated with HCV+ kidneys remained unchanged (aHR, 1.071.191.32 in both eras). CONCLUSIONS:Given the elevated risk of death on dialysis facing HCV+ candidates, improving quality of HCV+ kidneys, and DAA availability, broader utilization of HCV+ kidneys is warranted to improve access in this era of organ shortage.

Organs from deceased donors with suspected false-positive HIV screening tests were generally discarded due to the chance that the test was truly positive. However, the HIV Organ Policy Equity (HOPE) Act now facilitates use of such organs for transplantation to HIV-infected (HIV+) individuals. In the HOPE in Action trial, donors without a known HIV infection who unexpectedly tested positive for anti-HIV antibody (Ab) or HIV nucleic acid test (NAT) were classified as suspected false-positive donors. Between March 2016 and March 2018, 10 suspected false-positive donors had organs recovered for transplant for 21 HIV + recipients (14 single-kidney, 1 double-kidney, 5 liver, 1 simultaneous liver-kidney). Median donor age was 24 years; cause of death was trauma (n = 5), stroke (n = 4), and anoxia (n = 1); three donors were labeled Public Health Service increased infectious risk. Median kidney donor profile index was 30.5 (IQR 22-58). Eight donors were HIV Ab+/NAT-; two were HIV Ab-/NAT+. All 10 suspected false-positive donors were confirmed to be HIV-noninfected. Given the false-positive rates of approved assays used to screen > 20 000 deceased donors annually, we estimate 50-100 HIV false-positive donors per year. Organ transplantation from suspected HIV false-positive donors is an unexpected benefit of the HOPE Act that provides another novel organ source.

BACKGROUND:The donation of multiple allografts from a single living donor is a rare practice, and the patient characteristics and outcomes associated with these procedures are not well described. METHODS:Using the Scientific Registry of Transplant Recipients, we identified 101 living multiorgan donors and their 133 recipients. RESULTS:The 49 sequential (donations during separate procedures) multiorgan donors provided grafts to 81 recipients: 21 kidney-then-liver, 15 liver-then-kidney, 5 lung-then-kidney, 3 liver-then-intestine, 3 kidney-then-pancreas, 1 lung-then-liver, and 1 pancreas-then-kidney. Of these donors, 38% donated 2 grafts to the same recipient and 15% donated 2 grafts as non-directed donors. Compared to recipients from first-time, single organ living donors, recipients from second-time living donors had similar graft and patient survival. The 52 simultaneous (multiple donations during one procedure) multiorgan donors provided 2 grafts to 1 recipient each: 48 kidney-pancreas and 4 liver-intestine. Donors had median of 13.4 years (interquartile range, 8.3-18.5 years) of follow-up. There was one reported death of a sequential donor (2.5 years after second donation). Few postdonation complications were reported over a median of 116 days (interquartile range, 0-295 days) of follow-up; however, routine living donor follow-up data were sparse. Recipients of kidneys from second-time living donors had similar graft (P = 0.2) and patient survival (P = 0.4) when compared with recipients from first-time living donors. Similarly, recipients of livers from second-time living donors had similar graft survival (P = 0.9) and patient survival (P = 0.7) when compared with recipients from first-time living donors. CONCLUSIONS:Careful documentation of outcomes is needed to ensure ethical practices in selection, informed consent, and postdonation care of this unique donor community.

One criticism of kidney paired donation (KPD) is that easy-to-match candidates leave the registry quickly, thus concentrating the pool with hard-to-match sensitized and blood type O candidates. We studied candidate/donor pairs who registered with the National Kidney Registry (NKR), the largest US KPD clearinghouse, from January 2012-June 2016. There were no changes in age, gender, BMI, race, ABO blood type, or panel-reactive antibody (PRA) of newly registering candidates over time, with consistent registration of hard-to-match candidates (59% type O and 38% PRA ≥97%). However, there was no accumulation of type O candidates over time, presumably due to increasing numbers of nondirected type O donors. Although there was an initial accumulation of candidates with PRA ≥97% (from 33% of the pool in 2012% to 43% in 2014, P = .03), the proportion decreased to 17% by June 2016 (P < .001). Some of this is explained by an increase in the proportion of candidates with PRA ≥97% who underwent a deceased donor kidney transplantation (DDKT) after the implementation of the Kidney Allocation System (KAS), from 8% of 2012 registrants to 17% of 2015 registrants (P = .02). In this large KPD clearinghouse, increasing participation of nondirected donors and the KAS have lessened the accumulation of hard-to-match candidates, but highly sensitized candidates remain hard-to-match.

BACKGROUND:HIV+ donor organs can now be transplanted into HIV+ recipients (HIV D+/R+) following the HIV Organ Policy Equity (HOPE) Act. Implementation of the HOPE Act requires transplant center awareness and support of HIV D+/R+ transplants. METHODS:To assess center-level barriers to implementation, we surveyed 209 transplant centers on knowledge, attitudes, and planned HIV D+/R+ protocols. RESULTS:Responding centers (n = 114; 56%) represented all UNOS regions. Fifty centers (93 organ programs) planned HIV D+/R+ protocols (kidney n = 48, liver n = 34, pancreas n = 8, heart n = 2, lung = 1), primarily in the eastern United States (28/50). Most (91.2%) were aware that HIV D+/R+ transplantation is legal; 21.4% were unaware of research restrictions. Respondents generally agreed with HOPE research criteria except the required experience with ≥5 HIV+ transplants by organ type. Centers planning HIV D+/R+ protocols had higher transplant volume, HIV+ recipient volume, increased infectious risk donor utilization, and local HIV prevalence (P < 0.01). Centers not planning HIV D+/R+ protocols were more likely to believe their HIV+ candidates would not accept HIV+ donor organs (P < 0.001). Most centers (83.2%) supported HIV+ living donation. CONCLUSIONS:Although many programs plan HIV D+/R+ transplantation, center-level barriers remain including geographic clustering of kidney/liver programs and concerns about HIV+ candidate willingness to accept HIV+ donor organs.

Development of end-stage renal disease (ESRD) in living kidney donors is associated with increased graft loss in the recipients of their kidneys. Our goal was to investigate if this relationship was reflected at an earlier stage postdonation, possibly early enough for recipient risk prediction based on donor response to nephrectomy. Using national registry data, we studied 29 464 recipients and their donors from 2008-2016 to determine the association between donor 6-month postnephrectomy estimated GFR (eGFR) and recipient death-censored graft failure (DCGF). We explored donor BMI as an effect modifier, given the association between obesity and hyperfiltration. On average, risk of DCGF increased with each 10 mL/min decrement in postdonation eGFR (adjusted hazard ratio [aHR] 1.06, 95% confidence interval [CI] 1.02-1.10, P = .007). The association was attenuated with higher donor BMI (interaction P = .049): recipients from donors with BMI = 20 (aHR 1.12, 95% CI 1.04-1.19, P = .002) and BMI = 25 (aHR 1.07, 95% CI 1.03-1.12, P = .001) had a higher risk of DCGF with each 10 mL/min decrement in postdonation eGFR, whereas recipients from donors with BMI = 30 and BMI = 35 did not have a higher risk. The relationship between postdonation eGFR, donor BMI, and recipient graft loss can inform counseling and management of living donor kidney transplant recipients.