Epstein-Barr virus (EBV) transmission from donor to naïve recipients (D+/R-) is a major risk for post-transplant lymphoproliferative disorder (PTLD). Blood EBV-DNA monitoring (EBV-DNAemia) is recommended, but the optimal blood matrix remains unclear. This 2-year prospective study of de novo kidney transplant recipients investigated the incidence and clinical significance of EBV-DNAemia in plasma and whole blood. The study estimated the positive and negative predictive values (PPV, NPV) of EBV-DNAemia kinetics for EBV-associated PTLD. Persistent EBV-DNAemia was examined as a predictor of excessive immunosuppression, defined by a composite endpoint of ≥2 infections requiring hospitalization, infection-related death, or EBV-associated PTLD. Of 509 enrolled recipients, 11 developed PTLD; 8 were EBV associated (20% of EBV D+/R- recipients, incidence rate = 8.0 (95% CI, 4.0-16.1) per 1000 patient-years). Plasma or whole-blood EBV-DNAemia were detected in 107 (21.0%) and 311 (61.1%) recipients, respectively, yielding an NPV >99% for EBV-associated PTLD in both matrices. PPVs were highest for a ≥3-fold increase in plasma EBV-DNA (PPV = 88.9%) and whole-blood EBV-DNA levels ≥50 000 IU/mL (PPV = 50.0%) among EBV D+/R- recipients. Persistent plasma EBV-DNAemia was associated with the composite endpoint (HR = 3.2; 95% CI, 1.8-5.7), predominantly driven by PTLD. Recognition of specific EBV-DNA kinetics in plasma and whole blood should promote clinical evaluation for PTLD.

Posttransplant lymphoproliferative disorder (PTLD) poses a serious challenge in kidney transplant recipients. Epstein-Barr virus (EBV)-seronegative recipients have a significantly increased risk of PTLD, but few studies have investigated risk factors for PTLD in EBV-seronegative recipients in the current era of immunosuppression. This cohort study from Norway and western Denmark included first-time kidney transplant recipients between 2007 and 2021 and estimated the cumulative incidence, risk, and prognosis of PTLD. In total, 80 of 5084 recipients developed biopsy-proven PTLD (median follow-up of 6.8 years). Two-year cumulative incidence of PTLD was 7.3% in EBV-seronegative adults and 14.1% in EBV-seronegative children. The age-adjusted hazard ratio (HR) for PTLD was 30.7 (95% CI, 13.9-67.9) in EBV-seronegative vs EBV-seropositive adults and 5.4 (95% CI, 1.1-26.9) in children. Recipients receiving induction therapy with antithymocyte globulin had an increased risk of PTLD (HR, 4.4; 95% CI, 1.8-10.6), while rituximab induction was associated with a lower risk of PTLD (HR, 0.20; 95% CI, 0.03-1.49). The age-adjusted mortality rate was higher in EBV-seronegative recipients with vs without PTLD (HR, 3.3; 95% CI, 1.3-8.3). In conclusion, the risk of PTLD in EBV-seronegative kidney transplant recipients is high in the contemporary era of immunosuppression. Induction therapy should be carefully considered in this high-risk population.

BackgroundAn inflammatory environment following kidney transplantation is associated with increased risk of graft loss and mortality, however, evaluation of systemic inflammation is not implemented in structured risk assessment in kidney transplant recipients. Long-term results after transplantation are not satisfactory, and thus tools addressing these issues are needed. In this study, we tested the associations and predictive abilities of a predefined systemic inflammation score one year after transplantation on death-censored graft loss and mortality.MethodsWe included 805 patients who underwent kidney transplantation between 2013 and 2017 at the Oslo University Hospital, Rikshospitalet. The inflammation score included five specifically selected biomarkers known to reflect various inflammatory pathways and to be associated with adverse outcomes following transplantation. The score was assessed in relation to outcomes in models with established risk factors. Discriminatory analyses were performed using Harrell´s C-statistic, and model assessment were evaluated using internal validation, calibration, and likelihood ratio tests.ResultsThe median follow-up time was 6.4 years. There were 168 deaths (20.9%) and 42 graft losses (5.2%). The inflammation score one year after transplantation was significantly associated with graft loss (P<0.001) and mortality (P<0.001). The diagnostic performance of the model for graft loss revealed a c-statistic of 0.77 both with and without histological data. The diagnostic performance for mortality displayed a c-statistic of 0.79. In all tested scenarios, the model fit significantly improved after including the inflammation score.ConclusionsThese results suggest a strong association between systemic inflammation one year after transplantation and both graft loss and mortality. Predictive models including the inflammation score and established risk factors were particularly informative when considering mortality. Evaluation of systemic inflammation using this score could be an important tool for risk-assessment after transplantation.

Background. The clinical significance of kidney transplant protocol biopsies has been debated. We studied the frequency of borderline changes and T cell–mediated rejection (TCMR) in 1-y protocol biopsies in standard risk kidney transplant recipients. Methods. Consecutive non-HLA-sensitized recipients of kidney transplants between 2006 and 2017, who underwent a protocol biopsy at 1 y in 2 national transplant centers were studied retrospectively (N = 1546). Donor-specific HLA antibodies (DSAs), graft function (plasma creatinine), and proteinuria were measured at the time of 1-y protocol biopsy. The occurrence of subclinical acute TCMR (i2t2v0 or higher) or borderline changes suspicious of TCMR (i1t1v0 or higher) in the protocol biopsy was studied, together with frequency of findings causing changes in the composite score iBox. Results. Subclinical acute TCMR was detected in 30 of 1546 (1.9%) of the protocol biopsies, and borderline or TCMR in 179 of 1546 (12%). Among patients with no history of acute rejection, and no proteinuria or DSA, TCMR was detected in only 1 of 974 (0.1%) and borderline or TCMR in only 48 of 974 (4.9%) patients at 1 y. In the absence of proteinuria (<30 mg/g, or equivalent as measured with a negative dipstick proteinuria) or DSA, or history of acute rejection, only 50 of 974 (5.1%) biopsies showed any lesions significant for the iBox score. Conclusions. The likelihood of pathological findings in 1-y protocol biopsies in non-HLA-sensitized patients without previous immunological events is low. Clinical usefulness of protocol biopsies seems limited in these patients.

IntroductionCytomegalovirus (CMV) infection remains a challenge following kidney transplantation (KTx). Currently, CMV-IgG serostatus at transplantation is used to individualize CMV preventive strategies. We assessed the clinical utility of CMV-IGRA for predicting CMV infection following KTx.MethodsWe performed a nationwide prospective cohort study from August 2016 until December 2022. Data from all adult KTx recipients in Norway, n=1,546 (R+; n=1,157, D+/R-; n=260, D-/R-; 129), were included with a total of 3,556 CMV-IGRA analyses (1,375 at KTx, 1,188 at eight weeks, 993 one-year after KTx) and 35,782 CMV DNAemia analyses.ResultsIn R+ recipients CMV-IGRA status, measured at any of the time-points, could not identify any differential risk of later CMV infection. D+/R- recipients remaining CMV-IGRA negative 1-year after transplantation (regardless of positive CMV DNAemia and/or CMV IgG status at that time) had increased risk of developing later CMV infection compared to D+/R- recipients who had become CMV-IGRA positive (14% vs. 2%, p=0.01).ConclusionKnowledge of pre-transplant CMV-IGRA status did not provide additional information to CMV-IgG serostatus that could improve current post-transplant CMV treatment algorithms. However, D+/R- recipients with a persisting negative CMV-IGRA one-year after transplantation remained at increased risk of experiencing later CMV infection. Therefore we advocate post-transplant CMV-IGRA monitoring in these patients.

Background Preemptive kidney transplantation (PEKT) has better outcomes when compared with transplantation after dialysis. We aimed to examine trends in PEKT between 2000 and 2019 in Europe and to provide an overview of associated policies, barriers and initiatives.Methods Adult patients from 12 European countries who received a preemptive kidney transplant were included. The representatives of the registries providing these data were questioned on the policies, barriers and initiatives around PEKT.Results Between 2000 and 2019, 20 251 adults underwent PEKT [11 169 from living donors (LDs), 8937 from deceased donors (DDs)]. The proportion of first kidney transplantations that were preemptive more than doubled from 7% in 2000 to 18% in 2019, reflecting a similar relative increase for LD kidney recipients (from 21% to 43%) and DD kidney recipients (from 4% to 11%). Large international differences were found. The increase in PEKT was observed across all age, sex and primary renal disease groups. Countries had similar criteria for preemptive waitlisting. Barriers mentioned included donor shortage, late referral to the transplant center and long donor or recipient work-up. Suggested initiatives included raising awareness on the possibility of PEKT, earlier start and shorter work-up time for recipient and LD.Results Between 2000 and 2019, 20 251 adults underwent PEKT [11 169 from living donors (LDs), 8937 from deceased donors (DDs)]. The proportion of first kidney transplantations that were preemptive more than doubled from 7% in 2000 to 18% in 2019, reflecting a similar relative increase for LD kidney recipients (from 21% to 43%) and DD kidney recipients (from 4% to 11%). Large international differences were found. The increase in PEKT was observed across all age, sex and primary renal disease groups. Countries had similar criteria for preemptive waitlisting. Barriers mentioned included donor shortage, late referral to the transplant center and long donor or recipient work-up. Suggested initiatives included raising awareness on the possibility of PEKT, earlier start and shorter work-up time for recipient and LD.Conclusions Over the last two decades the proportion of patients receiving a first kidney transplant preemptively has more than doubled, reflecting a similar relative increase for living and DD kidney recipients. Graphical Abstract 10.1093/ndt/gfae105 Video Abstract Watch the video of this contribution at https://academic.oup.com/ndt/pages/author_videos gfae105Media1 6362063390112

Background. Trabecular bone score (TBS) is a new tool to assess trabecular bone microarchitecture based on standard dual-energy x-ray absorptiometry (DXA) of lumbar spine images. TBS may be important to assess bone quality and fracture susceptibility in kidney transplant recipients (KTRs). This study aimed to investigate the effect of different bone therapies on TBS in KTRs. Methods. We reanalyzed DXA scans to assess TBS in 121 de novo KTRs at baseline, 10 wk, and 1 y. This cohort, between 2007 and 2009, participated in a randomized, placebo-controlled trial evaluating the effect of ibandronate versus placebo in addition to vitamin D and calcium. Results. Although bone mineral density (BMD) Z scores showed a subtle decrease in the first weeks, TBS Z scores increased from baseline to 10 wk for both treatment groups, followed by a slight decline at 12 mo. When comparing treatment groups and adjusting for baseline TBS, there were no differences found in TBS at 12 mo (P = 0.419). Correlation between TBS and BMD at baseline was weak (Spearman’s ρ = 0.234, P = 0.010), and change in TBS was not correlated with changes in lumbar spine BMD in either of the groups (ρ = 0.003, P = 0.973). Conclusions. Treatment with ibandronate or vitamin D and calcium did not affect bone quality as measured by TBS in de novo KTRs, but TBS increased early, irrespective of intervention. Changes in TBS and BMD during the study period were not correlated, indicating that these measurements reflect different aspects of bone integrity. TBS may complement BMD assessment in identifying KTRs with a high fracture risk.

Background:Kidney transplant recipients (KTRs) experienced reduced SARS-CoV-2 vaccine response and were at increased risk of severe COVID-19. It is unknown if level of vaccine induced anti-receptor binding domain IgG (anti-RBD IgG) correlates with protection from and survival following COVID-19. We aimed to evaluate the effect of vaccine response on risk of breakthrough infections (BTI) and COVID-19 death in KTRs. Methods:We performed a nationwide study, examining the competing risk of SARS-CoV-2 infection, COVID-19 related/unrelated death, and vaccine efficacy as assessed by level of anti-RBD IgG response 4-10 weeks after each vaccination. The study included all KTR in Norway alive and with a functioning graft on February 20th, 2020, and events after November 11th, 2022 were right-censored. A pre-pandemic reference-cohort from January 1st 2019 to January 1st 2020 was included to evaluate excess mortality. The study was conducted at Oslo University Hospital, Rikshospitalet, Norway. Findings:The study included 3607 KTRs (59 [48-70] years) with a functioning graft at February 20th, 2020, who received (median [IQR]) 4 [3-4] vaccines (range 2-6, 99% mRNA). Anti-RBD IgG was measured in 12 701 serum samples provided by 3213 KTRs. Vaccine response was assessed 41 [31-57] days after vaccination. A total of 1090 KTRs were infected with SARS-CoV-2, 1005 (92%) were BTI, and vaccine response did not protect against BTI. The hazard ratio for COVID-19 related death 40 days post-infection was 1.71 (95% CI: 1.14, 2.56) comparing vaccine response levels (≥5 vs. ≥5000 BAU/mL). No excess non-COVID-19 mortality was registered in KTRs surviving SARS-CoV-2 infection compared to a 2019 pre-pandemic reference. Interpretation:Our findings suggested that SARS-CoV-2 mRNA vaccine response did not predict protection against infection, but prevention of fatal disease progression in KTRs and greater vaccine response further reduced the risk of COVID-19 death. No excess non-COVID-19 mortality was seen during the pandemic. Funding:CEPI and internal funds.

ABSTRACTBackgroundThe aim of this study was to describe the trends in the incidence, prevalence and survival of patients on kidney replacement therapy (KRT) for end-stage kidney disease (ESKD) across Europe from 2008 to 2017.MethodsData from renal registries in 9 countries and 16 regions that provided individual patient data to the ERA Registry from 2008 to 2017 were included. These registries cover 34% of the general population in Europe. Crude and standardized incidence and prevalence per million population (pmp) were determined. Trends over time were studied using Joinpoint regression. Survival probabilities were estimated using Kaplan–Meier analysis and hazard ratios (HRs) using Cox regression analysis.ResultsThe standardized incidence of KRT was stable [annual percentage change (APC): −1.48 (−3.15; 0.21)] from 2008 (146.0 pmp) to 2011 (141.6 pmp), followed by a slight increase [APC: 1.01 (0.43; 1.60)] to 148.0 pmp in 2017, although trends in incidence varied across countries. This increase was primarily due to a rise in the incidence of KRT in men older than 65 years. Moreover, as a cause of kidney failure, diabetes mellitus is increasing. The standardized prevalence increased from 2008 (990.0 pmp) to 2017 (1166.8 pmp) [APC: 1.82 (1.75; 1.89)]. Patient survival on KRT improved in the time period 2011–13 compared with 2008–[adjusted HR: 0.94 (0.93; 0.95)].ConclusionThis study showed an overall increase in the incidence and prevalence of KRT for ESKD as well as an increase in the KRT patient survival over the last decade in Europe.

Summary: Background: Kidney transplant recipients (KTR) are at high risk for severe COVID-19 and have demonstrated poor response to vaccination, making it unclear whether successive vaccinations offer immunity and protection. Methods: We conducted a serologically guided interventional study where KTR patients that failed to seroconvert were revaccinated and also monitored seroconversion of KTR following the Norwegian vaccination program. We analysed IgG anti-RBD Spike responses from dose 2 (n = 432) up to after the 6th (n = 37) mRNA vaccine dose. The frequency and phenotype of Spike-specific T and B cell responses were assessed in the interventional cohort after 3–4 vaccine doses (n = 30). Additionally, we evaluated the Specific T and B cell response to breakthrough infection (n = 32), measured inflammatory cytokines and broadly cross-neutralizing antibodies, and defined the incidence of COVID-19-related hospitalizations and deaths. The Norwegian KTR cohort has a male dominance (2323 males, 1297 females), PBMC were collected from 114 male and 78 female donors. Findings: After vaccine dose 3, most KTR developed Spike-specific T cell responses but had significantly reduced Spike-binding B cells and few memory cells. The B cell response included a cross-reactive subset that could bind Omicron VOC, which expanded after breakthrough infection (BTI) and gave rise to a memory IgG+ B cell response. After BTI, KTR had increased Spike-specific T cells, emergent non-Spike T and B cell responses, and a systemic inflammatory signature. Late seroconversion occurred after doses 5–6, but 38% (14/37) of KTR had no detectable immunity even after multiple vaccine doses. Interpretation: Boosting vaccination can induce Spike-specific immunity that may expand in breakthrough infections highlighting the benefit of vaccination to protect this vulnerable population. Funding: CEPI and internal funds.

Background Early graft loss following kidney transplantation is mainly a result of acute rejection or surgical complications, while long-term kidney allograft loss is more complex. We examined the association between systemic inflammation early after kidney transplantation and long-term graft loss, as well as correlations between systemic inflammation scores and inflammatory findings in biopsies 6 weeks and 1 year after kidney transplantation. Methods We measured 21 inflammatory biomarkers 10 weeks after transplantation in 699 patients who were transplanted between 2009 and 2012 at Oslo University Hospital, Rikshospitalet, Norway. Low-grade inflammation was assessed with predefined inflammation scores based on specific biomarkers: one overall inflammation score and five pathway-specific scores. Surveillance or indication biopsies were performed in all patients 6 weeks after transplantation. The scores were tested in Cox regression models. Results Median follow-up time was 9.1 years (interquartile range 7.6-10.7 years). During the study period, there were 84 (12.2%) death-censored graft losses. The overall inflammation score was associated with long-term kidney graft loss both when assessed as a continuous variable (hazard ratio 1.03, 95% CI 1.01-1.06, P = 0.005) and as a categorical variable (4 th quartile: hazard ratio 3.19, 95% CI 1.43-7.10, P = 0.005). In the pathway-specific analyses, fibrogenesis activity and vascular inflammation stood out. The vascular inflammation score was associated with inflammation in biopsies 6 weeks and 1 year after transplantation, while the fibrinogenesis score was associated with interstitial fibrosis and tubular atrophy. Conclusion In conclusion, a systemic inflammatory environment early after kidney transplantation was associated with biopsy-confirmed kidney graft pathology and long-term kidney graft loss. The systemic vascular inflammation score correlated with inflammatory findings in biopsies 6 weeks and 1 year after transplantation.

Background. Kidney transplantation (KT) is considered the best treatment for end-stage kidney disease (ESKD). In the increasing elderly ESKD population, KT should be reserved for carefully selected candidates who are expected to experience favorable outcomes. We aimed to prospectively evaluate pretransplant recipient factors that may predict patient survival and can eventually guide therapeutic decisions in elderly with ESKD. Methods. Recipient factors were evaluated in KT candidates aged ≥65 y. Comorbidity was assessed at waitlisting according to the Liu comorbidity index (LCI). Health-related quality of life outcomes were measured using the Kidney Disease Quality of Life Short Form, version 1.3. The Cox proportional hazard regression was used to evaluate predictors of patient survival. Results. We included 192 recipients, with a mean age of 72.1 (4.1) y, who were transplanted with kidneys from deceased brain-dead donors. During a median observation period of 4.6 (3.2–6.3) y, 66 recipients died. Elevated LCI consistently predicted poor patient survival. In recipients with LCI ≥4, dialysis >2 y comprised a 2.5-fold increase in mortality risk compared with recipients on dialysis ≤2 y. Self-reported pretransplant physical function was also proven to be a significant positive predictor of survival. Conclusion. The implementation of LCI and a physical function score during the evaluation of older kidney transplant candidates may improve the selection and thereby optimize posttransplant outcomes.

In the general population, low-grade inflammation has been established as a risk factor for all-cause mortality. We hypothesized that an inflammatory milieu beyond the time of recovery from the surgical trauma could be associated with increased long-term mortality in kidney transplant recipients (KTRs). This cohort study included 1044 KTRs. Median follow-up time post-engraftment was 10.3 years. Inflammation was assessed 10 weeks after transplantation by different composite inflammation scores based on 21 biomarkers. We constructed an overall inflammation score and five pathway-specific inflammation scores (fibrogenesis, vascular inflammation, metabolic inflammation, growth/angiogenesis, leukocyte activation). Mortality was assessed with Cox regression models adjusted for traditional risk factors. A total of 312 (29.9%) patients died during the follow-up period. The hazard ratio (HR) for death was 4.71 (95% CI: 2.85-7.81, p < .001) for patients in the highest quartile of the overall inflammation score and HRs 2.35-2.54 (95% CI: 1.40-3.96, 1.52-4.22, p = .001) for patients in the intermediate groups. The results were persistent when the score was analyzed as a continuous variable (HR 1.046, 95% CI: 1.033-1.056, p < .001). All pathway-specific analyses showed the same pattern with HRs ranging from 1.19 to 2.70. In conclusion, we found a strong and consistent association between low-grade systemic inflammation 10 weeks after kidney transplantation and long-term mortality.

In March 2009, the Scandiatransplant acceptable mismatch program (STAMP) was introduced as a strategy toward improving kidney allocation to highly sensitized patients. Patients with a transplantability score <= 2% are potential candidates for the program. Samples are analyzed and acceptable antigens (HLA-A, B, C, DRB1, DRB3/4/5, DQB1, DQA1, DPB1, DPA1) are defined by the local tissue typing laboratory and finally evaluated by a steering committee. In the matching algorithm, patients have the highest priority when the donor's antigens are all among the recipient's own or acceptable HLA antigens. In the period from 2009 to 2020, we have transplanted 278 highly sensitized kidney patients through the program. The graft survival of the STAMP patients was compared with 9002 deceased donor kidney-transplanted patients, transplanted in the same time period. The 10-year graft survival was 73.4% (95% CI: 60.3-90.0) for STAMP and 82.9% (95% CI: 81.6-84.3) for the reference group. (p = .2). In conclusion, the 10-year allograft survival demonstrates that the STAMP allocation algorithm is immunological safe. The program is continuously monitored and evaluated, and the introduction of matching for all HLA loci is a huge improvement to the program and demonstrate technical adaptability as well as clinical flexibility in a de-centralized organization.

Background: In 2003 we introduced the B-cell depleting agent rituximab as induction therapy for paediatric immunologic high-risk kidney transplantations (KT). Still, the use of rituximab induction has been limited and primarily restricted to ABO-incompatible KT. In adults, rituximab induction has been evaluated in two placebo-controlled trials as prophylactic anti-rejection therapy in KT (Tydén 2009 & van Hoogen 2015) However, although rituximab appeared safe, none of these studies could prove any clear benefit of the agent within 180 days of follow-up. In paediatric KT no such prospective trial has been performed. In fact, little has been reported on rituximab induction in paediatric organ transplantation. With the aim of evaluating long-term effects of rituximab induction, we conducted a retrospective multi-centre study within the Nordic Paediatric Renal Transplantation Study Group (NPRTSG), comparing paediatric KT with and without rituximab induction. Methods and Materials: Relevant data was retrieved from the Scandiatransplant registry, the NPRTSG registry and the electronic medical records. Six out of 11 NPRTSG centres had used rituximab induction in paediatric kidney transplantation (recipient age < 16 years) during the study period (2003-2018). A complete set of data was available for 240 paediatric first-time kidney recipients and further analysed, 27 (11%) with single-dose rituximab induction (RIT group) and 213 (89%) without rituximab induction (NoRIT group). A thorough analysis of outcome long-term including infections and other complications was undertaken. Results: Follow-up was 9 years (± 4.4) overall. Patient survival in the RIT group was 100% at 10 years compared with 96.8% in the NoRIT group (p=ns) and graft survival 92.9% in RIT group compared with 84.6% in the NoRIT group (p=ns). In the RIT group 30.8% of patients were treated for acute rejection first year vs. 15.6% in the NoRIT group (p=0.09). EBV serologic mismatch status did not differ significantly between groups (41% overall). EBV mismatch was however associated with EBV viremia in the NoRIT group (OR 4.1) (p<0.001). No patient (0%) in the RIT group was diagnosed with EBV viremia within 36 months of KT. The incidence of CMV and BK viremia was similar in the two groups. Seven patients (3.3%) in the NoRIT group were diagnosed with malignancy during follow-up (5 with PTLD) compared with no one in the RIT group. Conclusion: Based on the findings in this study, we conclude that single-dose rituximab induction in paediatric KT appears safe and to effectively prevent EBV viremia long-term. We therefore postulate that rituximab induction could be a forceful strategy to significantly reduce the risk of PTLD in paediatric solid organ recipients. Yet, in line with RCTs in adult KT, rituximab may have limited potential as inhibitor of early acute rejection. To fully appreciate the effects of rituximab induction in paediatric KT, prospective trials are needed. Scandiatransplant. Swedish Kidney Foundation. Swedish Order of Freemasons.

Kidney transplant recipients (KTRs) experience increased risk of cardiovascular disease. Guidelines recommend HMG-CoA reductase inhibitor (statin) therapy when tolerated. We aimed to study changes in the prescription of statins and patients’ adherence to treatment over time. A population-based observational study utilizing linked data from the Norwegian Renal Registry (national coverage of 99.9%) and the Norwegian Prescription Database was performed. Data from a total of 2250 first KTRs were included (mean age—54 years, 69% men). Dispensed prescriptions of statins and immunosuppressants for the period 2004–2016 for all first KTRs engrafted in the period 2005–2015 were analyzed. Seventy-two percent received statins the first year after kidney transplantation and the proportion increased with age. The proportion receiving a statin varied according to the time frame of transplantation (77% in 2005–2010 vs. 66% in 2012–2015). Among new users of statins, 82% of the patients were adherent both the second and third year after kidney transplantation, while the corresponding figure for those already receiving statins before transplantation was 97%. Statin continuation rates in KTRs were high. In conclusion, our findings show a slightly lower overall proportion of patients receiving statins after kidney transplants than the national target level of 80%. The proportion of statin users increased with the age of the KTRs but showed a decreasing trend as time progressed.

Understanding and communicating the risk of pregnancy complications post-living kidney donation is imperative as the majority of living kidney donors (LKD) are women of childbearing age. We aimed to identify all original research articles examining complications in post-donation pregnancies and compared the quality and consistency of related guidelines. We searched Embase, MEDLINE, PubMed, society webpages, and guideline registries for English-language publications published up until December 18, 2020. Ninety-three articles were screened from which 16 studies were identified, with a total of 1399 post-donation pregnancies. The outcome of interest, post-donation pregnancy complications, was not calculable, and only a narrative synthesis of the evidence was possible. The absolute risk of pre-eclampsia increased from ~1%-3% pre-donation (lower than the general population) to ~4%-10% post-donation (comparable to the general population). The risks of adverse fetal and neonatal outcomes were no different between post-donation and pre-donation pregnancies. Guidelines and consensus statements were consistent in stating the need to inform LKDs of their post-donation pregnancy risk, however, the depth and scope of this guidance were variable. While the absolute risk of pregnancy complications remains low post-donation, a concerted effort is required to better identify and individualize risk in these women, such that consent to donation is truly informed.

Background Previous reports suggest increased risk of hypertension and cardiovascular mortality after kidney donation. In this study we investigate the occurrence of ischaemic heart disease and cerebrovascular disease, diabetes and cancer in live kidney donors compared with healthy controls eligible for donation. Methods Different diagnoses were assessed in 1029 kidney donors and 16 084 controls. The diagnoses at follow-up were self-reported for the controls and registered by a physician for the donors. Stratified logistic regression was used to estimate associations with various disease outcomes, adjusted for gender, age at follow-up, smoking at baseline, body mass index at baseline, systolic blood pressure at baseline and time since the donation. Results The mean observation time was 11.3 years [standard deviation (SD) 8.1] for donors versus 16.4 years (SD 5.7) for controls. The age at follow-up was 56.1 years (SD 12.4) in donors versus 53.5 years (SD 11.1) in controls and 44% of donors were males versus 39.3% in the controls. At follow-up, 35 (3.5%) of the donors had been diagnosed with ischaemic heart disease versus 267 (1.7%) of the controls. The adjusted odds ratio for ischaemic heart disease was 1.64 (confidence interval 1.10-2.43; P = 0.01) in donors compared with controls. There were no significant differences for the risks of cerebrovascular disease, diabetes or cancer. Conclusions During long-term follow-up of kidney donors, we found an increased risk of ischaemic heart disease compared with healthy controls. This information may be important in the follow-up and selection process of living kidney donors.

Background. Optimized health-related quality of life (HRQOL) at the time of kidney transplantation (KT) is associated with improved survival. In older KT recipients, we aimed to prospectively evaluate if HRQOL evolution during the first posttransplant year was associated with long-term patient survival. Methods. Recipients older than 65 y at KT who received an organ from a deceased brain-dead donor and survived >12 mo posttransplant were eligible. HRQOL was assessed pre-KT, at 10 wk, 6 mo, and 12 mo post-KT, using the Kidney Disease Quality of Life Short Form version 1.3 survey. A mixed-effect model was used to explore HRQOL evolution during the first posttransplant year in long-term survivors compared with nonsurvivors. Distinct HRQOL clusters were identified using a group-based trajectory modeling and their association with patient survival was investigated with Cox proportional hazard regression models. Results. We included 192 elderly recipients of deceased brain-dead donor kidneys who were transplanted from 2013 to 2020. Eleven died during the first year leaving 181 for evaluation (male, 125; mean age at KT, 72 y [65–84 y]). During a median observation time post-KT of 4.9 y (11.1–8.5 y), 57 recipients died. In survivors, all the generic and kidney-specific HRQOL domains substantially improved during the first year, whereas in nonsurvivors HRQOL deteriorated. Three longitudinal HRQOL trajectories indicating poor, fair, and good HRQOL evolution were identified. Poor physical function trajectory was significantly associated with higher mortality risk independent of covariates, as compared with good physical trajectory (hazard ratio, 2.38; 95% confidence interval, 1.15–5.01). Conclusions. In elderly KT recipients, detection of declining posttransplant physical function may imply impaired survival. Systematic HRQOL monitoring following KT provides added value when evaluating mortality and may guide therapeutic decisions.

Introduction: ABO-incompatible (ABOi) living donor kidney transplantation (LDKT) in adults has become routine practice at many centers worldwide. Pediatric ABOi LDKT has nonetheless remained a relatively rare event and reports on outcome following pediatric ABOi LDKT using rituximab induction are few. With the aim of evaluating long-term results and complications of pediatric ABOi LDKT, using a protocol based on antigen-specific immunoadsorption and rituximab, we undertook a retrospective multi-center study within the Nordic Paediatric Renal Transplantation Study Group (NPRTSG), comparing pediatric ABOi LDKT with ABO-compatible (ABOc) pediatric kidney transplantations with both living and deceased donors. Material & Methods: Data was retrieved from the Scandiatransplant registry, the NPRTSG registry and medical records. In total, 6 out of 11 NPRTSG centers performed pediatric ABOi kidney transplantation (recipient age <16 years) during the study period (2003-2018). Data is currently available for 337 patients: 32(9,5%) ABOi LDKT, 73 (21,7%) ABO-compatible (ABOc) deceased donor kidney transplantations (DDKT) and 232 (68,8%) ABOc LDKT. A case-cohort analysis of graft survival, patient survival, complications and measured GFR was undertaken. Results: Mean follow-up was 9.2 years (±4.6 years). Patient survival at 10 years was 100% in the ABOi group, 97.2% in ABOc LDKT group and 93.5% in the DD group (p=ns). Graft survival was higher in the ABOi group compared with the other two groups (Figure 1.). The length of first hospitalization did not differ (mean 19.6 ± 12.9 days), neither did the incidence of any medical, surgical, or infectious complication during first stay (52.1% overall) (p=0.68). More episodes of acute rejection were observed during the first year in the ABOi LDKT group and the ABOc DDKT group (overall 18.4%, p=0.03). Although, no higher incidence of antibody-mediated rejection was observed in the ABOi LDKT group. First year unscheduled readmissions were more frequent in the ABOi group (74.2%) and the DDKT group (74.2%) compared with the ABOc LDKT group (62.7%, p=0.01). Graft function using measured GFR did not differ in any of the groups during the first 5 years (overall 71 ± 25, 63 ±20, 56±25 ml/min/1.73 at 1, 3 and 5 years). In the ABOc LDKT group, 13 (6%) were diagnosed with malignancy during the study period compared with none in the other two groups (p=0.05). Conclusion: Our findings suggests that pediatric ABOi LDKT is comparable to ABOc LDKT and superior to DD kidney wait listing. We did not observe any significant increase in mortality, graft failure or complications. In fact, graft survival was the highest in the ABOi LDKT group and the incidence of malignancy 0%. ABO-incompatibility should therefore not impede living donation. Finally, if the favorable outcome of ABOi LDKT is ascribed to a protective effect of rituximab induction in pediatric patients calls for further investigation. Scandiatransplant. Swedish Kidney Foundation. Swedish Order of Freemasons.