ABSTRACTBackgroundExtended‐spectrum beta‐lactamase–producing gram‐negative rods (ESBL‐GNR) are a rising cause of bacteremia in kidney transplant recipients (KT). The study purpose was to examine patient mortality, allograft survival, estimated glomerular filtration rate (eGFR) at the end of 1 year, and readmission rates while looking at treatment strategies among KTs with ESBL‐GNR and non–ESBL‐GNR bacteremia at our institution.MethodsThis study was a retrospective, cohort analysis of KTs with gram‐negative bacteremia from January 1, 2020, to December 31, 2021. The primary outcome of the study was mortality. Patient outcomes were assessed for 365 days after positive blood cultures.ResultsThe study included 63 patients. Of these, 18 (29%) patients had bacteremia caused by an ESBL‐GNR and 45 (71%) patients had bacteremia caused by a non–ESBL‐GNR. Patient survival at 90 days was 94% in the ESBL‐GNR group and 96% in the non–ESBL‐GNR group. Ciprofloxacin was the most common antimicrobial therapy at discharge (68.9%) in the non–ESBL‐GNR group whereas ertapenem was the most common in the ESBL‐GNR group (44.5%). Median eGFR at discharge was 41 mL/min/1.73 m2 in the ESBL‐GNR group and 48 mL/min/1.73 m2 in the non–ESBL‐GNR group. Ninety‐day readmission occurred in 9 (50%) ESBL‐GNR patients and 14 (32%) non–ESBL‐GNR patients. None of the above comparisons are statistically significant (p > 0.05). Eleven (61%) ESBL‐GNR and 2 (4%) non–ESBL‐GNR patients used outpatient parenteral antimicrobial therapy (p < 0.001).ConclusionsAmong KTs with ESBL‐GNR bacteremia, no significant difference was detected in mortality or allograft function compared to non–ESBL‐GNR bacteremia.

Kidney transplant is not only the best treatment for patients with advanced kidney disease but it also reduces health care expenditure. The management of transplant patients is complex as they require special care by transplant nephrologists who have expertise in assessing transplant candidates, understand immunology and organ rejection, have familiarity with perioperative complications, and have the ability to manage the long-term effects of chronic immunosuppression. This skill set at the intersection of multiple disciplines necessitates additional training in Transplant Nephrology. Currently, there are more than 250,000 patients with a functioning kidney allograft and over 100,000 waitlisted patients awaiting kidney transplant, with a burgeoning number added to the kidney transplant wait list every year. In 2022, more than 40,000 patients were added to the kidney wait list and more than 25,000 received a kidney transplant. The Advancing American Kidney Health Initiative, passed in 2019, is aiming to double the number of kidney transplants by 2030 creating a need for additional transplant nephrologists to help care for them. Over the past decade, there has been a decline in the Nephrology-as well Transplant Nephrology-workforce due to a multitude of reasons. The American Society of Transplantation Kidney Pancreas Community of Practice created a workgroup to discuss the Transplant Nephrology workforce shortage. In this article, we discuss the scope of the problem and how the Accreditation Council for Graduate Medical Education recognition of Transplant Nephrology Fellowship could at least partly mitigate the Transplant Nephrology work force crisis.

Background Kidney transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV is an emerging practice. It has been performed since 2016 under the U.S. congressional HIV Organ Policy Equity Act and is currently approved for research only. The Department of Health and Human Services is considering expanding the procedure to clinical practice, but data are limited to small case series that did not include donors without HIV as controls.Methods In an observational study conducted at 26 U.S. centers, we compared transplantation of kidneys from deceased donors with HIV and donors without HIV to recipients with HIV. The primary outcome was a safety event (a composite of death from any cause, graft loss, serious adverse event, HIV breakthrough infection, persistent failure of HIV treatment, or opportunistic infection), assessed for noninferiority (margin for the upper bound of the 95% confidence interval, 3.00). Secondary outcomes included overall survival, survival without graft loss, rejection, infection, cancer, and HIV superinfection.Results We enrolled 408 transplantation candidates, of whom 198 received a kidney from a deceased donor; 99 received a kidney from a donor with HIV and 99 from a donor without HIV. The adjusted hazard ratio for the composite primary outcome was 1.00 (95% confidence interval [CI], 0.73 to 1.38), which showed noninferiority. The following secondary outcomes were similar whether the donor had HIV or not: overall survival at 1 year (94% vs. 95%) and 3 years (85% vs. 87%), survival without graft loss at 1 year (93% vs. 90%) and 3 years (84% vs. 81%), and rejection at 1 year (13% vs. 21%) and 3 years (21% vs. 24%). The incidence of serious adverse events, infections, surgical or vascular complications, and cancer was similar in the groups. The incidence of HIV breakthrough infection was higher among recipients of kidneys from donors with HIV (incidence rate ratio, 3.14; 95%, CI, 1.02 to 9.63), with one potential HIV superinfection among the 58 recipients in this group with sequence data and no persistent failures of HIV treatment.Conclusions In this observational study of kidney transplantation in persons with HIV, transplantation from donors with HIV appeared to be noninferior to that from donors without HIV. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT03500315.) In a study involving kidney-transplantation candidates with HIV, results of transplantation from donors with HIV were noninferior to those of transplantation from donors without HIV.

You have accessJournal of UrologyTransplantation & Vascular Surgery II (PD56)1 May 2024PD56-05 URINARY FACTORS INFLUENCING DECISIONS TO PROCEED WITH LIVING KIDNEY DONATION AMONG CANDIDATES WITH KIDNEY STONE DISEASE Tyler Compher, Sambhavi Krishnamoorthy, Kyle D. Wood, Shikha Mehta, Michael J. Hanaway, Dean G. Assimos, Vineeta Kumar, Anna L. Zisman, and Joseph J. Crivelli Tyler CompherTyler Compher , Sambhavi KrishnamoorthySambhavi Krishnamoorthy , Kyle D. WoodKyle D. Wood , Shikha MehtaShikha Mehta , Michael J. HanawayMichael J. Hanaway , Dean G. AssimosDean G. Assimos , Vineeta KumarVineeta Kumar , Anna L. ZismanAnna L. Zisman , and Joseph J. CrivelliJoseph J. Crivelli View All Author Informationhttps://doi.org/10.1097/01.JU.0001008928.01012.0d.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Guidelines recommend that patients with a self-reported history of kidney stones or stones found on imaging during living kidney donor evaluation undergo 24-hour urine testing. We report 24-hour urine findings that were associated with the decision to proceed with living kidney donation in candidates with kidney stone disease at two high-volume transplant centers. METHODS: We identified potential living kidney donors with either a self-reported history of kidney stones or stones identified on imaging, all of whom underwent 24-hour urine collection at the University of Alabama at Birmingham (UAB) or the University of Chicago (UC). Patients who couldn't donate due to other medical conditions were excluded. All recommendations and decisions regarding donor candidacy were made by multidisciplinary living donor teams. Statistical analysis was performed using t tests and chi-square tests, or corresponding non-parametric tests when appropriate. RESULTS: A total of 106 kidney donor candidates met study criteria, of whom 22 (21%) were rejected for donation (Table 1). Candidates rejected for donation had significantly higher calcium excretion and supersaturations of calcium oxalate and calcium phosphate. Thirty-four candidates repeated 24-hour urine analyses following dietary or medical interventions for stone prevention (Table 2). Candidates approved for donation had a significant increase in urinary volume and reduction in calcium excretion, oxalate excretion, as well as supersaturations of calcium oxalate, calcium phosphate, and uric acid. Those rejected for donation had no statistically significant changes in urinary parameters. CONCLUSIONS: Several urinary risk factors for kidney stones, as well as improvement in these factors following dietary or medical management were associated with the decision to proceed with living kidney donation. A prospective longitudinal study needs to be undertaken to determine the factors predicting stone recurrence for the donor. Source of Funding: N/A © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e1203 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Tyler Compher More articles by this author Sambhavi Krishnamoorthy More articles by this author Kyle D. Wood More articles by this author Shikha Mehta More articles by this author Michael J. Hanaway More articles by this author Dean G. Assimos More articles by this author Vineeta Kumar More articles by this author Anna L. Zisman More articles by this author Joseph J. Crivelli More articles by this author Expand All Advertisement PDF downloadLoading ...

Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.

Background. Kidney transplant (KT) candidates with HIV face higher mortality on the waitlist compared with candidates without HIV. Because the HIV Organ Policy Equity (HOPE) Act has expanded the donor pool to allow donors with HIV (D + ), it is crucial to understand whether this has impacted transplant rates for this population. Methods. Using a linkage between the HOPE in Action trial (NCT03500315) and Scientific Registry of Transplant Recipients, we identified 324 candidates listed for D + kidneys (HOPE) compared with 46 025 candidates not listed for D + kidneys (non-HOPE) at the same centers between April 26, 2018, and May 24, 2022. We characterized KT rate, KT type (D + , false-positive [FP; donor with false-positive HIV testing], D – [donor without HIV], living donor [LD]) and quantified the association between HOPE enrollment and KT rate using multivariable Cox regression with center-level clustering; HOPE was a time-varying exposure. Results. HOPE candidates were more likely male individuals (79% versus 62%), Black (73% versus 35%), and publicly insured (71% versus 52%; P < 0.001). Within 4.5 y, 70% of HOPE candidates received a KT (41% D + , 34% D – , 20% FP, 4% LD) versus 43% of non-HOPE candidates (74% D – , 26% LD). Conversely, 22% of HOPE candidates versus 39% of non-HOPE candidates died or were removed from the waitlist. Median KT wait time was 10.3 mo for HOPE versus 60.8 mo for non-HOPE candidates ( P < 0.001). After adjustment, HOPE candidates had a 3.30-fold higher KT rate (adjusted hazard ratio = 3.30, 95% confidence interval, 2.14-5.10; P < 0.001). Conclusions. Listing for D + kidneys within HOPE trials was associated with a higher KT rate and shorter wait time, supporting the expansion of this practice for candidates with HIV.

Transplantation is a high-risk, high-cost treatment for end-stage diseases and is the most strictly regulated area of healthcare in the United States. Thus, achieving success for patients and the program requires skillful and collaborative leadership. Various factors, such as outcomes, volume, and financial health, may measure the success of a transplant program. Strong collaboration between clinical and administrative leaders is key to achieving and maintaining success in those three categories. Clinical leaders of adult programs, such as medical and surgical directors, bear the primary responsibility for a program's volume, outcomes, and patient safety, while administrative directors are focused on business intelligence and regulatory compliance. This paper aims to provide readers with insights into the critical role of collaborative leadership in running a successful program, with a focus on clinical, business, and regulatory perspectives.

Background:Women represent a meaningful proportion of new HIV diagnoses, with Black women comprising 58% of new diagnoses among women. As HIV infection also increases risk of chronic kidney disease (CKD), understanding CKD risk among women with HIV (WWH), particularly Black women, is critical. Methods:In this longitudinal cohort study of people with HIV (PWH) enrolled in CFAR Network of Integrated Clinical Systems (CNICS), a multicentre study comprised of eight academic medical centres across the United States from Jan 01, 1996 and Nov 01, 2019, adult PWH were excluded if they had ≤2 serum creatinine measurements, developed CKD prior to enrollment, or identified as intersex or transgendered, leaving a final cohort of 33,998 PWH. The outcome was CKD development, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1·73 m2 calculated using the CKD-EPI equation, for ≥90 days with no intervening higher values. Findings:Adjusting for demographic and clinical characteristics, WWH were 61% more likely to develop CKD than men (adjusted hazard ratio [aHR]: 1·61, 95% CI: 1·46-1·78, p<0·001). This difference persisted after further adjustment for APOL1 risk variants (aHR female sex: 1·92, 95% CI: 1·63-2·26, p<0·001) and substance abuse (aHR female sex: 1·70, 95% CI: 1·54-1·87, p<0·001). Interpretation:WWH experienced increased risk of CKD. Given disparities in care among patients with end-stage kidney disease, efforts to engage WWH in nephrology care to improve chronic disease management are critical. Funding:US National Institutes of Health.

BACKGROUND:Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety. METHODS:We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors. RESULTS:Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL <400 copies/mL. The median CD4 T-cell count (interquartile range) was 194/µL (77-331/µL), and the median CD4 T-cell percentage was 27.0% (16.8%-36.1%). Major HIV DRMs were detected in 42%, including nonnucleoside reverse-transcriptase inhibitors (33%), integrase strand transfer inhibitors (4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history. CONCLUSION:The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor-based regimens is rare, which is reassuring regarding safety.

The HIV latent viral reservoir (LVR) remains a major challenge in the effort to find a cure for HIV. There is interest in lymphocyte-depleting agents, used in solid organ and bone marrow transplantation to reduce the LVR. This study evaluated the LVR and T cell receptor repertoire in HIV-infected kidney transplant recipients using intact proviral DNA assay and T cell receptor sequencing in patients receiving lymphocyte-depleting or lymphocyte-nondepleting immunosuppression induction therapy. CD4+ T cells and intact and defective provirus frequencies decreased following lymphocyte-depleting induction therapy but rebounded to near baseline levels within 1 year after induction. In contrast, these biomarkers were relatively stable over time in the lymphocyte-nondepleting group. The lymphocyte-depleting group had early TCRβ repertoire turnover and newly detected and expanded clones compared with the lymphocyte-nondepleting group. No differences were observed in TCRβ clonality and repertoire richness between groups. These findings suggest that, even with significant decreases in the overall size of the circulating LVR, the reservoir can be reconstituted in a relatively short period of time. These results, while from a relatively unique population, suggest that curative strategies aimed at depleting the HIV LVR will need to achieve specific and durable levels of HIV-infected T cell depletion.

Background. Surveillance biopsies permit early detection of subclinical inflammation before clinical dysfunction, but the impact of detecting early subclinical phenotypes remains unclear. Methods. We conducted a single-center retrospective cohort study of 441 consecutive kidney transplant recipients between 2015 and 2018 with surveillance biopsies at 6 months post-transplant. We tested the hypothesis that early subclinical inflammation (subclinical borderline changes, T cell-mediated rejection, or microvascular injury) is associated with increased incidence of a composite endpoint including acute rejection and allograft failure. Results. Using contemporaneous Banff criteria, we detected subclinical inflammation in 31%, with the majority (75%) having a subclinical borderline phenotype (at least minimal inflammation with mild tubulitis [>i0t1]). Overall, subclinical inflammation was independently associated with the composite endpoint (adjusted hazard ratio, 2.88; 1.11-7.51; P = 0.03). The subgroup with subclinical borderline inflammation, predominantly those meeting the Banff 2019 i1t1 threshold, was independently associated with 5-fold increased hazard for the composite endpoint (P = 0.02). Those with concurrent subclinical inflammation and subclinical chronic allograft injury had worse outcomes. The effect of treating subclinical inflammation was difficult to ascertain in small heterogeneous subgroups. Conclusions. Subclinical acute and chronic inflammation are common at 6 months post-transplant in kidney recipients with stable allograft function. The subclinical borderline phenotype with both tubulitis and interstitial inflammation was independently associated with poor long-term outcomes. Further studies are needed to elucidate the role of surveillance biopsies for management of allograft inflammation in kidney transplantation.

Background Donor-derived cell-free DNA (dd-cfDNA) is a marker of allograft injury in transplant recipients; however, the relationship between dd-cfDNA and other clinical parameters associated with adverse allograft outcomes is not well-characterized. Methods We performed a retrospective analysis of kidney transplant recipients from the DART cohort (ClinicalTrials.gov Identifier: NCT02424227) to evaluate the associations between eGFR decline, de novo donor-specific antibodies (dnDSA), and dd-cfDNA. Results Both elevated dd-cfDNA (>= 1%) and dd-cfDNA variability (>=.34%) in the first post-transplant year were associated with decline in eGFR >= 25% in the second year (21.4% vs. 4.1%, P = .005; 25% vs. 3.6%, P = .002, respectively). Compared to samples from DSA negative patients, samples from patients with concurrent de novo HLA DSAs had higher dd-cfDNA levels (P < .0001). Discussion Abnormalities in dd-cfDNA levels are associated with clinical parameters commonly used as surrogate endpoints for adverse allograft outcomes, raising the possibility that molecular injury as characterized by dd-cfDNA could help identify patients at risk of these outcomes.

The aim of this study was to characterize end‐stage renal disease (ESRD) patients with obesity as their only contraindication to listing and to quantify wait‐list and transplant access.

HIV‐positive donor to HIV‐positive recipient (HIV D+/R+) transplantation is permitted in the United States under the HIV Organ Policy Equity Act. To explore safety and the risk attributable to an HIV+ donor, we performed a prospective multicenter pilot study comparing HIV D+/R+ vs HIV‐negative donor to HIV+ recipient (HIV D−/R+) kidney transplantation (KT). From 3/2016 to 7/2019 at 14 centers, there were 75 HIV+ KTs: 25 D+ and 50 D− (22 recipients from D− with false positive HIV tests). Median follow‐up was 1.7 years. There were no deaths nor differences in 1‐year graft survival (91% D+ vs 92% D−, P = .9), 1‐year mean estimated glomerular filtration rate (63 mL/min D+ vs 57 mL/min D−, P = .31), HIV breakthrough (4% D+ vs 6% D−, P > .99), infectious hospitalizations (28% vs 26%, P = .85), or opportunistic infections (16% vs 12%, P = .72). One‐year rejection was higher for D+ recipients (50% vs 29%, HR: 1.83, 95% CI 0.84‐3.95, P = .13) but did not reach statistical significance; rejection was lower with lymphocyte‐depleting induction (21% vs 44%, HR: 0.33, 95% CI 0.21‐0.87, P = .03). In this multicenter pilot study directly comparing HIV D+/R+ with HIV D−/R+ KT, overall transplant and HIV outcomes were excellent; a trend toward higher rejection with D+ raises concerns that merit further investigation.

OBJECTIVE To examine the largest single-center experience of simultaneous kidney/pancreas transplantation (SPK) transplantation among African-Americans (AAs). BACKGROUND Current dogma suggests that AAs have worse survival following SPK than white recipients. We hypothesize that this national trend may not be ubiquitous. METHODS From August 30, 1999, through October 1, 2014, 188 SPK transplants were performed at the University of Alabama at Birmingham (UAB) and 5523 were performed at other US centers. Using Kaplan-Meier survival estimates and Cox proportional hazards regression, we examined the influence of recipient ethnicity on survival. RESULTS AAs comprised 36.2% of the UAB cohort compared with only 19.1% nationally (P < 0.01); yet, overall, 3-year graft survival was statistically higher among UAB than US cohort (kidney: 91.5% vs 87.9%, P = 0.11; pancreas: 87.4% vs 81.3%; P = 0.04, respectively) and persisted on adjusted analyses [kidney adjusted hazard ratio (aHR): 0.58, 95% confidence interval (95% CI) 0.35-0.97, P = 0.04; pancreas aHR: 0.54, 95% CI 0.34-0.85, P = 0.01]. Among the UAB cohort, graft survival did not differ between AA and white recipients; in contrast, the US cohort experienced significantly lower graft survival rates among AA than white recipients (kidney 5 years: 76.5% vs 82.3%, P < 0.01; pancreas 5 years: 72.2% vs 76.3%, P = 0.01; respectively). CONCLUSION Among a single-center cohort of SPK transplants overrepresented by AAs, we demonstrated similar outcomes among AA and white recipients and better outcomes than the US experience. These data suggest that current dogma may be incorrect. Identifying best practices for SPK transplantation is imperative to mitigate racial disparities in outcomes observed at the national level.

Purpose of review We report the risks and benefits of utilizing HIV-positive organ donors. Recent findings The utilization of HIV-positive organs came with significant concerns including poor organ quality, increased risk of rejection, HIV disease progression, transmission of varying HIV strains and opportunistic infections, virologic failure due to antiretroviral resistance, increased risk for posttransplant malignancy, and recurrent HIV-associated nephropathy. Recently published data have shown, however, that despite the above mentioned risks, patient survival, and graft survival in persons living with HIV (PLWH) who received a kidney transplant from a HIV-positive donor (D+/R+) is similar to a kidney transplant from a HIV-negative donor (D−/R+). Summary To date, 268 PLWH have received an organ from a HIV-positive donor, including 198 kidney transplants and 70 liver/liver–kidney transplants. The utilization of HIV-positive donor organs has proven to be a safe and feasible approach to expanding the donor pool and improving access to lifesaving therapy for PLWH with end-stage organ disease.

We represent a group of investigators funded by the National Institutes of Health (R01AI120938, U01AI134591, U01AI138897) to conduct a prospective multicenter study of the landscape of HIV-infected (HIV+) donors and two prospective multicenter trials comparing outcomes between HIV+ recipients of HIV+ and non-HIV+ donor kidneys and livers.These clinical trials are ongoing (NCT02602262, NCT03500315, NCT03734393).We read with interest the Brief Communication entitled "National landscape of HIV+ to HIV+ kidney and liver transplantation in the United States" by Wilk et al of the United Network for Organ Sharing (UNOS). 1 The study utilized data from the Organ Procurement and Transplantation Network (OPTN) database managed by UNOS under a federal contract.The authors concluded that one-year patient and graft survival in HIV+ recipients of HIV+ donors did not deviate from that observed in non-HIV+ donor recipients.As acknowledged by Wilk et al, an important limitation of the study is the inability of OPTN data to accurately identify donors with HIV infection.In their report, HIV+ donors were defined by any report of a positive HIV antibody (Ab), nucleic acid test (NAT), or antigen/ antibody combination assay (Ab/Ag). 1 These assays have a low false-positive rate (0.1-0.5%); however, given the number of deceased donors screened annually, we have estimated there should be 50-100 donors with false-positive HIV tests annually in the United States. 2 Confirmatory testing is not routinely done or reported by the OPTN.

BACKGROUND:HCV-infected (HCV+) ESRD patients derive significant survival benefit from kidney transplantation (KT) over remaining on dialysis. Given high mortality rates on dialysis and the unique ability to accept HCV+ and HCV- donor kidneys, understanding their access to KT is essential.METHODS:Three thousand nine hundred and sixty-three adult kidney-only candidates reported as willing to accept an HCV+ kidney from 2008 to 2014 were identified and assumed to be HCV+. Time-at-risk began at date of listing. Cumulative incidence of transplant and waitlist mortality were assessed using competing risks, and separate mixed effects Cox proportional hazards models were used to examine waitlist mortality and transplantation rates. All models were adjusted for candidate demographic and clinical characteristics with a random effect for listing organ procurement organization with nested listing center.RESULTS:HCV+ candidates were commonly older (>50 years: 82.6%), African American (52.8%), and male (73.6%). Five years after listing, 35.5% of candidates were transplanted with an HCV+ donor kidney, 9.7% transplanted with an HCV- donor kidney, and 23.6% died on the waitlist. Overall transplant rates exceeded waitlist mortality rates (22.69 vs 11.45 per 100 person-years [PY]), largely driven by transplantation with HCV+ donor kidneys. Utilization of HCV+ donor kidneys was associated with increased transplantation rate (17.72 per 100 PY), while rate of transplant with HCV- donor kidneys was much lower (4.97 per 100 PY) than waitlist mortality (11.45 per 100 PY).CONCLUSION:In light of effective HCV therapies, it may be prudent to institute strategies to decrease waiting time and waitlist mortality for HCV+ candidates by increasing utilization of HCV+ donor kidneys.

Depressed left ventricular ejection fraction (LVEF), LV mechanical dyssynchrony (LVMD), and prolonged QTc interval predict poor outcomes in end-stage renal disease (ESRD). Renal transplantation improves mortality in ESRD patients but the effects of transplantation on these indices remain undefined.