Background Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic cause of ESKD and occurs without racial predilection. In general, non-White patients with ESKD have less access to transplantation, especially living donor transplantation. We examined long-term outcomes of patients with ADPKD-ESKD by self-reported race, with attention to the trajectory of Estimated Post-Transplant Survival (EPTS) scores over time. Methods United Network for Organ Sharing Standard Transplant Analysis and Research files were used to identify 32,611 ADPKD transplant recipients between January 2000 and December 2022. EPTS scores were calculated from the date of waitlisting until transplantation occurred. Cumulative incidences of living and deceased transplantation were calculated and plotted. Cox models were made for graft failure and death, and a subdistribution hazards model for graft failure accounted for death as a competing outcome, with adjustment for patient, donor, and transplant factors. Results Compared with White patients with ADPKD, all other groups had more dialysis years, more delayed graft function, and fewer living and preemptive transplants; mean EPTS scores were lower in Black and Hispanic patients at each time point on the waitlist. However, EPTS scores at the time of transplant was less likely to be <20% in Black and Hispanic patients because of longer waiting time. Black patients had a significantly higher risk of graft failure with death as competing risk compared with White patients. Asian and Hispanic patients had similar graft survivals but better patient survival compared with White patients. Conclusions Waitlist experience, allograft quality, and post-transplant outcomes of patients with ADPKD are influenced by patient race.

INTRODUCTION:Guidelines recommend that patients with a self-reported history of kidney stones or stones on imaging during living kidney donor (LKD) evaluation undergo 24-h urine stone risk testing. We examined eligibility decisions for LKD candidates at two high-volume academic transplant centers based on 24-h urine testing and imaging findings. METHODS:We identified potential LKDs with a self-reported history of kidney stones or stones identified on imaging, who underwent 24-h urine collection. Patients who could not donate due to other medical conditions were excluded. Differences in characteristics of patients approved versus rejected for donation were determined using t tests and chi-square tests, or nonparametric tests when appropriate. RESULTS:In total, 105 candidates met study criteria, of whom 22 (21%) were rejected for donation. Candidates rejected for donation had higher urinary calcium excretion (p < 0.001), supersaturation of calcium oxalate (p < 0.001), and supersaturation of calcium phosphate (p = 0.02). Thirty-four candidates repeated 24-h urine analyses following dietary or medical interventions for stone prevention. Candidates approved for donation had an increase in urinary volume (p = 0.045), reduction in urinary calcium excretion (p = 0.02), reduction in urinary oxalate excretion (p = 0.04), and reduction in supersaturations of calcium oxalate (p < 0.001), calcium phosphate (p = 0.004), and uric acid (p = 0.004). Those rejected for donation had no statistically significant changes in urinary parameters. While those rejected for donation had more stones on imaging compared to those approved, this did not reach statistical significance (p = 0.06). CONCLUSION:Overall, urinary risk factors for nephrolithiasis and improvement in them following dietary or medical management were associated with approval for donation.

Existing literature on best practices to reduce the risk of infectious complications associated with ureteral stent removal in kidney transplant recipients is limited. Prior to 2021, a formal process surrounding stent removal was not in place at our institution. In June 2021, a stent removal protocol was established. This protocol included the following: obtaining a preprocedure urine culture, prescribing universal culture-directed antimicrobial prophylaxis, earlier stent removal posttransplant, and patient education. We performed a retrospective quasi-experimental study of kidney transplant recipients who had their stents removed between July 2020 and June 2022. The primary outcome was the incidence of infectious complications within 30 days. Infectious complications were defined as urinary tract infection and bacteremia due to urinary source, as well as hospitalization, emergency department visit, or outpatient encounter for possible urinary tract infection. Secondary objectives included infectious and immunologic complications within 30 days to 1 year from transplant. During this study period, 239 adult kidney transplant recipients were included: 88 in the preprotocol group and 151 in the protocol group. The median time to stent removal was shorter in the protocol group (25 vs 36 days, P < .001). More patients in the protocol group received preprocedure antibiotics (99% vs 36%, P < .001). Infectious complications were higher in the preprotocol group (9% vs 3%, P = .035). Overall, the stent removal protocol was associated with fewer infectious complications (odds ratio, 0.18; 95% CI, 0.05-0.73). Further investigation is necessary to determine which individual interventions, if any, drive this benefit.

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 ...

Krishnamoorthy, Sambhavi; Satishchandra, Niveditha Girimaji; Chapman, Arlene B.; McGill, Rita L. Author Information

Introduction: Multiorgan dysfunction involving the kidneys is not uncommon in patients with end stage heart and liver disease. Simultaneous heart-liver-kidney transplants (HLK) are less commonly performed than simultaneous heart-kidney or liver-kidney transplants due to the complex nature of the surgery and challenges with patient selection. 19 HLK were performed in the US from 2008 to 2020, out of which 8 were performed at our center. Given the limited availability of organs for transplant and the lack of standardized qualifying criteria for these patients, it is imperative to understand the factors involved in better outcomes, to optimize utilization of scarce resources. Method: We performed a retrospective review of all HLK recipients at the University of Chicago medical center between 2008-2020 using Epic EMR. We evaluated their renal outcomes, infection rates, number of hospitalizations, and mortality over a 12-month period post transplantation. Results: Baseline characteristics are summarized in the table 1. 4(50%) were between the ages of 50-64, 2(25%) were between the ages of 35-49, and 2(25%) were between the age of 18-34. Four (50%) were Caucasians, 3(37.5%) were African Americans, and 1(12.5%) was Asian Indian. 6 (75%) had pre-transplant GFR between 30-40 ml/min, 1(12.5%) had GFR between 15-30 ml/min, and 1(12.5%) had GFR <15 ml/min. The etiology of CKD was as follows, 5(62.5%) were cardiorenal, 2(25%) were diabetic, 1(12.5%) was acute interstitial nephritis. All had Kidney Donor Profile Index (KDPI) below 20%. All had GFR above 50 ml/min at 3 months post-transplant, out of which 5 (62.5%) had GFR above 60 ml/min. At 6 months and 1 year, 3 (37.5%) had GFR above 60 ml/min, 3 (37.5%) were between 45-60 ml/min, and 2 (25%) had GFR between 30-45 ml/min. Only 1 patient developed delayed graft function requiring 2 sessions of dialysis post-transplant. All 8 were alive with intact kidney allograft function at 12 months after transplant. Only 2(25%) required a hospitalization within the 1st year of transplant for infection related reason. 2(25%) developed BK viremia and 2(25%) developed CMV viremia. Conclusion: Our experience suggests that with careful selection of patients, simultaneous HLK can lead to successful patient outcomes at one year post transplantation. Longer follow up of these patients is needed to define long term allograft and patient survival which will help to standardize selection and allocation criteria of this subset of patients.

Background: Infectious complications are a major cause of mortality and morbidity after kidney transplantation. During the COVID-19 pandemia there were several changes in the management and behavior of patients after transplant. These included measures such as universal masking, social distancing and reinforcing hand hygiene. Our objective was to evaluate if these differences affected the incidence of infections after kidney transplant. Methods: This is a retrospective cohort study of all kidney transplants performed in our institution from March 2017 to November 2020. We examined the incidence of wound infection, urinary tract infection (UTI), pneumonia, and gastrointestinal (GI) infections. Pediatric and multi-organ transplants were excluded. We used the Fisher test, Chi-squared test of independence and logistic regression models in the analysis. All tests were based on a level of significance of α=0.05. Results: A total of 185 deceased donor kidney transplant patients were reviewed, 153 before and 54 after the beginning of the COVID-19 pandemic in the United States. The incidence of wound infection, pneumonia and GI infection were similar before and after COVID (Table 1). There was a significant increase in UTI after the COVID-19 pandemic, the main organisms isolated were Klebsiella pneumonia (50%) and E. coli (25%) (Table 2). Overall the presence of UTI and wound infection were significantly associated (OR 4.2, p = 0.06). Other clinical variables such as age, body mass index (BMI), kidney donor profile index (KDPI), estimated post-transplant survival score (EPTS), and the occurrence of delayed graft function were not associated with UTI. The incidence of viral infections (CMV, EBV and BK viremia) was similar before and after COVID. Infections due to COVID-19 itself were present with similar incidence: 12% in patients transplanted before and 14.8% in patients transplanted after the onset of the pandemic. Induction with Thymoglobulin or Basiliximab was not significantly different before and after COVID-19, and the choice of induction was not associated with the rate of UTI. Conclusions: While multiple changes in the management of patients and patient behavior are different before and after the onset of the COVID-19 pandemic, this analysis did not find significant change in the incidence of infections except for UTI in comparative cohorts of kidney transplant recipients. This study did not identify specific factors associated with the increase of UTI in our population. However, in response certain measures were implemented, such as reducing the time to ureteral stent removal and giving 24 hrs of prophylactic antibiotics at the time of stent removal.

Kidney transplantation is the best treatment modality for end-stage kidney disease, leading to improvement in a patient’s quality and quantity of life. With significant improvements in short-term outcomes, prolonging long-term allograft and patient survival remain ongoing challenges. The ability to monitor allograft function, immune tolerance and predict rejection accurately would enable personalization and better prognostication during post-transplant care. Though kidney biopsy remains the backbone of transplant diagnostics, emerging biomarkers can help detecting kidney allograft injury early enough to prevent permanent damage and detect injury before it is clinically apparent. In this review, we summarize the recent biomarkers that have shown promise in the prediction of acute rejection with a focus on antibody-mediated rejection in kidney transplantation.

Chimeric antigen receptor T cells (CAR-T) are genetically modified T cells with a chimeric antigen receptor directed against a specific tumor-associated antigen like CD19 in lymphoma. CAR-T cells have shown encouraging activity against recurrent and refractory diffuse large B cell lymphomas (DLBCL). However concurrent use of immunosuppressive agents was prohibited in most CAR-T trials effectively excluding patients with prior solid organ transplantation (SOT) and posttransplant lymphoproliferative disorders (PTLD). We report the outcomes for three patients with PTLD refractory to immunochemotherapy 10-20 years after SOT who received CAR-T therapy between January 2018 and December 2019. One patient had an orthotopic heart transplant, the second had a deceased donor kidney transplant, and the third had a pancreas after kidney transplant (PAK). All patients developed complications of CAR-T therapy such as cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and acute kidney injury requiring renal replacement therapy in the two out of three patients. All patients expired after withdrawal of care due to lack of response to CAR-T therapy. In addition, the PAK patient developed acute pancreatitis after CAR-T therapy. This case series identifies the challenges of using CAR-T therapy to manage refractory PTLD in SOT recipients and its possible complications.