Search for: All records

Abstract BackgroundWe hypothesized that alemtuzumab use is safe in pediatric kidney transplant recipients (KTRs) with equivalent long‐term outcomes compared to other induction agents. MethodsUsing pediatric kidney transplant recipient data in the UNOS database between January 1, 2000, and June 30, 2022, multivariate logistic regression, multivariable Cox regression, and survival analyses were utilized to estimate the likelihoods of 1st‐year and all‐time hospitalizations, acute rejection, CMV infection, delayed graft function (DGF), graft loss, and patient mortality among recipients of three common induction regimens (ATG, alemtuzumab, and basiliximab). ResultsThere were no differences in acute rejection or graft failure among induction or maintenance regimens. Basiliximab was associated with lower odds of DGF in deceased donor recipients (OR 0.77 [0.60–0.99],p = .04). Mortality was increased in patients treated with steroid‐containing maintenance (HR 1.3 [1.005–1.7]p = .045). Alemtuzumab induction correlated with less risk of CMV infection than ATG (OR 0.76 [0.59–0.99],p = .039). Steroid‐containing maintenance conferred lower rate of PTLD compared to steroid‐free maintenance (HR 0.59 [0.4–0.8]p = .001). Alemtuzumab was associated with less risk of hospitalization within 1 year (OR 0.79 [0.67–0.95]p = .012) and 5 years (HR 0.54 [0.46–0.65]p < .001) of transplantation. Steroid maintenance also decreased 5 years hospitalization risk (HR 0.78 [0.69–0.89]p < .001). ConclusionsPediatric KTRs may be safely treated with alemtuzumab induction without increased risk of acute rejection, DGF, graft loss, or patient mortality. The decreased risk of CMV infections and lower hospitalization rates compared to other agents make alemtuzumab an attractive choice for induction in pediatric KTRs, especially in those who cannot tolerate ATG. 

Abstract IntroductionIgA nephropathy (IgAN) can cause end‐stage kidney disease (ESKD). This study assesses the impact of induction and maintenance immunosuppression on IgAN recurrence, graft survival, and mortality in living and deceased donor kidney transplants (LDKT and DDKT). MethodsRetrospective analysis of the UNOS database in adults with ESKD secondary to IgAN who received kidney transplants between January 2000 and June 30, 2022. Patients with thymoglobulin (ATG), alemtuzumab, or basiliximab/daclizumab induction with calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) with or without prednisone maintenance were analyzed. Multivariate logistic regression was performed to identify factors correlated with IgA recurrence. Multivariable Cox regression analyses were performed for clinically suspected risk factors. Kaplan Meir Analysis was utilized for overall graft survival. ResultsCompared to ATG with steroid maintenance, alemtuzumab with steroid increased the odds of IgAN recurrence in DDKTs (OR 1.90,p <.010, 95% CI [1.169–3.101]). Alemtuzumab with and without steroid increased the odds of recurrence by 52% (p = .036) and 56% (p = .005), respectively, in LDKTs. ATG without steroids was associated with less risk of IgAN recurrence (HR .665,p = .044, 95% CI [.447–.989]), graft failure (HR .758,p = .002, 95% CI [.633–.907]), and death (HR .619,p <.001, 95% CI [.490–.783]) in DDKTs. Recurrence was strongly associated with risks of graft failure in DDKTs and LDKTs and death in LDKTs. ConclusionIn patients with IgAN requiring a kidney transplant, Alemtuzumab induction correlates with increased IgAN recurrence. Relapse significantly affects graft survival and mortality. ATG without steroids is associated with the least graft loss and mortality. 

Key PointsA2 to B incompatible transplantation is not fully practiced in the country, and further policies should encourage centers to perform more blood incompatible transplants.Centers that currently practice A2 to B incompatible transplants should give priority to blood type B patients who are willing to accept an A organ. This will benefit Asian and Black patients. BackgroundThe rate of A2 to B incompatible (ABO-i) kidney transplant continues to be low despite measures in the new kidney allocation system (KAS) to facilitate such transplants. This study shows how the number of ABO-i transplants could increase if KAS policies were used to their fullest extent through a boost in ABO-i priority points. MethodTransplant outcomes were predicted using the Kidney Pancreas Simulated Allocation Model, preloaded with national data of 2010. We used this simulation to compare KAS with a new intervention in which priority equal to cPRA=100 has been given to blood type B candidates who are willing to accept an A blood type organ. ResultsThe number of Black recipients increased by 375 (from 35% of the total recipient population to 38.7%), the number of blood type B Blacks increased by 65 (from 8% of the total recipient population to 9%), and the number of blood type B Black patients receiving blood type A kidneys increased by 49 (from 2% of the total recipient population to 2.5%). The same change occurred for Asians, particularly blood type B Asians (from 0.54% of the total recipient population to 0.7%). The average wait time notably decreased by 27 days for blood type B Black patients. In the proposed scenario, 263 blood type B Black patients received a blood type A organ (2.5% of the total recipient population) while only 181 (1.1%) of such transplants were performed in 2021. These results signify a considerable opportunity loss of ABO-i transplants for Black patients. ConclusionsIf this policy was universally adopted, we would expect to see an overall increase in A2 to B transplantation, but in reality, not all centers perform ABO-i transplantation. Thus, adopting this policy would incentivize other centers to perform more subtyping of A-type kidneys, and it would increase access to organs for blood type B Asian and Black patients in centers where ABO-i transplantation already takes place. 

The objective of this study was to investigate factors influencing one’s decision to become a live kidney donor under the framework of sociotechnical systems, by expanding the focus to include larger organizational influences and technological considerations. Semi-structured interviews were conducted with live kidney donors who donated through University of Louisville Health, Trager Transplant Center, a mid-scale transplant program, in the years 2017 through 2019. The interview transcripts were analyzed for barriers and facilitators to live kidney donation within a sociotechnical system. The most salient facilitators included: having an informative, caring, and available care team; the absence of any negative external pressure toward donating; donating to a family or friend; and the ability to take extra time off work for recovery. The most recurrent barriers included: short/medium-term (<1 year) negative health impacts because of donation; the need to make minor lifestyle changes (e.g., less alcohol consumption) after donation; and mental health deterioration stemming from the donation process. The sociotechnical systems framework promotes a balanced system comprised of social, technical, and environmental subsystems. Assessing the facilitators and barriers from the sociotechnical system perspective revealed the importance of and opportunities for developing strategies to promote integration of technical subsystem, such as social media apps and interactive AI platforms, with social and environmental subsystems to enable facilitators and reduce barriers effectively.