Early rehospitalization after kidney transplantation (KT) is common and
may predict future adverse outcomes. Previous studies using claims data have
been limited in identifying preventable rehospitalizations. We assembled a
cohort of 753 adults at our institution undergoing KT from January 1,
2003—December 31, 2007. Two physicians independently reviewed medical
records of 237 patients (32%) with early rehospitalization and
identified 1) primary reason for and 2) preventability of rehospitalization.
Mortality and graft failure were ascertained through linkage to the Scientific
Registry of Transplant Recipients. Leading reasons for rehospitalization
included surgical complications (15%), rejection (14%), volume
shifts (11%), and systemic and surgical wound infections (11%
and 2.5%). Reviewer agreement on primary reason (85% of cases)
was strong (kappa=0.78). Only 19 rehospitalizations (8%) met
preventability criteria. Using logistic regression, weekend discharge (OR 1.59,
p=0.01), waitlist time (OR 1.10, p=0.04), and longer initial
length of stay (OR 1.42, p=0.03) were associated with early
rehospitalization. Using Cox regression, early rehospitalization was associated
with mortality (HR 1.55; p=0.03) but not graft loss (HR 1.33;
p=0.09). Early rehospitalization has diverse causes and presents
challenges as a quality metric after KT. These results should be validated
prospectively at multiple centers to identify vulnerable patients and modifiable
processes-of-care.
Background
Vitamin D deficiency is associated with fractures, infections and death. Liver disease impairs vitamin D and vitamin D binding protein (DBP) metabolism.
Aims
We aimed to determine the impact of liver transplantation on vitamin D, particularly on DBP and free vitamin D concentrations.
Methods
Serum 25(OH)D, 1,25(OH)2D and DBP concentrations were measured in 202 adults before liver transplantation and 3 months later in 155. Free vitamin D concentrations were estimated from these values. Risk factors for 25(OH)D deficiency (<20 ng/ml) and low 1,25(OH)2D (<20 pg/ml) were examined with logistic regression, and changes in concentrations following transplantation with linear regression.
Results
Pretransplant, 84% were 25(OH)D deficient, 13% had 25(OH)D concentrations <2.5 ng/ml, and 77% had low 1,25(OH)2D. Model for end-stage liver disease score ≥ 20 (P < 0.005) and hypoalbuminemia (P < 0.005) were associated with low 25(OH)D and 1,25(OH)2D concentrations. Following transplantation, 25(OH)D concentrations increased a median of 17.8 ng/ml (P < 0.001). Albumin increased from a median of 2.7 to 3.8 g/dl (P < 0.001) and DBP from 8.6 to 23.8 mg/dl (P < 0.001). Changes in total 25(OH)D were positively and independently associated with changes in DBP (P < 0.05) and albumin (P < 0.001). Free 25(OH)D concentrations rose from 6.0 to 9.7 pg/ml (P < 0.001). In contrast, total 1,25(OH)2 Dconcentrations rose only by 4.3 pg/ml (P < 0.001) and free 1,25(OH)2 Dconcentrations declined (P < 0.001).
Conclusions
Serum total and free 25(OH)D and DBP concentrations rose substantially following transplantation, while 1,25(OH)2D concentrations showed modest changes and free 1,25(OH)2D decreased. Studies of the effects of vitamin D status on diverse transplant complications are needed.
Background
The proportion of elderly (≥65 years) kidney transplant recipients (KTRs) doubled in the United States (US) from 1999 – 2008. Given higher mortality, more medication side effects, and less rejection among elderly KTRs, optimal care of these patients may require tailored decisions about transplant therapeutics. It is unknown whether participants in transplant clinical trials – which generate the best evidence for patient care – are representative of the aging population of KTRs.
Methods
Using PubMed, we identified randomized trials involving KTRs from 1999 – 2008 and determined age-exclusion criteria and the mean age of participants. The mean age of these trial participants was compared to the mean age of the overall population of incident KTRs in the US.
Results
The 87,222 participants in 573 trials were significantly younger than the US KTR population (p<0.05). This age discrepancy worsened over the study period (during the years 2006 – 2008, the mean age was 45 years for trial participants versus 50 years for US KTRs, p<0.05). Thirty percent of trials had an exclusion criterion based on older age, and 16% excluded recipients ≥65 years. In multivariable regression, immunosuppression trials (p<0.01) and trials in higher-impact journals (p=0.03) were more likely to exclude the elderly, but there was no significant difference in exclusion of elderly patients based on a trial’s geographic location.
Conclusions
Trial participants are younger than KTRs in the US and many trials exclude older patients. Transplant investigators should make strong efforts to recruit patients across the total age spectrum.
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