Background and objectives The calcimimetic cinacalcet reduced the risk of death or cardiovascular (CV) events in older, but not younger, patients with moderate to severe secondary hyperparathyroidism (HPT) who were receiving hemodialysis. To determine whether the lower risk in younger patients might be due to lower baseline CV risk and more frequent use of cointerventions that reduce parathyroid hormone (kidney transplantation, parathyroidectomy, and commercial cinacalcet use), this study examined the effects of cinacalcet in older ($65 years, n=1005) and younger (,65 years, n=2878) patients.Design, setting, participants, & measurements Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) was a global, multicenter, randomized placebo-controlled trial in 3883 prevalent patients on hemodialysis, whose outcomes included death, major CV events, and development of severe unremitting HPT. The age subgroup analysis was prespecified.Results Older patients had higher baseline prevalence of diabetes mellitus and CV comorbidity. Annualized rates of kidney transplantation and parathyroidectomy were .3-fold higher in younger relative to older patients and were more frequent in patients randomized to placebo. In older patients, the adjusted relative hazard (95% confidence interval) for the primary composite (CV) end point (cinacalcet versus placebo) was 0.70 (0.60 to 0.81); in younger patients, the relative hazard was 0.97 (0.86 to 1.09). Corresponding adjusted relative hazards for mortality were 0.68 (0.51 to 0.81) and 0.99 (0.86 to 1.13). Reduction in the risk of severe unremitting HPT was similar in both groups. ConclusionsIn the EVOLVE trial, cinacalcet decreased the risk of death and of major CV events in older, but not younger, patients with moderate to severe HPT who were receiving hemodialysis. Effect modification by age may be partly explained by differences in underlying CV risk and differential application of cointerventions that reduce parathyroid hormone.

Background Living donor kidneys with multiple arteries (MA) are increasingly procured laparoscopically for transplant. Methods We compare long-term graft function and survival of kidneys with single arteries (SA) and MA over a 10-year period. Results There were a total of 218 grafts with SA and 60 grafts with MA. The MA group had longer operative and ischemic times than SA group. There was a small increase in ureteral complication (8.3% vs. 2.3% P=0.06) and a significantly higher incidence of rejection (23.3% vs. 10.1%, P=0.01) in MA group than in SA group. Graft function was lower in MA group than SA group. The 5-year graft survival by Kaplan Meier analysis was better in SA group than in MA group (P=0.023). The estimated graft survivals at 1, 3, and 5 year were 94.4%, 90.6%, and 86% for SA group and 89.6%, 83.2%, and 71.8% for MA group. There was a higher percentage of graft loss from chronic allograft nephropathy in MA group than in SA group (16.7% vs. 5.5%, P=0.01). The presence of MA (vs. SA) was an independent risk for acute rejection (OR 3.60, 95% CI 1.59–8.14, P=0.002) and for graft loss (HR 2.31, 95% CI 1.05–5.09, P=0.038). Conclusion Laparoscopic procurement of living donor kidneys with SA may be associated with a lower risk of rejection, better function, and superior long-term survival when compared with kidneys with MA.

BACKGROUNDThe effect of HLA match on renal graft survival has become controversial as has the policy of mandatory sharing of kidneys.METHODWe performed a retrospective analysis of HLA matched (M) and mismatched (MM) kidney transplants in our center. Tacrolimus, mycophenolic acid, and steroids were used as maintenance therapy and basiliximab induction was added for high‐risk patients.RESULTA total of 229 kidney transplants were included with median follow‐up of 5.1 years. The 5‐year death‐censored graft survival by Kaplan‐Meier method was significantly higher in the M group than in the MM group for deceased‐donor kidney transplants (log‐rank, p = .018). This graft survival advantage was detected in patients with a peak panel reactive antibody (PRA) greater than 20% (p = .023), but not in those with a PRA level of less than 20% (p = .32). The graft survival was not statistically different for live donor kidney transplants (p = .077). A mismatched kidney was an independent risk for graft loss (hazard ratio: 2.27, 95% confidence interval: 1.009–5.09, p = .047) and acute rejection was a significant cause of graft loss in mismatched deceased‐donor transplants (p = .035).CONCLUSIONAcute rejection remains a significant cause of graft loss in HLA‐6‐antigen mismatched deceased‐donor kidney transplants. Our data support mandatory sharing of HLA‐matched kidneys in sensitized patients with a PRA level greater than 20%.

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