Clinical Characteristics and Outcomes of Kidney Transplantation under Urgency Priority Condition

Abstract

Background: In several countries, patients with end-stage renal disease who are ineligible for dialysis are considered urgency priority (UP) for kidney transplantation (KT) through distinct allocation rules. There are scarce published data on clinical features and outcomes after KT of these patients. Methods: We retrospectively reviewed and compared demographic and clinical pretransplant characteristics and outcomes after KT of all patients transplanted under UP allocation in a single Brazilian transplant center from January 10 to March 16 (n = 74) and 1: 1 patients transplanted under standard allocation in the same period (n = 74). A propensity score (PS) matching analysis was performed to evaluate risk factors for death-censored graft loss. Results: UP KT group presented higher percentage of women (58.1 vs. 33.8%, p = 0.005), higher class I (22.2 ± 32.9 vs. 13.1 ± 25.3%, p = 0.027) and class II panel reactive antibodies (11.5 ± 24 vs. 5.2 ± 19.1%, p = 0.002), higher HLA mismatches (4.9 ± 0.9 vs. 3.7 ± 1.2, p < 0.001), higher percentage of retransplants (27 vs. 4.1%, p < 0.001), and spent longer time on dialysis off the waiting list (WL; 54.5 ± 52.5 vs. 31.2 ± 29.0 months, p = 0.03). After transplantation, UP KT patients presented longer hospital stay (29.3 ± 35.7 vs. 18.5 ± 19.5 days, p = 0.003) and inferior death-censored graft survival at 3 years (82 vs. 95.8%, log rank = 0.016), with 33.3% of graft losses due to vascular thrombosis. In PS-matched multivariable analysis, UP status hazard ratios (HR 4.791, 95% CI 1.052–21.722, p = 0.042) and donor age (HR 1.071, 95% CI 1.003–1.145, p = 0.041) were independent risk factors for death-censored graft loss. Conclusion: Patients transplanted under UP status remained a longer time on dialysis off the WL, suggesting that long-term dialysis led to exhaustion of accesses. After transplantation, outcomes are inferior and UP status was a risk factor for graft loss. These results point to the need for local policies to encourage and monitor the early referral to KT.

Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review

“…A total of 6656 records underwent title and abstract screening. The full-text review was undertaken for 886 eligible articles; of these 78 articles discussed HLA incompatibility at the level of the antigen mismatch only, 64-141 whereas 163 articles assessed incompatibility by molecular genotyping, molecular mismatch analysis, and/or pretransplant DSA verification by solid-phase and/or by cell-based assays. 3,142-303 The Preferred Reporting Items for Systematic reviews and Meta-Analyses diagram outlining the article selection process is provided in Figure 1.…”

Ethical Issues in Kidney Transplant and Donation During COVID-19 Pandemic

“…Examples are those who have limited access to dialysis, who have exhaustion or imminent lack of vascular access and either have absolute contraindications to or technique failure of peritoneal dialysis. 27 Highly sensitized patients with high percentage panel reactive antibodies and impending dialysis technique failure could also be given priority status for kidney transplantation. Adoption of a broad-brush approach stopping all kidney transplantation could have significantly disadvantaged these high-priority waitlisted transplant candidates who will have the lowest life expectancy in the absence of a kidney transplant.…”

Prevalência e fatores associados a não inscrição para transplante renal

“…Quando considerado o óbito como causa de perda do enxerto, os dados do RBT mostram sobrevida de 92% em um ano para transplantes com doador falecido. Ressalte-se que esses dados do RBT representam a média nacional e não a experiência de centros de excelência, onde as sobrevidas do enxerto e do paciente costumam ser ainda melhores 17,21,22 . Infelizmente, não há dados publicados sobre a mortalidade em lista de espera no Brasil.…”

“…Um grupo de pacientes transplantados sob urgência por falência de acesso vascular permaneceu, em média, 54,5 ± 52,5 meses (med = 33,9 meses) em diálise antes de todos os acessos se extinguirem. Os pacientes transplantados nessa situação apresentaram desfechos do transplante piores que os de pacientes transplantados sob alocação regular, incluindo um elevado percentual de perda do enxerto por trombose 17 . Seis pacientes entrevistados afirmaram não estar inscritos por acreditarem haver benefício de permanecer um tempo em diálise antes de transplantar, mais uma resposta que reflete desinformação sobre o transplante renal.…”