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Background Kidney transplantation (KT) improves clinical outcomes of patients with end stage renal disease. Little has been reported on the impact of early post-operative surgical complications (SC) on long-term clinical outcomes following KT. We sought to determine the impact of vascular complications, urological complications, surgical site complications, and peri-graft collections within 30 days of transplantation on patient survival, graft function, and hospital readmissions. Methods We conducted a single-centre, observational cohort study examining adult patients (≥ 18 years) who received a kidney transplant from living and deceased donors between January 1st, 2005 and December 31st, 2015 with follow-up until December 31 st , 2016 ( n  = 1,334). Univariable and multivariable analyses were performed with Cox proportional hazards models to analyze the outcomes of SC in the early post-operative period after KT. Results The cumulative probability of SC within 30 days of transplant was 25%, the most common SC being peri-graft collections (66.8%). Multivariable analyses showed significant relationships between Clavien Grade 1 SC and death with graft function (HR 1.78 [95% CI: 1.11, 2.86]), and between Clavien Grades 3 to 4 and hospital readmissions (HR 1.95 [95% CI: 1.37, 2.77]). Conclusions Early SC following KT are common and have a significant influence on long-term patient outcomes.

Background: Functional disability is defined as the need for assistance with self-care tasks. Objective: To document changes in functional status over time among older prevalent renal transplant recipients. Design: Single center, prospective, follow-up study. Setting: Single center, tertiary care transplant center. Patients: Patients, with a functioning kidney transplant, aged 65 years or older who underwent assessment of functional status approximately 12 months previously. Measurements: Validated tools used included Barthel Index, the Lawton-Brody Scale of Instrumental Activities of Daily Living, the Timed Up and Go test, the Veterans Specific Activity Questionnaire, the Mini-Cog, and dynamometer handgrip strength. Methods: Outpatient assessment by a trained observer. Results: Of the 82 patients previously studied, 64 (78%) patients participated in the follow-up study (mean age 70.5 ± 4.4 years, 58% male, 55% diabetic). Among those completing functional status measures, 32 (50%) had functional disability at baseline. Over the 1-year period, 11 (17%) of these patients experienced progressive functional decline, 6 (9%) exhibited no change, and 15 (23%) had functional recovery. Eleven patients (17%) initially independent, developed new-onset disability. One of the strongest predictors of progressive functional decline was having 1 or more falls in the previous year. Limitations: Assessments were performed only on 2 occasions separated by approximately 1 year. Conclusions: Fluctuations in disability states are common among older adults living with renal transplants. Episodes of functional disability may place individuals at higher risk of persistent and/or progressive disability.

Delayed graft function (DGF) is commonly considered a risk factor for acute rejection, although this finding has not been uniformly observed across all studies. The link between DGF and acute rejection may have changed over time due to advances in immunosuppression and medical management. Here we conducted a cohort study of 645 patients over 12 years to evaluate the association of DGF and biopsy-proven acute rejection (BPAR) in a modern cohort of kidney transplant recipients. DGF was defined as the need for at least one dialysis session in the first week after kidney transplantation. The 1-, 3-, and 5-year cumulative probabilities of BPAR were 16.0, 21.8, and 22.6% in the DGF group, significantly different from the 10.1, 12.4, and 15.7% in the non-DGF group. In multivariable Cox proportional hazards model, the adjusted relative hazard for BPAR in DGF (vs. no DGF) was 1.55 (95% confidence interval (CI): 1.03, 2.32). This association was generally robust to different definitions of DGF. The relative hazard was also similarly elevated for T-cell- or antibody-mediated BPAR (1.52 (0.92, 2.51) and 1.54 (0.85, 2.77), respectively). Finally, the association was consistent across clinically relevant subgroups. Thus DGF remains an important risk factor for BPAR in a contemporary cohort of kidney transplant recipients. Interventions to reduce the risk of DGF and/or its aftereffects remain of paramount importance to improve kidney transplant outcomes.

ObjectiveTo describe the incidence, characteristics, clinical management, and outcomes of renal cell carcinoma (RCC) among a large, single-centre cohort of kidney transplant recipients (KTR).MethodsWe conducted an observational cohort study looking at KTR transplanted between January 2000-December 2017 (n = 2443) with ≥ 1 year of follow-up. Simultaneous kidney/pancreas transplants were excluded. The Kaplan–Meier product-limit method was used to determine the incidence of RCC. Characteristics and management of RCC were examined using descriptive statistics. Risk factors and clinical outcomes were analyzed using Cox regression models.ResultsThe incidence of RCC among our cohort was 0.32 per 100 person-years, 2.1% of all KTRs. Almost half (47.1%) of cases occurred within 4 years post-transplant. The majority of cases were T1a (86.3%), clear-cell (45.1%), and in the native kidney (80.4%). KTR diagnosed with RCC had a twofold higher incidence of other malignancies versus KTR without RCC. Overall mortality, but not cancer-specific mortality, at 2- and 5-years post-transplant was threefold higher among KTR with RCC than those without.ConclusionsIncidence of RCC among our KTR was slightly higher than the general population; majority of cases occur in the native kidneys and are low stage, low grade. Indolent histologic variants were more common than the general population. KTR with RCC had a higher incidence of other malignancies. Overall, but not cancer-specific, mortality was higher among KTRs diagnosed with RCC.

Wide variations in tacrolimus levels have been identified as a risk factor for inferior kidney allograft survival but past studies have not properly accounted for the dynamic nature of drug exposure over time. Here we evaluated whether time-varying exposure to tacrolimus increases the risk of long-term adverse outcomes in a retrospective cohort study in adult kidney transplant recipients on tacrolimus-based immunosuppression. Time-dependent Cox proportional hazards models were used to examine the association between the standard deviation of tacrolimus levels (TacSD) starting at 1-year post-transplant and the composite end point of late allograft rejection, transplant glomerulopathy, or total graft loss (including death). Among 356 patients, there was a significant 27% increase in the adjusted hazard of the composite end point for every 1-unit increase in TacSD (hazard ratio 1.27 (95% confidence interval 1.03, 1.56)). There was also a graded increase in the relative hazard for the composite end point by TacSD threshold (hazard ratios 1.33, 1.50, 1.84, and 2.56 for TacSD 1.5, 2, 2.5, and 3, respectively). The results were similar for total graft loss and the composite end point excluding death. Thus, increased time-dependent TacSD may be an independent risk factor for adverse kidney transplant outcomes. TacSD may serve as a monitoring tool to identify high-risk patients. Whether interventions to decrease TacSD will improve outcomes requires further study.

Few studies have examined predictors of paid employment post-transplant and impact of employment on clinical outcomes. Our objectives were to investigate rates, predictors, and clinical outcomes associated with post-transplant employment in kidney transplant recipients (KTR). Data were collected from electronic charts of adult KTR transplanted at a single centre between January 1, 2007, and December 31, 2014, with follow-up until December 31, 2015. Kaplan-Meier product limit method was used to assess time to return to work (RTW) and time to total graft loss. Multivariable Cox proportional hazards models were fitted to examine RTW predictors and association between employment and total graft loss. Among 1,069 KTR, 319 returned to work during the first year post-transplant. Independent RTW predictors included pre-transplant employment status, age, length of hospital stay after transplant, physical disability, and drug coverage. RTW was associated with lower risk of total graft loss. Pre- and/or post-transplant interventions are necessary to improve participation in paid work post transplant.

Surgical site complications (SSCs) are an important source of morbidity after kidney transplantation. We assessed the incidence, risk factors, outcomes and economic impact of SSCs in a large, diverse population of kidney transplant recipients. We conducted a single-centre, observational cohort study of adult (age ≥ 18 yr) patients who underwent kidney transplantation between Jan. 1, 2005, and Dec. 31, 2015, with a minimum of 1 year of follow-up. Cases of SSC, including infections and wound dehiscence, were determined from patient records. Inpatient and outpatient hospital costs were determined 6 and 12 months after transplantation. We used the Kaplan–Meier product-limit method to determine the cumulative probability of SSCs and other outcomes. We evaluated risk factors and clinical outcomes using Cox proportional hazard ratios. Linear regression models were used to study the effect of SSCs on graft function. The incidence rate of SSCs within 30 days after transplantation was 4.19 per 100 person-months. The cumulative probability of developing an SSC within 30 days after transplantation was 4.13% (95% confidence interval [CI] 3.23%–5.28%). Increased recipient body mass index (BMI) (hazard ratio [HR] 1.07, 95% CI 1.02–1.11), longer cold ischemic time (HR 1.05, 95% CI 1.01–1.09) and transplantation in 2010–2012 versus 2005–2009 (HR 2.20, 95% CI 1.19–4.04) were risk factors for SSC development. In multivariable stepwise Cox proportional hazard models, SSC was a significant risk factor for death-censored graft failure (HR 3.08, 95% CI 1.60–5.90) and total graft failure (HR 2.09, 95% CI 1.32–3.32). Cumulative median hospital costs were $2238.46 greater for patients with an SSC than for those without. Increased BMI, longer cold ischemic time and the 2010–2012 transplantation period predisposed to SSCs. The development of SSCs was associated with a higher risk of graft failure. Strategies to minimize SSCs may improve outcomes after kidney transplantation and reduce costs. Les complications affectant le site opératoire (CSO) sont une importante cause de morbidité après la transplantation rénale. Nous avons évalué l’incidence, les facteurs de risque, les résultats et l’impact économique des CSO auprès d’une volumineuse population hétérogène de receveurs de transplantations rénales. Nous avons procédé à une étude de cohorte d’observation monocentrique regroupant des patients adultes (âge ≥ 18 ans) soumis à une transplantation rénale entre le 1er janvier 2005 et le 31 décembre 2015, et suivis pendant au moins 1 an. Les cas de CSO, incluant les infections et les déhiscences de plaies ont été confirmés à partir des dossiers des patients. Le coût des hospitalisations et des soins ambulatoires a été calculé 6 et 12 mois après la transplantation. Nous avons utilisé l’estimateur de produit-limite de Kaplan–Meier pour établir la probabilité cumulative de CSO et d’autres paramètres. Nous avons évalué les facteurs de risque et les paramètres cliniques par la méthode des risques proportionnels de Cox. Des modèles de régression linéaire ont servi à l’analyse de l’impact des CSO sur le fonctionnement des greffons. Le taux d’incidence des CSO dans les 30 jours suivant la transplantation a été de 4,19 par 100 mois-personnes. La probabilité cumulative d’une CSO dans les 30 jours suivant la transplantation a été de 4,13 % (intervalle de confiance [IC] de 95 % 3,23 %–5,28 %). Les facteurs de risque de CSO étaient indice de masse corporelle (IMC) élevé (risque relatif [RR] 1,07, IC de 95 % 1,02–1,11), durée plus longue de l’ischémie froide (RR 1,05, IC de 95 % 1,01–1,09) et transplantation effectuée en 2010–2012 c. 2005–2009 (RR 2,20, IC de 95 % 1,19–4,04). Dans les modèles à risques proportionnels de Cox multivariés séquentiels, les CSO ont été d’importants facteurs de risque d’échec du greffon après censure des décès survenus avec des greffons fonctionnels (RR 3,08, IC de 95 % 1,60–5,90) et d’échec total du greffon (RR 2,09, IC de 95 % 1,32–3,32). Les coûts hospitaliers médians cumulatifs ont été de 2238,46 $ de plus chez les patients ayant connu une CSO par rapport aux patients indemnes de CSO. Un IMC élevé, une durée plus longue de l’ischémie froide et la transplantation effectuée entre 2010 et 2012 ont prédisposé les patients à des CSO. Les CSO ont été associées à un risque plus grand d’échec du greffon. Les stratégies visant à prévenir les CSO pourraient améliorer les résultats de la transplantation rénale et en réduire les coûts.

Because kidney transplant recipients may be at increased risk for deep vein thrombosis (DVT) following transplantation, we investigated the incidence, risk factors, treatments and outcomes of early DVT among kidney transplant recipients. An observational, single-centre cohort study was conducted among adult kidney transplant recipients from Jan. 1, 2005, to Dec. 31, 2016 with 1-year followup. Time to DVT was assessed using the Kaplan–Meier method. Cox proportional hazards and linear regression models were used to analyze risk factors for and outcomes of DVT. The cumulative incidence of DVT was 4.25% at 3 months after transplant. In multivariable analysis, the use of depleting induction agents (hazard ratio [HR] 2.13, 95% confidence interval [CI] 1.05–4.35]), white recipient race (HR 1.84. 95% CI 1.08–3.12), the use of kidneys from expanded criteria donors (HR 2.13, 95% CI 1.05–4.32) and lower recipient body mass index (HR 0.95, 95% CI 0.91–1.00) increased the risk for early DVT. Peritransplant DVT prophylaxis was not associated with early DVT. Early DVT was not associated with reduced graft function, death, graft failure or first hospital readmission. Risk factors for early DVT in our cohort of kidney transplant recipients included white recipient race, use of depleting agents, lower recipient body mass index and use of expanded criteria donors. As practice patterns of donor and recipient selection in kidney transplantation evolve, the results of this study may aid in perioperative risk assessments and decision-making about the use of DVT prophylaxis. Étant donné que les receveurs de transplantation rénale peuvent être exposés à un risque accru de thrombose veineuse profonde (TVP) après l’intervention, nous avons voulu examiner l’incidence, les facteurs de risque, les traitements et l’issue de la TVP précoce chez les receveurs de transplantation rénale. Nous avons procédé à une étude de cohorte observationnelle monocentrique auprès d’adultes ayant subi une transplantation rénale entre le 1er janvier 2005 et le 31 décembre 2016, suivis pendant 1 an. L’intervalle avant la TVP a été évalué par la méthode de Kaplan–Meier. Des modèles d’analyse à risques proportionnels de Cox et la régression linéaire ont servi pour l’analyse des facteurs de risque et l’issue de la TVP. L’incidence cumulative des TVP était de 4,25 % 3 mois après la transplantation. Dans l’analyse multivariée, l’utilisation d’agents d’induction antirejet (risque relatif [RR] 2,13, intervalle de confiance [IC] de 95 % 1,05–4,35]), des receveurs de race blanche (RR 1,84, IC de 95 % 1,08–3,12), l’utilisation de greffons rénaux provenant de donneurs à critères élargis (RR 2,13, IC de 95 % 1,05–4,32) et un indice de masse corporel (IMC) moindre chez les receveurs (RR 0,95, IC de 95 % 0,91–1,00) ont fait augmenter le risque de TVP précoce. La prophylaxie anti-TVP entourant l’intervention n’a pas été associée à la TVP précoce. La TVP précoce n’a pas été associée à une diminution du fonctionnement du greffon, au décès, à la défaillance du greffon, ni à la première réhospitalisation. Dans notre cohorte de greffés du rein, les facteurs de risque de TVP précoce incluaient race blanche des receveurs, utilisation d’agents antirejet, IMC moindre des receveurs et donneurs à critères élargis. À mesure qu’évolueront les principes de sélection des donneurs et des receveurs pour la transplantation rénale, les résultats de cette étude pourraient aider à évaluer le risque péri-opératoire et à éclairer les prises de décision entourant la prophylaxie anti-TVP.

PurposeThe effect of living donor kidney allograft size on recipient outcomes is not well understood. In this study, we sought to investigate the relationship between preoperatively measured donor kidney volume and recipient estimated glomerular filtration rate (eGFR) in living donor kidney transplantation (LDKT).MethodsWe studied computed tomography (CT) donor kidney volumes and recipient outcomes for 438 LDKTs at the Toronto General Hospital between 2007 and 2016. Estimated glomerular filtration rate (eGFR) was calculated at 1, 3, and 6 months and a multivariable linear regression model was fitted to study the effect of donor kidney volume on recipient eGFR.ResultsThe mean volume and weight of the donated kidneys were 157.3 (± 32.3) cc and 186.7 (± 48.7) g, respectively. Kidney volume was significantly associated with eGFR on multivariable analysis (P < 0.001). Specifically, for every 10 cc increase in kidney volume, there was a 1.68 mL/min, 1.25 mL/min and 0.97 mL/min rise in recipient eGFR at 1, 3, and 6 months, respectively.ConclusionsDonor kidney volume is a strong independent predictor of recipient eGFR in LDKT, and therefore, may be a valuable addition to predictive models of eGFR after transplant. Further research may determine if the inclusion of donor kidney volume in matching algorithms can improve recipient outcomes.

Background: Kidney transplant recipients' (KTR) adherence to prescribed regimens is vital for optimal recovery and long-term graft function. Purpose: The objective of this study was to identify risk factors of KTR non-adherence and their impact on post-transplant outcomes. Description: A retrospective single-centre cohort study was conducted among KTR transplanted between January 1, 2003-December 31, 2017. Non-adherence was defined as one or more of the following in the first year post transplant: (1) at least one missed clinic visit; (2) > 30% missed laboratory visits; and/or (3) > 40% coefficient of variation of calcineurin inhibitor levels. Univariable and multivariable logistic and Cox proportional hazards models were fitted to identify adherence risk factors and outcomes, respectively. From a total of 2,714 patients, 1,803 (66.4%) were included in the analysis. The mean recipient age was 51.7 (± 13.4) years, and 60.7% were male. Overall non-adherence was identified in 34.9% patients; 11.2% patients were non-adherent to clinic visits, 5.4% to laboratory tests, and 25.2% to medication. Recipient history of psychiatric disorders (OR 1.57 [95% CI: 1.22, 2.02]) or non-adherence (OR 1.82 [95% CI: 1.31,2.54]) were independent risk factors for non-adherence. Private (vs. public) drug coverage reduced the risk for non-adherence (OR 0.62 [95% CI: 0.48,0.80]). Any episode of non-adherence over the first-year after transplant was associated with total graft failure (HR 1.52 [95% CI: 1.20,1.91]), death with graft function (HR 1.51 [95% CI: 1.11, 2.05]), and biopsy-proven acute rejection (HR 2.35 [95% CI: 1.38,3.99]). A trend toward an increased risk of death-censored graft failure was observed (HR 1.39 [95% CI: 0.96,2.01]). Implications for practice: KTR adherence is influenced by both psychosocial and socioeconomic determinants, which impact post-transplant outcomes. Our results emphasize the need for multifaceted interventions to improve patient adherence and further investigation to determine if our results are generalizable to younger patient populations.